SECTION II. COMMUNICATION SKILLS

If you were to try to explain the process of human interaction, you might define it as a huge and very complex communication system. Nevertheless, it is essential that you develop and maintain an understanding of the methods and skills of communication in order to meet the needs of the patient. The quality of care you can provide is, in many ways, dependent on the quality of communication that exists between you and your patient. Through your direct contact, the patient must perceive your intentions of support and your positive expectations. You must accurately assess the patient's physical and emotional symptoms. Communication has only taken place if the message being sent was accurately received.

• To correct the information a person has about himself and others.

• To provide the satisfaction or pleasure of expressing oneself.

The essential components of communication are:

• Sender--the originator or source of the idea.

• Message--the idea.

• Channel--the means of transmitting (either verbally or nonverbally) the idea.

• Receiver--someone to receive and interpret the message.

• Feedback--the response to the message.

• Facial expressions (smile, frown, blank look, grimace).

• Gestures/mannerisms (fidgeting, toe tapping, clenched fists).

• Eye behaviors (avoiding eye contact, staring, wide eyes).

• Use (and avoidance) of touch or physical contact.

• Posture (erect, slouching, leaning toward/away from someone).

• Walk.

• Silence can be used to communicate the deepest kind of love and devotion, when words are not needed.

• Silence can be a cold and rejecting sort of punishment, the "silent treatment" received for coming home late or forgetting an anniversary.

• Silence can be used in an interview or conversation to encourage the other person to "open up." Conversely, it can be used to intentionally create anxiety and discomfort in the other person.

Convey to the patient and family that they are important to you and that you want to help them. There are many ways to do this; you must do what is comfortable and natural for you. However, there are some things everyone can do.

• Convey honesty and trustworthiness.

• Try not to overwhelm the patient with embarrassing or personal questions. When it is necessary to ask personal questions, explain why and keep it short and matter-of-fact.

• Don't make promises you can't keep. If you say you are going to do something, make every effort to do it or see that it gets done.

• Try to be there when you say you will. If you are late, explain why.

• Communicate with each patient as an individual. (This is especially important in a hospital setting, where patients often experience a loss of identity.) In order to do so, you must try to get to know the patient. Listen to him. Put yourself in his place.

• Accept and respect the patient despite the symptoms of his illness.

Establishing the Setting.

• Provide a comfortable environment (lighting, temperature, furnishings).

• Establish a relaxed, unhurried setting.

• Sit down when speaking to the patient. Although you probably have dozens of things you need to be doing at that moment, try to relax. Don't stand at the doorway or sit on the edge of your seat, as if you are preparing to jump and run as soon as you can get away.

• Face the speaker and maintain eye contact.

• Provide for privacy.

• Avoid interruptions and other distracting influences.

• Let the patient do the talking.

• Keep questions brief and simple.

• Use language that is understandable to the patient. Avoid acronyms and medical/nursing jargon if the patient is nonmedical.

• Ask one question at a time. Give the patient time to answer.

• Clarify patient responses to questions, not just for your own use, but also to let the patient know that you are listening (be sure you really are) and that you understand.

• Avoid leading questions. You want the patient to tell you what he is feeling, not what he thinks you want to hear. So avoid putting words in his mouth. For example, it might be better to ask, "How are you feeling?" rather than "I suppose you're feeling rested after your nap."

• Avoid how or why questions; they tend to be intimidating.

• Avoid the use of cliché statements like, "Don't worry; it'll be all right." or "Your doctor knows best."

• Avoid questions, which require only a simple "yes" or "no" response. You want to encourage the patient to talk to you.

• Avoid interrupting the patient. If you need to ask a question, wait until he has completed his thought.

• Reflection. Repeating content or feelings. You might simply repeat what the patient has said, to give him time to mull it over or to encourage him to respond. Or, and often more effectively, you can reflect on what you think the patient is feeling. "It sounds like you're concerned about your family." or "I don't think you're very happy about this." By reflecting on his feelings, you may be encouraging him to talk about something he may have been hesitant to bring up himself. Or you may be helping the patient to identify his own feelings about something.

• Restating. Rephrasing a question or summarizing a statement. "You're asking why these tests are needed?" or "In other words, you think you're being treated like a child."

• Facilitation. Occasional brief responses, which encourage the speaker to continue. A nod of the head; an occasional verbal cue, such as "go on" or "I see;" and maintaining eye contact throughout the conversation all imply that you are listening and that you understand.

• Open-ended questions. Questions that encourage the patient to expound on a topic. If you want to encourage the patient to speak freely, you might ask "How are you feeling?" rather than "Are you in pain?"

• Closed-ended questions. Questions, which focus the patient on a specific topic. If you want a short, straight answer, ask a question which will allow only for a direct response, such as "When was your accident?" or "Do you have pain after eating?"

• Silence. A quiet period that allows a patient to gather his thoughts. Of course, this would be an occasional practice, used when you feel that the patient could use a little time to think about his response to a question or just to think.

• Broad openings. A few words to encourage the patient to further discuss a topic; for example, "and after that..." or "you were saying..."

• Clarification. Statements or questions that verify a patient's concern or point. "I'm a bit confused about...Do you think you could go over that again please?"

• Practicing therapeutic communication is in many ways simply developing a good bedside manner. When your patient asks you a question or discusses something with you, be careful to respond in a helpful and caring manner. By encouraging the patient to speak up, you are probably helping him/her to decrease his level of stress and thereby his recovery time.

• Study the techniques discussed in paragraphs 1-15 and 1-16. Become familiar enough with them so that they become a natural part of your conversations.

• When your patient communicates with you, you must be able to correctly observe, evaluate, and respond. Your knowledge, understanding, and skill in human relations will enable you to do so.

Be able to decipher the patient's message. Get to know the patient well enough to discover the underlying meaning (intent) of his/her communication. Be alert and perceptive enough to pick up the correct message. Many people feel uncomfortable talking about their feelings, especially if they are trying to be "good patients." Learn to "read between the lines."

Be realistic in your relationships with people; avoid making assumptions or judgments about your patients' behavior. If you have negative thoughts about something a patient says or does, try to keep in mind that he is an adult, responsible for making his own decisions. You do not want him to feel he must conceal anything from you. You want him to see that you will accept him for what he is; you will allow him his own identity.

Be emotionally mature enough to postpone the satisfaction of your own needs in deference to the patient's. Find sources other than the therapeutic relationship to meet your own needs.

• Always speak to the patient when you enter the room so he will know who is there.

• Speak directly to the patient; do not turn your back.

• Speak to the patient in a normal tone of voice; he is blind, not deaf.

• Speak to the patient before touching him/her.

• Offer to help with arrangements for patients who may enjoy hearing tapes or reading Braille literature.

• Look directly at the patient when speaking with him/her.

• Do not cover your mouth when speaking because the patient may read lips.

• If the patient does not lip-read, charts with pictures may be used, or simply writing your questions or comments on a piece of paper may be helpful.

• Charts with hand signs are available at the local society for deafness and/or hearing preservation.

• Obtain a translator if possible. The Red Cross or the Patient Administration Division (PAD) may be of assistance.

• Have a chart with basic phrases in English and the foreign language.

• Consider using charts with pictures.