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Janlce B.
Foust |
TEN RULES FOR TALKING WITH PATIENTS
i Respect each patient as a unique human being, with
rights, cultural and ethnic background, and personal values
and responses.
Be punctual and polite; introduce yourself at the beginning of
any patient encounter and definitely before any intervention.
Demonstrate respect for patient privacy, comfort,
and confidentiality.
Assess verbal and nonverbal communication because what is
not spoken may be as important as the words that are heard.
Use professional language. Avoid rote responses or slang
expressions because they may patronize patients, minimize their
feelings, or make them uncomfortable.
Do not force patients to talk when they are not ready or able.
Be humble and honest about what you know, and seek other
sources of information that may benefit the patient, as needed.
Maintain hope in adversity, strive for independence in disability,
and use creativity to plan nursing care.
Use humor to convey humility and joy, to lighten a situation,
and to share common human experiences.
. Utilize any form of communication that allows patients’
needs, questions, and concerns to be expressed so they
be better understood.
 Communication
for NULSES
Edited by
Lisa Kennedy Sheldon, PhD, APRN-BC, AOCNP®
Assistant Professor
University of Massachusetts, Boston
Boston, Massachusetts
Oncology Nurse Practitioner
St. Joseph Hospital
Nashua, New Hampshire
Associate Member
Dana-Farber/Harvard Cancer Centers

Janice B. Foust, PhD, RN

Assistant Professor
University of Massachusetts, Boston
Boston, Massachusetts
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Library of Congress Cataloging-in-Publication Data

Kennedy-Sheldon, Lisa, author.
Communication for nurses : talking with patients / Lisa Kennedy Sheldon, Janice B. Foust.—Third edition.
p.;cm.
Includes bibliographical references and index.
ISBN 978-1-4496-9177-6 (pbk.)
I. Foust, Janice B., author. II. Title.
[DNLM: 1. Nurse-Patient Relations. 2. Communication. 3. Models, Nursing. 4. Nurses—psychology.
5. Nursing Theory. WY 88]
RT23
610.7306'99—de23
2013022672
6048
Printed in the United States of America
Upey ailsy EE OS SS
SS 4h yD Tl
DEDICATION

To my parents ... from my first words

—Lisa Kennedy Sheldon

To future nurses and colleagues

—Janice B. Foust

eee

TT
 Digitized by the Internet Archive
In 2022 with funding from
Kahle/Austin Foundation

https://archive.org/details/communicationforO000shel
TABLE OF CONTENTS

PERHOMTICCIOINICHIS ser anccss concrete reece ene ee amet enn xili

About the Authors asnisinatt Ayman. cerisinicatl
deities. cocuace XV

hal (cra... 2h744ck ppSnr er rewire Merete ereaienp, bbb ibe an a. A XVII

KZOMUEMDULGOIS v.5.0cosart ccacecsoces sree or cntens astra otters ane ee eee Xxl

SECTION | SETTING THE STAGE FOR EFFECTIVE

COMMUNICATION
ONE
The. First Encountejtiis-aseexs op tee ee ese eet. 3
Lisa Kennedy Sheldon
ITEORUCHON, «.08:<to.09 sunt) sccooeenbrs tee came tenes etc 4
HhetINOIOGY 2,225, -cp--a0nscerssePasgteecacsamee duet coc to 4
Wheoretical. Background ,.......:52:::-ssssoeratereramos enscett ae= 6
SUITUMANY cecacrccecceonicieens
cord cance canacc Uaeaeae eee naa g
RETEPEN CES... oc tieeeconnutce <oscuninccieesotecoseaat
snoremen caeNaescaseee 11
TWO
The Nurse as a Person: Theories of Self and Nursing ........ 13
Lisa Kennedy Sheldon
WILFOGUGLION :.«.25.0:-+.-250-020000000
eG ye OR Gaiden det 14
SGIGAWALENESS co..ecseecens uses sossoypsone-Ptere
aang» s.caetanes 14
Theoretical,Background tasaitirssett-eageesh+.. U0. 15
MHEINUrse. aS, A PEPSON 5 s.c-5:00-0s0050525 REGENT) +0200 aoe: 21
DEVELOPING AS ANUMSC wescscpscsrs--sptvnseseetee tRtEETaa sosmore> 22
SOUTH W Le Goneeneenerne ER Penn Pe PCy, oer res re tet tte 22
REREGENCES cet ccsc. teeters hea ak, ee ct ormbae ey awsnsahane ZS
vi Table of Contents

THREE
Patients as People: Standards to
Guide CommuniCationts.ccasrevssss corre eters eee 27
Lisa Kennedy Sheldon
INtFOGUGCTION wessnmorvenoseoreenmnnrre meen R nT 28
Patient Rights......3:.:.ge-ob-4Ah
todas tenes arenas Meee e29
Institutional StamclardS<\c.veses-cser
ee eee ee 30
Professional Standards m2 ee ee 31
LegalStandards iocics.ssev<ceuypevsge eerie eterna 32
Contidentialitys..ec<d ee vie eee eee eee 32
Communication and Malpractice............cceesccseeseeeeeees 33
ValLlOS Joe ccieccecs Aevsss ohh At aude eee ee eee ad 34
Code ‘of Ethics for NGOS s5..uuees. ee cee 34
Ethical Reasoning and Decision Making ...............:0:08 Bhs,
SUNTUNI ANY <2 coe ee cee tes eect re eset satis ote nec ecreee e e 37
REFERENCES hoo a ee ee ot a Pen Ae 40

FOUR
Cross-CulturalsGonmunication:. scxn. ceeera st... a kere 41
Judith Healey Walsh
INtROGUCTION:: canter t ae acacia ny eee 42
Culture, Cultural Competence, and Health Care.......... 44
Barriers to Effective Cross-Cultural
COMMUNICATION. Sceatck ee ee ee eee 46
Strategies to Improve Cross-Cultural
Clinical Encounters chee ee eee ce ee 50
SUNT Vallry Uteaee heresentnen: OUR neers een dar een © Snes 53
Referencesrcsssisiteysie.
tee cere eae encase on

SECTION If THE NURSE-PATIENT RELATIONSHIP

FIVE
Establishing a Therapeutic Relationship ................cc:cc08 50
Lisa Kennedy Sheldon
Introduction cs.iszscesecessteeevanterices
REMC rot cscs toeoee60
Respect: Unconditional Positive Regard..............c00c00 61
GeNUINENeSS secrete
EE BS OTR 62
 Table of Contents vii

Trusts Apeeniniate Lommnaientionsal tae 65

Confidentialitynser. minatiandn ceri ecan eh 66
The Nurse—Patient Relationship............:cccccccccsseesseeeees 66
Setting,Boundaries scesesccssesacccaercaraganea Lee oon 71
Self-DisGlosure :cscccsicttczes cencteaxeaaseatt eal 72
SUMIMANY ses es sgees ca coracceazoaiaerethti dees ee ent 43
References: A eisesnesertegscsactetesectagciteritacrss
Wo east 74

SIX
Interviewing Skills: A Clinical Art and Science ............c00 dell
Lisa Kennedy Sheldon
INCEOGUCHON cc ke nat eterre ce teeta ee Nee eco, ee 78
SELL GECIOAIS susan saeech corde tee uantasedee cca tettinc. ae ee Thy)
The Role of Student Nurses..a10.2. 42. 2isu8 2) can/asqeak 80
ACTIVE, LISTENING, cyacciscaceseeseanceensanseaa Binds tte-See U Sere 80
SH OIIC OG coc rcsanecearnas Soc hncccha Waiadtenecaysateaec
sce Eee eee 83
TYDES.OE RESPONSES. <.savesisreeacceroavenoceaaste te meee tence: 84
Patient-Centered Interviewing ....0....5...c.ece cede esesteeeees 85
Objeetvity. 4.2.0 Or ReRI EE aera ROTOEE 88
Reliability. givvesscsouseorsizsce RST ate a see Eso. 88
Styles of. Questions.....c# VAC te eee ae SEMIS, 5. 89
TUM Pyeesvieettoren nn LUNIMER AIL SHAN Ca ES SIE MENT de 2 91
SeIE-DISGIOSUG <2 dc.00s-4ccvepsneectssasrvilariatioae ome eet 91
SUMNMNAN ieseo oss vollS 52, aoc sacvsreg foes cedeateeen cree ee ee eo 23
WEDSibeS... tm tts csecircae (Mewar est ftoathee piney toto 95
ROTEL NGOS riot cra Saccanateae) aut pee meee Tae ee 96

SEVEN
Nonverbal Communication: Cues and
Body, LanGidge, fet Bye uni0. 8. SOR RUA Me NIRS ost 97.
Lisa Kennedy Sheldon
HAR OGMICUON ssecterncesssntxxzacenatsiverssanearaniea
st tee ee 98
Body LAanQuag @rstesessszencsestuestscerssernsten
cgtao eeettrasecst 98
STEINER.he ee tener eM REPT POP AT SORS TTL otek 102
Websites sa: tirnn}ittenan
Otic cttbkllc 104
viii. Table of Contents

EIGHT
HUMOls wis Cercotteas dteeayah eal be eas cxv scar ae 107
Lisa Kennedy Sheldon and Janice B. Foust
Introduction alii? ...:1:.-14 ee eIOe eaaeee- 108
Positive HUION scnicensdezenredeconeerscr ences spepbpeeeeeen 108
Negative Humor ..-csssaseccvecscessepsecteeeacaneces tome Reniatanmees 109
Black Humps peers. .:-Jacccosececnctaaseceancramerreeeeremeee: 109
Appropriate UsenshitMmion. -iy--cvecae ere daacertenee <a? 109
Scrutiny vee arc 5 ecvcaascediacsveacee cascenectperenesesize agence 133
Rehereinee iets cn o.c. oi drareeaereereccatewes cate caeeacees a2

SECTION III SPECIFIC COMMUNICATION

NINE
Improving Quality of Care and Safety During
ATAMSIIONS AM Cave Lage evvecacssercnertreoovae
tte mae anne etes di Ws
Janice B. Foust
(REPOGMUCHON ac cedsaseaccesyusdertaceess
SATIS IM IO SRN Pn. 118
Models to Improve Care Transitions ...........::cceeeeeeeeeee 149
Targeted Assessment of Common
Transition-Related Problems........<...:0-:-:as9veeseeeeenw!120
Patient and) Family. Education:.....aecweateo do aah... 123
Communication Among Professionals ...........::::ccc000 125
Web sitesdeat var sissanscasocccassesspauie
sedinus ee ee 127
Relerences.as.\evwierisues hasan Ac audlagep line csccs ITER ons 128
TEN
Physical Impairments to Communication ..............:c08 134
Janice B. Foust
ltrOCUCHON ct ae conte ene A332
Speech ‘and Language Deficitsiat waeen ee 133
Sensory Deprivation in Intensive Care Settings........... 138
SUNMOMALY:..ce3sssc0neeosseyhon
stand earsoicnnd SUMRSORN. See PenteRaat140
WIAIDSILGS, «Ce schutrentscc.c5cyneinazsnvng
coucaan barcaeee meen Teate: 140
RELEICI COS vcicsascssansnssvasonetetanysracsatas
oes maa es141
ELEVEN
Talking with Children: Working with Families ................. 143
Esther Seibold
Background ciducsmaceniete Gere eee me meee 144
Communicating with Children yates 144
 Table of Contents ix

Developmentally Appropriate Communication .......... 146

Nonverbal Commu nication..................cccseccccessseccceeees 147
Communicating with Family Members ................0006 148
SUITILTIALY << sauscartduneoun cue taet cseecte pee eeur ese tare mee eee mee 149
WVEDSITOS cece tosstesteesessttrncs
cokesrenmaer anaateety eam neee 149
RETEFENICOSes restr street tek trce snes sen nem te enna ene 150
Additional Reterenices asc we contre ceteris 150

TWELVE
Nurses as Educators: Simulation, Communication,
and Patient Caren. sues... einen ceciaeaas... 151
Judith Healey Walsh and Jennifer Mardin Small
INtTrOdUCHION A 152
Simulatione:): WH LAAHR AER Braet vere eee: 153
Communication Lessons Learned.........ccceccccseeeecceeeeees 155
SUMMMALY I DAR Oe 161
REFETENCOS IES. ATI FU ccdececavesetesdadeoosteece
BONA nes162

SECTION IV DIFFICULT COMMUNICATION

THIRTEEN
Communicating About Sexual Health Needs.................. 165
Teri Aronowitz
ELar 3 [(cld 16|§beans chensbee pnb beste hdss tunedtin-ricrash trey Sean ee 166
Be TRALeTe|.04b aabpec aorta oa kee espramemapchy oven Inner ante eee 167
Barriers to Addressing Sexual Health Needs................ 168
SexnalstlealthAssessinentisrac tt cccterahcesearesaectenscertccs 169
ST FID
Felkh2 eebeertdent kieteaapr entero re epee nepbhr (imph hear arnfee170
Acichtional Resounceses secur
crt ererctennteases E71
FOURTEEN
Helping iPatiemts/ witht Pain sesiwisctise
R028 sas.d ak hon ees173
Jeannine Brant
PEFOCUCHIONY 5 cccscccaitaccnceccnacenceage
steeot eee a eae 174
ASsessmentiOh Pain. yak R20. SC... WAS)
Management.of Paints. bak. auailn7. 2a 22... 77
Healthcare: Jeam Gommiunication: eck... BOIS... 180
SUM Aanyer as MINS AO ER LAD OU Ma. « 180
Web Siles See a ciccnndessaccacsasiniavcedc.o
Memos: 181
RARGROTECSS accaccecca sc cadee toe ree Ai ch iexe cn tna ntl eve MMs 182
x Table of Contents

FIFTEEN
Communication in Life-Threatening Illness and
Spiritual Carentan?
AAU Ee later epee: 185
Amy Rex-Smith
latrochadtionwetindc sce ciscicceeeuhie cee eee ees 186
kife- Threatening NIMESSo.ci..:ci20:-cs2erernes--- peermereatate 13?
Spiritual Assessment: Meeting Standards for
PatienteCeanterediC ateriee |)
osscccccetelesephtsaseta
onteoeasens 188
Guidelines for Spiritual Care Interventions..............05 189
Attentiveclistenings) 1 xishumié..asote
she 26.2er 190
Presence: Communicating Caring Without
Using: Wordsi das ae Pe DRA ON anges Oe 191
Advance: Directives sszssiasssseissnscszciarie deena oe ies 191
Palliative Care: More Than End-of-Life Care................ 192
Grief, Loss,.and. Mowrnittig: 2.220. Riana ceed... 192
SUPRMIALY.<sacszcresastvaeslavagsasien
castiariaesvizasat aorta ottenss195
WeDSitCS. .:a:szcaceceassaazeeisdeaave
artes cesesrsneenee eee OT. 196
RERGT INC OS cork etait hh tant sl arene eee gre ee ToL

SIXTEEN
Anger, Anxiety, and Difficult
COmmunicatiomstyles WO iss uc sepiecentoee
sae sett 199
Lisa Kennedy Sheldon
IRQ GUGUI ON as es orccescesanaeareseet eae eee 200
Puifhiculislnteractions cnc nec ee 201
Interviewing, DithiGUltles. o-oo: ofa acute beck pate eae ZZ
Difficult BenAVions i248 tee ent eee ee eee 214
SUSTAINSBysshe rs says tenenzn tee toate hese eee ee 218
[email protected] versa aia ae ee eae ee Zz 19
REIGLON GES i915 Jc sl ie le thee cee ce ere ee 220

SEVENTEEN
Compassion Fatigue: Caring for Yourself .............ccccceeee 2)
Lisa Kennedy Sheldon
Spectrum of; Comipassion.::.:5.5.<. cae acne ene eee 222
Compassion, Fatigue, and Burnout..............000.ccceeeeee 2a3
SelfsGare: dnuniierkmen eit ero bay 224
Recovering from, BUIMOUL...<.20cs.e.00c400.0ccs ee as 225
SCUTATEMIESG NE,«25 aavanethyotadanneanessdaaeenceeneee
ate amen 225
Welasities, 2c Atiiug. vsiht Sih cc cesacan cove 226
 Table of Contents xi

SECTION V COMMUNICATING WITH OTHER

HEALTHCARE PROVIDERS
EIGHTEEN
Practicing Conflict Resolution, Negotiation,
and Interprofessional and Intraprofessional
COMA DOUAUOT eet cctcees ecetats tertee: Sete creer ace eee
JoAnn Mulready-Shick and Janice B. Foust
PPP OCLUCUIOI <5. facto tay soc teeta ee ents aeons encom areas
Nurse—Physician Communication Challenges.............
GContlictResolution Strategies amuse ee er
Intraprofessional COMMUNICATION ............ eseeeeeeeeeeeeeeee
SUNTAN ANY.4252 22.2: ccs coct mr cese eae Rares laste a aimee ene
RETETEMCES (Coico. Sie heseee mere rete eee ri ae
NINETEEN
Electronic Communication: Media, Social Networking,
Medical Records,-and: Emattias.:cns.cc.s0ss-
sce.ctee ae ene
Sheryl LaCoursiere
HIVEFOGUCTIONT, rreceetecccact eerrures ter rteee creer rete eeenrere tree
SOCiat NETWOrking Eon Sees, Bee seee etretiees.ceeeee os
Personal, Patient, and Family Social Networking ........
Professional: SocialiNetworking.n2. 2e0x coi. meek
MedicaliRecordsiie: sheer... iss gies ee, Sees

SUP AVY cet ek aA ohpusshnlocs du anges’ ga cgien socben eatoa eee “eon Sar
Websiteseeresttn- an ehcarice inet veearreeo trie areca eee
RETCIONCOS neste re seec steer ecto ven een es
BAGIUOMAUREICFENCES.<..ccccrescsectaeecte ese cee thee ners cece
TWENTY
Delegation and Assertive Communication...........::cceeee
JoAnn Mulready- Shick
URL OCUICRIOS Wea octet cs oak a tctcustes ak cdu tena eroewectar tue aan ee eames
Effective Communication Standards
AVIA SUAUCOleSie.meratsest cette Cee crtrceencres iiontscfuMen center
Communication Strategies: Check-Back, Call-Out,
Wo-ChallengqeRule and: GUSi Aericcsssscesesce
seenetertes
BSFECLIVE WEIS AUOM rc co cnaeer ce canp tet cteveanussy ueatoucresenss
SUUTMTIALY sacs csvorses cater sunaesvesssivissunesssseteactescetenesevacesdes
RELCLENIGES earnest erie etre min oc (oek ouncesea cas teu dandaronoeRecnes
xii Table of Contents

SECTION VI CONCLUSION
TWENTY-ONE
A,Conclusion;and a Beginning ......0::.:0snseens-:ael
eines 275
The Nurse a$:'a COMMUNICAatOl..........2..000cc.eccdeveconseoee's 276
ACKNOWLEDGMENTS

No publication is a solo effort, and particularly not one about communica-

tion. Many of my friends, family members, and colleagues have listened to
my ideas about improving communication in health care.
First, I want to thank all the people who have allowed me to participate
in their health care over the years. Your stories have inspired me and
profoundly changed my life, both professionally and personally. My ability
to talk with my patients has changed and continues to evolve because of
each of you. I am humbled by your trust and truly honored to be a part of
your care.
To my colleagues at the University of Massachusetts, Boston and
St. Joseph Hospital, I appreciate your patience, wisdom, and wonderful—
often humorous—contributions to this text. To the staff at Jones & Bartlett
Learning, I appreciate all your efforts on behalf of this text.
Finally, I want to acknowledge my family—my parents, Everett
(Ray) and Louise Kennedy; Meredith, Laurie, and Everett Kennedy;
Zane Shatzer; Jay Gardner; Paul, Grace, Jamie, Judy, Patty, and Margaret
Sheldon—for talking, listening, laughing, and sharing your lives with me.
To my children—Brad, Greg, Andrea, and Luke—thank you for all the joy
xiv Acknowledgments

and endless light you bring to my life. And, finally, to my husband, Tom, I want to
express my love and gratitude for your ongoing support—you are my foundation.
—Lisa Kennedy Sheldon

I am so grateful to my wonderful family—past and present—as well as my many

friends and colleagues who have supported, encouraged, and inspired me, both
during my early formative years before I became a nurse and then continuing
throughout my career. To my family, special thanks for sharing your lives, laugh-
ter, encouragement, and love.
As a nurse, I am grateful to the numerous patients and their families who have
shared their amazing stories and experiences. I am impressed by how you faced
difficult situations with grace, and in doing so, you helped me become a better
nurse.
To all my wonderful colleagues and mentors, too numerous to mention
individually, I thank you. From you, I learned to value the importance of
collaboration and exemplary communication skills as ways to improve patient
care by working together and bringing out the best in teams. Your leadership, pas-
sion, and drive to improve the rigor and visibility of nursing practice continue to
motivate me. I also want to thank the Jones & Bartlett Learning staff for all their
help in the making of this text.
—Janice B. Foust
ABOUT THE AUTHORS

Lisa Kennedy Sheldon, PhD, APRN, is on the faculty at the University of

Massachusetts, Boston, is a writer and researcher, and works as an oncology
nurse practitioner at St. Joseph Hospital in Nashua, New Hampshire. She
graduated from Saint Anselm College with a bachelor of science degree in
nursing. After working in a variety of oncology settings, Dr. Sheldon attended
Boston College, where she obtained a master of science degree in nursing as
an oncology clinical nurse specialist. Later, she returned to Boston College
to obtain postgraduate certification as a nurse practitioner. Dr. Sheldon holds
a doctor of philosophy degree from the College of Nursing at the University
of Utah with a concentration in cancer control and research. Dr. Sheldon’s
postdoctoral fellowship was at the Dana-Farber Cancer Institute’s Cantor
Center with her mentor and research collaborator, Donna L. Berry, PhD, RN,
AOCN, FAAN.
Dr. Sheldon has published several books, book chapters, and articles,
and has served as an associate editor for the Clinical Journal of Oncology
Nursing. She serves on national and international panels and advisory
boards and is the co-director of the Global Nursing Caucus. She delivers
educational programs to healthcare providers and community groups,
and presents nationally and internationally on cancer nursing, oncology

XV
xvi About the Authors

care, and communication research. Dr. Sheldon’s program of research focuses

on patient—provider communication, oncology nursing, and issues in global
cancer care.

Janice B. Foust, PhD, RN, is an Assistant Professor at the University of

Massachusetts, Boston, College of Nursing and Health Sciences. After graduating
from the University of New Hampshire with a bachelor of science degree in nurs-
ing, she later obtained a master of science degree in nursing from Boston College
as a clinical nurse specialist. She earned her doctor of philosophy degree from the
University of Pennsylvania, School of Nursing, where she also completed her post-
doctoral training as a Claire M. Fagin Fellow in the John A. Hartford Foundation,
Building Academic Nursing Capacity program, guided by her mentor, Mary D.
Naylor, PhD, FAAN, RN.
Dr. Foust’s program of research focuses on care transitions of older adults,
and more specifically on the issues of posthospital medication management.
She has published several articles and book chapters, along with presenting her
work at local, regional, and national conferences. Dr. Foust has also served as
manuscript reviewer for national and international journals. She has held clinical,
research, and leadership positions within various practice settings, such as home
health care and academic teaching hospitals.
PREFACE

m@ CASE STUDY

A 42-year-old man comes to the oncology center to begin chemotherapy for

metastatic renal cell carcinoma. The chart says his first name is Edmund, and
the staff begins calling him Ed. He is a quiet man and often does not share
much with the nurses during his weekly chemotherapy. One day, 3 months
into his treatment, the nurse looks at his chart to assess his status prior to
beginning chemotherapy. She says, “Ed, I was just looking at your chart and
thinking Edmund must be a family name. What do you like to be called?”
The patient answered, “Mike. I never liked my first name.”

m@ OVERVIEW
How embarrassing! The staff assumed that he must be called Ed. It would
have taken only a moment during the first visit to discover his preferences.
Small mistakes take place every day between nurses and patients.
Some are based on assumptions, such as calling the patient by the wrong
name, and others may be more complicated, such as not understanding a
patient’s pain because of cultural differences in the expression of pain. As
nurses, we do not intentionally misunderstand our patients, nor do we want

xvii
xviii Preface

to hurt them. It takes a few minutes a day to not only improve how well we talk
with our patients, but also how well we listen to what they are telling us. Better
understanding of patients’ experiences, preferences, and resources improves the
ability of both nurses and patients to set more realistic goals and plan more appro-
priate interventions.
Becoming better communicators means changing our ability to relate to peo-
ple who happen to be our patients. I want to compare your communication skills
to a geographical situation. In Japan, there is a beautiful mountain called Mount
Fuji. Not only is this peak picturesque, but it is also where three of the earth’s
tectonic plates meet and collide. The pressures in the earth related to these plates
have caused frequent tremors and even deadly earthquakes. To combat the danger-
ous consequences of tremors, many Japanese buildings have been seismically ret-
rofitted not only to be functional, but also to withstand the earth’s shaking. Some
buildings have deep pilings that secure them to bedrock and prevent collapse.
Others have sliding plates between the foundation and the upper stories of the
building to allow the building to slide during seismic activity.
Like these buildings, your communication skills may be functional, even
admirable, but they need to be able to withstand the forces that will challenge
them every day. Perhaps a deeper understanding of your values or more flexibil-
ity in discussing sensitive issues will enhance your ability to listen and respond
to your patients. The goal of this text is to develop your communication skills
by providing a sturdy foundation and introducing techniques that will withstand
the stressful healthcare environment to help you become a better communicator.
Along the way, you will learn about your professional and moral obligations, your
own values and personality, and the resources available to provide a foundation
for your clinical interactions with patients.

@ HOW THIS TEXT IS STRUCTURED

Many of the techniques discussed in this text are meant to enhance professional
and personal development. The text first takes a closer look at patients and nurses
as people and at ethical, legal, and professional guidelines for communication as a
facet of nursing care. A detailed chapter reviews the therapeutic relationship from
the beginning through the actual provision of nursing care and, finally, to the clo-
sure of the relationship. Interviewing skills are reviewed as both a science and an
art, with case studies serving as examples of potential clinical encounters.
 Preface xix

Next, the text examines communication with specific patient populations

and situations. How do you deal with a patient in a crisis situation? How do you
communicate with an intubated patient? What is the best way to give construc-
tive criticism to a colleague? These are a few of the topics covered here as part of
practical approaches to difficult communication situations. They are intended to
serve as guidelines for when you are at a loss for words.
Finally, in response to requests and changes within the profession, the third
edition of this text contains new sections on compassion and the emotional work
of nursing, the nature of suffering, and working with colleagues. Additionally,
websites have been added to provide more extensive online resources, and the ref-
erences have been updated.
With time and experience, you will grow into the nurse and communicator
you want to be, given your personal strengths and professional goals. A nurse may
be respectful, caring, funny, sensitive, insightful, precise, concise, empathetic,
spiritual, inquisitive, logical, gentle, and peaceful. Each nurse is a unique mixture
of many qualities. The development of your communication style is up to you.
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CONTRIBUTORS

Teri Aronowitz, PhD, FNP-BC Amy Rex-Smith, DNSc, RN,

University of Massachusetts, Boston ACNS, BC
College of Nursing and Health Sciences University of Massachusetts, Boston
Boston, Massachusetts College of Nursing and Health Sciences
Boston, Massachusetts
Jeannie M. Brant, PhD, APRN, AOCN
Billings Clinic Esther Seibold, DNSc, RN
Montana State University University of Massachusetts, Boston
Billings, Montana College of Nursing and Health Sciences
Boston, Massachusetts
Sheryl LaCoursiere, PhD, FNP-BC,
APRN Jennifer Mardin Small,
University of Massachusetts, Boston RN, MSN
College of Nursing and Health Sciences University of Massachusetts, Boston
Yale University College of Nursing and Health Sciences
New Haven, Connecticut Boston, Massachusetts

JoAnn Mulready-Shick, EdD, RN, Judith Healey Walsh, EdD(c),

CNE, ANEF MS, RN
University of Massachusetts, Boston University of Massachusetts, Boston
College of Nursing and Health Sciences College of Nursing and Health Sciences
Boston, Massachusetts Boston, Massachusetts

XI
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Setting the Stage
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 CHAPTER ONE

The First Encounter

Lisa Kennedy Sheldon

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4 CHAPTER ONE The First Encounter

m CASE STUDY
“Good Morning, Mrs. T. My name is Jay, and I will be your nurse today. We have
a full day today with some tests. How about getting washed up now? Is it all right
to call you Mrs. T.?”
Mrs. T. is a 76-year-old woman with metastatic lung cancer being cared for
by the nurse, Jay. It is her second day in the hospital after developing a fever and
cough. She is quiet, giving one-word answers to Jay’s questions. Mrs. T. thinks
that Jay is being too aggressive, making her wash up and scheduling tests without
asking her permission. Jay is beginning to wonder about why Mrs. T. is reluctant
to talk with him.
Later, when he comes in to bring her morning medications, Jay says, “Mrs. T.,
I have your medications.” She responds, “What am I supposed to do, take those now
just because you say so?”

Introduction
In each room, bed, or chair, nurses encounter different people seeking health care.
Each time a nurse meets a new person in a healthcare setting, a new relationship
begins for both parties. These relationships often develop at vulnerable points, when
people seek assessment, treatment, information, and often reassurance about their
health. Some interactions will proceed smoothly, with both parties having the same
goals for the visit. At other times, the nurse may encounter more challenging situa-
tions, such as the one presented in the case study. The nurse’s communication style and
responses will establish the framework for future conversations and the implementa-
tion of the plan of care. Often, it is the unspoken communication that influences the
words to follow. The nurse’s role is to explore and understand both the patient’s needs
and the healthcare goals in order to deliver patient-centered care. High-quality com-
munication in health care requires more than words; it requires careful tailoring of
communication for the interaction and, most importantly, the person who is the patient.

Terminology
For the purposes of this text, it is useful to define the terms used for the people
involved in communication in the healthcare setting. Patients are people seeking
and/or receiving healthcare services from healthcare providers. While the term
“clients” is sometimes used in nursing and communication literature, the term
 Terminology 5

“patients” will be used in this text because it conveys a level of ethical responsibil-
ity to a person in a vulnerable position seeking services.
Healthcare providers are sometimes described in books as “clinicians” or by
healthcare profession, such as “doctors” or “nurses.” This text discusses just one
type of healthcare provider—nurses.
Patient—provider communication refers to the communication between
the patient, family member(s), and provider(s) during visits to receive health
care, often involving multiple types of healthcare providers. Much of patient-
provider communication is similar across healthcare professions, and improving
communication requires an interdisciplinary approach.
The nurse—patient relationship is a different type of relationship, as it involves
the nurse as a professional healthcare provider communicating with a person seek-
ing health care. Gone are many of the social boundaries that define everyday rela-
tionships. Both parties have expectations about how the interaction will proceed
and what the outcomes will be. These are different relationships—ones that have
the potential to affect both patients and nurses. Communication is a process of
mutual influence.
During healthcare visits, patients are often placed in dependent, vulnerable
roles. Within a short period of time, they may be required to reveal intimate infor-
mation about their lives and bodies to people (healthcare providers) they have just
met, or they may even undergo painful procedures. For patients to feel respected,
cared for, and safe, nurses must create an environment that puts patients at ease,
allowing revelation, understanding, and mutual planning to facilitate assessment,
treatment, and healing or perhaps peaceful death.
Health care is a fast-paced environment. Time is often short, and quickly
establishing these relationships may sound like an impossible task. Nevertheless,
good communication is a clinical skill that can be learned. Beginning with basic
education, nurses learn the fundamentals of establishing the relationship, basic
communication skills, and specific nursing interventions. These professional skills
build on previous experiences and begin a lifetime of learning for the professional
nurse as both a person and a communicator. After graduation, nurses use their
clinical experiences with patients and families to build and refine their own com-
munication style. Each room, chair, and bed brings a unique situation requiring
nurses to become flexible communicators.
Communication is a universal word with many meanings. It has been
described as a transfer of information between a message sender and a
6 CHAPTER ONE The First Encounter

message receiver. In nursing, communication entails a sharing of health-related

information between a patient and a nurse, with both participants acting as send-
ers and receivers of information. Communication occurs in many ways and may
be verbal or nonverbal, written or spoken, culturally appropriate, personal or
impersonal, issue specific, or even relationship oriented. It can pertain in a larger
sense to public health campaigns and policy issues, or to information on the
Internet, or to a single patient’s personal experience with a health issue. Human
communication is a continuous and dynamic process, with the nurse and patient
developing a relationship not only to share information but also to facilitate
health, growth, and healing.

Theoretical Background
Human communication is multidimensional and has been studied by research-
ers from many disciplines, including nursing, medicine, psychology, social
work, and pastoral care. Watzlawick, Beavin, and Jackson (1967) describe com-
munication as occurring on two levels: the relationship level and the content
level. The relationship level refers to how the two participants are bound to each
other. The content level refers to the words, language, and information that are
exchanged by the participants. The two levels are inextricably bound, and the
content is relayed more effectively in healthy relationships. The opposite occurs in
strained relationships—that is, the content of the message is not clearly relayed or
heard because of struggles within the relationship.
Relationships between patients and healthcare providers such as nurses influ-
ence communication and care. This section reviews four models of communica-
tion with applicability to nurse—patient communication in the healthcare setting.
While not distinctly nursing theories, each contributes to the understanding and
provides theoretical frameworks for communication models and some components
of nursing theory (see the chapter titled The Nurse as a Person: Theories of Self
and Nursing for more on nursing theories). The models to be discussed are as
follows:

Health Belief Model

Orlando’s theory of the deliberative nursing process
Rogerian model
Social information processing models
Exploring the Variety of Random
Documents with Different Content
 Sir Launcelot and Qii Me saw not far : liis eyes were. dim :
But ours he swore were all diseased. ' A ship of fools,' he shriek'd in
spite, ' A ship of fools,' he sneer'd and wept. And overboard one
stormy night He cast his body, and on we swept. XI. And never sail
of ours was furl'd. Nor anchor dropt at eve or morn ; We lov'd the
glories of the world, But laws of nature were our scorn. For blasts
would rise and rave and But whence were those that drove the sail
Across the whirlwind's heart of peace, And to and thro' the counter
gale .' Again to colder climes we came, For still we follow'd where
she led : Now mate is blind and captain lame, And half the crew are
sick or dead. But, blind or lame or sick or sound. We follow that
which (lies before : We know the merry world is round. And we may
sail forevermore. SIR LAUNCELOT AND QUEEN GUINEVERE. A
FRAGjMENT. Like souls that balance joy and pain With tears and
smiles from heaven again The maiden Spring upon the plain Came in
a sun-lit fall of rain. In crystal vapor everywhere Blue isles of heaven
laugh'd between, .-\nd far, in forest-deeps unseen, The topmost elm-
tree gather'd green From draughts of balmy air. Sometimes the
sparhawk, ^^ along, Hush'd all the groves from fear of Y,\ L'l --• iii. -
uith fuller sound In cur\. - 1 1 ' i>\ n liver ran. And di. M - , . I.iids
began To spri I I iiih. tl j« if.-ct fan. Above the teeming ground.
Then, in the boyhood of the year. Sir Launcelot and Queen
Guinevere Rode thio' the covert,-, of the deer, With bli-isfui treble
ringing clear. She seem'd a part of joyous A gown of grass-green silk
she wore, Buckletl with golden clasps before; A light-green tuft of
plumes she bore Closed in a golden ring. No V on so ne t wisted -
net. No V by so. le t t^\ ol ulet He crean set: -wh te mi le his
pastern And fleete now she skin m'd the plains Than she whose elfin
prancer springs By night to eery warblings, When all the glimmering
moorland rings With jingling bridle-reins. As fast she fled thro' sun
and shade. The happy winds upon her'play'd. Blowing the ringlet
from the braid : She look'd so lovely, as she swav'd The rein with
dainty finger-tips, A man had given all other bliss, And all his worldly
worth for this, To waste his whole heart in one kiss Upon her perfect
lips. A FAREWELL. Flow down, cold rivulet Thy tribute wave dellv No
more by thee ray si For ever and for evei
 The Beggar Maid— The Eagle— The Letters Flow, softly
flow, by lawn and lea, A rivulet then a river : Xo where by thee my
steps shall be, For ever and for ever. lint here will sigh thine alder
tree, .■\nd here thine aspen shiver ; .-Vnd here by thee will hum the
bee, Yor ever and for ever. A thousand suns will stream on thee, A
thousand moons will quiver ; But not by thee my steps shall be. For
ever and for ever. THE BEGGAR MAID. She^ say : Bare-footed came
the beggar maid Before the king Cophetua. In robe and crown the
king stept down, To meet and greet her on her way; ' It is no
wonder,' said the lords, ' .She is more beautiful than day.' As shines
the moon in clouded skies, .She in her poor attire was seen : One
praised her ancles, one her eyes, One her dark hair and lovesome
mien. Si) sweet a face, such angel grace, In all that land had never
been : Cophetua sware a royal oath : ' This beggar maid shall be my
THE EAGLE. FRAGMENT. :lasps the crag with crooked hands ; Close
to the sun in lonely lands, Ring'd with the azure world, he The
wrinkled sea beneath him crawl: He watches from his mountain And
like a thunderbolt he falls. Move eastward, happy earth, and leave
Von orange sunset waning slow : From fringe's of the faded eve, O,
hapijy planet, eastward go ; Till over thy dark shoulder glow Thy
silver sister-world, and rise To glass herself in dewy eyes That watch
me from the glen below. .\\\, bear me with thee, smoothly borne.
Dip forward under starry light, And move me to my marriage-morn.
And round again to happy night. Come not, when I am dead, To
drop thy foolish tears upon my grave, To trample round my fallen
head. And ve.\ the mihappy dust thou wouldst not save. There let
the wind sweep and the plover cry ; But thou, go by. Child, if it were
thine error or thy crime I care no longer, being all unblest : Wed
whom thou wilt, but I am sick of Time, And I desire to rest. Pass on,
weak heart, and leave me where I lie : Go by, go by. [-HE LETTERS.
Still on the tower stood the vane,. A black yew gloom'd the stagnai
air, I peer'd athwart the chancel pane And saw the altar cold and
bart A clog of lead was round my feet, A band of pain across my
brow
 The Vision of Si, ' Cold altar, Heaven and earth shall Before
you hear my marriage vow.' I turn'd and humm'd a bitter song That
mock'd the wholesome human heart, And then we met in wrath and
wrong. We met, but only meant to part. Full cold my greeting was
and dry ; She faintly smiled, she hardly moved ; I saw with half-
unconscious eye She wore the colors I approved. She took the little
ivory chest, With half a sigh she turn'd the key, Then raised her head
with lips comprest. And gave my letters back to me. And gave the
trinkets and the rings, My gifts, when gifts of mine could please ; As
looks a father on the things (_)f his dead son, I look'd on these. IV.
She told me all her friends had said ; I raged against the public liar ;
She talk'd as if her love were dead, But in my words were seeds of
fire. ' No more of love ; your sex is known : I never will be twice
deceived. Henceforth I trust the man alone, The woman cannot be
believed. ' Thro' slander, meanest spawn of Hell— And women's
slander is the worst, And you, whom once I lov'd so well. Thro' you,
my life will be accurst.' I spoke with heart, and heat and force, I
shook her breast with vague alarms — Like torrents from a mountain
source We rush'd into each other's arms. We parted: sweetly
gleam'd the And sweet the vapor-braided blue. Low breezes fann'd
the belfry bars. As homeward by the church I drew. The very graves
appear'd to smile. So fresh they rose in shadow'd swells ; ■ Dark
porch,' I said, ' and silent aisle. There comes a sound of marriage
THE VISION OF SIN. I. I H.-iD a vision when the night was late: A
youth came riding toward a palacegate. He rode a horse with wings,
that would have flown. But that his heavy rider kept him down. And
from the palace came a child of sin. And took him by the curls, and
led him in. Where sat a company with heated eyes. Expecting when
a fountain should arise : A sleepy light upon their brows and lips —
As when the sun, a crescent of eclipse. Dreams over lake and lawn,
and isles and capes — Suffused them, sitting, lying, languid shapes.
By heaps of gourds, and skins of wine, and piles of grapes. Then
methought I heard a mellow sound. Gathering up from all the lower
ground ; Narrowing in to where they sat assembled Low voluptuous
music winding trembled.
 The Vision of Si. les : they that heard it siglid, Panted hand-
in-hand with faces pale, Swung themselves, and in low tones replied
; Till the fountain spouted, showering wide Sleet of diamond-drift
and pearly hail ; Then the music touch'd the gates and died; Rose
again from where it seem'd to fail, Stonn'd in orbs of song, a
growing gale ; Till thronging in and in, to where they waited. As
'twere a hundred-throated nightingale, The strong tempestuous
treble throbb'd and palpitated; Ran into its giddiest whirl of sound.
Caught the sparkles, and in circles. Purple gauzes, golden hazes,
liquid mazes. Flung the torrent rainbow round : Then they started
from their places. Moved with violence, changed in hue, Caught each
other with wild grimaces. Half-invisible to the view, Wheeling with
precipitate paces To the melody, till they flew, Hair, and eyes, and
limbs, and faces. Twisted hard in fierce embraces. Like to Furies, like
to Graces, Dash'd together in blinding dew: Till, kill'd with some
luxurious agony. The nerve-dissolving melody Fliitter'd headlong
from the sky. And then I look'd up toward a mounI saw that every
morning, far with. drawn Pjeyond the darkness and the cataract,
God mads Himself an awful rose of dawn. Unheeded : and
detaching, fold by fold, From those still heights, and, slowly drawing
near. A vapor heavy, hueless, formless, cold. Came floating on for
many a month and year. Unheeded: and I thought I would have
spoken. And warn'd that madman ere it grew But, as in dreams, I
could not. Mine was broken. When that cold vapor touch'd the
palace gate. And link'd again. I saw within my head A gray and gap-
tooth'd man as lean as death. Who slowly rode across a wither'd
Ireath, And lighted at a ruin'd inn, and said : ' Wrinkled ostler, grim
and thin! Here is custom come your way; Take my brute, and lead
him in. Stuff his ribs with mouldy hay. ' Bitter barmaid, waning fast !
See that sheets are on my bed ; What ! the flower of life is'past : It
is long before you wed. ' Slip-shod waiter, lank and sour, At the
Dragon on the heath ! Let us have a quiet hour. Let us hob-and-nob
with Death. ' I am old, but let me drink ; Bring me spices, bring me
wine ; I remember, when I think. That my youth was half divine.
Wine is good for shrivell'd lips. When a blanket wraps the day. When
the rotten woopland drips. And the leaf is stamp'd in clay. ' Sit thee
down, and have no shame. Cheek by jowl, and knee by knee : What
care I for any name .' What for order or degree ? ' Let me screw
thee up a peg : Let me loose thy tongue with wi
 The Vision of Sin. thine or mine ' Thou shalt not be saved
by works : Thou hast been a sinner too : Ruin'd trunks on wither'd
forks, Empty scarecrows, I and you ! ' Fill the cup, and fill the can :
Have a rouse before the morn : Every moment dies a man, Every
moment one is born. ' We are men of ruin'd blood ; Therefore comes
it we are wise. Fish are we that love the mud, Rising to no fancy-
fiies. ' Name and fame I to fly sublime Thro' the courts, the camps,
the schools. Is to be the ball of Time, Bandied by the hands of fools.
' Friendship I — to be I Let the canting liar pack ! Well I know, when
I am gone, How she mouths behind my back. ' Virtue I — to be
good and just — Every heart, when sifted well. Is a clot of warmer
dust, Mix'd with cunning sparks of hell. ' O ! we two as well can look
Whited thought and cleanly life As the priest, above his book Leering
at his neighbor's wife. ' Fill the cup, and fill the can : Have a rouse
before the morn : Every moment dies a man. Every moment one is
born. ' Drink, and let the parties rave : They are fill'd with idle spleen
; Rising, falling, like a wave. For thev know nut what thev mean. ' He
that roars for liberty Faster binds a tyrant's power; And the tyrant's
cruel glee Forces on the freer hour. ' Fill the can, and fill the cup
.■\11 the windy ways of Are but dust that rises up. And is lightly laid
again. ' Greet her with applausive breath, Freedom, gaily doth she
tread; In her right a civic wreath. In her left a human head. ' No, I
love not what is new ; She is of an ancient house : And I think we
know the hue Of that cap upon her brows. ' Let her go I her thirst
she slakes Where the bloody conduit runs. Then her sweetest meal
she makes On the first-born of her sons. ' Drink to lofty hopes that
cool — Visions of a perfect State : Drink we, last, the public fool.
Frantic love and frantic hate. ' Chant me now some wicked stave. Till
thy drooping courage rise, ."^nd the glow-worm of the grave
Glimmer in thy rheumy eyes. ' Fear not thou to loose thy tongue ;
Set thy hoary fancies free ; What is loathsome to the young .Savors
well to thee and me. ' Change, reverting to the years, When thy
nerves could understand What there is in loving tears. And the
warmth of hand in hand. ' Tell me tales of thy first love— .April
hopes, the fools of chance; Till the graves begin to move. And the
dead begin to dance. ' Fill the can, and fill the cup : All the windy
ways of .■\re but dust that rises up, And is lightly laid again. '
Trooping from their mouldy dens The chap-fallen circle spreads :
 Welcome, fellow-citizens, Hollow hearts and empty heads ! '
You are bones, and what of that ? Every face, however full, Padded
round with flesh and fat. Is but modell'd on a skull. ' Death is king,
and Vivat Rex ! Tread a measure on the stones, Madam — if I know
your sex, From the fashion of your bones. ' No, I cannot praise the
fire In your eye— nor yet your lip : All the more do I admire Joints of
cunning workmanship. ' Lo ! God's likeness — the groundplan —
Neither modell'd, glazed, nor framed : Buss Tne, thou rough sketch
of man. Far too naked to be shamed ! ■* Drink to Fortune, drink to
Chance, While we keep a little breath ! Drink to heavy Ignorance !
Hob-and-uob with brother Death ! ' Thou art mazed, the night is
long. And the longer night is near : What ! I am not all as wrong As
a bitter jest is dear. ' Youthful hopes, by scores, to all. When the
locks are crisp and curl'd ; Unto me my maudlin gall And my
mockeries of the world. ' Fill the cup, and fill the can : Mingle
madness, mingle scorn ! Dregs of life, and lees of man ; Yet we will
not die forlorn." And slowly quickening inl By shards and scurf of
salt, : of dross, Old plash of rains, and refuse patch'd Then some
one spake: ' Behold! it was a crime Of sense avenged by sense that
wore with time.' Another said : ' The crime of sense became The
crime of malice, and is equal blame.' And one : ' He had not wholly
quench'd his power ; A little grain of conscience made him sour.' At
last I heard a voice upon the slope Cry to the summit, ' Is there any
hope .' ' To which an answer peal'd from that high land, But in a
tongue no man could understand ; And on the glimmering limit far
withdrawn God made Himself an awful rose of You might have won
the Poet's name. If such be worth the winning now. And gain'd a
laurel for your brow Of sounder leaf than I can claim ; But you have
made the wiser choice, A life that moves to gracious ends Thro'
troops of unrecording friends, A deedful life, a silent ^
 o6 To E. £., OH His Travels hi Greece—The Poefs Song. Of
those that wear the Poet's crown : Hereafter, neither knave nor
clown Shall hold their orgies' at your tomb. For now tlie Poet cannot
die, Nor leave his music as of old. But round him ere he scarce be
cold Begins the scandal and the cry : ' Proclaim the faults he would
not show : Break lock and seal : betray the trust : Keep nothing
sacred : 'tis but just dec" ' -headed beast should kno Ah shameless !
for he did but sing A song that pleased us from its worth ; No public
life was his on earth. No Uazon'd statesman he, nor king. He gave
the people of his best : Mis worst he kept, his best he gave. My
Shakespeare's curse on clown and knave Who will not let his ashes
rest ! Who make it seem more_sweet to be The little life of bank and
brier, The bird that pipes his lone desire And dies unheard within his
tree. Than he that warbles long and loud And drops at Glory's
temple-gates. For whom the carrion vulture waits To tear his heart
before the crowd ! TO E. L., ON HIS TRAVELS IN GREECE. ILLYRIAN
woodlands, echoing falls Of water, sheets of summer glass. The long
divine Peneian pass. The vast Akrokeraunian walls, Tomohrit, Athos,
all things fair. With such a pencil, such a pen. You shadow forth to
distant men, I read and felt that I was there : And trust me while I
turn'd the page, And track'd you still on classic ground, I grew in
gladness till I found My spirits in the golden age. For me the torrent
ever pour'd And glisten'd — here and there alone The broad-limb'd
Gods at random thrown By fouutaiu-urns; — and Naiads oar'd A
glimmering shoulder under gloom Of cavern pillars ; on the swell
The silver lily heaved and fell ; And many a slope was rich in bloom
From him that on the mountain lea By dancing rivulets fed his flocks
To him who sat upon the rocks. And fluted to the morning sea.
Break, break, break. On )hy cold gray stones, O Sea ! And I would
that niy tongue could utter The thoughts that arise in me. O well for
the fisherman's boy. That he shouts with his sister at play! O well for
the sailor lad. That he sings in his boat on the bay ! And the stately
ships go on To their haven under the hill ; • But O for the touch of a
vanish'd hand. And the sound of a voice that is still ! Break, break,
break, At the foot of thy crags, O Sea I But the tender grace of a day
that is dead Will never come back to me. THE POET'S SONG The
rain had fallei He pass'd by the the street, the Poet arose,
 1 ,/> 1 A light wind blew from the gates of The swallow
stopt as he hunted the - ■ the sun, fly, . . And waves of shadow
went over The snake slipt under a spray, c^ the wheat, The wild
hawk stood with the down O^ And he sat him clown in a lonely on
his beak. place, And stared, with his foot on the And chanted a
melody loud and prey. sweet. And the nightingale thought, ' I have
That made the wild-swan pause in her sung many songs. cloud, But
never a one so gay. And the lark drop down at his For he sings of
what the world will be feet. When the years have died away.' ENOCH
ARDEN AND OTHER POEMS. Anchors of rusty fluke, and boats
upENOCH ARDEN. drawn ; And built their castles of dissolving Long
lines of cliff breaking have left sand a chasm ; To watch them
overflow'd, or followAnd in the chasm are foam and yeling up low
sands ; And flying the white breaker, daily Bevond, red roofs about a
narrow left wharf The little footprint daily wash'd away. In cluster;
then a moulder'd church ; and higher A narrow c^tve ran in beneath
the A long street climbs to one tallcliff: tower'd mill ; In this the
children play'd at keeping And high in heaven behind it a gray
house. Enoch was host one day, Philip the With Danish barrows; and
a hazelwood. While Annie still was mistress; but By autumn nutters
haunted, flourishes Green in a cuplike hollow of the Enoch would
hold possession for a down. week : ' This is mv house and this mv
little Here on this beach a hundred vears wife.' ago. ' Mine too ' said
Philip ' turn and turn Three children of three houses, Annie about:'
Lee, When, if they quarrell'd, Enoch The prettiest little damsel in the
port. stronger-made And Philip Ray the miller's onlv son. Was master
: then would Philip, his And Enoch Arden, a rough sailor's lad blue
eyes _^ Made orphan by a winter shipwreck. An flooded with the
helpless wrath of J, . play'd tears. Among the waste and lumber of
the .Shriek out ' I hate you, Enoch,' and shore. at this Hard coils of
cordage, swarthy fishThe little wife would weep for coming-nets, V .
. . -M '
 Enoch Arden. quarrel for her Id be little wife to But when
the dawn of rosy childhood past, And the new warmth of life's
ascendWas felt by either, either fixt his heart On that one girl; and
Enoch spoke his love, But Philip loved in silence ; and the girl
Seem'd kinder unto Philip than to him ; But she loved Enoch ; tho'
she knew And would if ask'd deny it. Enoch set A purpose evermore
before his eyes, To hoard all savings to the utterTo purchase his own
boat, and make a home For Annie: and so prospered that at A
luckier or a bolder fisherman, A carefuller in peril, did not breathe
For leagues along that breaker-beaten Than Enoch. Likewise had he
served a year On board a merchantman, and made himself Full
sailor; and he thrice had pluck'd a life From the dread sweep of the
down-streaming seas: And all men look'd upon him favorably : And
ere he tonch'd his one-andtwentieth May He purchased his own
boat, and made a home For Annie, neat and nestlike, halfway iber'd
m a golden autumn eventide, ger people making holiday, With bag
and sack a and small. Went nutting to the hazel; (His father lying
sick and needing him) An hour behind; but as he climb'd the hill,
Just where the prone edse of the wood began To feather toward the
hollow, saw the Enoch and An hand, His large gray eyes and
weatherbeaten face All-kindled by a still and sacred fire. That burn'd
as on an altar. Philip look'd. And in their eyes and faces read his
doom; Then, as their faces drew together. groan 'd, And slipt aside,
and like a wounded life Crept down wood ; There, while the rest
were merry-making. Had his dark hour unseen, and past Bearing a
lifelong hunger in his ing hand-inhe hollows of the rest were loud in
d rose So these were wed, and merrily rang the bells, And merrily
ran the years, seven happy years. Seven hapjjy years of health and
competence. And mutual love and honorable toil ; With children ;
first a daughter. In him woke, With his first babe's first cry, the noble
wish To save all earnings to the uttermost. And give his child a
better bringingup Than his had been, or hers ; a wish renew'd.
When two years after came a boy to be The rosy idol of her
solitudes,
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accurate

"Are there no beggars at your gate?"— /to^e ij.

 Enoch Arden. While Enoch was abroad on wrathful seas, Or
often journeying landward ; for in truth Enoch's white horse, and
Enoch's ocean-spoil In ocean-smelling osier, and his face, Rough-
redden'd with a thousand winter gales, Not onlv to the market-cross
were known. But in the leafj' lanes behind the down, Far as the
portal-warding lion-whelp. And peacock-vewtree of the lonely Hall,
Whose Friday fare was Enoch's ministering. Then came a change, as
all things human change. Ten miles to northward of the narrow port
Open'd a larger haven: thither used Enoch at times to go by land or
sea ; And once when there, and clambering on a mast In harbor, bv
mischance he slipt and fell: ' A limb was broken when they lifted
him; .\nd while he lay recovering there, his wife r.nre him another
son, a sickly one : Another hand crept too across his trade Takinc;
her bread and theirs: and on '^him fell, .Altho' a grave and staid
God-fearing man, Vet lying thus inactive, doubt and He seeni'd, as in
a nightmare of the nii;ht, To see Ims children leading evermore Low
miserable lives of hand-to-mouth. And her, he loved, a beggar : then
he pray'd ' Save them from this, whatever comes to me.' And while
he pray'd, the master of Enoch had red \ Came, for he knew the
valued him, Reporting of his vessel China-bound, And wanting yet a
boatswain. Would he go ? There yet were many weeks before she
sail'd, Sail'd from this port. Would Enoch have the place ? And Enoch
all at once assented to it, Rejoicing at that answer to his prayer. So
now that shadow of mischance appear'd No graver than as when
some little cloud Cuts off the fiery highway of the sun, And isles a
light in the offing ; yet the wife — » When he was gone — the
children — what to do .' Then Enoch lay long-pondering on his plans
; To sell the boat — and yet he loved her wellHow many a rough sea
had he weather'd in her I He knew her, as a horseman knows his
horse — And yet to sell her — then with what she brought Buy
goods and stores — set Annie forth in trade With all that seamen
needed or their wives— So might she keep the house while he was
gone. Should he not trade himself out yonder i' go This voyage more
than once ? yea twice or thrice — As oft as needed — last, returning
rich, Become the master of a larger craft. With fuller profits lead an
easier life, Have all his pretty young ones educated. And pass his
days in peace among his own. Thus Enoch in his heart determined
all: Then moving homeward came on
 Nursing the sickly babe, her latestborn. Forward she started
with a happy cry, And laid the feeble infant in his arms ; Whom
Enoch took, and handled all his limbs. Appraised his weight and
fondled father-like. But had no heart to break his purposes To Annie,
till the morrow, when he spoke. Then first since Enoch's golden ring
had girt Her finger, Annie fought against his will : Yet not with
brawling opposition she, But manifold entreaties, many a tear. Many
a sad kiss by day by night renew'd (Sure that all evil would come out
of Her blossom or her seedling, paused ; and he. Who needs would
work for Ar the last. Ascending tired, heavily slept till rning of Annie's
And Enoch faced this m^ farewell Brightly and boldly. All hi; fears.
Save, as his Annie's, were a laughter to him. Yet Enoch as a brave
God-fearing man Bow'd himself down, and in that mysWhere God-in-
man in-God, Pray'd for a blessing on hi: it) , if he cared Besought
him, supplicating, if h For her or his dear children. t lor his own self
caring but her, nd her children, let her plead in .So grieving held his
will, and bore it For Enoch parted with his old seaBought Annie
goods and stores, and set his hand To fit their little streetward
sittingroom With shelf and corner for the goods and stores. So all
day long till Enoch's last at Shakii the pretty cabin, hammer Auger
and saw, while Annii to hear Her own death-scaffold raisini j.shrill'd
nded, and his careful ; narrow, — having or. one with manife and
Whatever came to him : and then he ' Annie, this voyage by the
grace of God Will bring fair weather yet to all of us. Keep a clean
hearth and a clear fire for me. For I'll be back, my girl, before you
know it.' Then lightly rocking baby's cradle ' and he. This pretty,
puny, weakly little one, — Nay — for I love him all the better for God
bless him, he shall sit upon my knees And I will tell him tales of
foreign parts, And make him merry, when I come cheer up before
Him running on thus hopefully she heard. And almost hoped herself;
but when graver and close Natu he j The current of his talk things In
sailor fashion roughly sermonizing On providence and trust in
Heaven, she heard,
 E?ioih Ariicn. Heard and not heard him; as the village girl,
Who sets her pitcher underneath the spring, Musing on him that
used to fill it for At length she spoke ' O Enoch, yon are wise ; And
yet for all your wisdom well know 'Well then,' said Enoch, 'I shall
look on yours. Annie, the sliip I sail in passes here (He named the
day) get you a seaman's glass. Spy out my face, and laugh at all
your fears.' But when the last of those last moments came, ' Annie,
my girl, cheer up, be comforted. Look to the babes, and till I cunie
again Keep everything shipshape, for I must goAnd fear no more for
me; or if you fear Cast all your cares on God ; that anchor holds. Is
He not yonder in those uttermost Parts of the morning ? if I flee to
these Can I go from Him .' and the sea is His, The sea is His : He
made it.' Enoch rose. Cast his strong arms about his drooping wife,
And kiss'd his wonder-stricken little But for the third, the sickly one,
w , slept After a night of feverous wakefulne When Annie would
have raised h Enoch said ' Wake him not; let him sleep: should the
child Remember this ? ' and kiss'd h from her baby's forehead dipt .\
tiny curl, and gave it : this kept Thro' all his future; but now ha
caught His bundle, waved his hand, andi his way. .She when the day,
that Enoch i tion'd, came, Borrow'd a glass, but all in vain : She
could not fix tl eye; Perhaps her eye wa lous ; She saw him not : on
deck Waving, the monn past. 1 the le glass to suit her IS dim, hand
tremuand while he stood ent and the vessel dip of the vanishing!
She watch'd it, and departed weeping for him ; Then, tho' she
mourn'd his absence as his grave, Set her sad will no less to chime
with his. But throve not in her trade, not being bred To barter, nor
compensating the want By shrewdness, neither capable of lies, \or
asking overmuch and taking less. And still foreboding 'what would
Enoch sav ? ' For more than 6nce, in davs of difficulty And pressure,
had she sold her wares for less Than what she she sold : She fail'd
and sadden'd k and thus, Expectant of that news which came. n
buying what
 Gain'd for her own nance, And lived a life of silent
melancholy. Now the third child was sickly-born Yet sicklier, the' the
mother cared for [Other's care : neverthebusiness often call'd her
hat it needed ^•ith all a IT less, Whether her from it, Or thro' the
want of Or means to pay the voice who best could tell What most it
needed — howsoe'er it was, j\fter a lingering, — ere she was Like
the caged bird escaping suddenly. The little innocent soul flitted
away. =k whe In that samt buried it, Philip's true heart, which
hunger'd for her peace (Since Enoch left he had not look'd upon
her). Smote him, as having kept aloof so long. ' .Surely,' said Philip, '
I may see her now. May be some little comfort ; ' therefore went.
Past thro' the solitary room in front, Paused for a moment at an
inner door, Then struck it thrice, and, no one opening, Enter'd ; but
Annie, seated with her grief. Fresh from the burial of her littid Cared
not to look on any human i:ic-. But turn'd her own toward the wall
and wept. Then Philip standing up said falteringly • Annie, I came to
ask a favor of you.' spoke ; the passion in her 'd reply am ! ' half
abash'd him ; vet unask'd, His bashfulness and tenderness at himself
beside her, saying to peak to you of what he her l came to : wish'd,
Enoch, }-our husTjand I ha You chose the best among us — a
strong man : For where he iixt his heart he set his hand To do the
thing he will'd, and bore it thro'. And wherefore did he go this weary
way. And leave vou lonely ? not to see the world— For pleasure? —
nay, but for the wherewithal To give his babes a better bringing-up
Than his had been, or yours : that was And if he come again, vext
will he be To find the precious morning hours were lost. And it would
vex him even in his grave, If he could know his babes were running
wild Like colts about the waste. So, Ankno each other all I do
beseech you by the love you bear Ilim and his children not to say me
nay — For, if you will, when Enoch comes again Why then he shall
repay me — if you Annie — for I am rich and well-to-do. Xovv let me
put the boy and girl to school : This is the favor that I came to 8sk.'
 Enoch Anien, Answer'd ' I cannot look yuu ii> the face ; I
seem so foolish and so broken down. When you came in my sorrow
broke me down ; And now I think your kindness breaks me down ;
But Enoch lives ; that is borne in on He will repay you : money can
be repaid; Not kindness such as yours.' And Philip ask'd ' Then you
will let me, Annie ? ' She rose, and fixt her swimming eyes .■\nd
dwelt a moment on his kindly face. Then calling down a blessing on
his head Caught at his hand, and wrung it passionately. And past
into the little garth bevc .So lift( spirit he Then Philip put the boy and
girl to school. And bought them needful books, and everyway. Like
one who' does his duty by his Made himself theirs ; and tho' for
Annie's sake, Fearing the lazy gossip of the port, He oft denied his
heart his dearest wish, .•\nd seldom crost her threshold, yet he sent
Gifts bv the children, garden-herbs and fruit, The late and early
roses from his wall, ( Ir conies from the down, and now and then.
With some pretext of fineness in the the offence of charitable, the ill
mill that whistled did not fathi But Philip mind : .Scarce could the
woman came upon her, Out of full heart and boundless gratitude
Light on a broken word to thank him with. But Philip was her
children's all-inall; From distant corners of the street they ran To
greet his hearty welcome heartily; Lords of his house and of his mill
were they ; Worried his passive ear with petty wrongs Or pleasures,
hung upon him, play'd with him And call'd him Father Philip. Philip
gain'd As Enoch lost; for Enoch seemd to them Uncertain as a vision
or a dream. Faint as a figure seen in early dawn Down at the far end
of an avenue. Going we know not where : and so ten Since Enoch
left his hearth and native land. Fled forward and no news of Enoch
came. It chanced one evening Annie's children long'd To go with
others, nutting to the wood. And Annie would go with them ; then
they begg'd For Father Philip (as they call'd him) Him, like the
working bee in blossomdust, Blanch'd with his mill, they found ; and
saying to him ' Come with us Father Philip ' he denied ; But when
the children pluck'd at him
 But after scaling half the weary down. Just where the prone
edge of the wood began To feather toward the hollow, all her force
Fail'd her ; and sighing, ' Let me rest ' she said : So Phi nth h< well-
conwith jubiWhile all the younger ones lant cries Broke from their
elders, and tumultuously Down thro' the whitening hazels made a
plunge To the bottom, and dispersed, and bent or broke The lithe
reluctant boughs to tear Their tawny clusters, crying to each other
And calling, here and there, about the wood. But Philip sitting at her
side forgot Her presence, and remember'd one dark hour Here in
this wood, when like a wounded life He crept into the shadow : at
last he Lift: his honest fori =rry they are d le wood. >nde Tired,
Annie ? ' for she did not speak a word. 'Tired.'' but her face had fall'n
upon her hands ; At which, as with a kind of anger in him, ' The ship
was lost,' he said, ' the ship I'hy should you kill orphans quite ? '
Their voices make me feel so solitary.' ;\vhat thing upon my been
upon my mind so Then Philip con closer spoke And n it first last. O
That tho' I know not w came there, I know that it will out Annie, It
is beyond all hope, against all chance. That he who left you ten long
years ago ■Should still be living; well then— let me speak : I grieve
to see you poor and wanting help : I cannot help you as I wish to do
Unless — they say that women are so quick — Perhaps you know
what I would have you know — I wish you for my wife. I fain would
prove A father to your children : I do think They love me as a father
: I am sure That I love them as if they were mine own ; And I
believe, if you were fast my wife. That after all these sad uncertain
years. We might be still as happy as God grants To any of his
creatures. Think upon For I am well-to-do — no kin, no care, No
burthen, save my care for you and And we have known each other
all our lives, 1 longer than you Then answer'd Annie ; tenderly she
spoke : ■ You have been as God's good angel in our house.
 Enoch Anien. . bless vou for it, God reward for it, Philip,
with something happier t myself. Can one love twice ? can you be c
As Enoch was? what is it that he A little after Enoch.' ' O ' she cried,
Scared as it were, 'dear Philip, wait a while: If Enoch comes — but
Enoch will not come — Yet wait a year, a year is not so long : Surely
I shall be wiser in a year : 0 wait a little ! ' Philip sadly said ' Annie,
as I have waited all my life 1 well may wait a little.' ' Nay ' she cried '
I am bound : you have my promise — in a year Will you not bide
your year as I bide mine ?' And Philip answer'd ' I will bide my year.'
Here both were mute, till Philip glancing up Beheld the dead fiame
of the fallen day Pass from the Danish barrow overhead ; Then
fearing night and chill for Annie, rose And sent his voice beneath him
thro' the wood. Up came the children laden with their Then all
descended to the port, and there At Annie's door he paused and
gave his hand. Saying gently ' Annie, when I spoke That was your
hour of weakness. I was wrong, I am always bound to you, but you
are free.' Then Annie weeping answer'd 'I am She spoke ; and in
one moment as While yet she went about her household ways. Ev'n
as she dwelt upon his latest That he had' loved her longer than she
kne Th: flash'd before And there he stood on her face. Claiming her
promise. ' Is it a vear ? ' she ask'd. ' Yes, if the nuts ' he said ' be
ripe again : Come out and see.' Hut she — she put him off — So
much to look to — such a change — a month — Give her a month —
she knew that she was bound — A month— no more. Then Philip
with his eyes Full of that lifelong hunger, and his ke a drunkard's ,
Annie, take Shaking a littl hand, ' Take your own tim your own time.'
And Annie could have wept for pity of him ; And yet she held him on
delayingly With many a scarce-believable excuse, Trying his truth
and his long-sufferance, Till half-auother year had slipt away. By this
the lazy gossips of the port, Abhorrent of a calculation crost. Began
to chafe as at a personal wrong. Some thought that Philip did but
trifle with her ; Some that she but held off to draw him on ; And
others laugh'd at her and Philip too. As simple folk that knew not
their own minds, And one. in whom all evil fancies clung Like
serpent eggs together, laughingly
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