At this point there were no distractions in the environment as Betty was in a cubicle; the television was on, however she had no known hearing impairments so I did not turn it off as she may have found it relaxing. Shutting the door as to minimize noise from the ward, this also would help to maintain confidentiality in case Betty felt she wanted to disclose any information to me.
Verbal and nonverbal communication need to be used in conjunction with each other. Hargie (1988) argues that words play only a minor part in conveying a message, and non-verbal messages communicate real meaning.
Egan (2002) derived the acronym SOLER to describe non-verbal communication, which I used to initially make contact with Betty; face the patient Squarely, maintain Open posture, Lean slightly over patient, keep Eye contact and stay Relaxed. I was aware that Betty couldn’t see me very well but I felt it was important to keep eye contact nevertheless.
Observation of a patient’s non-verbal behaviour may reveal vital information about their situation. Betty’s non-verbal communication was compromised due to her health status, so I ensured I paid more attention to her facial expressions to realise any potential complaints. Puetz (2005) proposes that we react to facial expressions and eye contact without often realising, with eye contact communicating honesty, whilst wandering eyes during a conversation may convey a disinterest. Betty’s facial expression could be described as impassive; frozen in a visually emotionless manner and expressionless (Russell and Dols, 1998). Frowning, sadness or looking away by Betty would cause me to be concerned about how she is feeling.
Verbal Communication
I then asked Betty if she was ready to eat and she told me she was. I sat next to her and informed her of what the meal was before I proceeded to feed her. When talking to Betty I varied my tone of voice and spoke in a low, soft and calm manner. This is very important as when speaking in a loud voice and perhaps very quickly, the patient may perceive this as aggressive (White and Duncan 2002). I felt it was now appropriate to introduce myself by name, and decided I would see if she would remember it at the end of the conversation. Poor memory and mental capability are features of Dementia and I wanted to test Betty’s ability to remember names. For future interactions I could then simply introduce myself by name and the hope would be that she would remember me from our previous conversations. There are tests of cognitive function for patients who may be suffering with dementia, the most common being the Mini Mental State Examination (MMSE) (Rutherford, 2004). It is from researching the recall section of the MMSE that I decided to test Betty.
Betty did not instigate any form of conversation herself whilst eating so I asked her some basic questions to gauge how much she could interact with me.
Very quickly I noticed that Betty would echo what I had said or asked her, as if she had learned responses prepared. An example of this would be when upon hearing Bob Dylan on the television, I asked her if she liked him. “I like him”, was her response. After telling her that I had seen him live and he was amazing, she responded with, “He is amazing”. Similarly, when enquiring how her dinner, pudding and drink tasted, the response was always the same; “it’s lovely”. Commonly used phrases seemed to come freely, perhaps this was a device Betty had assumed in order to cope in social situations.
Jargon and slang are known as sub languages (Aquino, 2008). That is, a language only known by specific groups of people. For example, I could have said ‘That’s cool’ to Betty, meaning that I liked something, whereas an individual of an older generation will see it as a reference to the temperature of something. It was best to avoid this kind of language when communicating with Betty as it was unlikely that she would understand and would be left confused.
There is great need to make an extra effort when communicating with a patient suffering from dementia. With this in mind, I was sure to plan my sentences. Ensuring the structure was simple and coherent, as to alleviate any confusion from Betty. It was clear to see when a question or sentence was not understood, as Betty would simply open her mouth for more food and not say anything.
I was aware that Betty was fairly responsive to the majority of my questions but I was also conscious that she was slow in vocalising to me. It seemed she needed a few moments to gather her words together, so I allowed her ample time to receive what I was saying. As a nurse and active listener, it is important that the patient is not rushed to answer, and has time to express themselves.
Questioning
Questioning and listening go hand in hand. Liehr (1992) suggests that nurses who listened attentively to patients produced lower blood pressure and heart rate in the patients when they were communicating with them.
As Betty did not instigate any conversation, I asked some questions in the hope to engage with her. Keeping to basics and topics she may be familiar with, being careful to not ask too many questions, as this could be seen as interrogative (Renwick, 1992). There are two main categories that questions fall in to; closed-ended and open-ended. Initially I asked Betty if she was enjoying the food that she was eating, she told me that it was lovely and continued to open her mouth for more. From this it was clear that Betty did not hold much capacity for in depth conversation. It was important that I ensured Betty had finished her mouth of food before I spoke to her, and I was not to ask her a question preceding a mouthful of food, as it was likely she would forget what I had asked by the time she had finished chewing. To discover more about Betty’s life I questioned if she was married. Instead of asking this in way of a close-ended question such as “are you married?” I asked her if she was having any visitors today. By asking an open ended question Betty would be able to disclose more information to me and express herself (Arnold and Boggs 2007). I didn’t need to gain any elicit information so there is no need for a focused question. The main barrier to open-ended questions is that the nurse has no control over how relevant or lengthy the patients’ response will be (Niven 2006). To combat this, a few closed-ended questions can be used to focus the patient. This was not a concern with Betty as her sentences were no more than 4 to 5 words. It was important I didn’t ask any multiple questions as this would confuse Betty and she would simply not answer, as she didn’t know which one to respond to first. Betty informed me of ‘David, my husband’. I reflected back to her by saying “Your husband is coming to see you, that will be nice”. Reflecting or echoing is a way of encouraging the patient to say more, by way of echoing the patient’s own thoughts and prompting more conversation (Morrison and Burnard, 1991).
I was able to make small talk with her about her life when she was younger, alongside her husband. She seemed content to talk to me about this as she verbally expressed affection about him towards me. I did not feel it necessary to talk about Betty’s illness with her as she suffered with Dementia and there was potential for confusion and emotional harm.
During our conversation about her younger years, we discussed that Betty had liked to dance, but David was not a very good dancer. She smiled a great smile for the first time during our interaction and told me not to tell David that she had told me. As much as this could be perceived as a joke, it is vital to maintain confidentiality for the patient. It could be damaging and implicate the relationship if I was to disclose this information to Betty’s husband. Smiling is a very expressive form of non-verbal communication. Ekman (2004) suggests that we can noticeably tell a forced smile from a genuine smile; observing the narrowing of the eyes can help detect the difference. Betty’s smile, in turn, made me smile.
It is paramount to realise the significance of the therapeutic relationship that can be provided by a nurse. Differing to a social relationship in that it is client centred with a focus on achieving a goal. Define more/put in conclusion?
Barriers to effective communication
A recent article in the Journal of Advanced Nursing, regarding nursing patients with complex communication needs, suggests that time is one of the greatest potential barriers to building up relationships with patients in a hospital setting (Hemsley et al 2011). A patient with more needs such as Betty would require more time by staff. Results of the study show that in these cases, nurses would simply avoid direct contact with the patient. This shows a lack of self-awareness by the nurse and may negatively influence the patient.
Effective communication can be blocked if the patient has a sight or hearing problem. In this instance, Betty has impaired vision. This would stop Betty from correctly receiving my expression visually. To help overcome this issue, I can assist in many ways. To start with I asked Betty how well she could see me; thus providing me with an honest guide of how good her vision is. I learned that I was visible but not in any detail. Additionally, when agreeing or confirming anything with Betty I used spoken language rather than just a nod, as she may have not seen it.
Alongside ensuring I was visible to Betty, I was aware not to allow for too much silence in our interaction. Certain kinds of silence can communicate an understanding or approval of some sort. Conversely, silence could indicate a misunderstanding or confusion, resulting in an uncomfortable situation for the patient (Riggio and Feldman, 2005).
-Judgemental responses
-Sterotyping
Self awareness
Non verbal – posture, facial expression etc
Conclusion what have I learned/achieved/will implement in the future? Quote codes of conduct etc
Reflecting on my time with Betty I was surprisingly aware of the ways in which I was communicating with her.
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