The aim of this essay is to describe and analyse a personal incident, involving the inner feelings experienced and the appropriateness of the interactions involved. This will include the appropriate models of communication and also show an awareness and ability to utilise effective communication skills to meet the individuals’ needs. To reflect and be more critical of what happens in practice, to gain greater awareness of strengths and weaknesses and improve upon them to provide a therapeutic relationship in which you can facilitate the discussion of the clients concerns.
Communication can be broken down into two parts, verbal and nonverbal and it is generally accepted that communication is two or more people sending and receiving messages. The use of words, voice, tone and rate of speech are classed as verbal communication, whereas Smith suggests that nonverbal signs of communication are eye contact, facial expressions and posture (Smith 1992). Nonverbal messages such as a smile, widened eyes or an anxious glance, can all be types of powerful nonverbal communication, in a situation of face to face contact, where the use of telephones and other types of electronic media can mean that, vital nonverbal communication is lost. The nurse has the advantage of face-to-face communication and should make full use of the nonverbal techniques (Blazer 2000).
On the human face the eyes are vital in sending messages and often showing feelings, therefore eye contact can portray many messages just by the length of glances and movement of eyelids. Nurses can tell a lot from the eye contact they receive from a patient, often if patients are stressed about their health they will avoid eye contact with the nurse. Bradley ; Edinberg (1990) suggest that facial expressions are the most commonly used indicator of nonverbal communication. Difficulties may arise for a nurse when a patient’s facial expressions are not noticed; the danger with this is that people manage to conceal anxieties verbally. However, facial expressions hold the true message and therefore nurses should look more carefully at their patient’s expressions when communicating with them.
Bradley ; Edinberg (1992) state that posture is an area that nurses often overlook, they continue by arguing that posture can communicate a patients emotions, attitude, self-worth and anxiety. Patients with restless hand or foot movements can also be seen to be anxious, nervous or stressed. Sundeen (1998), cited in Balzer (2000), gives a summary of therapeutic communication techniques for nurses. Listening is one of the key nonverbal skills that nurses can use to demonstrate their interest in a patient, and over a period of time it can be used to gain respect and trust. The importance of good communication between health care workers and the patient, should not be under estimated when looking at the overall well being of a patient receiving medical care.
The most important factor when two people communicate is to understand and to be understood. It could be suggested that one of the problems found between a patient and a health care worker, is the use of medical jargon, which most patients are unlikely to understand. Following years of study and academic reading, Klein (1979) found that it was understandable, that health care workers sometimes forgot that patients might not understand the medical terminology being used, he goes on to say that It should also be recognised that some patients may find it hard to make themselves understood and this might lead to difficulties when expressing their feelings.
Coles (1990) illustrates how people can emerge from even well intentioned interviews with health care workers still not understanding fully what has been communicated, the problem being that the patient-centeredness is superficial in that the person ends up being told what the professional assumes they need to know. In other words, actual needs are not really dealt with. Patients within a hospital environment might experience feelings of discomfort, they may become anxious about any tests or surgery that might have to be undertaken and it can therefore be suggested that good communication between patient and Health Care Worker is essential for the patent’s well being. Fairburn and Fletcher (1986), Cited in Davies and Fallowfield (1993 p.6), highlight this point when they found that the ability of doctors to communicate information about test results, diagnosis, aetiology, treatment and prognosis was very poor, even in doctors who had previously had training in interviewing skills, where the focus was on electing rather than providing information.
It is generally accepted that communication through positive body language, could have a beneficial influence on the overall well being of a patient. It could be argued that direct patient communication is a key part of the patients experience and therefore should be addressed as a component part of the patient journey alongside clinical and other considerations. Some recent research from the NHS Learning Zone (1999) shows that patients consistently say that they need good information and clear communication. Health Care Workers may find it difficult to give good information and clear communication to patients in intensive care units (ICUs) as the patient may have an injury that would impede any conversation, or they may find it difficult to receive a communication. Hospital staff can be extremely busy and therefore give the impression that they do not have time to listen to the patients. Some patients in intensive care may feel too ill or too tired to ask appropriate questions. Turnock (1991) suggests that appropriate communication skills must be learned by the nurse in order to identify priorities between the patients’ physical/technical needs and the psychological needs, so that the person’s coping strategies can be enhanced.
Dimbleby & Burton (1992) suggest that an individuals’ previous experience might affect how a person interoperates interactions that involve communication, either consciously or unconsciously, they go on to say that beliefs, attitudes and prejudice can influence conversations, and an individual could, without realising, reveal their emotional state through facial expressions; anger, disapproval, disgust, irritation, love and understanding are all impressions, which could be seen, just by facial gesture. Some other important factors, which play an important part in contributing to a conversation, are the use of hands, which are particularly important to body language, especially when a person is showing empathy.
To empathize is to set aside our own perception of things and attempt to think the way the other person thinks, or feel the way he feels…a very different quality to sympathy (Burnard 1998 p.126).
Robinson and Whitfield (1985) suggest that patients may think they understand information and advice from Health Care Professionals only to discover later, that they have doubts and queries. It would appear that if psychological and social skills are developed with all Health Care Workers, then an effective nurse/patient relationship could be maintained. The nurse brings to the relationship between herself and the patient a maturity which permits toleration of frustration if, for example, the person presents challenging behaviour (Kay 1995).
Some people might say that, the nurse should be realistic in a mature way, as to not reflect any annoyance on to the patient, it could be said that Health Care Workers also have personal needs, however, these needs should at all times, be met by other supporting staff. If better communication is to be achieved, then Health Care Workers will need to develop a better understanding, of how patients understand the information being related to them, whether it is written, oral or through body language. It is important that all Health Professionals understand the diversity of their patients; therefore the onus should always be with the Health Care Worker to make sure that their patients are well informed by enhancing their communicative skills.
Models of communication are useful in the analysis of the communication process, and can be useful to recommend methods of solving or avoiding problems. The linear model indicates three key elements in the communication process, the source, the message and the receiver, the importance being that the meaning is transferable but fails to take into account perception, value and culture. However the circular model includes the source, message, receiver, and then the feedback from the receiver to the original source of the message, it provides information on whether or not the message will be acted upon (Burgoon et al. 1994).
Rubenfield (1995) believe that critical analysis is important to the nurse for the development of good interpersonal skills and self-awareness. According to Burnard (1997) the person who develops a strong sense of self-awareness has greater security of being, which allows autonomy and thought of action. An essential part of reflective practice is learning from practical experience. According to Schon (1983) practioners can either engage only in superficial problem solving according to tradition or engage on a deeper level, which is more meaningful. Over recent years reflection has become an important aspect of nurse training, according to Taylor (2000) the general view is to reflect on personal experiences which can provide the student nurse with the opportunity to form their own views of a situation, therefore the ability to analyse the quality of their actions. In order to help me with my reflection, I have chosen Gibbs (1988) model. This model has six points, description, feelings, evaluation, analysis, and conclusion and action plan using these points as headings I am able to reflect fully on the incident.
Description of incident
The incident that will be discussed occurred whilst out on placement, on a paediatric ward. The age of the children on this ward, ranged from birth, up to eighteen years old, with many different types of illnesses and conditions. This particular incident involved a young girl, the student nurse and senior staff nurse. In order to respect the rights of confidentiality, throughout this report, the girl will be referred to as Charlie (NMC 2004)
Charlie was diagnosed with Rett Syndrome (RS) when she was two years old.
According to Candy et al (2001), only girls can be affected by RS and for no explicable reason, between the age of nine and twenty-four months they begin to deteriorate, their limbs become stiff and may be regarded as showing spastic quadriplegia. Apraxia, the inability to program the body to perform motor movements, is the most severely handicapping aspect of RS. Charlie is now nine years old and no longer has control over her body. Due to Apraxia, she lacks any verbal communication skills, although Charlie understands everything that is being said to her.
It was during the morning on the second week of my placement on this ward, when the incident occurred. I was walking down the ward, when I noticed that Charlie seemed quite distressed, she was propped up into a sitting position in her bed, supported by a number of pillows. Her arms were waving about and she was making some crying sounds. I walked over to Charlie and tried to ask her what was wrong. Due to Apraxia, Charlie had great difficulty communicating verbally. At this point in my training, I had little knowledge of the effects of RS and I did not realise that Charlie could understand everything that I was saying. However, Charlie’s non-verbal behaviour indicated to me that something was wrong. Charlie tried so hard to verbally tell me what was wrong, but she could not make me understand, I tried to appear relaxed and therefore encourage Charlie to try again, although with her arms moving about, some rapid eye movement, and the same crying sounds, I was not able to understand what it was she wanted. As time went by it seemed as though she was becoming upset and frustrated at my inability to understand her and it could be clearly seen that this child was in some sort of discomfort. Following several attempts to understand her, I only seemed to add to her desperation, where she became quite tearful and defeated.
I felt desperately sorry for the child and found it difficult it imagine how she must be feeling. I then asked for the help of a nurse who was passing. The nurse also recognised Charlie’s distress and confidently comforted the child holding her hand and encouraging her not to worry.
Whereas I had tried to communicate with Charlie, not knowing if she could understand what I was saying, the nurse pointed to and held up different items to see if they were what she wanted, and to my surprise, when the nurse picked up Charlie’s cup of juice from the table, Charlie got all excited, showing that all she wanted was a drink. Together the nurse and myself helped Charlie to have some of her juice.
The outcome of the incident was that Charlie had become totally distressed and was understandably deeply upset. The nurse explained to me that although Charlie cannot verbally communicate, she could understand everything that is being said to her. I held Charlie’s hand apologising profusely for my inability to fulfil what under ordinary circumstances would have been a very basic need.
One of Charlie’s problems resulting from Apraxia was that she had no control over her body movement and was unable to point to what she wanted.
By comparing my interactions with that of the nurse, the incident has enabled me to become more self aware, by highlighting my experience in relating to theatrical concepts regarding interpersonal skills in the practice setting. In comparison to the nurse who seemed so natural and confident when interacting with this child, it was obvious that I was very much the learner. Furthermore, it also became apparent to me that in any situation the interpersonal skills applied can depend very much on the clients themselves and in Charlie’s case, the effects of her illness, this was highlighted by Hargie (1994), that social skills should be appropriate to the situation that they are being employed and adapted to meet the demands of that particular situation.
Later I discussed the incident with my mentor and she was quite helpful in determining where I had gone wrong. The nurse actually praised my attempts to understand Charlie and reassured me that communicating with Charlie can be difficult for the most experienced of staff. Although in this situation I had tried to the best of my ability to apply the appropriate interpersonal skills, when encouraging Charlie to speak, my downfall was really due to my lack of knowledge regarding Charlie’s condition. She advised me to read around the subject of Rett Syndrome and Apraxia to enable me to understand that in line with interpersonal skills, communicating effectively with a child suffering Apraxia often relies on a deeper understanding of the condition. The actual reading helped me to reflect on the incident and put it in perspective.
According to Barber (1993), communication is about sharing understanding, involving direction of attention, perception, receptivity and empathy towards the client. Burnard (1997) proposed that to attend and listen to the client is the most caring aspects of all and goes on to define three different aspects of listening. The linguistic aspect, that includes listening to the verbal expressions, the paralinguistic aspect, that involves the client volume and pitch of voice and the non-verbal aspects that encompasses the client’s facial expression, gestures and body language. However, the latter can only be a clue as to how the client is really feeling.
Non-verbally, Charlie appeared distressed and the way she was moving and trying to talk, did seem to indicate that she was in some sort of discomfort. Unfortunately, I was unable to understand what it was that she wanted. However, the pitch and tone of her voice indicated that she was becoming annoyed or frustrated at my inability to meet her needs.
Faulkner (1992) suggests there is a need for skills training as most nurses do not exhibit the skills required for effective communication. However studies on nurses have shown a great improvement in their skills after brief training. As communication skills improved, so did their empathetic and warm responses. Therefore maybe more skills training, is also required to improve the awareness of the skills. When interacting with the clients basic communication skills, if used effectively, can enhance interpersonal interactions and facilitate client centred development. Interactions are often superficial, brief and ignore or deny clients the chance to express their feeling and emotions. By having these skills and by being able to put them into practice effectively, can help prevent cliched responses to people’s problems and to enhance the ability to work in a therapeutic way.
Reflecting back on the incident, the way the nurse held Charlie’s hand and comforted her, seemed to convey a feeling of empathy towards the child, as though she was with her and understood her distress. Riley (2000) states that touch is an integral part of nursing care and may have many potential benefits for the client. Reading the literature it seems that empathy can be difficult to define, however, Egan (1998) proposes that empathy can be viewed as an intellectual process that involves understanding correctly another person’s emotional state. According to Ley (1992), empathy is the essence of the nurse client relationship, and that the most effective way to communicate such empathy, is through non-verbal behaviour, for example, head nods, gestures, a steady gaze and minimal bodily movement.
Argyle (1978) suggests that non-verbal communication has five times as much effect of a persons understanding of a message compared with words, which alone, makes me wonder if I was actually conveying any negative message to the child, as I began to feel inadequate to the situation. According to Davies (1994), negative cues such as altered facial expression, can be sensed quickly by the client, and may add to the vulnerability they are already feeling. Egan (1998) suggests the face and body are extremely communicative; sometimes the facial expressions, body motions, voice quality and physiological responses of the client communicate more than words.
A framework was developed in the early sixties by Berne (1975), which examined how our internal world effects the way we perceive and relate to others, called ‘Transactional Analysis’, the basis of which is the Ego state. Our feelings and behaviour are demonstrated in one of three ego states – parent, adult or child. The parent ego state is one that criticises, but also nurtures. This behaviour is copied from parents. The child ego state accepts this criticism and nurturing behaviour learned in childhood. The third ego state is that of the adult. In this state the person makes informed, objective decisions, and behaves appropriately to the situation. A consistent, self-aware individual is one in which all states are readily accessible to interact and play their role. Individuals can then respond to any situation. Kenworthy et al. (2002)
By using the Gibbs (1998) model, each component is associated with a key question. The principle of this model is based on the idea that the reflective process is described as a ‘cycle’ because of repeated clockwise movements; it gives a deeper awareness, increases knowledge and skilfulness. Reflecting on this incident will likely seem somewhat ordinary to the more experienced carer, however this incident was actually significant to me. Following discussion with my mentor, I have gained some valuable insight into nursing children, in which I have been able to identify my learning needs regarding communicating with a child suffering Apraxia.
I acknowledge the need to read further literature regarding communicating with children and the different conditions that they have and aim to achieve more experience in the clinical setting. I have realised that in this instance there are communication barriers that perhaps would not occur in another situation. However, I have recognised that these boundaries can be overcome with the help, encouragement and patience on the carer’s behalf. I have become aware that communication is central to good nursing care and have identified that for my own personal development, perhaps more practice is needed in this area, if I am to provide the child with a holistic approach to their care.
Looking back on my experience with Charlie, I feel that I could have helped the situation by asking for the help of an experienced nurse much earlier than I did. For my own personal development, I feel that I still need more practice in utilising the knowledge I have of these skills into practice. Reading around the subject of RS and Apraxia gave me a greater understanding of the condition and in the future I can use this incident as a positive learning experience.
In conclusion, communication is a highly complex process and to improve interpersonal communication, a fuller knowledge and understanding of communication skills are essential. These skills need to be continually practiced, as every client we meet, is an individual and so is their situation. A theoretical knowledge is needed as a base, but is ineffective if it cannot be put into practice in an empathetic and caring way.