Therapeutic Communication PDF

THERAPEUTIC COMMUNICATION DEFINITION Communication is the means of transmitting information from one person to another in a most effective way so that the intended meaning can be readily grasped or understood Communication is a process of transmitting and receiving information on a particula...

THERAPEUTIC COMMUNICATION DEFINITION Communication is the means of transmitting information from one person to another in a most effective way so that the intended meaning can be readily grasped or understood Communication is a process of transmitting and receiving information on a particular topic between two or more people that share the same code (verbal or non-verbal) aimed at reaching a mutual understanding(Stone et al, 1991). Components of communication Sender Message Channel Receiver Feedback The sender The sender is a person or group with the intention to communicate a message to another party. The sender initiates the process of communication by generating a message. The nurse must be mindful of medical jargons when communicating to a non-professional. Message The message is the content of the communication. This is usually in the form of verbal and nonverbal. The message should be expressed in clear terms to avoid confusion. Channel (medium) This refers to the means through which the message is sent or received. This can be through face to face, telephone, radio, written, emails, audiotapes or videotapes. Spoken words are received through auditory channels, facial expressions through visual channels and touch through tactile channels. Using more than one channel to convey messages makes it easier to comprehend. This also requires that the verbal and nonverbal communication corresponds. Receiver The recipient of the message is the one to whom the message is intended. The receiver is also known as the decoder because s/he makes the effort to establish a connection between the messages perceived and his/her own existing body of knowledge and experiences. Feedback The message received by the sender from the receiver which indicates to the sender whether the communication has been effective or otherwise. Feedback can also be verbal, non-verbal or both. The Communication Process An effective communication cycle involves six main stages. 1. Conceiving the idea or message to be sent 2. Encoding – to convert a message from a plane text into a code. Thought formulation into spoken /written words 3. Selecting the right medium or channel to obtain the right response. Example; letter, text message, phone, personal factor like cost, nature, confidentiality, time, etc. are considered 4. Decoding – translating the message received in to understandable language or vocabulary. Transform an encoded message in to understandable form. 5. Interpretation – trying to get the actual meaning of the message. 6. Feedback – the response or communication from the recipient to the sender. Levels of Communication 1. Interpersonal communication - Face to face interaction between the nurse and another person. 2. Transpersonal communication- interaction that occurs within a person’s spiritual domain. 3. Small-group communication- interaction that occurs when a small number of people meet and share a common goal such as focus group discussion. 4. Intrapersonal communication- Powerful form of communication that occurs within an individual. 5. Public communication- interaction with an audience (nurses are required to use eye contact, gestures, etc.). COMMUNICATION STYLES There are four communication styles. 1. Passive communication 2. Aggressive communication 3. Passive-aggressive communication. 4. Assertive communication Passive Communication It is a style in which individuals have developed a pattern of avoiding expressing their opinions or feelings, protecting their rights, and identifying and meeting their needs. A passive communicator puts peoples’ needs before his/her own. They are apologetic and subjugate their feelings and needs for others. Passive communication is usually born of low self-esteem. These individuals believe: “I’m not worth taking care of.” Passive behaviours You hope that you will get what you want. You sit on your feelings and rely on others to guess what you want. You do not express your needs 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. Thus, aggressive communicators are verbally and/or physically abusive. Aggressive communication is an ineffective way of communication, however, a common style adopted by many. An aggressive communicator humiliates and embarrasses others which eventually destroys interpersonal relationships, reduces productivity and endangers clinical outcomes. Aggressive behaviours You try to get what you want You think that only you have rights Imposing your will or needs on others. Passive–Aggressive It is a style in which individuals appear passive on the surface but are really acting out anger in a subtle, indirect, or behind- the-scenes way. Instead, they express their anger by subtly undermining the object (real or imagined) of their resentments. They smile at you while setting booby traps all around you. Passive-Aggressive communicators will often: mutter to themselves rather than confront the person or issue have difficulty acknowledging their anger use facial expressions that don't match how they feel - i.e., smiling when angry use sarcasm appear cooperative while purposely doing things to annoy and disrupt Assertive Communication Assertive communication is the process of clearly and confidently expressing ones opinions, needs, wishes and desires without infringing on the rights of others. Assertive communication is born of high self-esteem. One can also be said to be assertive if s/he confidently and honestly expresses opinions, thoughts, ideas and rights without guilt feelings or undue anxiety in a manner that respects the rights of others. Assertive communicators will: state needs and wants clearly, appropriately, and respectfully use “I” statements communicate respect for others listen well without interrupting have good eye contact  speak in a calm and clear tone of voice have a relaxed body posture feel competent and in control not allow others to abuse or manipulate them stand up for their rights. ADVANTAGES 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 help us achieve our goals It minimizes hurting and alienating other people  It reduces anxiety Assertiveness enables us to make decisions and free choices in life. It enables us to express both verbally and non-verbally a wide range of feelings and thoughts, both positive and negatives. Characteristics of assertiveness 1. Eye contact: demonstrates interest, shows sincerity 2. Body posture: congruent body language will improve the significance of the message. 3. Gesture: appropriate gestures help to add emphasis. 4. Voice: a level, modulated tones is more convincing and acceptable and is not intimidating 5. Timing: use your judgement to maximize receptivity and impact. 6. Content: how, where and when you choose to comment is probably ,ore important than WHAT you say. The importance of “I” statements Being assertive involves the ability to appropriately express your needs and feelings. It indicates ownership, do not attribute blame, focuses on behaviour, identifies the effect of the behaviour, is direct and honest and contributes to the growth of your relationship with others. “I feel angry when…” “I like your hairstyle” “I feel frustrated when you are late for classes” TECHNIQUES FOR ASSERTIVE COMMUNICATION 1. Behaviour Rehearsal Practicing how you want to look and sound. It is very useful when you first want to use “I” statements, as it helps dispels any emotion associated with an experience and lets you to precisely identify the behaviour you wish to confront. 2. REPEATED ASERTION (the ‘broken record’) It allows you to feel comfortable by ignoring manipulative verbal side traps, argumentative baiting, and irrelevant logic while sticking to your point. Say what you want to and stay on the issue. Example: “I would like to show you some of our products” “No thank you, I’m not interested”. “I really have a great range to offer you” “that may be true, but am not interested at the moment” “ok, would you take this brochure and think about it” “yes, I will take a brochure” “thank you” “you are welcome” 3. FOGGING It allows you to receive criticism comfortably, without getting anxious or defensive, and without rewarding manipulative criticism. There may be some truth to what they say, but remain the judge of your choice of action. Example: “I agree that there are probably times when I don’t give you that attention”. 4. NEGATIVE ENQUIRY It seeks out criticism about ourselves in close relationships by prompting the expression of honest, negative feelings to improve communication. Listen to the critical comments, clarify your understanding of those criticisms, use the information if it will be helpful or ignore if not. Example: “so you think/believe that am not interested?” 5. NEGATIVE ASSERTION It lets you look more comfortably at negatives in your own behaviour or personality without feeling defensive or anxious, this also reduces your critics’ hostility. Accept your errors or faults but not apologize. Instead, tentatively and sympathetically agree with hostile criticism of your negative qualities. Example: “yes, you are right. I don’t always listen closely to what you have to say.” 6. WORKABLE COMPROMISE When you feel that your self-respect is not in question, consider a workable compromise with the other person. You can bargain for your material goals unless the compromise affects your personal feelings of self-respect. However if the end goal involves a matter of self-worth and self-respect, THERE CAN BE NO COMPROMISE. Example: “I understand that you have a need to talk and I need to finish what I’m doing. So what about meeting in half an hour?” 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. 2. Focus on specific behavior, not generalities. Focusing on specifics helps everyone understand what needs to be worked on. 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 am angry because I am going home late because you were not available for me to hand over to you. General = “You are never organized” or “You are never punctual.” 3. Describe what you would like to be different “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.” 4. Don't say "YES" when you want to say "NO". 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. Factors Affecting Assertive Communication. Low self confidence Fear of rejection or ridicule Fear of upsetting others Lack of knowledge Culture Socialization FORM COMMUNICATION Verbal Communication Non verbal communication VERBAL COMMUNICATION Verbal communication involves the exchange of information using words and includes both the spoken and the written word. Language is primarily used in communicating verbally. Both spoken and written communication reveal a great deal about a person. Choice of words can reflect age, education, developmental level, socioeconomic background and culture. Characteristics of an effective verbal communication Simple brief Clear well timed Relevant Adaptable Credible Pace and intonation. Simplicity Simplicity involves the use of easily understood words considering the age, knowledge, culture, and educational level. Clarity A message is said to be clear if the sender’s intention is precisely expressed. In other words go straight to the point. The message is also clear when verbal and nonverbal communication matches. Timing and Relevance The client is the focal point of our care therefore the clients priorities or interest is taken into cognizance when planning for an interaction. Another aspect of timing is about asking several questions in a row without giving the client the chance to respond. Adaptability Adaptability on the part of the nurse demands that the nurse modifies his or her statements based on cues from the client. Nurses need to be sensitive in order to identify these cues. Credibility Nurses should provide honest responses to clients in order to earn their trust. Being knowledgeable about what is being discussed enables the nurse to speak with confidence. Pace/Intonation Pace is a key to effective communication when speaking to groups, during presentation and public speaking A perfect speed can be found when a sender stays totally connected with receivers or listeners Intonation on the other hand is the variation of tone or pitch when speaking. This also tells the mood of your voice. NON-VERBAL COMMUNICATION Non-verbal communication involves the part of an interaction that does not involve spoken or written words. This form of communication is often taken for granted but in reality conveys more information than verbal communication. It is often the nonverbal cues (or signs) or the paralinguistic elements of speech rather than what is actually said that betray true feelings and emotions. Your attitude may be determined by the way You stand, Sit /Walk Dress Use facial expressions Wave hands etc. Aspects of nonverbal communication cues Physical appearance Body movement/gestures Facial expression Posture and gait Vocal cues Touch BARRIERS OF COMMUNICATION Physical impartment or disability Hearing Impairment Speech Impairment Vision Impairment Physical Disability Intellectual Disability Noise (from outside, bad handwriting, Weather distance Use of medical jargons Premature evaluation Resistance to change  Lack of Subject Knowledge Language/linguistic barriers/semantics Emotions Personality Conflict and Communication Psychological barriers Technological barriers Premature evaluation Inadequate attention Organizational structure barriers Status barriers (superior-subordinate relationship) Premature evaluation Forming a judgement before listening to the entire message. Premature evaluation distorts understanding and acts as a barrier to effective communication. Resistance to change Human beings have the tendency to stick to old and customary patterns of life. They resist change to maintain the status quo – opposing new ideas to effect change. Lack of Subject Knowledge If a person who sends a message lacks subject knowledge, they may not be able to convey their message clearly and the receiver could misunderstand the message, thus affecting communication Language/linguistic barriers/semantics Semantic is the science of meaning. Same words and symbols carry different meanings to different people. The meaning intended by the sender may be quite different from the meaning followed by the receiver. People may interpret the message in terms of their own behaviour and experience. Emotional attitude The emotions of the communicator and the communicate, obstruct free flow of transmission and understanding of messages. Strong emotions makes it difficult to know the frame of mind of other person or group. Example when one is angry, resentful, happy, fear, mistrust and suspicion Personality Conflict Personal factors like judgement, social values, inferiority conflict, attitude widen the psychological distance between the communicator and the communicate. Credibility gap i.e., inconsistency between what one says and what one does, also, acts as a barrier to communication. Technological Barriers Inadequate Attention Communication remains a one-way process and there is no understanding of the message , if the receiver pays little attention to the message. Listening is the most neglected skill of communication. Half listening is like racing your engine with the gears on neutral. You use gasoline but you get nowhere. Organizational structure barriers Communication gets distorted particularly as it goes up the hierarchy. It is establish fact that every layer cuts off a bit of information if then structure is complex involving several layers of management, the breakdown or distortion in communication wall arise. Status barriers (superior-subordinate relationship) Status or position in the hierarchy of an organization is a fundamental barrier that obstructs free flow of information. A superior may give information to his subordinates so as to maintain status difference. Subordinates also convey only those messages which the superior would appreciate. The superior feels that he cannot admit to his subordinates those problems, conditions or results which may affect adversely on his ability and judgement as this will undermine his position. Lack of Mutual Trust Communication is sharing of ideas in common. One will freely transfer information and understanding with another only when there is mutual trust between the communicator and the communicate, the message is not followed. Credibility gap also causes lack of mutual trust. Ambiguity and Abstractions Overuse Leaving things half said, using too many generalisations, proverbs or sayings, leading to misinterpretations can all be barriers to communication. Gender Barriers COMMUNICATION TECHNOLOGIES Technology is a body of knowledge devoted to creating tools, processing actions and extracting of materials used to simplify our daily lives. It can also be described as the application of science used to solve problems. Technology is dynamic; it keeps on improving because our needs and demands for technology keep on changing. TYPES OF TECHNOLOGIES 1. Construction technology 2. Assistive technology 3. Medical technology 4. Information technology 5. Entertainment technology 6. Business technology 7. Educational technology 8. Communication technology ADVANTAGES OF TECHNOLOGY Increase production It helps small business gain competitive advantage Saves time Technology accelerates innovation It improves sharing of information It improves on data storage It simplifies business communication DISADVANTAGES It is expensive It is not safe Social/workplace disconnection Advantages in the classroom It promotes individual learning It promotes students engagement in the classroom It helps students learn how to write and spell It encourages group learning  It prepares students for technical working environments Technology encourages risk-taking due to the challenges it presents It assist students with disabilities It bridges the gap between teachers and students Technology simplifies teachers work DISADVANTAGES Distraction in the classroom It is expensive Requires training COMMUNICATION TECHNOLOGY This is the system that uses technical means to transmit information or data from one place to another or from one person to another. Communication is essential for all; it is used to convey ideas, exchange information and express emotions. Humans use communication technology to stay in touch with friends, family and our patients and their relatives. EXAMPLE: sms, social media, email, phone calls Social media Social media refers to websites and applications that are designed to allow people share content quickly, efficiently, and in real-time. It may be described as the collective of online communications channels dedicated to community-based input, interaction, content-sharing, personal messages, ideas and collaboration. While the use of social networks, including Facebook and Twitter, is relatively new in healthcare, it represents an important opportunity for the e-communication effort in any healthcare setting. Because of its newness, however, what is appropriate and productive is not always clearly established. For instance posting a client online without express consent will amount to breach in confidentiality. E-MAIL It is an information stored on a computer that is exchanged between two users over telecommunication. It is a message that may contain text, files, images or other attachment sent through a network to a specified individual or group of individuals. The first email was sent by Ray Tomlinson in 1971. WRITING AN E-MAIL The TO field is where you type the email address of the person who is the recipient of your message The FROM field should contain your email address The SUBJECT should consist of a few words describing the email contents. It makes the recipient have an idea of the message The CC (Carbon Copy) field allows you to specify recipients who are not direct recipients who are not direct addresses. The BCC (blind carbon copy) field, the recipients are secret. Each BBC recipient will receive the email but will not see who else received a copy. The MESSAGE BODY is the location you type your message. ADVANTAGES Free delivery aside the cost of internet service Global delivery Instant delivery File attachment Long term storage It is environmentally friendly, it is paperless The recipient don’t necessarily have to be online. PHONE CALL (manners) Answering a professional call are very different from answering personal calls. It is easy to slip up and accidentally speak to your client the way you would to your best friend or parents. PERSONAL CALLS Phones are great device which keep us in touch with friends and family and can be life savers in an emergency situation. However, they can also be annoying if not used thoughtfully. Remember your phone doesn’t have to be on you all the time and you don’t always have to answer it immediately. Learn to use the phones features like silent ring, vibrate and voice mail to handle the time when your phone would be bothering others if it happens to ring and you answered it. RULES/GUIDELINES HANDLING PHONE Be in control of your phone, don’t let it control you Speak at low tone (softly) Be courteous to those you are with, turn off your phone if it will be interrupting a conversation or activity Watch your language especially when others can over hear you Avoid talking about personal or confidential matters in a public place  If it must be on and could bother others use the silent ring mode and move away to talk Don’t make calls in a library, church, theatre or when attending to a client Don’t text during class, in a meeting or when attending to a client. Private information can be forwarded, so don’t text it Never drive or ride while using your phone at the same time. Phone Etiquette (WORKPLACE) Answer the call within three rings. Immediately introduce yourself. Speak clearly. Only use speakerphone when necessary. Actively listen and take notes.  Use proper language. Remain cheerful. Ask before putting someone on hold or transferring a call. Be honest if you don't know the answer. Be mindful of your volume. Check for and respond to voicemails. ADVANTAGES OF COMMUNICATION TECHNOLOGY Communication Speed / time – money can be saved because it’s much quicker to move information around. With the help of ICT it has become quicker and more efficient to contact either a business or family member. We can now correspond with anyone around the globe by simply texting a message to them, or sending them an email, for an almost instantaneous response. Globalization Video conferencing saves money on flights and accommodation. ICT has not only brought the countries and people closer together, but it has allowed the world's economy to become a single interdependent system. This means that we can not only share information quickly and efficiently, but we can also bring down barriers of linguistic and geographic boundaries. Cost effectiveness It can be said it is quite free to send an email (although it isn’t); it’s however without doubt cheaper than phone calls. ICT has also helped to automate business practices, thus restructuring businesses to make them exceptionally cost effective. This, in turn, increases productivity making the business more profitable; for instance the nursing and midwifery council (NMC) of Ghana has designed a system that would enable nurses to have quick access and be able to enter patient information from unit/ ward to the other making working conditions less strenuous working. Greater Availability ICT has made it possible for businesses to be automated giving clients access to a website or voicemail 24 hours a day, 7 days a week. This means that a business can be open anytime, anywhere, giving a customer the capability to make a purchase from different countries thus making it easier and more convenient. It also means that you can have your goods delivered right to your doorstep from places that you would never have had access to before. Bridging the cultural gap Greater access to technology has helped to bridge the cultural gap by helping people from different cultures to communicate with one another, and allow for the exchange of views and ideas, thus increasing awareness and reducing prejudice. Creation of new jobs Probably, the best advantage of ICT has been the creation of new and interesting jobs. Computer programmers, Systems analysts, Hardware and Software developers, and Web designers are just some of the many new employment opportunities created with the help of ICT. Education Computer’s along with their programs and the Internet have created educational opportunities not available to previous generations. Information is freely available to any and all with an internet connection. BASIC COMMUNICATION SKILLS This includes the use of Clarification Reflection probing summarizing open questions  Clarification can be illustrated as the client saying: “I don’t think I can cope with chemotherapy.” And the nurse asking “what is it about chemotherapy worries you?” Here the nurse is seeking to understand more specifically what the client means and the use of clarification gives the client the chance to expand and amplify their previous comment.  Reflection may be used to communicate understanding, to check accuracy and to facilitate further explanation.  Probing may be employed at times to invite the client to expand on a particular issue and clarify any vagueness. For example the nurse may ask: “you mentioned you were having trouble sleeping since your surgery. Can you tell me more about that?”  Summarizing helps the nurse and the client to draw the main issues of the interaction together and allows for the clarification of mutual understanding. open questions can be considered one of the simplest and yet most effective means of encouraging patients to disclose their concerns and to communicate at a level comfortable for them. Open questions are useful in the assessment of client’s/ patient’s problems. An open question is prefixed by words such as ‘When’, ‘what’ or how and will; help discourage a ‘YES’ or ‘NO’ answer. ADVANCED COMMUNICATION SKILLS Some advanced skills that require more practice and self- awareness are; Empathy, Unconditional positive regard and challenging.  EMPATHY has been defined as the ability to communicate understanding of another person’s experience from that person’s perspective and has been found to facilitate client/patient’s disclosure of their concerns and feelings. It differs from identification and sympathy and requires being alert to what feelings may lie behind client’s words and paying attention to what may be implied but not spoken.  UNCONDITIONAL POSITIVE REGARD means that the client is viewed with dignity and valued as a worth-while human being without judgment or criticisms.  CHALLENGING can be described as giving an invitation to change and may involve confronting inconsistencies and picking up on what the client has implied but is unaware of themselves. Challenges can result in clients seeing a wider perspective, deepening their perceptions or altering their point of view. LEVELS OF COMMUNICATION We communicate with one another on many different levels. Because we do not have direct access to the thoughts and feelings of other people, we must rely on communication to convey messages to one another. There is more to communication than simply using language to speak to one another. Communication exists on a number of levels and in a variety of forms. 1. Intrapersonal communication 2. Interpersonal communication 3. Public communication 4. media communication 5. Group communication Intrapersonal Communication Also known as self-talk or thinking, and refers to the ways we communicate with ourselves. We use intrapersonal communication to plan our lives, rehearse scenarios before we act them out, and tell ourselves what to do or not do. The way we communicate with ourselves greatly affects our self-esteem. The individual becomes his or her own sender and receiver, providing feedback to him or herself in an ongoing internal process/ Interpersonal Communication Interpersonal communication is the communication we have with other people. This type of communication varies from highly impersonal to extremely personal. The degree to which we communicate, or fail to communicate, with others influences how our relationships with them develop, continue or come to an end. Interpersonal communication encompasses: Speech communication Nonverbal communication summarizing  Paraphrasing Listening Questioning Turn-taking: Managing the flow of information back and forth between partners in a conversation by alternating roles of speaker and listener. Having good interpersonal communication skills support such processes as: Parenting intimate relationship Management Selling Counseling Coaching mentoring and co-mentoring, which is mentoring in groups conflict management Public Communication Public communication refers to public speeches that we deliver in front of audiences. Public communication serves three main purposes: to entertain, to persuade and/or to inform. It is different from other forms of interaction in that it requires greater levels of planning and preparation on the part of the speaker and involves less direct interaction. Audience/members still interact with the speaker via mostly nonverbal symbols, but there is a lesser degree of give and take than there is in one-on-one conversations. Mass Communication Mass communication refers to any type of media that is used to communicate with mass audiences. Examples of mass media include books, television, radios, films, computer technologies, magazines and newspapers. Mass communication is responsible for giving us views of events, issues and people from cultures that differ from ours. It enables us to learn what is going on in distant places in the world and lets us learn the viewpoints of people and cultures with whom we do not have direct contact. GROUP COMMUNICATION refers to the nature of communication that occurs in groups that are between 3 and 12 individuals. Small group communication generally takes place in a context that mixes interpersonal communication interactions with social clustering. Types of Communication Based on Purpose and Style Based on style and purpose, there are two main categories of communication and they both bears their own characteristics. Communication types based on style and purpose are: 1. Formal Communication 2. Informal Communication Formal Communication In formal communication, certain rules, conventions and principles are followed while communicating message. Formal communication occurs in formal and official style. Usually professional settings, corporate meetings, conferences undergoes in formal pattern. In formal communication, use of slang and foul language is avoided and correct pronunciation is required. Authority lines are needed to be followed in formal communication. Informal Communication Informal communication is done using channels that are in contrast with formal communication channels. It’s just a casual talk. It is established for societal affiliations of members in an organization and face-to-face discussions. It happens among friends and family. In informal communication use of slang words, foul language is not restricted. Usually, informal communication is done orally and using gestures. PATIENT TEACHING When teaching clients and their families, the teaching can be either planned in advance, or spontaneous, depending upon the context. Advance planning is always preferred since it helps to eliminate errors and omissions. Strategies for Teaching Clients and Their Families There are three main types of teaching intervention, depending on who does the initiating.  Nurse –Initiated Teaching This is teaching that the nurse feels the patient requires, for example how to administer his or her own insulin and also teaching that the nurse feels the family requires , for example how to deal with an elderly patient following discharge home. Client –Initiated Teaching This is the teaching that the client request. For example client may ask “how can I maintain my weight loss after I have been discharged”. This type of teaching has been initiated by the client and therefore the nurse will have to give the client the necessary information. Family-Initiated Teaching This is the teaching that the family request. Giving Information to Clients and Their Families Ascertain what they already know about the subject or issue, and then build upon that knowledge Deal with the most important aspects of the topic or issue and add those of lesser importance later. In order to avoid overloading the client and family with information, proceed in a sequence of small steps, checking their understanding at each step.  Avoid the use of medical terminology as much as possible by translating into layman’s language Observe learner(s) closely for signs of puzzlement and if detected help clarify the point of concern Observe learner(s) closely for signs of fatigue or distress and if detected discontinue the session At the middle and end of the teaching session, ask the client / relative to repeat to you in his/her own words the gist of the information that you have given. Using Questioning Questioning is an important strategy when teaching clients and their families. Types: Open Questions: These are phrased so as to allow the clients to respond in any way they like and are particularly useful for ascertaining the client’s feelings. Probing Questions: These are used to follow up a previous response by the client and allow the teacher/nurse to explore the response in more depth. However their uses require skill and sensitivity on the part of the nurse as this type of question may provoke anger or distress in some situations.  Factual Questions: These are used to check whether clients have understood the nurse’s points and consist simply of asking them to repeat certain items of information. Factors Affecting Nurse–Client Communication As mentioned previously, factors such as age, education, emotions, culture, language, attention, and surroundings affect both parties in a communication. In nurse client communications, additional factors relating to both the nurse and the client also come into play. The nurse must be sensitive to these factors and avoid personal biases in order to provide appropriate nursing care. NURSE Many factors pertaining to the nurse influence nurse–client communication. The nurse’s state of health, home situation, workload, staff relations, and past experiences as a nurse can all impact the attitude, thinking, concentration, and emotions of the nurse. These all influence the way a nurse sends and receives messages. Self-awareness (an awareness of all these factors) is very important for the nurse when communicating. CLIENT Factors related to the client that must be considered include social factors, religion, family situation, visual ability, hearing ability, speech ability, and level of consciousness, language proficiency, and state of illness. LEVEL OF CONSCIOUSNESS True communication cannot be accomplished with unconscious or comatose clients. It should be remembered, however, that unconscious or comatose clients may be able to hear even though they cannot respond. Caregivers should speak to these clients just as they would to alert clients. Always greet the client by name, identify yourself, and explain why you are in the room. Then let the client know when you are leaving and, if possible, when you will return. Although one sided, this interaction is critical to the client’s care. LANGUAGE PROFICIENCY The client’s ability to communicate effectively through spoken language also influences the nurse–client interaction. Learning about the other culture, especially about the values and beliefs, will help prevent the nurse from violating those values and beliefs. A family member who speaks English could be used as an interpreter. When another health care worker on the nursing unit speaks the same language as does the client, that person could also be used as an interpreter as long as it does not interfere with his or her work. Speak directly to the client whether an interpreter is present or not. Make eye contact with the client and speak slowly and clearly. Use simple words and avoid slang and medical jargon. The nurse may recommend a professional interpreter when obtaining informed consent. When another language is prevalent in the community, nurses should learn some phrases in that language to use in client assessment and care. SOCIAL FACTORS Socially acceptable health concerns, such as having the gallbladder or appendix removed or having the flu, are easy to discuss. It may be more difficult to communicate with a woman who is having a breast removed. The symbolic meaning of the breast may make it difficult for the client to accept its removal and may influence how she relates to others. A person who is HIV positive or has another sexually transmitted infection may be very reluctant to discuss the illness. STAGE OF ILLNESS The stage of a client’s illness may influence the client’s desire to communicate with the nurse. Clients in the early stages of illness may be eager to learn all they can about the illness or may express anger and resentment at their current state of health. Terminally ill clients may pose special challenges for the nurse. Most terminally ill clients know they are dying and are concerned about those whom they love. It is thus important for the nurse to have the client identify those persons the client considers to be “family.” Remember that silence and listening are both part of communication and can relay caring, compassion, and acceptance. Whenever a client begins talking about death, the nurse must be willing to listen and take part in the conversation. Many times nurses hesitate to communicate with the terminally ill for fear they will say the wrong thing. The client who wishes to talk needs a good listener. Allow the client to guide. PERSONALITY CONFLICT AND COMMUNICATION What are your likes? It is not unusual for people to have an instant like or dislike of others - they are too in your face or too retiring and shy, too controlling or too disorganized, emotionally effusive or too cold, don't pay attention to the detail or can't see the big picture. What people often do not realize is that these dislikes are primarily generated by personality differences and preferences and not by some flaws in peoples' character as they are often deemed to be during dysfunctional conflict.  Personality preferences result in different communication styles. Having a way of understanding and being able to talk about differences and preferences is of enormous benefit in social interaction and can also help diffuse personality clashes. We tend to get on better with people who have similar preferences to our own and are more likely to be irritated by people who have opposite preferences to our own. All preferences have their strengths and drawbacks, none is more valuable than another but they may become help or hindrance if we do not recognize the differences and appreciate how they can complement or divide.  Extrovert - those energized by the external and social world Introverts - those energized by their internal world of experience Sensing - those who gather information primarily via the five senses - the observable Intuiting - those who gather information through intuition, detecting undercurrents, possibilities, etc. Thinking - a preference for logic, deduction, 'objectivity', rationality Feeling - a preference for 'subjective' response based on emotion, values, etc. Judging - a preference for order, predictability, structure Extrovert May not listen enough -too full of what they want to say Talk louder and faster - clarify their viewpoint as they talk If they can say "just one more thing" it will be sorted - may say too much Want to talk out problems now - may get frustrated/ panicky if they can't Introvert May not say enough - may miss the opportunity to speak and regret it Most often at disadvantage when conflict erupts - need time to reflect before responding Like advance notice of issues and time to prepare/ rehearse before interaction May want to withdraw inside themselves when conflict takes them by surprise.  Sensing Like to argue the facts - the more specific the better. Search for truth may distract from what is most important. Prone to sidetrack bigger issue by focusing on details of less relevant issues More concerned with sorting the present hurt/injustice than creating a better future.  Intuiting Tend to make broad generalizations - may inflate specific incident to sweeping pattern May miss the obvious or 'forget' inconvenient details  Thinking Tend to get too analytical/ task focused in a dispute - fail to attend to impact on people Logical arguments may have little to do with hurt feelings involved "Try not to get emotional" tactic - may miss own and other's emotional signals and needs Tells the story from outside experience - disassociated/ objective - seem cold/ unsympathetic  Feeling Tend to personalize everything - even things that were not meant to be personal - blame self or others, may overlook context. View conflict as something to be avoided - tend to give in before issue is resolved to re-establish harmony May confuse how it is with how they are feeling  Judging Tend to see things in black and white and demand others do too Know that you/they are right or wrong - difficult to change their mind May fear losing control - be too attached to their particular solution Tend to reach for closure before considering all the options.  Perceiving Tend to see many options - can see/ argue for all sides - few things are black and white Trouble bringing conflict to a conclusion - always more data emerging so more possible solutions or conclusions May fail to give due consideration to time pressure and priorities. May over-complicate and lose momentum for action. PRESENTATION SKILLS “Great speakers aren’t born, they are trained.” Presentation “Something set forth to an audience for the attention of the mind “ Effective “…producing a desired result” These are the skills that a nurse need in delivering effective and engaging presentations to a variety of audiences. Developing Effective Presentation Communication skills A clear structure of the presentation A well researched content relevant to the topic The use of technology to account for various learning styles Working audience participation and knowing them (engaged and interest) Effective Presentations Control Anxiety – Don’t Fight It Audience Centered Accomplishes Objective Fun For Audience Fun For You Time management (not too long or short). Why Give A Presentation? 1. Inform 2. Persuade 3. Educate Planning Your Presentation The structure of the presentation A well organized presentation creates an impression that the nurse/midwife know what he/she is talking about. This will help to gain the audience trust and be more willing to listen to you. It provides a logical flow and makes you more comfortable following this flow. The process includes: Determine the Purpose Ask yourself what you want your audience/patients and their relatives to take away from the presentation. This provides focus for the nurse and the patient is clear on what they will gain listening to you. Assess Your Audience “Success depends on your ability to reach your audience.” Size Demographics Knowledge Level Motivation Needs Background To ascertain that you are delivering the right presentation to the right patient/audience. Plan Space Number of Seats Seating Arrangement Audio/Visual Equipment Distracters 4. What Day and Time? Any Day! Morning The Presentation Sequence: 1. build rapport 2. open your presentation 3. complete your presentation 4. presenting main points 5. concluding the presentation #1: Build Rapport … relation marked by harmony or affinity Audience members who trust you and feel that you care Start Before You Begin Mingle; Learn Names Opportunity to reinforce or correct audience assessment Good First Impression People Listen To People They Like. #2: Opening Your Presentation Introduce Yourself – Why Should They Listen Get Attention, Build More Rapport, Introduce Topic Humor Short Story Starling Statistic Make Audience Think Invite Participation Get Audience Response #3…Completing the Opening Clearly Defining Topic If Informative… Clear parameters for content within time If Persuasive… What’s the problem Who cares What’s the solution Overview #4: Presenting Main Points (Solution) Main Point-Transition-Main Point-Transition-Main-Point….. Supporting Evidence Examples Feedback & Questions From Audience Attention to, and Focus on, Audience (Listening). #5: Concluding Your Presentation Goal Inform audience that you’re about to close Summarize main points Something to remember or call-to-action Answer questions “Tell ’em What You Told ‘em.” Part 4: Effective Presentation Techniques Presentation Style 3 Elements a. Vocal technique b. Body language c. Use of space Vocal Techniques Loudness Pitch Rate Pause Deviations From the Norm for Emphasis 2.Body Language Eye Contact, Gestures, Posture 3.Use of Space Can Everyone See You? Movement Common Problems Verbal filters “Um”, “uh”, “like” Any unrelated word or phrase Swaying, rocking, and pacing Hands in pockets Lip smacking Fidgeting Failure to be audience-centered Presentation Tips 1. Smile 2. Breathe 3. Water 4. Notes 5. Finish On Or Under Time 6. 6 words per slide (varies) 7. 10 slides (varies) 8. 20 minutes (varies) 9. At least 30 font size Creating Effective Visual Aids Enhance Understanding Add Variety Support Claims Lasting Impact Used Poorly…A Distraction…Ineffective Presentation Visual Aids - Example PowerPoint Slides Overhead Trans Graphs/Charts Pictures Films/Video Flip Charts Sketches Visual Aids Should… Supplement presentation Outline of main points Serve audience’s needs, not speaker’s Simple and clear The Purpose of Using Visual Aids Visual aids support your ideas and improve audience comprehension of your presentation Visual aids add variety to your presentation by giving the audience a break from listening and letting the see something Visual aids help illustrate complex ideas or concepts and are helpful in reinforcing your ideas.  Improve comprehension Add variety Illustrate complex ideas Constructive criticism At some point in our life, we will be criticized in a professional way. CRITICISM is the expression of disapproval of someone or something on the basis of perceived faults or mistakes. It is the act of expressing disapproval and noting the problems or faults of a person or thing. We normally perceive criticism as finding fault on with somebody or something, or somebody finding fault with us. When a nurse offers his or her opinions on, or valuations of, a patient, subordinate or colleague’s behaviour or performance. Criticism can have both positive and negative effects on us depending on how it is given and how we receive it. You can either use criticism in a positive way to improve, or in a negative way that can lower your self-esteem and cause stress, anger or even aggression. The way in which you choose to handle criticism has a knock-on effect in various aspects of our life, therefore it is better to identify ways in which you can benefit from criticism and use it to your advantage to be a stronger and more able person. To deal with criticism positively may require good self-esteem and some assertiveness skills. TYPES OF CRITICISM DESTRUCTIVE CRITICISM CONSTRUCTIVE CRITICISM DESTRUCTIVE CRITICISM Criticism made out of anger or envy and with the intention of hurting or demeaning the person being criticized without offering any suggestion as to how the particular problem, behaviour or situation may be improved. They are mostly blunt accusations, that makes the person feel hurt and angry, fails to highlight the mistakes, it offers no help or support for improvement, which normally focus on the person and not the behaviour. It is harmful and counter productive and must be avoided if a nurse wants to promote therapeutic communication. CHARACTERISTICS OF DESTRUCTIVE CRITICISM It is blunt It makes the person being criticized feel hurt and angry It fails to highlights the mistakes of the individual so that he/she can change them It target the individual, his/her skills or attributes, but not the behaviour It brings down the individual. CONSTRUCTIVE CRITICISM Constructive criticism is the process of offering valid and well-reasoned opinions about the work of others, usually involving both positive and negative comments, in a friendly manner rather than an oppositional one. It is motivated by the desire to help an individual to improve. Done in a rational and balanced manner, not in anger or hatred Done from the viewpoint of knowledge and experience not ignorance. Its principal objective is to promote change and improvement in the individual. HOW TO OFFER CONSTRUCTIVE CRITICISM Start with praise Don’t make it personal Be specific Be kind Lead by example Criticize your own behaviour first Ask questions instead of giving orders Pick the right time HOW TO DEAL WITH CONSTRUCTIVE CRITICISM/FEEDBACK Acknowledging Thanking Apologizing disarming THERAPEUTIC RELATIONSHIP Therapeutic relationship is a purposeful, goal directed relationship that is directed at advancing the best interest and outcome of the client. It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client. THERAPEUTIC NURSE-PATIENT RELATIONSHIP It is a helping relationship that’s based on mutual trust and respect, nurturing of faith and hope, being sensitive to self and others, and assessing with the gratification of your patient’s physical, emotional and spiritual needs through your knowledge and skill. Be conscious of verbal and non-verbal communication and use them effectively. SOME TIPS TO CONSIDER 1. Introduce yourself to your patient and use his/her name while talking with her. Shake hands if its appropriate. 2. Make sure there is privacy when providing care. Meet her basic needs like relieving of pain and other sources of discomfort 3. Actively listen to your patient and make sure you understand her/his concerns by restating what he/she has verbalized. Don’t use restating too much in your conversation. 4. Maintain eye contact. Smile at intervals and nod your head as you and your patient are engage in a conversation. Speak calmly and slowly in terms that she can understand. 5. Maintain professional boundaries. Respect differences in culture. Some patients need therapeutic touch such as hand- holding and hugging than others and some prefers no touching. PHASESOF THERAPEUTIC NURSE-PATIENT RELATIONSHIP Pre-orientation phase Introductory/orientation phase Working phase Termination phase Pre-orientation/interaction phase It is the phase in which he nurse goes through before actual interaction with the patient. Tis phase begins when the nurse is assigned a patient to develop therapeutic relationship with him till she goes to him for interaction. Task of Pre-orientation/interaction phase Obtaining available information about the client from his or her charts, significant others or other health team members. From this the initial assessment begun. Examine ones feelings, fears and anxieties about working with a particular patient. Set objectives for the interaction phase. The nurse thinks and feels about the patient before interacting according to her knowledge, fears and miss concepts.  The nurse plans how he/she is going to interact with the patient, what he/she is going to achieve from this interaction and how to help the patient. Introductory/orientation phase It begins when the nurse goes to the patient, introduces himself/herself and gets introduction about him. The nurse and patient gets acquainted The orientation phase ends when the nurse and the patient begin to accept each other as a unique human being. Task of Introductory/orientation phase a. Establishment of contact Nurse introduces him/herself to the patient Build trust and rapport by demonstrating acceptance Establishing a therapeutic environment ensuring safety and privacy. b. Making agreement or pact Initiating a therapeutic contract by establishing a time, place, and duration of each meeting as well as the length of time the relationship will be in effect. C. Talking with the patient while talking with the patient, shows trust in her behaviour. The nurse establishes a mode of communication which is acceptable to both the client and the nurse. d. Assess the clients needs, coping strategies, defense mechanisms, strengths and weakness. BARRIERS TO ORIENTATION PHASE Establishing and agreement or pact Social class of the patient or nurse Status of the patient Anxiety level of the patient and nurse Transference Counter transference WORKING PHASE Problems and issues are identified and plans to address these are put into action. It starts when the nurse and the patient are able to overcome the barriers of orientation and introductory phase. During this phase the nurse and the patient actively work on meeting the goals which they had establish during the orientation phase. The characteristic feature of this phase is that the nurse is able to overcome anxiety and the patient’s fear of unknown is also decreased.  The working phase helps the nurse to develop knowledge and skill in nursing /midwifery. The person identifies her strengths and weakness as a nurse while interacting with patient. It enables the nurse to achieve the goals which they have plan for this phase. The end results lead the patient to verbalize, socialize, identify and faces the problems realistically. TASK OF WORKING PHASE The nurse collects the data in detail from primary and secondary sources and identifies the needs of the patient. The nurse assist the patient to identify his or her problem Helps the patient to communicate The nurse helps the patient to find an alternative solution to his or her problems She encourage the patient to use new patterns of behaviour Helps the client to develop positive coping behaviours Identify available support system  The nurse help the patient to understand that he has a significant role in his treatment. Exploring the clients perception of reality and provide constructive feedback Developing and implementing plan of action with a realistic goals. Evaluating the results of plan of action. The nurse prepares the patient for termination of relationship by reminding him during the interviews BARRIERS OF WORKING PHASE Testing of the nurse The patient tests the nurse for the ability and competence. Progress of the patient A terminally ill patient may not show a quick progress. The patient may progress then regress and remains stagnant before making further progress. In therapeutic relationship the nurse must understand the realistic progress in the client.  Difficulty in collecting and interpreting the data The nurse is unwilling to engage in TDS task in collecting and interpreting the data, applying the knowledge and skills in helping the patient, the nurse finds too hard to do, this acts as a barrier in completing the task of working phase.  TRANSFERANCE COUNTER TRANSFERANCE