When two or more people are together they cannot help but to communicate (Watzlawick et al 1968). Caring is a process that offers people, both carers and the cared for, opportunities for personal growth. Major aspects of caring include- knowledge, alternative rhythms (learning from experience), patience, honesty, trust, humility, hope and courage. (Milton Mayeroff, 1972). Communication is used in everyday life and is a crucial part of working within the healthcare service. Knowing how to communicate correctly is a skill that must be acquired, in order to be successful as a healthcare professional and is an integral and essential part of all nursing practices (Macleod Clark and Sims et al, 1998, as quoted in Mallett and Dougherty, 2000 and Shelvington, 2007). In its broadest perspective, occurs whenever an individual assigns significance or meaning to an internal or external stimulus, (Lee Thayer). Failure to give accurate and easily understood information could lead to anxiety and could have serious consequences when sensitive treatments are concerned, it could also cause conflict, misunderstandings and could jeopardise the patients safety.
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There are many different mechanisms that improve communication with the public and media. You should always be clear about the message and consider the language used very carefully. Good communication among all health care professionals is vital to ensure they receive a comprehensive service which involves as little misunderstanding as possible.’ There are two differing clinical approaches to the same patient that highlight how communication among professionals can affect the patient’s quality of life.’ The non- collaborative approach- ‘a 45 year old woman with advanced ovarian cancer and multiple liver metastases was admitted to hospital. The surgeon told her that her disease was now advanced and was inoperable. He referred her to an oncologist, who felt she would not benefit from chemotherapy. She was discharged from hospital, and referred back to her general practitioner and district nurse. She became withdrawn and took to her bed where she died, 3 weeks later.’ The collaborative approach- In this scenario, the surgeon requested a joint assessment by the oncologist and a specialist palliative care nurse. During this joint assessment, the patient revealed she was worried: she feared she would be in pain and that her husband would not be able to cope on his own. The specialist nurse addressed each of the patients concerns and advised her on the resources which were available. The patient was relieved to hear that her symptom control would be regularly monitored by her general practitioner and district nurse and that a community specialist palliative care nurse could also be involved to support both her and her husband. She felt confident about her discharge home and died at home peacefully 3 weeks later. Three months after her death her husband accepted bereavement support offered by the community specialist palliative care nurse.’ These two different methods illustrate two different qualities of life as a result of differing communications among health care professionals. In the first approach, although the patient’s physical symptoms were well controlled there was neglect of her psychosocial concerns. In contrast, in the second approach, the patient had the same short survival but was able to come to terms fears and was able to be involved with her husband’s planning support. The non-collaborative model adopts a problem based approach, whilst the collaborative model anticipates problems.
In one study, when deaths occurred in the hospital the general practitioner was informed within 24hours in only 16 per cent of cases. In order for communication to be effective there must be opportunities to meet, exchange information, plan interventions, and take shared responsibility of the patient’s care. This approach involves good communication among general practitioners, community nurses between hospital staff. The communication among these professionals forms the lynch pin of care provision. There is a need for regular meetings between the doctor and nurse to hand over details of the patient’s progress, drug changes, and any important communications between the professional and the patient or family. Good communication among the professionals can maximize therapeutic effectiveness and create an environment in which the patient and family can feel a sense of security. Collaborative practice involves good communication, an understanding of each other’s roles, and trusting interpersonal relationships. Professionals in hospital and the community need to maintain clear channels of communication.
I will discuss an example of communication between a healthcare professional and a patient within this assignment; I will not breach their confidentiality and will therefore abbreviate their details. I will refer to the patient as Mr Jones. I will do this to comply and respect the Nursing and Midwifery code of conduct.
During my clinical placement Mr Jones’s communication skills were undeniably misread. On one occasion for example, Mr Jones rang the bell to gain the nurses attention. The nurse discontinued her previous job which was in this case assisting to feed another patient and went over to care for Mr Jones needs. As she went over he was pointing to the bedside table. She automatically looked at the table and picked up Mr Jones tissue box and placed it on his bed! As she was walking away to return to her previous job, Mr Jones was shaking his head. The nurse could not see this as she had her back to Mr Jones. Mr Jones rang the bell again 15minutes later to gain attention once more from the nurse. This time a different nurse went to see to his needs. Again he was pointing to the bedside table, this nurse picked up his glasses, held them up and waited for Mr Jones response. Again he was shaking his head. The nurse then put down the glasses and picked up his hearing aids, she then did the same procedure and held them up to Mr Jones and waited to see his response. He nodded enthusiastically! The nurse then fitted his hearing aids and continued with her work.
Communication is hampered by dysarthria in patients who suffer strokes involving the dominant (usually the left) temporo- parietal hemisphere. Prolonged speech and language disorders are associated with poorer prognosis. (Kehayia and co workers) found that aphasic stroke patients received less pain medication than non-aphasic ones.
There are some effects with normal ageing on communication and therefore Mr Jones needs additional support from their listener/ speaker in a conversation. There is a reduction in the ability to hear accurately and with this a difficulty understanding speech. Also Mr Jones has impaired vision which is due to his pathological changes glaucoma and as a result of these Mr Jones has a reduction in acuity and focussing power, and possible problems with colour discrimination. This means Mr Jones needs a longer period of time to look at materials and could need encouragement to scan materials. Ageing involves motor slowing, Mr Jones’s ability to respond (reaction time), has slowed down especially when there are distractions such as the radio or television being on and also if Mr Jones is tired. Mr Jones also has difficulty retaining more recent information such as what he had for breakfast. It takes longer to receive information from the long- term memory and Mr Jones may need to be reminded/ encouraged. Mr Jones has difficulty attending to complex activities, particularly if complicated language instructions are used. Multitasking can also prove a problem with Mr Jones’s therefore over facing him with too many tasks can cause confusion and could lead to total retirement of all tasks. There could be difficulty comprehending complicated language, but words and simplistic sentences are usually understood with no difficulty. Speaking slowly and clearly with correct punctuality and the use of some clear facial expressions could help. It is important to note that an Mr Jones may not perform as well on an intelligence task due to the reduced speed of performance in reaction time tasks and decreased speed of processing ability (that is, slowing of motor movement and ability to respond quickly to questions). So therefore meaning, it is not necessarily intelligence that decreases with age.
Mr Jones does suffer from glaucoma. This is an eye condition where the optic nerve is damaged at the point where it leaves the eye. The nerve carries information from the light sensitive layer of the eye, the retina, to the brain where it is perceived as a picture. So with this when attempting to communicate with Mr Jones you should try to be at the same eye level as him, constantly checking if he can see you or not. To gain Mr Jones’s attention and to maintain his concentration throughout the conversation, the use of touch is essential.
Mr Jones is 78 years of age and has a history of medical problems. He has recently suffered from a severe stoke! He is on a PEG feed and is therefore nil my mouth. Because of this he now suffers from Dyspraxia this basically means he has difficulty with controlling movements. This has affected his mouth and facial movements, speech, pointing and sign language (such as miming for a drink). This doesn’t affect his language ability and it is not the cause of muscle weakness it simply affects the control over the muscle movements. Mr Jones also has Dysphagia a swallowing problem which has occurred as he is nil by mouth and his nerve cells and muscles involved with swallowing have been damaged. He also suffers from dysarthria which affects the muscles in the face, tongue, lips, throat, voice and breathing. The muscles become may floppy or tight or bunched. With these Mr Jones also has dysphasia, it has affected his ability to use language to speak, to understand speech and to read and write (word finding problems).
Mr Jones’s Physiotherapist conducted a session, with duration of 30 minutes and allowed me to observe and take notes. There are many signs that indicate when someone is sensitive to touch. The most noticeable are a change in facial expression when touched, a bite reflex, or sometimes a grinding of teeth. The physiotherapist followed out a procedure that reduces or alleviates hypersensitivity. She explained how important it is to stand directly in front of Mr Jones and try to gain eye contact throughout. She also discussed the importance of explaining her actions before she carried them out, this was to illuminate confusion for Mr Jones. She started by touching Mr Jones’s hands then gradually moving them up his arms finishing on his shoulders, she explained this was in order that the patient, (in this situation Mr Jones), gradually becomes used to being touched. She then placed both hands on the side of Mr Jones face gently and started with the exercises. Her aim was to warm up the muscles in his face. Due to his stoke the muscles in the left side of his face have become very weak. She conducted a series of strokes on Mr Jones face involving his forehead, cheeks, upper and lower lip and just inside the lips. The physiotherapist then gave Mr Jones some facial expressions to try and carry out such as frowning, yawning, happiness, anger, surprise and sadness. This loosens the muscles and in time will improve Mr Jones’s speech and his ability to express facial movements. There was an obvious improvement noticed from the beginning of the session to the end, Mr Jones was able to express more movement in his face as the muscles were warmed up and loosened. This procedure needs to be carried out as often as possible to maintain the looseness of the muscles, even family and friends could help Mr Jones with these exercises. It is important to carry out the exercises when Mr Jones isn’t tired or in pain. Also make sure they are carried out properly with plenty of time, as if they are rushed they will not be performed properly.
Mr Jones also suffers from Memory impairment therefore there are things that need to be considered when attempting to communicate with him. He wears hearing aids so it is essential to ensure they are ‘fit for use’. It is important to keep objects in a familiar place and to establish a constant routine and environment to avoid/ minimise distractions. Keeping Mr Jones orientated by reminding him of date and time can help; also try to maintain the conversation by talking to him about daily events and who people are in the current news. It is very important to refer to Mr Jones by his name this gains attention and also retains a respectful manner for him to communicate to as directed to me by the other nurses on my placement. If the conversation seems to be going ’round in circles’ it should be stopped and continued after a short break. Also if Mr Jones becomes argumentative or if he denies problems or if he is blaming others, the conversation should be changed or diverted from the previous subject and you should never become involved or ‘take sides’ as this could upset Mr Jones further.
There are certain strategies to be taken into account when communicating with a Dysphasic patient (Mr Jones). It is essential to make sure you are talking face to face with Mr Jones, if necessary, bend or sit down so you are at the same eye level. Never address him from behind or turn away when communicating. There are also cues that can encourage Mr Jones to communicate such as touching the arm, smiling, pleasant general remarks or comments and using his name before launching into general conversation can help Mr Jones to feel more comfortable to engage in a conversation. To maintain a flowing conversation the healthcare professional must use questions, prompts and probes as required (Stretch, 2006). It is important to recognise that some questions encourage conversation and other questions don’t. A closed question can either be answered with a one word answer or a short phrase, such as ‘yes’ or ‘no’. An open question is more likely to receive a long thoughtful answer. The open questions encourage as they ask the respondent to think and reflect upon the question, they may give you thoughts and feelings and they also hand control of the conversation to the respondent (Niven and Robinson 1994). Probes are basically short questions Clarity probes help you obtain additional information on a preceding response. In contrast to completion probes, they press the patient to explain a response that was unclear or did not make sense in the context of the question. Frequently, clarity probes ask the respondent for an example or an explanation of a specific word or phrase (John R Snyder). When communicating with Mr Jones if he is struggling to find the correct words, instinctively we want to help by giving them the word we think they are trying to remember. This doesn’t help the problem, although it might speed up the message it could also annoy the person we are initially trying to help. It is important never to assume what Mr Jones is trying to say, give him time, it could take up to 30 seconds for him to remember. During my clinical placement my mentor probed the patient, Mr. Jones helping him to ask for a cup of coffee, the nurse said ‘So do you mean you would like a cup of….’Mr Jones then attempted to say coffee.
-maintaining a flowing conversation
-prompts and probes
The extent to which we rely on non- verbal signals (e.g. facial expression, body movements, or gesture) to support our spoken output is not often fully recognized. The patient who is seriously ill, weak or in pain may find these non verbal signals difficult to produce; and with Mr Jones’s severe motor impairment, particularly of the facial muscles, this can intentionally give signals that are misinterpreted. The speech and language therapist’s job is to try to discuss this with Mr Jones and his family to look at possible options for circumventing this potential breakdown in communication. Where verbal communication is reduced through aphasia or cognitive changes, the non-verbal channel can provide an alternative and effective main mode of both message receiving and giving. There are different channels in which interpersonal communication can be preserved. Maintaining social communication, this helps to maintain Mr Jones’s dignity. Always try to keep talking, Mr Jones may find some of the non-verbal actions helpful and many are understood. Use touch judiciously, it is obvious that Mr Jones relaxes at ease when touch is involved even if it a simple hand on his shoulder. Encourage attempts to communicate and provide other types of stimulation with Mr Jones.
-distance and level between patient and nurse
According to Aristotle’s Triad of communication, there are three elements that ensure effective communication, The speaker, the Subject and the audience.
-model- berlo or Shannon and Weaver
The hospital ward is a very noisy place therefore this interferes with the transmission of the message. Environmental barriers such as background noise, poor lighting, poor print quality, illegible handwriting, static on the phone lines, or poor contrast in printed materials have to be considered. Physical noise such as hunger, pain, exhaustion also has an impact and could be minimised. Psychological noise such as preconceived ideas, previous experience and knowledge, attitude and current emotional status could interfere with communication. Cultural noise such as values, Knowledge and belief systems, culturally based healthcare practices, direct or indirect communication styles need to be acknowledged. Semantic barriers such as word usage, idioms, metaphors and learning styles have an impact. Language barriers play a huge part in the transmission of communication from the healthcare professional to the patient or the other way around. Words may have a different meaning even when using the same language. So when attempting to communicate with Mr Jones these aspects should be highly considered beforehand.
-reflective listening techniques
Honest communication is surely an ethical imperative for the truly caring clinician. Behaviour and communication of caring and competence at this time have a major influence on the ability of patients and families to assimilate the news, consider options, and adapt and adjust to what lies ahead. Even if the news is gloomy the right touch, look, and supportive kind word always makes a difference.
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