The book Reframing: Neuro-Linguistic Programming and the Transformation of Meaning starts with a Chinese Taoist tale of a farmer rich by virtue of owning a horse.¹ One day the horse runs off. The neighbors sympathize with the farmer about his loss, but the farmer simply replies, “Maybe.”

A couple of days later, the horse returns with two wild horses. The neighbors remark on the farmer’s good fortune. The farmer retorts, “Maybe.”

Several weeks later, the farmer’s son breaks his leg while riding one of the wild horses. The neighbors console the farmer. Again the farmer says, “Maybe.”

The following month, a conscription officer comes to the village to collect young men for the army. The farmer watches as his neighbors’ sons are taken away. His son is exempt because of his broken leg.

Events like losing a horse and breaking a leg are simply events. The meaning we give these experiences is affected by our culture and individual upbringing, which is our frame of reference. This gives us a tool to evaluate each situation. In the above story, as the frame of reference changed, the meaning of the incident changed. When you change the frame, that is reframe, you change the meaning of the experience.²

When we elected to become healthcare professionals, our education provided us with new frames related to somatic events. This knowledge became part of our culture and upbringing. This gives us frames of references to evaluate our patients. At times, our frame of reference differs greatly from our patients’. We become like the farmer and his neighbors — we see the same experience from a different perspective.

Pain can be a sign of injury or of an intact nervous system. A fever can mean illness or the body’s natural course of healing. Cigarette smoking can mean you are “cool” and rebellious or subjecting your body to a carcinogen. Somatic signs of illness, such as a cough, can be seen as “unhealthy” or as part of the body’s natural course of healing. Hypertension can be seen as a “family destiny” or something to be managed. Some frames of reference promote better outcomes than others.

By using our knowledge coupled with our experiences, we can help our patients put a new or different frame around an experience to transform its meaning.³ Here are some examples:

• Surgical discomfort causes a patient to awaken in the postanesthesia care unit. The patient mutters, “I hurt.” The nurse calmly says, “Yes, and that means that your surgery is over and you have come through it well. I’m going to give you medicine to make you feel comfortable.”
• A patient with pneumonia refuses to cough because it is impolite. The nurse asks the patient whether a person who has food stuck in his or her throat should just sit down and let nature take its course. The patient responds, “Absolutely not!” The nurse continues to reorient the patient’s thinking by agreeing that there are times when coughing is considered impolite and times when it is considered appropriate.
• A person newly diagnosed with diabetes is not interested in a new diet plan. This patient insists it’s “just a little sugar problem.” The nurse explores this patient’s family history. Some family members have or have had this disease. As the patient recounts his family’s assorted health problems, the nurse explains how these problems can be managed or averted through dietary compliance.

The goal of reframing is to create a frame of reference that focuses on the desired outcome as opposed to the current problem or to look at the same situation from a different perspective. The response a person has to an event depends on his or her interpretation of the event.4 Reframing redirects interpretation.

Reframing the experience

Humans are “meaning makers.” Unlike animals, which have the preprogrammed instruction known as instinct, we construct meaning by linking events together. Meaning is a product of the mind and neurology interacting with the world. This creates a frame of reference, an internal assumption of how the world works. Thinking, feeling, acting, and responsiveness take place within these frames.³

The neighbors and the farmer had different frames that each referenced when thinking, feeling, and responding to the events of losing a horse, gaining two horses, and a young man’s breaking his leg.

In one study, positive reframing reduced negative symptoms across four menstrual cycles in women with premenstrual syndrome. In this study, women with premenstrual syndrome attended four two-hour classes coupled with homework assignments. Embedded in each class were positive reframing components intended to alter each woman’s perception of her menstrual cycle. These positive reframes included discussion about cultural attitudes, emphasis on increased activity in relation to nutrition, and the effects of increased beta-endorphins from exercise. Homework included keeping a diary that identified positive changes.⁵

At the end of four months, the women had a significant reduction in premenstrual impairment as measured by a menstrual distress questionnaire. These test results were reinforced by anecdotal comments by participants. One said, “I never thought about my need to be alone as a time for creativity,” demonstrating a reframe of a premenstrual symptom from a symptom of impairment to one of empowerment.⁵ The symptoms remained the same, but the meaning given to them shifted away from a disease model often held by the medical community, and previously, by the women in the study.

In another study, successful coping was linked to a reduction in depression and anxiety. The results showed that women who used more positive reframing had less depressive symptoms than women who use less positive reframing. It also found that women who were more prone to self-blame had increased levels of anxiety.⁶

In a third study, family members of a child with autism were helped by learning how to reframe their personal and family goals. After they were able to redefine their problems in a more positive way, they were able to find solutions to their problems and not become discouraged.⁷

Transformation of meaning

Reframing is about changing the meaning of an experience. The experience exists, but now it has been recategorized to have a different meaning.³ This is known as content reframing.

Content reframes are all around us. The birth of a child is a blessed event or another mouth to feed. It is still a child. Cancer can be viewed as a death sentence or an invitation to focus on the importance of family and friends. It’s still cancer. Menopause can be the end of the reproductive years or the beginning of a new phase of life. It is still menopause.

Politics is the art of content reframing. A new power plant can be good for the economy or bad for the environment. It is still the same power plant. High interest rates are bad for borrowers and good for savers. They are still the same interest rates.

Advertising reframes products to put them in the best light. New tires mean that you love your family and want to keep them safe — or that you now have the ability to take corners at a faster speed. They are still tires. Being a blonde means you have more fun or you are dumb. It is still a hair color.⁴

In another study, a patient’s ability to find meaning in chronic illness and reframe its implications positively was a key element in self-care. This study found that chronically ill patients who had not found meaning in their illnesses resorted to nonaccommodating behaviors, such as continuing to seek a cure or finding a scapegoat for their resentment. It also is reported that patients who rejected their illness “were so overwhelmed by feelings of futility that they gave up on life.”⁸

On the other hand, the patients in the study who went on to find meaning in their illness became committed to self-care. Instead of seeking a cure, looking for a scapegoat, or giving up, these patients found symbolic meaning that reframed the meaning of the illness in their lives. This attitude allowed them to adapt to a life that included managing a chronic illness, as opposed to being managed by the chronic illness.⁸

One of the tools for reframing used in this study was cognitive optimizing, which is comparing oneself favorably with others: “I may have this condition, but a lot more people are worse off.” Nurses can encourage cognitive optimizing by positively comparing a patient with others. Another way to cognitively optimize is by offering a historical perspective that shows that a patient is better off than patients having the same condition 20 or 50 years ago.

Another tool used was identifying with others with similar health problems who are living effective lives. Nurses can offer information about support groups and identify celebrities who have a similar illness.

A number of people in this study actually found their lives had improved as a result of their illness. For example, the illness helped some patients clarify life values, resulting in a commitment of time and energy to family or to self.⁸

This study also suggested that nurses should pay attention to the symbolic meaning that illness has for a patient. Once nurses know the meaning, they can help patients reframe the illness and integrate the meaning into life.

Where this behavior is useful

Another way to reframe is by looking at a behavior and finding a context in which that behavior or event would be of value. In the case of the farmer’s son, a broken leg is a major inconvenience, but in the context of avoiding conscription, the broken leg
has value.

Coughing at the opera is frowned upon. Coughing after surgery is encouraged. Urinary urgency is the sign of a bladder infection. Urinary urgency is normally experienced with a Foley catheter. Yelling at your boss is discouraged. Yelling at a ballgame shows team spirit. Every behavior is appropriate in some context.⁴

Daniel Pesut, RN, PhD, noted that nurses “were excellent at reframing and redefining client behaviors when they focused on a patient’s strengths, not their weaknesses.”9 A parent may be seen as overly critical or one who sets good standards for life out of love. A spouse may seem clingy or attentive. A person can be perceived as a victim or a survivor.

One way to change the context of an event is to look for another word or words to describe the event. A patient can be a challenge or a train wreck. A hospital’s fiscal policies can be conservative or cheap. An overweight patient can have mild obesity or a Rubenesque figure. A change in words easily alters the interpretation of an experience.³

In the confusion that often accompanies healthcare, it is often challenging to reframe undesirable behaviors. Patients who yell, act oddly, or are generally noncompliant often are easier to dismiss or avoid. An effective way to look at a context reframe is to separate the undesired behavior from the intent of the behavior.

The classic nursing film titled Mrs. Reynolds Needs a Nurse features “Mrs. Reynolds,” a demanding patient with Guillain-Barré syndrome who requires more than seven hours of care each day. The couple is depicted as being irritating. She has a constant need for attention and bad-mouths the staff. Her husband is omnipresent and takes his complaints about her care all the way to the state legislature. The staff and the Reynolds are engaged in a vicious cycle of accelerating annoyance and fear.

In the film, the staff reframe the Reynolds’ behaviors and focus on their unmet needs. By doing this, the staff recognize that Mrs. Reynolds is afraid of dying and her husband feels helpless. The staff initiate a plan that includes frequent assessments coupled with reassurance. Mr. Reynolds’ hypervigilance is put to use in teaching him to care for his wife. He is taught how to suction her trachea and is encouraged to feed her. As a result, Mrs. Reynolds becomes a content patient, requiring a little more than an hour of care each day.¹⁰

Framing the attitude

If the frames of reference associated with healthcare delivery are positive, the patient perceives his or her care environment as a positive place. We all have experienced these patients. They accepted you as a professional who knows what to do. If you could, you would bottle this attitude and have it dispensed by the pharmacy or piped through the air vents of your institution.

Norman Cousins, author of The Anatomy of an Illness as Perceived by a Patient: Reflections on Healing and Regeneration, is famous for his use of humor in his recovery from ankylosing spondylitis, an arthritic and rheumatoid-like collagen disease of the connective tissue that can cause the spine and joints to fuse.¹¹ He treated himself with old Marx Brothers movies and Candid Camera reruns.

Cousins’ positive attitude toward healing started at the age of 10 when he was misdiagnosed with TB. In the sanatorium, he aligned himself with a group that was confident that they would beat the disease. This group became good friends and involved themselves in creative activities and had little to do with the group that was resigned to dying. As new patients entered the sanatorium, Cousins and his group would try to recruit them before the “bleak brigade” went to work. Cousins noticed that compared to the bleak brigade, most of his group were discharged as cured. Cousins notes that this early lesson demonstrated to him the power of optimism and the mind. This continued as a frame of reference in his life.

Some years later, Cousins had a heart attack coupled with congestive heart failure. The physicians who worked closely with Cousins described five factors that contributed to his self-therapeutic attitude:

• Good humor and cheerfulness that created a healing environment
• The absence of panic in the face of obvious grave symptoms
• An unshakable confidence in his body’s ability to use its own wisdom to facilitate healing and in the hospital staff
• His taking full responsibility for his recovery by establishing a partner relationship with his physicians
• His focus on meaningful and creative goals that made life worth fighting for and living for^2,11

Cousins had a frame of reference that promoted health. It was part of the culture he was exposed to as a child and was fostered by his personal experience.

Often our patients do not come with positive frames of eference. During their lives, their family members or friends may have gone to the hospital and never returned home.  These people may think, feel, and respond as if everything is going to go wrong. They may act as if everyone is going to abandon them and may push staff away with their attempts to demand attention. We call them problem patients, but they are patients with problem frames.³

As stated earlier, the goal of reframing is to create a frame of reference that focuses on the desired outcome as opposed to the problem. This is not Pollyannaish, claiming that everything is going to be wonderful.¹² The farmer moved through the events of losing a horse to saving a son from conscription by keeping his mind open. With each event, the story wasn’t over. The same can be applied to our patients with less positive outlooks. We can reframe events for them to promote realistic outcomes that address issues such as safety, comfort, and autonomy.

Reframing our attitudes toward patients

Reframing is a tool to empower our patients, but occasionally we as nurses miss our opportunity to empower because of limited perspectives of our patients and our ability to affect their lives. An example is nursing interactions with abused women.¹³ The survivors of abuse reported feeling their victimization was doubled — occurring once with the abuser and again with the healthcare staff. The women felt the nurses were somehow cold in their treatment and tended to avoid them.

This situation results from both myths and fears about abuse. Some people still believe, for example, that women who remain in abusive situations do so because they like it. Others believe that “what happens behind closed doors is none of my business.”

As nurses, we have client groups to which we comfortably offer empowerment, therapeutic communication, validation, support, and respect for client autonomy. This attitude needs to be reframed and extended to all patients.¹³ If an abused woman is viewed in the same manner as a patient with chronic illness instead of seen as someone harboring a dirty little secret, healthcare providers could offer better care to this population.¹³

Reframing gives the healthcare practitioner another perspective for evaluating a patient’s behaviors. In viewing our patients in a different light, we often find new and creative ways to manage their problems. This process enriches our experiences and reframes our nursing practice.