Communications in Health & Social Care.

* Self-esteem needs - A child has problems talking to the rest of the class as she becomes very shy when asked to tell the class what she did over the weekend. The best way is for the staff to use communication to encourage her not to threaten her self-esteem. To do this first talk to only a few children instead of the whole class. Also the staff should continue to ask open-ended questions and become enthusiastic by using interventions e.g. "Wow!" This will help the child to continue to talk as she feels you are interested.

* Belonging and affection needs - A child who gets upset when no other child in the class is interested in playing with him. Communication skills are essential to resolve this problem. If the staff see that the boy is playing with something, they should make it obvious to the class that they want to play with the boy, as it looks like fun. This will attract others attention, as not only do the children like playing with other children, but they also like playing with staff. Other children will become intrigued of what the staff are making all the fuss about. Resulting in the boy feeling a sense of belonging.

* Emotional and physical safety - A new boy starts attending the nursery, his parents come into the room where they leave him with the staff. When his parents leave he begins to cry because he knows no one and everyone looks like a stranger to him as they all stand there staring at the new boy. The new boy feels threatened by the other children and lonely. In order to overcome this the staff need to first introduce the boy to the class so that he feels welcomed and then use their conversational skills to help him feel safe and welcome.

* Physical needs - A new girl starts attending the nursery with physical difficulties as she is in a wheelchair. She feels as though she doesn't belong in the new group as she isn't as able as the other children. Communication skills will be needed to ensure her emotional safety and so that she doesn't feel rejected from the group. The staff will need to communicate to her by acting and talking to her in a certain way so that her self-worth and esteem is promoted. Also so that the new girl feels a sense of value in the new group.

There are also two main types of interaction; formal and informal. Informal interactions are often used in care settings. Formal interactions is where care workers need to use a range of communication skills to carry out formal procedures. Formal interactions also require the appropriate use of verbal and non-verbal skills, here are some examples of formal interactions, (Heinemann AVCE, Advanced Health and Social Care, Page 76, Figure 2.4 'Examples of formal interaction'):

* The reporting of accidents to managers.

* Leading a planned group activity and teaching a skill.

* Explaining procedures, how to apply for a service and how o appeal or complain about a decision.

* Handing over details of work to new colleagues.

* Negotiating with others about care plans in a case conference.

* Assessing needs of the care planning process.

Informal interactions involves care workers communicating constantly with others, whether this is verbal or non-verbal communication. The use of informal communication in a appropriate manner makes people feel that they are respected and valued. Here are some examples of informal interactions in care, (Heinemann AVCE, Advanced Health and Social Care, Page 75, Figure 2.2 'Informal interactions in care'):

* Interaction in groups whilst practical work is being carried out e.g. when lunch is being prepared.

* Greeting and introducing yourself to relatives of the clients.

* Chatting with clients and relatives.

* Asking others to make choices or decision e.g. what they want for lunch.

* Sharing information and ideas with colleagues.

* Short conversations whilst giving practical assistance to people e.g. helping young children to eat their food.

Effective Communication

Communication is a two-way process, thereby effective communication always changes both parties in some way. Effective communication can be described as rapport, this is where a relationship emurges naturally and is built between two people when they are at ease with each other and generally interested or enjoying what the other has to say.

Effective communication involves...

* Funnelling - This is a skill which enables carers to lead into questions 'gently'. Therefore the carers use open questions (offers the respondent a free choice of response) should lead into a closed question (allows a limited choice of response e.g. "yes/no" answer), these closed questions may start off a series of open questions.

* Empathy - Involves building bridges of trust - showing you understand how someone is feeling by offering support and help in solving the problem.

* Pace at which you are talking - e.g. fast or slow, too fast may make the information unclear, the listener may not understand or may miss the information. Whereas, too slow may lead to a conversation becoming boring so that the listener loses interest. Therefore, it is essential to speak on one level.

* Speak on one level - This is so that the listener can understand if the speaker is being sarcastic through the use of inflection (changing pitch or tone of voice).

* Direction - Talk to the person you are supposed to be talking to, eye contact is always a good technique.

* Knowing when to be quiet and listen - Otherwise this could lead to a break-down in communication. When listening; gather their thoughts and use non-verbal communication to show the speaker that you are listening.

* Being powered by the conversation - This is where you are saying something clearly without the use of anger or aggression.

Effective communication is a result of enhancing and inhibiting factors. Enhancing factors help to enhance (to make greater) or promote good communication and interaction, whereas inhibiting factors restrain or hinder communication or interaction and therefore causes barriers in communication. When a group of people inhibit the interaction this is usually because they do not share the same care values. In order for an interaction to work effectively (enhance) in a group is to encourage and develop a share of beliefs and a feeling of 'belonging'. Such factors as physical, emotional, social, skills and special needs there are both enhancing and inhibiting factors which may affect the interaction between two people or between several people.

To ensure effective communication by using very effective and appropriate use of each skill in non-verbal and verbal communication and in listening skills. Which are as follows, in non-verbal communication ('62 AVCE Advanced Health and Social Care Tutor's File Activity 2.2.1 Effective Communication' class worksheet):

* Eye contact - Feelings and thoughts can be guessed and sometimes we can understand just by looking at a person's eyes and giving eye to eye contact. When our eyes widen this often means that we are happy, excited, attracted or interested in someone. A constant stare can be because this person is angry and looking away may mean that someone is bored, not interested or possibly shy.

* Facial expression - Facial expressions indicate our emotional state. Just from the eyes, mouth and muscle tension in the face we can clearly interpret a person's state.

* Tone of voice - This refers to the manner of an expression, so it isn't just what we say, it is also how we say it can send out different messages.

* Position of hands and arms - Many messages can be read by just examining the positions of the hands and arms, for example if someone is sitting with their arms folded this might suggest that this person is possibly shy and not open to discussion. However, if a person's arms were by their side or behind their head in a very relaxed manner this would show that the person is open or comfortable for discussion, possibly even confident.

* Posture - Body postures all convey messages whether we are standing or sitting down. For example if we were sitting upright with our arms and legs cross, this may show that we are a very closed person. A laid back posture which show that we are leaning back in our chair, stretched out may show that we are bored or very relaxed. However, if someone were to lean forward with their hands on their knees this shows interest in what the other is saying or doing. Sat upright with hands crossed or together on laps and with feet and knees together is a very formal posture, usually used in a formal interview for e.g. a job.

* Proximity - This is very important as it is all about a sense of personal space. If someone was standing very close to you, face-to-face, this may show signs of intimacy or possibly overpowering (showing authority). Friends often have reasonably close proximities. Whereas strangers often stand away from each other at arms length.

* Touch - Touching other people sends messages of authority, affection, care or sexual interest.

* Gestures - These are hand and arm movements helping us to understand what a person is trying to say.

* Muscle tension - Tension in our hands, fingers, feet and even faces send messages to others of how relaxed or tense we are. From muscle tension feelings and emotions can be determined.

* Body movement - The way in which people may walk, sit, position their arms and legs, move their heads can send messages about whether they are happy, sad, tired, bored, excited or scared etc.

In verbal communication and listening skills ('62 AVCE Advanced Health and Social Care Tutor's File Activity 2.2.1 Effective Communication' class worksheet):

* Turn taking - This involves taking turn to listen and speak.

* Using appropriate questions - e.g. open and closed questions.

* Encouraging others to talk - This is where a person may inspire with hope, courage, or confidence to talk or to keep talking, therefore the use of probes and prompts could be used. Also the use of encouraging interventions can be used e.g. "mm mm", or such words as "yes...", or non-directive comments e.g. "I see..." or repeat key words.

* Use of probes and prompts - A probe is a very short question e.g. "Can you tell me more?" Whereas a prompt are short questions or maybe words which offer the person you are talking to, to answer or to give more information so that they keep talking e.g. "Would you do it again?"

* Reflective listening - Where we are reflecting or thinking back on what the other has said in order to check understanding. The key skills of reflective listening is to encourage the other person to speak without interruption, paraphrase (clarify meaning) what the speaker says at appropriate intervals. Also reflect the speakers feelings, this involves feeding back to the speaker the emotions they are communicating in a way which shows you have understood them.

* Active listening - Where the words of the other person are heard, the person listening thinks back to what it means and then starts thinking of what to say back to the other person.

* Using silence as a listening skill - This is when we use silence whilst giving off non-verbal communication to show the other person that they are being listened to and show that we respect them by listening and being quiet when they talk.

* Clarity of conversation - This is the quality or condition of being clear so that the listener can hear and understand what the speaker is saying.

* Pace of conversation - This involves speaking at one level and the rate of speech, therefore not too fast or too slow as this could inhibit the conversation between two people.

Here is a table which shows each factor I have observed in my work placement or an example of a likely situation. Here I have observed a type of interaction between either a member of staff and a child or a member of staff and a parent, under the appropriate factor, and then used this observation to distinguish the enhancing and inhibiting factors (based on 'Unit 2: Communication in Health and Social Care (7291)', Page 3, 'Effective Communication' class OCR 2000 booklet):

Factors Observation Enhancing Inhibiting

factors factors

Physical Staff and client - Client lines up with the Non-verbal communication Invading personal

rest of the children, ready to be led out e.g. offers affection and space - girl is not

into the garden. As she walks out the warmth (but rejected). happy being

door she traps her finger and starts However, there is cuddled (closed

crying. Member of staff notices and appropriate touch and position, this soon

kneels down to take a look and goes to proximity after staff is changes to

cuddle the client but she doesn't want to. distracted. an open positi-

Staff is then distracted as the group of on). Staff becomes

children begin to lead themselves out distracted.

to the garden. Staff then has to hurry

to bring everyone back into the class-

room. Returns to the girl and rubs her

finger until she calms down.

Emotional Staff and client - Client plays with a toy The staff member showed High degree of

car. Another child comes along and takes a relaxed manner, offers distress in the

the toy car off the boy not giving it warmth and sincerity. She situation from the

back. The boy became upset and started also showed a level of client. The boy who

crying. A member of staff stepped into the understanding and she took the toy car

situation and knelt down beside the upset knelt down to his level showed he was

boy. She put her arm around him, whilst he showing respect. minimising the

says "It's my car!" The carer says softly importance of the and calmly "It's the nursery's toy car." The boy's feelings. client explained what happened, whilst the

carer listened intently and told him to calm

down, suggesting they both play with the

toy car. The carer tells the other boy it was

wrong to take the car without asking and

told him to say sorry.

Social Staff and carer - A 'coloured' carer comes Staff member shows At first when the

to collect their child. They approach a staff attentiveness by listening, carer approaches

member with a smile, who returns with a showing she understands the staff, the staff

negative facial expression (gives a 'dirty by nodding etc and resp- member seems as

look'). The carer says "Sorry to bother you, onding back to the carer. though she is stere-

but I am here to pick up my friend's Son, Common interest as carer otyping or labelling

'David' (not real name), his Mother wanted gives sympathy and empa- the carer by her

me to ask you how 'David' is getting on." thy. Also shows receptivity. facial expression,

The staff member replies "Sorry Darling I this also shows lack

didn't recognise you, David has been..." of respect for the

They start a conversation on 'David's' carer. "Darling"

progress, staff listens, understands and is inappropiate

responds back using eye contact, nodding language this could

and other non-verbal communication. The of caused offence as

carer explains how his Mother is too ill in it's too informal (a

hospital to look after him, the staff offers skill factor). Also

sympathy and empathy when she starts to an emotional factor

explain what it was like for her when her was shown as even

Mum had to go to hospital. though the staff was

showing empathy, she was also off-

loading her own

experience.

Skills; Verbal Staff and client - A staff member was Clarity was used as the staff The member of

writing the weekly progress reports on member corrected the client staff used closed

each child. These progress reports were to clearly and slowly (showing questions, few were

see if a child could answer the staff's good pace). The right tone inappropriate.

questions correctly about e.g. objects, of speech was used because

pictures, shapes, colours etc. The member she praised the client

of staff was being very positive when the enthusiastically every time

child answered a question correctly, she she answered a question

would then award them by saying enthus- right, also showing encour-

iastically e.g. "Well done!" The client then agement. The staff also

answered a question incorrectly, in which asked some open-ended

the staff member corrected her, saying it questions, where she

slowly and then asked the girl to repeat listened intently to the

what she said and then praised her. This client's reply (respecting

shows a positive interaction and when the silence). The client showed

client encountered a problem this went some assertiveness.

from a negative to a positive interaction.

Non-verbal Staff and client - A staff member is sitting (No enhancing factors). The member of

on a chair whilst playing a game with the staff was sitting in a

children. A client wishes to sit on the closed position,

staff's lap to be comforted, however the therefore the clients

staff member has her arms and legs crossed would not feel at

not allowing the child to sit on her lap. The ease with the staff

client becomes upset by her facial expression, member. She was

crossing her arms and lowering her head. also sitting on a

While the staff recognises this although chair which I think

chooses to ignore the client. is unnecessary

because if the staff wishes to interact with the clients she needs to be at the same level - this way there would be better communicat- ion. Also the staff member ignored the client's feelings.

Special Staff and carer - A parent in a wheelchair (No enhancing factors). The member of

needs came to pick up her daughter from the staff showed a lack

nursery. When a member of staff answered of respect for her

the door and saw that she was in a wheel- disability. She paid

chair, she said "Sorry but this nursery is no thought to how

wheelchair bound" in a negative tone. The the parent must feel

parent replied "I've come to pick up my about not being

daughter Susan (not real name)" and the able to pick up her

staff member answered "Wait here and I'll daughter normally

get her." like any other

parent, as she is being restricted from doing so.

Communication is influenced by gender, culture and beliefs. Carers can pick up background knowledge on different ethnic and religious customs, to do this they listen and communicate with people who lead different life styles from ourselves. In order for the staff at 'Alphabet Corner' to maintain people's equality, diversity and rights, they must work within the guidance of the Care Value Base. This Care Value Base may also meet the needs of clients in a way which will enable them to develop to their full potential. Here are the Care Value Base's main principles (Heinemann AVCE Advanced Health and Social Care, Page 4, 'Unit 1 Equal opportunities and clients' rights', 'Figure 1.2 The care value base: foster people's equality, diversity and rights'):

* Foster equality and diversity of people; such as age, gender, race, class, religion, sexual orientation, ability, health, relationships and presentation and dress.

* Foster people's rights and responsibilities; such as rights e.g. confidentiality and choice, advocacy, effective relationships, role boundaries, needs and resources, and challenging when other's rights are not met.

* Maintain the confidentiality of information; this can value and protect a client, there needs to be policies, procedures and guidelines, boundaries and tensions in maintaining confidentiality, the need and right 'to know' and the security of recording systems. Which includes The Data Protection Acts 1984 and 1998, Access to Personal Files Act 1987 and Access to Health Records Act 1990.

* Trust; the trust between a carer and client that they will withhold from telling others personal information about a client. This will benefit the staff and client as the client will then feel comfortable telling them what they really think and feel.

* Self-esteem; keeping things confidential shows respect and values towards the client, showing that you matter.

* Safety; carers need to keep personal details confidential to protect the client's property and personal safety.

These elements should be assessed in any care setting. Effective communication may still be seen as a right to which clients may expect and a responsibility which carers should meet.

Ineffective communication can include emotional barriers which inhibit communication, such as:

* Stereotyping and labelling - People are often stereotyped or labelled when they have a difficulty in hearing or seeing, or even if they use a different language systems or cultural differences. Stereotyping is when a person conforms to a widely accepted idea, attitude or belief, this is often in a very negative, biased or discriminating way of identifying someone e.g. wheelchair users are 'stupid'. Labelling is where it can be based on an individual interpretation or ideas of someone e.g. speaking a posh accent means they are upper class so therefore they're good parents, whereas as having a rough accent portrays you as being lower class, therefore a bad parent.

Therefore, effective communication is necessary to help and protect the mental well-being of vulnerable people because poor communication or ineffective communication can be considered as abuse resulting in damaging the mental well-being of a person. Ineffective communication is where carers inhibit the communication with their clients resulting in e.g. a loss of support, self-esteem, purpose in life or feeling threatened. The way in which we communicate with others can change or damage their views, opinions or themselves. Effective communication is vital if staff are to foster people's equality, diversity and rights. Thereby in my care setting, 'Alphabet Corner Nursery', effective communication is essential for the staff to use as this will value the clients as individuals.

Assertive Skills

Assertive behaviour is where a care worker is in control of their own actions, it is a balance of an appropriate expression of your own need while understanding the needs and rights of others, therefore not behaving aggressive (anger) or submissive (fear) in a care environment as both emotions will have an affect on others and a possible short or long term affect on you. Being assertive will help to challenge how other people feel about you. Assertive behaviour in a person listens and shows respect to others, tries to solve problems, aiming that no one needs to lose, negotiating (come to an agreement) with others and maintaining a clear, calm voice. An assertive person is able to:

* Understand the situation they are in.

* Control their personal emotions and remaining calm.

* Use the right non-verbal assertive behaviour including varied eye contact, relaxed facial muscles, looking 'in control', keeping hands and arms by their side.

* Use the right words and statements in any situation.

If a care worker were to act aggressive, this is where they some how threaten someone, put them down or make them feel inferior to you. This type of behaviour has long and short term affects; the short term affects are that you are releasing some emotions that have been building up or getting some sense of power. Whereas the long term affects may lead to you feeling guilty and over apologetic, and you blame others for your behaviour. This will all result in people mistrusting you which will make you feel isolated from others and will contribute in high blood pressure. Being aggressive not only affects you but it also affects others as they may feel hurt, angry or humiliated and therefore retaliate or they may stop being in your company.

Some people are aggressive whereas others are indirectly aggressive, this means storing your aggression to be released later or onto someone not related to your aggression. Again this affects you long and short term, short term being that you are able to let off steam onto someone else, you have less anxiety because you are not confronting the cause for your aggression directly, you get what you want and enjoy 'working behind the scenes'. The long term affects is that you could lose control of your aggression, suffer from stress and stop being honest with yourself. Others are also affected as they may feel unfairly criticised by you and come to distrust and distance themselves from you.

This is why it is important for care workers to learn assertive skills by watching other professionals and doing the same, as being assertive will help to resolve and problems. Vulnerable people need to be 'empowered' to control their lives, whilst rights and responsibilities also need to be thought through. Assertive behaviour from a member of staff in a care setting will lead to effective communication, as assertive skills help to create an atmosphere for vulnerable people where they don't lose out.

Empowerment

Effective communication is making sure clients and service users are empowered. Empowerment means authorising or enabling, whereby you are giving the client the choice or half of the authority, so that you are enabling them to make a decision for themselves. In my work placement a lot of positive re-inforcement is used, this is where everytime a client achieves something or does something right, they are praised by the staff. Praising a client for doing something good or right will promote their good behaviour and social practice. As the children attending the nursery are learning what is right and what is wrong through watching how staff act and behave. When someone is being passive or submissive this is where they are self pitying, over apologetic, helpless and held back. Passive behaviour is where you get the feeling that other people's needs and wants are more important than your own.

Passive behaviour affects you in the short term as you would have relief that you have avoided a possible conflict and you may feel sorry for yourself or proud. Others will admire and praise you for 'putting yourself before others'. However, long term affects are included as you will feel a increase loss of self confidence, you will be more frustrated, hurt, self pitying, stressed or feel more anxiety. Again passive behaviour not only affects you but it affects others as they may cease to respect or spend time with you, they may pity you or feel guilty for them taking advantage of you or they may feel irritated by you.

The principles shown in the Care Value Base shows that staff need not have power just for themselves but the clients need to be empowered to control their own lives, therefore leaving them to do things for themselves e.g. simply by pouring their own drink, going to the toilet by themselves or choosing what they wish to eat first from their lunchbox. This means that each client will not always be dependent on the staff to take control of simple matters for them.

Personal grooming and dress

There is often a clothing and personal appearance policy in many health and social care settings. These policies are there so that all members of staff convey a professional image and standards. This is because if a member of staff were to dress not suitable or inappropiate this may affect the client's reaction to them and therefore inhibit the communcation between the staff and client, (based on 'Week two, Activity - The effects of clothing and appearance on communication' class worksheet). The appearance of a care worker is a source of non-verbal communication, therefore if a carer is appropriately dressed this alone doesn't create good communication between the care worker and client. So not only does a member of staff's dress effects the communication but also the way in which they communicate can lead to barriers in communication. However, clothing and appearance contributes to how effective communication is between a care worker and their clients.

Before I went to my work placement at 'Alphabet Corner Nursery' I was told to look presentable by my Health and Social Care teachers. To do this I was to wear smart black trousers, hair tied back, minimum make-up and jewellery e.g. no hoop ear-rings, necklaces, rings etc. I felt that this was acceptable and was what I had expected as hoop ear-rings etc. is a safety issue when looking after young children and it is the staff's duty to set a good example to all the children in their care.

When I first entered the nursery, my first impressions of the staff and their appearance and clothing were 'scruffy'. The majority of the staff wear black trousers, and the polo neck tops with jumpers (red or blue) which have the 'Alphabet Corner Nursery' logo imprinted on them. My first feelings on this 'uniform' was that wearing a logo gives a positive feeling towards the clients and carers, as they are giving out a good image of the team at the nursery. This also distinguishes the staff from the carers (parents) or students how help out. This 'uniform' looks comfortable with trainers or non-heeled shoes (for safety), conveying a comfortable, happy environment.

However, there are many negative aspects to their appearance. Some of the staff come to work with hugh hoop ear-rings, lots of make-up, big rings, necklaces and nose studs. This made me feel uncomfortable because I feel that they look 'common' and the clients they care for may think it is acceptable to look this way. It also made me think that why do the staff wear this unsuitable clothing when they know that it is hazardous for the children in their care? The staff are risking causing a safety hazard for themselves and the children, as the jewellery can be pulled or swallowed etc. The staff/carers are role models for their clients, therefore they are influencing them when showing a bad image of themselves. I feel they should set a much better example towards the children.

I think that others such as the parents/carers would feel as strongly as I do. I don't think that they would want their children to grow up looking 'common', as the appearance of all staff will affect the children's appearance some time in their lives. The parents may feel that the staff are influencing their children and should set a better example of how to appear. I'm not sure if any parent or carer has arised this issue, but they may feel they cannot openly discuss this with the staff or a member of management. The parents or carers should be able to talk to staff or the manager, as this is causing 'Alphabet Corner' to receive a bad reputation because the carers of the children do talk to other parents which could be about the unacceptable appearance of the team. This could result in less amounts of new children attending the nursery or possibly children being removed from the nursery by their carers because of this, especially if an accident were to occur e.g. a child swallowing a nose stud. The staff are portraying a bad image to children and carers therefore could cause a bad reputation.

However, I think this could be improved by the manager and management team introducing stricter policies about dress and personal appearance e.g. a list made of appropriate and inappropiate wear, so that if a member of staff were to continually dress inappropiately disciplinary action should be taken. Also new forceful policies should be made about the children's welfare and safety in the nursery linking to staff's dress. To me, and possibly parents or carers the clothing and appearance of the nursery's staff confirms how the nursery's management is out of touch with their staff and possibly parents and carers, as they may not feel they can openly talk about this issue with any of the staff.

Communication Difficulties

The blocking of communication is usually due to individual difficulties and differences not being fully understood. Everyone has communication needs, this may be due to a disability, known as 'special needs'. Some communication barriers maybe a visual or hearing disability, a physical and intellectual disability, language differences, misunderstandings and environmental constraints; temperature, light, noise etc, can affect communication because dark lighting can make it difficult to maintain eye contact. Also if the environment is to noisey this will restrain from others hearing information given and temperature (low and high) can make our bodies feeling uncomfortable therefore not allowing our energy to be wasted on communication, it also affects our emotions e.g. increase in frustration etc. A care setting needs to overcome each one of these barriers.

We had a talk on communicating with people with special needs by Debbie Le Fevre who is a Inclusion Co-ordinator and Respite Carer. From her presentation I learned that we need to have an awareness of how some people with special needs communicate and it is important to have a range of familiar strategies to which we can use to enable us to enhance the communication between two people. Debbie referred to communication difficulties such as...

* Unable to speak because they have a physical disability, medical condition, had a stroke, autism (a disability that prevents people making contact with others, affecting behaviour, outlook and the ability to communicate), bilingual, or articulation problems.

* Lack of understanding of speech due to memory problems, autism, global delay, stroke or bilingual.

* Deaf or hard of hearing.

* Behaviour difficulties due to ADHD, autism, global delay or emotional/social problems.

When communicating with children with special needs, many strategies are used to help communication, such as PECS (Picture Exchange Communication System) this involves a person giving another person a picture/word of what they desire. PECS is used by autistic people, people who have communication delays or unclear speech. PECS teaches and helps these people to express their needs and to be more independent. Another way of a person with special needs expressing their desires is to use a Dynobox, this is a computerised method used by the children attending the Futchers School. The Head Teacher, John Meek, explained to the class how children with special needs benefit greatly from using the Dynobox. The Dynobox is a touch-screen computer, where children with difficulties can select a series of pictures in which the computer will then say aloud what the child would like e.g. for lunch. This technique however, does have its disadvantages such as:

* It costs £6,000 each.

* An extra £1,000 to attach onto a wheelchair.

* Children who do not only struggle with verbal communication but also physical communication e.g. has difficulties with the movement in their hands will suffer from using the Dynobox as the pictures they need to select are close together, so some children accidentally select a picture they don't need.

Not only do the children at Futchers School use Dynobox's but they also use Big Mac's, this is an object which allows a member of staff to record a need the child may have and when the child needs this need they will press the big red button. The disadvantages again are:

* They cost £100 each.

* Big Mac's only allow 20 seconds of recording, so only one need can be recorded each time.

* Not every Big Mac is heard in the room because of the level of noise from other specialised equipment. Therefore the child has to keep pressing the Big Mac until a member of staff or another special need child's attention is drawn, resulting in the Big Mac's not having much effect although they are useful.

* Also there are written instructions on the bottom surface of the Big Mac which isn't helpful for those children who have reading difficulties.

Debbie Le Fevre also described people with special needs using TEACCH (Treatment and Education of Autistic and Related Communication Handicapped CHildren). This is a visual aid to help someone with special needs to be able to understand what they have to do, not only is this technique used by autistic people, but it is also used by people who struggle with the understanding of speech and those who have emotional/behavioural difficulties. The TEACCH aid is a schedule made up of various 'jobs' for each person to complete in a certain order from left to right, once one 'job' is completed it is either crossed off from the schedule or removed.

Communicating with "signs" is also used, such as BSL (British Sign Language) and Makaton. The signs given helps the person because it gives them extra visual clues as to what is being said. When using Makaton the words are also said as Makaton is used to support what is being said ass appose to its own language. Makaton includes not only signs but also written symbols which are both used or either one is used depending on a person's particular needs and cultures. British Sign Language differs from Makaton because with Makaton not all the words are signed, the signs are simpler and the words are spoken. For example, when saying "Good morning", you first say "Good" by showing your thumb (fingers folded into palm), then for "morning" you touch your chest with your finger tips from left to right. This image is used as a symbol of the curtains opening in the morning.

At 'Alphabet Corner Nursery' there are no children with special needs attending e.g. physical disabilities as the setting is wheelchair bound. So therefore the nursery has no need to buy specialised equipment for their clients. As far as I no there is only one child who struggles with behavioural difficulties, as he suffers from ADHD, also his speech is very difficult to understand. There are no special methods involved in helping this child apart from oral methods of communication. Also when children are all asked to sit on the floor for story time, where they listen to a book being read by a member of staff, the child suffering from ADHD is allowed to be left at his own devices, where he can go and play with the toys e.g. bricks.

Oral communication is mainly used at the nursery, this type of communication is most effective between the staff and their clients. Using this type of communication the staff are able to put information clearly across so that the clients understand.

Written communication is also used when members of staff are teaching the clients to sound out words, this includes words from books. This helps them increase their potential and learn new skills.

Communicating with pictures is also used often. In each classroom of the nursery there is a schedule like a diary of all the activities carried out during each day. This schedule attached to the wall (in reach by children) and is in a particular order using the aid of pictures to help the client's understanding, beneath these pictures are one or two words summing up the pictures. Here is are the some of the usual activities carried out in the day:

* Arrive - Children arrive at the nursery.

* Play time - Children play with toys, takes place approximately four times a day.

* Story time - Children listen to stories read by staff in the book corner, takes place twice a day (morning and afternoon).

* Snack time - A tray of cut up mixed fruit is handed round each table and each child has a choice of milk or water to drink, takes place twice a day.

* Garden time - Half of the class play out in the garden for 25 minutes whilst the other half has play time then swaps over, takes place twice a day.

* Lunch time - Only for the children at the nursery during lunch time.

* Activities - Either drawing, painting, colouring, sticking or watching suitable television etc, takes place twice a day.

* Sing or listen and dance to music - The whole class take part in either singing nursery songs or playing music whilst dancing in a circle, takes place twice a day.

* Dinner time - Only for the children who are staying for dinner.

* Home time - Parents or carers come to collect their child.

Computerised methods are also used, as there is a computer in the 'Swan room', this is where children use CD-Roms as a process of learning words, colours, shapes etc. This is very effective because it is teaching the children to use computers as they are widely used today and the CD-Roms also speaks the words aloud using speech-synthesis software to the children helping them to learn. There are no special methods of communication.

The client with ADHD has very challenging behaviours, this is his way of attempting to communicate, he does tend to get frustrated as he does lack a communication system. He has difficulties gaining others attention appropriately and therefore resorts to challenging behaviour. By using improved communication aids, this client can communicate more appropriately, so that the staff and other clients will have a greater understanding of what his needs or wants. To improve the methods of communication, especially for the child with ADHD problems I think that TEACCH should be used as it is partly used for behavioural difficulties in children or even PECS. This may be effective as when the child with ADHD has a need to do something he can use his pictures as a way of communicating with the staff when he wishes to carry out an activity. This will reduce a lot of anxiousness and behavioural problems.

Also I think that the nursery should firstly train their staff on how to help children with special needs by teaching them how to use sign language, Braille etc. So that then children who live in the nursery's area and who suffer from difficulties, even wheelchair users (design the nursery so that wheelchair users can use their services) can then attend their local nursery. I think that 'Alphabet Corner Nursery' should equip the nursery with communication methods for special needs, such as:

* Braille (introduced by 1838 the Frenchman Louis Braille) - a system of imprinting raised dots on paper standing for letters of the alphabet, numbers, and punctuation. With this system, blind people can read by running their fingers across the dots, and can write by impressing the raised dots into paper using a frame called a Braille slate, or a Braille writer.

* Sign language - a system of making signs for letters, words, and groups of words using fingered signs and body gestures, this system helps the communication for deaf people.

* The Kurzweil reading machine, e.g. electronically scans printed text and speaks the words aloud using speech-synthesis software. Some personal computers can read typed-in text aloud for blind or visually impaired people.

* Personal computers can also show text on the screen large enough for visually impaired people to read, or can be equipped with touch-sensitive screens or pointers for people whose physical disabilities make them unable to type.

* Computers can also recognize a person's voice, and with special software can turn lights on and off, engage security systems, or make emergency medical, police, or fire calls. This technology is especially helpful for people who need to use a wheelchair or who have limited use of their limbs.

* Equip the nursery's televisions with closed-captioning devices. Most broadcast and cable television signals are sent out with closed captions, the text of the words that are being spoken or descriptions of music or sound effects, encoded into part of the video signal. Some programs are broadcast (or recorded onto videotape) with additional sound tracks, so that blind people can hear not only the dialogue, music, and sound effects of a program, but also an announcer quietly describing the pictures.

In my evaluation I think that all effective communication will receive a good interaction between the carer and the client, effective communication is where only enhancing factors such as respect, encouragement, non-verbal communication, sign language etc, can enhance the communication and good interaction between to people. If inhibiting factors are used e.g. stereotyping, aggression, blocking, excluding etc, are used in a care setting this can only inhibit the communication between two people and cause it to break-down. Inhibiting factors can also have a long term affect on a client and can affect their mental well-being, they can also begin to feel negative emotions e.g. they don't matter, helplessness etc.

I think that Abraham Maslow's theory helps us to understand the different types of personal needs, it is a great theory of communication that actually occurs in 'Alphabet Corner Nursery'. Therefore helps each child to develop his/hers personal ability and potential, (see Heinemann AVCE, Advanced Health and Social Care, Page 74, Figure 2.1 'Communication within Maslow's levels of need').

I think that the oral communication works well in the placement and is therefore most effective, however if special need children were attending the nursery a lot of the communication methods would need to be improved to help their needs e.g. training the staff on using Braille and sign language, therefore they will have a better understanding of children suffering from difficulties or disabilities needs.

Communication helps the interaction between people and allows people's needs to be put across. It is also important for developing relationships in the nursery. Communication and interaction skills are the centre of every care practitioner's work, so therefore I feel as if the nursery should improve their communication skills by increasing their use of enhancing factors and limiting to a minimum the inhibiting factors e.g. off-loading own experiences, closed position, invading personal space, distractions etc. If the staff were to use more enhancing factors this would ensure better communication with the clients, therefore developing and maintaining relationships.