This essay will look at the importance of communication in nursing. To begin, the essay will consider the use of communication in nursing in the general context. The latter section will go on to reflect on the application of communication in practice in relation to conversation and basic psychotherapeutic support within the dementia care environment.
Communicating is a fundamental skill in nursing. It governs every task a nurse undertakes from the point of admission to the point of discharge. There are a number of levels from simple phatic exchanges used to initiate conversation, extending to complex counselling techniques. Effective use of communication has been shown to benefit the nurse-patient relationship, contributing to overall well-being and accelerating the process of treatment. It is therefore an essential aspect of the nursing process. In some cases, it can even mean the difference between life and death. Good communication is often regarded as a delicate and complex art, requiring a good understanding of the interplay between numerous factors. This essay intends to provide a definition and to highlight a number of important professional, ethical, legal and moral responsibilities of the nurse in relation to communication (Sheldon, 2005).
There are numerous definitions for communication. Potter and Perry (2001 p.445) offer a definition for communication as ‘…a process in which people affect one another through the exchange of information, ideas, and feelings.’ Thus, it is about sending and receiving a message, both verbally and non-verbally, with a shared goal of conveying a mutual understanding. In general regard to the verbal domain, the process is often reciprocal in nature as both informant and referent change role, seek clarification and offer an acknowledgement of understanding throughout the exchange.
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It is imperative to be aware of the effect that body language and paralinguistic features have on communication. Thinking about body posture and implementing the principles of SOLER (identified by Egan (1982) cited in Burnard and Gill (2009)) is useful in nursing. A relaxed posture can help in the process of active listening, helping to convey an empathic response to the patient. Argyle (1994) points out that people are often unaware of their own non-verbal communication, whilst it is clearly visible to the receiver. Incongruence between what is being said verbally and what otherwise is perceived does not help in facilitating a positive relationship from a patients’ perspective. However, for a nurse who is trained to be sensitive to such cues (particularly in mental health settings), it can sometimes present useful information about a patient’s mental state and is a possible indicator of deterioration.
The Fundamentals of Care (2003) document published by the Welsh Assembly Government highlights that communication should take place using appropriate language and in a sensitive manner. Care should be taken to communicate effectively with people who are mentally impaired. In all patient communication the use of medical jargon should be limited wherever possible. As the Department of Health Valuing People Now (DH 2007) points out, as cited in Baillie (2009), people with learning disabilities have a right to healthcare just as much as other people and it should be just as accessible. In essence, nurses have to be open, flexible and versatile in their approach.
Stuart and Laraia (2005) cited in Riley (2008) suggest that communication facilitates the development of a therapeutic relationship. Nurses should adopt a suitable style of questioning, using open and closed questions appropriately depending on the situation. It is always important to convey a warm and accepting attitude that is objective and value free, taking into account the different cultural variations that exist. Nursing is increasingly recognised as a holistic and person-centred process, with so many aspects of a patient’s life regarded as important to the process of recovery that communication in itself forms a significant aspect of treatment. Caris-Verhallen et al. (1999), cited in Crawford et al (2006), imply that communication promotes an increased level of self-esteem and reduces stress. These benefits also promote staff wellbeing. In addition, Watkins (2002) mentions the usage of self-disclosure as a factor that helps develop therapeutic relationships with patients, particularly within mental health settings.
Teamwork is a factor too which relies heavily on good communication. Nurses are surrounded by different types of health care professionals and as Peate (2006) acknowledges, interdisciplinary communication can be difficult. The Nursing and Midwifery Council (2008) Code of Conduct states that, as a nurse ‘you must work cooperatively within teams and respect the skills, expertise and contributions of your colleagues.’ It is often the nurse that acts as an intermediary between the patient and another healthcare professional, disseminating information and explaining it in terms suitably appropriate to the understanding of the patient.
Poor communication creates barriers which can often lead to patients feeling alienated and making complaints as well as often being a significant factor in cases of malpractice, neglect and negligence. Within many clinical settings, a lack of time presents difficulties in utilising effective communication. Nurses often have to take opportunities to build rapport using synchronous communication whilst carrying out other tasks and duties. As Crawford et al. (2006) point out, healthcare professionals are increasingly task driven and laden with administration which prevents them from spending time talking with patients using the ideal but time consuming ‘counselling type’ communication. Therefore, in modern healthcare settings, they suggest a newer model is used that encompasses Brief, Ordinary and Effective (BOE) communication Crawford et al. (2006).
With regard to written communication, the NMC Code of Conduct (2008) highlights that nurses are expected to ensure that accurate and up to date records are maintained, with clear information about when the entry was made together with a signature of the person making the entry. Not only is this therapeutically useful, it is also an essential legal requirement and offers evidence that treatment has been carried out. Finally, Baillie (2009) explains that the telephone also forms an important, often overlooked mode of communication. As with all clinical work, it is essential for nurses to maintain professional etiquette and confidentiality, as well as acknowledge their level of competence to the caller and ensure that the call is documented where necessary (Baillie, 2009)
Communication has been demonstrated to have an important positive influence on treatment outcome. Nurses as a collective group represent a substantial aspect of all clinical health care professionals. They probably spend the most amount of time with a patient. As such, there is an enormous capacity for influence on treatment. It is therefore clear why there is a need for significant emphasis on this matter in nurse pre-registration programmes. Encouraging future and present generations of nurses to communicate more effectively could have a significant influence on increasing patient satisfaction and recovery time. It is therefore suggested that promoting effective communication has potential cost saving implications for local healthcare authorities too. This is important given the enormous strain that the NHS is under in the current economic climate. From a wider perspective, it could be speculated that effective communication indirectly has some bearing on aspects of future health and social policy.
Reflection: Communication in The Dementia Care Context
This next section looks reflects on communication within a dementia care setting and utilizes a Reflective Cycle model (appendix 1) adapted from Gibbs et al (1988) as cited in Bulman and Schutz (2008). The model begins by using a description about what has happened and then encourages the person whom is reflecting to acknowledge their feelings about the situation/event. From this, the evaluation phase encourages the reflector to make value judgements and to say what was good or bad about the experience. Next, an analysis can be made about the situation and this should hopefully generate ideas and themes about the situation. Through doing so, conclusions can be drawn both in the general sense and in terms of the reflectors specific personal experience. The final part of the reflection process with this model is the personal action plans stage whereby the reflector can suggest different, perhaps better ways of doing things in a similar future situation.
The placement was a dementia care ward which was all-female bedded with people who were at various stages in terms of the development of their dementia condition. The majority of the patients were still relatively active in a physical sense and often quite talkative.
I spent a significant amount of time sitting with various patients in the dayroom, often for observation reasons to help ensure their safety. This enabled frequent opportunity to talk to the patients and also to gain some insight into the nature of how dementia can affect people. There was one patient that particularly concerned me. In the interests of preserving confidentiality I will change her name and refer to her as Abigale. Although this reflection is predominantly focused on my interaction with Abigale, much of what I mention is relevant to the patient population at large in respect of dementia care.
Abigale was an elderly lady, perhaps in her early 70’s, who used to be a school teacher during her working years. Her condition was such that she was often quite talkative although the conversation was very much disjointed. She conveyed a range of emotions and often talked to me as if I resembled a particular character in her former life. Sometimes she spoke in a manner that suggested that she was seemingly happy about something and then for no apparent reason, she would become very upset and tearful. This happened on a frequent basis, with her emotions appearing to cycle between positive and negative affect in relatively short periods of time.
Throughout the time I spent talking with Abigale, I always tried to talk warmly to her and convey an accepting attitude along with empathy, interest and compassion, reflecting the core principles of Roger’s client centred therapy. I was aware that my non-verbal communication was very important both to her and other patients. Within the dementia care setting, non-verbal communication is often even more important because it is often relied to a great extent. I always tried to portray openness in my body language, using the SOLER principles acronym outlined by Egan (1994), (see appendix 2). I found that she often used the mode of touch to communicate when sitting and/or talking with people and I attempted to replicate this in a similar, acceptable manner. I found this to be very effective which did surprise me. With a younger generation, touch tends to be a form of communication that I tend to perceive as not working very well for me. This maybe because I just haven’t utilised this method very much outside of friendship and family settings.
I enjoyed spending time talking with Abigale. I particularly liked the way she continued to speak with a degree of authority that would perhaps be commensurate with her former role as a teacher. Even though her conversation was markedly unfocused and incongruent, she spoke in a very articulate manner. When I was able to answer her with a response she appeared to find satisfactory, it felt quite rewarding and it was good to see when she appeared to be happy. Sometimes she acted as if I resembled various people from her life. It was difficult to know whether to simply accept these non-sequiturs and go along with them, or correct her and risk upsetting her.
Unfortunately, there were also times when I could not give her a response that she needed. I occasionally found it difficult to determine what she was actually talking about and I didn’t want to respond with something that wasn’t relevant. Despite my best efforts, it was difficult to seek clarification from her as she would often move on to some other topic. I also found it emotionally challenging at the times where she was upset for no apparent reason and I would have liked to have been able to offer more support.
Sometimes, I have observed staff using diversion techniques to help distract patients from distressing situations. I have tried to use these occasionally. However, I tend to be a little uncomfortable doing this and I would rather be able to help somehow by having a greater understanding of the person and addressing their questions and concerns more directly.
Finally, not having access to the computerised notes system (PARIS) was very frustrating as it meant that I only had information passed verbally from staff.
Whilst communicating with Abigale and indeed, other patients within the setting, I tried to maximise my listening capacity by blocking out noises that were external to interactions. However, because I felt I had a duty to the other patients, blocking all noises was impracticable. The dayroom tended to be a difficult place to have a conversation. The television appeared to be more or less continually switched on, and there were often domestic staff performing various cleaning duties. The ambient noise levels tended to be quite high and somewhat distracting both for myself and no doubt, the patients.
Access to PARIS would have allowed me to gain a greater awareness about the patient as I would have been able to read comments and assessments made by the whole multidisciplinary team.
Good communication forms an intrinsic part of the nursing process and is part of many nursing models. Roper et al. (1996) as cited in Peate (2006) list it as an aspect of daily living. Unfortunately, people who suffer with dementia experience a number of cognitive difficulties according to Mace (2005) as cited in Adams (2008) (see appendix 3) which make communication very difficult. The associated pathological diseases and consequences of aging also exacerbate these difficulties making effective communication even more problematic (Adams, 2008). The role of communication is therefore especially important for dementia patients as they are likely to have difficulties with interpretation of messages (Kitwood, 1997 as cited in Adams (2008)). Indeed, I often found that what Abigale said and how she acted on the responses that I gave was often incongruent suggesting there was a problem with interpretation. However, when I attempted to seek clarification, it was very difficult or indeed impossible.
According to Cheston and Bender (2003), dementia care can be improved by beingpsychotherapeutic and using every interaction as an potential opportunity to help and support them. The humanistic and Rogerian aspect of empathic listening is particularly important and provides clues about embedded emotional messages according to Cheston and Bender (2003). However, they go on to suggest that in order to be psychotherapeutic in an approach requires a good understanding of a person’s life history. Unfortunately, the short term nature of the placement meant that I was likely to remain relatively naive in terms of understanding her history and condition to any useful extent, so being truly psychotherapeutic in my actions was difficult. Nevertheless, I attempted to provide a contribution to the nursing process.
I found that some of the communication strategies that nurses are encouraged to use in many settings need to be changed when consideration is given to the dementia care environment. Watkins (2001) suggests that clients respond better when nurses ask open questions. However, for dementia patients, asking open questions would appear to have a tendency to induce cognitive overload. As such, the Alzeimer’s Society Advice Sheet (2000) recommends that carers should ask short questions, one at a time which require only short answers.
The Alzheimer’s Society (2000) also highlight the need to try and see the person behind the illness: Interests, likes and dislikes, hopes and fears, early life, places they have lived and visited, working life, people they love/have loved, friendships and personality. I did try to find out from Abigale aspects of her former life but in truth, I had very little understanding about these factors. Abigale tended not to respond directly to questions but rather hinted certain aspects on an adhoc basis. Therefore, hypothetically, if I was a named nurse for Abigale in the future, it would perhaps be useful to speak to her close family to gain some insight and as well as potential stimulus for conversations. Perhaps a reminiscence box containing various items such as photographs and objects would be useful in terms of triggering memories and developing conversations.
I think it is important to acknowledge that it would have been better to take Abigale to somewhere quieter when she was upset. This would have been more conducive to conversation as well as offering some level privacy for Abigale. However, in the reality of the situation, there were limited places that were actually available on the ward. In addition, it was likely there were other patients that were also episodically distressed that made it difficult to devote full time to Abigale. The other patients tended to demonstrate similar emotions which coincided with the majority; hence there were ‘good’ and ‘bad’ days in terms of patient behaviours.
Overall, I feel that on balance I offered a good level of support for Abigale. At times, I believe that I could have offered her more in terms of conversation if I had a better level of knowledge about her background. Indeed, sometimes I felt that I lacked the relevant stimulus to have a lengthy conversation. Despite it being my first placement, there were times where I would have liked to have had the knowledge to use certain basic level therapeutic approaches that are applicable to patients whom suffer from dementia. My mentor also mentioned an interest in validation therapy and I am aware too of the existence of other forms of therapy such as pre-therapy, reminenscence therapy, resolution therapy and the person-focused approach. However, I can clearly appreciate that as a 1st year nursing student, to gain such knowledge is totally impracticable, as well as potentially unethical and unprofessional if actually used without proper registered status. Indeed, under the NMC Code of Conduct (2008) I must recognise and practice within the limits of competency. As such, in order to be in a position to use many therapeutic techniques effectively, I would need significant further training and/or further professional accreditation.
Communication with patients who have dementia is an extremely difficult and complex process. It is absolutely essential that nurses practice effective communication to help maintain the quality of life of the patients in their care. In practice, it is very difficult to ensure that psychotherapeutic support is well provided, particularly as psychological needs are more subtle and discrete. It could be argued that relatively low levels of staff and the often high levels of physical interventions often found within dementia settings means that the provision for effective communication regarding psychological care presents a significant challenge. I think the psychotherapeutic aspect of care is a important issue, particularly with the number of cases of dementia predicted to rise to almost 1 million in the UK by 2020 (according to Alzeimers Disease International, 1999, cited by Burgess, 2003).
Overall, I feel quite positive about my experience on placement and about the use of communication. I believe that I worked to the best of my ability. Abigale and many other patients appeared to be quite advanced in terms of their dementia condition. This proved to be quite a challenge. I would like to have had more awareness about Abigale’s history. I can now more readily appreciate the importance of family and friends, not only in terms of direct contribution to care but also the indirect contributions that they make through providing information about the patient. Early recognition of emotional distress helps with the nursing process. It could have made it more feasible for me to talk to Abigale to provide reassurance and limit the likelyhood of her becoming upset, therefore preserving her dignity.
I have gained a great deal of insight into dementia care both through the placement experience and through the process of reflection. In retrospect, I would like to have been able to offer more in terms of psychological support and this provides some insight into the psychotherapeutic aspect of care for future placements.
In future, I would like to have acquired a higher level of therapeutic skills to enhance my ability to communicate with people who have dementia. The predicted rise in dementia cases as previously mentioned means there is a greater likely hood of coming into contact and providing nursing care for a patient who has dementia. I think it would therefore be useful to develop a greater awareness into the condition, especially from a psychological perspective.
I also hope to have training and therefore approved access to PARIS computerised notes system.
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The Reflective Cycle (adapted from Gibbs et al.1988) cited in Bulman and Schutz, (2008).
Egan’s SOLAR Principles (Egan, 1994) as cited in Crawford et al. (2006)
S Face people Squarely
O Maintain an Open shape to the body
L Lean forward slightly
E Use appropriate Eye contact
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