Therapeutic Communication PDF

CHAPTER ONE THERAPEUTIC COMMUNICATION COMMUNICATION Nursing. is a profession which depends largely on communication. Nurses have contact with various types of people: patients, family members, other health professionals and many others. It is therefore very essential f...

CHAPTER ONE THERAPEUTIC COMMUNICATION COMMUNICATION Nursing. is a profession which depends largely on communication. Nurses have contact with various types of people: patients, family members, other health professionals and many others. It is therefore very essential for a nurse to develop and utilize communication skills. Communication is deeply rooted in human behaviours and the contexts of society that it is difficult to imagine social or behavioural transactions without it, for these reasons, communication is the fundamentals to all nursing and interpersonal relationship. Communication is often taken for granted as it is a part of daily life. In the healthcare setting particularly, it can have disastrous outcomes when it is ineffective. It is accepted that history- taking is far more important than examination in making a diagnosis yet it is only recently that communication has been recognized as a clinical skill that, like all other clinical skills, should be formally taught. Nurses who communicate effectively find it easier to collect assessment data, initiate interventions, evaluate outcomes of interventions, initiate change that promotes health, and prevent the Legal issues associated with nursing practice. It is rather unfortunate that sometimes patients are treated as objects rather than people. This is because the work culture is that of task-rather than person-oriented. That is to say patients or clients are treated as 'bodies' to be washed, fed, dressed, etc. rather than as people to be listened to, or to be involved in their care and in healthcare decisions made about them. Clients are often anxious and uncertain using the healthcare system. Sensitive, responsive and thoughtful communication helps to address the anxieties and ensure that the care the patient subsequently receives meets both their needs and aspirations Communication with patients is not an optional issue but rather a core clinical skill which is a vital component of nursing care at whatever grade or level (Wilkinson 199; Fallowfield et al.2001b). Ineffective communication has been associated with emotional burnout, stress and poor job satisfaction in health care professionals (Wilkinson 1994; Ramirez et al. 1995). Conversely, effective communication with patient can help improve satisfaction, compliance and pain control, reduce anxiety, establish trust and rapport, support and educate the patient and establish a plan for treatment (Stewart 1995; Fallowfield & Jenkins 1999) 1 DEFINITIONS: COMMUNICATION Communication is any means by which a thought is transferred from one person to another (Chappel & Read, 1984). Communication is the transfer of information, feelings or message that becomes the common property of both the sender and receiver (Peretomode, 1992). It is giving, receiving and interpreting of information through any of the five senses by two or more interacting people. Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures or other actions. “Who says what, in which channel, to whom, with what effect” (Harold,1950). Elements/Components of Communication process Sender/Encoder/Source. Message Medium/Channel. Receiver Feedback /Return Signal. There are five main components of communication SENDER/ENCODER/SOURCE The person or group who initiates or begins the communication process. The person or group who wishes to convey a message to another. NB-In daily life situations we are all sources of information as we relate to others and speak our ideas to them. MESSAGE Verbal or non-verbal expression of thoughts or feelings from the sender to the receiver. 2  It is the unit of information that is transmitted from the sender to the receiver It is the object of communication or the thing that is being communicated. NB-The message takes various forms such as speech, interview, chart, conversation, memorandum or nursing note. When one speaks, the speech is the message. -When one paints, the picture is the message and when one gestures the movement of arms, the expressions on the face are the messages. MEDIUM/CHANNEL The means the sender has selected to send the message. The means by which message moves from one person to another. The routes of conveying the message. NB- They act as communication vehicles thereby transferring a message from the sender to the recipient. RECEIVER The person who must listen, observe and attend to the message. This is the person to whom the message is directed or carried to. That is the person who receives and interprets the message. -In the health care system, the receiver can either be a nurse, a patient, patient’s family member, a colleague health worker or members of the community. FEEDBACK OR “RETURN SIGNALS” Feedback is the verbal or nonverbal response the receiver gives to the sender about the message. It is a response from the receiver indicating whether a message has been received in its intended form. It is any response to a communicated message. -Feedback can either be verbal, non-verbal or both. Example of non- verbal responses are nodding of the head and yawning. 3 -Feedback helps to determine the success or failure of the communication. -Feedback may also be positive or negative. Positive feedback indicates the receiver has received and understood the message. E.g. Smiles, clapping, laughter, etc. Negative feedback indicates that the receiver either has not received or not understood its content. E.g. frowns, unkind remarks, silence etc. Thus, feedback alerts the sender to verify whether the message has been understood as intended which allows any confusion to be corrected. Feedback can focus on: -The content of the message. -The feelings generated by the message. -The parts of the communication that is not clear Definition of Therapeutic Communication The purposeful use of communication is to build and maintain helping relationships with clients, families and significant others. A face to face process of interacting that focuses on advancing the physical and emotional well-being of a patient. A healing or curative interaction between the nurse and the patient. An interaction between a health care professional and a patient that helps the patient to adjust to his/her circumstances and to move in the direction of health and away from illness. Involves interpersonal interactions between the nurse and client that is geared towards client’s wellness. 4  PURPOSES OF THERAPEUTIC COMMUNICATION To encourage or facilitate expression of feelings, emotions and ideas by patient. To provide the information and emotional support that each client needs to achieve maximum health and wellbeing. THERAPEUTIC VERSUS SOCIAL COMMUNICATION Two types of communication-social and therapeutic –may occur when the nurse works with friends’ families who seek help for physical or emotional needs THERAPEUTIC SOCIAL It occurs with purpose of helping patients It involves equal disclosure of personal information and intimacy and both parties enjoy equal opportunities for spontaneity. Both participants seek to have personal needs met. The focus is on the needs of the patient. The identification of needs may not occur. Needs are identified by the client with the help of the nurse/midwife if necessary. A variety of resources may be used during Specialized professional skills are used while socialisation. employing nursing intervention. WHY NURSES/MIDWIVES NEED THERAPEUTIC COMMUNICATION To be able to offer their patients satisfactory service through relationship To establish and know the goals, wishes and preferences of the patient To build a good therapeutic relationship 5  To facilitate patient autonomy and to reduce risk Lack of communication or miscommunication may lead to harm to the patient. PRINCIPLES OF THERAPEUTIC COMMUNICATION Therapeutic nurse-patient communication is bounded by three main principles; Gaining trust Showing genuineness Being empathetic ESSENTIAL COMPONENTS OF THERAPEUTIC COMMUNICATION Time- plan for and allow adequate time to communicate. Attending behaviours or active listening- these are non-verbal means of conveying interest in another. Caring attitude- show concern and facilitate an emotional connection with the client and client’s family. Honesty- be open, direct, truthful and sincere. Trust- demonstrate reliability without doubt or question Empathy- convey an objective awareness and understanding of the feelings, emotions and behaviours of others including trying to envision what it must be like to be in the position of the client and client’s family. Nonjudgemental attitude- this is a display of acceptance that will encourage open, honest communication THERA PEUTIC COMMUNICATION SKILLS/TECHNIQUES Therapeutic communication techniques assist the flow of communication and always focus on the client. 6  AREAS THAT THERAPEUTIC COMMUNICATION TECHNIQUES ARE VERY USEFUL Interviews History collection Health education Counseling THERAPEUTIC COMMUNICATION TECHNIQUES TECNIQUE DESCRIPTION EXAMPLE INFLUENCE IN COMMUNICATION 1.Accepting Indicating reception: recognizing the “yes” other person without inserting own It indicates the nurse has “I follow what you values or judgements. heard and followed the said” “Nodding” thought of train An active process of receiving Maintain eye The nurse is able to hear, 2.Active information and examining one’s contact and observe and understand what listening reaction to the messages received receptive nonverbal the client communicates and communication. to provide feedback Use of this technique demonstrates a willingness to 3.Offering self Making oneself available “I’ll sit with you for spend time with the client. a while” It is making oneself professionally available. The nurse can offer his or her presence, interest, and desire understand the client without making I will sit here quietly demands or attaching conditions that with you for a while; we don’t 7  the client must comply with to need to talk unless receive the nurse’s attention. you would like to. I’ll like to feed you if you like. 4.Seeking “I don’t understand. clarification A method of making client’s broad Can you say it in a It is used to determine if a overall meaning of a message more different way”, message received was understandable. In other words, accurate check out or make clear either the “Are you saying….. intent or hidden meaning of the message Active listening Listening extends beyond hearing words and being silent. It involves the use of all senses in paying attention and making sense out of both verbal and non-verbal communication. Active listening means paying attention to what is being said, observing non-verbal communication of the client, and using actions such as having eye contact and nodding. It requires energy, concentration, genuine interest, patience and self-control. It is important to pay attention to the client’s entire statement without interrupting or completing the sentences for them. The nurse is not selective or picks out the information s/he wants to hear. The client should be the one to determine when the interaction ends. When the nurse closes the conversation, the client may assume that the nurse considers the message not to be important. Nurses must be self-aware of their own biases and beliefs and should use that as bases of discrediting the client’s message. Characteristics of active listening Maintaining eye contact Give evidence of understanding through restating or summarize what you heard Taking time to listen 8  Giving the client your undivided attention Suspending judgment Understanding the feelings behind the facts Analyzing and validating throughout the conversation. Noticing discrepancies between facts and feelings Barriers to active listening Giving advice Language barriers Personal filters e.g. Values, biases, culture, beliefs, stereotyping. Interrupting Blaming Expressing disapproval or surprise e.g. Frowning, raising eyebrow Environmental noise Lack of privacy Hearing what you want to hear Using jargons Showing anxiety or fear Hurried approaches Active listening ▫ several nonverbal skills have been identified as facilitative skills for attentive listening and it’s as follows; 9 SOLER S – Sit facing the client O– Observe an open posture L – Lean toward the client E – Establish and maintain intermittent eye contact R – Relax 5. Confrontation Confrontation in this context is not the hostile reaction to disagreement or opposing opinions. In therapeutic communication, it involves helping the client become more aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviours. Inexperienced nurses find this technique uncomfortable because of the misperceptions. This technique should be used only after trust has been established, and should be done gently, with sensitivity: “You say you’ve already decided what to do, yet you’re still talking a lot about your options.” 6. Focusing Taking notice of a single idea expressed or even a single word. The nurse gathers more information to validate a specific point. It decreases anxiety in the client and helps the easily distracted client to focus on a single subject matter. “You mentioned that you are having a problem with...” “On a scale of 0 to 10 tell me the level of the pain you are experiencing in your great toe right now.” 10 7. Giving information Giving information involves periodically providing the client with facts or information whether the client requests for it or not. When information is not known, the nurse must be honest and say it and then refers the client or directs him/her as to how to obtain the needed information. Below are some examples ‘the doctor will be here at 8:00am’ ‘You will feel a little pinch and then pressure when the drug is being injected.’ ‘I don’t have that information, but I will find out from sister Ivy, the nurse in charge’. 8. Seeking clarification To check whether understanding is accurate, or to better understand, the nurse restates an unclear or ambiguous message to clarify the sender’s meaning. “I’m not sure I understand what you mean by ‘sicker than usual’, what is different now?” ‘I’m not sure I understand that.’ Would you please say that again? Would you like to tell me more? I’m sorry that wasn’t clear. Let me try to explain another way 9. Silence Silence is the absence of verbal communication. It is a time for the nurse and client to observe one another, sort out feelings, think of how to say things, and consider what has already been communicated. Many people feel uncomfortable with silence but when used appropriately, it can serve as a means for the client to organize thoughts or regain the right composure to respond or communicate effectively. Pressing clients to talk is disrespectful and conveys impatience. Sometimes silence may also mean the client has lost his train of thought or has totally forgotten 11 the question. The nurse must be quick to realize it and provide support and sometimes repeat the question. Normally silence lasts for just a few minutes but may feel like hours. The nurse should as much as possible allow the client to break the silence. 10. Clarifying time or sequence It involves putting events in the proper sequence. This enables the client gain insight into cause and effect relationships. It helps to determine things that are related and those that are not. What seemed to lead up to….? Was this before or after……..? When did this happen………? 11. Reflecting It is also known as reflective listening. It involves the use of statements to mirror the client’s comments to confirm assertions or assumptions. It enables them to explore their own ideas and feelings about a situation. The scenario below demonstrates how the nurse uses reflection or reflective listening enabled her to elicit vital information from the client by simply making statements about what s/he thought the client meant. Client: I spend too much time on the internet and not enough time with my wife. Nurse: you feel you are spending too much time on the internet. [Statement not an assumption] Client: yes. My wife complains every evening because I am on the computer. Nurse: she is angry because you spend too much time on the internet. Client: she slams the door and refuses to cook sometimes. Nurse: are you concerned about your marriage.[a guess at his feelings(reflecting feelings or interpretations)] Client: yes 12 12. Restating or paraphrasing Restating the client’s message using one’s own words. It consists of repeating in fewer and fresher words the essential ideas of the client. This communicates understanding to the client offers the client a clearer idea of what they have said. For example the client says “I can’t focus. My mind keeps wandering.” The student nurse says,” You’re having difficulty concentrating?” 13. Self-Disclosure This is the intentional revelation of true personal experiences about the self, to another person for the purpose of emphasizing both the similarities and the differences of experiences. These exchanges are offered as an expression of genuineness, trust, empathy, encourages shared decision making, reduces fears and normalizes the client’s experiences. Disclosures should be relevant and appropriate. The decision to disclose information about self must be carefully considered, and used only to advance the client’s health goals based on the needs of the client (rather than the nurse’s)They are used sparingly so the client is the focus of the interaction: “That happened to me once, too. It was devastating, and I had to face some things about myself that I didn’t like. I went to counselling and it really helped.....what are your thoughts about seeing a counsellor?” When used inappropriately it can be dangerous communication technique for blurring boundaries. Inappropriate self-disclosures include sharing personal information such as home address, telephone number or email address. 14. Asking Relevant Questions Questions are used to seek information needed for decision making. It is advisable to ask only one question at a time and fully exploring one topic before moving to another area. Open-ended questions allows for taking the conversational lead and introducing pertinent information about a topic. It invites elaborate answers beyond one or two words. For example “What is your biggest problem at the moment?” or “How has your pain affected your life at home?” “What brought you to the hospital today?” 13 15. Summarizing It is a concise review of key aspects of interaction. it pulls together information for documentation. Gives a client a sense you understand. Summarizing brings a sense of closure. Example “It is my understanding that your arm pain is a level 1 since you’ve taken Diclofenac one hour ago. Taking your pain medication before physical therapy seems to help you complete the activities the doctor wants you to do for your rehabilitation. Is this correct?” Client responds “Yes It really helps to take the medicine before I do my physical therapy because it helps reduce the pain in my arm.” This technique can be used to review a health teaching session and often serves as an Introduction to future care planning. Other examples of summary introductory statements are “During the past 30minutes we have discussed....” “In a few days I’ll review what you have learned about the dietary modifications for diabetes 16. Sharing Empathy The ability to understand and accept another person’s reality, to accurately perceive feelings, and to communicate understanding. Example “It must be very frustrating to know what you want and not be able to do it”. 17. Making observations Without appearing to be judgemental, you should be ready to make your perceptions about the client and his/her condition known. For example if a client comes with a swollen leg but does not tell you the history behind it, you may ask, “your leg is swollen what happened” 18. Broad openings/giving the client the opening. It is sometimes necessary to allow the client initiate the discussion. This can be achieved by using open ended questions such as, “what concerns would you like to talk about or what brings you here today. 14 NON-THERAPEUTIC COMMUNICATION TECHNIQUES Non therapeutic communication techniques hinder communication and generally focus on the nurse and meet the nurse’s needs Asking irrelevant personal questions; Asking person questions that are not relevant to the situation, is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. “Why aren’t you married to Mary?” is not appropriate. What might be asked is “How would you describe your relationship to Mary. Offering personal opinions; Giving personal opinions, takes away decision-making for the client. Remember the problem and the solution belongs to the patient and not the nurse. “If I were you I’d put your father in a nursing home” can be reframed to say,” Let’s talk about what options are available to your father.” Giving advice; Giving personal opinions, takes away decision-making for the client. Remember the problem and the solution belongs to the patient and not the nurse. “If I were you I’d put your father in a nursing home” can be reframed to say,” Let’s talk about what options are available to your father.” Giving false reassurance; “Don’t worry, everything will be all right.” When a client is seriously ill or distressed, the nurse may be tempted to offer hope to the client with statements such as “you’ll be fine.” Or “there’s nothing to worry about.” When a patient is reaching for understanding these phrases that are not based on fact or based on reality can do more harm than good. The nurse may be trying to be kind and think he/she is helping, but these comments tend to diminish the client’s feelings and discourage further expressions of feelings. it can also give a patient false hope in the face of a negative outcome. A better response would be “It must be difficult not to know what the surgeon will find. What can I do to help?” Changing the topic/subject; “Let’s not talk about your health insurance problems it’s time for your walk” Changing the subject when someone is trying to communicate with you is rude and shows a lack of empathy. It ends to block further communication, and seems to say that you don’t really care about what they are sharing. “After your walk let’s talk some more about what’s going on with your insurance company.” 15  Arguing ; “How can you say you didn’t sleep a wink when I heard you snoring all night long!!?” Challenging or arguing again perceptions denies that they are real and valid to the other person. They imply that the other person is lying, misinformed, or uneducated. The skilful nurse can provide information or present reality in a way that avoids argument: “You feel like you didn’t get any rest at all last night, even though I thought you slept well since I heard you snoring.” Passive or aggressive response or Defensive Responses; Patients sometimes express dissatisfaction and unhappiness with the care received. The nurse should never become defensive in such an instance. Being defensive sometimes change the terms of the nurse- patient relationship to attacker – defender and in such a situation, the therapeutic communication which is built on trust collapses. “No one here would intentionally lie to you.” When clients express criticism, nurses should listen to what they are saying. Listening does not imply agreement. To discover reasons for the client’s anger or dissatisfaction, the nurse must listen uncritically. By avoiding defensiveness the nurse can defuse anger and uncover. Asking “why” questions; Example, Why did you insult your mum! Offering value judgements; Nurses must not impose their own attitudes, values, beliefs, and moral standards on others, while in the professional helping role. “You shouldn’t even think about assisted suicide, it’s just not right.” Judgmental responses by the nurse often contain terms such as should, ought, good, bad, right or wrong. “That’s good (bad).” These responses imply that the client must think as the nurse thinks which ends up hampering client independence. The nursing response “I’m surprised you are considering assisted suicide. Tell me more about it...” gives the client a chance to express ideas or feelings without fear of being judged. Excessive questioning; Asking too many questions. Sympathy; feeling for the patie 16  CHAPTER TWO PRINCIPLES AND BASIC SKILLS IN COMMUNICATION IN HEALTH CARE ENVIRONMENT PRINCIPLES OF COMMUNICATION 1. Correct Time The timing of communication significantly affects the outcome. Apart from the duration of the interaction, an interaction schedule at a wrong or inconvenient time will be ineffective. E.g. scheduling an interaction during visiting hours or when the client is engaging in some sort of recreation such as watching a programme on TV is likely to result in a hasty interaction. Involving the client in scheduling the time will show the client that the nurse has the client needs in mind. 2. Conducive Place The nurse should take into consideration the environmental conditions such as good lighting, minimal noise, good ventilation and most importantly the place should be as private as possible. 3. Ensure client’s comfortability An uncomfortable client will have a short attention span by getting easily distracted. Comfortability may vary from client to client and may vary based on circumstances. Just as mentioned above the physical environment should be conducive in terms of adequate temperature, comfortable seats etc. a client who cannot get up in bed may be propped up or placed in a comfortable position. Reports of pain or anxiety should be well catered for. 4. There should be clear guidelines. The health professional should be ready to share some basic information with the client. 17  Name Purpose of the interaction Duration Assurance of confidentiality Setting the stage in this manner enables the client to feel at ease. 5. Accepting the client. The health professional must approach the interaction with an open mind. This implies that s/he recognizes personal prejudices, values and feelings and doesn’t bring them into the interaction. This non-judgemental approach enables the health worker to be more receptive to the client’s feelings and behaviours even if they contradict that of the health professional. In certain instances, the nurse’s feelings may be based on the wellbeing of the client, but accepting the client requires the health professional not to be quick to judge but rather try to accept and understand the client. 6. Self-awareness As health workers, we must periodically perform a self-examination I order to identify which feelings of ours can interfere with a therapeutic communication. A health worker who is not comfortable with a particular interaction may conveniently attempt to interrupt the client or change the subject entirely. 7. Active listening 18 Active listening goes beyond the mere act of quietly listening what a client says. It is an active process requiring effort in paying close attention to both spoken words and non-verbal cues. The health worker must be genuinely interested in the client in order to generate that effort. One listening behaviour is by providing periodic feedbacks. This communicates understanding and acceptance of client’s thoughts and emotions. 8. Inform patient about who you are and enquire about his background to help you know more about him or her. 9. The nurse/midwife should not try to feel superior, inferior, apprehensive, belittle or intimidated based on the patient appearance or intention. 10. Let the client/patient talk without unnecessary interruption from the nurse. 11. Consider the cultural background of the client/patient. 12. Identify the purpose of the conversation. 13..Ask open ended questions. 14.Take care of your own emotions. 15.Be non-judgmental. 16.Exhibit confidence. 17.Be consistent. 17.Deal with public speaking anxieties. 18.Manage the conversation 19.-Focus on the goa 20. - Provide privacy 21. - Maintain eye contact 22. -It should be done at a convenient place 19  LEVELS/COMPONENT OF COMMUNICATION Intrapersonal Communication Interpersonal Communication Group Communication Public communication- Transpersonal communication 1. Intrapersonal Communication It is the communication that occurs in one’s mind. Example, when you make any kind of decision-when you think about whether you should dress a patient wound now or later 2.Interpersonal Communication This is a communication between two people. An example is a patient and nurse discussing a treatment. 3 Group Communication -Small group- communication within formal or informal groups or teams -One-to-group communication-involves a speaker who seeks to inform, persuade or motivate an audien4. Small-group communication- Interaction that occurs when a small number of people meet and share a common goal. 4. Public communication- Interaction with an audience (nurses are required to use eye contact, gestures, etc.).ce. 5. Transpersonal communication- Interaction that occurs within a person’s spiritual domain. CHARACTERISTICS OF COMMUNICATION Communication is transactional Communication is complex Communication is unavoidable Communication is continuous Communication is learned 20  TRANSACTIONAL Communication is transactional because it involves exchange. One has to give and another receive for communication to take place. COMPLEX Communication is complex for several reasons. It is symbolic-Symbols are open to interpretation. It is personal and cultural-A person’s culture can add a new or different meaning to a phrase or gesture. It is irreversible-Once a message is sent it cannot be taken back. It is circular -It involves both original message and feedback which is necessary to confirm communication. It is purposeful-There is always a reason behind a message and it helps meet our needs. UNAVOIDABLE Communication is unavoidable because it is impossible not to communicate. CONTINUOUS Communication is continuous because it continues to impact and influence future interactions and shapes our relationships. LEARNED Communication skills can be learned because they can always be improved upon. Context in Communication This refers to the “when” and “where” of a communication event. -When-Refers to the time of the communication. -Where-Refers to the location/setting and situation in which the communication takes place. 21 Dimensions of context Physical Social Chronological Cultural. Physical context It refers to the physical environment in which communication takes place. The physical environment can influence the content and quality of interaction. For example, imagine how asking your ward in-charge for permission to stay out of work for three days might be received differently in each of the following settings: -In your in-charge’s office. -In the clinical area with others observing the conversation. -On her way home. Social context This refers to the nature of the relationship between the communicators as well as who is present. Imagine for instance, the difference in asking a ward in-charge for the permission under a variety of different social contexts: -You and the ward in-charge have been friends for several years or you and the ward in- charge have no personal relationship. -You are the same age as your ward in-charge or he/she is 15 years older (or younger) than you. -You and your ward in-charge have gotten along well in the past or have had an ongoing conflict with the ward in-charge. Chronological context This refers to the ways in which time influences interaction. -Is it busy time of the day (e.g. during ward rounds)? -Is it before, during or after work hours? 22 Cultural context This includes the ethnic or national backgrounds of the persons communicating. Differences in the cultural backgrounds of the nurse and the patient can have a great impact in the communication process between the two (2). How? Students are to give reasons. PROCESS OF COMMUNICATION PROCESS OF COMMUNICATION 23  CHAPTER THREE MODES/TYPES OF COMMUNICATION Nurses communicate with client’s often and in several ways. The two main types of communication are verbal communication and non-verbal communication. A. Verbal Communication It consists of all the words a person speaks or writes. Nurses and midwifes use verbal communication extensively. As nurses and midwifes, we converse with clients, interview patients and give oral change of shift-report. Types of verbal Communication Oral Communication Written Communication Electronic or Video Communication 1.Oral Communication All forms of speech between a sender and receiver. Advantages More effective than written when trying to influence a receiver’s opinion on some matter. Receiver’s response is faster Disadvantages Leaves no permanent, retrievable record of the message and response unless recorded. Nonverbal communication can affect the final interpretation of the message. 2.Written communication Come in the form of handwriting, printed memo or report. 24 Advantages Over Oral Communication Retrievable Almost permanent Comprehension is better because of rereading’s. Disadvantages Receiver’s response is more delayed in written communication than in oral communication Receiver must first read the message before interpreting and responding to it. 3.Electronic or video communication Communication through email, computer networks, fax machines, computer conferencing. Advantages High speed transmission and reception Accurate transmission of a message Easy dispersal of the same message to people in scattered locations Direct interaction and quick feedback 25  HOW TO USE VERBAL COMMUNICATION EFFECTIVELY AS NURSES AND MIDWIVES ESSENTIAL FACTORS INFLUENCE IN COMMUNICATION PACE AND INTONATION- Speaking rapidly may communicate the impression that the nurse is in a rush and does not The rate of speech can communicate meaning to have time for the client. the receiver. The nurse can communicate feelings such as The tone of voice can also communicate a variety acceptance, judgement and dislike through tone of feelings. of voice. CLARITY AND BREVITY- Clarity is saying The shortest, simplest communication is usually most precisely what is meant and brevity is using the effective. fewest words necessary. Communication that is long and complex may be difficult to understand. TIMING AND RELEVANCE- Know when to Knowing when to communicate allows the communicate and the messages need to relate to receiver to be more attentive to the message. the person or to the person’s interest and concerns Communicating with client who is in pain or distracted will make it difficult for the message to be conveyed. SIMPLICITY-This involves the use of It elicits a positive feedback from the client as commonly understood words and fewer words. he/she understands the message being conveyed by the nurse. Use of medical jargons may decrease client understanding CREDIBILITY- Refers to the worthiness of It promotes trust. belief, trustworthiness and reliability of the -A patient who is given false information will communication. soon distrust the nurse Credibility is ensured by being consistent, dependable and honest. 26 FLEXIBILITY- It is better to follow the patient’s It facilitates the flow of communication and lead whenever possible, in due time the nurse can therefore enhance a therapeutic relationship return to the subject ADAPTABILITY- The nurse’s verbal messages It demonstrates empathy and therefore enhances should be in accordance with behavioural cues the flow of communication. from the client. 27 B. NONVERBAL COMMUNICATION -Nonverbal behaviour is a major dimension of human communication. It is often said that, ‘it is not what you say but how you say it.” That is to say, it is the nonverbal behaviour that may be sending the “real” message. -Nonverbal communication accounts for 65% to 93% of the total meaning of communication (Birdwhistell, 1970; Mehrabian, 1981). -It is generally accepted that nonverbal communication expresses more of the true meaning of message than verbal communication. How true is this? Students are to discuss. Definition: Nonverbal communication represents a portion of the communication process that is free of words which includes messages created through body motion, the use of space, the use of sounds and touch. Any intentional or unintentional nonverbal behaviour which affects the interaction between two or more people. Nonverbal communication includes all relayed information that does not involve spoken or written word including cues from all the five senses. NOTE-Nonverbal communication can either be vocal or nonvocal. Vocal nonverbal communication encompasses sounds that do not involve language or words. For example, a patient experiencing pain may scream. Nonvocal nonverbal communication involves the other parameters of nonverbal communication either than sounds e.g. a smile or a frown on the midwife’s face. Nonverbal messages can also be intentional or unintentional. -If a person is communicating an important message to others, he or she will probably use a facial expression that notes the seriousness of the situation. For example, a nurse who maintains 28 a serious facial expression while telling a client about potential side effects of a new hypertensive drug is using intentional nonverbal communication. PURPOSES OF NONVERBAL COMMUNICATION 1.Expression of feelings and emotions Nonverbal communication is a channel for releasing built up feelings as well as an avenue for expressing day to day feelings. Nonverbal communication allows clients to tell nurses/midwives that they feel anxious. For example, a man whose wife is in ‘labour’ is seen standing at entrance of the ward nervously rubbing his hands together. 2.Repeating the verbal message If a visitor arrives at a patient’s bed and says ‘Hello dear, I‘ve brought you some flowers’ and proceeds to point to her basket with a flower, she is providing a nonverbal repetition of the verbal message. 3.Regulation of interaction Nonverbal communication may also regulate the flow of information between people. Nonverbal cues regulate an interaction by indicating to others whether individuals want to talk, when they want to talk, whether they want to listen and when conversation is over. A person by a nod or by eye contact may signal another he has finished speaking or if another is speaking that he wishes to say something. 4. Complementing verbal messages This means that it completes, adds to or modifies the verbal communication. The nurse who comments to her colleague that a patient on bland diet needs more color on his tray and places a flower on the napkin is adding to or complementing the verbal language. 5. Substituting the verbal language 29 This type of message actually replaces the verbal one. If a nurse drops a tray of medicine, the glare of her ward sister may clearly state, “don’t let that happen again”. 6. Validation of verbal messages It could be argued that of all the functions of nonverbal communication, the main function is validating the verbal dimensions of an interaction. Communication is most effective when nonverbal dimensions of messages validate the verbal dimensions. Reasons why patients and family members are attentive to nonverbal communication of health care providers i. Health care settings evoke considerable fear and uncertainty in patients and family members. To lessen their uncertainty, patients and family members become alert to information in their environment and to the nonverbal cues emitted by health care professionals. ii. Patients sometimes believe that health professionals are not completely honest with them. Patients may think that health professionals are trying to protect them from bad news or hiding their real feelings from them. Nonverbal communication becomes increasingly important during times of illness because people believe that the truth is often “leaked” through nonverbal channels. iii. Patients and family sometimes rely on nonverbal observations as a rapid means of gaining information even before any verbal interaction takes place. DIMENSIONS OF NONVERBAL COMMUNICATION The various forms of nonverbal communication include the following; Eye contact Facial expression Posture and gait Gestures Physical Appearance Mode of dressing and grooming 30  Smell Vocal cues ❖ Personal space Intimate distance: ranges from touch to 18 inches. Intimate distance is being used for lovemaking, comforting and protection. Personal distance: ranges from 18 inches to 4 feet- about arm’s length. Therapeutic communication occurs in this zone-explaining procedure to patient, reading pre- operative instruction to patient or educating patient on his/her condition. Social distance: ranges from 4 feet to 12 feet apart. Social distance in the nurse/midwife-patient relationship would be characterized by the nurse or midwife who stands in the doorway of the patient’s room to carry on a conversation. Public distance: when people are from 12 to 25 feet or more apart, they are at public distance. In health care setting, a community health nurse who is presenting a public seminar on hypertension at a community durbar would most likely be using public distance. Touch PURPOSES OF TOUCH IN HEALTH CARE SYSTEM Touching often expresses deep feelings impossible to rely by verbal means. When giving nonverbal indications of care and concern, the feelings conveyed may sound inane if expressed in words. 1. In the healthcare system, touch can often be synonymous with reassurance. How much a hand gently placed upon a shoulder or a slight pressure of fingers to other fingers may mean to a patient on the way to surgery can only be expressed by that patient. 2. Touch is also an important tool for diagnosing health problems. For instance, the fingers of a nurse or midwife as he/she palpates a patient’s body tell him/her more about the condition of the internal organs or of lumps than almost other method of examination.. 31 CLINICAL CONSIDERATIONS REGARDING TOUCH ✓ Use a form of touch that is appropriate to the particular situation. ✓ Do not use touch that imposes more intimacy on a patient than he or she desires. ✓ Observe the recipient’s reaction to touch ✓ 32  CHAPTER FOUR STYLES OF COMMUNICATION There are four main communication styles. Passive communication [non therapeutic] Aggressive communication [non therapeutic] Passive-aggressive communication [non therapeutic] Assertive communication [effective and healing] PASSIVE COMMUNICATION It is a communication style in which the individual does not express honest feelings, thoughts and beliefs, therefore, allowing others to violate their rights. It is a style in which individuals have developed a pattern of avoiding expressing their opinions or feelings, protecting other’s rights, and identifying and meeting other’s needs. As a result, passive individuals do not respond overtly to hurtful or anger-inducing situations. Avoiding aggressive communication doesn’t warrant being passive. Thus, this style is about pleasing other people and avoiding conflict. A passive person behaves as if other peoples’ needs are more important and other people have more rights. CHARACTERISTICS OF PASSIVE COMMUNICATION Reluctant to express their own feelings Always compliance / Find it difficult to refuse offer from others Put self-down Don’t disagree Try to support both sides of argument or will keep quiet to avoid conflict Finding difficulty in taking responsibility or decisions beat‐around‐the‐bush apologetic, e.g., “I’m terribly sorry to bother you” non-verbal characteristics voice- volume is soft 33  use minimal eye contact posture-looking down covering mouth with hand crossing arms for protection ghost smiles when expressing anger or being criticized jaw trembling lip biting People on the receiving end may feel Frustrated Guilty you don’t know what you want They can take advantage of you AGGRESSIVE COMMUNICATION It is a style in which individuals express their feelings and opinions and advocate for their needs in a way that violates the rights of others. They behave as if their needs are the most important, as though they have more rights and have more to contribute than others. They therefore tend to violate the rights of others and are therefore more physically or verbally abusive or both CHARACTERISTICS OF AGGRESSIVE COMMUNICATION STYLE o Tend to advocate for their needs in a way that violates the rights of others o Expresses opinion in a harsh sarcastic way o Find nothing wrong putting others down o Get angry and argues often o Poor listeners o Close minded and always want their opinion to be on top burner o Criticize blare and attack others o Act threateningly and rudely 34  o Use “you” to begin most statements when having conversation with others NON-VERBAL BEHAVIORS o Maintains a piercing eye contact o Posture-bigger than others o Gestures- pointing, fist clenching o Facial expression-frown, glare o Spatial position-invades others’ personal space, try to stand over others. o Crossing arms (unapproachable) o Intimidating, bullying o Evaluative comments, emphasizing concepts such as: should”, “bad”, “ought” o gender / racist remarks o Boastfulness, e.g., “I haven’t got problems like yours” Thus their statements always imply that; o The other person is inferior, wrong and not worth anything. o They are superior and right. o The problem is the other person’s fault. o They are entitled and that the other person owes them. People on the receiving end may feel o The receiver may feel; o Defensive, aggressive o Uncooperative o Humiliated/degraded o Hurt o Afraid o A loss of respect for the aggressive person o Fails to report mistakes and problems 35 PASSIVE-AGGRESSIVE COMMUNICATION It is a type of communication style in which the individual appears passive on the surface but communicates anger behind the scenes an indirect way. CHARACTERISTICS OF PEOPLE WITH PASSIVE-AGGRESSIVE COMMUNICATION o mutter to themselves rather than confront the person or issue o have difficulty acknowledging their anger o use facial expressions that don't match how they feel - i.e., smiling when angry o use sarcasm o deny there is a problem o appear cooperative while purposely doing things to annoy and disrupt o Unreliable o Gossips o Feel incapable to deal directly with the object or the person whom they resentments. o Pleasant to people to their faces but poisonous behind their backs (sabotage, rumours, etc). o Facial expression-often looks sweet and innocent People on the receiving end may feel o Confused o Angry o Hurt ASSERTIVE COMMUNICATION o It is a communication style in which individuals clearly states their opinions and feelings and firmly advocates for their rights and needs without violating the rights of others. Assertive communication is the healthiest and most effective style of communication. Individuals therefore have the confidence to communicate without resorting to manipulation. CHARACTERISTICS OF PEOPLE WITH ASSERTIVE COMMUNICATION STYLE Selection of an appropriate location for the verbal exchange 36  Maintains direct eye contact without staring Sensitivity to cultural needs Speaking using “I” statements Avoiding using “you” statements that can indicate blame Stating concerns using open, honest and direct statements Conveying empathy His/her communication show congruence Disagree with you but with respect Refuse request without feeling guilty Negotiate, bargain and will postpone decisions Use normal tone and exhibits good body posture Focusing on the behaviour or issue of conflict and avoiding personal attack Concluding with statements that describes a fair solution People on the receiving end feel They can take the person at their word Respect for the person The person can cope with justified criticism and accept compliments ADVANTAGES OF ASSERTIVE COMMUNICATION It helps us feel good about ourselves and others. It leads to the development of mutual respect with others. It increases our self-esteem. It helps us achieve our goals. It reduces anxiety. It protects us from being taken advantage of by others. It minimizes hurting and alienating other people. o It enables us to make decisions and free choices in life. 37 WAYS NURSES USE ASSERTIVE COMMUNICATION Make statements without conveying aggressiveness or passivity Make confidence statements of fact Express feelings freely but respectfully Communicate comfortably Communication styles Principles of Assertiveness 1. Use “I” statements: Being assertive requires taking responsibility for your own feelings. E.g. use expressions such as “I feel sad”, “I feel angry”, and “I feel happy”. Do not say “You make me feel…”.This gives others control over your feelings and blames others for what’s going on inside you. Everyone is responsible for his/her own feelings. No one can “make” you feel but rather you have learned to feel certain ways about certain situations. Everyone has the choice to feel anyhow he/she wants. use “I” statements for thoughts and opinions “I think…” 38  “In my opinion...” “I would like…” “I want…” “I need…” “I don’t want you to” “I liked it when you….” In summary, starting a statement with “You” often means you are blaming someone else. Blame often leads to arguing about whose feeling or thought are right. Your feelings are neither right nor wrong Other’s feeling are neither right nor wrong Using “I” statements removes right and wrong from the conversation. You can practice the use of “I” by staring with compliments. Walk up to your colleague. In the persons eyes, say one thing that you like about him or her. E.g. "I like that wig you are wearing, Vida." "I liked what you said in class today, Cyril." Practice till you feel comfortable with a deliberate use of the word "I" and expressing your likes positively. Assertiveness is a habit worth developing, a skill to master. 2. Focus on specific behavior, not generalities. Focusing on specifics helps everyone understand what needs to be worked on. Labeling someone, doesn’t tell the other person what exactly needs to change. Describing the specific behavior enables the other person know what you are reacting to and what could be changed Below are two examples. Specific = “I felt angry when you called me stupid because I do not like being insulted.” General = “You make me mad because you are a rotten person.” Specific = “I am very angry because I am serving medications lately, because you did not hand over to me on time.” Or I am angry because I am going home late because you were not available for me to hand over to you. 39  General = “You are never organized” or “You are never punctual” 3. Describe what you would like to be different “I felt angry when you called me stupid because I felt insulted. I would like for you not to call me names.” “I feel unimportant to you when you avail yourself late for handing over’ I would like to be called if you can’t make it on time.” In summary Always remember to Start with an “I” statement – “I feel…”, “I think…”, “I want/need…” ii. Talk about specific behavior. iii. Ask politely for specific behavior changes you might want iv. Allow the other person to respond based on their own needs, feelings, and thought. 3. Don't say "YES" when you want to say "NO". 4. This does not go endorse egoism or selfishness, but for responsibility. Response + ability= assertiveness. The ability to respond "No" to unreasonable requests. 5. Be direct by talking to the person for whom it is intended. Don’t go around talking to other people he/she knows hoping that he/she gets the message. 6. You should explain exactly what you mean or do not mean. Example: I don’t want to break up over this, but I think we need to talk about how we can prevent this from happening again. 6. It often causes resistance and resentment, rather than cooperation and understanding when you suggest someone should change for his/her benefit, when actually it would rather please you. 40  CHAPTER FIVE BARRIERS OF COMMUNICATION Barriers to communication can be defined as the aspects or conditions that interfere with effective exchange of ideas or thoughts. A communication barrier is anything that prevents an individual from receiving and understanding the messages others use to convey their information, ideas and thoughts. These barriers that affect communication between the nurse and patient are classified as follows: Physical impairment to communication Outside impairment affecting communication Mental impairment affecting communication Personality conflict and communication Medical jargons PHYSICAL IMPAIRMENT AFFECTING COMMUNICATION Impairment such as vision, hearing and speech has a potential effect on communication. Patients with Hearing Disorders do not hear sounds clearly. Such disorders may range from hearing speech sounds faintly, or in a distorted way, to profound deafness. Visual impairment is defined as the limitation of actions and functions of the visual system. It is very hard for people who are visually impaired to communicate with others because although they can hear people it is hard to fully understand what someone is saying unless you can see them. Stuttering which is interruption in the rhythm of speech characterized by hesitations, repetitions, or prolongations of sounds, syllables, words, or phrases also affects communication for example, he he he head-ache, tuh-tuh-tuh-table, etc. 41  OUTSIDE IMPAIRMENT AFFECTING COMMUNICATION There are several outside impairments affecting communication. These are environmental factors that act as impediment to communication. They include external noise, time, physical distance, space, climate and place. PERSONALITY CONFLICT AND COMMUNICATION o Personality conflict refers to a situation in which two or more people have very different characters and are unable to have a good relationship with each other (Cambridge Dictionary). o Personality conflicts occur when two or more people find themselves in a disagreement not over a particular issue or incident, but due to a fundamental incompatibility in their personalities, their approaches to things and their style of life. These personality conflicts can disrupt communication as it can lead to disagreements among nurses, nurses and physicians as well as nurses and patients and/or relatives. MEDICAL JARGONS Medical Jargons are terminologies used by health professionals to simplify a particular concept. These medical jargons are meant to enhance communication but at times it can act as the biggest barrier to communication. If a patient or a relative is unaware of the terminologies a nurse/midwife is using, it means then they are likely to lose concentration thereby affecting the communication between the two. 42  CHAPTER SIX COMMUNICATION TECHNOLOGIES Communication Technology: electronic systems used for communication between individuals and groups. Communication technology facilitates communication between individuals or groups who are not physically present at the same location. Systems such as telephones, fax, radio, television, and video are included, as well as more recent computer-based technologies, including electronic data interchange and e-mail. MODERN TYPES OF COMMUNICATION TECHNOLOGIES Fax (facsimile) sometimes called telecopying or telefax. Email: Communication sent to individual(s) or a discussion list. Instant Messaging (IM): instant, text based 'chat' programs through which users on a private contact or "buddy list" can communicate. SMS text/digital image messaging: Messages or images sent via mobile-phones. Other social networking communities: ✓ Web site such as facebook and MySpace can be essential to getting your message out. You gather “friends” on these sites. ✓ Tweeting- The website Twitter allows you to broadcast very short messages “tweets” to people who have elected to follow your posts. o Video Conferencing: TELEPHONE COURTESY Below are some general principles in maintaining positive phone manners Answering the Phone Pick the phone within 3 rings Greet Announce your name/unit/department Ask how you may assist. 43  Example; “good morning, Dormaa Presby Hospital, Emergency department, how may I help you please” OR “thank you for calling Ankaful Hospital, Good afternoon, OPD, Serwaa speaking” o Avoid saying “hello”. Placing caller on hold o Ask if you may put them on hold o Give time frame. Be honest about time required and give the option of calling them back. Example; “I’m trying to reach Dr. Oppong, would you like to hold on for a minute or we should call you back” o Wait for a response o Thank the client for holding after you return to the line How to take a message o Explain your coworkers absence in a positive light ✓ Stephen has stepped out ✓ Stephen isn’t available at the moment o Inform the caller of the availability of the person he wants to talk to BEFORE asking his name. o Give estimate time of your co-worker’s return if possible o Offer to help the person yourself, take a message or transfer them to another person Ending the call ▪ Talk in the past tense and use closing phrases, e.g. “I’m really glad you called”. ▪ State the action you will take. ▪ Spell out follow-up action, including time frames/deadlines. 44  Telephone language When communicating on telephone, we should try as much as possible try to avoid the use of the following phrases: “You have to….” “hang on” “Hold on” “I can’t hear you, speak up” “Who is calling?” “the Nurse in-charge is busy you can’t talk to him/her now” The following would be more appropriate: o “May I put you on hold?” o “May I know w ho is calling, please” o “I am having a little difficulty hearing you. Can you speak up?” o “I am sorry the Nurse in-charge is currently with a patient, may I take a message and we will return your call as soon as possible.” PHONE ETIQUETTE AT THE WARD The nurse communicating on phone should not talk on top of his/her voice The nurse should avoid using phone while attending to patient. Call should be received at appropriate place The nurse should avoid fidgeting with the phone whilst at the ward Avoid using gestures The nurse should not be on phone for long time. o The phone should be on silence mode ADVANTAGES OF COMMUNICATION TECHNOLOGY Improved communication – advanced communication technology tools makes it possible to communicate from anywhere in the world (e.g. one can easily talk to people anywhere in the world using a phone). 45  Easy access to information – at anytime and anywhere; We can share data with people by sending them things or sharing things with them over the internet. Improved entertainment - we have more video games now, good music to listen and visual systems like smart TV. Convenience in education – (online and mobile education) Computer’s along with their programs and the Internet has created educational opportunities not available to previous generations. Information is freely available to any and all with an internet connection. faster method of communication during emergencies DISADVATAGES OF MODERN TECHNOLOGY Job Loss Modern technology has replaced many humans; robots are doing the jobs which used to be done by humans. Many packing firms have employed robots on production lines to increaseproduction and efficiency, this is good news for businesses because it helps them make more money and serve customers in time, but it is bad news to employees because they get replaced by a robot. Effect on health Thought various technologies have made our life comfortable, they have come at the cost our health. The impure air and water are hazardous to human health. Loud noise of vehicles and running factories disrupts the human auditory senses. Excessive use of smartphones causes stress and posture related health issues. Excessive exposure to radiations (x-ray) Environmental Problems Technology brings all sorts of environmental problems. As well as machines and devices often being made from toxic or non-biodegradable materials, most technologies need a power source, which can often mean an increase in the consumption of electricity and fossil fuels. Aside from power, some technology produces materials that are toxic. Reduced Human Relations 46  Human relations are diminished in the virtual world. As online social networking increasingly replaces face-to-face and physical contact, alienation can increase, as well as problems such as cyber-bullying. Humans are social beings and lack of interaction could lead to anxiety and depression. Communicating over the phone remains an important tool for businesses. Phone calls are often the first positive impression a client or customer will have of your business. Phone etiquette is the way you use manners to represent yourself and your business to customers via telephone communication. This includes the way you greet a customer, your body language,tone of voice, word choice, listening skills and how you close a call. 47  CHAPTER SEVEN THERAPEUTIC RELATIONSHIP (helping relationship) Relationship is defined as a state of being related or state of affinity between two individuals. Example-friendship and colleagues TYPES OF RELATIONSHIP Social Relationship Intimate Relationship Therapeutic Relationship SOCIAL RELATIONSHIP It is the most common type of relationship between two individuals in everyday life. Individuals are equally involved in this relationship and meet their needs through relationship. There is no predetermined goal or focus in the relationship. INTIMATE RELATIONSHIP It is the relationship between two individuals committed to one another, caring for and respecting each other. The intimate relationship forms the basis for marriage and other partner type of relationship. THERAPEUTIC RELATIONSHIP A therapeutic relationship is a planned and goal-directed process between a nurse and a client for the purpose of providing cares to the client and the client family or significant others. Therapeutic relationship refers to the relationship between a healthcare professional and a client (or patient) involving interaction between the two that hope to effect beneficial change in the client. 48  It is the relationship where the nurse and client work together towards the goal of assisting the client to regain inner resources to meet life challenges and facilitate growth. CHARACTERISTICS OF A HELPING RELATIONSHIP It is a professional relationship Respects the client as an individual, including o Maximizing the client ability to participate in decision making. o Considering ethnic and cultural aspects. o Considering family relationship and values. Respects client confidentiality Focuses on client’s well-being Is based on mutual trust, respect and acceptance. FACTORS THAT POSITIVELY AFFECT THE DEVELOPMENT OF THE THERAPEUTIC RELATIONSHIP NURSE FACTORS CLIENT FACOTRS o Consistent approach to interaction o Trusting attitude o Adjustment of pace to client’s needs o Willingness to talk o Attentive listening o Active participation o Positive initial impressions o Comfort level during the relationship o Self-awareness of own thoughts and feelings o Consistent availability PHASES OF THE THERAPEUTIC RELATIONSHIP Peplau, 1952, identified four main phases of a helping relationship. These include; Pre-interaction phase Introductive phase/orientation phase/ pre-helping phase Working phase Termination phase 49  Task and Skills for Each Phase of the Helping Relationship PHASE TASKS SKILLS This is the phase in a nurse goes through before the Pre-interaction Phase Organized data gathering actual interaction with the client. The nurse reviews pertinent assessment data and knowledge, considers potential areas of concern and develops plans for interaction. This is a phase which begins when the nurse goes to the client o A relaxed, attending o Both client and nurse identify each other by attitude name. o Open ended questions o The nurse/midwife explains his/her role in the relationship o The nurse helps the client to express concerns and reasons for seeking help. Attentive listening, Paraphrasing, o Help client to clarify the problem. Clarifying o Nurse and client develop a degree of trust and Introductory Phase verbally agree about (a) overall purpose of the Other therapeutic communication relationship (b) how confidential materials will skills be handled, (c) tasks to be accomplished and (d) duration and indication of termination. During this phase the nurse and client actively work on meeting the goals which they had established during the orientation phase 50  o The nurse assists the client to identify his or her problems Listening and attending skills, o The nurse helps the client to find an alternative Working Phase empathy, respect, genuineness, solution to his or her problem or development concreteness, self disclosure and of insight confrontation. o The nurse helps the client to understand that he/she has significant role in his treatment. o Remind the client about the termination of the Decision making skills. relationship The goal of this phase is to bring a therapeutic end to the relationship Nurse and client accept feelings of loss. The client accepts the end of the relationship without feelings of anxiety or dependence. Nurse-summarizing skills Client-ability to handle problems independently Termination Phase CONDITIONS ESSENTIAL FOR THERAPEUTIC RELATIONSHIP The nurse must acquire certain skills or qualities to `initiate and continue a therapeutic relationship. ▪ Empathy: 51  Case study empathy ‘Following the placement of your second semester examination result, you realized that you had low grade in two of the papers. Having never received low grade before, you became disappointed and surprised at your assessment. You wonder where you went wrong and you started feeling depressed. You started blaming yourself and felt being a failure. Your friends decided to cheer you up. Birago tells you how sorry she is that you failed the exams. Kisiwaa places her arm around your shoulder and says, 'I know how you're feeling. I failed anatomy last semester. I know you must be disappointed and upset with yourself, but try not to be too harsh.' Kisiwaa’s response is an example of empathy What is empathy? o Katz (1963) describes empathy as the capacity to “see with the eyes of another, to hear with the ears of another and to feel with the heart of another”. o The capacity to sense the client’s private world as if it were your own without losing the “as if” quality o Empathy is the nurse’s ability to zero in on the feelings of another person or to “walk in another’s shoes.” o Empathy is the ability to understand what another person is feeling. Showing empathy involves seeing things from another person's perspective so that you can understand and relate to his or her feelings. o Empathy is the ability of the nurse to enter into the client’s relational world, to see and feel the world as the client sees and feels it, and to explore the meaning it has for the client. It is easier to empathize with someone when you have been in a similar situation. For instance, kisiwaa, was easily able to show empathy because she had previously failed in anatomy. 52  EMPATHY VERSUS SYMPATHY A simple way to distinguish between them is that in empathy we understand the feelings of others whilst in sympathy we feel the feelings of others. Sympathy is associated with feelings of pity and commiseration. When people express sympathy, they express agreement with another, which in some situations may discourage further exploration of person’s thought and feelings. Therapeutic effects of empathy on patients Showing empathy reduces client’s feeling of alienation and of being “all alone” with their predicament. Empathy breaks down the sense of being an isolated island that people with illness often experience. It also provides clients with a sense of confirmation. SKILLS THE NURSE OR MIDWIFE SHOULD POSSES FOR EMPATHY Active listening skills Set aside judgement or personal biases. Appropriate questioning Give yourself time to think about what client has said before responding or before asking the next question. Provision of requisite information when needed. The use culturally appropriate gestures including touch ▪ Trust: Trust involves accepting others without evaluating or judging them. Strong foundation of trust promotes comfort, security and honesty.. Trust is bidirectional in the nurse-client relationship. Not only must the client trust that the nurse will provide quality care based on his unique skills but also the nurse must trust that the client will provide honest information. 53  TECHNIQUES DESIGNED TO PROMOTE TRUST Convey respect Consider the client uniqueness Show warmth and caring Use the client’s proper name Give sufficient time to answer questions Use warm friendly voice Smile Maintain confidentiality Use appropriate eye contact Be flexible Be honest and open Provide consistency o Use an attending posture ▪ Confidentiality: o This refers to the ethical responsibility of a health care professional that prohibits the disclosure of privileged information without the patient’s informed consent. The nurse or the midwife should reassure the client that confidentiality will be maintained except when the information may be harmful to self or others or in instances of an abuse (such as reporting contagious disease, gunshot and child abuse). The nurse is to share information only with professional staff that needs to know. A written permission obtained from the client before sharing information with others outside the treatment team. Rules of keeping confidentiality Only health care team members directly responsible for the client’s care should be allowed access to the client’s records. 54  Keep discussion of patients and families professional. Do not remove medical records from the patient care areas unless this is essential for patient care. Do not make copies of patients’ records without the consent of the patient or other appropriate authority Client medical records must be kept in secure area to prevent inappropriate access to the information Electronic records should be password protected, and care must be taken to prevent public viewing of the information. Client information should not be disclosed to unauthorized individuals, including family members who request it and individuals who call on the phone ROLE OF THE NURSE/MIDWIFE IN THERAPEUTIC RELATIONSHIP Nurse teacher- educate client about his/her illness and the medication prescribed to promote early recovery. Mother surrogate: the nurturing needs of clients who are unable to carry out simple tasks are met by the sub role of the mother surrogate. Technical nurse: here the nurse usually completes vital signs, medical or surgical treatment procedures, administration of medication and physical assessment. Counselor: the nurse uses therapeutic skills to help clients identify and deal with stressors. ETHICAL CONCERNS OF THERAPEUTIC NURSE-PATIENT RELATIONSHIP Definition of ethics: It is a system dealing with standards of character and behaviour related to what is right and wrong. An ethic is ‘what ought to be’, these are rules or principles that govern right conduct. NURSING ETHICS o Nursing ethics refers to the study of principles of right and wrong conduct of nurses. 55 Nursing ethics state the duties and obligation of nurses to their clients, other health professionals, the profession and the community. Ethical principles in the nurse-patient relationship Ethical principles that the nurse/midwife has to consider when making decisions in the therapeutic relationship include; Autonomy Beneficence Nonmaleficence Justice Veracity fidelity ETHICAL PRINCIPLE DESCRIPTION Beneficence ❖ This relates to the quality of doing good. Thus this principle maintains that the nurse ought to do or promote good, prevent evil or harm and remove evil or harm. In other words, providing care that is in the best interest of client. Non-maleficence This principle states that one should do no harm. That is the explicit duty not to inflict harm on others intentionally. This principle therefore requires the nurse or midwife to avoid causing harm. Autonomy This refers to the client’s right to make his/her own decision. The client must accept the consequences of those decisions. Justice This is fair and equal treatment for all. In the nurse/midwife relationship, it refers to a duty of the nurse/midwife to treat all patients equally and fairly despite their race, gender, marital status, medical diagnosis, social standing, economic level or religious beliefs. 56 Veracity Veracity concerns truth telling and incorporates the concept that individual should always tell the truth. This principle states that the nurse or midwife is obliged to tell the truth in their communication with clients and clients’ family (thus being honest when dealing with the client). Fidelity This refers to loyalty and faithfulness to the client and to one’s duty. It therefore, means that the nurse should be faithful to agreements and promises made to patients. 57  CHAPTER EIGHT CULTIVATING CONVERSATION SKILLS ACTIVE LISTENING Active listening People want more than just physical presence in human communication. Most people are looking for the other person to be there for them psychologically, socially and emotionally. ✓ To listen actively is to be attentive to what the client is saying, both verbally and nonverbally. With active listening the nurse communicates acceptance and respect for the client and trust is enhanced. SKILLS THAT FACILITATE ACTIVE LISTENING These skills have been identified by the acronym SOLER S- Sit squarely facing the client. This gives the message that the nurse is there to listen and is interested in what the client has to say. O- Observe an open posture. Posture is considered open when arms and legs remain uncrossed. This suggests that the nurse is open to what the client has to say. L- Learn forward toward the patient. This conveys to the client that you are involved in the interaction and interested in what is being said. E- Establish eye contact. Eye contact intermittently directed is another behaviour that conveys the nurse’s involvement and willingness to listen to what the client has to say. The absence of eye contact or the constant shifting of eye contact elsewhere in the environment gives the message that the nurse is not really interested in what is being said. R- Relax. During the interaction, the nurse should communicate a sense of being relaxed and comfortable with the client. 58 OPEN ENDED VERSUS CLOSED ENDED QUESTIONS o A closed question is a question which can be answered with either a single word or a short phrase. A closed question can be answered with either 'yes' or 'no' or a specific information o A closed-ended question is a question format that limits respondents with a list of answer choices from which they must choose to answer the question CHARACTERISTICS OF CLOSED ENDED QUESITONS They give you facts. They are easy to answer. They are quick to answer. They keep control of the conversation with the questioner. Open ended questions o Open-ended questions are questions that require more than one word answers. The answers could come in the form of a list, a few sentences or something longer such as a speech, paragraph or essay. Open-ended questions require a response with more depth and a lengthier response. Open-ended questions are helpful in finding out more about a person or a situation CHARACTARISTICS OF OPEN-ENDED QUESTIONS They ask the respondent to think and reflect. They will give you opinions and feelings. They hand control of the conversation to the respondent. Open questions begin with words such as: what, why, how, describe. 59 The main difference between a closed-ended question and an open-ended question is the type of response that can be given. With a closed-ended question there are a limited number of choices to choose from when answering, but with an open-ended question the respondent can answer in their own words allowing for a wide variety of answers. CARRYING OUT CONVERSATION WITH CLIENTS/PATIENTS WITH DISABILITY Patients who are visually impaired Identify yourself by name Remember that the visually impaired will be unable to pick most nonverbal cues during communication. Speak in normal tone of voice Explain the reason for touching patient before doing so. Indicate to the patient when the conversation has ended and you are leaving the room. Keep bell within easy reach of patient. Orient the patient to sounds in the environment to the arrangement of the room and its furnishing. Be sure eyeglasses are clean and intact. Communicating with the hearing impaired patient Orient the patient to your presence before initiating your conversation. This can be done by gently touching the patient or moving so that you can be seen. Talk directly with patient whiles facing him or her. Do not chew gum or cover your mouth with hand talking with the patient. Use short sentences If the hearing deficit predominantly in one ear, move closer to the less affected ear. Demonstrate ideas you wish to express as appropriate. Use sign language as appropriate. Write any idea that you cannot convey to the patient in another manner. Be sure that hearing aids are clean, functioning and inserted properly. 60 Communicating with the unconscious patient Be careful of what is said in the presence of the patient. Assume the patient can hear you. Talk in a normal tone of voice about the things you will ordinarily discuss. Consult with previous caregivers or the family to determine what the client responds to Speak with the patient before touching Keep environmental noises at as low a level as possible. I Begin each interaction by identifying yourself and calling the client by name Explain all health procedures CONSTRUCTIVE CRITICISM Definition of Constructive Criticism It is communication technique intended to identify and find solutions to problems in a positive way. It usually applies to work a person does or to an individual’s behaviour. Constructive criticism therefore identifies ways in which the recipient can make changes that improve matters. It is designed to point out one’s mistakes, but also shows an individual where and how improvements can be made. Constructive criticism should be viewed as useful feedback that can help nurses or midwifes improve themselves rather than put them down. It builds up the other person and helps them to make positive changes to their behaviour in order to avoid future problems. Some clues that constructive feedback is needed at the ward are when: a colleague asks for your opinion about their approach to patients 61  unresolved problems persist errors occur again and again a nurse/midwife performance doesn't meet expectations a nurse/midwife has poor work habits Offering Constructive Criticism Feedback is an essential element for nurses, midwifes, other team members as well as patients and relatives in the health delivery. The way an individual presents his/her comments can make the difference between their being accepted and considered or being disputed and rejected. Below are steps which can help nurses/midwifes maximize the chances of their comments being understood and accepted by other health workers, patients or relatives. State the constructive purpose of your feedback. First, briefly state your purpose by indicating what you'd like to cover and why it's important. If you are initiating feedback, this focus keeps the other person from having to guess what you want to talk about. Limit the criticism to one topic. There may be several complaints but it is smart to focus on only one at a time. The respondent may be able to handle a single problem at a time but he/she may become emotionally upset or defensive following multiple complaints. Make sure the criticism is accurate. The critic should be absolute sure that he/she has the facts before speaking out. If even a small detail is out of line, the other person can argue about that, diverting the discussion from the real problem at hand. Focus on the situation, not the person. Thus offer criticism of the person's behavior, not on the person. Refer to what a person does, rather than his/her traits, or character. For example: "You talked considerably during the staff meeting, which prevented me from getting to some of the main points," rather than "You talk too much." Detach the situation from the person 62  Comment on the issue not the person Don’t make personal attack Be specific with your criticism/feedback. Describe the other’s problematic behaviour in clear terms. It should be straight to the point. Thus the individual should be direct when delivering feedback and avoid giving mixed messages. Don’t ‘beat about the bush’. The more detailed you can be about the behaviour that you want to see, the easier it is for the other person to do it. Let’s look at the example below: a ward-incharge criticizing a report by a staff midwife. “Good effort on the report but I didn’t like it” as compared to “Good effort but there are things which can be improved namely {a} the diagnosis and {b} the nursing care”. Feedback can be made specific through the following means; Focus more on objective points than subjective opinions. Break your feedback down into key points Give specific examples of each point. Deliver remarks as part of a positive relationship. Let the other person know that your specific criticism doesn’t diminish your respect or appreciation for the person in other areas. Sincerely acknowledging the positives can make the negatives easier to accept. Deliver criticism in a face-saving manner. Feedback should be given in private. Allowing other people to see and hear the discussion will embarrass all concerned. Provide a balance of positive and negative feedback. If you consistently give only positive or negative feedback, people will distrust the feedback and it will become useless. Avoid sounding judgemental. 63  Give recommendations on how to improve. When all is said and done, it helps to give recommendations on what the person can do to improve. Giving recommendation will give the person a clear idea of what you have in mind. It also provides a strong call to action. 64  CHAPTER NINE MANAGING DIFFICULT SITUATIONS THROUGH TALK Nurses/midwives in the process of discharging their duties may encounter difficult situations which they have to control. The nurse/midwife has to be equipped with the needed verbal skills required to deal with such situations. Why nurses need this knowledge? The knowledge of dealing with difficult situations by nurses/midwives is essential because of two main reasons; o Different nurses/midwives have different levels of communication competencies. This communication competencies may be related to self confidence, past experience, cultural background etc. o For nurses/midwives to become aware of difficult situations that might occur in the course of their duty and the skills required to handle such situations. Situations that possess d