1. Communication and Health Care Provider Relationship
Practicum Health Science II

2. Objectives Define the term communication
Explain why communication is an important concept in health care
Describe what is meant by the communication process
Discuss four factors that affect communication
List five examples of therapeutic communication

3. Objectives List five examples of blocks to communications
Explain why multicultural health care is important
List three components of a cultural sensitivity assessment
List two questions that would elicit information about the client’s spiritual issues.

4. Objectives Demonstrate the steps for beginning client interaction.
Explain why it is therapeutic to encourage the client to express feelings and thoughts.
Describe the phases of the health care provider-patient relationship
List three components for maintaining a health care provider-patient relationship

5. Objectives
Describe the rationale for discussing termination at the beginning of the relationship

6. Communication
Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions.
Messages sent and received define the relationship between people.
It is a vital element in health care and includes both verbal and non-verbal expresions.

7. Guidelines That Influence Effective Communication
A person cannot not communicate. People have an inherent need to communicate, whether it is verbal or non-verbal. Even silence is a form of communication.
There is a content, or informational value to messages sent and received that explains what the message is about and expresses how the sender regards the receiver.

8. Guidelines That Influence Effective Communication
The message sent is not necessarily the meaning received.
Messages contain overt and covert meanings.
Communication becomes dysfunctional when a person does not assume responsibility for his or her communication. Dysfunctional communications results from failing to learn to communicate properly and leaving the responsibility for communicating to others.

9. Guidelines for Communicating with Patients
Accept the patient as a valued and worthwhile individual, for this acceptance is a prerequisite for a health care provider-patient relationship.
Be aware of the total patient, not just his or her physical needs. The client’s social, emotional, and spiritual needs are also important.

10. Guidelines for Communicating with Patients
Understand your own needs, feelings, and reactions so that they do not interfere with the therapeutic process with the client
Be prepared to feel some degree of emotional involvement with your patient, evidencing caring and concern for his her welfare. At same time, however, it is necessary to remain objective.

11. Guidelines for Communicating with Patients
Remember that the health care provider-patient interaction is a professional one. As such you as the health care provider possess the skills, abilities, and resources to relive the other person’s pain and discomfort and your patient seeks comfort and assistance for alleviation of some existing problem.

12. Guidelines for Communicating with Patients
A heath care provider-patient relationship does not require a long term agreement or formal meetings between health care provider and patient to be effective.
Take an active role and guide the conversation if the client is overly hesitant.
Give broad opening statements and ask open ended questions to help the patients describe what is happening to him or her.

13. Guidelines for Communicating with Patients
Use body language to convey empathy, interest, and encouragement to facilitate communication.
Use silence as a therapeutic tools, as it allows the patient to pace and direct his or her own communications. Long periods of silence, however, may increase the patient’s anxiety level, so use this technique wisely.

14. Therapeutic Communication Techniques

15. Purpose
Therapeutic communication techniques assist the flow of communication and always focus on the client.

16. Acknowledgment
Acknowledge the client without inserting your own values or judgments. Acknowledgment may be simple and with or without understanding, verbal or non-verbal.

17. Clarification Clarifying the patient’s message.
Check out or make clear either the intent or hidden meaning of what the message, or determine if the message sent was the message received.

18. Feedback
Using feedback to relay to the patient the effect of his or her words.
This method helps keep the client on course or alters the course. It involves acknowledging, validating, clarifying, extending, and altering.

19. Focus Focusing or refocusing on the patient’s statement.
Pick up on central topics or “cues” given by the patient.

20. Incomplete Sentences
Encourage the client to continue.

21. Listening
Consciously receiving the patient’s message.

22. Minimum Verbal Activity
Keeping your own verbalization minimal and letting the client lead the conversation.

23. Mutual Fit or Congruence
Creating harmony of verbal and non-verbal messages.

24. Nonverbal Encouragement
Using body language to communicate interest, attention, understanding, support, caring, and listening to promote data gathering.

25. Open – Ended Questions
Asking questions that cannot be answered with a simple “yes” or “no” or “maybe”/
Generally ask questions requiring an answer of several words to broaden conversational opportunities and to help the client communicate.

26. Reflection
Identifying and sending back a message acknowledging the feeling or repeating the last few words the patient said.

27. Restatement
Repeating the patient’s statement as encouragement for him or her to continue.

28. Validation
Verifying the accuracy of the sender’s message.

29. Blocks to Communication

30. Changing the Subject
Introducing new topics inappropriately, a pattern that may indicate anxiety.

31. False Reassurance
Using cliché’s, cherry words, and advice, and “comforting” statements in an attempt to reassure the patient. Most of what is called “reassurance” is really false reassurance.

32. Giving Advice
Telling the client what to do. Giving your opinion or making decisions for the patient implies that he or she cannot handle his or her own life decisions and that you are accepting responsibility for him or her.

33. Incongruence
Sending verbal and nonverbal messages that contradict one another; two or more messages, sent via different levels, seriously contradicting one another. The contradiction may be between the verbal/nonverbal content or time/space content.

34. Assumptions
Making an assumption about the meaning of someone else’s behavior that is not validated by the other person.

35. Invalidation
Ignoring or denying another person’s presence, thoughts or feelings.

36. Overloading
Talking rapidly, changing subjects, and giving more information than can be absorbed at one time.

37. Social Response
Responding in a way that focuses attention on the nurse instead of the patient.

38. Value Judgments
Giving one’s own opinion, moralizing or implying one’s own values by using words such as nice, good, bad, right, wrong, should, and ought.

39. Multicultural Health Care

40. Multicultural Health Care
As we move into the 21st Century thee are demographics shifts occurring that will change the direction of health care.

41. Population: Texas 70.4%Caucasian 11.8%African American
0.7% American Indian or Alaskan native
3.8% Asian
0.1% Pacific Islander or native Hawaiian
10.5% Other race
37.6% Hispanic or Latino

42. Population: US 72.4%Caucasian 12.6%African American
0.9% American Indian or Alaskan native
4.8% Asian
0.2% Pacific Islander or native Hawaiian
6.2% Other race
16.3% Hispanic or Latino

43. Multicultural Health Care
Because of the change in the US, and more specific Texas population demographics, there are emerging barriers to health care.
The greatest barrier is language.
Approximately 20% of the US population cannot speak English at all.
It is estimated that over half a million people in the state of Texas do not speak English.

44. Barriers to Health Care
Living in urban, poor neighborhoods
Poor health care prevention
Poverty
Beliefs that affect how certain cultural groups understand illness and respond to treatment
Reduced access to health care

45. Cultural Competence
As more and more people are migrating to the US, health care providers will be faced with cultural diversity problems in administering health care.
Cultural Diversity implies the range of differences in values, beliefs, customs, folklore, traditions, language, and patterns of behavior for the various culture groups.

46. Cultural Competence
The health provider needs to be aware that personal space is related to culture, gender, and group behavior.
Because all of these aspects potentially affect how an individual experiences, copes with, and responds to illness, health care providers must be aware of these cultural differences.

47. Cultural Sensitivity
Health care providers must become sensitive to people from cultures other than their own.
People from different cultures may have different beliefs and values about illness and treatment, and different health practices and patterns of behavior.
In order to treat the patient holistically, the health care provider should be aware of these differences and be able to incorporate them into the patient’s plan of care.

48. Cultural Assessment
When completing a total assessment on a client, the individual cultural components that would be important to include are:
Cultural background and orientation
Communication patterns (based on culture)
Nutritional practices

49. Cultural Assessment Family relationships
Beliefs and perceptions relating to health, illness, and treatment modalities.
Values relating to health practices
Education
Issues affecting the delivery of health care.

50. Spiritual Assessment This need not be invasive or intrusive.
The purpose of such an assessment is to open the channels of communication so that the patient will feel comfortable in discussing spiritual issues.
If the patient does not experience an opening from the nurse, he or she may conclude that the health care provider does not wish to discuss spirituality.

51. Relationship Therapy

52. Relationship Therapy
Health care providers are given the unique opportunity to share part of who they are with others who have asked directly or indirectly for assistance.
It is within this interpersonal relationship that the patient care relationship begins to develop and take on its individual characteristics.

53. Relationship Therapy
Both individuals bring into the relationship their thoughts, feelings, sense of self or self-worth, behavior patterns, abilities to adapt and cope, belief systems, and points of view about life and how they interact with it.
Characteristics of the relationship include acceptance, honesty, understanding, and empathy of the nurse towards the patient who is willing or unwillingly seeking help.

54. Relationship Therapy
The goal of relationship therapy is to assist the patient to identify and meet his or her own needs.
The health care provider may assist the patient in reaching the goals by demonstrating acceptance so that the client may experience the feeling of being accepted as an individual; by developing mutual trust through consistent, congruent nursing behaviors; by providing corrective emotional experiences to increase self-esteem; and finally by creating a safe, supportive environment.

55. Relationship Principles
Principles underlying a helping relationship include:
Awareness of the total client, including emotional and physical needs, cultural and spiritual needs.
Some degree of emotional involvement while maintaining objectivity.
The setting of appropriate limits and consistency in behavior while caring for the client.

56. Relationship Principles
Open, honest, clear communication
Encouragement of the expression of feelings
Focus on the “here and now”

57. Phases in Health Care Provider-Patient Relationship
There are three phases in a traditional health care provider-patient relationship.
Initiation or Orientation phase
Continuation or Active Working phase
Termination Phase

58. Initiation or Orientation Phase
In this phase, you introduce yourself to the client and establish boundaries of the relationship.
Identify problems, expectations, and relevant issues that need to be addressed during the relationship.
Identify any impairments such as hearing, speaking, developmental, or psychological that must be taken into account so that adjustments in the relationship may be made.

59. Continuation or Active Working Phase
This is the phase in which you would develop a working relationship, and in conjunction with meeting the patient’s needs, begin resolving the patient’s problems.

60. Termination Phase
At this final phase, when the patient is soon to be discharged; you would follow the plan that you began when the patient was admitted, that includes anticipating any problems or concerns the patient may have when they go home; complete discharge planning and teaching; deal with the patient’s fears about being on their own after leaving the hospital or clinic.

61. Therapeutic Communication

62. Introducing Yourself to the Patient:
Obtain the patient assignment.
Read the chart and review the patients chief complaint, past medical history, and history of present illness.
Clarify any questions about patient assignment
Proceed to patient’s room and check room number
Introduce yourself to the patient.

63. Introducing Yourself to the Patient:
If the patient is blind, introduce yourself as you come into the room: tell exactly what you are doing and when you are leaving. Rationale: Blind clients become anxious when they hear someone enter the room who does not speak.
Begin to establish a health care provider-patient relationship using clear, open communication.

64. Beginning a Client Interaction
Following introduction, relate purpose of interaction. State your purpose.
Tell the patient specifically what you will be doing in terms of his or her care.
Ask if the patient understands or has any questions.
Encourage the patient to describe how he or she is feeling at the time.
Encourage the patient to participate in his or her care-both verbally and non-verbally.

65. Beginning a Client Interaction
Pay attention to communication as well as the procedure you are administering. Rationale: Often, your best information is drawn from observation.
Assess non-verbal behavior and determine if it fits with verbal communication, especially when you are evaluating pain level.
Complete communication by asking patient for feedback.

66. Beginning a Client Interaction
Complete interaction by telling patient when you will return, and what you will be doing in relation to their care.
Follow through on agreed upon meeting time to build patient trust.

67. Assessing Cultural Preferences
Review patient medical history related to cultural orientation to determine if adequate information pertaining to cultural preferences is included. Rationale: A complete history will detail cultural diversity patterns; a. Ethnic heritage and language; b. Family orientation and role of members; c. Dietary practices and knowledge about nutrition; d. Education, formal and informal; e. Health care practices and beliefs.

68. Assessing Cultural Preferences
Determine patient’s perception of illness based on cultural beliefs
Validate verbal and non-verbal communication from patient based on cultural understanding. Rationale: When the patient’s cultural background is different from the health care provider’s, communication problems may occur.

69. Assessing Cultural Preferences
Consider using an interpreter if communication seems unclear. Rationale: An interpreter will facilitate communication and reduce stress on the patient.
Examine expectations of health care based on the patient’s cultural influences. Rationale: Health care should be congruent with the patient’s expectations or a positive outcome of treatment can be in jeopardy.

70. Assessing Spiritual Issues
Ask the patient relevant questions concerning spiritual issues. Rationale: If the health care provider never opens this subject, the patient will not feel free to discuss spiritual issues.
Are there any spiritual issues that you would like to discuss? If so, lets arrange a time to talk about these issues. Rationale: This approach will open communication and notify the client that you are willing to discuss these issues.

71. Assisting the Patient to Describe Personal Experiences
Encourage the patient to describe his or her perceptions and feelings.
Focus on communication as well as body reactions.
DO NOT dominate the conversation. Rationale: The less you, the more you encourage spontaneity and verbalization from the patient.

72. Assisting the Patient to Describe Personal Experiences
Assist the patient to clarify feelings.
Maintain an accepting, non-judgmental attitude. Rationale: Making value judgments, even non-verbal ones, negatively affects the health care provider-patient relationship.
Give broad opening statements, and ask open-ended questions. Rationale: This open approach enables the patient to describe what is happening.

73. Encouraging a Patient to Express Needs, Feelings, and Thoughts
Focus on feelings rather than superficial topics during interactions.
Assist patient to identify thoughts and feelings.
Pick up on verbal cues, leads, and signals from the patient.
Convey attitude of acceptance and empathy toward the patient. Rationale: Being aware of your own feelings and attitudes and separating them from the patient’s contributes to acceptance.

74. Encouraging a Patient to Express Needs, Feelings, and Thoughts
Note what is said as well as what is not said.
Assist the patient to become aware of differences between behavior, feelings, and thoughts.
Give honest, non-judgmental feedback to the patient.

75. Using Communication to Increase a Client’s Sense of Self-Worth
Use body language as well as verbal communication to convey empathy. Rationale: Sitting down at the patient’s bedside or not acting as if you are in a hurry encourages communication.
Respect the patient’s need for emotional privacy, but be available to the patient.
Encourage the patient to apply the problem solving approach to different situations.

76. Using Communication to Increase a Client’s Sense of Self-Worth
Be non-judgmental.
Mutually identify goals to meet the patient’s individual needs.
Keep all agreements with the patient.
Become the patient’s advocate.
Give patient positive feedback when appropriate.

77. Health Care Provider – Patient Relationship

78. Initiating a Health Care Provider-Patient Relationship
Assess the patient’s symptoms and problems, and communicate a willingness to help alleviate these discomforts.
Establish a beginning relationship. Rationale: Open, honest, congruent communication and consistent behavior help lay the groundwork for trust in a relationship.

79. Initiating a Health Care Provider-Patient Relationship
Establish mutual goals as a basis for the relationship. Rationale: Goals mutually set and agreed on are more easily accepted by both parties in the relationship.
Be consistent in your behavior; do what you say you will do, and only make promises that you are willing to keep. Rationale: The MOST IMPORTANT element is the beginning of trust. Without trust the health care provider-patient relationship is ineffective.

80. Initiating a Health Care Provider-Patient Relationship
Encourage the patient’s participation in his or her care. Rationale: This focus enhances compliance to treatment.
Approach the patient in a warm, accepting manner. Rationale: The patient may interpret a cool, aloof manner as a lack of interest.

81. Facilitating a Health Care Provider-Patient Relationship
Assume the role of facilitator in the relationship.
Accept the patient ass having value and worth as an individual. Rationale: Basic acceptance is a fundamental prerequisite of a relationship.
Provide a safe environment conducive to patient’s willingness to share.

82. Facilitating a Health Care Provider-Patient Relationship
Maintain the relationship on a professional level. Rationale: Responding on a professional rather than a social level defines the relationship.
Keep interaction reality oriented, that is, in the here and now. Rationale: Discussion of past or future experiences does not contribute to a change in behavior now.

83. Facilitating a Health Care Provider-Patient Relationship
Listen actively, that is, responding to the patient’s cues.
Use non-verbal communication to support and encourage patient.
Recognize meaning and purpose of nonverbal communication, especially in assessing pain.
Keep verbal and nonverbal communication congruent.

84. Facilitating a Health Care Provider-Patient Relationship
Focus on content and direction of conversation on patient’s cues, not on social or superficial topics.
Interact on patient’s intellectual, developmental, and emotional level.
Focus on “how”, “what”, “when”, “where”, and “who” rather than “why”. Rationale: Asking “why” places the patient on the defensive because it requires justification of behavior.

85. Facilitating a Health Care Provider-Patient Relationship
Teach patient problem solving to correct maladaptive patterns.
Assist patient to identify, express, and cope with feelings.
Help patient develop alternative coping mechanisms that are more adaptive.
Recognize a high level of anxiety, and assist patient to deal with it.

86. Terminating a Health Care Provider-Patient Relationship
Work closely with the patient in discharge planning and in planning the termination of the relationship from its beginning. Rationale: This approach promotes the patient’s independence and increases his or her sense of self-esteem.
Anticipate problems of termination and plan for their resolution. Rationale: Saying goodbye is often uncomfortable and difficult for both the patient and the health care provider.

87. Terminating a Health Care Provider-Patient Relationship
Be aware that the patient’s behavior may reflect fear that he or she can’t cope at home, overdependence, depression and withdrawal. Rationale: Allowing this behavior to be expressed helps the patient to work through it.
Do not terminate the relationship too abruptly or allow it to persist beyond the patient’s needs.

88. Terminating a Health Care Provider-Patient Relationship
Complete a satisfactory termination of the relationship. Rationale: This enables the patient to move on.

89. Documentation for Health Care Provider-Patient Relationship
Primary goals of health care provider-patient relationship and identified patient needs.
Ongoing process of relationship therapy, including patient’s expressed feelings, thoughts, and so forth.
Patient’s behavior and changes in behavior, both positive and negative.
Cues to other team members on how best to relate to this particular patient.
Elements of discharge planning.

90. Critical Thinking:

91. Scenario One
A 25-year old male comes to the emergency department. He has a bleeding wound on his arm and he refuses surgical intervention when told he must remove his clothes and jewelry.

92. Questions:
What effect would this patient response have on the initial health care provider plan of care?
What is your understanding of this patient response? What are some questions you might ask the patient?
Describe the strategies and goals you would devise to solve this problem.
Describe the measures you would implement to resolve this situation.

93. Scenario Two
A client has just been admitted with a diagnosis of rectal cancer. He is scheduled for surgery the next day. When you are completing an assessment and you ask about spiritual beliefs, the patient says, “I’m a washed out Catholic and I don’t think I’m going to live, so what’s the sense in talking about it?”

94. Questions:
What would be the consequence of not responding to the patient’s comments about spiritual beliefs?
How would the goals of establishing a health care provider-patient relationship and assessing spiritual beliefs overlap in this situation?
Describe the actions you would take to engage this patient in a discussion about these issues.