Communication is natural to most people. We learn to communicate from birth and it is something that most people do without being aware of it. Communication is simply the name for expressing, sharing and understanding information. To examine a model of communication, for example, Shannon and Weaver’s model of communication (Brooker and Waugh, 2007) there are three components to successful communication. The first part is the sender. This is the source of the information which is to be shared. It could be a person talking, a radio or a newspaper or book. The next part of the model is the message. This is the information itself. It could be words spoken by the person or words from the book or newspaper. The last stage is the receiver. This is the person who is receiving the message. That would be the person listening to the words of another, the person hearing the radio or the person reading the book or newspaper.
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Communication can be separated into two categories, verbal communication and non-verbal communication. Knapp et al (2010) defines Non-verbal communication as communication without the use of words. Non- verbal communication can include body language, touch and gesture. Non-verbal communication can be more influential than verbal communication (Argyle, 1988 cited in Chambers, 2003) Verbal communication is achieved through the use of spoken or written language. Scammell (1990) states that it’s purpose include: to instruct, to teach, to educate, to express feelings and emotions, to help or seek help. Although there are two separate categories, both are used together in everyday life by most people without thinking.
In this explanation, communication sounds very straight forward but the barriers to communication can be very complex, this is especially relevant in people who have had a stroke as will be explored later in this text.
The nurse has a vital role in caring for the patient who has had a stroke. It is within the nurse’s role to assess, plan, implement and evaluate a personalised care plan for the patient (Brooker &Nicol 2003 cited in Brooker and Waugh, 2007). Although the nurse will be assessing the patient holistically, they must also ensure they realise the importance of communication in the patient’s recovery. It is fundamental the nurse understands and expects the communication problems that the patient may encounter. It is also essential that the nurse can communicate effectively with other members of the multi disciplinary team to ensure that patient receives high quality evidence based care. The nurse must also communicate well with the relatives of the patient as they may not fully understand what to expect in the recovery process (Glass & Maddox 1992).
The Nursing and Midwifery Council (2008) have clear guidelines on the responsibility of the nurse to communicate effectively with patients in their care. The nurse has a duty of care to meet the patient’s communication and language needs. The nurse should use evidence based practice and research to decipher effective communication strategies for each patient, trying to get to know the patient as an individual and documenting successful communication techniques. The nurse may also refer to the patient’s relatives to gain knowledge of communication strategies which work already. The nurse must have a sound knowledge of the pathophysiology of a stroke to understand how to communicate; this is explored in the next paragraph.
Firstly, to understand the communication problems that a patient who has suffered a stroke encounters, how a stroke manifests must be understood. According to the World Health Organization (WHO) statistics, 15 million people will have a stroke on an annual basis (WHO, 2004 cited in Ross, 2009) the correct medical terminology for a stroke is a cerebral vascular accident (CVA). A stroke usually happens when an artery within the brain becomes blocked thus leading to the death of cells which have had their blood supply cut off (Chang et al, 2006a). The term for cell death, in this way, is infarction. Another reason for a stroke is when there is a haemorrhage within the brain, or an artery bursts also resulting in cell death.
If the blood supply is cut off then the cells dies and this can cause serious damage to important areas of the brain (Chang et al, 2006b).
Different areas of the brain control different aspects of the body and depending on where the stroke has taken place can affect how the patient recovers. The patient who has suffered a stroke may have very serious communication difficulties after the stroke. For most people, the language centre of the brain is in the left hemisphere, although a small amount of left handed people may have their language centre on the right hemisphere. If the stroke happens within this area and there is damage then the person can suffer language problems (Horton, 2001). This is called Aphasia. Aphasia can prove to be a very complex barrier in communication. Aphasia can alter the way they communicate, from speaking and pronouncing words, having correct grammar to understanding words (Bannister, 1992 cited in Clarkson, 2010). Aphasia can also disrupt the patient’s ability to write and read.
When a patient suffers a stroke they may be left with aphasia. The patient may not be able to adequately understand language or express language (Clarkson, 2010). A patient with a stroke can be left unable to even recognise simple words or instructions. This can be very infuriating for the patient as they may not be able to express their needs or preferences. The nurse may also find it hard to assess what the patient’s needs are which could effectively slow recovery. Communication strategies are essential in the plan of care for the patient who has had a stroke, as will be discussed in the next paragraph.
There are many communication strategies which have been implemented within a clinical setting to overcome barriers in communication. The nurse must strive to increase the patient’s confidence when communicating ensuring that the patient has opportunity to make decisions about their care. Alternative and Augmentative communication systems can be put in place to assist with communication (Glennen & DeCoste, 1996a). One of these methods is the use of picture cards. Picture cards are used to give the patient the opportunity to express a fundamental need (Speakability.org.uk, 2010). These picture cards can be of varying size but are usually about A4 size.
They contain pictures of basic items and usually a phrase accompanying the item, e.g. a pair of spectacles and a phrase stating “I need my glasses”.
The cards are accessible to the patient so it means that they can express needs without speaking. The nurse can quickly decipher what the patient needs and can deliver the care quickly and effectively. Although picture cards may be effective, they can be reinforced by gesture or mime. The patient may use a cup to signal the fact that they are thirsty. This could also be reversed with the nurse holding the cup to ask the patient if they are thirsty. The use of a medical passport has also become more common within clinical area. This consists of a booklet which is usually passport size, which is full of pictures and phrases, like the picture cards (Speakability.org.uk, 2010). This may have pictures of things like a clock and the phrase “How long will I have to wait?” This means the patient can maintain control over their healthcare and also be more involved in decisions and treatment options. The picture cards and the medical passport are a non-verbal way of the patient communicating with the nurse or even family members (Glennen and DeCoste, 1996b). However in order to obtain these responses from the patient, the nurse may have to use a different communication strategy such as questioning.
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Referring back to the communication model from earlier, the nurse must understand that although it seems very straight forward, it is altered completely in a stroke patient. The patient may be trying to send a message but be unable to find the correct words or grammar to express themselves (Clarkson, 2010). The patient may also have difficulty understanding the message so although the words are correct, they may be unrecognisable to a stroke patient. The nurse could use a verbal form of communication to encourage the patient to, for example, use the picture cards or medical passport. The nurse could use questioning as a tool to assess needs and deliver appropriate care. The nurse must assess the type of questioning needed in certain situations, e.g. if there is important information needed quickly then the nurse could use closed questions to ascertain a yes or no response. Closed questioning may also be useful in stroke patients as an open question may be difficult to answer because of the aphasia. It is important to add that sometimes people with aphasia can say yes when they mean no and vice versa (Clarkson, 2010) so the nurse could summarize what the patient wants, by repeating back to them verbally, just to clarify the correct information has been communicated.
The nurse must communicate with clarity, avoiding medical jargon or eloquent grammar, using clear and concise language which is not too complex.
Nurses are often seen by the patient as their link to understanding the medical jargon which doctors may use (Castledine, 2002). When relaying information, the nurse must simplify the language so that the patient has a better understanding of the definition, this is especially relevant to patients who have had a stroke due to nature of this condition. Simple language may even be difficult for the patient to understand, so the nurse must relay the information in a simple format, always clarifying that the patient has understood what is being said.
In conclusion, this essay has explained the importance of the nurse understanding what communication actually is and why it is relevant in patients who have had a stroke. This text has explored how a stroke manifests and what barriers a stroke patient may encounter when trying to communicate. In summary, it is evident that there are many different ways to communicate with a patient who has had a stroke but it is the nurse’s responsibility to ensure that they research and build rapport with the individual patient to effectively communicate in the easiest manner. The nurse has legal obligations to meet communication and language needs of the patient. This essay explored two specific strategies used in communicating with patients with aphasia. This essay concludes that communication barriers can be complex and the nurse must ensure that care is delivered in a person-centered, individual, holistic basis.
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