This essay will describe an example of communication from recent clinical experience and discuss the factors that contributed to its outcome. The Oxford English Dictionary (2003) states communication to be the transmission or exchange of information, the science and practice of transmitting information involving conference, a conversation, social contact, shared position and common participation.
To comply with the Nursing and Midwifery Council (2008, p2) requirement to maintain confidentiality, all patient names will be substituted in cases of supporting evidence, place names will not be mentioned, and the pseudonym Mrs. Griffin will be used. Throughout this assignment I will discuss; factors affecting communication with Mrs Griffin, overcoming barriers of communication, the use of body language and will go on to reflect on practices of effective and ineffective communication. I will make analytical judgements of the effectiveness of Mrs Griffin's and my own communication skills I will use literature to support my writing and be subjective in my final conclusion. I will refer to Berlo's Model of communication (1960) to keep the essay on focus. Mortensen (1972) said, "In the broadest sense, a model is a systematic representation of an object or event in idealised and abstract form". The Berlo model considers communication skills, attitudes, knowledge, social system and culture of the source. It is important to remember that these factors are not only important for the nurse but the patient also. I will identify the necessary skills to be able to provide effective communication, concentrating specifically on the conscious and subconscious body language factors of communication,
Mrs Griffin, aged 75 years old, after suffering a stroke had been moved into a nursing home after being in Hospital. She had previously lived alone and cared for herself until the stroke. Mrs Griffin, was irritable, anxious, she continually suffers from cognitive, language and word association difficulties. When I met Mrs Griffin in the morning after her breakfast she seemed very confused, and she was asking for the nurse a lot. Mrs Griffin had asked for her "baby", but at first I could not comprehend what Mrs Griffin was asking for and she started to feel a little anxious about my lack of understanding. She pointed and waved her arms around and got quite distressed, her tone of voice lowered but the volume increased. Mrs Griffin repeated the word "baby" over and over to me until I understood. However I realised and understood that Mrs Griffin had actually meant a teddy that was in her room, and I recognised the cerebral default of expressive dysphasia Mrs Griffin had after her stroke.
In clinical practice I have witnessed cases with elderly patients where communication has been difficult, some applications of communication have been effective and some, ineffective. To become; hard of hearing, immobile, suffer from memory loss and to become more vulnerable to disease are unfortunate traits of old age. Consequently when caring for these clients it is difficult to treat them, and talk to this entire client group at a normal volume of speech, this can affect their rights to privacy and maintaining their confidentiality. The importance of paralinguistic language is increased when communicating with these clients and I will investigate further into these aspects verbal, non-verbal, and barriers affecting communication.
As all factors of communication cannot apply because it is so varied, I will identify Mrs Griffin has problems with spoken language, but has learnt to use non-verbal communication in the absence of ability to converse verbally. In the medical profession communication is used in every appropriate way; verbal, non-verbal, formal and written. The NMC (2008) guideline for medical records says, "Record keeping is an integral part of nursing and midwifery practice, it is a tool of professional practice and one that should help the care process" (p8). I found this an interesting task and liked knowing how Mrs Griffin and other patients had been when I had not been on shift. Note taking is considered non-verbal communication between medical staff. When rapport is created between client and / or a client's relatives, informal actions also take place to communicate care rather than competency. "Rapport is a sympathetic relationship or understanding that allows you to look at the world from someone else's perspective Making other people feel that you understand them creates a strong bond. Building rapport is the first step to better communication" (Inneridea.com). Creating rapport and psychological support could involve actions such as; hand on shoulder, a hug or holding someone's hand; these actions create a psychological feeling of support, which cannot be created for example, when writing a letter. As professionals we can deliver or be assistants to the delivery of news about a patient's health, of which they may be unaware, or fearful of. If effective communication is not in place, the opportunity to support a client decreases. QUOTE. Support is defined by Dictionary.com as: to sustain (a person, the mind, spirits, courage, etc.) under trial or affliction. Without support, the effects on clients could be detrimental to; recovery, after care, and in the possibility of causing, rather than the prevention, of knock on after effects. It is important to think in every instance what the knock-on effects could be, this is supported by the NMC (2008) "you must support people in caring for themselves to improve and maintain their health".
With mentally ill clients in nursing homes communication becomes even more difficult, as in some cases I witnessed. Mrs Griffin's after affects from the stroke are those that have affected the brocas- the speech centre in the left side of the brain. The Stroke Association states that "over 300,000 people are living with moderate to severe disabilities as a result of stroke". The effects of a stroke cut off part of the blood supply in the brain, causing detrimental effects such as cerebral infarction - when brain tissue dies. Mrs Griffin was suffering from; regular irritability, anxiousness, cognitive, language and word association difficulties including receptive dysphasia and expressive dysphasia. Receptive dysphasia is when a person finds it hard to understand what is being said because of the inability to associate words with the correct feelings or objects. Expressive dysphasia is when a person finds it difficult to express themselves, or explain something using the correct words, both due to damage to the brocas. This is proof that the client-nurse relation improves care, being knowledgeable of the patient and their condition improves the effectiveness of patient advocacy. "Knowing the patient", is about being able to empathise and understand which is good for the psychological state of the client. Many researchers have emphasised that "knowing the patient is a critical aspect of nursing practice" (Fisher, Fonteyn, fit Liaschenko, 1994; Jenny & Logan, 1992; Liaschenko, 1993; Tanner, Benner, Chesla, Gordon, 1993). Mrs Griffin had limited communication skills and at the time was not presenting a healthy attitude.
In this short time I began to realise how important Mrs Griffin's other language skills were when her speech was deemed "ineffective". Argyle (1978) states "we speak with our organs but converse with our whole body", Mrs Griffin's body language was crucial and although I did not understand right away, Mrs Griffin was helping me to understand via non-verbal communication. Non-verbal communication can be the body language we use which considers facial expressions and posture, also haptic communication which is communication through touch, which creates a more trusting and personal relationship. Speech also contains non-verbal elements such as paralanguage; emotion and speaking style, as well as prosodic features; rhythm, intonation and stress. Albert Mehrabian (1971), a pioneer researcher of body language found that the total impact of a message was about 7% verbal (words only) and 38% vocal (including tone of voice, inflection and other sounds) and 55% non-verbal. Regarding relative importance of verbal and nonverbal messages, these were derived from experiments dealing with communications of feelings and attitudes (i.e., like-dislike). Therefore although at first I saw Mrs Griffin as being unable to communicate because of impaired linguistic ability, but according to Mehrabian (1971), her ability to communicate has only decreased by 7% when communicating her feelings and attitudes. A natural process of communication is working out what people are 'saying' and subconsciously we take in and decode their body language as well. Decoding is the process after the message is channelled to the receiver by either; hearing, seeing, touching, smelling or tasting - shown in Berlo's Model of Communication. The progress and quality of decoding depends on the; communication skills, attitude, knowledge, social system and culture of the receiver. The ability to encode and decode is also an aspect of body language, if the source is not aware they are presenting negative body language this could have subconscious negative effects. If the receiver has their arms crossed whilst listening to someone, it can feel off-putting to the person speaking as it acts like a barrier, as if they aren't being listened to because something is between them, like a table between interviewees and interviewers.. Berlo's communication model shows the processes of communication in four simple steps, commonly known as the SMCR model (Source- Message- Channel- Receiver). In verbal communication it would seem that it's obvious what someone is saying by what they say, regardless of mental capacity, verbal communication can also be thought to mean something it does not. For example the tone, pitch, pauses, intonation of the speaker's voice, facial expression and stance have effects on what they are saying to the patient. This is why we reinforce what we say with our body language, it is not always a conscious decision, and once it is highlighted it is easier to pick up on. Argyle (1970) states that "spoken language is normally used for communicating information about events external to the speaker's, non-verbal codes are used to establish and maintain interpersonal relationships". This is very important to mention in a care setting because communication in a care setting is not always about the verbal expression but communicating feelings. Although I sometimes felt out of place when talking to Mrs Griffin, because of her communication barriers, as in Berlo's model the channel and receiver (listener) are just as important as the source (speaker) and the message. The channel needs to be; hearing, seeing, touching, smelling or tasting and the receiver needs to have an understanding of the source, when it comes to; communication skills, attitude, knowledge, social system and culture.
The factors I have chosen to cover that have arose from this situation are the body language and non-verbal communication skills that Mrs Griffin has started to use more because of the barrier of cerebral damage, affecting her speech. According to Argyle (1978), humans have more than 700,000 forms of body language. I want to focus on the positives of Mrs Griffin's communication skills and the wide range of body language she did use, rather than the verbal language she did not use effectively, although it is still a factor to be considered.
The issues that have become apparent to me, even when a patient is able to talk are that they may not mean what is said, and the importance of "knowing the patient" when it came to the issue of receptive and expressive dysphasia, which I have only recently learnt about. I looked into the word association difficulties and came across the conditions and their connection to stroke, after the first time I met Mrs Griffin and was not aware that receptive and expressive dysphasia were side effects of having a stroke. I also was not aware of the differences between the after effects dependant on which side of the brain the stroke takes place. The right hemisphere of the brain controls the movement of the left side of the body. It also controls analytical and perceptual tasks, such as judging distance, size, speed, or position and seeing how parts are connected to wholes. The left hemisphere of the brain controls the movement of the right side of the body. It also controls speech and language abilities for most people. A left-hemisphere stroke often causes paralysis of the right side of the body. This is known as right hemiplegia (stroke.org). I found that once I got to know Mrs Griffin and got over the daunting thought of not being able to understand her, even though her memory of me was not always good, I cared for her better as time went on, and as I learnt and developed my own communication skills. Mrs Griffin seemed more content and more comfortable in my presence. In his fourth edition of "The Skilled Helper" Gerard Egan says "awkwardness in the use of helping skills lessens as they begin to become a part of you" (p18). This I feel extremely relevant when first trying to understand Mrs Griffin's condition, and not yet understanding that I needed to stop focusing on verbal language. I do feel the improvements to our communication were because I had a better understanding of Mrs Griffin and the receptive and expressive dysphasia, and also because I had learnt not only more practical skills for care but also got to know her, what she wanted and the helping skills she needed, despite the confusing linguistic conflicts of expressive and receptive dysphasia.
Listening to what Mrs Griffin was saying was usually not the best way in which to understand her and looking out for her hand movements the tone of her voice and facial expressions became more of a priority. On the other hand, body language will also tell someone or not if you are listening to them and how interested you are, and in the possibility that I would convey that I was not listening to her, it would have negative effects. Listening would seem to come naturally but in fact it is more so hearing that comes naturally, listening is a process of concentration and attentiveness. Hearing and listening are not the same. Some of the best hearers are the worst listeners (Stocker, 1973). Ferrington (1994) suggests listening requires a quantity of mental effort, a sound, being temporal, must be remembered long enough to be assimilated and interpreted. So by listening it is not only the words that need to be assessed there is a constant need to listen to the fluctuations in tone of voice and pitch, especially in patients such at Mrs Griffin.
Verbal communication has sub-aspects of the way in which we talk, hence the saying "it's not what you said; it's how you said it". The repercussive actions to how someone says something can be negative or positive, however when Mrs Griffin raised her voice and repeated the word "baby" I became aware she was not happy with me, the recognition of these non-verbal aspects of verbal language were subconscious to me and it is a feeling of "knowing" someone isn't happy with you. Verbal communication can be very effective in everyday life, it is often thought to be our primary aid to communication and this is a common misconception most of us have, including myself until investigating these communication processes. However when verbal communication isn't understood and feelings and information is not interpreted effectively situations can become distressing for both source and receiver, as when Mrs Griffin began to raise her voice at my lack of understanding when asking for her "baby". This evolved to make Mrs Griffin seemingly annoyed and distressed, which evidently through my panic at the time also passed on to myself. It is understandable for both communicators to feel distressed in situations such as this one, however when in and around Wales another factor that is vital to recognise and appreciate is that that not all patients feel comfortable speaking English if it is their second language. It has often been described to me as a 'connection' between professional and patient. With children or elderly clients they may only know, or refer back to Welsh because it is their mother tongue. When talking to someone who prefers to talk Welsh in practice I felt a little reluctant to talk, I have realised that calming someone in their second language is better than not calming them at all. By explaining that I don't mind others talking Welsh because I recognise it helps to make the patient feel more comfortable helps a patient gain trust because it can make them aware you do have their best interests at heart. Also I feel it is appreciated when trying to use Welsh in practice, even though I am not a Welsh speaker myself it shows empathy and determination to give a patient the care they want.
I also became more aware of my own body language and non-verbal communication around Mrs Griffin, other patients and my colleagues; having an open posture, leaning in when someone is talking to you with my arms uncrossed, and removing all formal barriers between speakers can have a positive effect on communication. These are similar to the ideas of Gerard Egan's in "The Skilled Helper". It is important to remember the positive effect of psychological support which is created in an interpersonal caring environment, and this is not possible when barriers are present without being recognised and removed.
Although at first I saw Mrs Griffin as being unable to communicate because of impaired linguistic ability, apparently her ability to communicate according to Mehrabian (1971), has only decreased by 7% due to 'impaired' linguistic ability, however I have to question this 'statistic'. I personally do not feel we can deem the source as any percentage less ineffective. The case may be that if the communicating source had a learning disability they may be completely unaware of the negativity they are conveying non-verbally, but because they are conveying non-verbal communication this means they are not any less effective? Also I have to think of myself at this point and question my own effectiveness as a receiver, after all if I do not have sufficient knowledge of the patient and their ability, how can I question the ability of the patient? The example which I experienced at the beginning of being uncomfortable, anxious and feeling unable to help was down to my lack of understanding, and it may seem very self critical but it was not Mrs Griffins fault I was not aware of her condition. On reflection it is clear to me it was my poor communication skills and naivety that contributed to the inefficient understanding of Mrs Griffin at first, but I feel I have a better understanding and knowledge of the way to act in similar situations that I came across with other patients.
The recent clinical experience I have had has highlighted many different factors of communication to which I was previously unaware. I believe each factor I have discussed and the research I have carried out has caused me to constantly reflect on each situation I have been, and will be presented with in the future. I believe knowing the psychological effects of physical non-verbal actions has helped me develop not only as a nurse, but in myself as well.
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