NHS Gloucestershire CCG
This workbook can help employers provide evidence towards CQC standards, Common induction standards and the Knowledge & Skills Framework and are mapped to the end of Life Common Core competencies.
The workbook has been adapted from and reproduced, with kind permission, from workbooks created by Leeds Palliative Care Team. This formed part of a Communication Skills Project led by Education Coordinator, St Gemma’s Hospice.
Your feedback on the contents of this workbook would be most welcome by:
Jane Hamilton: jane.hamilton@great-.uk and
Alison Middleton: alisonm@st-gemma.co.uk
Important: Please note that this resource was written and funded as part of an NHS project and author/s may not be in a position to update material after 2012. Therefore it is important that trainers, managers and facilitators take responsibility to ensure materials are current and evidence based.
Further information and support regarding End of life Care within Gloucestershire
Gloucestershire EoLC
nhsglos.nhs.uk/your-services/help-for-those-with-a-long-term-condition/
EoLC Education Resources and the Calendar of training events:
nhsglos.nhs.uk/your-services/help-for-those-with-a-long-term-condition/eolc-training/
An A-Z of EoLC Resources
WORKING IN PARTNERSHIP WITH
2gether NHS Foundation Trust
Cotswold Care Hospice
Gloucestershire County Council
Gloucestershire Hospitals NHS Foundation Trust
Great Oaks Hospice
NHS Gloucestershire Care Services
Sue Ryder Hospice
Important
This resource was funded and written by members of the Gloucestershire End of Life Education group. Please be aware that materials will need to be reviewed and updated periodically (last update 01/2012).
How confident are you when communicating with the dying?
| | | |Before workbook|Before |After workshop |3 months later |
| | | | |workshop | | |
| |5 |Very confident | | | | |
| |4 |Fairly confident in most | | | | |
| | |scenarios | | | | |
| |3 |I’m OK | | | | |
| |2 |I get a bit anxious | | | | |
| |1 |I am struggling quite a bit | | | | |
| |0 |Not confident at all | | | | |
Monitor your progress through this module by completing above as instructed.
COMPLETE FIRST COLUMN BEFORE LOOKING AT THE WORKBOOK!
This page forms back of self evaluation and should be kept clear and used for any personal comments.
COMMUNICATING WITH CONFIDENCE
This communication skills learning package has been adapted for use with health and social care staff who provide palliative and end of life care as part of their professional role. It is by no means exhaustive, but is intended to give the learner an overview of communication skills required at level B as outlined in the framework of National Occupational Standards.
These standards are “to support core competencies and principles for health and social care workers working with adults at the end of life”. Level B in Communication Skills requires those with an individual role and responsibilities with Assistant, Practitioner or Advanced Practitioner status to be able to:
“develop and maintain communication with people about difficult and complex matters or situations related to end of life care”.
Quotes from: A Framework of National Occupational Standards
The total communication skills package consists of:
Workbook 2-4 hours
e-.uk 6 x 20 min modules
Practical skills workshop 3 hours
You are asked to complete this workbook and/or the 6 communication modules on the e ECLA website prior to attending the Communication with Confidence skills workshop. This workbook is intended to revisit previous learning and existing experience in communication skills. The workshop will then help you use these skills more confidently in your particular work environment.
On completion of this learning package you should be able to demonstrate your knowledge and understanding to meet level B learning outcomes.
| |
|Level B: learning outcomes |
| |
|a) Understand how to communicate with a limited range of people, on day-to-day matters in a form that is appropriate to the individual |
|and the situation |
| |
|b) Recognise the need for timely communication |
| |
|c) Understand the process that leads to effective listening and information giving, including the importance of non-verbal |
|communication |
| |
|d) Understand how to reduce barriers to effective communication, including environmental (noise/ privacy) personal (health of patient) |
|and social (language, ability to understand) |
| |
|e) Recognise how culture and ethnicity can impact on communication styles, expectations and preference |
| |
|f) Understands the importance of presenting a positive image of her/him self and the service |
| |
|g) Understands how to accurately report and/or records work activities according to organisational procedures |
| |
|h) Understands the importance of communicating information only to those people who have the right and need to know it consistent with |
|legislation, policies and procedures, for example confidentiality, data protection act, complaints resolution, language interpretation,|
|family dynamics. |
| |
|i) Reflects on their limitations with regard to communication and involve appropriate colleagues as necessary |
| |
|j) Recognise subjects that are inappropriate for general discussion in front of others, i.e. own social life etc |
| |
|k) Understands the emotional impact on people when coping with their illness and how that influences communication. |
| |
|l) Recognise the importance of giving clear explanations and gaining permission prior to carrying out any activity, and to understand |
|the reporting procedures if permission is not obtained. |
| |
| |
COMMUNICATION WITH CONFIDENCE
SKILLS TRAINING
INTRODUCTION
What is Palliative Care?
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Palliative care for adults:
• provides relief from pain and other distressing symptoms
• affirms life and regards dying as a normal process
• intends neither to hasten or postpone death
• integrates the psychological and spiritual aspects of patient care
• offers a support system to help patients live as actively as possible until death
• offers a support system to help the family cope during the patient's illness and in their own bereavement
• uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated.
• will enhance quality of life, and may also positively influence the course of an illness
• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications
Source: World Health Organisation (WHO) definition of palliative care 2002
What Is Communication?
Communication is the exchange of information. Whenever two or more individuals are together, communication is taking place. The impact your communication has on another depends on:
• What is said
• How it is said
• How it is interpreted
Exercise 1
Write down 6 words to describe a banana.
1
2
3
4
5
6
Now ask a friend or colleague to do the same and compare results.
1
2
3
4
5
6
The purpose is to show that there is more to good communication than words. Everyone has different interpretations of things which are associated with life’s experience; your interpretation may be different to someone else’s.
This is where communication can break down and misunderstandings arise.
Always check back that you understand what is being said and that the person understands what you have said.
‘If they haven’t heard you, you haven’t said it.’
Studies show that the effectiveness of how you communicate is split into the following figures (Mehrabian, 1981).
• Words are 7% effective
• Tone is 38% effective (Tone is how you say things e.g. too loud, too quickly, impatient, patronising or sensitively and with respect)
• Body Language is 55% effective
Communication means different things to different people and there are many methods of communication some of which are more effective than others.
COMMUNICATION ROLE IN HEALTH AND SOCIAL CARE SETTINGS
Communication is an essential aspect of our everyday role. It is a vital element of the role of all health and social care staff. The literature identifies a number of key characteristics in the process of communication when helping and counselling individuals these include;
• Genuineness
• Empathy
• Warmth
• Acceptance
Genuineness
To be truly genuine means to be authentic and be able to express what one feels for example “what you see is what you get”. As health and social care staff we often have to try and deal with difficult situations. It is easy to hide behind a uniform or a role. It is easy to forget sometimes that it is alright to say “I don’t know”. Inevitably, at sometime, people with palliative care needs and/or their families may say, “You don’t know how I’m feeling” and unless we have been in a similar situation we probably truly don’t!
Empathy
Empathy is the ability to recognise and understand how another person feels. An empathic response indicates that if placed in similar circumstances you would have similar feelings.
There are two components of empathy, recognising the feelings and then communicating to the speaker that you understand and acknowledge how they feel. It does not mean you share their feelings; this is sympathy. You can show empathy through gestures, facial expressions, appropriate touch and words.
Examples:
“That must be difficult for you”.
“I’m not surprised you feel anxious.”
“I imagine you were very frightened”
We don’t always get it right;
“I bet that was a shock.”
Reply; “well no, I was half expecting it.”
This is not wrong; it indicates that you are trying to understand how the other person feels which is better than ignoring it.
Avoid saying, “I know how you feel” because you don’t, you can only try to imagine how another person feels.
Warmth
By being warm a person will usually come across as genuine. Being warm doesn’t have to mean being demonstrative and overenthusiastic, especially if that isn’t your normal way or style of behaving. It does however, mean respecting another person; who they are and what they stand for. To a person with palliative care needs, experiencing warmth from others is extremely important. As health and social care staff we have our own agendas, beliefs and values which can affect the way we respond and act with others.
Acceptance
Acceptance means taking the whole of a person not just the bits we like i.e. “warts and all”. It is virtually impossible to be totally acceptable. As health and social care staff our role requires us to try and accept other people without judgement. Awareness of ourselves and our character will make us more aware of others.
Other key characteristics include
• Respect
• Dignity
• Trust
• Caring
• Beliefs and values
Warmth, acceptance, genuineness and empathy add a humanistic dimension to communication (Rungapadiachy, 2003).
Exercise 2
Mr Jones has deteriorated suddenly and his family have been called in. When they arrive the doctor is with him and you are asked to go and speak to the family.
How do you feel?
How do you think the family feel?
What will you say to demonstrate:
Warmth
Acceptance
Genuineness
Empathy
EFFECTIVE LISTENING IN COMMUNICATION
One of the best ways to communicate with people is to stop talking and start listening; but listening is more than not talking. Listening means not only hearing what is being said but also attempting to understand what lies behind the words spoken. The good listener recognises that the other person has something constructive to offer and seeks to discover what it is, even though their thoughts may be unclear.
Effective listening requires a continuous determined effort to pay attention to the speaker and to his/her words. Listening is not easy and not the same as hearing.
The process of listening could be broken down further into 4 distinct but interrelated components:
• Attending
• Hearing
• Understanding
• Remembering
Listening by definition isn’t a natural process; it refers to paying attention, remembering and understanding the content of what the speaker has said. Hearing or passive listening however is a natural process as one doesn’t have to learn to hear. Listening is by far the most important of all communications skills. It does not come naturally to most people, so we need to work hard at it; to stop ourselves “jumping in” and giving our opinions.
Passive Listening
Passive listening is the process of emptying the mind. The listener must not allow themselves to make judgements or question the other person. This is difficult to achieve and requires constant practice.
Active Listening
Active listening is the process of listening to others in order to understand their ideas, opinions and feelings and to demonstrate you have understood.
Tips for active listening
• Maintain eye contact by looking at the speaker
• Stop talking and avoid interrupting
• Sit/stand still maintaining a body state that reflects attentiveness
• Nod your head to show you understand
• Lean slightly towards the speaker to show you are interested
• Check for understanding by repeating information and asking questions for clarification
Exercise 3
You are taken to hospital by ambulance suffering from severe headaches. No one seems to know what is wrong with you and you are waiting to be taken for a scan. You are lying on a trolley in a corridor and someone comes to take you for the scan. The person does not introduce themselves but they check your notes and start calling you by your name as it is written on the notes: “Brian”. You say that you do not wish to be called by your first name and that as you are always referred to as “Bob” you do not feel comfortable being addressed as “Brian”. The person is not looking at you while you are explaining and they are looking around and nodding to members of staff but obviously not paying any attention to you. You finish your explanation and the member of staff becomes aware that you have finished talking; they say “OK, Brian, I’ll take you for your scan now”.
How do you feel?
What feelings do you have about this person?
Symptoms of poor listening:
• Deciding that the subject is uninteresting or irrelevant without first giving others the chance to say what is on their mind
• Allowing your prejudices such as colour, accents, personal appearance etc. to determine your decision whether or not to give the person your full attention, i.e. being judgemental
• Selective listening i.e. pre-programmed to turn off at some topics
• Interrupting
• Daydreaming
• Being distracted by other people
Potential Barriers to Active Listening
Exercise 4
Inevitably there are barriers to active listening. Identify what you think may be some of the major barriers these may include:
Personal
Role Responsibilities
Environmental
Skills
Fears
Reflect
There will have been times when you have not really paid attention to what someone is saying to you. Perhaps you were under pressure to do something else? Perhaps you were struggling to understand what they were saying (speech impairment, accent, language used)? Perhaps you were worried they might say something you didn’t want to hear?
One way of improving how you manage difficult situations is to reflect for yourself on what happened. You can do this by considering:
• what worked well?
• why?
• what did not work well?
• why not?
• what will I do the same next time?
• what will I do differently next time?
[pic] Reflect
Think of an incident at work when you avoided, or you feel you mishandled, a conversation with a patient or client.
What happened?
Describe the situation.
So What?
What were the consequences of you avoiding the communication? How did this make you feel?
Now What?
How might you now approach the same situation?
Repeat this exercise by reflecting on a communication that you feel was difficult yet you handled well.
(Rolfe et al: 2001)
HOW DO WE COMMUNICATE?
Communication falls into two broad categories; Verbal and Non-Verbal communication. Verbal communication relates to all means of communication that has speech and language as its foundation. Non-verbal communication is less easy to define.
Exercise 5
Make a list of all the possible non-verbal means of communication that you can think of.
Exercise 6
You receive a text message or email.
“Sorry, can’t make lunch tomorrow, Josh ill, will be in touch”.
This message gives the information but no clues as to the sender’s feelings.
What extra information would you be able to get from the same message if it was a phone message and you could hear the sender’s voice?
What extra information would you get from the message if you actually spoke to the person face to face?
This exercise demonstrates how much extra information we can get from the “non- verbal” cues.
Remember it’s not just what you say, but how you say it
WHAT IS BODY LANGUAGE?
Body language is a term for communication using body movements or gestures instead of, or in addition to, sounds, verbal language or other communication. It describes all forms of human communication that are not verbal language. This includes the most subtle of movements that many people are not aware of, including winking and slight movement of the eyebrows. In addition body language can also incorporate the use of facial expressions.
Positive body language shows you are interested in what the person is saying.
Tips for positive Body Language
• Relaxed Body Position- (though don’t slump) this helps put the other person at ease as you look friendly and helpful. If you appear tense you may seem unreceptive or nervous.
• Open Posture -by standing at a slight angle to the other person so that you don’t seem threatening and if the other person is sitting try and match their position by also sitting.
• Lean Slightly Forward-as a sign of involvement, but don’t overdo it or you will invade their personal space.
• Eye Contact-should be appropriate (normally there is more eye contact as the other person is talking). Two extremes of inappropriate eye contact would include diverting the eyes or staring. If you look down or away too often it may indicate tension or boredom where as staring may be interpreted as aggression. In some cultures regular eye contact (70%) can either be seen as offensive or even flirtatious, particularly female to male eye contact
• ‘I trained in Switzerland and I was astonished when a Swiss doctor told me that I would be considered to be telling a lie if I did not look straight into a person’s eyes’ (Pakistani doctor)
• Pointing and waving your finger, standing with your hands on hips, fists clenched and frowning are all examples of where your body language could be interpreted as aggressive.
• Appropriate Facial Expression-be friendly and relaxed. Smiles demonstrate interest, but remember your expression needs to be consistent with what you or the other person is saying.
• Nod Your Head-this indicates that you are paying attention, encourages further discussion and shows that you are following what is being said. Acknowledge the other person’s arrival, even if you are busy (for example on the telephone).
RESPONDING
Responding may be defined as the ability to give appropriate feedback to the message received either verbally or non-verbally. It involves the processes of listening and attending. It is argued that at the heart of good effective interpersonal communication is the skill of responding with accurate understanding. Listening without responding may be seen as passive listening. By responding appropriately you demonstrate that you understanding the individual’s needs and feelings, and values what has been said.
Verbal Responding
This relates to all activities that make some kind of verbal statement:
Questioning
• Open questions – Example: “How are you feeling?”
• Closed questions – Example: “Are you feeling better?”
Checking for understanding
• Reflecting – Example: “Am I right in thinking you prefer to be called Bob?”
• Echoing – Example: “You said you are called Brian, but prefer to be called Bob?”
Non-Verbal Responding
Generally most non-verbal responding tends to accompany some form of verbal responding. This includes:
• Proximity
• Gesture
• Posture
• Silence
• Touch
• Facial expression
• Body language
Silence
When thinking about how we communicate we shouldn’t forget silence. Silence can be a very powerful tool. Silence in every day conversations can be awkward but when caring for people who may wish to discuss sensitive issue silence has an important role. Try not to jump in to avoid periods of silence.
Touch
Touch can be a powerful form of communication, it can convey warmth and empathy but it can also be patronising or condescending e.g. a pat on the head or worse a pat on the bottom!
Touch is a very individual thing; some people are more tactile than others. Think about your own circle of family and friends - there is probably a wide range of occasions when it would be comfortable to touch or be touched by different people. Are you a naturally tactile person?
As health and social care workers we are familiar with touching people intimately as part of our work but others may not be. Touch is not always appropriate; you would be surprised if your bank manager held your hand even if it was bad news!
We need to be mindful of cultural and sexual factors when considering touch as a form of communication, what is acceptable for you may not be for the other person.
Remember.
In a care setting touch can convey warmth, empathy, concern and acceptance but:
• Don’t make assumptions, each situation is unique.
• Be genuine.
• Be guided by the other person.
• Touch may be acceptable in one culture but not in another
CULTURE AND COMMUNICATION
The meaning of culture
Culture is a set of rules that an individual inherits as a member of a particular society and which tell him how to view the world and learn how to behave in it in relation to other people. It also provides him with a way of passing these rules on to the next generation by use of symbols, language, art and ritual (Helman, 1994)
The meaning of race
Race is defined as a classification of people on the basis of physical appearance …with skin colour the usual popular physical characteristic (Fernando, 1991)
The meaning of ethnicity
Ethnicity has been defined as a group of people who have specific background characteristics such as language, culture and religion in common. These provide the group with a distinct identity, as seen by themselves and by others in society (Baxter, 1997)
There is much that could be done to improve staff education regarding culture & diversity and people with palliative care needs education & support whatever their background. Lack of good communication skills will affect the individuals care and their perception of services.
Exercise 7
Consider the following factors – what cultural issues need to be considered?
Touch & Contact
Distance
Terms of Address
Gender
Exercise 8
Whilst carrying out your day to day work you meet an Asian lady who does not speak the same language as you. You realise from this lady’s body language and her agitated speech that she is distressed.
What would you do in this situation?
Suggested Actions
• Acknowledge her distress
• Recognise there is a communication difficulty
• Try to make the lady understand you will tell someone
• Find someone to tell straight away
Exercise 9
What resources are available in your area to meet different communication needs?
CONFIDENTIALITY
Confidentiality is an essential part of communication in the health and social care setting.
Exercise 10
Imagine you are feeling very unwell. You call at the GP Surgery to make an appointment. The receptionist is very abrupt and clearly not listening to your request and refusing to arrange an appointment with the GP. The receptionist starts to ask what is wrong with you in a loud voice which carries across the waiting area.
Think of words to describe how you would feel at this point.
[pic]Reflection
What do we mean by confidentiality?
When is it appropriate to share information?
How does this apply to your area of work?
FIRST IMPRESSIONS
First impressions are vital and can stay with you for a long time, sometimes years. They can also influence the relationship you have with someone and can be difficult to alter. A smile of welcome and acknowledgement of someone is as important as how efficiently you complete a task.
Exercise 11
You are visiting a close family member who has been admitted as an emergency to a hospital which you are not familiar with.
You go to the enquiry/reception desk where two staff are sat talking to each other. They notice you standing there and continue their conversation. You say ‘excuse me, could you tell me where Mr A is?’ Without looking in your direction one receptionist says ‘What ward?’ You reply ‘I think it is ward 2’.
The receptionist points and gives you vague directions.
How do you feel?
Suggested Key Words
Upset, embarrassed, unimportant, a nuisance, apprehensive, not welcome, anxious
Exercise 12
You are being admitted to a hospital. The staff on the ward greet you by name. They acknowledge the relatives who have come with you. You are made to feel welcome. Someone shows you to your bed giving you time to settle in and make it clear they are there to answer any queries you may have before they start asking their questions.
Describe how you would feel with this welcome
Suggested Key Words
Special, people taking time, important, a human being, valued, reassured, listened to, respected, acknowledgement of the people important to you
Exercise 13
Imagine yourself needing to come to hospital through the accident and emergency department. You are feeling very unwell but don’t know why. You are struggling to walk so need help. You are seen by a Doctor and are now in a wheelchair. You have been told you need some tests. Someone then appears in front of you. They don’t introduce themselves and don’t ask your name but take the wheelchair and start wheeling you away.
Think of words to describe how would you feel at this point?
Suggested Key Words
Frightened, unsure, out of control, an object, not human, disrespected
COMMUNICATION WITH CONFIDENCE IN PALLIATIVE CARE
The person with palliative care needs may be very ill, weak and fatigued and may have high levels of distress. The individual and their relatives and carers may feel powerless. It is hard to listen to someone else’s suffering and can raise emotions or fears within the health and social care worker themselves.
Remember
• Be yourself
• Listen!
• Acknowledge the pain – “It must be difficult for you”
• Be sensitive
• You may think you haven’t done much but people often feel better for talking, “A problem shared......”
Exercise 14
Angela is a 40 year old woman with advanced breast cancer. You are her key worker and whilst helping her have a bath she says, “I wish it was all over”.
How do you respond?
Give an example of who you would share this information with.
How do you feel?
Check what Angela actually means. Use skills to convey warmth and empathy. Try to explore what is unbearable for Angela. Sometimes it takes courage to stay alongside, but it is important to hear how bad things are. It is essential that the key worker/named nurse is aware of any key issues or concerns. Discuss with Angela the importance of sharing her concerns with her key worker/named nurse and negotiate how you will do this.
It can be hard to listen to someone else’s suffering and can raise painful emotions or fears within ourselves. Sometimes talking with a colleague can be helpful.
REMEMBER TO ALWAYS LOOK AFTER YOURSELF.
SUMMARY OF LEARNING POINTS
The exercises in this learning package have been designed for you to consider your own thoughts and feelings, in every day situations, in order to highlight the communication skills required when dealing with people with palliative care needs.
• Due to the stage in their illness and often unfamiliar surroundings, this group of people are likely to have a heightened emotional state
• Their behaviour may not be as you would normally expect.
• It is important to demonstrate that you are listening and treating people with dignity and respect.
•
‘If you want to treat me equally you may have to be prepared to treat me differently.’
The Policy Framework for Substantive Equality. WA
For communication to be effective you need to understand how to reduce barriers to good communication, which include environmental (noise/ privacy), personal (health of patient) and social (language, ability to understand).
The importance of communication between health and social care workers and people with palliative care needs cannot be overestimated, as it is the basis of the therapeutic relationship upon which successful health and social care relies.
Communication is influenced by:
• attitudes
• knowledge
• social background
• culture
• religion
• experience
Remember:
• Misconceptions and misunderstanding is often inevitable due to differences between individuals.
• It is often difficult to see the world through another’s eyes.
• Even within the context of a common language words can have different meanings for different people.
• Good communication should be at the heart of all person centred care.
• Each person is unique therefore bring differing needs and abilities requiring an individual approach.
• The type of communication must be assessed with regard to an individuals needs
• Information should be given as appropriate in a variety of formats.
If you are unclear about how any elements of this learning package applies to you and/or your role please discuss with your line manager or supervisor.
REFERENCES
Baxter, C (1997). Race Equality in Health Care Education. London: Baillière Tindall
.
Helman, C (1994). Culture, Health and Illness. Bristol: John Wright PSG Inc
Fernando, S (1991). Mental Health, Race and Culture. Basingstoke: Macmillan
Mehrabian, A. (1981) Silent messages: Implicit communication of emotions and attitudes. Belmont, CA: Wadsworth (currently distributed by Albert Mehrabian, email: am@)
Rolfe, G., Freshwater, D. & Jasper, M. (2001) Critical Reflection in Nursing and the Helping Professions: A User's Guide. Basingstoke. Palgrave Macmillan
Rungapadiachy, D. M. (2003). Interpersonal Communication and Psychology For Health Care Professionals: Theory and Practice. London: Butterworth Heinemann
FURTHER STUDY
Those wishing to develop skills in communication further should:
• Explore specific modules on e learning websites by registering as required eg.e-.uk
Please contact your education lead to clarify which route you are able to access these. NHS staff need to register through the National Learning Management System (NLMS) and non NHS staff via e learning for healthcare
• Finding the Words Skills workbook
endoflifecareforadults.nhs.uk
• Access Advanced Communication Skills Courses –if available in your area of work
-----------------------
End of life Care Training in Gloucestershire
COMMUNICATING
WITH
CONFIDENCE
WORKBOOK
Introductory Level
Ref code: CC.WB
If you have any problems downloading this workbook, please email
jane.hamilton@great-.uk or Georgina.king@glos.nhs.uk
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