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Clinical experience

Describe an example of communication from your recent clinical experience and discuss the factors that contributed to its outcome

“Most people have felt anger and helplessness at not being listened to when saying something important. Also the intense frustration of being misunderstood...” Ellis, RB. (2003). Defining Communication. In: Ellis, RB, Gates, B, Kenworthy, NInterpersonal Communication in Nursing. 2nd ed. London: Churchill Livingstone. p3.

All names in this text have been changed, to respect the confidentiality of the patient and other healthcare professionals (NMC 2002).

I have recently been on 7 week placement in a nursing home for the elderly. It was a residential home but also had a small dementia unit in which patients with mental health problems were taken care of. This experience has taught me that communicating with elderly patients with dementia can be extremely difficult due to their loss of memory, language skills, lack of attention and general disorientation. In certain circumstances although the patients indicated that they wanted my attention I found it hard to understand what they wanted due to these communication barriers.

In my essay I begin by outlining what dementia is, what communication is and how important verbal and non verbal communication is to sufferers of dementia. Currently in the UK it is estimated that 700,000 people are suffering from dementia (BBC statistics)

Dementia is a condition that is connected with an ongoing declineof the brain and itsabilities. It is generally caused by damage to the structure of the brain and is most common in people over the age of 65. Thinking, language, memory, understanding, and judgement are all affected in someone who has Dementia. Sufferers may also have problems in controlling their emotions andbehaviour when in social situations. Due to this their personalities may appear to change.

There are 4 kinds of dementia. Alzheimer's disease, Vascular dementia, Dementia with Lewy bodies and Front or temporal dementia. These 4 kinds were all present in patients in the dementia unit, where I spent 7 weeks; however I will be concentrating on Alzheimer's.

Communication is commonly defined as "the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs". Although there is such a thing as one-way communication, communication is normally a two-way process in which there is an exchange and progression of thoughts, feelings or ideas towards a mutually accepted goal or understanding.

Communication is a process whereby information is imparted by a sender to a receiver via some medium. The receiver then decodes the message and gives the sender a feedback. All forms of communication require a sender, a message, and a receiver. Therefore communication requires a common medium. There are auditory means, such as speech, song, and tone of voice, and there are nonverbal means, such as body language, sign language, touch, eye contact, and writing. (Unknown Author (2000).Communication.Available: http://en.wikipedia.org/wiki/Communication#Communication_Modeling . Last accessed 2 Jan 2010)

All forms of communication verbal and non are used by a healthcare worker. With dementia sufferers, good non verbal communication is essential. (Argyle, 1978) believes that non verbal communication can have five times as much effect on a person's understanding of a message compared to the verbal communication at the time.

Chomsky calls the act of speech (verbal communication) ‘performance' and the knowledge of the language ‘competence'. People perform the complexity of speech daily but have no real knowledge of why or how they came to be able to. Speech allows us to hold conversations, ask question, give instructions, hide the truth, build routines and most importantly talk about interactions in which we are involved (Argyle, 1978).

Berlo has produced the following model of communication. It is stated below, taken from Berlo, D.K ( 1960) The Process of Communication: an introduction to the theory and practice. New York. Holt, Rinehart and Winston.

Berlo believed that the most valuable tool for successful communication is in the relationship between the communicator, known as the Encoder or Source, and the listener, known as the Receiver or Decoder. He believed that common factors must exist between the encoder and decoder for successful communication to occur; as well as an agreed format of communication, known as a Channel.

Berlos' SMCR model describes the communication process into four components: Source, Message, Channel and Reciever.

Berlo states that the source and receiver must share the same set of fundamentals in order to have successful communication. He argues that the way people communicate relate to their position within the socio‐cultural system - whether they are educated or non‐educated, wealthy or poor. He claims that it is these factors that affect both Source and Receiver and in turn, affect the communication process. Both Source and Receiver have to possess the following elements:

Communication skills: Both Source and Receiver have to use the same language or code in order to converse. They also have to share the same usage of signs, words and imagery.

Berlo states that there are five verbal communication skills that fall under this category. The first four are taken from the Shannon‐Weaver model; two encoding skills being speaking and writing and two decoding skills - listening and reading. The fifth skill is the most crucial as it relates to thought and reasoning. Take for instance a highly skilled linguist who is fluent in numerous languages. As the linguist travels abroad, he succeeds in speaking and communicating with the natives of the country but fails to comprehend the codes of etiquette or gestures. In doing so, the receiver's opinion of the source alters whilst the source is unaware of this mishap; resulting in a changed relationship between the two.

Good communication skills are extremely important for health workers. It is essential for a healthcare worker to understand a patient's needs and individual requirements in order to ensure best care and patient well being and to ensure that the patient feels respected, valued and is treated with dignity. All of these considerations contribute to patient care. If a patient cannot be understood properly it is very hard to give appropriate care. If there is good communication between a patient and healthcare worker, it will also ease the patients' anxiety. Research has shown that patients are at risk of high levels of anxiety and frustration if communicative attempts are unsuccessful. (Finkee, Erin HMS 2008). Communication helps the carer and patient get to know each other better, it helps them to bond which usually results in the patient feeling able to express what makes them happy or upset, what foods they like and more importantly any problems they are experiencing. A good bond can be hard to achieve with a patient with dementia as short term memory is often lacking so previous conversations can be forgotten. Approach towards patients with dementia is very important, facial expressions, tone of voice, uniform and how we present ourselves can say a lot about us and our attitude to the patient.

When communicating with the elderly residents if I were to raise my voice in an aggressive way they may feel threatened and scared by me, but if I speak to them in a pleasant tone of voice the then the resident is more likely to feel at ease around me. Eye contact was very important particularly when trying to engage a disorientated patient. I could then start gaining trust and understanding between myself and the resident. When a patient has dementia they can't speak by the final stage. Closed questions are usually more effective by this stage. There are 2 types of questions, open and closed. Open questions leave the answer open to respond with a lot of information or a little. Closed questions are those that a patient has nod or shake their head to or use other body parts such as thumbs up or down. Closed questions such like "Are you okay?”, "Are you hungry?” allowed the patient to communicate with us without having to construct a sentence. These types of closed questions are a type of non verbal communication.(Berlo's communication channel) It was often very difficult to use verbal communication with Alzheimer's patients because there short term memory is limited so they quickly lost the thread of the conversation. Nevertheless it is essential to communicate with dementia sufferers in order not only to care for them but to provide comfort and reduce the fear and isolation associated with the disease. On several occasions during the placement I drew on the communication skills I had learned from caring for very young relatives such as my younger brothers. Using games and closed questions to engage them, opening discussions on items around them which were precious to them such as photos or ornaments. Allowing them to discuss the game or object. However I was careful never to push them to recall memories as this may have caused them distress especially if they could not remember such things as where they were born. (In Berlo's model I was trying to ensure a common channel)

Even using closed questions one sometimes had to explore further than one answer. I witnessed a female patient who was obviously agitated. When questioned she indicated that yes she would like to go to the toilet. When the duty nurse attempted to assist her she became severely distressed to the point of hysteria. Even after she had been to the toilet she remained upset. After some time it became apparent through much questioning that although she needed assistance she had not wanted it from the male duty nurse. Bearing in mind the fact that the patient was a very elderly female who may have been raised with certain attitudes to propriety this incident could have been avoided with more effective communication. (This appears to be an incompatability between the codes of te two individuals making communication impossible. The nurse understood the language of the lady in that she wanted the toilet but did understand the cose/ etiquette of her upbringing)

According to Argyle (1990) in a conversation, words make up only 7% of a message; tone, tempo and syntax make up to 38% and body language makes up to 35%. Non verbal communication can be expressed by our facial movements, gaze and eye contact, gesture and body movement, body posture and body contact, use of space and time and how we dress. (Henley 1977) states that how powerful we feel in an interaction can be expressed non- verbally. Our unspoken communication can be shown through our body language. Touching patients can be an essential tool for a nurse. It can offer support and understanding, comfort and security. It adds extra meaning to the spoken word. Often a patient would simply ask me to sit or stand with them or hold their hand. Although this seemed a very simple form of care it was often very emotional for me but seemed to be of benefit to the patient. I have wondered if at such moments the patients were feeling disorientated and the simple act of someone trustworthy being close seemed to help reduce their anxiety for a short while. It was my experience that a smile when appropriate often initiated an attempt to communicate. Macleod and Clark (1991) suggest that most touch between nurses and elderly patients is related to practical procedures, fulfilling a practical rather than an emotional purpose. However i found this not to be true, as i mentioned often i patient would just want you to hold there hand for emotional comfort. Care workers are not always able to spend as much time with individual patients as they would like. This on occasion led to a mismatch between verbal and non-verbal communication. Patients got upset with care workers who although they were carrying out a helpful task looked tired or impatient possibly because of their workload but not because they didn't care. Some patients would like care workers to sit with them during meal times but this could not always be done and on occasion such patients did not eat their meal. It is well recognised that giving nurses the time to listen and be attentive assist patient well-being. Contrary to this were the occasions when patients refused to eat or drink either because they did not want to eat or drink or because they were neither hungry nor thirsty or they did not like the food or drink. These opinions were communicated non-verbally by patients refusing to open their mouth, spitting food out. The inability to explain verbally was a significant barrier to communication. Staff in turn needed to ensure that their verbal and non-verbal communication did not cause further barriers e.g. impatient tone of voice, facial expression or body language.

Where patients could communicate verbally barriers still existed to ensuring full understanding especially where lack of concentration was a concern. Background noises, e.g. loud radios or televisions, people around talking as well as us, this can confuse and provide distraction patients. Turning the television down whilst having a conversation with a patient can help. Speaking clearly in a language, style or accent understood by the patient improves verbal communication. Speaking clearly and giving simple instructions also helps patients understanding but listening is by far the most important verbal communication in understanding patients' needs. It is important to learn patients names and use them. This helps attract and hold patients attention and more importantly identifies them as an individual with individual needs and not simply a patient.

Working in the dementia unit was very emotional. Patients were often distressed and unhappy and seldom happy. Regardless the patients were welcoming and often keen to engage on differing levels. I endeavoured to maintain a positive attitude and outward appearance, to listen and be aware of my own body language. Although I endeavoured to show empathy rather than sympathy it is impossible to really understand how terrible it must be to lose our communication skills so dramatically but most nurses make every effort to ensure maximum two way communication with patients, utilising different means of communication. A nurse can also ensure that she/he obtains a full understanding of the problems dementia sufferers face and guidance on professional best practice.

The following case study from my recent clinical experience illustrates communication and the factors that contributed to its outcome.

Mr. Jones was brought to the nursing home by his son. He is 88 and has suffered from dementia for a number of years but in the past year Alzheimer's has progressed fairly quickly and the need for round the clock care has left his son unable to care for him. Mr Jones's symptoms include major confusion, withdrawal from society, delusions and extreme mood swings, he often gets extremely angry. He needs carers for certain normal activities essential for daily living such as finding the toilet, helping him on with his clothes and generally watching over his throughout the day. Some of his needs may also be due to his age; he has problems with his mobility so needs a carer for that not just due to the Alzheimer's. My mentor asked me to spend some time with Mr Jones, talking to him and trying to build up a rapport with him. The day before my mentor had given me some leaflets on the subject of dementia and Alzheimer's to prepare me and give me a better understanding.

When I first sat down with Mr Jones he just seemed like a ‘normal' elderly gentleman of fine health for his age, however as I began speaking to him I found quickly how advanced his Alzheimer's was. It was quite upsetting for me as I had never been in that situation before. Within the first 20 minutes of speaking to Mr. Jones he had asked me the same question and we had the same conversation around 5 times. I found this rather awkward as I was unsure whether to continue with the repetitive conversation or try to change the subject as I was not sure if either of these would cause Mr. Jones to become distressed. I decided to continue to listen to Mr Jones showing interest in his conversation. Eventually Mr Jones was able to extend that particular conversation little by little telling more of the story. Mr Jones mentioned to me that he was the homes Gardener. Confused by this I went to my mentor who assured me that this was a delusion he had thought was real since his son moved him into the home and to just ‘leave him to it'. I was not able to speak to a dementia expert on the subject but I did wonder if this ‘delusion' was an expression of a proud man's need to be independent and a provider. Perhaps it was a coping technique at the thought of being put into a home. I therefore chose to discuss gardening with Mr. Jones. I was very careful not to ask any questions about the particular gardening he did at the home for fear of causing embarrassment or confusion. During these conversations one would not have known that they were based on a delusion and Mr Jones remained calm at all times.

I found that after the first week of my working there Mr Jones recognised my face, he still continued to ask me the same questions such as ‘where do you live?', ‘do you know my son?' and tell me about his gardening job but he would remember by name. The outcome of listening and being attentive during our conversations had enabled Mr Jones to remember my face and in time he might have associated my name with my face. Would this have provided some sense of continuity in his life?

The thing that worried me the most however was that Mr Jones would ask me when he was going to get his pay cheque. The other staff told me to tell him ‘next week'. I found this shocking and an insufficient answer. I felt that if I did as the other staff told me this would just reinforce the delusion and so I when he asked me the next time I told him the truth. This however made him very distressed and upset. The NMC (2002) advises that we must not add extra stress or discomfort to a patient by our actions. I should have asked my mentor for an explanation of her advice. I have now read further on the subject of dementia and by telling him ‘next week' it allowed him to stop worrying about it at that time and enabled us to change the subject to one we could communicate about or to engage in an activity such as a board game. Telling him ‘next week' was using his short term memory to prevent distress.

This experience has shown me that I have lack of knowledge in my communication skills; I had focussed too much on my morals and worry that I was being untruthful with him when infact perhaps reinforcing his view would have caused him less displeasure. I had not considered his other needs like his wishes or desires and I had not gathered enough personal information about him beforehand to know this - maybe he liked gardening.( It would appear that we (Mr Jones the source and me the encoder were speaking the same language but were not on the same cultural channel which led to poor communication in that neither of us understood the others message)

This experience was very frustrating and upsetting and highlighted the need for me to improve my communication skills and ensure better understanding of patients' conditions and needs before attempting anything more than basic needs communication e.g. are you hungry?

I tried not to communicate my frustration, lack of understanding and emotional distress to Mr. Jones by being attentive, asking appropriate questions and using open, non agitated body language ( promoting empathy in the form of my own body language to promote active listening (Egan 2002) until the moment he became distressed at which point I did not have the necessary communication skills to deal with the situation positively

I should have allowed more time to understand what Mr. Jones was thinking and feeling by maybe asking him calm questions such as do you know where you are, how long have you been here? And perhaps he would have come to a gradual realisation by himself. I now realise that my concerns about the value of truth (truth is always the best policy) were not compatible with his care needs.
when taking into account Berlo's model, when one element is missing the communication fails. In the example given, the source and the receiver had a common channel but the message was interpreted differently, there was no common understanding of the message. I hope with further training i will develop a better understanding of communication. Rowe (1999) explains that a person must identify their weaknesses as an initiative for becoming self-aware. I will take all this into account when on my next placement and through the rest of my nursing career.

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