In 2006, a patient named Robin became pregnant. In the 5th month of pregnancy, the patient began having trouble with diarrhoea and then developed a severe infection in her upper respiratory system. Robin’s obstetrician immediately hospitalized her and within 24, hours, Robin had a temperature of 105 degrees and was in preterm labour. Just before Christmas, Robin was diagnosed with Acute Viral Pneumonia. After getting permission from the doctor to go home for Christmas, Robin was back at the hospital 15 days later because she was in preterm labour yet again. It was then that Robin was introduced to a gastroenterologist who diagnosed her with Crohn’s Disease. Robin was immediately put on medications to try to save her and her unborn child’s lives. On 3rd February, Robin’s contractions were five minutes apart but her due date was the 17th of March. Robin came to the hospital and within one hour, I performed an ultrasound on Robin, only to let her know that her unborn baby boy was no longer alive. After the funeral of her son, Robin was diagnosed with Deep Vein Thrombosis (DVT) in her inner thigh.
Reflection: Interpersonal communication skills
Listening is an active and basic process that involves not only taking the content of the person speaking by looking at their body language and listening to their words, but also being perceptive. Good listening skills are shown by attending behaviour that is practiced by establishing eye contact, maintain a relaxed posture and sending appropriate messages to the patient through gestures. Attending behaviour works well in that it encourages the patient to verbalise their feelings and ideas freely. During listening, the nurse paraphrases the words of the patient in fewer words so as to make sure that the nurse understood what the patient wants. Paraphrasing is an important part of listening because it exposes and clarifies any mixed or double messages sent when the patient fails to make a direct statement. The third part of listening is clarifying. Clarifying goes beyond paraphrasing with an intention of bringing vague material into sharper focus. Perception checking is an effective part of ensuring accuracy of a communication because it is a method of giving and receiving feedback from the patient. When helping Robin, I can say that I had effective listening skills. I made a point of listening to what Robin told me and I made sure that when she was talking, I made her feel comfortable and showed that I was interested in what she was saying.
Leading is a communication skill that encourages the patient to respond in an open communication so as to invite verbal expression. The helper slightly anticipates what the patient is thinking and where those thoughts are headed. In anticipating these thoughts, the nurse leads the patient so as to stimulate the communication. Leading encourages the patient to retain primary responsibility for the direction of the communication and helps them to be active in the process. Leading also encourages the patient to explore and elaborate on their feelings. One of the tools used in leading is using open questions that can be answered by more than just a ‘yes’ or a ‘no’. Choosing appropriate questions lead to clarification for the patient. Another tool used in leading is by being indirect when leading the patient. Indirect leading keeps the responsibility of keeping the communication going on the patient. Indirect leading allows the patient to control the direction of the communication and protect their ideas. Direct leading on the other hand specifies a topic and the nurse uses suggestions to direct the patient. Direct leading is important in elaborating, clarifying and illustrating what the patient has been saying. In the case of a patient who has multiple problems or is vague, focussing is an important aspect that should be used in leading the communication. Focussing is a way that emphasizes on a certain idea or feeling and helps the patient get in touch with their feelings. I did not use leading skills when communicating with Robin and this is a skill I should in the future. I will enhance my abilities in leading skills by using open questions that will encourage the patients to share their ideas and feelings freely.
Reflecting feelings, experience and content of the patient expresses that the nurse understands and wants to perceive the world as the patient does. Reflecting the patients’ feelings brings those feelings into clear awareness from the vague expressions that they were. Helping the patients to own their feelings is done by identifying both the obvious and subtle feelings that are hidden behind words. In reflecting experience, the nurse broadly observes the patient’s verbalised feelings and their nonverbal feelings. Like paraphrasing, reflecting content involved repeating the essential ideas of the patient in fewer and fresher words. When the patient is having difficulty in expressing an idea, reflecting content helps the nurse to clarify those ideas. During communication, reflecting helps the patient to recognise and express their feelings effectively. In communicating with Robin, I sounded monotonous and insincere when I began my reflection with saying, ‘It seems you were very upset even after yelling for everyone to get out.’ In saying this I also said words that that Robin was unprepared for because they had too much depth of feeling. In future communication with patients, I should not read more interpretations into the statement than was intended, and I should use less monotonous words that sound sincere.
Confronting the patients is intended to help them recognize what is going on or what the nurse infers is going on. A patient may feel threatened and anxious at first when they are confronted. However, the patient is also grateful for the honesty albeit direct expression that shows that the nurse cares. Confronting the patient presents feedback that is difficult to hear, and as such, the nurse should poses good timing to ensure that the patient is ready for honest feedback. Sometimes I find it hard to confront patients. In Robin’s case, I was finding it hard to understand and deal with her. I know that confronting the patient is one of the crucial skills that I must poses. I must recognize my feelings as the nurse and share those feelings with the patient. I must be able to involve myself in self-reflection as a form of confrontation. I believe that by practicing, training and observing others, I can develop my confronting skills.
Using interpretation helps the patient to see their problems in new ways. Unlike paraphrasing where the patient’s frame of reference is maintained, in interpreting, the nurse offers the patient a new frame of reference. The nurse adds his or her own meaning to the patient’s basic meaning. When the nurse adds on to the basic message from the patient, and the patient understands the new idea, then communication is accelerated. Interpreting is useful in helping the patient get a broader perception their feelings. Interpretation is a communication skill that I used with Robin. While talking to Robin, she mentioned that she felt that the nurses around her were angels who lit her fire up in a time when she needed much encouragement. I told Robin that the way I saw it, she could join also become a nurse. Due to the Crohn’s disease, Robin could only live a stress-free life. However, after living the hospital, the first thing that Robin did was to go to Upper Valley Joint Vocational School where she applied for pre-requisite classes in the Licensed Practical Nurses (LPNs) program. Robin graduated in November 2009 and has been working in the nursing profession since then.
The most important thing that a nurse can do for the patient is sharing simple facts. Informing is a communication skill that is integrated with giving advice. Under some circumstances, where advice giving does not foster dependency and is not arrogant, giving advice can be helpful to the patient. Communication through informing gives the patient a recommended course of action that the nurse has experience with. Through giving suggestions, the patient can decide the course of action that he or she will take. Crisis situations where the patient has to adjust to a readjustment in life are an appropriate situation for giving the patient advice. In Robin’s case, after she had a stillbirth, I advised her to take her time with her son, Benjamin. I encouraged Robin to spend as much time as she wanted holding the five pound fifteen ounce baby boy. As much as Robin did not want to, I took pictures of robin and Benjamin for the memory album. I knew that that was the best albeit hardest thing robin had ever done.
Summarising skills involve paying attention to what, how, why, when and the effect of what the patient said. After communicating with a patient, the nurse should try to gather all the ideas and feeling expressed in one statement. Summarising is important in that it gives the patient awareness of progress in exploring ides and feelings, problem solving and learning. In summarising, the communication ends in a natural note that clears a way for new ideas and clarifies scattered ideas. Patients also gain confidence in that the nurse was attentive to them throughout the conversation. The nurse can use summarising as a means to check the accuracy of the ideas and feelings that were communicated by the patient. When communicating with Robin, I did not use summarising skills. In future communications, I should use the ideas from the patients to make a summary of the statements made. Instead of making the summary myself, I could ask the patient to summarize the themes, agreements and plans made during the communication.
Enablers and impediments to interpersonal communication
While communicating with Robin, the physical environment did not pose as an obstacle. However, my discomfort as a nurse was an obstacle when communicating with Robin. This discomfort originated from death and dying in general. I dealt with this discomfort by thinking that it was not my responsibility to communicate with Robin about hospice care and prognosis. My desire to maintain positive thoughts in Robin and her parents was also an obstacle. I would put off discussions about Robin’s possibility of a stillbirth until I felt that Robin and her parents could handle that conversation. In the future, I will initiate communication on prognosis and hospice care without thinking it is too much trouble. I will also control fear that emerges after telling the patient bad news. The patient can also be an obstacle to effective communication when he or she is unwilling to accept prognosis or hospice care. This unwillingness that was evident in Robin’s case is ascribed to her non-acceptance of her son’s death and her diagnosis with Crohn’s disease. In helping with Robin’s acceptance, I encouraged her by letting her know that I would be there to help her and listened to her. Because this worked well, I will continue being an encouraging factor for future patients. Cultural and social issues did not act as an obstacle while I was communicating with Robin. During Christmas, Robin when home to celebrate the holiday with her family, and when she was admitted back a few days later, I gave Robin a Christmas present that facilitated communication.
Conclusion and recommendation
Nurses play an important role in communicating with patients because they are always in close contact. A nurse-patient relationship is improved by communication and as such, having effective communication skills is an important factor and a priority for every nurse. I must develop my skills further in leading, confronting and summarising by participating in training activities. By participating in learning activities, I can develop strategies and acquire new skills as well as effectively employ those skills. Another strategy I will use is practicing key skills with actors and simulated patients because I will be able to control the nature and complexity of the task. Lastly, I must use the communication skills acquired in practice.
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