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Communication: Core Interpersonal Skills for Health Professionals 2nd edition

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Communication: Core Interpersonal Skills for Health Professionals 2nd edition

Gjyn O’Toole

Sydney  Edinburgh  London  New York  Philadelphia  St Louis  Toronto

Churchill Livingstone is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 This edition © 2012 Elsevier Australia First edition © 2008 Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. Proudly sourced and uploaded by [StormRG] Kickass Torrents | TPB | ET | h33t This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data National Library of Australia Cataloguing-in-Publication entry Author: O’Toole, Gjyn. Title: Communication: core interpersonal skills for health professionals / Gjyn O’Toole. Edition: 2nd ed. ISBN: 9780729541008 (pbk.) Subjects: Communication in medicine. Medical personnel and patient. Interpersonal communication. Dewey Number: 610.696

Publisher: Melinda McEvoy Developmental Editor: Rebecca Cornell Project Coordinators: Karthikeyan Murthy & Nayagi Athmanathan Edited by Brenda Hamilton Proofread by Gabrielle Challis Cover design by Georgette Hall Internal design by Georgette Hall Index by Robert Swanson Typeset by Toppan Best-set Premedia Ltd. Printed by China Translation & Printing Services Ltd.

Contents How to use this book Reviewers Preface Acknowledgements

SECTION ONE – THE SIGNIFICANCE OF INTERPERSONAL COMMUNICATION IN THE HEALTH PROFESSIONS

xi xiii xv xvii

1

1

Defining effective communication for health professionals Why learn how to communicate? – Everyone can communicate! Factors to consider when defining effective communication Chapter summary References

2

The overall goal of communication for health professionals A model demonstrating the importance of communication A model to guide the general purpose of communication for the health professions Chapter summary References

11 12

3

The specific goals of communication for health professionals: 1 Making verbal introductions Providing information: a two-way process Chapter summary Review questions References

20 21 24 26 27 28

4

The specific goals of communication for health professionals: 2 Interviewing and questioning to gather information Comforting: encouraging versus discouraging Confronting unhelpful attitudes or beliefs Chapter summary Review questions References

30 31 35 37 39 40 42

SECTION TWO – DEVELOPING AWARENESS TO ACHIEVE EFFECTIVE COMMUNICATION IN THE HEALTH PROFESSIONS 5

Awareness of and need for reflective practice The ‘what’ of reflection: a definition The result of reflection: achieving self-awareness The ‘why’ of reflection: reasons for reflecting The ‘how’ of reflection: models of reflection Reflection upon barriers to experiencing, accepting and resolving emotions Chapter summary

3 4 4 8 9

13 17 18

45 47 48 49 50 52 56 59 v

CONTENTS

6

7

8

9

vi

Review questions References

60 62

Awareness of self Self-awareness: an essential requirement Beginning the journey of self-awareness Individual values Is a health profession an appropriate choice? Values of a health professional Characteristics and abilities that enhance the practice of a health professional Personal unconscious needs Conflict between values and needs Perfectionism as a value Self-awareness of personal communication skills Self-awareness of skills for effective listening Reasons for the use of barriers to listening Self-awareness of skills for effective speaking Preferences for managing information and resultant communicative behaviours Personality and resultant communicative behaviours Chapter summary Review questions References

65 66 67 69 69 70 71 71 73 74 75 76 78 78

Awareness of how personal assumptions affect communication Reasons to avoid stereotypical judgement when communicating Stereotypical judgement that relates to roles Developing attitudes that avoid stereotypical judgement Overcoming the power imbalance: ways to demonstrate equality in a relationship Chapter summary Review questions References

88 89 90 92

Awareness of the ‘Person/s’ Who is the Person/s? The purpose and benefit of an essential criterion: respect Defining respect Demonstrating respect What information will assist the health professional when relating to the Person/s? Chapter summary Review questions References Awareness of listening to facilitate Person/s-centred communication Defining effective listening Requirements of effective listening

79 81 81 82 85

93 94 95 98 100 101 101 101 103 104 118 119 121 123 124 124

CONTENTS

10

Results of effective listening Benefits of effective listening Barriers to effective listening Preparing to listen Characteristics of effective listening Disengagement Chapter summary Review questions References

125 126 126 126 127 128 129 130 133

Awareness of different environments that can affect communication The physical environment The emotional environment The cultural environment Environments relating to sexuality The social environment The spiritual environment Chapter summary Review questions References

135 136 142 143 146 146 148 148 149 150

SECTION THREE – UNDERSTANDING AND MANAGING REALITIES OF COMMUNICATION IN THE HEALTH PROFESSIONS

153

11

Communication with the whole Person/s Defining the whole Person/s Holistic care Holistic communication Chapter summary Review questions References

155 156 157 160 161 162 163

12

Non-verbal communication The significance of non-verbal communication The effects of non-verbal communication The components of non-verbal communication Communicating with the Person/s who has limited verbal communication skills Chapter summary Review questions References

165 166 166 167

Conflict and communication Conflict during communication Resolving negative attitudes and emotions towards another Patterns of relating during conflict Bullying How to communicate assertively

179 180 182 182 183 185

13

172 173 174 177

vii

CONTENTS

viii

Chapter summary Review questions References

187 187 189

14

Culturally competent communication Defining culture Cultural identity affecting culturally competent communication Defining culturally competent communication Why consider cultural differences? A model of culturally competent communication Understanding context Ethnocentricity Managing personal cultural assumptions and expectations Strategies for demonstrating culturally competent communication Using an interpreter The culture of each health profession The culture of disease or ill-health Chapter summary Review questions References

191 192 193 193 195 195 198 198 200 202 204 206 206 207 207 209

15

Communicating with Indigenous Peoples Correct use of terms The 4 Rs for reconciliation: Remember, Reflect, Recognise, Respond The complexity of cultural identity Principles of practice for health professionals when working with Indigenous Peoples Factors contributing to culturally safe communication with Indigenous Peoples Barriers to culturally safe communication Chapter summary Review questions References Further reading Websites and/or organisations

212 213 213 215

16

Misunderstandings and communication Communication that produces misunderstandings Factors affecting mutual understanding Causes of misunderstandings Strategies to avoid misunderstandings Resolving misunderstandings Chapter summary Review questions References

232 233 233 235 237 239 240 241 242

17

Ethical communication Respect regardless of differences Honesty

244 245 246

216 222 225 225 226 229 230 230

CONTENTS

18

Clarification of expectations Consent Confidentiality Boundaries Ethical codes of behaviour and conduct Chapter summary Review questions References Further reading Useful websites Informed consent

247 247 249 250 252 252 253 255 257 257 258

Remote communication Characteristics of remote forms of communication for the health professional Principles that govern professional remote communication Documentation: written reports, medical records and letters Telephones Video/teleconferencing or using Skype The Internet Online collaboration tools Chapter summary Review questions References

260

SECTION FOUR – THE FOCUS OF COMMUNICATION IN THE HEALTH PROFESSIONS: PERSON/S Person/s experiencing strong emotions Person/s in different stages of life Person/s fulfilling particular life roles Person/s experiencing long-term conditions Person/s in particular contexts References Further reading Glossary Index

261 263 263 264 267 268 269 271 271 274

277 281 291 303 320 342 351 351 353 361

ix

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How to use this book

Section 1 examines why studying communication is important and basic types of relevant communicative acts required by health professionals.

Section 2 highlights the importance of reflection and the resultant awareness of self, those around the health professional and the various environments that affect health care.

Section 3 emphasises the realities of elements of communication relevant when practising as a health professional: these include non-verbal cues, conflict, cultural variations, ethical issues and remote communication.

Section 4 uses 48 scenarios to encourage readers to explore in-depth needs of people typically encountered in practice. It provides opportunities through role-plays to practise communicating with such people.

Each section includes various types of activities that encourage reflection as well as communicative interaction with others to promote deeper understanding of the requirements of communication and personal tendencies when communicating. The activities also aim to provide opportunities to develop skills in communication while practising as a health professional. These opportunities are indicated by the following icons: â•… Thinking – a reflective activity designed for completion by an individual â•… Doing – an activity for completion by an individual student â•… Thinking and Doing – an individual activity requiring both reflection and action â•… Scenario – a case study â•… Group Thinking – a reflective activity for a group â•… Group Doing – an activity for a group â•… Group Thinking and Doing – a group activity requiring both reflection and action xi

How to use this book

â•… Role Play – an opportunity to ‘act out’ a scenario â•… Two Doing – this is an activity for two people The scenarios presented in Section 4 facilitate application of the aspects of communication explored throughout the first three sections, as well as potentially developing both confidence and competence in communicative interactions.

xii

Reviewers Pete Haynes BPhty School of Community Health, Charles Sturt University, Albury, New South Wales Krista Mathis BA, MComm, MePrac School of Communication and Media, Bond University, Robina, Queensland Charles Mpofu, MHsc(Hons), BEd, DIPEd, DCTD Faculty of Health, Auckland University of Technology, Auckland, New Zealand Karina Waring, BHlthSc(Nursing), RN-(Perioperative Certificate) Ballarat Campus, Australian Catholic University, Ballarat, Victoria Jacqueline Yoxall, BAppSc-(App-Psych), GDip-AppSc-(App-Psych), PhD School of Health and Human Sciences, Southern Cross University, Gold Coast, Queensland Psychologist in Private Practice

xiii

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Preface Development of skills in communication is an ongoing journey for each person. It requires awareness of personal biases and prejudices, awareness of the needs of the Person/s seeking to communicate, awareness of the effects of environment and background (including culture), as well as reflection about communicative practice. Even the best communicators have times when they experience unsatisfactory communicative acts and regret the effects of an interaction. The journey for a health professional in developing communication skills is often eventful and sometimes difficult. However commitment to overcoming the barriers to effective communication is a beneficial and rewarding process for any person, but especially for a health professional. Communication: Core Interpersonal Skills for Health Professionals, 2nd edition contains four sections that focus on particular elements of communication. Section 1 examines the significance of communication for the health professional. It explores the reasons for learning about communication and presents a model to facilitate family/Person-centred practice for health professionals. It also examines some foundational aspects of effective communication for a health professional. Section 2 highlights the importance of reflection and increased awareness when communicating as a health professional. It indicates this awareness must be of ‘self’ and personal assumptions as well as the ‘Person/s’ and the importance of listening when practising as a health professional. It also outlines the need for awareness of the impact of various types of environments experienced in practice. Section 3 emphasises particular realities of communication in the health professions, and how to understand and manage these realities. Section 4 presents forty-eight scenarios that illustrate typical situations and people a health professional may encounter during their working week. This section challenges readers to consider in depth the circumstances and needs of the people in the scenarios. Section 4 encourages readers to validate the information found in the first three sections of the book, thus promoting application of the information learnt and consolidation of the skills developed in these sections. All sections include presentation of information and opportunity for reflection and discussion. They provide opportunities to communicate with both ‘self’ and ‘Person/s’ in an attempt to promote awareness of the major factors contributing to effective communication. Gjyn O’Toole March 2012

xv

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Acknowledgements Thanks to James Charles, Lecturer in Indigenous Medical Education at the University of Newcastle, NSW, Australia, and Charles Mpofu for their invaluable evaluation of the details found in Chapter 15. Jasen Brooks assisted in making my ideas about culture and competence a graphic reality. Thanks also to Esther, Jasen and Mitch who struggled with me to birth the ideas for each cartoon and also to Alex Zeeman who created cartoon summaries of most of the chapters. To the people who assisted with the compilation of Section 4, thank you. This includes all the Person/s I have had the privilege to assist in practice and Esther Brooks (teacher extraordinaire), Matt Peters (talented health professional) and Nell Harrison (creative and reliable health professional) – all phenomenal people. To say thanks is not enough! I especially thank four people: Mitch, a wonderful model of how to communicate in many forms; Esther, author, mother, communicator and editor extraordinaire; Jasen, an interested and invaluable communicator and designer, and also little Zeke who communicates with his eyes. The encouragement and support I receive from the four of you makes it all possible. Students, colleagues, friends and other family members I thank for their commitment to both challenging and encouraging me in my journey towards becoming an effective communicator. I am, however, most in debt to the Creator and Sustainer of the Universe, God.

xvii

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1

The Significance of Interpersonal Communication in the Health Professions

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CHAPTER 1â•…

Defining effective communication for health professionals CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Explain why it is essential to learn about effective communication • State an underlying principle for effective communication • Describe a model of interpersonal communication relevant to the health professions • Define effective communication • Demonstrate understanding of the importance of effective communication • Identify factors contributing to effective communication • Demonstrate understanding of the importance of considering the ‘audience’ to achieve effective communication.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Why learn how to communicate? – Everyone can communicate! Communication occurs constantly throughout the world and most individuals participate in acts of communication every day regardless of their nationality, age or interests. Most people would agree that communicative interactions are unavoidable and usually essential for satisfactory daily life. Even those who are unable to produce speech seek to effectively communicate every day. If everyone already communicates in daily life, then why is it necessary to learn how to communicate in healthcare settings? Simply, in most healthcare settings there are specific required characteristics of communication and particular situations that challenge the communication skills of any communicating person. Effective communication in a healthcare setting requires particular understanding of people and oneself (Zimmerman et al 2007), as well as highly developed communication skills. Individuals do not usually acquire such awareness or skill in everyday life, thus it is beneficial if preparing to be an effective health professional to learn about communication. Higgs et al (2005, 2010) indicate that effective communication is an essential core skill for any health professional. In addition, competent communication skills are a requirement to practise in many health professions. Ineffective communication negatively affects health outcomes, thus in New Zealand particularly, failure in communication is repeatedly the cause of complaints made to the Health and Disability Commissioner (Hill 2011a, 2011b). Certainly there is evidence to suggest that communicating after experiencing a health condition increases recovery rates and decreases the incidence of further conditions (Davison et al 2000, Pennebaker 1995, 1997). Generally, effective communication ensures positive outcomes for all people relating to health professionals (Hassan et al 2007, Koponen et al 2010). Thus if effective communication skills are vital for successful outcomes of practice in the health professions, it is crucial to understand both communication and what constitutes effective communication.

A GUIDING PRINCIPLE Before defining communication it is important to establish an underlying principle to guide communication for health professionals. Self-awareness and self-knowledge are necessary requirements for successful adherence to this principle. The principle simply states: Do not say or do anything to another person that you would not want said or done to you. Adapted from Hillel around 15 BC Consistent consideration of and adherence to this principle is not always easy, but it will generally produce effective communication in health care practice and in life.

Factors to consider when defining effective communication Many dictionaries indicate that communication involves the sending and receiving of messages. They state that communication occurs in auditory/verbal, visual and non-verbal forms. This understanding of communication suggests that the act of communicating resembles a game of tennis. In the same way that tennis players hit a ball to each other, 4

1 » Defining effective communication for health professionals

communicators send and receive messages in various forms. Initially this metaphor seems appropriate, but • Does communicating in the health tennis players only interact with the ball; they norprofessions require more than mally do not interact with each other. In addition the speech, hearing and sight? If so, tennis ball remains constant, unlike messages, which what does it require? change and develop when communicating. These realities suggest defining communication requires more than a comparison with playing tennis. Effective communication involves more than simply sending and receiving words by producing and receiving sound. As effective communication occurs in many forms, including vocalising without words (e.g. laughing or crying), non-verbal cues (e.g. eye contact, facial expressions, gestures and signing) and material forms (e.g. pictures, photographs, picture symbols, logos and written words) (Crystal 2007), it requires consideration of multiple factors.

MUTUAL UNDERSTANDING Each communicative act or interaction is unique, with unique requirements and constraints. These requirements and constraints influence the effectiveness of the interaction at the time. The combination of these factors along with ongoing discussion determines whether the interaction produces mutual understanding (Fig 1.1). Successfully negotiating mutual understanding will encourage those communicating to trust their ability to communicate effectively (Stein-Parbury 2009) and thus they will continue to communicate. Every communication act requires all communicators to be actively involved, to connect with and understand each other, and to understand the factors affecting the communication act (Brill & Levine 2005, Hassan et al 2007). Effective communication requires the communicating parties to have some basic knowledge about each other and their individual goals (Devito 2009).

Send Self/Person aware

Vulnerable Receive

Health Professional

Person/s negotiating mutual understanding

Send Receive

FIGURE 1.1â•… A model to guide communication in the health professions. Note: Person/s is used to describe those relating to the health professional during practice.

5

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Communication is ineffective, without mutual understanding. Therefore, the sending and receiving of a message achieves nothing unless there is shared meaning and meaningful exchange of information. The specific purpose of communication by health professionals (see Chs 3 & 4) is to share information and fulfil needs. If mutual understanding is not negotiated through words and non-verbal messages (Gietzelt & Jones 2002), there is no appropriate information to guide an intervention and potentially limited fulfillment of needs. For example, if there is no connection (Hassan et al 2007, Horan et al 2011) and exchange of information with mutual understanding when there is a need for a toilet or something in which to vomit, the results can be messy and, more importantly, time consuming. Effective communication in the health professions occurs when the sender and receiver connect with each other for the common purpose of exchanging information and achieving mutual understanding. It is essential for health professionals to negotiate or continue discussion during their interactions until achieving mutual understanding, thereby ensuring appropriate interventions and meaningful results.

A COMMON UNDERSTANDING OF WORDS

•

Consider the different meanings of the following words: file, stand, form, compress, bracing, crutch and ‘a simple case’. • Can you think of other words or combinations of words that might cause miscommunication? • What factors might change the meaning an individual assigns to a word or combination of words?

Mutual understanding is essential for effective communication. However, different factors influence the comprehension of a message. These factors may either facilitate or restrict communication. Effective communication requires two or more people to have a topic of mutual interest, a mutual desire, intent or need to communicate about the topic, the opportunity to communicate and the means of communicating. Thus, if there is no common understanding of language or way of communicating there will be no mutual understanding and thus no exchange of information or effective communication (Nunan 2007). This potentially will restrict health outcomes.

Factors external to the sender and receiver The words in the box above (file, stand etc) have meanings that might vary within the context of the situation or environment (Nunan 2007). Thus, if asked for a ‘file’ (e.g. Pass that file please) when there is no obvious folder with pieces of paper inside, the receiver of the request might search for other meanings of the word. They might see an implement used to file nails in the environment and assume that is the required file. In this case, the receiver of the message assumes the meaning because of features of the environment. There are other external factors that affect the meaning an individual might assign to a word. Someone who comes from a particular background (Purtilo & Haddad 2007) or who has particular life experiences might assign a particular meaning to one word. For example, someone with a scientific or nursing background might assume that the word ‘stand’ means a structure used to hold or support something, while someone with a political background might assume it means to run for election. Someone with a military background might assume it means to resist an onslaught without being harmed, while someone with another background or experience might assume it means to position themself on both legs with a straight back and stay in that position without moving. In this case it is the background and experience of the communicating individuals that affect the understanding of the particular word. The background or experience might be 6

1 » Defining effective communication for health professionals

particular to a family, socioeconomic group or culture; all of these factors and more can affect and vary the meaning of messages. It is important when communicating in the health professions, therefore, to consider related factors that might influence the achievement of mutual understanding, effective communication and thus positive health outcomes.

Factors specific to the sender Senders of messages often express their messages according to their own thoughts, agenda, needs or feelings at a given time. For example, senders often communicate their intended meaning through emphasis or stress on a particular word, rather than the actual words they use (Crystal 2007).

Factors specific to the receivers or ‘audience’

Consider: • It is time we had those ATOs in the store means: Can you put the ATOs in the store now? • Have you seen that splinting material? means: I have asked everyone else – do you know? It is often the emphasis on particular words that changes the intended meaning of a sentence. Compare: • I want a drink of water. • I want a drink of water. • I want a drink of water. The emphasis changes the meaning of each statement. The first is a statement of a desire to have a drink of water. The second suggests a focus upon the speaker; thereby implying the irrelevance of the desires of others. The third indicates that the desired drink is water and nothing else. In each case the emphasis indicates the particular desire of the person sending the message. If the receiver fails to note the emphasis in the last sentence, for example, the sender of the message may not receive the desired drink.

In every communicative event someone receives a message or information. The audience is the person or group of people who receive the message or information. In the health professions there are many people who constitute the audience including colleagues, Person/s and family members. There are many factors that influence the effectiveness of communication and some of these factors are specific to the receiver/audience. When communicating as a health professional, the potential impact of these audience factors upon communication mandates their consideration. Every person has particular knowledge and associated levels of understanding that affect their ability to comprehend particular messages (Milliken & Honeycutt 2004). Thus, when practising as a health professional it is important to communicate in ways that acknowledge the level of understanding and/or knowledge of the audience. The age of the person is one factor that can influence the knowledge or level of understanding. Therefore, when talking to a young child it is appropriate to adjust the communication style by using less complex words or sentences. This adjustment of communication style assists the mutual understanding of both the speaker and the child. Using the same simplistic language when talking to an adolescent or adult, however, may cause offence. An additional factor that requires adjustment of language is the cultural/language background of the audience • List all the people with whom a health professional might (Fageeh 2011) (see Chs 8 & 14 and Section 4). communicate. A further factor that requires consideration is • For each person or group of people whether or not to use professional jargon. The decilist factors specific to that person or sion of how and when to use professional jargon group that might affect their ability to requires the health professional to consider the expeunderstand a sent message. rience and background of the person (Purtilo & Haddad 2007). The use of medical terminology may 7

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

be appropriate if the person has a medical background and understanding of that particular field of medicine. It may also be appropriate if they have previous experience with such terminology, but may cause confusion if they do not have the knowledge, understanding or experience of such terminology. When communicating with health professional colleagues about medically related topics, use of non-medical terminology may cause confusion! In order to avoid confusion it is important to consider and sometimes request information about the knowledge and experience of the audience when communicating as a health professional. It is certainly beneficial to ensure there is understanding of all relevant terms. A particular disorder affecting an individual may also influence the success of the communicative event. In some circumstances it may be essential to communicate only one idea or step at a time. For example, individuals with limited cognitive ability and reduced affect require adjustments in the communication style of the health professional and their manner of constructing and delivering a message. It is not only the age, background and experiences of the receiver that can affect their levels of understanding. Receivers of messages often interpret messages according to their own thoughts, ideas, needs or emotions at that given time, which may assist or adversely affect their understanding of the messages (see Chs 5 & 6 and Section 4). Effective communication between a health professional and the people seeking their assistance should be an exchange of thoughts, ideas, needs and emotions that has a • List at least six factors that facilitate therapeutic outcome (Paré & Lysack 2004, Seikkula effective communication. & Trimble 2005). A health professional who consid• State whether these factors are ers and appropriately adjusts to the thoughts, ideas, external or internal to the sender or needs and emotions of the receiver will usually receiver. promote mutual understanding and thus achieve effective communication.

Chapter summary Effective communication occurs when people send, receive and understand messages. Such communication produces mutual understanding and is essential for health

FIGURE 1.2â•… Mutual understanding is essential!

8

1 » Defining effective communication for health professionals

professionals. There are both external and internal factors that influence information exchange through mutual understanding. These factors occur in the environment, in the sender and the receiver. A sound understanding and consideration of these factors contributes to effective communication and positive health outcomes.

REFERENCES Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Crystal D 2007 How language works. Penguin Books, London Davison K P, Pennebaker J W, Dickerson S S 2000 Who talks? The social psychology of illness support groups. American Psychologist 55(2):205–217 Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Fageeh A A 2011 At crossroads of EFL learning and culture. Cross-cultural Communication 7(1):62–72 Gietzelt D, Jones G 2002 Importance of language – single words don’t communicate all that is necessary. In: Bergland C, Saltman D (eds) Communication for healthcare. Oxford University Press, Melbourne, p 18–32 Hassan I, McCabe R, Priebe S 2007 Professional–patient communication in the treatment of mental illness: a review. Communication & Medicine 4(2):141–152 Doi:10.1515/CAM.2007.018 Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Hill A 2011a Consumer-centred care: seamless service needed. New Zealand Health & Disability Commission, August. Online. Available: http://www.hdc.org.nz/ 10 Jan 2012 Hill A 2011b Recurring themes. Society of Anaesthetists Newsletter, Feb Horan S M, Houser M L, Goodboy A K et al 2011 Students’ early impressions of instructors: understanding the role of relational skills and messages. Communication Research Reports 28(1):74–85 Doi:10.1080/08824096.2011. 541362 Koponen J, Pyööräälää E, Isotalus P 2010 Teaching interpersonal communication competence to medical students through theatre in education. Communication Teacher 24(4):211–214 Doi:10.1080/17404622.2010.514275 Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Nunan D 2007 What is this thing called language? Palgrave Macmillan, Basingstoke Paré D, Lysack M 2004 The willow and the oak: from monologue to dialogue in the scaffolding of therapeutic conversations. Journal of Systemic Therapies 23:6–20 Pennebaker J W 1995 Emotions, disclosure & health. American Psychological Association, Washington, DC Pennebaker J W 1997 Opening up: the healing power of expressing emotions. Guildford Press, New York Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia 9

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Seikkula J, Trimble D 2005 Healing elements of therapeutic conversations: dialogue as an embodiment of love. Family Process 44:461–473 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Zimmerman S S et al 2007 Using the power of student reflection to enhance professional development. Internet Journal of Allied Health Sciences and Practices 5(2):1–7

10

CHAPTER 2â•…

The overall goal of communication for health professionals CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Demonstrate understanding of the relevance of the World Health Organization (WHO) ICF model when communicating with a Person/s • Demonstrate understanding of the overall purpose of communication in health professions • Recognise the steps required to fulfil the overall purpose of communication in the health professions • Demonstrate recognition and understanding of the characteristics of each step of a model of family/Person-centred practice in the health professions.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

While the purpose of communication in the health professions is ultimately to facilitate the delivery of a service, the overall goal of communication for health professionals should be to communicate in a manner that makes the delivery of the service a positive experience for all (Hassan et al 2007, Horan et al 2011). This chapter describes the means of achieving this goal to ensure optimal outcomes and thus health and wellbeing for all Person/s relating within and relating to health professional services. NOTE: In this book the word Person/s has been used to mean those individuals working within a health service and those individuals seeking assistance from the particular health service.

A model demonstrating the importance of communication The International Classification of Functioning, Disability and Health (ICF) (WHO 2001), shown in Figure 2.1, is a biopsychosocial model that highlights the complex and multidimensional nature of health, and the factors affecting health and functioning (Allan et al 2006). It provides a common language for multidisciplinary or interdisciplinary communication. The ICF classifies the ‘components of health’ and places health on a continuum where any limitation in functioning can disrupt health. The ICF also describes the importance of participation in six interrelated domains or life situations (Ewert et al 2004, Weigl et al 2004), including: 1. Communication 2. Movement 3. Learning and applying knowledge 4. Participation in general tasks and the demands of those tasks 5. Self-care and interpersonal interactions 6. Major life areas associated with work, school and family life. Health Condition (disorder or disease)

Body Functions and Structures

Environmental Factors

Activity

Participation

Personal Factors

FIGURE 2.1â•… International Classification of Functioning, Disability and Health (ICF). Reproduced from World Health Organisation (2001). Geneva. International Classification of Functioning, Disability and Health (ICF), used with permission.

The ICF model encourages health professionals to consider the factors that affect function, participation and a sense of wellbeing. It directs health professionals to collaborate with the person to overcome the challenges that restrict participation in daily life, because 12

2 » The overall goal of communication for health professionals

participation contributes to health. It directs health professionals to develop holistic goals that are not driven merely by assessment results or opinion, but rather are person-centred and thus unique to the needs and goals of the individual (Brown et al 2003). The ICF model indicates that communication is an important domain that facilitates participation and functioning, thereby significantly affecting health. It demonstrates that poor communication potentially limits intervention outcomes, which can restrict functioning and disrupt health and wellbeing. It reminds health professionals to acknowledge the importance of communication for health and a sense of wellbeing, and therefore to encourage the individual to engage in the act of communicating (Eadie 2007, Hopper 2007, Larkins 2007).

A model to guide the general purpose of communication for the health professions Health professions exist to provide specific services to individuals seeking their assistance. Regardless of the particular health profession, communication is a vital activity within that service. Mutual understanding between the individual seeking the service and the health professional is a characteristic of any meaningful interaction. It is vital to ensure positive outcomes. Mutual understanding (successful exchange of information) provides the foundation for the development of a therapeutic relationship between the individual and the health professional. Similarly, this therapeutic relationship ensures that the needs and desires of the individual or group are at the centre of the goals and interventions, thereby facilitating family-centred, client-centred or Person-centred practice (Harms 2007, Harms & Pierce 2011, Hassan et al 2007, Higgs et al 2005, 2010, Holmes et al 2010, Parker 2006, Purtilo & Haddad 2007, Rini & Grace 1999, Stein-Parbury 2009) (see Fig 2.2). The concept of family or Person-centred practice is the focus of discussion and publication in some health professions. In other health professions it is an underlying assumption but rarely discussed, while in still others it is neither an assumption nor a topic of discussion. Please note the use of the word family applies particularly in practice involving children, although inclusion of the family in goal setting and interventions may occur in other contexts of practice. It is essential when working with children, but may significantly contribute to positive treatment outcomes in other practice contexts, depending on the desires and dynamics of both family and the Person.

FIGURE 2.2â•… A model to guide family/Person-centred practice.

Family/Person-centred practice is a partnership between the health professional and the Person/s seeking their services. This collaborative partnership exists to establish the 13

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Miss Brown, a 78-year-old woman, was admitted to a rehabilitation ward after experiencing a stroke. Initially she was drowsy, but happy and cooperative. After a few days she became distressed and refused to be involved in any interventions or relate to anyone from the multidisciplinary team. First response: In response, every health professional on the team gently repeated that Miss Brown did not need to worry, she was all right now and everything would be OK. Some told her she could relax, as everyone on the team was there to help her. One health professional sympathetically said it must feel terrible suddenly finding yourself in hospital from a stroke, but that it would be OK in the end, so she should cheer up. She was also kindly told she simply needed to do as she was asked and she would eventually go home. This made her sob. • Are these responses health professional-centred or Personcentred? Explain why.

Second response: One health professional on the team took a different approach, expressing empathy and developing trust with Miss Brown. This health professional was able to establish that Miss Brown was very worried about her best friend and constant companion, Billy. Billy was her pet bird who needed daily food and water. The health professional organised to bring Billy to the hospital. Miss Brown began seeing Billy every day and thus began enjoying her treatment and eventually returned home with Billy. • Is this response health professionalcentred or Person-centred? Explain the difference.

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needs and goals of the person (Unsworth 2004). It enables them to achieve their goals with the assistance of the health professional (Duncan 2006). Achievement of these goals empowers the individual to achieve positive outcomes including participation and fulfilment in their daily lives.

MUTUAL UNDERSTANDING Mutual understanding means that those communicating share a common meaning – all parties comprehend the verbal and non-verbal signals used during the interaction. In the health professions, mutual understanding must mean more than simply understanding words (see Ch 1). A foundational factor that builds mutual understanding and appropriate results in any health profession is respect (Egan 2010). Respect of self and other people is a fundamental value of all health professions. It affects the views that individuals have of themselves and of others. It requires unconditional regard for self and other people regardless of weaknesses or failures, position or status, beliefs and values, material possessions and socioeconomic level (Rogers 1967, Purtilo & Haddad 2007). Respect demonstrates that the health professional values every individual. It is the basis of empathic reactions in a health professional. As a health professional, it is imperative to understand that every person seeking assistance feels disconnected and vulnerable. Many such individuals often feel inadequate to meet the demands of their current situation (Stein-Parbury 2009) and may be afraid of the unknown elements of the situation. Vulnerable individuals want to know the health professional cares about them and desires to understand their life and experiences (Milliken & Honeycutt 2004). Demonstration of this understanding and care will increase the ability of the person to process and understand any information (Householder & Wong 2011). It is the responsibility of the health professional to demonstrate this care and understand the vulnerability of each individual. Direct, clear and accurate recognition of the emotions of the individual and expression of this understanding is known as empathy (Stein-Parbury 2009) (see Ch 8). This does not mean expressing similar emotions (sympathy) – but accurately identifying, validating and accepting their emotions.

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Draw a line down the middle of a page. Place the word ‘Empathy’ at the top of one column and ‘Sympathy’ at the top of the other column. Consider the scenario above. • Write responses to Miss Brown in each column that demonstrate both sympathy and empathy. • Suggest ways the health professional expressed empathy to discover the cause of the emotions dominating Miss Brown.

Davis (2011) and Morse (2010) state that expressing empathy to the vulnerable individual enables both humane and beneficial communication. This manner of communicating has a positive effect (Ley 1998) upon the participation of the individual in all activities associated with health professional interventions (see Fig 2.3). It is important to understand that statements like ‘I understand’ or ‘You are OK’ or ‘It will be all right’ do not demonstrate empathy and are rarely reassuring.

FIGURE 2.3â•… The doctor is IN. Copyright 2012 Peanuts Worldwide, Distributed by Universal Uclick.

Expression of appropriate empathy requires both personal and professional skill. Such skill necessitates • If you are feeling vulnerable, how do reflection about self (Pendleton & Schultz-Krohn you feel when someone indicates they 2006), practise in expressing empathy, making time are interested in what you are feeling to practise, commitment to the expression of empathy and attempts to understand/validate and in many cases self-control on the part of the your experiences and feelings? health professional. It requires awareness of and • What actions demonstrate that respect for the feelings of the individual – being able someone is interested? to see the world from their viewpoint and respecting • How might expressing such interest and care affect communication? that viewpoint. Appropriate expressions of empathy require the health professional to make responsible choices about when, what and how they communicate. The health professional needs also to be aware of and able to control, express or resolve their own negative emotions, without allowing them to affect the vulnerable individual (see Chs 5 & 6). Appropriate expressions of empathy take little time or effort, and they can result in the individual believing they are the only person in the world for that time. While expressions of empathy are beneficial in all areas of life, they are essential when practising as a health professional (Egan 2010, Harms 2007, Harms & Pierce 2011, Milliken & Honeycutt 2004, Stein-Parbury 2009). See Chapter 8 for a deeper exploration of expressing empathy. 15

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•

How do negative emotions affect your ability to send, receive or understand messages? • Why are positive feelings and reactions essential when communicating as a health professional?

From the perspective of the person receiving a health service, list the possible consequences of negative emotions either in you or in them.

Health professionals must consider whether they will validate and acknowledge the experience and associated needs of the individual and, if so, at which point (Davis 2011). While such choices require skill, health professionals must take every appropriate opportunity to express empathy with those around them because this indicates acceptance and validation of the emotions associated with the experience. Such acceptance and validation indicates respect. Respect is something that all individuals appreciate and it produces positive feelings that facilitate the development of trust during an interaction. The behaviour of a health professional will be open, honest, predictable and reliable if they are worthy of trust. In combination, respect, empathy and trust are foundational for developing mutual understanding, the first step in achieving family/Person-centred goals and practice.

A THERAPEUTIC RELATIONSHIP Mutual understanding (respect, empathy and trust) facilitates the development of a therapeutic relationship. Therapeutic relationships require connection beÂ�Â� • What behaviours help you trust tween the Person/s and the health professional. This someone? Make a list of behaviours connection is known as rapport. Rapport develops as that indicate someone is trustworthy. trust develops and can empower individuals to per• Are these behaviours you often severe in order to achieve their health-related goals. demonstrate? Why? Why not? List A therapeutic relationship requires independence ways of demonstrating them in your not dependence. It demands a focus on the needs of chosen profession. the Person/s, not fulfilment of the needs of the health professional. There may be expression of strong and deep emotions along with genuine distress with the individual, but this expression is always focused on the needs of the individual not the needs of the health professional (Purtilo & Haddad 2007). A therapeutic relationship desires neither to manipulate nor to be manipulated. In a therapeutic relationship the health professional desires to share their knowledge, skill and, where required, comfort and support to facilitate function and participation in life. Such a relationship empowers an individual to continue to face and overcome challenges that restrict participation and function. The support characteristic of a therapeutic relationship empowers the individual to overcome seemingly overwhelming situations. A Chinese scholar Lao Tsu (700 BC) when answering the question, What should a therapist do? (they did not have health professionals in 700 BC!) said: Go to the peopleâ•… Work with them Learn from themâ•… Respect them Start with what they knowâ•… Build with what they are And when the work is doneâ•… The task accomplished The people will say ‘We have done this ourselves’. 16

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A therapeutic relationship encourages a collaborative partnership. A collaborative partnership is one in which the contribution of each person is essential to achieve a satisfactory and appropriate outcome. It facilitates involvement from an individual who is intimately aware of their own needs. It also requires input from the health professional who has the knowledge, understanding and skill to assist. This collaboration enables the individual to face and overcome the relevant challenges. It gives them strength to achieve their own goals. It provides the mutual knowledge and understanding that is required to consider all relevant factors and resolve any areas of dysfunction. Collaboration allows people opportunity to be agents of change in their own circumstances, ultimately empowering them to increase their levels of function and participation in everyday life. Rapport, empowerment and collaboration are important components of therapeutic relationships, the second step in family/Person-centred goals and practice.

FAMILY/PERSON-CENTRED GOALS AND PRACTICE The steps above contribute to a focus on the Person/s. While each step has particular characteristics, one skill necessary for successful completion of each step, and the overall purpose of interpersonal communication in the health professions, is effective listening (see Ch 9). The health professional must invest the time to listen, validate and confirm understanding in every situation. The characteristic of each step mandates that the health professional should not place their own desires or values consciously or unconsciously upon the Person/s. Instead, these steps require investigation of the abilities, feelings, needs and desires of the person, in order to establish and prioritise their personal goals for participation in their life (Unsworth 2004). Such efforts will potentially provide the individual with feelings of control and thus increase positive emotional responses. They will maintain levels of motivation, effort and satisfaction in the person (Gilkeson 1997). These communication events contribute to and increase positive outcomes. While the ultimate purpose of communication in the health professions may be to deliver a service or intervention, this model can create an experience that facilitates function and empowers a person to participate thereby positively affecting their health and wellbeing. It potentially makes the delivery of any health service a positive experience for all. Figure 2.4 summarises the discussion in this chapter about the overall goal of communication for health professionals and a model of family/Person-centred practice.

Chapter summary Family/Person-centred practice is built upon therapeutic relationships involving development of rapport, empowerment of and collaboration with the Person/s. These are also built upon mutual understanding, which requires respect, expressions of empathy and development of trust when practising as a health professional. The model presented in this chapter can guide such practice. The components of each step can facilitate the achievement of the overall goal of communication by health professionals: family/Personcentred practice. The health professional can directly contribute to the establishment of each component, and thus can achieve effective communication and positive experiences that facilitate participation and function in activities that have meaning and produce satisfaction. 17

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Family/Person-centred goals and practice

Positive emotions from feelings of control Positive outcomes Effective listening Therapeutic relationships Collaboration—agent of change Empowering—to overcome barriers Rapport—connection Mutual understanding Respect—acceptance and value Empathy—skill, time, commitment Trust—predictable and reliable

FIGURE 2.4â•… The components of a model to guide family/Person-centred practice.

REFERENCES Allan C M, Campbell W N, Guptill C A et al 2006 A conceptual model for interprofessional education: the international classification of functioning, disability and health (ICF). Journal of Interprofessional Care 20:235–245 Brown G, Esdaile S A, Ryan S 2003 Becoming an advanced healthcare professional. Butterworth-Heinemann, London Davis C M 2011 Patient practitioner interaction: an experiential manual for developing the art of healthcare, 5th edn. Slack, Thorofare, NJ Duncan E A S 2006 Skills and process in occupational therapy. In: Duncan E A S (ed) Foundations for practice in occupational therapy, 4th edn. Elsevier, London, p 43–57 Eadie T L 2007 Application of the ICF in communication after total laryngectomy. Seminars in Speech and Language 28(4):291–300 Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Ewert T, Fuessl M, Cieza A et al 2004 Identification of the most common patient problems with chronic conditions using the ICF checklist. Journal of Rehabilitation Medicine 44(suppl):22–29 Gilkeson G E 1997 Occupational therapy leadership. Davis, Philadelphia Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Hassan I, McCabe R, Priebe S 2007 Professional–patient communication in the treatment of mental illness: a review. Communication & Medicine 4(2):141–152 Doi:10.1515/CAM.2007.018 Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holmes G N, Harrington N G, Parrish A J 2010 Exploring the relationship between pediatrician self-disclosure and parent satisfaction. Communication Research Reports 27(4):365–369 18

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Hopper T 2007 The ICF and dementia. Seminars in Speech and Language 28(4):273–282 Horan S M, Houser M L, Goodboy A K et al 2011 Students’ early impressions of instructors: understanding the role of relational skills and messages. Communication Research Reports 28(1):74–85 Doi:10.1080/08824096.2011.541362 Householder B J, Wong N C H 2011 Mood state or relational closeness: explaining the impacts of mood on the ability to detect deception in friends and strangers. Communication Quarterly 59(1):104–122 Doi:10.1080/01463373.2011.541363 Larkins B 2007 The application of the ICF in cognitive-communication disorders following traumatic brain injury. Seminars in Speech and Language 28(4):334–342 Ley P 1998 Communicating with patients: improving communication satisfaction and compliance. Chapman and Hall, London Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Morse C R, Volkman J E 2010 An examination into the dyadic effects of mood in social interactions. Communication Research Reports 27(4):330–342 Doi:10.1080 /08824096.2010.518914 Parker D 2006 The client-centred frame of reference. In: Duncan E A S (ed) Foundations for practice in occupational therapy, 4th edn. Elsevier, London, p 193–215 Pendleton H M, Schultz-Krohn W (eds) 2006 Pedretti’s occupational therapy: practice for physical dysfunction, 6th edn. Mosby, St Louis Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Rini D L, Grace A C 1999 Family-centered practice for children with communication disorders. Child and Adolescent Psychiatric Clinics of North-America 8(1):153–174 Rogers C 1967 On becoming a person. Constable, London Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Unsworth C A 2004 How do pragmatic reasoning, world view and client-centredness fit? British Journal of Occupational Therapy 67(1):10–19 Weigl M, Cieza A, Anderson C et al 2004 Identification of relevant ICF categories in patients with chronic health conditions: a Delphi exercise. Journal of Rehabilitation Medicine 44(suppl):12–21 World Health Organization 2001 International Classification of Functioning, Disability and Health. WHO, Geneva

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CHAPTER 3â•…

The specific goals of communication for health professionals: 1 CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Demonstrate understanding of the difference between the overall goal and the specific goals of communication for health professionals • State the role and purpose of introductions • Demonstrate understanding of the characteristics of a good introduction • Demonstrate skills in introductions • Recognise the scope of introductions in content and for developing a relationship • Demonstrate understanding of the importance of skills in providing information, specifically informing, instructing and explaining • Demonstrate understanding that the two-way process of providing information requires organisation, relevant ordering of information, timing and summarising.

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The overall goal of all health professionals is to provide family/Person-centred practice, which requires mutual understanding and a therapeutic relationship (see Ch 2). This goal should guide every interaction between health professionals and the Person/s. There are, however, specific goals that also guide communication for health professionals. These specific goals may vary from one interaction to another. This chapter examines the two major aims of: • making verbal introductions • providing information. Making introductions and providing information are two specific aims of communicating in the health professions. Many other goals for communicating fall within these two areas. The second piece of the discussion relating to the specific goals of communication in the health professions examines the skills of: • gathering information (by interviewing and using the related skill of questioning) • comforting • confronting. These skills require specific management to ensure appropriate outcomes for all individuals involved in an interaction, and thus are considered separately in Chapter 4.

Making verbal introductions In family/Person-centred services, the initial purpose of every health professional is to introduce themself, their role, their workplace environment and their service. Introductions are a form of giving information, and many overlook their significance and potential impact. Introductions can establish a precedent for any future interactions with the individual; they ‘set the tone and the scene’ (Gilleylen 2007, Harms 2007, Harms & Pierce 2011). Introductions tell the person listening about the health Every introduction should reflect professional performing the introduction, thereby estabthe essential characteristics that lishing the reliability and trustworthiness of that health demonstrate family/Person-centred professional (Mason & Morley 2009). Introductions also practice. demonstrate respect for and interest in the listening What generally occurs during an • person and in the circumstances surrounding that person introduction? (Gilleylen 2007). Introductions should reassure the lis What constitutes a good • tening person, allowing them to decide whether they introduction when you are in a will continue listening. They should produce a sense new environment and do not know of confidence that means the listening person will willanyone? ingly invest in any future interactions (Householder & • What makes introductions different Wong 2011). for a health professional? In the health professions, the Person/s listening – • What should the health professional introduce? whether the person seeking assistance, a related person Remember: The Person/s you are or a colleague – is often vulnerable (Milliken & Honeycutt assisting is vulnerable and may feel 2004). Person/s often feel unsure of and overwhelmed disconnected from others and life. by their circumstances, and the generally unknown enviConsider what you might need to know ronment surrounding the health professions. This may to feel less vulnerable if you were in also be the situation for new colleagues (including coltheir place. leagues unfamiliar with the particular context) and students (Higgs et al 2005, 2010). 21

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Introductions generally provide information that allows the speaker and listener to achieve mutual understanding and establish whether they share a common intent or experience (Holmes et al 2010). The vulnerable person listening to a health professional is certainly listening for answers. In their mind, they have often-unconscious questions they want answered about the health professional talking to them (Harms 2007, Harms & Pierce 2011), for example, Who is this person? What do they want? What can they do to help me? Do they really want to help me? Can I trust them? Will they listen to me? Will they understand me and therefore help me? Will they really want the best for me? Will they want what I want? Are they worth listening to? Do I want to keep listening? The verbal message or actual words used may contribute to the answers of only two or three of the questions in the mind of each listener. In fact, during their first introduction the manner and non-verbal messages (see Ch 12) of the health professional may provide the most powerful message to the Person/s (Devito 2009, Turner et al 2010). Both verbal and non-verbal messages must ‘send’ the same message as they influence all interactions and collaboration between the Person/s and the health professional (Bevan et al 2011, Lawton 2011).

INTRODUCING ONESELF AND THE ASSOCIATED ROLE Introducing oneself is simple; it is a statement of a name. Hi, I’m … is easy to say many times a day. However it can be challenging to introduce the role of a health profession. A well-known and well-understood health profession in the public mind may seem easy to introduce. It may even be tempting to not introduce such a health profession. However, possible preconceptions may cause confusion. If the role is not clearly understood in the particular context or setting, this confusion requires clarification using questions or a verbal or written explanation. Some health professions are unknown or commonly misconstrued in the public mind. In such cases, preconceptions can be equally challenging. It is important to use a clear and easy-to-understand explanation of the role of these professions (Lawton 2011, Staggers & Brann 2011). It is also important to avoid professional jargon and potentially confusing descriptions in this explanation (Bevan et al 2011). It may be useful to include specific examples of the role of the particular health profession in the spe• Write down the role of your health cific setting or context. It may be important when profession. explaining a role to understand the role of other health • Introduce yourself and explain your professions, as this may assist in dispelling confusion role to: about the role of this profession compared with that of  someone from your health other health professions. When working with adults, a profession. Do they understand written explanation may address any misconceptions you? Do they agree?  someone from another health concerning the role of a particular health profession profession. Do they understand (Johnson & Stanford 2005). you? Do they agree? Discuss Failure to introduce a particular role, or at least their perception of your health to question and clarify understanding of the role, profession. may result in a difficult-to-correct misunderstanding. • Do you need to adjust your More importantly, the Person/s who requires assistance explanation because of the above may not receive the appropriate service, thereby limitresponses? ing potential outcomes and possibly having legal implications. 22

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INTRODUCING THE UNFAMILIAR ENVIRONMENT There is usually an element of uncertainty and anxiety for an individual entering an unfamiliar environment (Purtilo & Haddad 2007). New environments create questions about a number of things – the physical layout of the environment, the people in the environment, the emotional safety and predictability of the environment, the possible events and routines that occur within the environment and, for some, survival within the new environment. These questions and the overall goal of a health professional determine the order of an environmental introduction. Thus, the first part of an environmental introduction is usually introducing the physical environment. Essential information for all newcomers to an unfamiliar environment includes the location of the toilet! In an inpatient setting information relating to ward routines, including how to order meals, meal times, visiting hours and particular relevant events, can assist in reducing anxiety. Introducing the physical environment and related routines does not merely assist in the orientation of the Person/s but also allows the health professional and the Person/s to begin progressing through the steps that facilitate family/Person-centred practice. Further information required for an environmental • Have a group member explain a introduction will depend on the needs of the newtime when feeling vulnerable, comer. If they indicate a need to know more about the anxious or in an unfamiliar situation events they can expect in the environment, then a verbal affected their understanding and memory. Consider the importance of or written description of the typical events should the information at the time. follow the initial physical introduction. It may be more Discuss why such feelings might • appropriate to provide a deeper explanation of possible produce this reduction in cognitive events as they occur, rather than when a person is new function. to an environment. Remember that the Person/s is • Suggest when it is important that the vulnerable and they may initially ‘miss’ important health professional compensate for information if too much information is given in a new the selective understanding of the and unfamiliar environment. When people feel vulnerPerson/s. able what they remember may be selective, that is they Suggest ways a health professional • may only remember particular parts of the information might assist the Person/s to and forget others, often significant, information (Morse overcome this tendency. & Volkman 2010). A verbal or written introduction of the other people or professionals in the environment should follow the initial environmental introduction. It is important to find a suitable time to introduce these people or at least arrange a time for such an introduction. It may be beneficial to provide a written description of the people they might encounter and their respective roles. Allowing a person to read such a document at their leisure facilitates understanding and may stimulate questions for future interactions. If the newcomer exhibits anxiety of any kind, it may be necessary to demonstrate particular interest in their emotional safety. This demonstrates empathy (Davis 2011) and respect. Emotional safety is achieved by answering their questions or indicating interest in and care about their concerns. This behaviour indicates to the person that the health professional is willing to consider and address their concerns. Physical concerns are often easy to address, for example, a cup of something or a blanket. Emotional concerns take more thought and time to address. It is important at this early stage to spend time acknowledging their concerns and fears, and reassuring them with relevant information to allay them (Stein-Parbury 2009). Statements such as You’ll be all right and You don’t need to 23

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Person 1 (age 24) has pain in the lower back. They have been to various health services and do not have much confidence in this one to care about their needs or assist with their particular difficulties. Person 2 (age 72) has never accessed any healthcare services – they have always been very healthy and active. They have had a fall while walking to their car after doing some grocery shopping and are experiencing extreme pain in their left hip. Suddenly finding themself at your health service they are worried about everything – they have no idea what is wrong, the pain is terrible, they are worried about their future, afraid they may not be able to return home, have no idea what happened to their shopping or the car or the cat food, and what about the cat? … who will feed the cat? … pain and anxiety make it difficult to think. This is the first time you have met the person described in each scenario. Decide how best to demonstrate empathy, respect and behaviour worthy of trust using introductions. List what needs to be said and done to develop a therapeutic relationship and ensure family/Person-centred practice.

Understanding information Consider a specific time when you received new information (e.g. listening to the person next to you introduce themself or listening to the news). What made it easy to understand? What limited your understanding? Was your understanding related to words only or were there other factors?

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worry – we’ll look after you here will not reassure and they do not demonstrate empathy or respect. It is sometimes helpful to introduce a concerned and fearful person to another person with similar difficulties who has positive experiences associated with assistance from the particular health profession or service. Consideration of emotional concerns during an initial introduction is important because it establishes the new, unfamiliar environment as a safe and caring environment for future interactions. Whether the health professional first provides or gathers information in their interaction with the Person/s varies according to the needs of the Person/s and the context. It is essential to consider the factors that affect both providing and gathering information. The order chosen in this book reflects the reality that introductions provide information. It is not intended to suggest that one has greater significance than the other or that one should occur before the other. In reality, when attempting to understand the perspective of the vulnerable individual, the health professional simultaneously provides and gathers information.

Providing information: a two-way process A health professional provides information to various people throughout the working day. This information takes two main forms, verbal or written, and generally has the purpose of informing, instructing or explaining. When a health professional informs, they provide information about people, possible events or situations – usually about what to expect. This information may empower the person to act and react appropriately (Egan 2010). Instructions are directions about ways to successfully complete tasks or required procedures. Information or instructions will reassure the Person/s and/or create questions. If the information creates questions, then the health professional responds with more information in the form of answers that inform, instruct or explain. The health professional must respond to the needs of the Person/s by providing the required information and ensuring the Person/s has understood that information. The provision of information is a two-way process requiring mutual understanding. Regardless of the reason for providing information, it is important to consider the factors that facilitate understanding. These factors fall into three main

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categories relating to the presentation and organisation of the information and environmental factors. Chapter • Divide a page into two, top to 10 describes the environmental factors affecting bottom. On one side list the factors understanding. that assisted your understanding Before presenting information it is important to and on the other side list those that prepare the listener. Preparing the listener involves limited your understanding. asking permission to provide the information at that • Using the information in this list, time. It requires a clear statement of the purpose and create a list of ways to effectively organise and present information to significance of the information. This simple, respectful ensure understanding. preparation potentially relaxes the person and ensures that they listen to and focus upon understanding the information. It is important to establish if they know anything about the particular topic, event or procedure. Establishing their existing knowledge can be an appropriate point at which to begin presenting the information. This not only demonstrates respect and can develop trust, but also provides an opportunity to establish the accuracy of their previous knowledge. Discussion of their existing knowledge may also develop interest and enhance concentration. The presentation of information must be clear and consider the language needs (Staggers & Brann 2011, see Ch 14 and Section 4) and the physical, emotional and cognitive needs (see Ch 8) of the person (Householder & Wong 2011, Morse & Volkman 2010). It is important to ensure the person is feeling well enough to concentrate, because if unwell or tired they will understand and retain less. In such circumstances, making another time to provide the information will be beneficial for all and is more likely to achieve effective communication. To ensure effective communication it is important to avoid overlaying the information with opinion, bias or uncertainty (Mohan et al 2004, 2008). For example, I think you should …, It is obvious you must …, Have you thought about doing …?, Maybe the procedure will be tomorrow, and so on. While presenting information it is important to avoid distractions. Present and explain one point at a time. State each point clearly and succinctly using precise language, and avoid using words such as here, there, thing etc. A long, complicated and wordy presentation of each point is time-consuming and often results in the listener losing concentration (Devito 2009). When presenting each point health professionals should focus on that point until they are sure the Person/s understands. It is often helpful to provide examples to illustrate or explain each point because examples can facilitate comprehension. If instructing, it may be beneficial to demonstrate the task while explaining each point. Reporting the experiences of another Person/s receiving assistance from the specific service or health profession may also facilitate understanding, but maintaining confidentiality is imperative (see Ch 17). Repeating the important points can be appropriate and may enhance understanding. Take care, however, because repeating information may not be necessary and may negatively affect the reception of and response to the information. Seeking an indication of their understanding may be more beneficial than repetition, and the use of specific questions will confirm their actual understanding. Careful observation of the non-verbal responses of the Person/s may also indicate their interest and understanding. When completing the presentation of the information, it is important to provide an opportunity for the Person/s to express their perception of the information, explore issues relevant to them and ask questions (Friess 2011). If giving instructions, close observation of the Person/s performing the task will demonstrate their understanding and ensure safe performance of the task. 25

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Organising the information is equally important. Compiling the information into well-ordered points assists in achieving understanding. It may be appropriate to begin with the points that generally stimulate the most interest and then move to related but less motivating points (Holli et al 2008). Initially it is helpful to introduce the main point of the information and then to present the detail of each connected point. It is important to use language appropriate to the audience (Lawton 2011, Staggers & Brann 2011, see Ch 1). When each point has been explained it is important to finish with either a summary of the main point(s) or questions that establish understanding of each point. This repetition provides an opportunity to further process the information and to ask questions that clarify meaning. Organising the information includes consideration of the timing of providing particular information. Providing detailed information about something that is four weeks away has limited relevance and meaning. Providing information about something that is immediate, however, will be both meaningful and relevant. Providing information in both verbal and written forms allows processing, answering of relevant questions and thus understanding. Research indicates that providing written information enhances retention and application levels (Johnson & Stanford 2005). The written form of any information must consider the above factors.

• •

Choose a procedure or routine typically used in your health profession. Compile a clear and easy-to-understand written form about the procedure or routine with all the relevant information. • Verbally present this information to someone who knows nothing about the procedure or routine. Respond to any questions or comments until they demonstrate clear understanding. • If necessary, adjust your verbal or written information to make it easier to understand. • Present your written explanation to people from your health profession. Discuss ways of refining and improving it.

Chapter summary Introductions are crucial in establishing the quality and thus success of future interactions. Introducing oneself, the role of the particular health profession and the environment is reassuring and important for family/Person-centred practice and positive outcomes. Introductory information about a health profession may be in verbal or written form. It must consider the needs of the people hearing or reading the information. Effective introductions should demonstrate respect and empathy, establish trust and the reliability of the health professional; achieve mutual understanding and result in positive interventions. They are most effective when they prepare the Person/s listening, establish their current knowledge, consider their needs including emotional needs, and avoid the personal opinion and/or bias of the health professional. They must also be clear and succinct, avoiding uncertainty, as well as organised, ordered and ‘timed’ with allocation of time to establish the understanding of the listening Person/s. The manner of presenting, organising and sequencing the relevant information (whether informing, instructing or explaining) has equal significance for positive health outcomes.

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3 » The specific goals of communication for health professionals: 1

FIGURE 3.1â•… Quality introductions achieve better results.

REVIEW QUESTIONS 1. The ultimate goal of health professions is:

_______________________________________________________ 2. Introductions establish the quality of future interventions and include introducing: i. ii. iii. 3. Providing information about a health profession can take two main forms: i. ii. 4. Providing information requires mutual understanding and may inform, instruct or explain. The manner of providing information should result in: i. ii.

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5. When providing information there are important principles to follow, including consideration of at least seven points. List the points below. i. ii. iii. iv. v. vi. vii. 6. Achieving mutual understanding when providing information requires: i. ii.

REFERENCES Bevan J L, Jupin A M, Sparks L 2011 Information quality, uncertainty, and quality of care in long-distance caregiving. Communication Research Reports 28(2):190–195 Doi:10.1080/08824096.2011.566105 Davis C M 2011 Patient–practitioner interaction: an experiential manual for developing the art of healthcare, 5th edn. Slack, Thorofare, NJ Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Friess E 2011 Politeness, time constraints and collaboration in decision-making. Technical Communication Quarterly 20(2):114–138 Doi:10.1080/10572252.2011. 551507 Gilleylen S E 2007 How to make a proper Introduction. The Washington Informer Feb 10:22–28 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia 28

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Holmes G N, Harrington N G, Parrish A J 2010 Exploring the relationship between pediatrician self-disclosure and parent satisfaction. Communication Research Reports 27(4):365–369 Householder B J, Wong N C H 2011 Mood state or relational closeness: explaining the impacts of mood on the ability to detect deception in friends and strangers. Communication Quarterly 59(1):104–122 Doi:10.1080/01463373.2011.541363 Johnson A, Stanford J 2005 Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home: systematic review. Health Education Research: Theory and Practice 20:423–429 Lawton B 2011 What’s in a name? denotation, connotation, and ‘A boy named Sue’. Communication Teacher 25(3):136–138 Doi:10.1080/17404622.2011.579906 Mason R, Morley M 2009 Trust: can occupational therapists take it for granted? British Journal of Occupational Therapy 72(10):466–468 Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Morse C R, Volkman J E 2010 An examination into the dyadic effects of mood in social interactions. Communication Research Reports 27(4):330–342 Doi:10.1080 /08824096.2010.518914 Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Staggers S M, Brann M 2011 Making health information clear and readable for the masses. Communication Teacher 25(2):94–99 Doi:10.1080/17404622.2010. 528004 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Turner M M, Banaw J A, Rains S A et al 2010 The effects of altercasting and counterattitudinal behaviour on compliance: a lost letter technique investigation. Communication Reports 23(1):1–13 Doi:10.3421100359.1080/089

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ANSWERS TO REVIEW QUESTIONS CHAPTER 3â•… The specific goals of communication for health professionals: 1 Answers to the following questions provide a summary of this chapter. 1. The ultimate goal of health professions is: The ultimate goal of health professions is Family-person centred practice. 2. Introductions establish the quality of future interventions and include introducing: i. Oneself ii. The role of the particular health professional iii. The particular service environment, both personnel and physical 3. Providing information about a health profession can take two main forms: i. Verbal ii. Written 4. Providing information requires mutual understanding and may inform, instruct or explain. The manner of providing information should result in: i. The development of trust and a therapeutic relationship ii. Appropriate interventions and positive outcomes 5. When providing information there are important principles to follow, including consideration of at least seven points. List the points below. i. Prepare the listener or person ii. Establish the current knowledge of the listener or person iii. Consider the needs of the person, including their emotional needs iv. Avoid giving personal opinion or showing bias v. Be clear, succinct, exact, well organised, well-time and relevant vi. Should avoid placating comments and generalisations vii. Commitment and time to establish mutual understanding 6. Achieving mutual understanding when providing information requires: i. RESPECT and demonstration of empathy ii. Time and commitment O’Toole 2e. © 2012 Elsevier Australia

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CHAPTER 4â•…

The specific goals of communication for health professionals: 2 CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Identify the role of interviewing and questioning to gather information • Outline the appropriate manner of interviewing and questioning to gather information • List the different types of questions, their purpose and their effect • Use questions to gather information • Demonstrate understanding of the significance of comforting • Demonstrate understanding that every response can encourage or discourage • State the significance and characteristics of encouragement versus discouragement • State the basis of, role of and reasons for confronting.

4 » The specific goals of communication for health professionals: 2

The overall aim of providing family/Person-centred practice should guide every interaction (see Ch 2). The specific purpose of communication for health professionals is outlined in this book in two parts. The first part of the discussion (see Ch 3) describes introductions and providing information. The second part occurs in this chapter and examines the specific purposes of: • interviewing and questioning to gather information • comforting – encouraging versus discouraging • confronting unhelpful attitudes and beliefs.

Interviewing and questioning to gather information

Ask the person next to you: • their name • their health profession • where they were born • how they travelled today • if they have a tattoo. If so, where is it?

A health professional gathers various types of information from many sources throughout the working day. Studies have identified particular instruments for measuring skills in gathering information in the health professional (Derkx et al 2007, Srinivasan et al 2006, Zabar et al 2009). Such skills develop with practice and reflection, however there are particular • How easy was it to obtain the important considerations when gathering informainformation about the person next tion. These include considering the possible responses to you? and emotions of the Person/s providing the informa Were there any difficulties? If so, • tion (Morse & Volkman 2010), the effect of the enviwhat were they? What caused the ronment upon these responses (see Ch 10) and the difficulties? possibly sensitive nature of the required information How did the interviewee feel? • (Murray et al 2009). The most common method of gathering information through personal interaction is either a formal or informal interview (Mohan et al 2004, 2008). The interviewing process in the health professions usually begins (although not always) with a more formal setting – the initial interview. This type of interview seeks to gather both general and specific information about the Person/s and the factors affecting them. Whether the interview is an initial interview or not, it is reassuring for the Person/s (the interviewee) to know the purpose of the interview (Holli et al 2008). Therefore, taking the time to explain the reason for each interview is a way of demonstrating respect and care for the interviewee(s). Regardless of the particular health profession or the purpose of the interview, the major tool used in any interview is the question.

QUESTIONING: THE TOOL A question is a tool and, in common with most tools, questioning requires practice to develop skill in successfully using questions. The skill of asking questions that gather the maximum amount of desired information in the required time is valuable in all resourcestretched health professions. It is important to know the purpose of questioning, types of questions, what they typically gather and the effect that particular questions may elicit in the Person/s. This knowledge assists health professionals in deciding what question types to avoid or use when gathering information. 31

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Why use questions? In the health professions using questions does more than gather information. Questions serve several purposes that contribute to family/Person-centred practice. Initially, questions assist the health professional to develop trust and rapport (Mohan et al 2004, 2008, Tyler et al 2005). The right question at the right time encourages the Person/s to relax and develop confidence in the health professional, and may assist them to recognise the interest of the professional interviewing them (Devito 2009). Secondly, the right question can encourage either verbal or non-verbal communication (Milliken & Honeycutt 2004). Questions can facilitate exploration of and elaboration about particular areas and thus provide additional relevant information (Davis 2011). Questions also establish mutual understanding – they clarify whether the Person/s understands the health professional and whether the health professional understands the Person/s. Finally, regardless of the type of question, the ultimate goal of questioning is to gather information. It is this information that will create a clear understanding of the Person/s and thus allow the health professional to act appropriately to establish and fulfil relevant goals.

TYPES OF QUESTIONS AND THE INFORMATION THEY GATHER There are two main types of questions – closed and open questions.

Closed questions Closed questions elicit discreet information that is short and definite (Harms 2007, Harms & Pierce 2011, Mohan et al 2004, 2008, Tyler et al 2005). They are often recognised as questions that have a yes or no answer. For example, Is the pain sharp? Did you use the splint? Have you kept to your diet? Is your workstation comfortable? Are you taking your medication? In family/Person-centred practice, after an introduction, the first question should be a closed one that seeks the permission of the Person/s to ask some questions. For example, Is it all right if I ask you some questions? Such a question demonstrates respect, a desire to empathise (Davis 2011) and an indication that the Person/s may have control over the events directly relating to them. After asking this initial question it is best to use open questions until there is trust and adequate levels of rapport. When communicating with people who do not have English as their native language, it is important to remember that there are different ways of answering particular kinds of closed questions that can cause confusion. In English, the question It doesn’t hurt, does it? requires a yes if it hurts or a no if it does not hurt. In some languages such a question requires the opposite answer – yes indicates it does not hurt, while no indicates it does hurt. This difference in responses provides a warning for health professionals; it indicates that the use of particular types of closed questions with individuals from non-Englishspeaking backgrounds requires careful clarification and negotiation to establish mutual understanding. It may be tempting to use closed questions with such people because they require minimal spoken language, however in such circumstances it may be more productive to use simply worded questions. When communicating with people from a non-English-speaking background it may also be tempting to rely on movements of the head to indicate yes or no. This can also create confusion, as different cultures use shaking and nodding the head to mean different things. Thus it is important for health professionals, when attempting to establish mutual understanding, to be aware of the possible confusion potentially related to this type of non-verbal communication. 32

4 » The specific goals of communication for health professionals: 2

Some closed questions require specific and discreet information rather than yes or no (Mohan et al 2004, 2008). For example, Where is the pain most severe? For how long did you wear the splint? How many days did you keep to your diet? What about your workstation (e.g. desk, chair, computer) causes the most discomfort or pain? What time do you usually take your medication? Another form of closed questioning that requires • Think of an issue specific to your discreet or specific information is the multiple-choice health profession and create a question. Multiple-choice questions can be useful if multiple-choice question about this people are unable to provide specific answers. Instead, issue. (If relevant you may use the questions above re pain, splinting, the health professional uses their knowledge of the diet, workstation or medication; if specific situation to provide possible answers. These not, devise a relevant and answers can assist the Person/s to clarify their appropriate question.) thoughts and thus provide an appropriate answer Use the question with a friend to test • (Stein-Parbury 2009). Would you describe the pain as its clarity and effect. Explain any burning, sharp, dull, gripping, pressing, in a particular place or terms specific to your profession if moving? is one example of a multiple-choice question. necessary. However avoid including too many options! In all closed questions there is only one answer, which is short, definite and clear. The question does not require elaboration or descriptive detail. Closed questions can be useful when the health professional requires particular types of information. They are sometimes the most appropriate questions to ask in particular situations, for example, in Emergency or if a Person is in extreme pain or is short of breath. Such questions demand little of the Person; they can save time and provide the exact answer without the complications of too much thought or too many words.

Open questions Open questions are the other main type of question. There is no wrong or right answer to an open question. These questions give the Person/s answering control over the interview and allow the health professional to listen, observe and learn (Harms 2007, Harms & Pierce 2011, Tyler et al 2005). Open questions are useful when the required information is not discreet and may need thoughtful use of memory, elaboration, opinion, detail and sometimes sharing of experiences and feelings. Open questions Change the following closed (some are can be less threatening because they allow the leading) questions into open ones. Person/s answering to control the information they • Do you feel angry? give and, therefore, are best used at the beginning of • How many children do you have? • Did you keep to your diet this week? an interaction. Open questions are useful when there • Did you follow your exercise regimen is a need to explore or elaborate on a particular carefully? subject (Devito 2009). They are also useful when Is your workstation comfortable? • changing the subject or when gathering information Does taking your medication make • from a sensitive or defensive Person/s. Open quesyou feel ill? tions may begin with How …? and What …?, but can also begin with phrases such as Tell me about …. QUESTIONS THAT PROBE

Questions that probe usually seek more information about a particular topic (SteinParbury 2009). They should encourage the Person/s to provide more detail about the already provided information (Tyler et al 2005). The subject of a probing question usually 33

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arises from information provided during the interaction and begins with phrases such as Can you tell me more about …? What happened before …? What were you thinking when … happened? How did you feel about …? The answers to probing questions provide specific detail about situations, people, events, thoughts and feelings. They can provide deeper insight into the Person/s, their supports and needs and, often, their feelings. Probing questions can also change the focus or return the focus to an earlier point in the conversation (Stein-Parbury 2009). A probing question is useful if the health professional requires information about something different to the current focus, or if the health professional remembers something more they need to know about a previous point. Overuse of probing questions may create a negative response in the Person/s, as probing questions can produce the feeling of interrogation (Harms 2007, Harms & Pierce 2011). It is important to be aware of the responses of the Person/s (see Ch 8) and react in a manner that fulfils both the general and specific goals of communication in the health professions. QUESTIONS THAT CLARIFY

Questions that clarify usually seek understanding rather than information (Stein-Parbury 2009). If the Person/s gives information that is unclear or may be interpreted several ways, the health professional can ask for clarification or an explanation (Devito 2009, Mohan et al 2004, 2008), for example, What did you mean when you said …? Can you explain what happened …? Do you mean …? Either the Person/s or the health professional can use questions that clarify particular points. Such questions are important in order to achieve mutual understanding and avoid misunderstandings (Purtilo & Haddad 2007). Any lack of understanding or incomplete meaning may result in assumptions that limit the possible outcomes of the interventions. Overuse of questions that clarify meaning may have a negative effect on the interaction. They may suggest the health professional is not able to understand or make themself understood to the Person/s. It is important in such situations to listen effectively and to demonstrate respect and empathy rather than frustration while attempting to establish mutual understanding. QUESTIONS THAT ‘LEAD’

Leading questions direct the response of the listener. They are not person-centred, do not give the Person/s control and usually do not provide honest responses. A vulnerable person will answer a leading question according to the cues in the question that indicate the desired answer. For example, It’s a beautiful day, isn’t it? leads the listener to agree and say Yes, beautiful; or Oh it’s a bit hot, isn’t it? leads the listener to agree that it is hot, regardless of their actual feelings. Leading questions such as these do not necessarily have a negative effect (Purtilo & Haddad 2007). If the subject of a leading question is external to the Person/s, their actions and needs, then the effect can be positive, creating a link between the health professional and the Person/s. Such questions do not ask for important information and thus are not threatening; they are a verbal recognition of the presence of the Person/s. Leading questions are not always positive, however. A health professional who uses leading questions will limit the development of trust and the accuracy of the gathered information. For example, questions such as You weren’t drinking while you were on this medication, were you? You’re all right, aren’t you? That didn’t hurt so much, did it? We covered how to care for your back and I know you understand the importance of caring for your back, so I know you didn’t try to move furniture, did you? usually direct the Person to the required answer of No, I was not drinking; Yes, I’m all 34

4 » The specific goals of communication for health professionals: 2

right; No, that was OK; and No, I did not move furniture regardless of the truth. It is best to avoid leading questions (Mohan et al 2004, 2008) if the health professional seeks to encourage an honest relationship based on trust, respect and non-judgement, as well as relevant and appropriate outcomes. The skill of questioning depends upon another beneficial skill – listening (see Ch 9). However, a successful interview involves more than skill in questioning and listening. It also involves appropriate timing of questions, the use of appropriate nonverbal messages (see Ch 12), the use of silences and, most importantly, a focus on the vulnerable Person/s (see Chs 8 & 9).

Comforting: encouraging versus discouraging

Think back to the earlier activity: ‘Ask the person next to you’. • What did you want to know more about? List questions that would gather this information. • Was there anything that was not necessarily clear? List the questions that would clarify your understanding. • Can you think of a leading question you might ask? • Now, if possible, ask the same person a question that probes for more information, one that clarifies your understanding, and then maybe even a leading question. (If the same person is not available, repeat the process with a different person.) • Discuss what feeling each question created in the interviewee. Note the different feelings experienced, if any, and relate them to the different types of questions.

Comforting can be a valuable means of developing a therapeutic relationship. The vulnerable and sometimes disconnected Person/s often share their anxieties and negative emotions with health professionals. The health professional has knowledge of their particular health service and understands exactly what that service offers, while the Person/s does not have that knowledge or understanding. The health professional also possesses knowledge about conditions and the consequences of those conditions, which may be unknown to the Person/s (Higgs et al 2005, 2010). This knowledge may make it difficult for the health • Consider a time when you were professional to understand the concerns, anxieties feeling anxious or negative about and negative emotions of vulnerable individuals. something – perhaps an examination However, it is this knowledge that dictates careful and or a job interview, or feedback from an assignment. respectful management of all interactions between the health professional and the Person/s (Egan 2010). • Did you share your feelings with anyone? How did they respond? The health professional is responsible for ensuring How did you feel after they that People are comforted in a manner that encourresponded? Was it the way they ages, affirms and empowers them to continue with responded that created your meaning, purpose and quality in their life (Sullivan feelings? et al 2009). Remember that such People may also include a colleague new to the service or a student. The way in which a health professional responds to expressions of anxiety or negative emotions either encourages, affirms and empowers or discourages, trivialises and dismisses that Person/s and their anxieties or emotions (Devito 2009).

CHARACTERISTICS OF ENCOURAGEMENT AND DISCOURAGEMENT Table 4.1 outlines the characteristics of encouraging and discouraging responses to expressions of negative emotions. 35

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

TABLE 4.1â•… Characteristics of possible responses to expressions of negative emotions Encouraging responses

Discouraging responses

Focus attention on the Person/s and acknowledge their emotions Indicate that in this situation such emotions are common Indicate (without a detailed description) that the health professional has some understanding because of a similar experience Ask for clarification of the emotions and the cause

State that there is no need to feel the emotions Acknowledge the emotions but change the subject Interrupt, to avoid hearing the expression of such emotions Totally ignore the expressions of emotions

Classifying responses to negative emotions Consider each response to the following expressions of anxiety and decide whether it is encouraging or discouraging. 1. Person: I am really worried about this surgery. Health professional (HP): You don’t need to worry. Dr Super is a great surgeon and the procedure is routine. 2. Person: I don’t know how I will cope at home. HP: Don’t worry, you’ll be OK. There’s lots of help available. 3. Person: I don’t like hospitals – my Dad died in one. HP: No wonder you don’t like hospitals! That must have been difficult. Can you tell me about it? 4. Person: Boy, we are busy today. Two new people have just arrived. I don’t think I will get everything done. HP: The quicker you get over that feeling the better. It is always the same here – busy, busy! 5. Person: I am just not coping here – I can’t do this. HP: You’re feeling overwhelmed. Mmm (watching as the person struggles to complete a task and then gives up) … that can be difficult. What are you struggling with most? 6. Person: I am angry. I need that report for the appointment tomorrow and it’s not ready. HP: I understand your anger. I am not too impressed either – it was supposed to be ready today. What time is the appointment? Maybe it can be delivered there tomorrow before the appointment. How would you typically respond to each of these statements? Change the discouraging, trivialising and dismissive responses to encouraging, affirming and empowering responses.

It is obvious from the examples above that the easiest and shortest way to respond to negative emotions has a discouraging effect. It may seem appropriate to the health professional because they have both relevant knowledge and previous experience, but such responses do not meet the needs of the anxious or negative individual. Health professionals are often busy and thus it is easy to respond in a manner that requires minimal time or effort. When communicating with anxious or negative Person/s, however, it is important to respond in a manner that indicates interest, respect and empathy. Such a response is an investment that ultimately saves time. Responding in this manner is not always easy as the health professional has knowledge and understanding that overrides the negative

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emotions. It is important, however, to respond in a non-judgemental way that indicates the value and equal status of the vulnerable Person/s. People often feel vulnerable when in an unknown area of expertise. Responses that demonstrate a superiority of knowledge without sharing that knowledge will only discourage and may appear dismissive. A dismissive response does not acknowledge the emotions – whether logical or illogical – of any Person/s. Producing encouraging, affirming and empowering responses is sometimes difficult, but it is essential to maintain family/Person-centred practice.

Practising encouraging responses Role-play each scenario in pairs, taking turns to be the health professional (who responds encouragingly) and the Person. Compare the responses and note the different effects of the responses. List encouraging, affirming and empowering responses. Person 1: You are worried about your family because you are the person who always prepares their meals and now you have a broken shoulder. Person 2: You are angry and frustrated because you have not improved in the way the doctor said you would after the surgery on your back. The doctor has not answered your questions nor given any explanation for your lack of improvement. Person 3: Your child is in the final stages of leukaemia. You are emotionally exhausted and worried about being able to remain emotionally calm and supportive to your spouse and family as you watch him die. Person 4: You have had your leg amputated because of a car accident. You cannot see how you can go back to work – you are a roof tiler. You are worried about your finances. Person 5: You are a national sports star and you have recently had a relatively minor knee injury. You are worried that your coach will replace you while you are recovering. Person 6: You are tired, frustrated and desperate because your 79-year-old husband fell more than 20 hours ago – he is in extreme pain, has been left to lie on a trolley for all that time and no-one seems interested in examining him.

In the busy life of a health professional it is important that all words are comforting and that they encourage and empower those seeking assistance.

Confronting unhelpful attitudes or beliefs Sensitive confrontation requires respect and trust, and can improve service outcomes. Many individuals who seek the assistance of health professionals express attitudes and beliefs that restrict their communication, recovery and participation. The health professional can challenge the Person/s to examine these attitudes and beliefs by appropriately and sensitively confronting them (Heron 2003). In some cases, confronting involves sensitively disagreeing with the Person/s (Milliken & Honeycutt 2004). If expressed sensitively and with empathy, confrontation or challenge can facilitate new perspectives, thoughts and behaviours in many individuals (Egan 2010, Ellis et al 2004, Stein-Parbury 2009, Salvador 2010), thereby improving the effectiveness of communication. 37

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Confrontation provides an opportunity to highlight the discrepancies or inconsistencies apparent in the life or environment of the individual (Holli et al 2008). It can empower individuals to face those discrepancies, patterns of thought and actions that require change and adjust them to facilitate improved communication, recovery and increased participation (Brill & Levine 2005). Only experienced health professionals should attempt to confront attitudes or beliefs. If an inexperienced health professional is concerned about the attitudes and beliefs of a particular Person/s, it is advisable to develop a therapeutic relationship with that Person/s and discuss any responses with a health professional experienced in confronting or challenging. Egan (2010) states that the health professional must ‘earn the right to challenge’. This statement indicates the significance of the therapeutic relationship when confronting. Any confrontation or challenge must arise from a developed therapeutic relationship that demonstrates respect and rapport (Polcin 2007). If there is genuine mutual understanding and freedom from judgement, confrontation may increase the likelihood of positive communication and outcomes. Brill & Levine (2005) and Egan (2010) agree that any confrontation or challenge must be specific and relate to a particular behaviour, attitude or belief. General confrontation that judges and intimidates the Person/s will damage rather than empower. Statements such as You are your own worst enemy – you depress yourself will only discourage. However, asking a question relating to a particular belief (e.g. Do you think it is true that your life is terrible? Can you think of anything that was good yesterday?) might confront the individual with the belief that is limiting their functioning and perhaps encourage them to think differently about their life. It is important to avoid underestimating the power of confrontation to promote radical change in thought patterns A young person has failed an (Sluzki 2010). A positive change in thought patterns assessment task, receiving a third of will increase interest, communication, participation the possible marks. Very distressed and and recovery. near to tears they express belief that When confronting, it is important that the health they just cannot do the course – that professional uses non-verbal messages that reinforce they are ‘dumb’ and cannot learn rather than contradict the verbal message. If the voice, anyway. face or hands of the speaker contradict the spoken The lecturer has noticed that the words, this inconsistency will produce confusion and general attitude and manner of the negative emotions in the listener (Tyler et al 2005) student suits the health professions and render the confrontation useless. and, while the lecturer feels there was Confrontation should not judge or criticise, blame limited application to the assessment or threaten. It should not provide the opportunity for task, makes a choice about how to the health professional to express anger or frustration respond. (Brill & Levine 2005). Nor should confrontation or challenge ever be direct and assertive, because strength of expression may become a barrier that • What is your response? • Will you judge? Write down how disempowers the Person/s (Egan 2010). Instead, tenand why. tative and sensitive expression will allow the Person/s • Will you encourage? Write down how to confront the attitude or belief and thus potentially and why. facilitate the required changes in thought and actions. • Will you confront and challenge? Confrontation is about respect and understanding Write down how and why. that encourage and strengthen the vulnerable Person/s to embrace changes in thoughts and behaviours.

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In groups of four, assign two people to observe and scribe, and two to play the following roles. Continue acting the role-play until there is some kind of closure. Person 1: You are the lecturer. Respond to the distressed student. Choose how you will respond before the role-play begins. Person 2: You are the distressed student. Talk to the lecturer. You feel that the mark for your assignment simply reinforces that you cannot be successful in this health professional course. You did very well during professional placement but you cannot do the academic work. • Discuss the effect of the interaction – the reactions and resultant feelings. How did the lecturer respond? Did the response encourage the student to change their beliefs about themself? Did the non-verbal behaviours support the words? • Repeat the role-play and the discussion with different people in the different roles.

It is challenging for health professionals to confront the attitudes or beliefs of another Person/s but, if performed appropriately, confrontation produces positive outcomes. The willingness of health professionals to challenge themselves, thereby increasing selfawareness, enhances the ability to confront (Egan 2010). If health professionals are comfortable with confronting and challenging their own attitudes and beliefs, they will be more able to understand the needs of the Person/s they seek to confront. Confrontation in the health professions is not something that necessarily occurs every day. When used appropriately, however, confrontation enhances and produces effective communication, participation and recovery.

Chapter summary Health professionals commonly gather information with an interview. Questions are a typical feature of interviews. Appropriate questions potentially assist the development of trust and rapport, and establish mutual understanding. A Person/s typically feels vulnerable. Therefore the health professional must consider the emotions of the Person/s and their possible responses. They must also consider the effect of the envi� ronment upon those responses, especially if they include sensitive information. It is important to explain the purpose of the interaction and to use the relevant type of questions, closed or open, for the situation. The health professional is also responsible for responding to negative emotions by comforting the Person/s in a manner that encourages and empowers them. Confronting behaviours, attitudes and beliefs that restrict the participation of the Person/s can facilitate improved participation and recovery. However it requires experience, effective listening, non-judgemental and appropriate non-verbal responses, along with tentative expression of those responses. In addition, in order to effectively use confrontation a health professional must confront their own attitudes and beliefs. Regardless of responses, interviewing and questioning to gather information in the health professions aims to produce relevant family/Person-centred interventions and positive outcomes.

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FIGURE 4.1â•… There is always a right time and place!

REVIEW QUESTIONS 1. When gathering information, the health professional must consider three major factors: i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 2. Health professionals gather information by interviewing. When interviewing it is important to: i. _______________________________________________________________ ii. _______________________________________________________________ 3. Questions can achieve much, but five main achievements are noted in this chapter: i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ iv. _______________________________________________________________ v. _______________________________________________________________

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4 » The specific goals of communication for health professionals: 2

4. There are two main types of questions. • List five features of closed questions. i. _________________________________________________________ ii. _________________________________________________________ iii. _________________________________________________________ iv. _________________________________________________________ v. _________________________________________________________ • List five features of open questions. i. _________________________________________________________ ii. _________________________________________________________ iii. _________________________________________________________ iv. _________________________________________________________ v. _________________________________________________________ 5. Vulnerable people do not usually have the required k_______________ or u_______________ to feel comfortable. 6. Responding to expressions of emotion can e_____________ or d_______________. 7. Encouraging and discouraging responses have particular characteristics. List three characteristics of encouraging responses: i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 8. The health professional should respond with _____________________________________________________________________________ 9. Confrontation challenges attitudes and beliefs and has positive results. It requires: i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ iv. _______________________________________________________________

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10. What must a health professional confront in themself in order to confront a Person/s effectively? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

REFERENCES Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Davis C M 2011 Patient–practitioner interaction: an experiential manual for developing the art of healthcare, 5th edn. Slack, Thorofare NJ Derkx H P, Rethans J E, Knottnerus J A et al 2007 Assessing communication skills of clinical call handlers working at an out-of-hours centre: development of the RICE rating scale. British Journal of General Practice 57(538):383–387 Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Ellis R B, Gates B, Kenworthy N 2004 Interpersonal communication in nursing, 2nd edn. Churchill Livingstone, London Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Heron J 2003 Helping the client: a creative practical guide, 5th edn. Sage, London Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Morse C R, Volkman J E 2010 An examination into the dyadic effects of mood in social interactions. Communication Research Reports 27(4):330–342 Doi:10.1080/ 08824096.2010.518914 Murray S A, Kendall M, Carduff E et al 2009 Use of serial qualitative interviews to understand patients’ evolving experiences and needs. British Medical Journal, 338:b3702 Doi:10.1136/bmj.b3702 Polcin D L 2007 Confrontation as a form of social support and feedback. Drugs & Alcohol Today 7(1):11–15 42

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Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Salvador B M 2010 Accompany death (in Spanish). Revista Rol de Enfermeria 33(11):22–26 Sluzki C E 2010 The pathway between conflict and reconciliation: coexistence as an evolutionary process. Transcultural Psychiatry 47(1):55–69 Srinivasan M, Franks P, Meredith L S et al 2006 Connoisseurs of care? Unannounced standardized patients’ ratings of physicians. Medical Care 44(12):1092–1098 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Sullivan C, Ellison S R, Quaintance J et al 2009 Development of a communication curriculum for emergency medicine residents. Teaching and Learning in Medicine 21(4):327–333 Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney Zabar S, Ark T, Gillespie C et al 2009 Can unannounced standardized patients assess professionalism and communication skills in the emergency department? Academic Emergency Medicine 16(9):915–918

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ANSWERS TO REVIEW QUESTIONS CHAPTER 4â•… The specific goals of communication for health professionals: 2 Answers to the following questions provide a summary of this chapter. 1. When gathering information, the health professional must consider three major factors: i. Possible responses of the person providing the information ii. Affects of the environment on any responses iii. The possibly sensitive nature of the required information. 2. Health professionals gather information by interviewing. When interviewing it is important to: i. To explain the reason for the interview ii. Chose the appropriate type of question for the situation. 3. Questions can achieve much, but five main achievements are noted in this chapter: i. They produce a clear understanding of the person ii. Questions can develop trust and rapport iii. Establish a therapeutic relationship iv. They allow those interacting to achieve mutual understanding v. They encourage collaboration to create appropriate goals and interventions. 4. There are two main types of questions. • List five features of closed questions. i. They produce short, clear and exact answers ii. The health professional maybe the focus of the interaction iii. They can create confusion with non-English speaking cultures iv. They save time, but there is only one correct answer v. They do not require much thought energy or memory to answer. • List five features of open questions. i. There is no wrong or right answer to an open question ii. The person has control; they decide what they will say or not say O’Toole 2e. © 2012 Elsevier Australia

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iii. Open questions are less threatening iv. They encourage elaboration, use of memory, opinion, experience v. They allow the health professional to look, listen and learn. 5. Vulnerable people do not usually have the required knowledge or understanding to feel comfortable. 6. Responding to expressions of emotion can encourage or discourage. 7. Encouraging and discouraging responses have particular characteristics. List three characteristics of encouraging responses. i. They acknowledge the emotions of the person ii. The acknowledge that such emotions and responses are ‘OK’ and that others would respond the same way iii. They place the focus on the person and their needs. 8. The health professional should respond with empathy and understanding. 9. Confrontation challenges attitudes and beliefs and has positive results. It requires: i. Experience ii. Effective listening iii. Non-judgemental responses iv. Tentative expression and non-verbal responses. 10. What must a health professional confront in themself in order to confront effectively? Their own attitudes and beliefs.

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Developing Awareness to Achieve Effective Communication in the Health Professions

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CHAPTER 5â•…

Awareness of and need for reflective practice CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Recognise the importance of reflection for effective communication • Demonstrate understanding of the importance of reflection for the health professions • State the difference between reflective and reflexive practice • Demonstrate understanding of the significance of the changes in thoughts and actions that result from reflection • List their own barriers (defences) to experiencing and resolving negative emotions • Reflect upon their use of humour and how to use it effectively while communicating • Reflect about their own functioning and thus their abilities when communicating.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Effective communication requires an understanding of how an individual affects those around them and how those people affect the individual (Higgs et╯al 2005, 2010). It requires awareness of the ‘self’ and the effects of personality and communication styles upon interactions. Effective communication requires an understanding of how elements of the self, the ‘Person’ and the environment affect the results of interactions. Reflection promotes understanding of these elements (Chapman et╯al 2008, Jack & Smith 2007, Zimmerman et╯al 2007). Reflection is the circular process that uses experience, knowledge and theory to guide and inform thoughts, action and practice (Hitchiner 2010, Thompson 2002). Reflection ultimately facilitates the transformation of the individual and thus transforms the thoughts and actions of that individual to achieve positive results during practice (Brown & Ryan 2003, Reid 2009). Reflection achieves the necessary awareness of those factors contributing to the self-maintenance essential for health professionals (Mann 2008). It also contributes to continuing professional development (Collins 2007), producing development of skills and effectiveness when communicating within practice. Reflection demonstrating continuing professional development is also a requirement for registration in many health professionals. These reasons make reflective practice important for health professionals.

The ‘what’ of reflection: a definition Reflection provides connection with, awareness of and clarity about unconscious emotional processing (Pritchard 2005, 2008). Please note that reflection in this context is not synonymous with meditation. Reflection occurs when individuals examine their attitudes and reactions to an interactive experience. It reveals causes of negative emotional responses, which facilitate understanding of these reactions. It allows resolution of these causes and, ultimately, changes in thought and thus behaviour in preparation for more positive responses in similar future interactions. The process of reflection usually makes some parts of an interaction clearer and may allow the fading or removal of other parts (see Figure 5.1).

FIGURE 5.1â•… Some things become clearer when reflecting and others fade.

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Boud & Walker (1991) suggest that reflection is the basis of knowledge. Reflection for the health professional is certainly the basis of self-knowledge. Payne (2006, 2011) describes reflection as being the bridge between theory and practice. Reflection can certainly form the theoretical basis of effective communication, because effective communication is difficult without reflection. Some view reflection as the process of revisiting experiences in order to understand them and promote different responses in future interactions (Thomas 2011). When reflection results in changes in behaviour over time to manage similar situations with greater satisfaction, this is known as reflective practice (Boud et╯al 1985, Gustafson & Fagerberg 2004, O’Connell & Dyment 2011, Stein-Parbury 2009). Others see reflection as a consideration of the way in which the self affects and is affected by particular events; this is known as reflexivity (Finlay & Gough 2003). Perhaps the best health professionals are both reflective and reflexive. Reflection for a health professional consists of thoughtful and often critical consideration of events and reactions occurring during previous interactions or times of decision making (Harms 2007, Harms & Pierce 2011). Such reflection promotes understanding of the thoughts, attitudes and associated reactions that occurred during those interactions or while making those decisions. It facilitates clearer understanding of the causes of the negative reactions that can occur during interactions. Reflection highlights areas needing conscious attention and further exploration, and can result in acceptance and resolution of the causes of negative reactions. Resolution facilitates behavioural change and thus positive outcomes during future interactions. It is important to recognise that reflection here is not about ‘reflecting back’ the perceptions of the feelings of the Person/s. For health professionals, reflection is about careful, deliberate and critical consideration of events that occur during communicative interactions. It does not provide a formula for thoughts or behaviours, or a ‘one-answer-fits-all’ solution, but it does provide insight and understanding upon which to base behaviour during future interactions (Thompson 2002).

The result of reflection: achieving self-awareness

•

How have the comments of others

about your abilities affected your Reflection is the primary method of achieving selfperformance in particular activities? awareness (see Ch 6). It reveals the reality of the unique Consider the positive or negative nature of each individual and promotes understanding comments of a parent, teacher, of self and others (Miller 2003). It has the potential to friend, acquaintance or fellow create a new awareness and provide direction for conworker. structive use of that awareness to establish the truth When someone does or does not • about the self and related events (Plack 2006). This believe in your abilities despite the truth allows the individual to institute different methods reality of the situation, do their of relating, reacting and being (Backus & Chapian comments enhance or erode your 2000). Thus reflection promotes change in future motivation and performance? responses during all interactions. • How important are the opinions of Reflection is a process through which the individual others to you? considers and learns from positive and negative experiences. The individual considers the meaning of their experiences and why the experiences have that particular meaning (Andrews 2000, Roberts 2002). This consideration facilitates understanding of the inadequacy, fear or vulnerability of the inner-self that manipulates and directs

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thoughts and responses during interactive events (Ben-Arye et╯al 2007). These inadequacies and fears often cause negative and regrettable events during interactions. Reflection is the process that facilitates understanding of the action required to overcome the inadequacies, fears or vulnerabilities that manipulate the reactions of individuals when communicating. Particular individuals react differently to reflecting, and factors such as personality, age and gender affect interest in and commitment to reflection. Because reflection promotes informed and controlled thought and thus constructive action, practising reflection has potential benefit for all health professionals regardless of personality, age or gender.

• • • • 1.

2.

Do you usually ‘reflect’ about interactive events? Do you replay positive interactions or simply savour the emotions associated with those interactions? Do you repeatedly replay unpleasant and uncomfortable interactions? Remember particular interactions you have had in which there were negative feelings. In situations where you cause the reason for bad feelings, what do you usually do after the interaction? Do you regret your actions? Do you replay the interaction while thinking of different ways to react next time? Do you feel guilty? Do you think the other person deserved the bad feelings? Do you try to think of how you can redeem the situation and/or relationship? Do you feel OK about admitting you were inappropriate and apologising? Do you simply forget it and move on? Can you describe your typical reaction if it is none of the above? Does your reaction depend on the closeness of the relationship? Why do you think this is so? Should the closeness of a relationship be relevant when practising as a health professional?  Consider each reaction listed above.  Which are unproductive? How can you avoid these reactions?  Which are productive and an investment for future interactions? How can you ensure such productive reactions in the future? In situations where another person provides the reason for discomfort, how do you usually react after the interaction? Do you feel hurt and continue ‘licking your wounds’ for some time? Do you think about it often and avoid seeing the other person if you can do so? Do you minimise interacting with them if you have to see them? Do you find it difficult to understand how anyone could treat you that way? Do you feel angry and resentful towards the person? Do you try to understand their behaviour and thus forgive them? Do you talk about their behaviour to other friends to try to discourage others from relating to that person? Do you reflect upon why you feel hurt, explore the reasons and resolve them? Do you place ‘walls’ around your emotions so you never again feel hurt in an interaction? Do you think the reaction of the other person tells you more about them than it does about you, and therefore understand that you do not need to feel hurt (i.e. do you have control of your emotional ‘button’)? Do you think life is too short and move on?  Consider each reaction listed above.  Which are unproductive? How can you avoid these reactions?  Which are productive and an investment for future interactions? How can you ensure such productive reactions in the future?

The ‘why’ of reflection: reasons for reflecting Reflection is an important means of learning about attitudes, experiences and self (Mohan et╯al 2004, 2008, O’Toole 2007, Plack 2006). It provides information that promotes 50

5 » Awareness of and need for reflective practice

improved performance when communicating with others, allowing health professionals to repeat actions • List at least five things you know you and reactions that achieve positive results and to change perform well. them when they have a negative effect (McKenna et╯al • List five things in which you would 2011). Reflection provides health professionals with like to improve your performance. awareness about their individual abilities (Jack & Smith • Ask someone who knows you well 2007, Kinsella 2001) and also highlights limitations in to make a similar list. their abilities and skills. Thus, through reflection health • Ask this person Do you know how I will react to your list? Was their professionals can focus on improving those skills that expectation of your reaction correct? will increase their emotional control and therefore • Compare both lists. Are they similar? facilitate effective communication and family/PersonConsider the list of the person who centred practice. knows you well and explore why Reflection allows health professionals to understand you might agree or disagree with the ‘chaos’ sometimes evident during interactions their list. (Purtilo & Haddad 2007, Stein-Parbury 2009). It indicates that individuals are responsible for their own reactions and emotions, whether the individual is the health professional or the Person/s. Reflection reveals that no-one can actually make another person feel particular emotions or make them react in a particular way. It indicates that feelings and emotional responses come from within the individual and usually originate from previous life experiences. Reflection releases the health professional to understand that they are not the cause of emotional responses in others, and that the other person is not the cause of the emotional responses of the health professional. It provides the understanding that individuals behave and respond in particular ways because of underlying, usually internal causes. This realisation encourages the tolerance and understanding that promotes unconditional positive regard of individuals regardless of the situation (Purtilo & Haddad 2007, Rogers 1967).

• • • • • •

•

When you have a negative emotional response to an interactive event, what is your usual reaction? Do you say or think They/It made me feel really bad? Is this your typical response? If so, have you ever explored the reasons why you respond in this manner in particular circumstances? Have you ever thought that negative emotions are your responsibility? Have you ever thought I make a choice about how I will feel during an interaction? Have you ever wondered about the other person and what caused them to relate in that particular way? Can you see the benefit of considering the above perspectives? That is, that:  your attitudes and reactions are your responsibility and you may need to explore your reactions and resolve the causes  a negative interaction reveals more about the other person than it does about you and thus their reactions are not your responsibility. Reflect on the benefits of understanding that you are responsible for your own reactions to situations – that you cannot make anyone feel a particular emotion and nor can others make you feel emotions. You alone control your responses; you alone can choose how you will feel and react.

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• •

What do you feel gives you value? What do you feel gives other people value? • From the perspective of a health professional, consider the benefits and limitations of believing that individual value comes from achievements or external factors (e.g. social status, colour, race, sporting skill or musical skill).

•

• • • •

•

How comfortable are you with considering your emotional responses? Do you find it easy or do you prefer to avoid experiencing emotions? Do you think that feeling emotions is a sign of weakness? If so, why? Do you think your emotional responses are never important? If so, why are the feelings of others more important than your feelings? Do you find that your emotions dominate your actions? If so, why is this? Do you think you really do not have emotional responses? If so, it is important to remember that everyone feels; why do you stop yourself from feeling your emotions? Are the thoughts isolated through answering these questions true? For example, is it true that the feelings of others are more important than your feelings? Where do these thoughts originate?

Reflection offers the individual an understanding of their primary need (see Ch 6), allowing them the opportunity to fulfil that need outside of their work environment. If health professionals seek fulfilment of their driving need within their professional life, not only will they experience disappointment they will also fail to provide family/Person-centred practice. All individuals are responsible for their emotional responses and for how they fulfil their driving need. Reflection provides understanding that the value of an individual does not come from what people think of them; the role they have in society; the car they drive or the clothes they wear. Individual value comes from within through understanding and respecting the self. Reflection provides understanding that not only increases self-control, but also promotes self-honesty, self-awareness, self-acceptance and ultimately selfrespect. If health professionals are able to practise these they will be more able to demonstrate awareness, honesty, acceptance and respect towards the vulnerable individuals seeking assistance (Purtilo & Haddad 2007). Demonstration of self-awareness promotes the overall goal of every health profession – successful family/ Person-centred interventions and outcomes. Rudduck & Turner (2007) indicate that reflection is important when learning about previously unknown cultural contexts. It provides an understanding about the culture of the health professional compared with the previously unknown culture. This understanding can facilitate appropriate behaviour and positive communicative interactions to ensure effective communication with people from other cultures (see Ch 14). Health professionals who reflect are able to identify the reasons for their negative reactions during interactions and, as a result, potentially resolve the causes of these reactions. They are potentially able to improve their skills in managing emotional responses (of themselves and others) that control and negatively influence their communication. Such health professionals are able to use their skills of reflecting to observe and recognise emotions in those around them and thus validate and clarify these emotions and their possible causes.

The ‘how’ of reflection: models of reflection So how does one reflect? It is not difficult to consider some past interactions – the more pleasant ones usually do not pose questions, just happiness and pleasure. However, the uncomfortable ones often leave an individual wondering how and why. To remove any 52

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guilt associated with such interactions, an individual will often wish to re-experience the events for an opportunity to react differently. Alternatively, individuals may feel hurt and resentful because of the actions or words of another during an uncomfortable interaction. The purpose of reflection is to provide information that empowers the health professional to react appropriately and thus (i) avoid regret and guilt; or (ii) understand, accept and forgive rather than feeling hurt and resentful as a result. A model of reflection is a helpful tool when attempting to answer the question of how to reflect. A model guides an individual through a process. It explains the way to complete a process. Some may think that the process of reflection does not require directions or a plan because it simply requires the individual to ask and answer questions (Mohan et╯al 2004, 2008). While this may be true, some people find it difficult to establish which questions to ask and to determine the exact focus of those questions. Sometimes thoughts lack clarity when uncomfortable emotions are experienced, and thus a model can bring clarity and resolution to those emotions by providing a focus for possible questions. Such focus facilitates appropriate and adequate answers for any communicative interaction, but is particularly useful when considering uncomfortable interactions. The information in the following paragraphs is adapted from an article by Boud & Walker (1990). Reflection upon an interaction requires describing the interaction by returning to it through thought, verbal expression, written expression or some combination of all three (Ellis et╯al 2004). Consideration should be given to the individuals involved in the interaction and all the known information about each person (e.g. knowledge of and • List the factors and skills relating past experience in relating to these individuals). Examto the ‘Person’ that require ining the process leading to the outcome of previous consideration when reflecting about interactions can guide the health professional to underinteracting (e.g. age, knowledge, stand this outcome. This understanding, together with experience, emotional state). First other information (e.g. whether they appear happy, consider the health professional, tired, hurried, preoccupied), is something most people then the Person/s and then a relate to and absorb unconsciously when beginning colleague. Refer to other chapters an interaction. The appearance of the person, their in this book when compiling non-verbal behaviour or perhaps an environmental the list. factor (e.g. the threat of rain can cause preoccupation) • What other factors might be included in the word all found in the provides this information. Consciously considering opposite paragraph? such information assists when reflecting about an interaction. Reflection should also involve consideration of the intention of each interacting person. It should establish whether the intent of each person was clear initially and throughout the interaction, and whether everyone in the interaction had the same intention or purpose. If there were differences in the intention of each person, consideration could be given to the way in which this variation influenced the outcome of the interaction. Reflection should involve consideration of a method for clarifying intent in future interactions. Consideration of how an individual was feeling before the interaction (i.e. were there related or unrelated events causing negative emotions before the interaction that may have adversely affected their intent unconsciously?) is important and may explain differences in purpose or intention. Reflection should consider the events occurring during the interaction, including actions, words, non-verbal behaviour and environmental factors. A person who is effective 53

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Edith is a 76-year-old mother of three. She has been falling regularly lately, and her last fall caused her to fracture her neck of femur. As Edith has indicated she feels unsafe living alone, a family meeting to discuss her future living arrangements is organised for today. One of her daughters has been happy to talk about Edith living with her, so the team is confident that this meeting will be positive with an agreeable outcome for all family members. The daughter who is happy to have Edith live with her arrives a little earlier to spend time with her mother, and during that time Edith experiences bowel incontinence. Because of her embarrassment, Edith has been successfully hiding this problem from her daughter. The daughter, while not showing her mother, has a strong emotional reaction to this event. A nurse cleans up the floor and Edith just in time for the meeting. The other children arrive feeling confident because they know their sister is happy to have their mother live with her; they have no idea of the ‘accident’ before the meeting.

• •

Suggest the possible team members who should be present for such a meeting. Decide how the negative emotion of the daughter might unconsciously affect her responses in the meeting. Remember that her intent was positive but she has had no time to process the event or her emotions, nor does she have any idea of the support services available for her mother, herself and her immediate family. • Discuss the possible effects this negative emotion might have on the events during the meeting and on the people interacting throughout the meeting. Remember that all members of the family are present, including Edith.

at reflecting considers the reason for each event, the outcome of each event and the overall consequence of the event or interaction. Sometimes the overall result is positive despite negative events during the interaction and – while answers to questions relating to each ‘event’ within an interaction are important – it is the overall result that must guide future interactions. However, reflection should include exploration of the necessity or suitability of each ‘event’. While negative events are sometimes necessary to produce positive outcomes, they require skilful management and experienced personnel. Discussion with significant others can result in expression of strong emotions that initially appear negative; however, the expression of these emotions may result in positive interventions and resolution of emotions. When the health professional is responsible for negative results of events they should reflect on the causes of these events and, if appropriate, how to avoid unnecessary events in future interactions. It is important to examine the causes and reactions of all the interacting individuals, including the health professional, to avoid the repetition of negative events during similar interactions. Reflection should consider the emotional responses of all interacting individuals. These emotional responses may or may not be expressed verbally during an interaction. They may simply be non-verbal responses that require exploration and understanding to guide future interactions and, perhaps, intervention. The cause of these responses should be considered and support or suggestions provided for resolution of these responses. Sometimes this support requires referral to an appropriate health professional. No health professional has all the answers for every Person/s, and this reality should guide health professionals when communicating with everyone involved in and relating to the health professions. 54

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1. When events become unsatisfactory what questions are beneficial? Consider an uncomfortable event you remember, preferably a recent one (e.g. with teachers, family members, fellow workers, or an accident, perhaps in a carpark). Use the following questions to guide your reflection about that event.  What was the purpose of the communicative interaction?  What was I feeling before the interaction?  Was I preoccupied? Was I focused?  Do I have a fundamental bias relating to this person or situation? Do I have a past negative history when communicating with the person or in similar situations? If so, why?  When did this interaction begin to deteriorate or go wrong?  Was the trigger one or more of the following?  Something that was said?  Something that happened before?  Something the person was already feeling?  Non-verbal? From who?  How do I feel in response to this event? What is the cause(s) of these emotions?  What could I have done differently?  What do I do now?  What do I need to do in relation to the other person?  What do I need to do within myself to ensure positive interactions in the future? 2. Do these questions assist you to isolate and highlight those factors that could promote a more comfortable and satisfactory interaction next time? 3. What other questions could assist you to change your patterns of thought and action to ensure positive reactions and outcomes that produce effective communication?

Johns (1993) provides a model to assist in the process of reflection. Although similar to the Boud & Walker model (1990), Johns expresses the steps differently and includes additional factors for possible consideration: 1. Describe the experience – what actually happened? 2. Consider the possible causes of the reactions, including the abovementioned contributing factors and any others. 3. Consider the significant background information relating to the environment and each individual in the interaction, and how this may have affected the interaction. 4. Consider the aims of each action and the possible reasons for the actions. 5. Consider the consequences of the actions, including the feelings of each individual. 6. Consider why possible alternative actions were not chosen and the possible consequences of such actions. 7. Consider the resultant learning and how to change reactions in the future. These seven points provide a sound basis for reflection about interactive experiences either while practising as a health professional or in daily life. Reflection is a process that although challenging does not have to be tedious. It takes commitment and varying amounts of time – the time decreases with practice. Writing in a journal and sipping an enjoyable drink may assist the process of reflecting. Other people may assist if they are willing to explore honestly the reasons for any negative responses. The benefits of reflective and reflexive practice are many for both the Person/s and the health professional.

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REFLECTION ON USING HUMOUR

• • • • • •

The appropriate use of humour can enhance the quality and effectiveness of communication as well as assist an individual in managing uncomfortable circumstances. Humour typically increases relaxation and the enjoyment of life (Berger 2006). It can be used to manage difficult situations. It potentially has a powerful effect when communicating (Holli et╯al 2008). Humour can subtly dissolve stress, tension and even fear (Purtilo & Haddad 2007, Sprenger 2003). The use of humour requires health professionals to have an established relationship with the Person/s. If health professionals have an established relationship they will be able to use humour at exactly the right time to achieve a therapeutic outcome. However, inappropriate use of humour can be harmful and destructive to future interactions. It can remove the possibility of trust and positive communication. If used to avoid uncomfortable emotions or as a substitute for confrontation, humour will cause harm rather than fostering respectful communication. Humour can be used to hide anger or aggression; however, the most appreciated type of humour is often the self-deprecating joke that allows health professionals to laugh at themselves with someone else. Health professionals who do not take themselves too seriously may be more able to develop and sustain a therapeutic relationship with those around them.

Do you regularly and deliberately use humour? Do you use humour successfully? What contributes to the successful use of humour? Do you use humour to:  diffuse tension  avoid negative emotions  help people relax? If you habitually use humour for one of the above, why do you do this? Does the above answer indicate you need to learn to manage tension and/or negative emotions? What might you do about this?

Reflection upon barriers to experiencing, accepting and resolving emotions There is some controversy and discussion about the definition, name and use of unintentional or unconscious barriers to experiencing, accepting and resolving the reality of emotions (Blackman 2004, Cramer 2000, 2005, 2006, Egan 2010, Hentschel et╯al 2004). There is also a long-standing argument about the reality of the effects and role of the unconscious in determining behaviour. The concept of an unconscious mind with power to influence behaviour can cause discomfort and thus some people prefer to avoid discussion about the possible role of a subconscious in everyday life (Murray et╯al 2009). The idea that there are ‘invisible’ processes affecting an individual is unnerving; however, currently psychologists do suggest that there are mental processes occurring outside the awareness of the individual that affect behaviour (Murphy 2001). Some of these processes are called defences or defence mechanisms. Defenses (American Psychiatric Association 1994), adaptive mental mechanisms (Vaillant 2000) or defence mechanisms assist the individual to unconsciously avoid uncomfortable emotions, thoughts, information or desires by removing them from the conscious mind. They are a method of managing otherwise unmanageable thoughts and emotions (Giroux Bruce et╯al 2002). Every individual unconsciously uses defences to avoid experiencing negative or anxiety-provoking emotions. Some defences are a form of deception (Smith 2004); they allow the individual to continue behaving in a particular way regardless of the outcome of that behaviour. Others are simply ways of ‘coping with life’ at a particular time; they maintain self-esteem and self-respect and, as such, are successful coping mechanisms that encourage mature functioning. Overuse of defence mechanisms, however, limits

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self-awareness and awareness of negative emotions, restricts the harmony within the individual, and limits • List reasons why health personal development and change (Egan 2010). professionals should be aware of Defenses can be important for survival in particular commonly used defences (defence situations – they may allow a person to continue funcmechanisms). tioning in extremely difficult circumstances (Murray • Discuss possible reasons why health et╯al 2009). Continual use of defence mechanisms by professionals should be aware of individuals will, however, habitually disconnect them their habitual use of defence mechanisms. from reality, sometimes distort reality and limit their ability to achieve effective communication. Overreliance on particular defences reduces the ability to consider and choose appropriate options or responses during difficult interactions. Recognition of the habitual use of particular defences allows an individual to understand their behaviour and facilitates the exercise of choice and control during difficult interactions. While description and categorisation of defences has occurred for many years, there is a suggestion that a continuum of maturity influences the use of defences (Cramer 2000). The ability of the individual to function as a mature adult indicates the use of the mature defences. These include altruism, sublimation, suppression, anticipation and humour, and are temporary, adult ways of managing particular emotions that are essential to positive mental health (Vaillant 2000). Children often demonstrate use of the immature defences, which are childish ways of managing negative emotions. These include projection, fantasy, hypochondriasis, passive aggression and acting out. The use of immature defences typically decreases as people develop into adulthood. The movement along the continuum usually indicates less self-deception. Consistent and prolonged use of defences typical of immature functioning is the cause of maladaptive behaviour, and the individual may demonstrate psychotic disturbances (Giroux Bruce et╯al 2002). While this is true from one perspective, from another it seems problematic because it suggests that only maladjusted individuals employ defences from the immature end of the continuum.This is not necessarily true. For example, individuals • Consider individually each of the experiencing grief may use denial for a time to facilitate commonly used defences. List adjustment and acceptance. While coping with grief does behaviours that indicate use of each. not usually require prolonged use of denial, denial in the Can you think of someone you know short term is an important defence for many individuals who regularly uses any of these? and does not demonstrate maladaptive behaviour or psyHow do you recognise these chotic disturbance. The neurotic defences – displacedefences? Can you explain their use? ment, isolation of affect (intellectualisation), repression • Consider those defences you have and reaction formation – usually require relatively less used in life. Why did you use those self-deception than the immature and psychotic defences, defences? Why did you stop using and may be used in times of stress. them? The commonly used defences and their definitions • If you still use defences, how will this affect your communication as a are outlined in Table 5.1. health professional? Do you need to Every individual uses defences in some form at some seek assistance from a psychologist time to continue functioning in life (Milliken & Honor counsellor to reduce the use of eycutt 2004). However habitual use of the defences defences that block your ability to causes maladaptive behaviour. Individuals who demonexperience, accept and resolve strate obvious maladaptive behaviour (i.e. some forms particular emotions? of psychosis) usually employ either psychotic or immature defences. 57

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TABLE 5.1â•… Commonly used defence mechanisms Category

Defence mechanism

Description

Psychotic

Denial

The person refuses to accept the truth about something (e.g. refuses to believe particular news).

Immature

Projection

Unacceptable feelings, thoughts and inadequacies, unwanted characteristics and inappropriate desires are attributed to another person (e.g. I am unconsciously angry with you, but I convince myself you are angry with me – that it is your fault, not my emotion). Such individuals always blame others for uncomfortable situations.

Fantasy

The person ignores the real world and retreats into an imaginary world that fulfils the needs that reality has not met. The fantasy relieves the discomfort of life. The individual does not usually insist on or act on the fantasy. Children may have a special imaginary friend.

Displacement

Strong feelings about one person are unhealthily redirected onto another (e.g. after a disagreement with a supervisor, the person goes home and shouts at their roommate or kicks the dog).

Repression

Painful or anxious memories are forced into the unconscious. This usually occurs during childhood. Repression has a powerful influence on behaviour and is often very destructive.

Reaction formation

Conscious thoughts and emotions are the opposite of the actual unconscious wishes and emotions (e.g. the person really likes another person but consciously thinks they do not like them).

Isolation of affect (intellectualisation)

Intellectual processes are used excessively in order to avoid uncomfortable emotions. The person may focus on details to avoid emotions (e.g. intellectualisation allows someone to organise a funeral without being overwhelmed by emotion).

Sublimation

Unacceptable impulses are rechannelled into personally and socially acceptable channels (e.g. aggressive impulses are channelled into a game of squash).

Suppression

The person makes a semiconscious decision to ignore a thought, idea or wish momentarily. They return to it later.

Humour

This subtle and elegant defence occurs when least expected and permits the expression of emotions without discomfort or paralysis. It does not deny pain or seriousness – it simply allows expression and improves life.

Neurotic

Mature

Adapted from Vaillant 1995, p 36.

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Consideration of the defences individuals regularly employ can assist the health professional or the Person/s to overcome barriers to experiencing particular emotions, thereby facilitating change in thoughts and actions, and thus in practice. Awareness of defences can empower individuals to ‘face’ the reality of their situation and negotiate required changes in the use of defences and thus in behaviour. With such awareness health professionals can learn to appropriately manage both expected and unexpected difficult situations in order to communicate effectively and provide consistent family/Person-centred practice.

Chapter summary Reflection promotes awareness of unconscious emotional processes. It considers these ‘invisible’ or unconscious processes and their negative effect on interactions, and can result in resolution of the emotions producing these processes. Reflection can facilitate transformation of the thoughts and actions of the health professional to achieve effective communication and positive outcomes in practice. It should involve reflexivity: examining the self and personal responses to events and experiences. The use of a model of reflection can guide reflection to achieve increased self-awareness and control. Such models suggest describing the events during the interaction, identifying the intentions of the people interacting, considering the factors (person and environment-related factors) contributing to the responses during the interaction along with the reasons for the responses during the interaction, and the resultant feelings about the interaction. It also encourages identification of ways to change any negative responses during similar interactions in the future. Reflection requires commitment, allocation of regular time to reflect and honest consideration of the causes of any negative results of a communicative interaction. It is important that health professionals consider how and when they use humour when relating. It is also important for health professionals to be aware of their personal barriers (defences) to identifying, accepting and resolving uncomfortable emotions. There four types of defences are psychotic, immature, neurotic and mature. Everyone uses defences during their life. Some defences demonstrate a disconnection with reality, while others demonstrate more mature management of life events. Knowledge of the defences and their use can promote effective communication and positive results from interactions with health professionals.

FIGURE 5.2â•… Reflection can identify areas that require changing.

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REVIEW QUESTIONS 1. What is reflexive practice?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 2. Reflection is thoughtful exploration and consideration of the _______________ of events and _______________ during events. 3. Reflection achieves ten possible outcomes – list at least eight of these. i. ii. iii. iv. v. vi. vii. viii. 4. What is the purpose of a model of reflection?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 5. What do most models of reflection encourage?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 6. What five actions are beneficial when reflecting regardless of the particular model of reflection? i. ii.

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iii. iv. v. 7. What does reflection encourage when considering future events within interactions?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 8. Reflection requires commitment and time, and perhaps a journal, a glass of your favourite drink and a good honest friend to join in the journey of self-awareness, acceptance and respect. Devise a plan or strategy that will encourage and develop your skills in reflection.

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 9. In everyday language, state a definition of defences.

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 10. State three reasons why everyone uses defences. i. ii. iii. 11. Defences include the following four categories (Vaillant 1995, p 36). When might they be seen? i. Psychotic: ii. Immature: iii. Neurotic: iv. Mature:

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12. Organise the following list into the appropriate type of defence mechanism: projection, humour, fantasy, displacement, altruism, denial, acting out, hypochondriasis, repression, isolation of affect, sublimation, reaction formation, suppression, anticipation, passive aggression. Psychotic

Immature

Neurotic

Mature

13. What can the use of humour achieve in an established therapeutic relationship?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________

REFERENCES American Psychiatric Association 1994 Diagnostic and statistical manual of mental disorders, 4th edn (DSM–IV). APA, Washington DC Andrews J 2000 The value of reflective practice: a student case study. British Journal of Occupational Therapy 63:396–398 Backus W, Chapian M 2000 Telling yourself the truth, 20th edn. Bethany, Minneapolis MN Ben-Arye E, Lear A, Mermoni D et al 2007 Promoting lifestyle awareness among the medical team by the use of an integrated teaching approach: a primary care experience. Journal of Alternative and Complementary Medicine 13(4):461–469 Berger A A 2006 50 ways to understand communication. Rowman & Littlefield, Oxford Blackman J S 2004 101 Defenses: how the mind shields itself. Brunner-Routledge, New York Boud D, Keogh R, Walker D 1985 Reflection: turning experience into learning. Kogan Page, London Boud D J, Walker D 1990 Making the most of experience. Studies in Continuing Education 12(2):61–80 Boud D J, Walker D 1991 Experience and learning: reflection at work. Deakin University, Melbourne Brown G, Ryan S 2003 Enhancing reflective abilities: interweaving reflection into practice. In: Brown G, Esdaile S A, Ryan S (eds) Becoming an advanced health care professional. Butterworth-Heinemann, London, pp 118–144 Chapman N, Dempsey S, Warren-Forward H 2008 Theory of reflection in learning for radiation therapists. Radiographer 55(2):29–32 62

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Collins M 2007 Spirituality and the shadow: reflection and the therapeutic use of self. British Journal of Occupational Therapy 70:88–90 Cramer P 2000 Defense mechanisms in psychology today. American Psychologist 55:637–646 Cramer P 2005 A new look at defense mechanisms. Guildford Press, New York Cramer P 2006 Protecting the self: defense mechanisms in action. Guildford Press, New York Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Ellis R B, Gates B, Kenworthy N (eds) 2004 Interpersonal communication in nursing: theory and practice. Churchill Livingstone, London (Original work published 2003) Finlay L, Gough B (eds) 2003 Reflexivity: a practical guide for researchers in health and social sciences. Blackwell, Oxford Giroux Bruce M A, Borg B 2002 Psychosocial frames of reference: core for occupationbased practice, 3rd edn. Slack, Thorofare, NJ Gustafson C, Fagerberg I 2004 Reflection: the way to professional development? Journal of Clinical Nursing 13:271–280 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Hentschel U, Smith G, Draguns J G et al (eds) 2004 Defense mechanisms: theoretical, research and clinical perspectives. Elsevier, Amsterdam Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Hitchiner J J 2010 A reflection on reflection. Midwifery News (58):36–37 Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Jack K, Smith A 2007 Promoting self-awareness in nurses: to improve nursing practice. Nursing Standard 21(32):47–52 Johns C 1993 Professional supervision. Journal of Nursing Management 1:9–18 Kinsella E A 2001 Reflections on reflective practice. Canadian Journal of Occupational Therapy 68:195–198 Mann K V 2008 Reflection: Understanding its influence on practice. Medical Education 42(5):449–451 McKenna V, Connolly C, Hodgins M 2011 Usefulness of a competency-based reflective portfolio for student learning on a masters health promotion programme. Health Education Journal 70:170–175 Miller L 2003 Understanding and managing human nature on the job. Public Personnel Management 32(3):419–434 Milliken M E, Honeycutt A 2004 Understanding human behavior: a guide for health care providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Murphy J 2001 The power of your subconscious mind. Bantam, New York (Revised by McMahan I; original work published 2000 by Reward) 63

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Murray S A, Kendall M, Carduff E et al 2009 Use of serial qualitative interviews to understand patients’ evolving experiences and needs. British Medical Journal 338:b3702 Doi:10.1136/bmj.b3702 O’Connell T S, Dyment J E 2011 The case of reflective journals: is the jury still out? Reflective Practice 12(11):47–59 O’Toole G 2007 Can assessment of attitudes assist both the teaching and learning process as well as ultimate performance in professional practice? In: Frankland S (ed) Enhancing teaching and learning through assessment. Springer, The Netherlands Payne M 2006 What is professional social work? 2nd edn. Policy Press, Bristol Payne M 2011 Humanistic social work: core principles in practice. Palgrave Macmillan, Basingstoke Plack M M 2006 The development of communication skills, interpersonal skills and a professional identity within a community of practice. Journal of Physical Therapy Education 20(1):37–46 Pritchard A 2005 Ways of learning: learning theories and learning styles in the classroom. David Fulton, London Pritchard A 2008 Ways of learning: learning theories and learning styles in the classroom. [Electronic resource] Taylor & Francis, Hoboken Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Reid D 2009 Capturing presence moments: the art of mindful practice in occupational therapy. Canadian Journal of Occupational Therapy, 76(3):180–188 Roberts A 2002 Advancing practice through continuing professional education: the case for reflection. British Journal of Occupational Therapy 65:237–241 Rogers C 1967 On becoming a person. Constable, London Rudduck H C, Turner D S 2007 Developing cultural sensitivity: nursing students’ experiences of a study abroad programme. Journal of Advanced Nursing 59(4):361–369 Smith D L 2004 Why we lie: the evolutionary roots of deception and the unconscious mind. St Martin’s Press, New York Sprenger M 2003 Differentiation through learning styles and memory. Corwin Press, Thousand Oaks, CA Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Thomas H K 2011 Student responses to contemplative practice in a communication course. Communication Teacher 25(2):115–126 Thompson N 2002 People skills, 2nd edn. Palgrave Macmillan, Basingstoke Vaillant G E 1995 The wisdom of the ego. Harvard University Press, Cambridge, MA (Original work published 1993) Vaillant G E 2000 Adaptive mental mechanisms: their role in a positive psychology. American Psychologist 55:89–98 Zimmerman S S, Hanson D J, Stube J E et al 2007 Using the power of student reflection to enhance student professional development. Internet Journal of Allied Health Sciences and Practice 5(2):1–7

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ANSWERS TO REVIEW QUESTIONS CHAPTER 5â•… Awareness of and need for reflective practice Answers to the following questions provide a summary of this chapter. 1. What is reflexive practice? Reflexive practice focuses on the reasons why a practitioner or professional responds to particular events and how they affect these events. It focuses on the self – not the event. 2. Reflection is thoughtful exploration and consideration of the causes of events and reactions during events. 3. Reflection achieves ten possible outcomes – list at least eight of these. i. Reflection increases awareness of unconscious or invisible emotional processes. ii. Reflection can produce honest self-awareness; self-knowledge; self-acceptance; self-control; self-respect and self-maintenance. iii. Reflection is an important means of learning about attitudes, experiences and self. iv. Reflection provides understanding of familiar and unfamiliar cultures. v. Reflection facilitates resolution of the causes of negative responses during interactions. vi. Reflection increases understanding of the influence of personality, other people and the environment upon communication. vii. Reflection can improve skills in successfully managing negative emotional responses while communicating. viii. Successful family/person-centred interventions. 4. What is the purpose of a model of reflection? A model of reflection guides the process of reflecting – provides a way to reflect. 5. What do most models of reflection encourage? A description of the event or interaction and comprehensive consideration of any factors that might explain the reactions during the event, exploration of the resultant feelings and how to resolve these and changes negative responses for future interactions. 6. What five actions are beneficial when reflecting regardless of the particular model of reflection? i. Commit yourself to regular reflection. ii. Allocate a regular time and place to reflect. iii. Honestly identify unconscious emotional processes that negatively influence responses during interactions. iv. Resolve emotional causes of these negative responses and/or suggest ways to avoid these responses during future interactions. v. Make time to clarify the intention and feelings of all the communicating people.

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7. What does reflection encourage when considering future events within interactions? Reflection can encourage consideration of how to clarify the intention or purpose of each interacting person during future interactions. 8. Reflection requires commitment and time, and perhaps a journal, a glass of your favourite drink and a good honest friend to join in the journey of self-awareness, acceptance and respect. Devise a plan or strategy that will encourage and develop your skills in reflection. FOR EXAMPLE: Choose a model of reflection that suits my personality and learning style. Buy or establish an electronic template for; a reflective diary. Allocate regular time to reflect upon particular interactions and how I might positively influence such future interactions. Allocate time each month to read the entries and reflect upon any positive changes in communicating and/or interacting in practice. 9. In everyday language, state a definition of defences. Defences are unconscious mental processes that assist people to stop experiencing particular uncomfortable feelings. 10. State three reasons why everyone uses defences. i. To manage distressing emotions. ii. To avoid experiencing uncomfortable thoughts, desires, emotions or information. iii. To ‘cope with’ distressing events in life to continue functioning. 11. Defences include the following four categories (Vaillant 1995, p 36). When might they be seen? i. Psychotic: When a person is disconnected from reality. ii. Immature: When a person is young and unaware of themselves or their needs. iii. Neurotic: When a person experiences times of stress. iv. Mature: When a person is functioning as a mature adult processing and accepting the difficult events in their life. 12. Organise the following list into the appropriate type of defence mechanism: Projection, humour, fantasy, displacement, altruism, denial, acting out, hypochondriasis, repression, isolation of affect, sublimation, reaction formation, suppression, anticipation, passive aggression. Psychotic Prolonged denial

Immature

Neurotic

Mature

Projection

Displacement

Sublimation

Fantasy

Repression

Suppression

Hypochondriasis

Reaction formation

Humour

Passive aggression

Isolation of affect

Altruism

Acting out

Intellectualisation

Anticipation

13. What can the use of humour achieve in an established therapeutic relationship? Humour can increase relaxation and the enjoyment of life. It can manage difficult situations, dissolving stress, tension and, sometimes, even fear 64.e2

O’Toole 2e. © 2012 Elsevier Australia

CHAPTER 6â•…

Awareness of self

CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Recognise the importance and benefits of self-awareness for a health professional • Demonstrate awareness of their abilities and ‘inabilities’ • State some of their own values, characteristics and abilities • List the values, characteristics and abilities that benefit a health professional • Demonstrate understanding of their own basic dominant need(s) • Recognise the effect of conflict between needs and values • Understand the concept of listening barriers and their effect on communication • Listen and speak more effectively • Recognise differences in learning and processing preferences • Understand their own learning and processing preferences.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Self-awareness: an essential requirement Self-awareness equips individuals for life. It also equips relevant individuals for an effective career as a health professional. Self-awareness allows a person to know and to understand themself. It allows a person to know how they will react in any situation and assists them to understand why they react as they do in those situations (Egan 2010). Self-awareness increases self-understanding and results in increased control of thoughts and behaviours (Devito 2009). The information resulting from self-awareness assists health professionals to achieve effective practice (Eckroth-Bucher 2010, Rogers & Ballantyne 2010). Self-awareness potentially enables the individual to use this information to relate positively. Schore (2005) suggests that self-awareness of personal emotional states increases the ability of health professionals to recognise and respond appropriately to the needs of others. Stein-Parbury (2009) states that self-awareness is essential for developing a therapeutic relationship and promotes open, honest and genuine health professionals who are not afraid to be caring human beings. Self-awareness potentially facilitates unconditional positive regard for others without prejudice, judgement or negativity (Rogers 1967). Health professionals who increase their self-awareness will continually reach the goal of achieving positive outcomes from every interaction (Shih et╯al 2009). Becoming self-aware is a life-long journey that requires commitment and perseverance (Taylor 2006). When embarking on the journey towards self-awareness it is important to remember that even the most self-aware individuals sometimes experience unsuccessful interactions. In these individuals the level of self-awareness varies, and thus they may experience negative outcomes when interacting at different times. Such times are inevitable and should motivate those committed to self-awareness to persevere in their attempts to achieve self-awareness. Self-awareness allows health professionals to respond to the needs of the Person/s, rather than responding to their own needs. This response ultimately facilitates family/Person-centred practice, the desired outcome of any interaction with a health professional.

THE BENEFITS OF ACHIEVING SELF-AWARENESS While achieving self-awareness is sometimes uncomfortable, there are many resultant benefits. Self-awareness allows health professionals to recognise, know, understand and resolve their emotional needs. It frees health professionals to choose how to react rather than reacting to fulfil unconscious emotional needs at any given time. Self-awareness provides understanding of the inadequacies and fears that unconsciously manipulate and direct thoughts and responses while interacting (Ben-Arye et╯al 2007). This understanding facilitates greater control while relating and decreases regrets after interactions (Shih et╯al 2009). The greatest benefit of self-awareness is self-acceptance and valuing of self (Bombeke et╯al 2010). Self-acceptance empowers health professionals to value and respect others regardless of the situation (Davis 2011). Reflection is a key component for achieving self-awareness (see Ch 5). There are also various management tools, for instance 360-degree feedback, which is anonymous feedback given by colleagues that can increase the level of self-awareness (Richardson 2010). In this chapter, the reader is encouraged to begin the journey of practising self-awareness. This chapter seeks to demonstrate the benefits of being self-aware for both the health professional and those around them. 66

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Beginning the journey of self-awareness A journal is a helpful learning tool when developing self-awareness (Holly 2002). Recording answers to questions and thoughts while reflecting assists in highlighting information and learning about self (Ellis et╯al 2004, Ellis 2009, Mohan et╯al 2004, 2008, 2010). It is helpful to revisit a journal at later times as a reminder of the growth and change achieved from a commitment to self-awareness. Answering questions about ‘self’ is essential for achieving self-awareness. Honest answers to such questions inform individuals and empower them to choose appropriate responses and behaviours when communicating (Dirette 2010). Answering questions about personal characteristics and related abilities begins the process of becoming self-aware. This is an extension of the reflective activity on page 51 of Chapter 5.

Part 1

• • • • • •

Make a list of things you enjoy doing. Of those things, what do you do well? What do you not do well? Make a list of things you dislike doing. Of those things, what do you do well? What do you not do well? Do you like the things you naturally perform well? Do you dislike things you perform badly? List the characteristics and abilities that assist your performance in these activities. List the characteristics and abilities that limit your performance in these activities.

Part 2

• • • • •

Make a list of all the things you feel you do well and those you feel you do not do well, whether or not you enjoy doing them. Share this list with someone who knows you well and ask if they agree. If they disagree, ask them for examples to demonstrate their understanding of what you do well and what you do not do well. Does this interaction change the way you see your abilities? Are you able to believe their understanding of your abilities? Why or why not?

Sometimes an individual has the characteristics and abilities to perform an activity well but experiences and negative emotions have clouded their accurate knowledge about and understanding of those characteristics and abilities. During the process of learning to read, a 6-year-old child changes schools. The new teacher notices that the report from the previous school states the child reads well. The teacher asks the new child to read to the whole class from a reader (booklet) considered an advanced reader for that class. The new child – presented with an unfamiliar reader and a sea of unfamiliar faces – stands in horror staring at the book. The child is so scared, she is not really sure that the book is not upside down. Several attempts to pronounce words find the child standing alone, in silence. The teacher says Well obviously you can’t read – sit down. →

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• • •

Discuss how the child is likely to react. Discuss how each member of the group would react if it had been them in this situation. Discuss any similar experiences that group members are willing to share and the effect of such negative experiences on the ability to perform the activity.

It took many years after that experience for the child to enjoy reading. Now an adult, that ‘bad’ reader is today a successful author of readers for children who do not enjoy reading! • What do you think encouraged this person to become an author of readers (booklets) for children? • Could this have resulted from unresolved emotions or does this require resolved emotions concerning the incident years ago? • Do you like any of the activities you listed in Part 2 of the reflective activity on the previous page because you were encouraged in doing them? Are there any you dislike because you had negative experiences that made you feel unable to do them successfully?

• •

Make a list of those things you perform well because of encouragement. Make a list of those things you perform well because you have persevered despite discouraging feedback.  Do you agree with the negative feedback you received in the past?  Have you proved to yourself that you can do these activities well?  What did you do to prove your abilities in these activities? • Make a list of activities you do not do well because you have experienced discouraging feedback.  Have you stopped doing these as a result?  Do you think you could ever attempt them again? Why or why not?  Is there any skill you feel you could never perform well?  What might you do to develop your skills in this area?

•

Is there a characteristic that you do not demonstrate well that you feel you need to develop to become an excellent health professional (e.g. patience or confidence when communicating with strangers)? • What can you do to develop this characteristic and the associated abilities?

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When told they do not perform an activity well, some people decide to practise that activity until they do perform it well. Many activities can be conquered with practice (e.g. playing basketball; creating a chair from timber; writing assignments, presentations and reports; teaching; managing others; providing leadership; and communicating). Other people, when told they cannot perform something well, withdraw from performing that activity and never conquer it. Such decisions might not be significant where the ability is something that is not essential to quality of life (e.g. knitting or washing a car). Some abilities (e.g. communication and self-control) are necessary for daily life however; thus perseverance is required to improve

6 » Awareness of self

skills in those activities. There are particular characteristics that individuals develop because of personality and experience that promote the development of abilities. An awareness of self provides information about those characteristics and allows thoughtful control to enhance communication.

Individual values All people have values that influence their thoughts and actions. A value is the measure of worth, importance or usefulness of something or someone (Banks 2006). Values develop as an individual experiences life. They originate from families, friends, teachers, the media, religious leaders and caregivers (Purtilo & Haddad 2007). Values influence thoughts, desires, dreams, decisions and actions. They contribute to the development of particular characteristics and thus abilities or inabilities. If an individual values handmade garments, they may persevere to learn knitting or sewing. If they do not, they may never begin the process of testing their abilities in either knitting or sewing. If a person values respect of self and others when interacting, they will take action to both demonstrate and expect respect (Harms 2007, Harms & Pierce 2011).

Is a health profession an appropriate choice?

What do I value? Make a list of what is important to you. The items on the list may be objects (e.g. car, computer), specific people (e.g. son, sister, father, partner), characteristics (e.g. perseverance, organisation, aggression), states of being (e.g. health, wellbeing, safety) and particular activities (e.g. shopping, travelling, volunteering).

Why do I value?

•

Consider the items on the list and decide why you value them. One reason might be the way they make you feel, while another reason may be that your family or friends think these things are important. • Have your values changed over time? List how they have changed and what caused the change.

Sharing the reasons for valuing There are particular values, characteristics and • Together share the reasons why you abilities that facilitate effective practice in the health value the things on your list. professions. It is important to be aware of these • List any common values among the values, characteristics and abilities because this awaremembers of the group. ness assists in verifying the choice to become a health • List any of these values that are essential for a health professional. professional. Some individuals pursue a career in a health profession because someone they admire is a health professional. These individuals may be seeking a career that does not suit their interests, values or abilities. Other individuals pursue a career in a health profession because they are aware of the role, the values and the required characteristics and abilities of the profession, and feel they meet the necessary requirements. Others may not pursue a career in the health professions because they are unaware that their interests, values, characteristics and abilities are well suited to such a career. Still others do not pursue a career in the health professions because it does not provide the economic return they desire or because it is too consuming of time and emotions. The reasons for the choice about whether or not to become a health professional usually indicate the values of the individual.

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Values of a health professional •

Together define ‘health’. Does your health profession value health? How does your health profession demonstrate this value? • Now define ‘quality of life’. Does your health profession value quality of life? How does your health profession demonstrate this value?

The overall purpose of the health professions centres on people (see Ch 2). Sometimes this overall purpose focuses on individuals, and at other times on individuals within the context of a family. If people are the central focus of all health professions, it seems appropriate to assume that all health professionals must value and appreciate people (Shih et╯al 2009). If health professionals do not value and appreciate people and their associated needs, they produce inappropriate and ineffective interactions and interventions. It is important that health professionals value both themselves and others (Fulford 2011). A health proIn groups of the same health profession: fessional must have a desire to understand and assist • List and define other values of your people through expressions of empathy, demonstrahealth profession. tions of respect and development of trust. It is impor• Does your health profession have these values in common with any tant that health professionals value a therapeutic other health profession? relationship that collaborates, empowers and develops rapport (see Ch 2). In combination, these essential factors for all health professionals promote family/Person-centred practice. It is also essential that health professionals value the knowledge and skills specific to their profession and those of other health professions. If these values are not important to an individual, that individual should not become a health professional.

Am I suited to a health profession? Stage 1 Answer the following and list characteristics or events that validate your answer. • Do I generally enjoy relating to people? • Do I enjoy relating to people who are different to me, regardless of the difference? • Do I enjoy relating to people who require assistance? • Am I able to relate to people who are expressing negative emotions? • Can I generally think clearly when others are expressing negative emotions? • Do I generally enjoy communicating with people? • Am I an effective and good communicator? • Do I enjoy creative problem solving? • Do I enjoy helping people to help themselves? • Do I enjoy encouraging people? • Do I enjoy assisting in solving problems for other people? • Do I enjoy challenges? • Am I generally patient with myself and others? • Am I a good listener? • Do I usually attempt to understand myself and other people?

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Stage 2 Consider the questions on the previous page and name the characteristic(s) and/or ability(ies) highlighted in the question. Does your health profession value these? Decide whether all health professions value these characteristics and abilities.

Stage 3 Do you feel you exhibit these characteristics and abilities?

• • • • •

Which ones do you feel you do well? What has contributed to your development of these? Which ones do you feel you do not do well? What has limited your development of these characteristics and abilities? What can you do to develop those you feel you do not do well?

Characteristics and abilities that enhance the practice of a health professional While particular health professions require specific interests and abilities, there are characteristics and associated abilities that benefit individuals in all health professions. The questions on the previous page (p 70) highlight some of these characteristics and abilities.

Personal unconscious needs There are needs every individual has that contribute to ‘inabilities’ or limitations in relationships (Stein-Parbury 2009). These unconscious needs create typical ways of relating and affect the characteristics and outcomes of relationships. This reality indicates that health professionals must be aware of the basic needs that dominate their expectations of relationships and ways of relating. There are three basic human relationship needs: 1. The need to be accepted and valued – to have a ‘place’, feel special and know that others care (Brill & Levine 2005, Milliken & Honeycutt 2004) 2. The need to be in control 3. The need for affection and affirmation (Stein-Parbury 2009). All humans have these needs. At different times individuals long to feel valued for who they are – to feel accepted and special. This need expresses itself through relationships in which the person is always fulfilling the needs of others and ‘doing’ for others, regardless of whether the person can ‘do’ for themself. These people find it difficult to say no when asked to assist. Some people have a predominant need for control, and thus will limit involvement in relationships and situations that are unpredictable. This need expresses itself in relationships with others who are happy to do exactly what the person demands, in the exact manner. These people find it difficult to enter situations that involve change or risk-taking. Other individuals predominantly seek affection and affirmation. This need expresses itself through the seeking of relationships that protect them and affirm whatever they do. These people may also find it difficult to say no, because they crave affirmation and fear rejection. While everyone experiences these needs, some people have a 71

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•

Discuss each basic human relationship need listed in the last paragraph on page 71 and suggest the effects of each need on the communication and relationships of health professionals. • For each need, state specific actions that reflect the basic need. How might these actions relate to your particular health profession?

consistently dominant area of need that influences all their relationships and interactions. The dominant need of individuals may vary according to the events in their lives at a particular time. It is important for individuals who choose a career in a health profession to be aware of which of these needs dominate their relationships, and the situations that might trigger this unconscious need. Awareness of the dominant area of personal need(s) allows the health professional to make choices that fulfil the needs of the Person/s rather than fulfilling their own needs. Answering the following questions may assist in highlighting which basic human relationship needs typically dominate an individual’s way of relating.

Answer each question with yes, no or sometimes. In reality, the three basic human relationship needs will be true for everyone some of the time (Stein-Parbury 2009). However, these questions ask for the usual tendency you experience. Remember that honest answers will increase your self-awareness and potentially empower you to overcome the ‘inabilities’ or limitations associated with relating because of a predominant need.  Do I have a well-defined comfort zone that I do not enjoy leaving?  Do I usually feel there is only one answer to a problem and one way to do tasks? Or that there is only one place to keep certain things?  Do I usually feel I must have the answer to every situation and problem?  Do I only enjoy relating to people who need my help?  Do I often feel I am the only person who can solve certain problems?  Do I define myself by doing things for other people who need me?  Do I often feel I must fix a problem?  Do I often feel I must do something to make things better and to rescue people?  Do I only feel OK if I am helping people?  Do I usually respond strongly to any critical comment about me?  Do I find that other people often act in ways that are inappropriate or annoying?  Do I find it easy to see the negative rather than the positive aspects of a person?  Do I find it easy to form negative ideas about people who are different to me?  Do I find it difficult to say no to requests for help?  Do I usually want other people to take care of me?  Do I often worry about whether people like me or not?  Do I feel most content when people do exactly what I want?  Do I feel better when people are telling me I am great?

• •

Classify each question into the three basic human needs. Consider your answers to the questions and decide which basic need(s) typically dominate(s) your way of relating. • Write down what you could do to control this need(s) in order to ensure that you, as a health professional, are able to meet the needs of others. →

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In small groups: • Agree on the classification of the needs represented in each question. • Match the following characteristics to one or more of the basic human needs: controlling, self-focused, inflexible, need-to-be-needed, scheming, rigid, selfish, cold, calculating, selfabsorbed, manipulative, stubborn, attention-seeking, judgemental, intolerant, perfectionist. • List any other characteristics that would represent one or more of the basic human needs. • Discuss the possibility that there may be gender differences in the experience and expression of these needs. Give examples of the possible differences. • Decide how knowledge of basic human needs affects a health professional.

Reflecting upon answers to these questions is important for health professionals. Such reflection increases self-awareness and control of thoughts and reactions. It also decreases the fulfilment of personal needs while practising as a health professional, thus increasing the ability to focus on fulfilling the needs of the Person/s.

A 74-year-old man who lives alone has just experienced the death of his golden retriever. They were constant companions for 15 years, ever since the death of his wife. The man is depressed and sees no reason to continue living.

• •

What is your personal response to this situation? What is your response as a health professional? The man would take his dog to the seniors’ centre every week for a few hours. Everyone loved his dog. When his dog died, he stopped attending because he hated walking to the centre alone. His children want to buy him another dog, but he refuses to have another dog. • What is your personal response to this situation? • What is your response as a health professional? • What is your response when you learn the man has committed suicide? Write down your personal responses to this scenario. Consider these responses carefully and identify the values and needs your reactions demonstrate.

Conflict between values and needs When practising as a health professional, it is possible to assist people who demonstrate detrimental habits resulting from conflict between personal values and relationship needs. In such circumstances it is the responsibility of the health professional to provide nonjudgemental assistance. Self-awareness of the personal values and needs of the health professional promotes self-control and positive understanding of the Person/s. Selfawareness potentially frees the health professional to make the choice to provide nonjudgemental assistance. Considering their own experiences of conflict between personal values and needs reminds the health professional of the difficulties associated with this 73

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• • • • • •

•

Is being healthy one of your values? How do you express this value? Do you value your quality of life? How do you express this value? Do you generally like to be accepted? How do you express this? Do you generally like to be included? How do you express this? Does acceptance generally make you feel valued? Why? As a health professional, how would you respond to someone who has developed a detrimental habit because their dominant need has overcome their values?

What do you feel about smoking? Or overeating? If you smoke or use food as comfort, you understand the desire for a cigarette or for food when stressed and upset. If you do not smoke or overeat, you may have a different addiction (e.g. television, computer games, chocolate, coffee, always being right, feeling resentful, being in control, extreme exercise); experience of any addiction will facilitate understanding of addiction to smoking or overeating. • As a health professional, what is your first response to someone who smokes or overeats? • If you value health and quality of life, you may have a strong opinion about the habit of smoking or about obesity caused by overeating. How do you temper or control these strong opinions?

conflict, and thus facilitates greater tolerance and genuine understanding of those seeking assistance. In situations where someone has developed a detrimental habit because their dominant need has overcome their values, the health professional should not express either verbal or non-verbal judgement. It is important to remember that the Person/s is feeling vulnerable and insecure. The health professional seeks to empower people to achieve change, and a judgemental response will only discourage rather than empower. Awareness of personal values and needs and the possible conflict between the two is important for all health professionals. This awareness assists them to understand the results of such conflict, which are usually detrimental habits such as smoking or overeating. Given that initially most people find the act of smoking unpleasant, it is remarkable that individuals continue to smoke. A possible explanation is that many people continue smoking because it gives them a perceived ‘place’ within a particular ‘group’. They may continue smoking to experience acceptance and inclusion despite valuing a healthy life and the associated quality of life. A person who is obese because of overeating experiences the overriding need for comfort above their value of a healthy life.

Perfectionism as a value

The value of ‘perfectionism’ or always being right in actions and words may override the need for affection and affirmation. Individuals who value perfectionism, value being right above everything else. When they experience being wrong, they cannot recognise the presence of affection and affirmation. For such individuals the value of perfectionism overcomes the need for and often the ability to receive affection and affirmation (Backus & Chapian 2000). Individuals who value perfectionism can develop the detrimental habit of constantly telling themselves that whatever they say or do is not good enough, regardless of the oftenexceptional quality of the attempt. Consistent affirmation, affection and repeated truth about the quality of the attempts are required to overcome this detrimental habit. This value of perfectionism results in some individuals finding it difficult to complete and submit something (e.g. a written assignment). It can also result in individuals redoing the same thing repeatedly despite their skill in the task and the adequacy of their initial attempt. Other individuals may perform a task but only see the imperfections of the

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performance regardless of the overall quality of the performance. For other individuals, the overriding Negative self-talk: ‘I am not value of perfectionism can mean they do not comgood enough’ plete something as well as they are able to because • How would you recognise evidence of they feel they will not do it well enough – they will this negative self-talk in a colleague or not reach perfection. When individuals refuse to do Person/s? something because they believe they will not achieve • List possible actions of a health an appropriate level of perfection, they may not be professional who believes they are not able to admit they feel inadequate. good enough. Negative self-talk can result in an individual refus• List possible ways of relating for a ing to attempt something while another person is Person/s who believes they are not good enough and is seeking the present, despite their competence in the activity. Perassistance of your particular health fectionism may mean that a person is constantly planprofession. ning future tasks – making lists of things to do and How might you assist a Person/s if • ways to complete those things – in an attempt to they exhibit evidence of negative remember everything or to mentally prepare to ‘perself-talk? fectly’ complete the tasks. It can also mean that people find it difficult to believe or accept any form of affirmation about the quality of their performance. Awareness of the existence of and experience of conflict between values and needs can assist health professionals to overcome their own detrimental habits. Such awareness also promotes understanding of people with detrimental habits encountered when working as a health professional.

Self-awareness of personal communication skills Some individuals are effective communicators from birth, others develop skills through life experiences and others make conscious efforts to become effective communicators. Effective communicators are able to express themselves clearly, listen carefully and observe all non-verbal messages. They are committed to understanding the needs of their ‘audience’ and producing messages that negotiate mutual understanding (Ellis et╯al 2004). If the audience does not demonstrate understanding, effective communicators take turns communicating and negotiating to guarantee mutual understanding and thus effective communication. They listen carefully and respond in ways that facilitate further positive communication. In providing answers to the questions opposite, many people may note that their role when communicating varies depending on the topic and the people communicating. This is often true and may indicate that the person is a good communicator who responds appropriately to the topic, situation and audience. Alternatively, it may indicate an uncertainty when communicating that could benefit from

• • • • • • • • • •

Do you enjoy communicating verbally? Why do you think this is so? Do you usually listen when communicating verbally? Why do you do this? Do you usually talk? Why do you do this? What do you usually talk about? Which do you prefer – listening or talking? Why is this so? Do you ask questions about the other person to continue the communication? Do you often request clarification? Do you let others ask questions or speak rather than you talking? Do you usually finish a verbal interaction feeling satisfied? Do you often feel dissatisfied after a communicative interaction? Do you enjoy communicating if you feel unmotivated to communicate?

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reflection and conscious efforts to develop skills in communicating. If the honest answers to these questions were predominantly yes, this could indicate skill in listening and speaking, while answers of predominantly no could indicate lack of skill or confidence in either. A health professional must demonstrate skill and confidence in communicating to facilitate excellence in practice and the achievement of family/Person-centred goals and practice (Higgs et╯al 2005, 2010).

Self-awareness of skills for effective listening Full attention is not always necessary for effective communication in personal situations (Ellis et╯al 2004). For a health professional, however, effective listening requires full attention, skill and often practice (see Ch 9). Listening must be adapted to the particular individual and the context (Devito 2007). It requires active engagement with the person and their message (Devito 2009). The listener indicates active engagement through appropriate non-verbal cues (see Ch 12). Effective listening requires understanding of more than the words being spoken; it also requires understanding of the expressed emotions. Effective listening is an essential skill for a health professional because it demonstrates empathy, respect and trustworthiness. Effective listening is characteristic of a therapeutic relationship and promotes family/Person-centred goals and practice. Everyone, however, is guilty of ineffective listening at particular times (Mohan et╯al 2004, 2008, 2010). Understanding the reasons for ineffective listening empowers the health professional to overcome those reasons and whenever necessary practise effective listening.

What do you typically do when listening? Answer the following questions honestly. 1. Do you concentrate totally on the person and their messages? 2. Do you allow yourself to think of things you have to do later? 3. Do you attempt to understand everything the person is communicating? 4. Do you sit quietly without responding verbally or non-verbally? 5. Do you attempt to identify the main point of the communication? 6. Do you often interrupt? 7. Do you wait for the person to complete their message before responding? 8. Do you avoid eye contact while listening? 9. Do you keep an open mind and avoid judgement about the person or topic? 10. Do you try to ‘double-guess’ or read the mind of the person speaking? 11. Do you focus on the other person regardless of how you are feeling? 12. Do you change the subject if the person begins expressing negative emotions?

Listening skills vary according to context and life events at any given time. Certainly everyone needs to ‘rest their brain’ when listening in order to regain concentration. The above questions are not about those times of rest but rather focus on regularly employed habits that restrict or enhance the listening effectiveness. Typically answering yes to the above odd-numbered questions and no to the even-numbered questions indicates effective skills in listening. Answering yes to any of the even-numbered questions indicates a need to practise listening to ensure more effective communication. Answering yes to some odd and some even questions also indicates a need to practise and improve listening skills. 76

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BARRIERS TO LISTENING Most individuals at different times use barriers that limit the effectiveness of their listening (Gordon 2004, 2007). These barriers may be a protective device used during a particular interaction or they may be a learned habit. The explanation for the use of barriers is irrelevant because if they are used at all they limit the possibility of effective listening. It is important that health professionals are aware of barriers to listening. They must be especially aware of the barriers they typically use themselves, in order to limit their use of such barriers when listening to individuals who require their assistance.

Read the following list of barriers to listening and write your definition for each. Agree on a definition for each barrier. Together think of an example of each barrier. Interrupting Intimidating Monopolising Placating Rehearsing Reassuring Switching off Breaking confidences Partial listening Advising Mind-reading Judging Being right Interrogating Changing the subject

•

Of these barriers, which ones have you experienced when you have been communicating with someone? • Have you experienced any of them regularly? • What is the major emotion you experience when someone uses a listening barrier while you are speaking? • List reasons why people would use these barriers to avoid listening.

• • • •

Do you sometimes use any of these barriers to listening? Why do you use them? Do you use one/some of them regularly? Are there particular circumstances in which you use these barriers or are they a habit? If you use barriers to listening in particular circumstances, describe the circumstances that prompt you to use the barrier(s). Explain why. How could you avoid their use?

• • •

Brainstorm ways to overcome habitual use of a barrier to listening. List circumstances that might tempt a health professional to use any of these listening barriers. Suggest ways to avoid using any of these barriers with people who require assistance.

If health professionals desire to demonstrate honest, open and empathic communication with the Person/s, it is essential that they recognise listening barriers and the circumstances that promote their use. 77

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There may be other barriers to listening in the health professions, including the Person/s who is unable to produce speech (Radtke et╯al 2011) or an inability because of cultural barriers that make listening difficult (Singleton & Krause 2010). A practising health professional may encounter such barriers in practice and should take appropriate measures to achieve effective communication.

Reasons for the use of barriers to listening There are many reasons for the use of listening barriers, some of which are reasonably positive explanations for the use of a barrier. These might include: • Excitement over something being said • Preoccupation with a difficult situation • Busyness • Tiredness • Greater knowledge of the situation than the speaker • Genuine interest in the topic • A desire to further understand the communication • A desire to compose words carefully to avoid misunderstanding or hurt • A need to communicate something urgently (e.g. a spider on the speaker’s head!) • A desire to share knowledge and understanding of the topic. There are also negative explanations for the use of each listening barrier: • An individual who finds a topic boring or not personally relevant may interrupt, ‘switch off’, listen partially or change the subject. • An individual who feels insecure and intimidated may monopolise, intimidate or interrogate during an interaction. • An individual may rehearse a statement in their mind instead of listening because they want to correct the speaker about an error. • When being right motivates a person, they might use several additional listening barriers including attempting to mind-read. • If mind-reading proves incorrect, an individual who feels they know more than the speaker might use advising as a way of avoiding listening. • An individual who feels someone is attacking them might respond by judging the person or attempting to intimidate or placate the person to stop them from continuing the perceived attack. • An individual who finds the expression of negative emotions difficult might placate or reassure without any real attempt to listen and understand the speaker. • An individual who wishes to change the subject or redirect the attention from the speaker to the listener may share confidential information about someone else. All of these barriers to listening restrict the possibility of developing real understanding, effective communication and positive intervention results.

Self-awareness of skills for effective speaking Self-awareness can assist an individual to identify the characteristics and abilities that enable effective speaking skills. Some people demonstrate interest in others with ease and efficacy. Such individuals demonstrate this interest naturally when communicating, whether speaking or listening. They demonstrate an engaging enthusiasm for their topic and their listeners that promotes understanding. Some individuals have a natural ability to effectively interpret non-verbal cues in messages, while others must learn from 78

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experience what such cues mean. Some can intuitively understand the abilities and needs of those around them, while others must ask for information concerning those abilities and needs. Some people can think quickly and respond appropriately regardless of the situation, while others must compensate for lacking this ability with various strategies to achieve effective communication. All these skills assist in achieving effective communication when speaking. It is important that individuals know and understand their abilities with regard to speaking. Such understanding allows the health professional to either practise the skill of speaking or employ strategies to facilitate effective speaking when communicating. Skills that produce effective speaking include perWrite down your answers to the following sonal abilities; familiarity and comfort with the topic; questions: experience in effective speaking; skill in interpreting • What factors encourage you to non-verbal behaviours; and skill in perceiving and demonstrate interest and enthusiasm understanding the characteristics of each Person/s. It for a subject when speaking? is important to be aware of this complexity when • What do you usually do to indicate this developing skills in speaking as a health professional. interest and enthusiasm? Effective speaking requires demonstration of interest • What encourages you to demonstrate interest and enthusiasm towards the and enthusiasm for both the topic and the ‘audience’. person/people (audience) listening? It requires skill in, as well as knowledge and under• What would you do to demonstrate standing of, the particular topic. Studying to become interest and enthusiasm towards each a particular health professional potentially provides individual person? this skill, knowledge and understanding. Effective How do you demonstrate interest and • speaking requires understanding of the non-verbal enthusiasm through your words? behaviours that affect the presentation and compre How do you demonstrate interest and • hension of spoken words (see Ch 12). It also requires enthusiasm through your non-verbal understanding of the listening individual(s) (see Chs behaviour? 1, 7 & 8 and Section 4). A genuine interest in and enthusiasm for both the topic and the audience is important. Such interest and In groups, discuss answers to these enthusiasm should produce a desire in the speaker to questions: understand and engage with the listener and the rel• What can health professionals do to demonstrate interest and enthusiasm? evant information about them. This desire and the • What might assist them in this resultant knowledge should promote the use of demonstration? appropriate words and sentence structures to facili• What factors might limit this tate listener understanding. The use of appropriate demonstration? How could they non-verbal behaviour will further facilitate listener overcome these factors? understanding and, ultimately, mutual understanding. Interest and enthusiasm on behalf of the speaker, in turn, creates an interest within the listener. These emotions encourage the listener to engage with the speaker and assist in developing and maintaining consistent concentration. They create a desire to know and understand the presented information.

Preferences for managing information and resultant communicative behaviours There are many descriptions of and theories relating to individual differences in styles of managing and responding to information (commonly known as learning styles or 79

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preferences). Information is taken to mean facts or experiences that change thinking or behaviour. Managing and responding to information involves perception, processing, recall of information and response to information (Reid 2006). Individuals adopt different information management styles and behaviours according to the expectations of different contexts (Pritchard 2005, 2008). While individual styles can vary, they represent tendencies not absolute choices (La Motta 2004). Individuals generally have preferred ways of functioning within particular contexts. The context and the personality type (Briggs & Myers 1975, Jung 1941) influence the particular style of information manage• What do you naturally do to become ment at a specific time. In combination, context and aware, to understand, to accept and personality influence the reactions, behaviours and to appreciate those around you? communication styles of every individual. It is therefore • How do you usually behave to important for health professionals to have an awareness increase awareness, understanding, of their own particular style, to understand that others acceptance, and to appreciate may have a different style and to realise that these difothers? ferences are perfectly acceptable (Woolfolk & Margetts Each of these actions has an 2007). individual meaning that results in Differences in individuals create both variety and different behaviour. diversity. While diversity is a challenge, it is here to stay (La Motta 2004). Conquering this challenge is essential and is one of the rewards of practising as a health professional. It requires awareness, understanding, acceptance and appreciation of such variety and diversity. Your instructor will provide a handout Such awareness enhances effective communication and (available in the instructor’s section on contributes to the development of family/PersonEvolve) on matching the four centred goals and effective practice. information management styles with the descriptions of likes and dislikes. It is beneficial for health professionals to consider, establish and appreciate their own preferences for man• Imagine you are a Theorist and you need to communicate information aging and responding to information before considerabout your health profession with a ing the preferences of others. Each particular preference Reflector who has not previously for managing information has advantages and disadvanhad any experience of your health tages (La Motta 2004). Awareness of personal strengths profession. List the differences in and weaknesses allows health professionals to compenyour styles of relating to information. sate for the weaknesses. It also empowers health profesWhat difficulties might you sionals to recognise who can support them because of experience? How will you similarities and who can challenge them to grow compensate for the differences to because of differences. Health professionals who underminimise the difficulties? stand and accept their individual style will be more able Continue this exercise until you have • to understand and accept the style of others. They will imagined yourself to be a Reflector, also be able to adjust their communication style to an Activist and a Pragmatist working accommodate the information management style of with someone who manages information in a different way. those around them to ensure effective communication • Decide which style you use most and positive results. and imagine you are working with There are many descriptions of and theories about someone who employs the same how individuals manage and respond to information style. What are the advantages of (Dunn et╯al 1989, Felder 1993, Fleming 2001, Gardner this scenario? What are the 1983, Given 2002, Honey & Mumford 1986, Kolb disadvantages? 1984, Kolb & Kolb 2005, Piaget 1968, Pritchard 2005, 2008, Reid 2006, Skinner 1989). Careful consideration 80

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of these and others would create volumes; however, the model presented by Honey & Mumford (1986) has value for the health professional and is relatively well known and accessible. Honey & Mumford (1986) suggest four possible styles of managing information: Activist, Theorist, Pragmatist and Reflector. They state that individuals with mature ways of learning adopt any of the four styles for managing information as appropriate (cited in Pritchard 2005, p 57).

Personality and resultant communicative behaviours Over the centuries there have been many descriptions of human personality types.The ideas of Hippocrates (460–370 BC) led to the description of four basic temperaments: sanguine, choleric, melancholic and phlegmatic (Arikha 2007, Kagan 1998). The ideas of Plato (approximately 428–347 BC) led to the development of four descriptors: artisan, idealist, guardian and rationalist (Keirsey 1998). The ideas of the Hellenist philosophers led to the development of the following descriptions of personality: idealist, traditionalist, hedonist and rationalist (Long & Sedley 1987). In the early twentieth century, Carl Jung (1875–1961) pursued theories of the collective unconscious, archetypes and personality types (Berger 2006). In the 1940s, Isabel Briggs Myers and her mother Katherine Briggs began exploring Jung’s theories to explain differences in personality: the Myers-Briggs Type Indicator (MBTI) (Briggs & Myers 1975). In the mid-twentieth century, Oscar Ichazo from Bolivia suggested the Enneagram of personality, which identifies nine types: reformer, helper, achiever, individualist, investigator, loyalist, enthusiast, challenger and peacemaker (Riso & Hudson 2000). Wilson (2004) suggested social styles of relating: analytical, driver, amiable and expressive. These are only a few of the ways of describing human personality. Understanding of the basic personality preferences and combinations thereof, regardless of the system, assists health professionals to understand their own communicative behaviour and the behaviour of others. Particular tendencies determined by personality produce particular characteristics. These characteristics predict a preference for relating in a particular manner within particular situations, and may predict a different style in other circumstances. An awareness of the different personality types assists understanding of differences in styles of managing information and thus styles of communication. Some personality types enjoy working with people and are better communicators than others; others are taskoriented and prefer to work alone. With well-developed skills in self-awareness, individuals can in most cases adjust their personality tendencies while communicating. Knowledge and awareness of individual tendencies can assist individuals to make the required adjustments and to recognise, understand and accept tendencies in others. Health professionals can use this knowledge to produce effective communication.

Chapter summary Self-awareness is important and beneficial for all health professionals. It requires commitment, time, reflection and a sense of humour. Self-awareness sometimes feels uncomfortable, but it allows the health professional to identify their personal values and abilities (along with communication preferences and skills) and to acknowledge and control their thoughts (including negative self-talk) and negative emotions while communicating. It facilitates positive attitudes, honest open interactions and promotes beneficial outcomes, while relating to the diversity experienced when practising as a health professional. 81

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Self-awareness assists health professionals to be aware of their basic primary relationship need and how to control that need when practising as a health professional. It also facilitates awareness of and ways to overcome personal listening barriers when communicating and relating. Self-awareness facilitates acceptance of people with different, sometimes opposite, values, learning styles and personalities allowing the health professional to relate with understanding rather than judgment. The results of self-awareness when practising in a health profession outweigh the challenges, producing positive outcomes that enhance family/Person-centred practice and effective communication.

FIGURE 6.1â•… An effective communicator knows when they communicate like a gorilla!

REVIEW QUESTIONS 1. What four actions does self-awareness allow the health professional to perform? i. ii. iii. iv. 2. What three areas of self-knowledge does self-awareness provide? i. ii. iii.

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3. Health professionals value, demonstrate and enjoy particular things. • State four things that most health professionals value. i. ii. iii. iv. • What three characteristics are essential for health professionals to demonstrate? i. ii. iii. • What should you enjoy if you wish to be a health professional? i. ii. iii. iv. 4. What are three unconscious primary needs that manipulate people? i. ii. iii. 5. Why is it beneficial for a health professional to understand the existence of conflict between needs and values?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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6. How does perfectionism affect people?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 7. What does self-awareness highlight about communication? i. ii. iii. 8. What four styles of learning do Honey & Mumford (1986) suggest? i. ii. iii. iv. 9. How might an understanding of the variations in personality assist a health professional?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 84

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10. What does self-awareness achieve for the health professional in practice ?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

REFERENCES Arikha N 2007 Passion & tempers: a history of the humours. HarperCollins, New York Backus W, Chapian M 2000 Telling yourself the truth, 20th edn. Bethany, Minneapolis, MN Banks S 2006 Ethics and values in social work, 3rd edn. Palgrave Macmillan, Basingstoke Ben-Arye E, Lear A, Mermoni D et al 2007 Promoting lifestyle awareness among the medical team by the use of an integrated teaching approach: a primary care experience. Journal of Alternative & Complementary Medicine 13(4):461–469 Berger A A 2006 50 ways to understand communication. Rowan & Littlefield, Oxford Bombeke K, Symons L, Debaene L et al 2010 Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Medical Education 44(7):662–673 Briggs K, Myers I B 1975 The Myers-Briggs type indicator. Consulting Psychologist Press, Palo Alto, CA Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Davis C M 2011 Patient–practitioner interaction: an experiential manual for developing the art of healthcare, 5th edn. Slack, Thorofare, NJ Devito J A 2007 The interpersonal communication book, 11th edn. Pearson, Boston Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Dirette D 2010 Self-awareness enhancement through learning and function (SELF): a theoretically based guideline for practice. British Journal of Occupational Therapy 73(7):309–318 Dunn R, Dunn K, Price G E 1989 The learning style inventory. Price Systems, Lawrence, KS Eckroth-Bucher M 2010 Self-awareness: a review and analysis of a basic nursing concept. Advances in Nursing Science 33(4):297–309 Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont, CA Ellis R 2009 Communication skills: stepladder to success for the professional [electronic resource]. Bristol, Intellect 85

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Ellis R B, Gates B, Kenworthy N (eds) 2004 Interpersonal communication in nursing: theory and practice. Churchill Livingstone, London (Original work published 2003) Felder R 1993 Reaching the second tier: learning and teaching styles in college science education. Journal of College Science Teaching 23:285–290 Fleming N D 2001 Teaching and learning styles: VARK strategies. VARK-Learn, Honolulu, HI Fulford K W M 2011 Bringing together values-based and evidence-based medicine: UK Department of Health Initiatives in the ‘Personalization’ of Care. Journal of Evaluation in Clinical Practice 17(2):341–343 Gardner H 1983 Frames of mind: the theory of multiple intelligences. Harper & Row, New York Given B K 2002 Teaching to the brain’s natural learning system. Association for Supervision and Curriculum Development, Alexandria, VA Gordon J (ed) 2004 Pfeiffer’s classic activities for interpersonal communication. Pfeiffer, San Francisco Gordon J (ed) 2007 The Pfeiffer book of successful conflict management tools [electronic resource]. Wiley, Hokoben Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holly M L 2002 Keeping a professional journal, 2nd edn. UNSW Press, Sydney Honey P, Mumford A 1986 Manual of learning styles, 2nd edn. P Honey, London Jung C G 1941 The development of personality. Routledge, London Kagan J 1998 Galen’s prophecy: temperament in human nature. Basic Books, New York Keirsey D 1998 Please understand me II: temperament, character and intelligence. Prometheus Nemesis Books, Delmar Kolb A Y, Kolb D A 2005 The learning style inventory, Version 3.1: technical manual. Hay Group, Boston Kolb D A 1984 The learning style inventory: technical manual. McBer, Boston La Motta T 2004 Using personality typology to build understanding. In: Gordon J (ed) Pfeiffer’s classic activities for interpersonal communication. Pfeiffer, San Francisco CA, pp 53–67 Long A A, Sedley D N 1987 The Hellenistic philosophers: Vol 1. Cambridge University Press, Cambridge Milliken M E, Honeycutt A 2004 Understanding human behaviour: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Mohan T, McGregor H, Saunders S et al 2010 Communicating as professionals. Licensed to iChapter Users 86

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Piaget J 1968 Six psychological studies. Vintage, New York Pritchard A 2005 Ways of learning: learning theories and learning styles in the classroom. David Fulton, London Pritchard A 2008 Ways of learning: learning theories and learning styles in the classroom. [Electronic resource] Taylor & Francis, Hoboken Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Radtke J V, Baumann B M, Garrett K L et al 2011 Listening to the voiceless patient: case reports in assisted communication in the communication in the intensive care unit. Journal of Palliative Medicine 14(6):791–795 Reid G 2006 Learning styles and inclusion. Paul Chapman, London (Original work published 2005) Richardson R F II 2010 360-degree feedback: integrating business know-how with social work values. Administration in Social Work 34(3):259–274 Riso D R, Hudson R 2000 Understanding the Enneagram: the practical guide to personality types. Houghton Mifflin, Chicago Rogers C 1967 On becoming a person. Constable, London Rogers W, Ballantyne A 2010 Towards a practical definition of professional behaviour. Journal of Medical Ethics 36(4):250–254 Schore A N 2005 Attachment, affect regulation and the developing right brain: linking developmental neuroscience to pediatrics. Pediatrics in Review 26:204–217 Shih F, Lin Y, Smith M C et al 2009 Perspectives on professional values among nurses in Taiwan. Journal of Clinical Nursing 18(10):1480–1489 Singleton K, Krause E M S 2010 Understanding cultural and linguistic barriers to health literacy. Kentucky Nurse 58(4):4–9 Skinner B F 1989 The origins of cognitive thought. American Psychologist 43:13–18 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Taylor B J 2006 Reflective practice: a guide for nurses and midwives. Open University Press, Maidenhead Wilson L 2004 The social styles handbook: find your comfort zone and make people feel. Nova Vista Publishing, Portland Woolfolk A, Margetts K 2007 Educational psychology. Pearson, Frenchs Forest, Sydney

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ANSWERS TO REVIEW QUESTIONS CHAPTER 6â•… Awareness of self Answers to the following questions provide a summary of this chapter. 1. What four actions does self-awareness allow the health professional to perform? i. Relate positively (unconditional positive regard) to those around them regardless of the presence of negative emotion. ii. Control their thoughts and actions while communicating. iii. Communicate openly and honestly with the courage to care for those around them. iv. Recognise and respond appropriately to the needs of the people around them. 2. What three areas of self-knowledge does self-awareness provide? i. Know how I will react in any situation. ii. Know why I will react to various situations. iii. Know how to control my thoughts and emotions to produce effective practice. 3. Health professionals value, demonstrate and enjoy particular things. • State four things that most health professions value. i. People and their needs. ii. The knowledge and skills inherent in their health profession. iii. Expressions of empathy and respect to develop trust. iv. Collaboration that develops rapport to empower the people to recover functioning in life. • What three characteristics are essential for health professionals to demonstrate? i. Respect and being worthy of trust ii. Honesty and openness iii. Patience and acceptance of others • What should you enjoy if you wish to be a health professional? i. People ii. Communicating iii. Helping people iv. Problem solving

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4. What are three unconscious primary needs that manipulate people? i. The need to be accepted and valued ii. The need to be in control iii. The need for affection and affirmation 5. Why is it beneficial for a health professional to understand the existence of conflict between needs and values? To avoid their specific human relationship need dominating their interactions during their practice. 6. How does perfectionism affect people? They might feel they are never good enough and always feel every comment is a judgement that indicates they are not good enough and have limited value, regardless of affirmation. 7. What does self-awareness highlight about communication? i. The role of successful listening in achieving effective communication. ii. It is essential to understand the needs of everyone communicating. iii. The need to negotiate mutual understanding. 8. What four styles of learning do Honey & Mumford (1986) suggest? i. Activist ii. Theorist iii. Pragmatist iv. Reflector 9. How might an understanding of the variations in personality assist a health professional? An understanding of the personality preferences and how personality types affect communication and behaviour assists health professionals to understand their own behaviour and the behaviour of others. 10. What does self-awareness achieve for the health professional in practice? Self-awareness allows the health professional to: • Ignore their personal need when relating • Assists them to identify and overcome their personal barriers to listening • Assists them to accept people regardless of how different they may be to the health professional • Facilitates interacting without judgement.

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CHAPTER 7â•…

Awareness of how personal assumptions affect communication CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Understand and recognise stereotypical judgement • Account for the effect of stereotypical judgement upon communication • Examine some of their personal stereotypical prejudices and expectations • Demonstrate the importance of communicating without stereotypical judgement • Describe the characteristics of a health professional who communicates without stereotypical judgement • Explain how to overcome tendencies to stereotype and judge • Develop strategies that promote non-judgemental communication.

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Communicating without judgement occurs when the individual avoids making a judgement about a Person/s based on personal values and beliefs. Value-laden judgements often occur because of appearance or some observable behaviour or characteristic that creates stereotypical expectations (Purtilo & Haddad 2007). The values and beliefs of an individual, although often invisible (Ellis et al 2004), provide the foundation for biases that create stereotypical judgements. These often-irrational biases develop over time from significant others or parental models (Milliken & Honeycutt 2004). They can create prejudice towards particular types of people or groups (Brill & Levine 2005). Stereotypical judgements may be positive or negative. For example, a judgement stating that all surfers are able-bodied and fit is positive, if being able-bodied and fit are considered positive attributes. However, this statement may not always be true. Similarly, a judgement stating that all Muslims condone violence and terrorism is negative, if violence and terrorism are considered negative attributes, but this statement is definitely not always true. A stereotype is a fixed impression about a person or group (Devito 2007, 2009, Eckermann et al 2010) that may have some connection with reality because there may appear to be some similarities within the people or group. A stereotype in itself may initially be beneficial because it provides a framework from which to commence communication (Eckermann et al 2010). However, if the stereotype produces judgements that dominate all communication with an individual or group it can be detrimental, because it limits the possibility of relating to more than the stereotype (Holliday et al 2010).

Reasons to avoid stereotypical judgement when communicating Biases, prejudice and resultant judgements can negatively affect communication – they may result in conflict (see Ch 13), misunderstandings (see Ch 16) and communication breakdown (Mohan et al 2004, 2008). These are good reasons why health professionals should avoid stereotypical judgements based on prejudice (Egan 2010, Vorman & Cote 2011). However, there are additional reasons to avoid stereotypical judgement. Stereotypical attitudes often develop from limited information (ignorance) or misinformed assumptions (Amering 2011, Brill & Levine 2005, Holliday et al 2010) thus producing incorrect resultant judgements. This potentially means that if a health professional is relating to someone through a stereotype, they have reduced the Person/s to something that is less than who they are and therefore the health professional is not allowing the Person/s to have thoughts and opinions that do not conform to the stereotype. It is also possible that the stereotype is based on an unconscious belief about an ‘in’ group and a subordinate ‘out’ group (Bowe & Martin 2007). This suggests the beliefs or culture of the person making the stereotypical judgement are the standard for evaluating the ‘other’

EXPLORE YOUR PREJUDICE (Adapted from Devito 2007) •

What are your honest answers to the following questions?  Are you willing to have a close friend from any other culture or religious group?  Are you willing to have a long-term romantic relationship with someone from another culture, political party or religious group?  Are you willing to choose to talk to someone who ‘lives on the street’ (is homeless) when you are out shopping?  Are you willing to allow people who are obviously different to you to have value and credibility? • Are you able to answer with a definite yes? If not, are you able to determine the source of your biases? • What can a health professional do to overcome any unconscious tendency to stereotypical judgements?

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Person/s or culture (Tyler et al 2005). Stereotypical judgement usually occurs unconsciously and thus has serious implications for health professionals (Lyons & Kashima 2003). If unconscious, prejudice and possible resultant stereotypical judgements will unknowingly influence the communication of the health professional, with potentially unpleasant results. Although a stereotypical judgement may benefit the person holding the stereotype because it justifies their own characteristics or values, it produces lenses that negatively affect communication. Devito (2007) states that a stereotypical judgement creates two major barriers when communicating. The first barrier occurs if there exists a set idea about the person or their group. This idea will limit the ability to hear or experience anything that is different to the constructs of the stereotype. The second barrier limits the possibility of relating to particular qualities or abilities within the person if those qualities contradict the stereotype. In such cases, the stereotypical judgement may not allow the person to be unique or different to the stereotype. For example, a young health professional can be as competent as an older one, but a stereotypical judgement may not allow them to be considered competent. Alternatively, an elderly person may lead a very active life despite the stereotypical judgement that elderly people are frail and dependent. If such stereotypical judgements occur, all communicators experience limited negotiation of meaning and mutual understanding – if they do occur, communication is likely to fail. More importantly, while these barriers limit the possibility of effective communication, they also limit the potential to achieve family/Person-centred practice and positive intervention outcomes.

Stereotypical judgement that relates to roles Stereotypical judgements often lead to expectations of particular behaviour within particular roles. This is potentially as detrimental as applying a stereotype to the characteristics of a person or group (Crawford et al 2011). Expectations of particular behaviour from a person in the role of an administration assistant, for example, are beneficial whenever that person behaves according to What behaviour represents an ‘ideal’ • those expectations. If an individual expects an adminPerson/s? Answer this question alone, istration assistant to make their favourite hot drink making a list of behaviours. Use your every morning but the administration assistant does expectations, not those of other health not consider that activity part of their role, there will professionals. be potential disappointment in one person and anger in the other. Understanding stereotyping facilitates consideration of what behaviour a health professional • Discuss the individual lists within a group and together agree upon a list. expects from the Person/s (Thompson 2006) and • How would these expectations affect what the Person/s might expect from a particular the reactions to, and communication health professional role. with, someone who does not behave according to these expectations? • How can a health professional ensure they allow the Person/s to be unique and thus fulfil their unique needs regardless of the particular role of the health professional?

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EXPECTATIONS OF A HEALTH PROFESSIONAL Many individuals have stereotypical attitudes that affect their expectations of people and situations. While parental influences contribute to the creation of these attitudes, experience will also influence them. A person who has a negative experience

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with one health service or health professional may generalise this experience to expect similar experiA young mother brings her 3-year-old ences from all health professionals (Holliday et al child who has Down syndrome to a 2010). It may take only one negative experience with speech pathologist for assistance with a particular health professional to create the expectaoral communication. At home, the child verbalises and communicates. However in tion that all individuals from that health profession the clinic, the child is nervous and will be the same (Harms 2007, Harms & Pierce overwhelmed by the situation, so the child 2011). It is the responsibility of the health profesdoes not communicate or respond in any sional to communicate without stereotypical judgeway. The health professional assumes the ment or expectations, because it is important to avoid child cannot verbalise and, not listening to reinforcing any existing negative stereotypes. the mother, provides strategies to manage An ‘ideal’ health professional demonstrates a non-verbal child. differing behaviours and communicative qualities according to the needs of the individual and the requirements of the particular situation (Green et al 2006). The following list highlights the characteristics and behaviours of an ideal health professional that will affect the quality of their communication. An ideal health professional should be: • Discuss honestly how the group members would respond. • Reflective and self-aware (Dossey et al 2005b, Harms 2007, Harms & Pierce 2011, Purtilo & The mother, upset and infuriated, never returned to that speech pathologist and Haddad 2007) took some time to seek the assistance of • Knowledgeable about and skilled in their health another. profession (Stein-Parbury 2009) This health professional demonstrated Respectful and caring (Brill & Levine 2005) • stereotypical judgements that negatively Warm and genuine (Ellis et al 2004, Harms • affected the vulnerable mother for some 2007, Harms & Pierce 2011) time. This response was not conÂ�ducive to • Open and humble (Devito 2007, 2009) fulfilment of family-centred practice and • Willing to be human and supportive, often certainly limited communication. emotionally and sometimes through touch (Dossey et al 2005a, Egan 2010, Harms 2007, Harms & Pierce 2011) • Concerned about others and open to differences (Tyler et al 2005) • Honest and sensitive (Devito 2007, 2009, Higgs et al 2005, 2010). People sometimes expect specific physical characteristics of an individual in a particular role. For example, some people seeking assistance refuse to see a young health professional. They believe a young health professional cannot possibly have enough experience to be competent, and therefore • If you have sought assistance from a health professional, what were your will only see a health professional over a particular expectations? Is there anything else to age. Some young health professionals take special care add to the above list? to appear older in order to combat this stereotypical • Do the characteristics in the above list expectation. Some people apply gender stereotypes to assist in the creation of a health particular health professional roles. In such cases, a professional who communicates person may insist on receiving assistance from a without stereotypical judgement? health professional of a particular gender if they Explain how and why. believe that only a female/male should fulfil that role. For example, some people believe that nurses or 91

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massage therapists should be female and medical specialists or physiotherapists should be male. If a Person/s holds any stereotypical expectations, this can affect the development of trust and rapport, thereby affecting any subsequent communication. Overcoming the stereotypical expectations of others requires perseverance and sound professional practice. Similarly, if a health professional holds stereotypical expectations of the Person/s there are usually comparable consequences. Overcoming personal stereotypical judgement in the health professional requires careful, self-aware vigilance and tolerance in order to maintain non-judgemental attitudes and communication (Mohan et al 2004, 2008).

Developing attitudes that avoid stereotypical judgement Most individuals have unconscious values and beliefs that create unconscious biases and stereotypical judgements. Many biases develop when a parent expresses a particular sentiment that the child then adopts (Milliken & Honeycutt 2004), often with more conviction than the parent. Such convictions create stereotypical judgements which, when superimposed upon information HONEST EVALUATION OF and behaviour, increase the complexity of any interaction and certainly create barriers to effective comVALUES AND PREJUDICE munication (Carter & Iacono 2002). Honest evaluation of current values and beliefs that cause bias and prejRead the following points and write down udice is essential to produce communication in your immediate and honest response to health professionals that avoids stereotypical judgeeach of these groupings. Avoid trying to ment (Brill & Levine 2005, Devito 2007, 2009, Egan explain or change your thoughts – simply 2010, Goodall 2011). write down the thoughts that immediately come into your mind. It is essential to overcome the biases that create stereotypical judgements that negatively influence • What are your attitudes or bias towards: responses to people who are different (Milliken &  A person who is obese Honeycutt 2004). Self-awareness is essential to over A person with an intellectual come these biases (see Chs 5 & 6). Seeking exposure disability to particular groups or people who are different with  A person who smokes an open and accepting attitude is also beneficial in  A person who has a hearing this process (Hill 2010, Purtilo & Haddad 2007). impairment Such exposure will allow development of perceptions  A person who is homeless or lives based upon experiences; it will provide information on the street about similarities as well as differences. Exposure to  A person who is Muslim (Did you particular groups or people will reveal that there are know there are various types of many variations within any grouping and reinforce groupings within the Muslim faith?)  A person with a different sexual the uniqueness of every individual regardless of their ethnicity or their departure from societal norms. An orientation to you? example of a common stereotypical judgement from • Are there any other ‘groups’ of people that elicit a negative stereotypical many Westerners is that Asians are all the same. In response in you? Explain why. reality, there are many different countries in Asia and • Consider how your reactions will affect within those countries there are a multitudinous your ability to communicate without number of ethnic groups and variations within these stereotypical judgement if assisting groupings. It takes exposure and willingness to anyone from these groups. perceive and accept the differences (tolerance) to understand that Asians are definitely not all the same.

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If the health professional finds it difficult to expose themself to and accept differences, it can be beneficial to explore the basis of the attitudes of those health professionals who regularly communicate without judgement (Mir & Sheikh 2010, Mohan et al 2004). Discussion of how the non-judgemental individual achieves this may assist a health professional who is struggling to overcome stereotypical judgements that negatively affect communication. It is important that health professionals understand and accept those around them despite the differences. In order to avoid judgemental communication health professionals will benefit from being aware of their personal stereotypical attitudes and from seeking experiences that will change those attitudes (Bowe et al 2003, Hill 2010). It is beneficial for health professionals to be flexible and willing to regularly evaluate their personal opinions and attitudes (Devito 2007, 2009). When reacting with a negative attitude based upon a stereotypical prejudice, it is important that health professionals strive to overcome that judgement. An awareness of the bias that produces the judgement facilitates change in that bias and ultimately acceptance of the ‘different’ individual or group. Stereotypical judgement will limit any perception of the worth or value of the person or their opinions. The judging person will find reasons why that particular individual does not have value or worth. For example, thoughts such as They will be lazy because they are overweight or They will be unreliable because they smoke – they’ll always be off smoking limit the ability to acknowledge any hard-working or reliable behaviour from that individual. Alternatively, thinking Oh here is another extremist – looks like recycling will be more important than the quality of the work they do limits the possibility of acknowledging the benefits of recycling or the value of the ‘extremist’. Stereotypes and biases prompt judgement of the person on outward appearances or behaviour (e.g. age, gender, skin colour, clothing, jewellery, religious grouping, nationality, political party or particular behaviours), rather than perceptions of their personal attributes and value. In the health professions, this tendency results in the labelling of people. The overweight person is ‘lazy’, the person who smokes is ‘unreliable’ and the person who values recycling is an ‘extremist’ or fanatic. • What labels did you or another student While labels may reflect something, in reality they have at school? are unhelpful and dehumanise the person, removing How did these labels make you or the • them from emotions and value. It is common to hear other student feel? statements such as The knee in Room 407 within some What are the implications of these • health professions and, while understandable from feelings for health professionals? many perspectives, such statements are unhelpful and unnecessary. A bias restricts the ability to understand a person, their thoughts and actions. The presence of bias and stereotypical judgement in a health professional does not allow the health professional to view the person as they actually are and, therefore, seriously restricts their ability to demonstrate empathy, acceptance and a sense of equality.

Overcoming the power imbalance: ways to demonstrate equality in a relationship Non-judgemental thoughts and behaviours promote equality and acceptance. The understanding that each person is vital and important (Milliken & Honeycutt 2004) assists in achieving equality when communicating. It is important to remember that health professionals are in a position of power because of their knowledge and familiarity with their 93

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TABLE 7.1â•… Promoting equality when communicating as a health professional Do:

Do not:

• Acknowledge the person • Acknowledge what they say, regardless of agreement with the statements • Acknowledge cultural differences and learn about those differences • Adjust practice to accommodate cultural differences • Be tolerant of differences.

• Make demands (e.g. Get that done now) – instead make polite requests • Make ‘should’ or ‘must’ statements (e.g. You must do these exercises or keep to that diet) – they imply judgement and non-compliance • Interrupt – this suggests your ideas are more important than those of others.

Adapted from Devito 2007.

role and the particular health service. This understanding emphasises the need to express acceptance and avoid communicating a sense of superiority. Flexibility and humility are key characteristics (Devito 2007, 2009) that contribute to the construction of equality in relationships in all health services. In addition – if differences stimulate stereotypical judgements – there are particular responses that promote equality when communicating (see Table 7.1). Non-judgemental communication requires conscious awareness of consistent thoughts and repeated responses, to avoid stereotypical judgements in communication. It requires self-awareness and tolerance that promote acceptance and respect for the Person/s regardless of the challenges. Non-judgemental communication has many rewards.

Chapter summary Stereotyping refers to biases that develop over time and create prejudice towards certain people or groups. Communication based upon stereotypical judgements limits the possibility of relating to the whole Person/s and can result in misunderstandings. It is important for health professionals to develop attitudes of unconditional positive regard for all Person/s who seek their assistance. Non-judgemental communication is the key to overcoming the inherent power imbalance in the relationship between the health professional and the Person/s.

FIGURE 7.1â•… Assumptions can form a barrier.

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REVIEW QUESTIONS 1. How can a health professional avoid communicating a stereotypical judgement?

2. What is a value-laden judgement?

3. What can value-laden judgements often create?

4. Where do values and beliefs originate?

5. What can values and beliefs create?

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6. Focus upon stereotypes: • Define ‘stereotype’ and give an example of a positive and a negative stereotype.

• Are the stereotypes you isolated representative of the social norms within your health profession?

• If not, are they important?

• What should you do to adjust your ideas?

7. Give three reasons why it is important for health professionals to avoid communicating stereotypical judgement. i. ii. iii. 8. What communication barriers can stereotypical judgement produce? i. ii.

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9. Give original examples of stereotypical expectations of behaviour that accompany particular roles.

10. Give original examples of stereotypical expectations of characteristics that accompany a particular role.

11. Identify the characteristics of a health professional that are most closely related to effective communication skills. Explain why and how.

12. Suggest three ways a health professional can avoid stereotypical judgement. i. ii. iii. 13. List five behaviours (some of which are communicative) to overcome the power imbalance in the relationship between the health professional and the Person/s seeking assistance. Give original examples of each behaviour. i. ii. iii. iv. v.

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REFERENCES Amering M 2011 Trialog – concept and research. European Psychiatry 26:2102 Bowe C M, Lahey L, Armstrong E et al 2003 Questioning the ‘big assumptions’. Part I: addressing personal contradictions that impede professional development. Medical Education 37(8):715–722 Bowe H, Martin K 2007 Communication across cultures: mutual understanding in a global world. Cambridge University Press, Melbourne Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Carter M, Iacono T 2002 Professional judgments of the intentionality of communicative acts. Augmentative & Alternative Communication 18(3):177–191 Crawford J T, Jussim L, Madon S et al 2011 The use of stereotypes and individuating information in political person perception. Personality & Social Psychology Bulletin 37(4):529–542 Devito J A 2007 The interpersonal communication book, 11th edn. Pearson, Boston Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Dossey B M, Keegan L, Gussetta C 2005a Holistic nursing: a handbook for practice, 4th edn. Jones & Bartlett, Sudbury MA Dossey B M, Keegan L, Gussetta C 2005b A pocket guide for holistic nursing. Jones & Bartlett, Sudbury MA Eckermann A, Dowd T, Chong E et al 2010 Binaŋ Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Ellis R, Gates B, Kenworthy N 2004 Interpersonal communication in nursing: theory and practice, 2nd edn. Churchill Livingstone, London (Original work published 2003) Goodall C E 2011 An overview of implicit measures of attitudes: methods, mechanisms, strengths and limitations. Communication Methods and Measures 5(3):203–222 Doi:10.1080/10312458.2011.596992 Green R, Gregory R, Mason R 2006 Professional distance and social work: stretching the elastic? Australian Social Work 59:449–461 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Holliday A, Hyde M, Kullman J 2010 Intercultural communication: an advanced resource book for students. Routledge, New York Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Hill T E 2010 How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. Philosophy, Ethics & Humanities in Medicine 5:11–24 Lyons A, Kashima Y 2003 How are stereotypes maintained through communication: the influence of stereotype sharedness. Journal of Personality and Social Psychology 85:989–1005 Milliken M E, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York 98

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Mir G, Sheikh A 2010 ‘Fasting and prayer don’t concern the doctors … they don’t even know what it is’: communication, decision making and perceived social relations of Pakistani Muslim patients with long-term illnesses. Ethnicity & Health, 15(4):327–342 Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Thompson N 2006 Anti-discriminatory practice. Palgrave Macmillan, Basingstoke Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney Vorman K, Cote S 2011 Prejudicial attitudes toward clients who are obese: measuring implicit attitudes of occupational therapy students. Occupational Therapy in Health Care, 25(1):77–90

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ANSWERS TO REVIEW QUESTIONS CHAPTER 7â•… Awareness of how personal assumptions affect communication Answers to the following questions provide a summary of this chapter. 1. How can a health professional avoid communicating a stereotypical judgement? The best way is to avoid making any judgements about people, by being self-aware and tolerant to any differences. 2. What is a value-laden judgement? A judgement made about a person because of their appearance or action or characteristic. 3. What can value-laden judgements often create? They can create judgements based on stereotyping people because of their behaviour, appearance or a particular characteristic. 4. Where do values and beliefs originate? Values and beliefs originate from parents or significant others. 5. What can values and beliefs create? They can create biases that produce prejudice toward particular people or groups. 6. Focus upon stereotypes: • Define ‘stereotype’ and give an example of a positive and a negative stereotype. A stereotype is a fixed idea about a person or group of people. An example of a positive stereotype is children are always resilient and ‘bounce back’ quickly. An example of a negative stereotype is that people with grey hairs need assistance because they will not be able to think clearly. • Are the stereotypes you isolated representative of the social norms within your health profession? Not really, but they often relate to children or people with grey hairs in my Western middle class society. • If not, are they important? They are only important if they affect the way I relate to people when I am practising as a health professional. • What should you do to adjust your ideas? You have to be aware of your ideas before you can adjust them! O’Toole 2e. © 2012 Elsevier Australia

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7. Give three reasons why it is important for health professionals to avoid communicating stereotypical judgement. i. They can produce conflict. ii. They often develop from ignorance or lack of information about someone or a group. iii. They may stop the health professional from relating to the ‘real’ person and this will affect communication and the results of interventions. 8. What communication barriers can stereotypical judgement produce? i. It can stop the health professional from hearing or experiencing anything that is contrary to the stereotypical judgement. ii. It can also stop the health professional from noticing or relating to particular qualities or abilities if they are contrary to the stereotype. 9. Give original examples of stereotypical expectations of behaviour that accompany particular roles. A teacher explains what they expect and then expects it to happen in the outlined time frame. 10. Give original examples of stereotypical expectations of characteristics that accompany a particular role. The person seeking assistance is always demanding – they expect too much of the health professional. 11. Identity the characteristics of a health professional that are most closely related to effective communication skills. Explain why and how. These characteristics include being self-aware and reflective; having knowledge and skills related to their particular health profession; being respectful and caring, warm and genuine; open and humble; willing to be supportive, even touching when appropriate; being concerned about others, sensitively honest and accepting of differences. 12. Suggest three ways a health professional can avoid stereotypical judgement. i. Honestly evaluating their personal values and prejudices. ii. Openly relating to those people about whom they have stereotypical judgements and learning about them, identifying the similarities, and being tolerant and accepting of any differences. iii. Talk to a health professional colleague who communicates and relates without stereotypical judgement and explore how they achieve this.

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13. List five behaviours (some of which are communicative) to overcome the power imbalance in the relationship between the health professional and the person seeking assistance. Give original examples of each behaviour. i. Acknowledge the person and their feelings. ii. Acknowledge what they say whether you agree or not with their ideas. iii. Identify any cultural differences and learn about those differences. iv. Where possible adapt practice and interventions to accommodate cultural differences. v. Be open and tolerant to differences thereby demonstrating respect and acceptance.

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CHAPTER 8â•…

Awareness of the ‘Person/s’ CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Demonstrate awareness of necessary information to understand the Person/s • Appreciate the required elements for effective communication with the Person/s, specifically respect, confidentiality and empathy • State and understand who the Person/s is from the perspective of the health professional • Define and demonstrate a holistic awareness of the Person/s • Consider the physical aspects and obvious needs of the Person/s when communicating • Demonstrate awareness of and skills in the use of validation, empathy, touch and silence to relate to the emotional aspects and emotional needs of the Person/s • Recognise the significance of the sexual aspect and needs of the Person/s while practising • Understand and describe the impact of the cognitive aspects and skills of the Person/s (see also ‘A person who has decreased cognitive function’ in Section 4) • Relate to the possible implications of the social aspects and needs of the Person/s • Understand the need to relate to the spiritual aspects and needs of the Person/s.

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Effective communication with the Person/s requires understanding and consideration of various aspects of that individual. However before discussing these aspects, it is necessary to consider important elements of communication that will assist the health professional when communicating with the Person/s.

Who is the Person/s? First, it is important to reiterate who constitutes the Person/s from the perspective of the health professional. As mentioned earlier in the book, this perspective indicates the Person/s includes both those seeking assistance as well as the various health professionals and supporting staff providing the assistance (Ogletree & Archer 2011). Those seeking assistance include the individual who requires direct intervention, along with the carers, families, friends, neighbours and, in some cases, guardians of that individual. Health professional colleagues include individuals from many health professions. Some of these health professionals may form a multidisciplinary, multi-professional team within the particular health organisation, while others may contribute to fulfilling the needs of the Person/s from outside the organisation. Supporting staff are found in every health service and provide essential assistance to both health professionals and those they assist. These Person/s include those who answer the phone and those who clean the floors and toilets. Their contribution is vital and it is important to recognise that their contribution is an equal part of the service of any health profession.

The purpose and benefit of an essential criterion: respect As mentioned in Chapter 2, respect is a foundational component of the aim of a health profession to achieve family/Person-centred practice and thus positive outcomes. Respect is essential in order to achieve both of these aims (Elander et al 2011). It is for this reason that this chapter contains a deeper exploration of this component. Respect is more than an attitude or a value about viewing people from a particular perspective (Egan 2010). It provides the basis for appropriate ways of relating to the Person/s and requires particular behaviour (Sander et al 1997). The demonstration of respectful behaviour toward the Person/s requires health professionals to respect themselves. Respecting the self protects the health and wellbeing of the health professional. It also maintains satisfaction and contributes to the fulfilment of both personal and professional goals (Purtilo & Haddad 2007). Demonstration of respect requires commitment to competent communicative and interpersonal practice – Person-centred practice (Chenowethm et al 2006). While the behaviours associated with demonstrations of respect are often non-verbal, they are easily recognised as respect.

Defining respect Respect is an underlying personal value that determines both attitudes and actions; as such, it is difficult to define. The following attempt to define respect combines various definitions of this value. Respect does not respond to an individual positively merely 101

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because of their status or position or role in society. It is not about liking someone or admiring someone. Respect is an interest in and acknowledgement of the Person/s, their viewpoint and their emotions (Stein-Parbury 2009). It assumes that everyone has innate worth and value (Egan 2010). Respect allows everyone to be themselves and to express themselves honestly without condemnation, ridicule or criticism (Long 1978). It does not impose personal values, and thus expresses no judgement (Davis 2011). Respect believes in the potential of each individual and provides the basis for action that assists in the fulfilment of this potential. It believes that each individual is valuable, regardless of their appearance or actions, past and present (Bergland & Saltman 2002). Respect values the Person/s regardless of age, colour, racial group, position, uniform, state, relationship, social status or other characteristics. It gazes past the negatives and positives to the inherent worth at the core of the Person/s (Purtilo & Haddad 2007) – a worth shared by all human beings.

•

What is your immediate emotional response to: Someone who lives on the street wearing one set of torn, dirty clothes with all their personal possessions in a damaged shopping trolley  Someone with a different sexual preference to you  A local sports star  A drunken person who offers you a drink  A policeman  A 58-year-old slightly overweight woman wearing a tight, short skirt and a singlet top, lots of cheap jewellery and heavy, poorly done make-up, whose lipstick is not restricted to her mouth  A Salvation Army officer? • Do you have an experience or particular values that explain your immediate response? 

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Compile a list of factors that contribute to negative and positive responses and thus potentially restrict demonstration of respect. Suggest ways of overcoming any negative responses in order to demonstrate respect. What feelings arise in response to the following?  I say what I think, it doesn’t matter what happens as a result.  No-one tells me what to do. I make my own decisions.  I don’t pay ‘board’ (contribution for food and so on at home). I couldn’t buy designer clothes if I paid to live at home.  I must be true to myself and do what I want to do.  I do whatever I have to for ‘the good life’. Decide what is important to the person making each statement. Write responses to the attitudes expressed in the statements that demonstrate respect but do not necessarily agree with the statement.

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Demonstrating respect

• Each group member thinks about The following attitudes, characteristics or behaviours someone they do not respect – demonstrate respect: interest, warmth, friendliness, sometimes this is someone with approachability, active concern, honesty, authenticity, different values and beliefs. responding to the needs of the Person/s and giving While thinking about that Person, • careful attention to those needs (Purtilo & Haddad each group member takes a turn to 2007). attempt to relate to another group It is not always easy to demonstrate respect even member who is pretending they are when there are shared values, beliefs and positive that Person. Try to relate with the feelings towards someone. Thus, to demonstrate following: warmth, friendliness, respect when the Person/s acts contrary to the values approachability, understanding, and beliefs of the heath professional can be extremely interest, active concern and challenging. In such situations it is difficult to recogacceptance. nise the worth of the individual – to believe in the • How easy is it to demonstrate these attitudes when you do not actually reality of that worth and to act according to that feel them? worth. • As a group, discuss whether the The Person/s seeking assistance is vulnerable, expression of the above attitudes thus responsibility lies with the health professional appeared authentic and honest. to demonstrate respect. It is imperative that the What would make them authentic health professional behaves in a manner that comand honest? municates the Person/s is important – worthy of the investment of time and energy (Wojciszke et al 2009). Also important is acceptance of the individual and being available for them regardless of their dysfunction, disfigurement or the demands on time. Discuss possible strategies that would Rogers (1967) suggests it is beneficial to expect or overcome the barriers to demonstrating believe that somehow the Person/s will be able to respect when relating to someone who overcome the current challenges; that they will peryou find difficult to respect. severe and reach the established goals. In situations where the Person/s appears resistant and uncooperative, it is important that the health professional demonstrates understanding of their perspective and their feelings, assisting as necessary to achieve collaboration. While challenging, it is also important to demonstrate respect when personal values and expectations are different to those of the Person/s. Respect does not mean that the Person/s can manipulate or avoid responsibility for their actions. Respect requires the health professional to challenge the Person/s to act to achieve the established goals of the intervention (Egan 2010). Respect is a foundational value that is essential for effective and positive communication in all health professions. CULTURAL EXPECTATIONS Demonstrating respect can cause difficulty for health professionals when relating to Person/s from particular cultural groups (see Chs 14 & 15). Different cultures have a variety of expectations related to respectful behaviour and thus may expect particular behaviour in specific situations as a demonstration of respect. Some of these behaviours relate to non-verbal cues (e.g. eye contact; see Ch 12) or the use of particular colours in specific circumstances (Devito 2009). Other behaviours relate to specific actions when first meeting or seeing each other after an initial introduction (e.g. some cultures allow men to embrace and kiss in public, others have particular handshakes, while others kiss 103

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twice or maybe three times on the cheek depending on the situation and the culture). Some cultures demonstrate respect according to gender and/or age, and thus expect particular behaviours related to the gender and/or age of either the health professional or the Person/s. When working with people from different cultural backgrounds it is essential to seek information about attitudes and expected behaviour governed by and relating to respect (see Chs 14 & 15).

USING NAMES AS A SIGN OF RESPECT The name of an individual has particular meaning and generally identifies them. Using the name of the Person/s indicates interest and acknowledges them as separate from other people. It indicates value and thus demonstrates respect. Asking an individual the name they prefer is very important when first communicating. Individu• If you are in an unfamiliar place, how als from particular generations or cultures prefer the do you feel if someone greets you use of their family name (e.g. Mr Thomas or Mrs by using your name? Berk), finding the use of their given name offensive. • What does this mean for a practising Using the preferred name during subsequent comhealth professional? municative interactions continues to demonstrate respect and contributes to the development of a therapeutic relationship.

CONFIDENTIALITY DEMONSTRATES RESPECT Confidentiality refers to ensuring information remains within a particular context (SteinParbury 2009; see Ch 17). It is another way of demonstrating respect. All information about the Person/s is confidential. Confidentiality involves keeping information private. The information, whether written or verbal, is available only to those with the right to access that information (Higgs et al 2005, 2010). It is important that health professionals avoid sharing any information about the Person/s they assist in any context except at work. It requires health professionals to restrict what information they provide, to whom they provide the information and when they provide that information. Some of this information is recorded in particular records or databases. Any such records should not leave the health service setting nor should databases be accessed anywhere but on the health service premises except for legal reasons. Such records or databases should not be taken off or accessed off the premises to complete an entry nor should they be left for easy access on a desk or screen overnight. When gathering information it is important to indicate to the Person/s whether particular information will be shared, how it will be shared, with whom it will be shared and the reason for sharing the information. Many healthcare services require the Person/s to sign an informed consent form (see Ch 17) before commencement of services. These forms generally indicate who may receive information about the Person/s (Higgs et al 2005, 2010).

What information will assist the health professional when relating to the Person/s? Some types of information will be more relevant to some health professionals than others. For example, knowing the dominant hand of the individual seeking assistance is highly relevant for particular health professions whereas for others it is irrelevant. There are other 104

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types of information about the Person/s that are important regardless of the health profession. It is Try to remember a time when the beneficial to know the abilities, age and gender of the messages you received were too simple Person/s because this can guide the expectations, or too complicated, that is, when practice and communication style of the health prosomeone thought you knew less or more about a particular thing. An fessional. For example, knowing their particular abiliexample could be when relating to a ties might facilitate adjustment of expectations; tradesman, doctor, mechanic or knowing the age of the Person/s allows the health astrophysicist – an expert in a particular professional to adapt their language level; and area who continues to inappropriately knowing their gender might guide the topic of use their jargon or unnecessarily conversation (Brito et al 2011). simplifies it. When communicating with the Person/s it is • Discuss the feelings associated with important to know the reason why they are seeking this experience. assistance and, where applicable, the cause, condition Discuss non-verbal ways of • or diagnosis that explains their need. It is important responding to this situation and their to know what they expect from the service of the possible effects – positive and particular health profession and to know the goals negative. they want to achieve through intervention. It may be • Suggest ways of avoiding important to know their previous experience with inappropriate methods of communicating when practising as a the health professions because this information may health professional. explain particular reactions. It may also be important to know their background and perhaps their interests. There are usually relevant forms specific to health services that provide a basis for questions to gather the required information. This type of information, while necessary, is not the focus of this chapter. The major focus of this chapter is the unseen needs of the Person/s, particularly their emotional, sexual, cognitive, social and spiritual needs. Although perhaps considered obvious, the noticeable physical needs of the Person/s also require brief consideration as they can affect the reaction of the health professional.

THE WHOLE ‘PERSON’ The consideration of the ‘Person’ in the health professions requires consideration of the whole Person (see Ch 11). The ‘whole’ Person is a dynamic system in which every aspect of the individual simultaneously affects and interacts with the other aspects. The whole Person contains five fundamental aspects: the physical; the emotional, including the sexual aspect; the cognitive; the social; and the spiritual aspect (Brill & Levine 2005). The dynamic interaction of these aspects influences and may determine skills in communicating and interacting. It is important for health professionals to consider the needs associated with all aspects of the Person. Consideration of the most obvious aspect of the Person while neglecting the less obvious aspects limits the potential outcomes of the health service. The most obvious aspect of an individual is usually the physical one, because it is immediately noticeable. However, the other aspects of this dynamic system become obvious during repeated interactions with the health professional. Ignoring the less obvious aspects of the individual can adversely affect the results of interventions. The emotional aspect of the vulnerable individual may not be immediately obvious but may dominate the Person/s seeking the assistance of a health professional. If it becomes obvious the emotional aspect of the Person/s is dominating their functioning, it is 105

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important to address the issues causing the emotional distress either directly or by referral to the appropriate health professional. Resolution of emotional distress allows the Person/s to focus on the relevant health-related goals rather than the dominating emotions. Recognition and willingness to relate to the sexual aspect of an individual may be essential in some health professions. In some cases, unconditional acceptance of the sexual preference of the individual is important for positive outcomes. As the health professional continues to relate to each individual, the cognitive aspect of that Person/s may become more obvious if there is difficulty in processing cognitive information. In such cases, lack of ability or desire to collaborate is not always resistance. It may arise from lack of understanding because of decreased cognitive ability or limited language skills. The previous social and cultural experiences or background of the individual may be the least obvious and often the most significant aspect affecting expectations and outcomes for individuals. Experiences because of previous social interaction may affect the • List the various health professions response of the Person/s to particular interactions that may also provide assistance to with health professionals. Cultural norms can also any person you might assist. influence interactions; thus awareness of cultural Consider both government and norms is essential when relating to people from difnon-government medical and ferent cultures (see Chs 14 & 15). An important alternative health services. Do not aspect that can dominate the individual is the spiriforget that the person might have tual aspect. Many health professionals neglect this feet, teeth, joints and various needs aspect, but it may influence the motivation and interthat health professionals outside the traditional medical model are best est of the Person/s and thus the outcomes of any qualified to fulfil. health professional intervention. All the above aspects • List the various support staff that are of an individual contribute to the functioning and necessary for the effective practice performance of the Person/s. Consideration of each of your health profession. aspect of the Person/s while practising as a health Remember the maintenance of the professional is potentially beneficial for the individubuilding and also the grounds if you als seeking assistance. It enhances the development of use an outside area for intervention. the therapeutic relationship and thus the results of the overall intervention.

PHYSICAL ASPECTS OF THE PERSON A Person/s with obvious physical needs, who is seeking the assistance of a health professional, may or may not require specific action from them. Someone in a wheelchair may require a clear passage to a particular destination or may feel more comfortable if the health professional sits to communicate with them rather than standing over them. There are obvious physical characteristics of the Person/s that communicate particular information and it is important that health professionals be aware of their reactions to these characteristics. It may appear possible to assume the socioeconomic background of an individual by their designer clothing or the amount and type of jewellery they wear. However, it is important to remember that this vulnerable Person/s is seeking to present a particular image and that their clothing may in fact be an attempt to present a nonexistent state. Assuming the socioeconomic background of a smelly ‘other’ with dirty and cheap clothing is equally dangerous. It is important that health professionals avoid making assumptions because of the appearance of the Person/s (See Ch 12) and remember to relate equally to each individual regardless of physical characteristics. 106

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It is sometimes possible to assume the cultural and religious background of an individual because of their clothing; once again, however, it is necessary to take care when assuming anything about someone because of their appearance. Respect and professional training in the health professions guide appropriate responses to the physical appearance and physical needs of the Person/s, and empower health professionals to respond appropriately to those needs regardless of the physical aspects.

EMOTIONAL ASPECTS OF THE PERSON Validation Validation of their emotions is important for the Person/s who typically feels vulnerable and uncertain when consulting a health professional. Validation confirms the existence of their negative emotions, and potentially allows them to acknowledge and accept the existence of these emotions. Acknowledging the legitimacy of the nega• In groups of four or five, choose five tive emotions is often difficult for the Person/s of the following emotions: happy, because they may feel confused and ungrateful at that frustrated, excited, sad, devastated, time (see the scenario about ‘Eric’ later in this unhappy, disappointed, confused, chapter). The process of validation requires the health bored, sleepy, depressed, guilty, professional to recognise the emotional cues of the embarrassed, rejected, helpless, Person/s and accurately name those emotions. These irritated, angry, ashamed, insecure. emotional cues are often communicated non-verbally • Have each member of the group (see Ch 12) and thus require sensitive and respectful simultaneously non-verbally express the chosen emotion. validation. This process, if performed sensitively, generally releases the Person/s to acknowledge those • Consider the variations in the ways of expressing each emotion. emotions with greater acceptance and less confusion. • Which of the emotions appeared to The Person/s often feels more able to express, underbe expressed in a similar manner stand and control their emotions after validation. It to each other? Why is it important to is important to note that validation does not indicate consider this when validating whether the emotions are reasonable or appropriate, emotions in the Person/s? it simply states the existence of the emotions. Health List the different ways each group • professionals indicate unconditional positive regard member used different parts of their by: (i) separating themselves from their values and body to express each emotion. judgements (Rogers 1967); (ii) recognising the • Decide what each of these answers emotion in the Person/s; and (iii) expressing awaremeans for a health professional. ness of the emotion – usually by asking a question relating to the particular emotion, but sometimes with non-verbal cues. CLARIFICATION WITHIN VALIDATION

Bergland & Saltman (2002) state it is important to recognise that each individual has a unique communication style. Recognition and understanding of the communication style of the individual ensures positive communication outcomes. Accurate validation of emotions cannot occur without this recognition of individual communication styles. Different cultures, different social groups and different families increase the variations in communication styles. Therefore, in recognition of these variations, health professionals might request clarification of their perceptions rather than assume they have accurately recognised the emotional cues of the Person/s. A request for clarification of the perception of the emotion is appropriate before recognising and validating an emotion. A question indicates the interest of the health professional in the Person/s and allows that Person/s 107

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to decide if they will admit or deny the presence of the emotion. If admission of the emotion follows, the health professional has the opportunity, if appropriate, to empathise and explore the emotion with the Person/s. If denial of the emotion follows then the health professional has lost nothing and is learning about the communication style of that individual. In this situation, it may or may not be appropriate to pose another question asking the Person/s to name the current emotion. The health professional must decide whether to pursue the presence of the emotional cues or to leave the Person/s to consider the question alone. The question may begin the exploration process of the emotions of the Person/s amidst their confusion and fear, and allow verbal exploration later. Strong emotions are inevitable in the lives of health professionals and those around them; denial of these emotions is unwise because of the enormous emotional cost (Davis 2011). Validation of strong emotions is necessary because it begins the journey of acknowledgement and resolution, both of which facilitate understanding and control of often overwhelming emotions potentially influencing intervention outcomes. Accurate validation requires the health professional to request clarification of the perceived emotions to facilitate honest communication. Such communication encourages the Person/s to honestly admit and consider the presence of their emotions. Validation prepares the Person/s for empathic exploration of their emotional responses. Honesty is not always easy when considering emotions; however, honesty is essential for the achievement of positive outcomes.

Empathy As expressing empathy is essential in health practice it requires further consideration. Empathy is a process (Rogers 1975) that requires a health professional to enter: … the private perceptual world of the other and becoming thoroughly at home in it … It includes communicating your sensing of his world as you look with fresh and unfrightened eyes at elements of which the individual is fearful. It means frequently checking with him for the accuracy of your sensings, and being guided by the responses you receive … To be with another in this way means that for the time being you lay aside the views and values you hold for yourself in order to enter another’s world without prejudice … (p 4) This definition reveals the reality of the complexity of expressing empathy. Unlike many definitions of empathy, it makes the health professional responsible for their emotional response to the Person/s. It demands that the health professional not only express emotional sensitivity that demonstrates understanding of the emotions (Northouse & Northouse 1992), but also requires them to separate themself from their values and personal prejudices. The definition requires the health professional to feel with the Person/s in a non-judgemental manner. It requires the health professional to patiently listen and reflect on what they hear in order to respond with empathy. It requires the health professional to avoid giving advice, regardless of their experience or understanding (Cilliers & Terblanche 2000). In addition, it requires the health professional to avoid interrupting, except to either affirm the Person/s without words or to encourage further expression of the emotions. The health professional verbally and non-verbally expresses empathy – by their actual words and how they express those words. Expressions of empathy require that the health professional makes no assumptions about the accuracy of their perceptions of the feelings in the Person/s, only that they request verification of 108

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those perceptions. It is the seeking of verification that allows the health professional to remain themself while focusing on the Person/s. In contrast to empathy, sympathy is the expression of the experiences, feelings and perspectives of the health professional and places the focus upon those experiences, feelings and perspectives rather than those of the Person/s (see Ch 2). Experiencing events that are similar to those of the Person/s may assist the health professional when communicating. However, this can also lead the health professional to assume they know exactly how the Person/s is feeling. This ‘feeling’ can assist understanding or it can create an illusion of understanding that limits the expression of empathy. That is, this ‘feeling’ may communicate either authentic understanding or a nonchalance that is inappropriate, depending on how the health professional communicates the commonality of experience. While in some circumstances self-disclosure may increase satisfaction for a Person/s (Holmes et al 2010), it is often safest to avoid sharing a similar experience with the Person/s because this places focus on the health professional instead of the Person/s. When communicating with empathy it is important to focus only on the needs and reactions of the Person/s.

Eric, a 28-year-old, and Mandy, his wife of six months, wait quietly in a private room for someone to tell them the results of his tests. To fill the time and stop thinking the worst, they talk about the work they are doing on the house they have just bought and their future plans to travel and have a family. The specialist doing the tests was highly recommended so they feel confident. He finally comes into the room reading some papers. He smiles quietly and looks up. The tests are all clear. Eric and Mandy visibly relax. The specialist does not notice this, however, because he is not convinced that the results are accurate. He suggests more tests to be sure of the diagnosis. He feels his hunch is right considering the symptoms that Eric has been experiencing and just wants to confirm this. A few weeks later Eric and Mandy sit in the same room with a feeling of déjà vu. This time they are not trying to avoid thinking about anything – they feel tired and afraid. When the pathology report arrives, the doctor and three other health professionals rush into the room. This time the specialist has a big smile on his face. He excitedly says he was right, these tests have confirmed his hunch and Eric does have the chronic condition he has suspected from the symptoms. I was right! he says repeatedly. Eric and Mandy are crushed – they have no idea of the implications of the condition, but they know their plans will need major changes. Their faces express devastation. The specialist stops smiling and looks at them, surprised. He simply says You should be happy; it could have been worse – you have at least 10 good years. Stunned, Eric and Mandy thank the specialist for his perseverance in the search for a diagnosis. Eric is feeling completely confused and afraid. Mandy is horrified and devastated. Eric does not want to seem ungrateful but this is not his idea of something to celebrate or something to smile about, and he is in shock. In the confusion he thinks these feelings must be inappropriate considering the response from the specialist – and then he notices the tears rolling down the face of the health professional who had spent time with them when they first arrived at the health service. The one who knows they are newly married with wonderful plans for the future. Eric in his mind thanks that health professional because it indicates that his feelings are appropriate – he is allowed to feel terrible – and he bursts into tears. (Adapted from Northouse & Northouse 1992)

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Consider this scenario from the perspective of Eric and Mandy. Consider this scenario from the perspective of the specialist – remember the times you have been preoccupied with something or excited about something and have not noticed the feelings of the people around you. • Consider this scenario from the perspective of the health professional who had the courage to cry. • Whose perspective do you find easiest to understand? • What does this mean about your ability to demonstrate empathy?

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Using the above thoughts, discuss the responsibility of the health professional to focus on the needs of the Person/s regardless of the feelings of the health professional. • List the reasons why this is the case. • What can a health professional do to ‘survive’ the process of sharing the perspective of hurting and often fearful people in order to express empathy on another occasion? • List actions or behaviours that will assist the health professional to express empathy when communicating with the Person/s around them.

THE IMPORTANCE AND RESULT OF EMPATHY FOR THE SEEKER OF ASSISTANCE

Empathy has a positive effect on both the health professional and the Person/s. The context of the particular health service, while familiar to the health professional, is unfamiliar to the Person/s seeking the assistance of that service. Each Person/s has a reason for seeking assistance and this reason may be creating confusion and fear in them. There may also be factors and events in the life of the Person/s, past or present, which cause confusion and fear, independent of the current reason for seeking assistance. In such circumstances, the emotional need for understanding and acceptance becomes the dominant need. The needy and fearful Person/s seeks that understanding and acceptance from anyone who will offer it.

John lives alone in a dark, cluttered room. His best friend is a bottle of cheap alcohol. He has recently experienced back pain and has come to an alternative health service for assistance. While he has plenty of money and clothes, he usually wears the same clothes that show little evidence of laundering. John rarely showers so people leave the waiting room whenever he attends for treatment! John does not feel that anyone cares about him, so he does not care about himself. Sam, the osteopath who treats John, is pleasant but distant. He usually works as quickly as possible and says very little while treating John. After treating John, he sterilises everything and thoroughly disinfects his hands. Adrian, the cleaner, has lost the ability to smell and often works close to John when he is there, chatting as he cleans. He regularly asks John how he is going and how he is feeling. John has come for treatment for several weeks and Adrian has learnt a lot about John in that time. Adrian makes it his business to clean the waiting room whenever John is there, regularly expressing empathy towards John, and once bringing him some homemade cooking (Adrian’s wife is a great cook). →

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• • • •

Why do you think John looks forward to attending the health service? Why do you think Sam reacts the way he does to John? What do you think Adrian has learnt about John? Use your imagination. Why do you think John is clean and in fresh clothes after he has been attending for several weeks?

Making an effort to enter the perspective of the Person/s without judgement is a sign of respect (Egan 2010). It communicates understanding and acceptance, and allows expression and exploration of sometimes debilitating emotions. It reassures the Person/s that their emotions are not ‘crazy’, and it potentially facilitates management of the confusion and fear in unfamiliar and sometimes unpleasant situations. Empathy can empower the Person/s to take control in a seemingly out-of-control situation, thereby facilitating a change in the way they manage the situation and the way they relate to themself. This reality indicates that empathy is a central component of family/Person-centred practice (Davis 2011).

PERSON-CENTRED PRACTICE AND SOLVING THE PROBLEM Divide the entire group into pairs. If there is an odd number, have that person observe the progress of the pairs. Role-play the following roles. Nancy: You have not been attending for the intervention you originally sought. You like the health professional who telephones, however you are reluctant to explain your lack of attendance at the mutually agreed time for appointments. (You must decide the reason why you have not been attending – you may discuss your reason with the group facilitator or instructor if appropriate.) Do not initially give the reason to the person playing the part of the health professional; wait until you experience feelings of safety and affirmation. Reasons for not attending might include illness; concern about someone in your family; a sick pet; nausea because of a new liquid oral medication that smells and tastes horrible, despite the existence of a more palatable flavoured variety; pain that makes showering very slow and tedious. Health professional: You are aware of the number of people waiting for intervention, but you are intent on establishing why Nancy has failed to attend over the past two weeks. You really want to assist Nancy so you persist when she is reluctant to provide an explanation for her absence. Demonstrate how you communicate both for Nancy-centred practice (using empathic responses) and to gather the information you need to assist Nancy.

• • • • • •

How successful was the health professional? Does confidentiality affect this scenario? If so, how? Did the person playing the health professional achieve their goals? How did Nancy feel? What assisted Nancy to trust and disclose? What made it difficult for Nancy to trust and disclose? Repeat the role-play, swapping roles, and discuss any differences.

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• • • • • • • •

•

Are you a person who naturally touches others to communicate? In what situations do you touch? What part of the body do you touch? How do you respond when someone you know touches you? How do you respond when a stranger touches you? Do these responses depend on where you are touched? Do these responses depend on your relationship with the person touching you? Are these responses a result of your upbringing? Social norms? Bad experiences? Your personal tendency relating to touching? Do you need to seek professional assistance if these responses will limit your effectiveness as a health professional?

List the social norms governing touching in each culture represented in the group. Consider greeting, introducing, saying goodbye, variations in touching because of age and gender, comforting an upset person who is familiar, comforting an upset person who is a stranger, and any other situations that might include communication by touching. • If there are people from different cultures in the group, compare the differences in the social norms governing touching in different situations. • If it is a monocultural group, discuss any experience of different norms governing touching – even within families. • List ways in which these differences might guide the practice of a health professional.

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Empathy is a time-saving tool for the health professional. Willingness to explore the needs and problems of the Person/s allows expression of the feelings associated with those needs and problems (Burnard 1992). The expression of these feelings can facilitate a sense of control for the Person/s. The health professional should note and acknowledge the feelings immediately, and should encourage their expression to avoid difficulties and further problems. An immediate empathic approach allows efficient provision of appropriate interventions. It usually ensures collaboration with and effective fulfilment of the needs of the Person/s.

Touch Touch is a powerful, non-verbal form of communication (Mohan et al 2008). The habit of touching to communicate reflects a personal style of communicating, and should not be forced if it is not naturally part of the communicative style of the health professional. The reality that different personality types have different communication styles (Houghton 2000, Opt & Loffredo 2003) means that sometimes the Person/s may find it difficult to communicate through touch. However, when there is a connection and resultant rapport, a gentle touch on the shoulder, pat on the arm or squeeze of the hand, for many demonstrates awareness of their plight. A gentle touch usually communicates a desire to collaborate to fulfil the needs of the Person/s without causing offence (Holli et al 2008), regardless of the personal style of communication. It is important that the health professional carefully observes responses to touching and avoids touching if there is a negative response. Asking permission to touch the Person/s before touching may avoid a negative response. If there is established rapport and the touch is intended to comfort and encourage – indicating support and empathy – the Person/s usually senses this and appreciates the touch. Each culture has norms that govern touch conventions when communicating. Sexual harassment is a reality in many professional workplaces. Awareness of the norms governing sexual behaviour for a particular workplace is essential for all health professionals in order to avoid communicating inappropriately when using touch. Touching can provide feedback about the emotions of the Person/s. A gentle touch may inform the

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health professional that the individual who appears relaxed and in control feels unsure and requires encouragement. This previously unnoticeable information encourages the health professional to communicate empathy by investing time and energy in exploring these upsetting emotions. Parents and significant others communicate emotions through touch with their children. In families, touch is a powerful form of communication that expresses parental or sibling emotion. Kisses, cuddles, tickles and rumbles are fun and comforting; they communicate ease, acceptance, love and affection (Mohan et al 2008). This manner of touch produces positive emotions in both the person touching and the person receiving the touch. Expressions of anger, frustration and disapproval communicated through either touch or tone of voice produce negative emotions in the child. Various types of touch, whether producing positive or negative emotions, can condition a child to respond in a particular manner when touched by anyone. Health professionals who use touch within their treatment media should consider the reaction of anyone they touch. Careful awareness of the responses and needs of children when touching is essential because this provides information about the touch experiences of that child. Accurate knowledge of the touch experiences of a child, if managed appropriately, has potential to restore and protect the emotional growth of the child and their future ability to both give and receive touch as a way of communicating expressions of concern. When used appropriately to communicate, touch can be a powerful tool for the health professional who feels comfortable touching others.

Silence Silence can be a powerful and comforting communication device. Words are sometimes inappropriate. • How comfortable are you with Saying nothing with someone – just being with silences in conversations? them – is more appropriate than words in particular What is your natural tendency when • circumstances. there is a silence in a conversation? When listening the health professional is silent, What does that mean for you as a • but the interaction is not silent because the Person/s health professional? is speaking. Refraining from speaking while listening, in combination with concentrating and focusing on the speaker, demonstrates skills in listening as well as interest and respect (Stein-Parbury 2009). There are occasions while communicating, however, when words are inappropriate or inadequate. In these cases, just being with a Person/s and saying nothing indicates interest, care, respect and even empathy. There are occasions when the Person/s does not seek words but the presence of an interested and caring health professional. A carer or relative found sitting outside the room of their seriously ill or dying family member may not desire verbal communication but the nonverbal, silent presence of a previously known, concerned and interested health professional. This presence communicates care and – even though the health professional may be skilful in verbal expressions of empathic care – simply sitting quietly with the Person/s can fulfil the needs of the Person/s at that time. When the Person/s has difficulty expressing themself verbally, it is appropriate in some health professions to silently perform an activity with them in an interested and observant manner to build rapport (Schmid 2005). The possible people with whom a health professional might use this type of silence include children, people with mental health disorders or communication difficulties, people experiencing severe pain and people in palliative care units. 113

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Amy is 14 years old and has an intellectual disability. She has recently begun menstruating and her mother has found it difficult to teach her how to manage this change in her body from the perspectives of both hygiene and sexual activity.

Different cultures have different uses for silence. Some cultures find that silence communicates more effectively than words. When communicating with a vulnerable Person/s from a different culture, it is important to clarify the uses and effects of silence (see Chs 14 & 15). Silence, when used appropriately, can powerfully communicate interest, regard and a desire to assist if possible.

•

SEXUAL ASPECTS OF THE PERSON

How would you feel if you were asked to assist Amy to manage the sexual changes in her body and ensure safe sexual activity in the future? • Write a list of the things you would find difficult in this situation and how you might overcome these difficulties.

•

Discuss possible strategies for assisting Amy and her mother to manage the emotional and sexual aspects of this situation.

Peter/Peta is a 25-year-old with paraplegia. He/she is about to begin sleeping with his/her partner for the first time since his/her accident. You have an excellent relationship with Peter/Peta, with many things in common – similar age and interests, same gender etc. He/she indicates fear about his/her sexual abilities since the accident and asks you for assistance about how to approach having intercourse with his/ her partner. The doctor says Peter/Peta should be able to function sexually but has given no other guidance or reassurance.

•

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Discuss the possible ways of responding to empower Peter/Peta.

People are sexual beings regardless of their culture or gender. Note that sexuality here is not synonymous with gender. Individuals usually have sexual organs, and while these may determine their gender, they do not necessarily determine their ability to discuss and relate to their sexuality. The sexual aspect of individuals refers to their particular reproductive organs and the responsibilities associated with the use of those organs (Milliken & Honeycutt 2004), as well as their sexual preference. Particular health professions may or may not relate to the sexuality or sexual functioning of the Person/s. All health professionals, however, may need to respond without verbal or non-verbal judgement to possible differences in their sexual preference and the sexual preference of the Person/s seeking their assistance. Some individuals find it difficult to explicitly discuss or consider their own sexuality. Such individuals may or may not find it difficult to relate to the sexual aspect of another person. This is true both for some health professionals and some individuals seeking assistance. Certainly some health professionals within the scope of their practice would not usually expect to consider the sexual aspect of a Person/s. However, if a particular health professional develops a safe therapeutic relationship with a Person/s, that Person/s may wish to discuss their sexual concerns with that health professional. This discussion may or may not feel comfortable, but if managed appropriately it may empower the Person/s to seek qualified assistance that will empower them to fulfil their sexual needs.

COGNITIVE ASPECTS OF THE PERSON Cognitive ability is the ability to process information using reasoning, interpretation, intuition and perception. Cognitive events are conscious thoughts (Holli

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et al 2008) that the Person/s has in an attempt to process and understand received information. It is important that the health professional and the Person/s possess basic cognitive abilities to negotiate mutual understanding and produce effective and emotionally comfortable interactions. It is also important to understand that when feeling vulnerable, the individual may experience temporary deterioration in their cognitive processing skills. An important cognitive ability is the ability to concentrate or attend throughout the communicative interaction. Understanding the limits of the attention span of the Person/s – whether they are developing cognitive skills (children) or losing them (ageing adults) – is important because it allows the health professional to adjust their communication as necessary. It is important that all communicating individuals understand that the words and non-verbal behaviours they use will produce particular effects and have consequences. Children (who are still developing their cognitive abilities) and individuals with limited cognitive abilities often find it difficult to understand the idea of cause and effect (Purtilo & Haddad 2007). For example, the individual who thinks they have lost their meal tray because they did not exercise enough care does not understand explanations about the cause and effect that resulted in the removal of the meal tray (i.e. the cleaning up at the end of lunchtime). Health professionals have a responsibility to communicate with such individuals with understanding and skill. It is imperative that health professionals adapt their manner of communicating according to the cognitive ability of the Person/s, and that they continue to make adjustments according to their observations of the effects of their communication upon that Person/s. When communicating with children it is important to remember that children have different cognitive skills at different ages (Berk 2006). Jean Piaget (1968) developed an explanation of the stages of cognitive development. Although there is discussion about the accuracy of the timing of these stages, it does appear that children develop cognitive skills as they grow and experience their world. Variations can occur because individual children may demonstrate highly developed cognition at a particular age while other children may not, despite apparently similar intelligence and experience. Adults with diminishing cognitive skills may revert to demonstrating cognitive abilities typical of some of these earlier stages. It is important to adjust communication styles according to the cognitive abilities of each Person/s. When communicating with people who have limited cognitive abilities or a disorder affecting their comprehension of language, it is important for health professionals to use short and simple sentences and, wherever possible, non-abstract words. This will maximise comprehension. There is no need to speak loudly unless they also have a hearing impairment. If someone does not understand what is being communicated, regardless of the reasons for the lack of comprehension, they will cease listening. In such situations, it is less possible to negotiate meaning and mutual understanding. Interpreting the non-verbal cues related to potential comprehension is sometimes useful, but may be unreliable in many situations. To confirm adequate comprehension the health professional should ask the Person/s to repeat in their own words the meaning they ascribe to the delivered message. Remember that emotional states may restrict cognitive functioning regardless of the considered cognitive abilities of the individual. Consideration of and attention to the emotional state of the Person/s may increase their ability to concentrate and thus improve the potential for effective communication. Some individuals are limited in their cognitive abilities but these abilities are stable – they are not developing or deteriorating. Most of these individuals have reached 115

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• • • •

• • • •

•

Discuss group member experiences with people who have limited cognitive abilities. Share, list and discuss possible strategies for communicating with such people. Discuss any experiences with using these strategies. List the characteristics of each strategy and discuss the factors that contribute to the success of each strategy.

a particular level of cognitive functioning that is below the typical level of their age. Individuals with an intellectual disability are representative of this group, and they may require the use of particular methods of communication to achieve effective communication (see Ch 12). Another group of individuals who may experience difficulty communicating are those who have a disorder related to the Autism Spectrum Disorder (American Psychiatric Association 2000). Other individuals who may experience communication difficulties include those with head injuries, sensory impairments, learning disorders, specific language disorders and some physical disabilities including cerebral palsy. Individuals with limited verbal skills may communicate using certain behaviours, such as biting, hitting, kicking, pushing, spitting, screaming, crying, Consider your response to the laughing, withdrawing, touching, smiling, smelling, behaviours listed in the opposite reaching, physically guiding, head banging/butting, paragraph. absconding from a particular situation, cuddling, Have you seen others respond to undressing in public and many more. If an individual such behaviours? has severe difficulties communicating verbally, resortWas their response appropriate? ing to such behaviours may be the only manner of Was it effective? Why or why not? expressing their feelings at the time. How would you respond? Why It is important for the health professional to would you respond in this manner? accommodate and appropriately manage difficult behaviours while implementing strategies to establish appropriate communicative behaviours for such individuals.

How might a health professional fulfil the social need of the Person when that Person would like to have someone present all the time? List ways. • If a Person/s seeking your assistance is lonely and often monopolises your time because of this loneliness, how might you assist this Person/s?

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SOCIAL NEEDS OF THE PERSON

Humans often seek social interaction. The extent and enjoyment of social interactions may vary according to personality type, but most typically functioning individuals seek the company of other humans some time during every day (Brill & Levine 2005). Individuals who feel vulnerable and fearful may desire the company of people they trust. In such situations the Person/s may not want to actively interact – they may simply desire the presence of a friendly, caring individual. In the busy world of the health professional, they may be unable to meet this demand. Many individuals have their needs for social contact met through the ownership of an animal. Underestimating the significance of the relationship with a long-term pet is

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unwise when assisting any individual regardless of age or gender. A vulnerable Person/s may feel their pet is their only reliable and supportive social relationship and thus acknowledgement of the pet is essential.

SPIRITUAL NEEDS OF THE PERSON Every individual has a spiritual aspect. This aspect of a Person/s determines the focus of their lives and dictates what is valuable and meaningful to them. It determines notions of self and the place of the individual in life. It can refer to the ‘things’ that renew, the ‘things’ that bring comfort and lift the spirit, as well as the ‘things’ that inspire and encourage. The spiritual aspect relates to the beliefs and values that motivate and sustain individuals. As such, it is the basis for explanations about the meaning and purpose of the events of life. Consideration of spirituality is an important element of healthcare and can benefit the health and wellbeing of both health professionals and the Person/s (White 2006). An individual may or may not be consciously aware of this aspect of their daily existence. It is an aspect of an individual that some prefer to keep You have been assisting an elderly private and may avoid discussing in a social context. Asian man for several weeks. He Despite spirituality often being unconscious, it may appears to benefit from seeing you and be when an individual feels vulnerable that this aspect there is indication of rapport between becomes conscious. you. He attends regularly but In the past 20 years there has been a growing demonstrates limited progress. Through interest in spirituality and religion among many of an interpreter, he indicates he is too the health professions (Miller & Thorensen 1999). tired to implement your suggestions Despite the growing awareness of spirituality and the except during your treatment sessions. affect of this aspect on health and wellbeing (Miller Empathic questioning reveals that he & Thorensen 2003, Powell et al 2003, Seemen et al cannot sleep because every night the 2003), many health professionals fail to recognise the spirits of his previous wives who died spiritual aspects of the Person/s. Failure of health some years ago torment him. professionals to recognise the importance of spiritual Regardless of your spiritual beliefs, issues may be a major source of distress for particular you know this man would improve quickly if he had the energy to individuals. If spiritual issues are important to the implement your suggestions outside Person/s then they require recognition and attention your treatment sessions. (Hall et al 2004). Some cultures are constantly aware of a spiritual existence; thus the spiritual aspect for individuals from such cultures will be very signifi• List possible appropriate actions to cant. If the Person/s expresses needs with spiritual assist this man. implications it is important that the health professional acknowledges and addresses those needs rather than ignoring them, regardless of the spiritual beliefs of the health professional. There are many ways of addressing the spiritual needs and concerns of the Person/s. It is important to remember that no health professional has all the answers and it is acceptable to indicate this reality to the Person/s. Regardless of the personal beliefs of the health professional, it is important to identify whether they require a person who understands their spiritual, religious or philosophical beliefs and, if necessary, connect them with such a spiritual specialist. Acknowledging the beliefs and values of the Person/s can motivate and sustain them in difficult situations. 117

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When assisting someone for whom spirituality is significant it is important to: • Demonstrate respect for the Person/s and their ideas of spirituality • Recognise the source of spiritual support for the Person/s and, as required, allow access to that form of support • Understand when the Person/s may be experiencing spiritual distress and behave in a manner that acknowledges and attempts to alleviate the distress. Spiritual functioning affects the value the Person/s assigns to their body, their spirit, their emotions, their thoughts and those around them. It may affect the reaction to the suggestions and intervention of the health professional. It may limit or encourage the cooperation of the individual seeking assistance and that of their family. Ignoring the spiritual aspect, even when that aspect is obvious, is often detrimental to effective communication. Spiritual issues may not appear relevant to the practising health professional; however, if the Person/s considers them relevant they require specific attention. Such attention will contribute to positive outcomes and is therefore a necessary consideration of the health professional.

Chapter summary Health professionals relate to various Person/s in their everyday practice and constantly seek to maintain confidentiality. The Person/s in everyday practice includes those seeking their assistance, health professional colleagues and various support staff who maintain both the daily work schedule and the working environment. When communicating with the Person/s it is important to establish the reason why they are seeking assistance, their current condition and their expectations of the particular health profession. While establishing this information it is important to demonstrate respect and empathy. Holistic care of the Person/s requires consideration of the physical, emotional (including sexual), cognitive, social and spiritual aspects of the Person/s. Communicating with the Person/s while considering these aspects promotes effective communication, family/Personcentred practice and positive outcomes.

FIGURE 8.1â•… Awareness of the Person/s can be challenging, but is worthwhile.

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REVIEW QUESTIONS 1. List the information a health professional requires in order to provide appropriate assistance. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 2. What three important elements does effective communication with the Person/s require? i. _____________________________________________________________ ii. _____________________________________________________________ iii. _____________________________________________________________ 3. List the Person/s who might seek assistance from a health professional. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. What are the aspects that ‘make up’ the whole Person? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 5. What are the potential effects of failure to recognise each aspect of the whole Person/s? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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6. Physical aspects of the Person/s may appear obvious. Suggest reasons why they might not always be reliable. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 7. What might assist in meeting the needs of the emotional aspects of the Person/s? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 8. What are the components of the sexual aspects of a Person/s? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9. How can a health professional communicate with a Person/s with limited cognitive skills? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 10. How might a Person/s communicate who cannot use the spoken word? _____________________________________________________________________________ _____________________________________________________________________________ 11. What can affect the social aspect of a Person/s? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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12. Why should a health professional acknowledge the spiritual aspect of a Person/s? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

REFERENCES American Psychiatric Association 2000 Diagnostic and Statistical Manual of Mental Disorders, 4th edn-TR (DSM-IV-TR), APA, Washington DC Bergland C, Saltman D (eds) 2002 Communication for healthcare. Oxford University Press, Melbourne Berk L 2006 Development through the lifespan, 4th edn. Allyn & Bacon, Boston Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Brito R, Waldzus S, Sekerdej M et al 2011 The contexts and structures of relating to others: how memberships in different types of groups shape the construction of interpersonal relationships. Journal of Social & Personal Relationships 28(3):406–432 Burnard P 1992 Teaching interpersonal skills. Chapman & Hall, London Chenowethm L, Jeon Y, Goff M et al 2006 Cultural competency and nursing care: an Australian perspective. International Nursing Review 53(1):34–40 Cilliers F, Terblanche L 2000 Facilitation skills for nurses. Curtaionis 23(4):90–97 Davis C M 2011 Patient–practitioner interaction: an experiential manual for developing the art of healthcare, 5th edn. Slack, Thorofare, NJ Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont, CA Elander J, Beach M C, Haywood C 2011 Respect, trust, and the management of sickle cell disease pain in hospital: comparative analysis of concern-raising behaviors, preliminary model, and agenda for international collaborative research to inform practice. Ethnicity & Health 16(4/5):405–421 Hall C R, Dixon W A, Mauzey E D 2004 Spirituality and religion: implications for counsellors. Journal of Counselling and Development 82:504–507 Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Holmes G N, Harrington N G, Parrish A J 2010 Exploring the relationship between pediatrician self-disclosure and parent satisfaction. Communication Research Reports 27(4):365–369 Houghton A 2000 Using the Myers-Briggs type indicator for career development. British Medical Journal 320(2):366–367 121

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Long L 1978 Listening/responding: human-relations training for teachers. Brooks/Cole, Monterey, CA Miller W R, Thorensen C E 1999 Spirituality and health. In: Miller W R (ed) Integrating spirituality into treatment: resources for practitioners. American Psychological Association, Washington DC, p 3–18 Miller W R, Thorensen C E 2003 Spirituality, religion and health: an emerging research field. American Psychologist 58(1):24–35 Milliken M E, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Northouse P G, Northouse L L 1992 Health communication: strategies for health professionals, 2nd edn. Prentice Hall, Englewood Cliffs, NJ Ogletree S M, Archer R L 2011 Interpersonal judgments: moral responsibility and blame. Ethics & Behavior 21(1):35–48 Opt S, Loffredo D 2003 Communicator image and Myers-Briggs type indicator extraversion–introversion. Journal of Psychology 137(6):560–568 Piaget J 1968 Six psychological studies. Vintage, New York Powell L H, Shahabi L, Thorensen C E 2003 Religion and spirituality: linkages to physical health. American Psychologist 58(1):36–52 Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Rogers C 1967 On becoming a person. Constable, London Rogers C 1975 Empathic: an unappreciated way of being. The Counselling Psychologist 5(2):2–10 Sander M R, Mitchell C, Byrne G J A (eds) 1997 Medical consultation skills: behavioural and interpersonal dimensions of healthcare. Addison Wesley, Melbourne Schmid T 2005 Promoting health through creativity: for professionals in health, arts and education. Whurr, Philadelphia Seemen T E, Dubin L F, Seemen M 2003 Religiosity/spirituality and health: a critical review of the evidence for biological pathways. American Psychologist 58(1):53–63 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney White G 2006 Talking about spirituality in healthcare practice: a resource for the multi-professional healthcare team. Jessica Kingsley, London Wojciszke B, Abele A E, Baryla W 2009 Two dimensions of interpersonal attitudes: liking depends on communion, respect depends on agency. European Journal of Social Psychology 39(6):973–990

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ANSWERS TO REVIEW QUESTIONS CHAPTER 8â•… Awareness of the ‘Person/s’ Answers to the following questions provide a summary of this chapter. 1. List the information a health professional requires in order to provide appropriate assistance. The information required includes the reason why the Person is seeking assistance, their condition or diagnosis that is contributing to this search for assistance and their expectations or goals associated with the particular health profession. 2. What three important elements does effective communication with the person require? i. Respect ii. Confidentiality iii. Empathy 3. List the persons who might seek assistance from a health professional. The Person/s who might seeks assistance from a health professional include the Person, their carers, families, friends and, in some cases, guardians of that individual as well as health professional colleagues inside and outside the service. 4. What are the aspects that ‘make up’ the whole person? The physical, emotional (including sexual), cognitive, social and spiritual aspects ‘make up’ the whole person. 5. What are the potential effects of failure to recognise each aspect of the whole person? Failure to recognise and consider every aspect of the person can limit identification of relevant information and the associated needs of the Person. This can restrict the development of a therapeutic relationship and the outcomes of any interventions. 6. Physical aspects of the person may appear obvious. Suggest reasons why they might not always be reliable. General appearance, clothing, cleanliness, smell, accessories are physical aspects of the person that may not be reliable as they can project an image that is not real. 7. What might assist in meeting the needs of the emotional aspects of the ‘other’? Validation of their emotional responses using clarification and questioning while listening using empathy and non-judgmental verbal and non-verbal responses, along with sensitive and appropriate use of touch and silence.

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8. What are the components of the sexual aspects of an individual? The sexual aspects of the Person include their sexual organs, how they view their responsibilities associated with use of these organs as well as their individual perception and understanding of their own sexual preferences. 9. How can a health professional communicate with an individual with limited cognitive skills? A health professional communicating with a Person with limited cognitive skills must consider their attention span, adjust the language level to the cognitive skills of the Person, attend to their emotional needs and when appropriate use an alternative form of communication. 10. How might a person communicate who cannot use the spoken word? Such a person might communicate using gestures, particular types of behaviour, simple language and sentence structure. 11. What can affect the social aspect of an individual? Feeling vulnerable and fearful can make an individual desire social contact, but usually with people they trust or who indicate genuine concern and care. 12. Why should a health professional acknowledge the spiritual aspect of an individual? When the Person indicates their spiritual aspect it is important the health professional acknowledges that aspect as it can determine what is important and meaningful to the Person. Failure to acknowledge this aspect of a person can compromise health professional outcomes and does not reflect family/person-centred practice.

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CHAPTER 9â•…

Awareness of listening to facilitate Person/s-centred communication CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Define effective listening • Explain the importance of listening in Person/s-centred communication • Identify and accommodate the benefits of active listening • Describe the barriers to listening • Explain the importance of preparing to listen • Discuss the characteristics of effective listening • Explore and examine cultural variations that affect listening • Understand the importance of appropriate disengagement.

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The fundamental nature of the health professions as helping professions mandates Person/s-centred com• What is listening? List the necessary munication. The skill of placing the Person/s at the abilities to achieve effective listening. centre of communicative interactions is one that is • How do you know someone is also beneficial in everyday relationships (Adler et╯al listening to you? What non-verbal and 2005, Devito 2007, 2009, Lauer 2003). Although verbal behaviours indicate achieving Person/s-centred communication is often they are listening? How can you challenging, it is essential in the health professions establish whether the listener has and requires effective listening. Listening is the most understood you? widely used communication skill in life. Individuals listen every day – some more actively than others. Considering the amount of time people spend listening each day, it is amazing that effective listening requires practice and conscious effort (Crossman et╯al 2011, Ewing et╯al 2010). Effective listening as well as skills in speaking, reading and writing are useful for any person to facilitate communication in general life, but are essential for a health professional (Egan 2010, Giroux Bruce et╯al 2002, Harms 2007, Harms & Pierce 2011, Holli et╯al 2008, Milliken & Honeycutt 2004, Parker 2006, Stein-Parbury 2009).

Defining effective listening Effective listening requires all the components of family/Person-centred practice. However to listen effectively a health professional must understand what it is and how to perform effective listening during their daily practice. Effective listening requires the health professional to consciously focus completely on the Person/s and visibly ‘tuned in’ (often known as attending listening) (Egan 2007, 2010, Mann 2010, Skovholt 2010). It also demands demonstration of an understanding of the words and emotions communicated by the Person/s. It necessitates expression of this understanding to the Person/s in both verbal and non-verbal forms – often referred to as reflecting back the messages expressed by the Person/s (Devito 2007, 2009). Effective listening may require the use of questions to clarify that the perceptions of the health professional are accurate (see Ch 4). Effective listening then involves the health professional validating the expressed emotions to demonstrate awareness of their existence and accurate understanding of those emotions (see Ch 8). It facilitates effective and meaningful services and thus positive and effective outcomes.

Requirements of effective listening Effective listening is an obligation of every health professional and requires the health professional to: • Prepare themself to listen by removing any distractions and ensuring there are no interruptions (Stein-Parbury 2009) • Adjust to all contexts and needs regardless of the strength of the emotions and the severity of the need (Devito 2007, 2009) • Demonstrate physically their interest by the position of their body and their gestures, so they are visibly ‘tuned in’ to the Person/s (Egan 2007) • Listen with their whole self (Davis 2011) by using not only their observational and social skills but also their emotional and cognitive skills, and sometimes their spiritual skills 124

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• Consciously focus all their attention fully on the Person/s (Holli et╯al 2008)

•

assist their continued focus (Mohan et╯al 2004)

•

• Seek areas of interest or relevance to their role to • Carefully observe all non-verbal messages of the

Person/s • Make conscious choices about which non-verbal messages are appropriate in response to the Person/s • Consciously communicate interest and commitment to the Person/s through the use of verbal sounds and non-verbal cues • Search for the meaning of all verbal and non-verbal messages (Devito 2007, 2009) • Predict and clarify their meaning (See Chs 4 & 12) • Communicate the importance of the contribution of the Person/s in the process (Stein-Parbury 2009) • Consider cultural variations in listening (Harms 2007).

• • •

Consider the listed requirements of effective listening. Divide a page into two. Label one side ‘Competent’ and the other ‘More effort’. Identify which of the listed actions you feel competent to perform and perhaps perform automatically when listening. Identify those you feel require more conscious effort. Share this list with someone who knows you well and ask them to comment on your allocation.

Results of effective listening Effective listening definitely improves outcomes and increases the satisfaction of both the Person/s and the health professional. However it also enables the health professional and ultimately the Person/s to: • Observe the non-verbal messages carefully, note their significance at the time and, if appropriate, validate those messages and sometimes diffuse emotions that may otherwise dominate interactions. • Connect and engage with (and often enjoy) different perspectives and emotions. It is often the non-verbal messages that encapsulate the less-obvious needs at the time. These observations offer the opportunity to Divide a page into two. On one side list validate. the first word of each result of effective • Understand and unravel the complexity of the listening: ‘Observe’, ‘Connect’, needs. The understanding of the gathered ‘Understand’, ‘Relax’ and ‘Design’. information may reduce unnecessary events and On the other side consider the 13 the likelihood of difficulties, while ultimately points listed in the requirements of increasing the possibility of meaningful effective listening and classify them outcomes. according to which contributes to Observe, Connect, Understand, Relax and • Relax and share relevant information, which Design. Some of them may contribute to increases the knowledge and potential insights more than one result. of the health professional and the Person/s. Design and develop relevant goals and • interventions because of the information How might you ensure you Observe, gathered through the collaborative relationship. Connect, Understand, Relax and Design When listening effectively the above points closely whenever listening to a Person/s during interact to produce mutual understanding, a therapÂ� practice? eutic and/or collaborative relationship and family/ Person-centred practice. 125

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Benefits of effective listening Effective listening benefits the health professional and the Person/s they assist by ultimately improving intervention outcomes. The health professional that listens effectively is able to make appropriate decisions that influence the quality of care (Brown et╯al 2003). When a health professional is committed to effective listening, the Person/s seeking assistance feels valued and has more confidence in the health professional because of their demonstrated listening skills (Bodie 2011, Nyström et╯al 2003). Thus, the therapeutic relationship develops appropriately because of effective listening skills (Egan 2010, SteinParbury 2009). In addition, effective listening increases the probability of achieving mutually established goals (Gilmartin & Wright 2008, Lauer 2003, Mohan et╯al 2004, 2008).

Barriers to effective listening Awareness of the barriers to effective listening prepares health professionals to avoid potential hazards that might negatively affect the listening process. There are various external and internal factors that hinder effective listening (see Chs 6 & 10). The external (environmental) factors are important and not always obvious (Smaldino 2004). Consideration of external interferences (Stein-Parbury 2009) – including noise levels, distractions and unrelated activity in the space allocated for the interaction – and adjustments where possible, will contribute to the understanding of the listener and enhance their confidence (Gilmartin & Wright 2008). A health professional who continues listening instead of answering a telephone or pager indicates commitment to the needs of the Person/s, encouraging trust and the development of a therapeutic relationship. An effective listener attends to the internal ‘noise’ of their emotions before listening, thereby ensuring they can listen unhindered by their needs (Bergland & Saltman 2002). A listener who is not psychologically prepared to listen because they are preoccupied with their own thoughts may misunderstand messages (Moscato et╯al 2007). Alternatively, a listener who is focused on their own ideas and assumptions may also fail to listen carefully if they attempt to predict what they will hear (Purtilo & Haddad 2007) because of preconceived assumptions or judgements. Individuals may have habitual internal barriers that affect their ability to listen (Gordon 2004; see Ch 5). These barriers fall into three major categories: (i) judging; (ii) ignoring the needs; and (iii) stipulating the solution. Overcoming these barriers is essential for a health professional because they significantly limit the effectiveness of listening. The language of the listener may hinder the effectiveness of the communication if their ability in the language of the Person/s is poor. Mutual understanding requires both communicators to have some level of competence in a common language. Effective listening is impossible without a common language.

Preparing to listen Effective listening requires preparation and awareness of the factors that contribute to interested and efficient listening. Systematic preparation of the necessary external and internal factors guarantees positive outcomes for the listening process.

CULTURAL EXPECTATIONS CHANGE THE REQUIREMENTS FOR EFFECTIVE LISTENING Some skills associated with active listening may not be appropriate in some cultures, for example, eye contact (Higgs et╯al 2005, 2010). In some cultures, the age and gender of 126

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the speaker will affect the expectations of the listener. A factor considered important for effective communication in one cultural context is often inappropriate or unimportant in another culture. For example, the use of direct questions facilitates sharing of information in many Western middle-class contexts, while in some indigenous cultures direct questions are offensive. In such indigenous cultures information may be shared through storytelling while performing activities together. The principle of SAAFETY (see Table 9.1) reminds the health professional of the necessary factors for preparing to listen and stresses the importance of a feeling of safety for the Person/s when communicating in the health professions. TABLE 9.1â•… SAAFETY: Principles of preparing to listen for the health professional S

Schedule an interpreter if required to ensure effective communication.

A

Arrange your mind to enable complete focus and concentration on the Person/s.

A

Arrange the seating in a culturally appropriate way and remove physical barriers.

F

Familiarise yourself with the history and/or culture of the Person/s.

E

Environmental factors affect effective listening. Remove all distractions and reduce noise or activity.

T

Time alone with the Person/s is important to ensure privacy.

Y

Y – Why listen? Clarify and understand the purpose of the interaction.

• • •

• •

Find someone you do not know well. Ask them to tell you about their fondest memory of school. Before preparing to listen, consider the principle of SAAFETY (see Table 9.1). Listen carefully – ensure that they:  Describe the environment at the time of the event  State who was present during the event  Describe every action during the event  Describe and explain the reactions of each person during the event  Explain why it is their fondest memory. If the person does not include these five factors, ask questions that will encourage them to provide this information. Make a verbal summary of the content of the description and have the person verify the accuracy of your listening.

Characteristics of effective listening Effective listeners use all of their knowledge and skills to understand and respond appropriately to the Person/s. They use active listening in preference to passive listening. Passive listening does not encourage continued interaction because the listener fails to engage with the speaker or the verbal or non-verbal content of their message (Jansen 2000). Active listening facilitates comprehension of all the messages of the Person/s and is a core skill in effective listening. 127

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•

Consider your usual style of listening. Are you naturally an active or passive listener? What conditions encourage you to listen actively? • List the situations in which you adopt passive listening. • How could you change your listening to active listening in these situations?

Effective listening, in common with all skills, requires commitment and practice. As mentioned above, it has particular characteristics and produces particular results. It also requires the health professional to constantly avoid particular thoughts and actions. A health professional aiming to be an effective listener should always avoid: • Stereotyping the Person/s, regardless of their appearance or skill in communicating (Purtilo & Haddad 2007) • Judging – this imposes personal values and beliefs onto the Person/s • Advising the Person/s, even if they request it • Taking extensive notes while listening • Losing concentration because of thoughts about external matters (e.g. the next appointment or dinner) • Interrupting with thoughts or ideas; instead allow the Person/s to finish • A closed mind when listening (Holli et╯al 2008) • Double-guessing the meaning by making assumptions (Devito 2007, 2009) • Over-identification – this interrupts the ability to remember and problem solve (See Ch 16) •â•… Changing the focus to yourself, regardless of the similarity of experiences (see Ch 8) • Consider each point listed here •â•… Negative and non-supportive non-verbal and suggest behaviours that behaviours (see Ch 12) demonstrate each point. â•… Passive disengagement while listening, regardless • • List ways to ensure you consistently of your interest in the subject (see discussion avoid doing any of these when below). listening as a health professional. For more than 20 years the SOLER model (see Table 9.2) has highlighted the major non-verbal methods for communicating solidarity with the Person/s (Egan 2007). This model is an excellent guide for the use of non-verbal communication while listening in some sectors of Western society. However, the SOLER model gives little weight to cultural variations and expectations while listening.

Disengagement Disengagement is the process that leads to the disconnection of the individuals communicating. It consists of the actions required to satisfactorily close the interaction. Disengaging is as important as introducing. It leaves the Person/s with a definite impression of the level of interest and care on the part of the health professional. Disengagement is essential to ensure the conversation is finished and that everyone understands the content of the interaction and the implications for the future. If each person engaging in the interaction 128

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TABLE 9.2â•… SOLER: A model of active listening for the health professional Sit

Sit to facilitate ease of sight and interaction between yourself and the Person/s. The orientation in space indicates an interest in and a commitment to the Person/s that communicates I am here for you.

Open posture

Assume a posture and facial expressions that communicate alert interest and openness to the Person/s. Avoid crossed arms because this may not indicate involvement and availability.

Lean towards the Person/s

Lean towards the Person/s slightly when listening to them. This will occur naturally if you are interested in the Person/s.

Eye contact

Use eye contact to indicate interest in the Person/s. When listening to a Person/s with a visual impairment, communicate interest by facing the Person/s as though they can see you. In cultures that consider eye contact rude there are other methods of communicating interest. Investigate these methods to assist you to communicate interest and concern to such Person/s.

Relax

Relax in order to assist development of trust and to encourage the Person/s to relax. Avoid loss of concentration through thoughts about unrelated things while listening – this is interpreted as lack of interest and is easily communicated to the listener/ Person/s.

Adapted from Egan 2007.

has a different understanding of the interaction, there was neither effective listening nor speaking and certainly no effective communication. There are definite non-verbal cues that signal the impending end of an interaction. These cues, however, vary across cultures. In the health professions it is sometimes necessary to explicitly state that the interaction is near completion. With the younger Person/s, a signal that indicates the amount of time left or the number of games remaÂ� ining before the conclusion of the conversation or intervention often makes the difference between uproar and an easy departure. The Person/s from another culture and indeed any Person/s will benefit from a direct statement indicating the end of an interaction, along with a question to ensure satisfaction; for example, We have finished now – do you have anything else you want to say? Disengagement is the polite method of concluding an interaction.

Chapter summary Person/s-centred communication cannot occur without effective listening, which requires active listening skills. Effective listening is beneficial for the health professional, the Person/s, the therapeutic relationship and the potential outcomes. It is important that 129

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health professionals are aware of the requirements, results and characteristics of effective listening, along with the barriers to effective listening. They must also understand how to prepare to listen effectively and what to avoid when preparing to listen or when listening. Health professionals must consider the cultural variations that govern expectations for effective listening, as well as the need for appropriate disengagement. These elements of effective listening contribute to effective family/Person-centred practice in any health profession.

FIGURE 9.1â•… Active listening requires focus.

REVIEW QUESTIONS 1. What is a basic characteristic of effective listening? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2. What abilities are required to listen effectively? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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3. What are the benefits of active listening? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. Effective listening allows the health professional to O, C, U, R and D. What do the letters in OCURD mean? O: C: U: R: D: 5. List the barriers to effective listening. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 6. What do the letters in SAAFETY mean? S: A: A: F: E: T: Y: 7. List six characteristics of effective listening and give examples of each. i. ii. iii.

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iv. v. vi. 8. List six behaviours a health professional should avoid when listening. i. ii. iii. iv. v. vi. 9. Suggest ways that cultural expectations might change the requirements for effective listening. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 10. Explain SOLER. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ What does each letter stand for? S: O: L: E: R:

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11. Explain the limitation of the non-verbal SOLER model of active listening. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 12. How does effective disengagement contribute to Peron/s-centred communication? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

REFERENCES Adler R B, Proctor R F, Towne N 2005 Looking out, looking in, 11th edn. Wadsworth, Belmont, CA Bergland C, Saltman D (eds) 2002 Communication for healthcare. Oxford University Press, Melbourne Bodie G D 2011 The Active-Empathic Listening Scale (AELS): conceptualization and evidence of validity within the interpersonal domain. Communication Quarterly 59(3):277–295 Brown G, Esdaile S A, Ryan S 2003 Becoming an advanced healthcare professional. Butterworth-Heinnemann, London Crossman J, Bordia S, Mills J 2011 Business communication for the global age. McGraw-Hill, Sydney Davis C M 2011 Patient–practitioner interaction: an experiential manual for developing the art of healthcare, 5th edn. Slack, Thorofare, NJ Devito J A 2007 The interpersonal communication book, 11th edn. Pearson, Boston Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Egan G 2007 The skilled helper, 8th edn. Thomson, Belmont, CA Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont, CA Ewing R, Lowrie T, Higgs J 2010 Teaching and communication: rethinking professional experiences, Oxford University Press, Melbourne Gilmartin J, Wright K 2008 Day surgery: patients’ [sic] felt abandoned during the preoperative wait. Journal of Clinical Nursing 17(18):2418–2425 Giroux Bruce M A, Borg B 2002 Psychosocial frames of reference: core for occupationbased practice, 3rd edn. Slack, Thorofare, NJ Gordon J (ed) 2004 Pfeiffer’s classic activities for interpersonal communication. Wiley & Sons, San Francisco Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario 133

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Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Jansen D 2000 Are you listening? Person-centred care in long-term care facilities. Occupational Therapy Now 2(3):11–12 Lauer C S 2003 Listen to this. Modern Healthcare 33:34–37 Mann D 2010 Gestalt therapy: 100 key points and techniques. Taylor & Francis, Hoboken Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Moscato S R, Valanis B, Gullion C M et al 2007 Predictors of patient satisfaction with telephone nursing services. Clinical Nursing Research 16(2):119–137 Nyström M, Dahlberg K, Carlson G 2003 Non-caring encounters at an emergency care unit: a life-world hermeneutic analysis of an efficiency driven organization. International Journal of Nursing Studies 40:760–769 Parker D 2006 The client-centred frame of reference. In: Duncan E A S (ed) Foundations for practice in occupational therapy, 4th edn. Elsevier, London, pp 193–215 Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Skovholt T M 2010 The resilient practitioner: burnout prevention and self-care strategies for counsellors, therapists, teachers, and health professionals, 2nd edn. Taylor & Francis, Hoboken Smaldino J 2004 Barriers to listening in the classroom. Volta Voices 11(4):24 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney

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ANSWERS TO REVIEW QUESTIONS CHAPTER 9â•… Awareness of listening to facilitate Person/s-centred communication Answers to the following questions provide a summary of this chapter. 1. What is a basic characteristic of effective listening? Making the Person/s the focus of and placing them at the centre of any interaction. 2. What abilities are required to listen effectively? An ability to respect everyone; ability to concentrate, to demonstrate empathy, to identify and discuss needs and emotions, and to care about the whole Person/s. 3. What are the benefits of active listening? Active listening demonstrates respect and the value of the Person/s as well as improving the therapeutic relationship and establishing meaningful goals, which generally improves the outcomes of interventions. 4. Active listening allows the health professional to A, E, I, O and U. What do the letters in AEIOU mean? A: Assist E: Enjoy I: Influence O: Observe U: Understand 5. List the barriers to effective listening. External barriers include noises, distracting movement, interruptions and lack of privacy. Internal barriers include being emotionally unprepared, judging the Person/s, ignoring their needs and stipulating a particular or specific solution. 6. What do the letters in SAAFETY mean? S: Schedule an interpreter if necessary A: Arrange your mind and your emotions to promote focus and concentration A: Arrange the environment to accommodate cultural variations and remove physical barriers F: Familiarise yourself with the history and cultural expectations of the person E: Environmental factors should be organised to limit distractions, reduce noise or movement and facilitate concentration and focus



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T: Time with the Person/s alone to ensure privacy Y: WHY listen – clarify the reason for the interaction 7. List six characteristics of effective listening and give examples of each. i. Being prepared to listen and adjusting the environment to promote active listening ii. ‘Tuning in’ to the Person/s: asking questions about their feelings iii. Focus attention completely on the Person/s and their needs iv. Observe and validate all non-verbal messages v. Communicate interest and commitment using non-verbal and verbal messages vi. Explore cultural variations in listening relevant to the culture of the Person/s. 8. List six behaviours a health professional should avoid when listening. i. Stereotyping the Person/s ii. Judging the Person/s according to the values of the health professional iii. Over-identifying and providing advice for the Person/s iv. Taking extensive notes while listening and not looking at the Person/s v. Losing concentration because of other thoughts, e.g. next appointment or dinner vi. Interrupting the Person/s. 9. Suggest ways that cultural expectations might change the requirements for effective listening. Some cultures do not encourage eye contact, especially with an older person. The age and gender of the person may affect expectations of communication and listening. Some cultures do not use direct questions to gather information, but share information by telling stories. 10. Explain SOLER. SOLER is a model that guides active listening. What does each letter stand for? S: Sit so you can observe the Person and they can easily see you O: Have an open posture that indicates interest L: Lean towards the Person/s slightly which happens naturally if you are genuinely interested in the Person/s

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E: Maintain eye contact if it is appropriate in the culture of the Person/s R: RELAX to promote development of trust and relaxation in the Person/s. 11. Explain the limitation of the non-verbal SOLER model of active listening. The SOLER model does not consider the cultural variations and expectations of listening. 12. How does effective disengagement contribute to Person/s-centred communication? It indicates to the Person/s that they are important and the health professional is interested in their needs and their future.



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CHAPTER 10â•…

Awareness of different environments that can affect communication CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Recognise the physical factors within the environment that influence communication and the quality of the health service and the service outcomes • Understand the importance of the emotional environment when interacting with all individuals in a healthcare service • Recognise the factors contributing to the creation of the emotional environment • Identify the benefits of acknowledging and accommodating the emotional environments of all relevant people to ensure family/Person-centred practice • Justify the importance of considering the cultural environment of the individuals in a healthcare service • Recognise some of the elements of a culture that vary across cultures • Appreciate the possibility of varying sexual environments and understand that the sexual environment can influence health service delivery • Demonstrate understanding of various social environments and their influence on the individuals in a healthcare service • State the benefits of being aware of and understanding the spiritual environments of the individuals in a healthcare service • Explain the importance of openness to all the environments that affects the outcomes of any health service.

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Individuals develop in many types of environments. Such environments initially include the physical set• Divide a page into two, top to bottom. tings within the family home, the local community On one side list the factors that have and the school. These physical environments provide assisted your ability to understand in the setting for other environments, particularly emoparticular environments and on the tional, cultural, sexual, social and spiritual environother list those that have limited your ments.These environments interact to form a dynamic comprehension (e.g. noisy, emotionally system that determines the development and expectatense or spiritually unfamiliar tions of each individual when communicating. These environments). Consider the aspects expectations therefore influence the prospects and of your whole person as well as outcomes of communicative interactions. Thus this cultural and financial aspects. chapter focuses upon increasing awareness of the • Using this list, construct the environment that best assists in effect of various environments upon communication establishing comprehension when rather than skills development. providing or receiving information. There are unique factors that affect the responses Consider the perspectives of the within and the results of interactions. Some of these health professional and the Person/s. factors are age, gender, social expectations, economic status, cultural norms, sexual preferences, attitudes, experience, professional knowledge and associated expectations, problem-solving strategies, types of thinking, personality types and motivational forces (Blanche 2007, Chen 2006, Slahova et al 2007). Environmental factors also affect the outcomes of interactions. They are many and varied and each has its own effect on potential outcomes. Environmental factors are akin to the factors affecting the Person/s, with some being obvious and others more obscure. Some are more immediate than others – directly affecting the individual in the present – while others have shaped them in their past. Some the health professional can manage within the routine of practice, while others require specific understanding and tolerance.

The physical environment PHYSICAL APPEARANCE: DRESS AND ODOUR The health professional has immediate control over their physical appearance, specifically clothing, jewellery, personal grooming and hygiene. Certainly facial features and other inherited characteristics are uncontrollable, but consideration of personal codes of dress, grooming and hygiene is essential for health professionals. While dress and grooming are components of body language (see Ch 12), from the perspective of the Person/s the physical appearance of the health professional is part of the new and unfamiliar physical environment. The odours of health professionals may also potentially affect the Person/s. Such odours include body odour, perfumes and aftershave. Health professionals must consider the effect of their odour upon those around them and ensure they have daily showers (in hotter climates more than daily may be necessary), use deodorant with minimal fragrance and minimise the use of heavily scented liquids when grooming themselves for work. Most healthcare services have specific codes of dress for staff members, however it is also important to consider the effect of personal appearance and odour upon the Person/s in the health service.

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A health professional recently joined a health service. Upon arrival, the manager explained the personal appearance code along with many other behavioural expectations. The personal appearance code included smart conservative dress, removal of nose or lip rings, particular footwear and guidelines for jewellery and hair.

• •

Decide why health services have restrictive codes of personal appearance. List the reasons for and against such codes; consider healthcare interventions for individuals in various stages of the lifespan. This new staff member chose to ignore many of the codes, arguing they wanted to maintain their individuality and that they were neat and clean. A nose ring, loose-fitting ‘hippy’ clothing, several large skull finger rings, sandals and unrestrained beautiful long hair were typical of the personal appearance of this health professional.

•

If this were you, how would you respond to any attempt to change how you dress or groom yourself in a professional setting? • How would your grandmother respond to a health professional with this physical appearance? • Now think of a small child you know – how would they respond? • Decide the best way to manage this behaviour to achieve a positive outcome for all.

When dressing as a health professional it is important to avoid expressions of economic status – either wealth or poverty – in clothing, footwear or jewellery (Holli et al 2008). Appearance of wealth or poverty might be intimidating, and is sometimes misinterpreted by those seeking assistance.

•

Discuss reasons for restrictive codes of personal appearance in health services – consider uniforms, hair restraint, jewellery and footwear.  Consider the importance of comfort and safety for all stakeholders.  List the benefits and disadvantages of wearing a uniform regularly. • Decide whether restrictive codes of personal appearance are necessary and appropriate in every healthcare setting.

FAMILIARITY WITH THE PHYSICAL ENVIRONMENT AND THE USUAL PROCEDURES Person/s seeking assistance Most people feel apprehensive when entering a new environment for the first time. New environments typically stimulate unsure and hesitant behaviours. If the new environment holds unknown procedures and perhaps pain, there might even be feelings of fear and anger (Garcia Barreiro et al 2004). Investing time to familiarise people with a new

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•

Have you ever sought assistance from a service about which you knew very little? • How did you feel initially? • What made you feel more comfortable?

A person waking from a ten-day coma asks to ‘get up’ to go to the toilet. A helpful nurse returns a few minutes later with a commode chair on wheels. This is a standard procedure where the person transfers onto the commode chair and the nurse wheels the person and commode to the toilet cubicle. This is appropriate for someone who is weak from lack of sustenance and exercise. Upon seeing the commode chair the person bursts into tears and states I don’t want to go that much!

•

Can you explain this reaction? How would you react? • Is there anything that could be done to avoid this reaction? • If so, what? If not, why? • Can you think of a regular procedure in your health profession that might illicit a similar reaction?

environment can avoid any negative emotions related to the novelty of the environment and the unknown procedures associated with the environment (Purtilo & Haddad 2007). In such situations it is helpful to imagine what the personal reaction of the health professional might be in a similar situation. Knowing where to find toilets and other necessary facilities is reassuring, however, understanding what to expect during a procedure or intervention, or as a result of a particular need, is equally important. Assisting the Person/s to become familiar with the environment – the facilities, people and procedures – is essential to ensure positive responses and outcomes (see Ch 3).

Health professional There are times when health professionals may find themselves in unfamiliar environments when assisting a Person/s. Some of these environments may feel cosy and relaxing, while others seem daunting, smelly or cluttered. (A visit to the home of a Person/s who lives adjacent to a fertiliser factory does test the ability of the health professional to successfully complete their task in such an environment.) When visiting a Person/s in their home or taking them to an unfamiliar environment as part of the intervention, it is important for health professionals to take the necessary measures to minimise their anxiety related to the novelty of the environment (e.g. outline every expectation and indicate the level of assistance available). In such circumstances it is imperative that the health professional continues to respond with respect and empathy.

ROOMS Furniture placement and physical comfort Various factors require consideration when choosing the type of furniture and how to place the furniture within a room. Placement of furniture can encourage or discourage interaction. Chairs side-by-side facing the same direction do not encourage communication, nor do they demonstrate interest and care. A desk between the people communicating is not only a physical barrier, it is also an emotional barrier. Such a desk communicates a desire to keep others distant. It is important to avoid using furniture as a physical barrier when aiming at family/Person-centred practice. Arranging the chairs around a desk, a comfortable distance apart, so they face each other or are adjacent to each other promotes communication that is more personal. This configuration facilitates eye contact, which is valued in most Western cultures, although not in some other cultures. It is important to ensure that all communicating individuals are physically comfortable before the 138

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commencement of the interaction. If a table is required for placement of written material, a round table allows a clear view for everyone seated at the table.

Waiting rooms

•

Consider the effect of your physical comfort on your ability to concentrate, understand and remember specific details. Can you concentrate regardless of your comfort? • Decide on the best way to establish whether a Person/s is physically comfortable. Remember the Person/s is feeling vulnerable so they may not tell you directly they are physically uncomfortable. How will you know they are comfortable or uncomfortable? What might you do to make them physically comfortable if you establish they are uncomfortable?

Waiting rooms are often crowded and noisy. Regardless of the busy nature of the room or the size of the room, there are basic principles that make a waiting room pleasant for those waiting. The colour of the room (paint and furniture), the texture and type of furniture, the lighting and ventilation create either a warm, welcoming atmosphere or a cold, clinical feeling. The first encourages a feeling of comfort, relaxation and safety, while the other feels impersonal and unfriendly. The first encourages people to linger, while the other encourages people to leave as quickly as possible (Northouse & Northouse 1992). The more impersonal the waiting room, the greater the • For each member of the group, list the likelihood of expressions of frustration and hostility colours and textures that create a (Purtilo & Haddad 2007). Such behaviour can result feeling of comfort and emotional from personal factors or having to wait too long, but warmth. Have these changed with may also result from the impersonal or clinical nature age? of the environment. • Consider the variations in personal The feeling of comfort gained from sitting or taste. lying on particular types of furniture varies from • What does this mean for a health service and the health professional? person to person according to size, height, physical condition, age and gender. Equipping waiting rooms with varying types of chairs and mattresses can assist to overcome these personal variations. Ventilation and natural light can contribute to the ambience of any room. However, sometimes these are not possible. In such cases it is important to consider the colour and type of furniture to create an inviting and comfortable environment.

Treatment rooms and rooms with beds The same principles outlined for creation of an appropriate waiting room atmosphere also apply to treatment areas. However, it is important to consider additional environmental factors when in such areas. Many treatment areas do not naturally facilitate confidential and private communication. It is important for health professionals working in such environments to consider individual needs for privacy. The need for privacy may vary according to personality type and the emotional state of the individual at any given time. Consistent consideration of these needs will promote personal disclosure when required and the development of rapport. It is important to consider the difference between visual privacy and auditory privacy. Drawing curtains around a treatment bed or a bed in a ward does not guarantee privacy. A private room will facilitate personal communication, while a public space will keep the communication at a superficial level in order to protect confidentiality. 139

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• • • • •

How do you feel if you discover someone talking about something personal when they do not know you can hear the conversation? What do you do in such situations – do you keep listening or do you move? What does this reveal about you? What implications does this have for a health professional? How do you feel if you discover someone talking about you when they do not know you can hear? What do you do then? What does this mean for a health professional?

AVOIDING DISTRACTIONS AND INTERRUPTIONS The use of a private room for discussion of personal information is very important, but it may not achieve personal disclosure if there are constant distractions. Distractions come from the telephone, people, regular or loud noises, particular objects in the room and sometimes movement outside a window. Think of a time when someone or something distracted you during a conversation, meeting or lecture. What was the distraction? Was it important? How did you feel about the distraction? Were you able to return to the exact point after the distraction occurred? How long did it take to regain concentration and the ‘flow’ of the information?

• • • • •

As a group, find a movie only one member of the group has seen. Have that person tell another group member, who wants to see the movie, the story of the movie and describe the major characters in the movie. Every other member of the group takes turns to interrupt the retelling with an unrelated statement or noise – asking for the time or when the next bus is due, tapping on the floor, or pointing out an event outside the window. The person listening responds to each distraction, taking interest and where necessary answering or commenting. As a group, observe the effect of the distractions on the flow of the story and on the person attempting to tell the story. Have the listening person retell the story of the movie and check for accuracy.

Personal and emotional communication requires concentration and focus. Distractions make this focus difficult and disturb the flow of the communication. Restoring the concentration and information flow during exploration of emotion is often difficult. More importantly, responding to distractions communicates that the distraction is more important to the health professional than the communicating Person/s. Thus, avoidance of such distractions is very important (Bergland & Saltman 2002). This is achieved by not answering the telephone, leaving a message that indicates disturbances are not acceptable (e.g. a sign on the door saying ‘Do Not Disturb’), decreasing or removing distracting noises and/ or objects where possible, and organising the seating to avoid distractions outside a 140

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window. If in a hospital ward, it is appropriate to arrange a time when there are no expectations from other health professionals or visitors. Some sounds are so much a part of the environment that the health professional no longer notices them, such as sounds from equipment or machinery. These sounds are often necessary and unavoidable, but they may be distracting to a Person/s unfamiliar with the environment. In such situations it may be necessary to recognise the distraction and encourage the individual to attempt to ignore it if possible. Sometimes the simple acknowledgement of the distraction may assist the individual to ignore it and focus on the communicative event.

TEMPERATURE Different healthcare settings have different constraints relating to resources and type of service. This may affect the presence of temperature controls within the setting. The external climate may make temperature alterations desirable. Health services in very cold climates usually have heating; however, those in hot, humid climates may not always have airconditioning. In such situations, the behaviour of those within the health service may reflect the temperature. If there is a pattern of irritability among people in those services – Person/s and staff alike – consideration of the heat in the environment may explain the ‘emotional temperature’ (Purtilo & Haddad 2007). List possible ways of compensating for Warm temperature and poor ventilation can the absence of, or a failure in, a climateencourage drowsiness, which will limit the quality of control system. Use your imagination, but the communication. Feeling cold can be equally detbe realistic – although the idea of hosing rimental to communication, with the physical temthe individuals with a garden hose is very perature of the Person/s dominating their responses. cooling, it is unlikely to be acceptable in Where possible, control of the temperature or comany health service! pensatory measures, when climate control is lacking, are essential to ensure effective communication.

THE PHYSICAL ABILITY OF THE PERSON Each individual has abilities and skills that facilitate their movement and comfort in particular environments. Children find stairs and large chairs and tables difficult to accommodate until they grow to a particular height and develop the abilities and skills to independently negotiate such objects in the environment. Extremely tall people can find the size of chairs and tables and the height of benches equally challenging – regardless of their abilities and skills. Individuals with physical limitations that restrict their ability to negotiate particular environments may find such objects to be barriers to participation and independent functioning. It is important for a health professional to consider the abilities and skills of the individuals seeking their assistance in order to adjust the environment to accommodate the needs of those individuals. Ramps with rails, height of chairs and tables, height of beds and toilets – in fact height of anything they must negotiate within the environment of the particular health profession – may be significant. Assistive devices that facilitate independent functioning for such individuals will reduce potentially negative emotions and increase the possibility of positive outcomes of communication and interventions. Trust, empathy, good rapport and a therapeutic relationship will compensate for deficits in the physical environment. These develop over time, however, and an unfriendly clinical environment creates an initial impression that may be difficult to overcome. 141

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The emotional environment •

Divide a page into two, top to bottom. Label one column ‘Formal’ and the other ‘Informal’. • Consider the expectations of each type of environment and how that makes you feel. If you find it difficult to determine the expectations of each, you might wish to consider a particular formal or informal occasion in your experience. For example, consider your emotional response to attending a formal dinner party or a barbeque where you are unsure about the expected level of formality. List the expectations of each environment. • List the emotional responses group members might have to these types of situations. • List the factors that might affect these responses (e.g. close friends present).

•

The emotional state and emotional response of individuals seeking assistance create a particular emotional environment that, in many cases, requires direct attention from the health professional. Direct and immediate attention to emotions can save time and effort for both the Person/s and the health professional (see Ch 8). The emotional environment within an individual may be as simple as feeling a sense of inconvenience because they require assistance for something simple and relatively minor. The emotional environment of a Person/s who has a life-limiting illness, however, is complex and requires management and collaboration to ensure positive outcomes for all stakeholders. Consideration of the emotional environments of those seeking the assistance of a health professional has numerous benefits that contribute to family/Personcentred practice.

FORMAL VERSUS INFORMAL ENVIRONMENTS

How do the emotions associated with the formality of the situation affect your desire to communicate? Do they affect the superficiality of the conversation? Explain why they affect the type of communication and the topic of communication. • On a separate piece of paper, list those things that facilitate your ability to talk about yourself at more than a superficial level.

Different occasions and places demand different types of behaviour – some more formal than others. In formal situations, individuals are expected to adhere carefully to particular norms. These norms might require the use of the family name when addressing an individual, they might require only speaking when asked a question, or they might perhaps require a controlled use of language. For example, the language and behaviour used in a courtroom is very different to the language and behaviour used with friends at a football game. The expected formality of a situation will affect the emotional response of the individual, their comfort when communicating and their willingDiscuss the implications of the above ness to communicate about personal matters. factors for a health professional. The various expectations and demands of the formality of the environment affect the individual. Situations that are more formal tend to create a more tentative and apprehensive emotional response in an individual. Less formal situations promote relaxation and generally encourage willingness to discuss personal matters at a deeper level.

EMOTIONAL RESPONSES TO ENVIRONMENTAL DEMANDS Emotional responses to the immediate environment There is a continual and dynamic interaction between the individual and their immediate environment. This interaction creates a particular emotional environment that will vary according to the dominant need at any given time (Gross et al 2007). If the personal 142

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emotional needs dominate an individual and the environment does not accommodate these needs, the stress level for that individual increases as they attempt to meet the demands of both self and the environment (Brill & Levine 2005). In such circumstances, it is beneficial for the health professional to note and where possible accommodate the emotional environment of the Person/s. Something as simple as the position of the health professional (e.g. standing over a person or standing too close or too far away) may evoke a negative response in particular individuals. Unfamiliarity with the surroundings, the individuals and the associated intervention or procedure in the environment can also create a particular emotional environment for the individual. This emotional environment may affect their responses and the quality of their interactions. It is possible to alleviate these particular emotional environments with direct attention, acknowledgement and action.

Emotional responses to an external environment Individuals often exhibit emotions because of an emotional environment established from a source external to the immediate environment of the health service. Potential contributing causes of negative emotional environments include: financial stress, social stress, physical discomfort or anxiety about an unknown future. It is not the role of every health professional to treat the causes of the dominating emotional environment. However, validation of the associated emotions, empathic responses and referral to a relevant professional will reduce the consequences of the particular emotional environment. Failure to note and accommodate the internal or external emotional environment of the individual can have negative results. Responding to the emotional environment does not usually take excessive amounts of time and has benefits for all people involved. The ultimate benefit for the individual is improved outcomes, but it also saves time for the health professional if dealt with immediately.

The cultural environment Individuals grow and develop in specific cultural environments. These cultural environments determine how individuals view themselves, how they view others and how others view them (Watson 2006). Examination and understanding of the cultural context of a person provides information about the rules and norms that govern their life, both individually and within groups. Cultural environments influence the values of societies and individuals. These values directly affect expectations and goals within the culture and outside the particular culture. Shared values and expectations (i.e. the cultural worldview) are inherent in cultural groups, thus individuals from those groups are often unable to verbalise the details of these values and expectations. An appreciation of the specific worldview of the individual seeking assistance promotes positive communication and family/Person-centred practice.

PERSONAL SPACE Different cultures have different norms that govern personal space, that is, the distance individuals stand or sit from each other during a communicative interaction. Recognising variations in ideas of personal space is important when relating to people from a different culture. If the Person/s uses non-verbal cues that demonstrate emotional discomfort and moves away from standing a particular distance apart, the Person/s has adjusted their emotional environment according to their cultural expectations. It is important to not move closer in response. Instead, the health professional should try to remain in their original spot, even if it feels impersonal and distant. If the health professional does move closer, they may ‘chase the Person/s around the room’ throughout the discussion. 143

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Mrs Gilles is a 78-year-old lady who lives alone with her cat. She is currently attending for weekly treatment. She generally appears happy and eagerly enters into collaborative goal-setting. Her level of improvement suggests she is implementing the particular regime suggested by you as her health professional. One particular day you intend to introduce Mrs Gilles to a more demanding ‘home program’ during her treatment session. You have a good relationship with her and often talk about her past and present life when she attends. She appears to enjoy attending. When Mrs Gilles arrives, she seems a little teary but smiles when she sees you. • You have two choices – to investigate her apparent tendency to tears or ignore it. • The treatment environment demands a happy and willing-to-participate Mrs Gilles. At this point, her emotional environment is not dominating her responses. She is able to respond to the demands of the treatment environment and continues in her happy, collaborative way of interacting. • What will you do? You decide to ignore it – you have a full day and decide you simply do not have the time to investigate. The next time Mrs Gilles attends it is obvious she has not been implementing her home program; in fact, she seems to be back to her status of three weeks ago. She is teary and, although participating, does not smile or look at you. • The emotional environment of Mrs Gilles is now beginning to dominate and she is no longer able to meet the demands of the treatment environment; she demonstrates being unable to continue her treatment regimen at home. • You are busier this week with more appointments than normal because you are going on holidays at the end of the week. You decide to ignore the emotional environment surrounding Mrs Gilles and hope it will be better when you come back from holidays. You think to yourself that most emotional things improve with time and a colleague will see her while you are away. You return from holidays two weeks later to find that Mrs Gilles has not attended since you went on holidays. You ring her and hear that she has been lying in bed since the last time you saw her – she says she cannot be bothered to get out of bed anymore. • What will you do? You know Mrs Gilles was improving with your intervention. You ask her a few questions but she is reluctant to talk to you. You finally ask her about her cat – she often talked lovingly about the cat, stating she had nothing else since the death of her husband. Mrs Gilles suddenly sobs uncontrollably – the cat had died the week when she was teary! This interaction took more than 10 minutes.

•

How long would it have taken to investigate the cause of the tears (the emotional environment affecting the person) the first time you saw the tears? • Might it potentially have created a different scenario for Mrs Gilles?

•

Have one person play Mrs Gilles and another the health professional who validates the cause of the tendency to tears with empathic responses and questions. • Time how long it takes to validate the emotions and demonstrate empathy. • Discuss the possible direction of the conversation with Mrs Gilles. • Should the health professional discuss the emotions related to grieving (see Section 4) and strategies for dealing with the death of the cat?

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Alternatively, if a Person/s moves closer when interacting, demonstrating emotional distress unless they remain closer, this may demonstrate a different cultural norm governing personal space. Variations in ideas of personal space when interacting, whether sitting or standing, require awareness in the health professional.

COLOUR Colours can communicate different emotions to different individuals. Some of this communication is culturally determined and some results from individual preferences. Different cultures assign sometimes totally opposite meanings to the same colours (Devito 2009).

TIME

What is your favourite colour? Can you remember if there is a particular reason or experience that explains why it is your favourite colour? The colour of a favourite comfortable piece of clothing may become your favourite colour when that piece of clothing becomes a rag. Wearing the same colour every day may make that colour your least favourite.

Different cultural environments have a different awareness of and place a different emphasis on time. Some cultures measure time by the movement of the Earth around the sun, that is, a seasonal calendar. In • Consider each of the colours listed and together decide if the colour is these cultural environments the seasons regulate the symbolic of or relates to something lives and expectations of the people. If the winter is particular. long and cold, then that season determines the cultural expectations of interactions between people at Black: Red: that time. If there is little seasonal change then the Blue: Green: cultural environment is unlikely to demand different White: Purple: ways of relating as the year changes. Some cultures Yellow: regulate their interaction by the movement of the moon around the Earth (phases of the moon) – the • If there are various cultures lunar calendar. In these cultural environments the represented in the group, note the movement of the moon determines the expectations different meaning each colour has in each culture. and norms that govern interactions between people at particular times. This means that a New Year cele• Decide if the cultural meaning of colour is important to the practice of a bration may sometimes occur in late February, and health professional. Easter may occur in mid-March. Other cultures regulate their interactions by the movement of the Earth on its axis – a 24-hour schedule based around the spinning of the Earth. In these cultural environments the 24-hour clock regulates the events and expectations of the people. In other cultures, time has a different significance and is unrelated to schedules throughout the day. The regard for time in different cultures delivers different messages. Some cultures value adherence to the time schedule above other cultural or social demands. In Western cultures, punctuality communicates respect, whereas being late communicates the opposite. Others consider the adherence to ‘being on time’ is not as relevant as other cultural or social demands – so much so that they may not attend a previously made appointment and not consider it necessary to notify the health professional that they are unable to attend. When differences in perceptions of the significance of time cause difficulties in the health professions, it may be important to sensitively communicate to a Person/s that the reality for the health professional of many appointments in one day makes it difficult to see someone after their allocated time.

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• • • • • •

In some cultures, inviting a person to have or do something requires a repeat of the request three times Is it important to you to be on time for before the person answers in the affirmative. In other social appointments? cultures, lack of an affirmative response after the first Is it important to you to be on time for request might indicate that the person is ambivalent professional appointments? about accepting the invitation. For example, in China Is there a difference? Why? Do you it is sometimes polite to ask a person three times if have friends who do not differentiate? they would like a drink. If the request occurs once, Does it annoy you when others are the person will indicate a definite no, regardless of late for an appointment? their desire for a drink. It is not until the occurrence Consider the above points relating to of the third request that they might indicate their different interpretations of the importance of time. What does that desire for a drink. In other cultures where one request mean for a health professional? is the expected norm, the first answer indicates the List the possible ways a health desire or lack of desire for a drink. professional might accommodate A cultural environment influences many compocultural differences relating to time. nents of human behaviour, too many to consider in this chapter. It is the responsibility of the health professional to acknowledge and accommodate the cultural variations in all interactions. Fulfilling this responsibility requires an awareness of the personal cultural expectations of the health professional and their emotional responses to variations in cultural expectations. It also requires an awareness of the cultural differences of the Person/s the health professional assists. Such awareness potentially prepares health professionals to open themselves to exploring and understanding those differences. Understanding cultural differences empowers the health professional to accommodate variations in the diverse cultural environments potentially represented by both the individuals seeking their assistance and their colleagues in the particular health service.

Environments relating to sexuality Different individuals may exist within environments with different sexual and moral expectations. These differences may affect the willingness of a Person/s to consider and discuss sexuality (Gilmer et al 2010). They may also determine the expectations of individuals relating to sexual intimacy and the significance of sexual experiences for particular individuals (Milliken & Honeycutt 2004). A person raised in an environment that practises regular casual sexual relationships would make particular assumptions about sexual practices and may either exhibit similar practices or carefully control any sexual activity. A sexually abused person may avoid any kind of physical touch or may have a fragile selfimage that does not allow them to relate sexually or communicate about sexual matters. It is important that health professionals understand that different individuals may have different sexual habits and preferences (McAuliffe et al 2007). Some individuals may practise sexual abstinence, others casual sexual relationships, and others may prefer sexual experiences with people of the same gender. Such sexual practices and preferences may or may not be the preference of the health professional; however, it is important to be aware of these various sexual environments to ensure a positive response to such individuals.

The social environment Individuals usually mature in the context of other individuals. The social environment of an individual consists of all the social relationships they experience with people and animals. Such relationships can be encouraging and supportive, discouraging and 146

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unhelpful, or a combination of both. The social environment of the person seeking assistance can influence their responses and their ability to communicate effectively.

FAMILY A supportive family can assist the health professional (Holli et al 2008). When desired and if appropriate, supportive family members should be included in establishing and supporting the goals of the collaborative process between the Person/s and the health professional. If the social environment of a family is a place of abuse and discouragement, this will shape the communication style of the individual. The behaviour associated with this type of social environment is not always interactive or easy. Understanding this behaviour might be difficult; however, it is important in such cases that the health professional relate to the individual with acceptance, consistency and definite boundaries. The creation of a safe, predictable environment for such a Person/s within the context of the health service is the immediate goal of the health professional.

PETS A relationship with a pet is often of great significance to a person (e.g. a dog to a child, a horse to a female adolescent, or a bird or cat to an ageing person). Different cultures or geographical settings may mean that the animal is different (it may even be a whale), but, if a pet, the animal may serve to be the most significant comforting social relationship for a particular individual.

FRIENDS, NEIGHBOURS, INTEREST GROUPS AND SPORTING TEAMS The social environment that includes groups outside a family is often significant to an individual. Friends, neighbours, special purpose groups or sporting teams may provide a social environment that reinforces the value of the individual, provides affection and affirms them in a unique way. Such friends or groups may become more significant if the individual lives alone. However, these social environments may also be the context for abuse (e.g. a ‘helpful’ neighbour may lock a person in a room thinking they are protecting them) and • Brainstorm and list possible strategies this may explain unreasonable behaviour in some for managing an unsupportive social environment. Note these are not circumstances.

INSTITUTIONS A health professional may assist an individual whose primary social environment is an institution. These individuals may have different styles of communication according to their experiences within the particular institution. In this situation, it is important for the health professional to demonstrate behaviour that reflects both the general (see Ch 2) and specific purposes (see Chs 3 & 4) of the health professions. The social environment of each health service team may vary. It is important that health professionals resolve any personal responses to their colleagues in that environment to avoid negatively affecting those seeking their assistance.

• • •

•

age-specific needs and occur throughout the lifespan. List strategies for managing an unsupportive family. List strategies for managing the loss of a special pet. List strategies for managing lost social environments through relocation of the family home, decrease in or loss of physical abilities, or the death of someone significant. List strategies for managing experiences from institutional social environments – whether pleasant or unpleasant.

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The spiritual environment Individuals adopt particular elements of spirituality that create their own spiritual environment for many reasons. Some simply adopt the dominant spiritual environment of their native culture, while others may choose a particular spiritual environment. The spiritual environment of an individual may be more relevant to particular health professions than others, thus some health professionals may appropriately choose not to relate to this environment (Mir & Sheikh 2010). Regardless of the relevance of spiritual issues to the particular health profession, it is important that health professionals demonstrate respect and sensitivity to the way in which the spiritual environment may assist in the management of the health issue and healing of the individual seeking assistance (Purtilo & Haddad 2007). Health professionals can choose to relate to or to ignore the spiritual environment of the people they are assisting (Egan 2010). Many Western health professionals prefer to avoid consideration of spiritual environments. However, growing interest in spirituality is producing an increasing body of knowledge that provides guidance for the use of spiritual understanding in the practice of health professionals (Miller 1999, Miller & Thorensen 2003, Powell et al 2003, Richards & Bergin 1997, White 2006.) Acknowledging and accommodating the spiritual environment of the Person/s can create deeper understanding of that environment, as well as encourage the individual in the use of images, medicine and rituals typical of that environment. The use of these elements of a particular spiritual environment may promote participation, healing and function (Eckermann et al 2010).

Chapter summary Health professionals may experience multiple environmental demands while fulfilling their role. These demands may arise from the physical, emotional, cultural, sexual, social and spiritual environments of the health professional, the particular health service or the Person/s. It is the responsibility of health professionals to overcome any personal and negative responses to the specific environmental demands experienced as part of their role. Successfully meeting the demands of particular environments while practising as a health professional will ensure positive outcomes and family/Person-centred practice.

FIGURE 10.1â•… The emotional environment can be paralysing.

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REVIEW QUESTIONS 1. Various environments form a dynamic system that affects each individual. These environments include: i. ________________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ iv. _______________________________________________________________ v. _______________________________________________________________ vi. _______________________________________________________________ 2. List seven elements of the physical environment that affect the individual seeking assistance. i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ iv. _______________________________________________________________ v. _______________________________________________________________ vi. _______________________________________________________________ vii. _______________________________________________________________ 3. Name three ways the health professional can accommodate the emotional environment. i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 4. Cultural environments vary and the heath professional must be open to differences between their own cultural environment and those of the individuals seeking assistance. Health professionals must respond with willingness to understand and accommodate such differences. Name three culturally specific elements that require understanding. i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________

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5. What differences can occur in sexual environments? i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 6. What do social environments include? i. i. i. iv. _______________________________________________________________ 7. Why is the spiritual environment of each individual important? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

REFERENCES Bergland C, Saltman D (eds) 2002 Communication for healthcare. Oxford University Press, Melbourne Blanche E I 2007 The expression of creativity through occupation. Journal of Occupational Science 14(1):21–29 Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Chen M 2006 Understanding the benefits and detriments of conflict on team creativity process. Creativity and Innovation Management 15(1):105–116 Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Eckermann A, Dowd T, Chong E et al 2010 Binan Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Garcia Barreiro G M, Montero Naviera J V, Montoiro Castro S M et al 2004 The elderly at home: architectural barriers [Spanish]. Gerokomos 15(3):140–146 Gilmer M J, Meyer A, Davidson J et al 2010 Staff beliefs about sexuality in aged residential care. Nursing Praxis in New Zealand 26(3):17–24 Gross R, Tabenkin H, Brammli-Greenberg S et al 2007 The association between inquiry about emotional distress and women’s satisfaction with their family physician: findings from a national survey. Women & Health 45(1):51–67 Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia 150

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McAuliffe L, Bauer M, Nay R 2007 Barriers to the expression of sexuality in the older person: the role of the health professional. International Journal of Older People Nursing 2(1):69–75 Miller W R (ed) 1999 Integrating spirituality into treatment: resources for practitioners. American Psychological Association, Washington DC Miller W R, Thorensen C E 2003 Spirituality, religion and health: an emerging research field. American Psychologist 58(1):24–35 Milliken M E, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mir G, Sheikh A 2010 ‘Fasting and prayer don’t concern the doctors … they don’t even know what it is’: communication, decision-making and perceived social relations of Pakistani Muslim patients with long-term illnesses. Ethnicity & Health 15(4):327–342 Northouse P G, Northouse L L 1992 Health communication: strategies for health professionals, 2nd edn. Prentice Hall, Englewood Cliffs, NJ Powell L H, Shahabi L, Thorensen C E 2003 Religion and spirituality: linkages to physical health. American Psychologist 58(1):36–52 Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Richards P S, Bergin A E 1997 The need for a spiritual strategy. American Psychological Association, Washington DC Slahova A, Savvina J, Cack M et al 2007 Creative activity in conception of sustainable development education. International Journal of Sustainability in Higher Education 8(2):142–145 Watson R M 2006 Being before doing: the cultural identity of occupational therapy. Australian Occupational Therapy Journal 53(3):151–158 White G 2006 Talking about spirituality in healthcare practice: a resource for the multi-professional healthcare team. Jessica Kingsley, London

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ANSWERS TO REVIEW QUESTIONS CHAPTER 10â•… Awareness of different environments that can affect communication Answers to the following questions provide a summary of this chapter. 1. Various environments form a dynamic system that affects each individual. These environments include: i. Physical ii. Emotional iii. Sexual iv. Cultural v. Social vi. Spiritual 2. List seven elements of the physical environment that affect communication with the individual seeking assistance. i. Physical appearance – clothing, dress, jewellery ii. Familiarity with the particular service and the procedures iii. Rooms and the physical comfort and placement of the furniture iv. Noise in the environment v. Avoiding distractions and interruptions vi. Temperature vii. Physical ability of the person and accessibility of the physical layout of the service. 3. Name three ways the health professional can accommodate the emotional environment. i. Create a less formal atmosphere for the interaction ii. Respond immediately to the appearance of emotions whether positive or negative by clarifying and validating, and if necessary referral to appropriate services iii. Position yourself appropriately and provide clear explanations and instructions.



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4. Cultural environments vary and the heath professional must be open to differences between their own cultural environment and those of the individuals seeking assistance. Health professionals must respond with willingness to understand and accommodate such differences. Name three culturally specific elements that require understanding. i. Personal space ii. Colour iii. Time 5. What differences can occur in sexual environments? i. Differences in expectations of casual sexual practices ii. Differences in sexual experiences regardless of age iii. Differences in sexual preferences. 6. What do social environments include? i. Family ii. Pets iii. Friends and neighbours, interest groups iv. Institutions 7. Why is the spiritual environment of each individual important? Allowing for the spiritual environment of the Person/s can encourage the individual to use relevant images, medicine and rituals typical of that environment. The use of these elements of a particular spiritual environment may promote participation, healing and function.

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Understanding and Managing Realities of Communication in the Health Professions

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CHAPTER 11â•…

Communication with the whole Person/s CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Demonstrate understanding of the concept of and components of the whole Person/s • Synthesise all aspects of the whole Person/s in order to achieve effective communication with those Person/s • Consider and develop strategies to overcome the difficulties associated with assisting the whole Person/s • List the various meanings of the concept of holistic care • Understand the importance of holistic communication • List some characteristics of holistic communication.

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Defining the whole Person/s

• • •

•

•

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The concept of the whole Person is important to many health professions. Those professions require inclusion, understanding and care for the whole Person/s. There is detailed discussion about the components of the whole Person/s in Chapters 8 and 9 of this book. In summary, there are five basic aspects of the whole Person/s (Brill & Levine 2005). Four of these aspects are the physical, cognitive, emotional/psychological and spiritual functioning of the Person/s. The physical functioning is the most obvious and includes the body of the person, the functioning of their internal organs and their external body parts. While there is some debate about the components of the mind, cognitive functioning definitely includes thoughts and memory processes. Some believe that emotional or psychological functioning is part of the mind, others believe it originates in the heart, while others believe it originates in the liver. Regardless of origin, psychological and emotional functioning is an aspect of every person and a component of the dynamic system of the whole Person/s (Sims-Gould et al 2010). Spiritual functioning refers Do the five aspects of the whole to that aspect of the person that gives meaning to self, Person/s ever operate separately? life and the universe. It involves moral values and Explain. relating to the world at a spiritual level. The whole List ways in which each aspect may Person/s exists in a social context, thus while the affect the functioning of the whole person may consist of the above four aspects, past and Person/s. Consider how the health present social experiences create the fifth aspect of professional might recognise the the whole Person/s – the social aspect. The social influence of each aspect of the aspect influences and often determines responses in whole Person/s. the other four aspects. These five components of the person interrelate to exist as a dynamic whole, and influence the ability to communicate in daily life. It is impossible to separate the individual aspects from the whole because they are mutually dependent and Consider the five aspects of the mutually affect each other. whole Person/s. Do you agree that While it is possible to focus upon one aspect of these aspects create the whole the whole Person/s, dividing the whole into parts for Person/s? Do you feel there are any analysis can be problematic (Dossey et al 2005a, more internal aspects of the whole Harms 2007, Harms & Pierce 2011, Reed & SanderPerson/s? If so, ensure your answers son 1999) because each aspect exists in an intricate do not belong in one of the other and sometimes delicate relationship with the other five aspects. parts. Analysis of one aspect is often useful and transConsider times in your life when one formative. Such analysis, however, should always of the aspects may have dominated consider the effects of the other aspects. your functioning (e.g. when playing There are times during life when one particular competitive sport or when studying). Were the other aspects dormant at aspect may dominate the dynamic system of the that time? How did the focus affect whole individual. The demands of life at that time or your overall functioning? Did other the particular choices made by the individual result aspects become less predictable or in the Person/s giving greater priority to a particular more sensitive? How did you aspect of their whole more often than the other manage this? What facilitated a aspects. For example, the physical aspect of an elite sense of wellbeing despite the focus athlete may dominate their focus and functioning upon one aspect? because of the requirement for physical training. A student is required to use the cognitive aspect

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regularly, thus the cognitive aspect may prescribe their focus and functioning. A grieving individual may experience extreme emotional stress, so the psychological aspect of a grieving Person/s may dominate their functioning. An individual who chooses to be a monk or nun usually makes choices based upon the spiritual aspect. The need for social acceptance during adolescence may mean that the social aspect of the adolescent drives/ dominates their existence at that stage in life.

Holistic care The principle of holism always considers the Person/s to be a whole, regardless of the specific demands upon that Person/s at a particular time (Lin & Tsai 2011). The concept of holism is not a new idea for many health professions (Brill & Levine 2005, Dossey et al 2005b, Milliken & Honeycutt 2004, Reed & Sanderson 1999, White 2006); in fact, a variety of health professions have developed because of a holistic philosophy of care (Punwar & Peloquin 2000). There are various ways of understanding holistic care. It can mean inclusive care that accommodates diverse cultural and spiritual systems (Taylor 2006), in particular the medicine of traditional indigenous healers and the traditional interventions of Eastern cultures. Holistic care can also mean complementary and alternative medicine (CAM) (Dossey et al 2005a) as opposed to traditional medical care. A holistic concept of healthcare is the basis of CAM (Milliken & Honeycutt 2004), thus some consider holistic care as synonymous with CAM. Some health professions perceive holistic care as the consideration of the whole Person/s – every aspect of the unique individual – using a variety of interventions depending on the • Consider the aspect of the Person/s needs of the individual. In these professions, holistic to which you feel most comfortable care means avoidance of focusing upon one aspect relating. Why? of the individual over another aspect. It requires recognition that healthcare is more than a focus upon the physical needs of the individual (White 2006). • Have each group member explain Holistic care fulfils more than the immediate needs which aspect of a Person/s they relevant to the particular health profession; it recogwould feel most comfortable nises there are many causes contributing to those addressing in their health profession. needs (Bertakis et al 2009). It recognises that the • As a group, decide which aspect of the Person/s is the easiest to relate immediate needs may arise from more than the to or address. Discuss why. physical aspect of the Person/s, even though the • As a group, decide which aspect is need initially may appear to be physical. Holistic care the most difficult to address. understands there is more than one way to fulfil a Discuss why. Suggest strategies that need and to achieve healing. It considers the less might assist in overcoming this obvious and often forgotten aspects of the cultural, difficulty. psychological, social and spiritual functioning of the individual. Holistic care does not merely treat symptoms but also searches for causes, understanding there are often multiple causes that arise from and relate to every aspect of the whole Person/s. Mutual respect is the foundation of holistic care, and it assumes equality (see Chs 2 & 8) within the therapeutic relationship. Mutual respect seeks involvement from the Person/s seeking assistance in the collaborative goal setting and decision making associated with their care and future (Dossey et al 2005b). In holistic care, the responsibility for change and healing lies within the Person/s. The role of the health professional is to 157

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facilitate and empower the Person/s to achieve their set goals (Milliken & Honeycutt 2004). Unless specifically taught to provide holistic care, a developing health professional may require experience to consistently provide holistic care (Liu et al 2000). It is possible for a health professional who practises within a particular specialty area to provide holistic care, despite a focus upon their specialty area (Cegala & Post 2009). Regardless of the situation, it is possible to consider the whole Person/s while practising as a health professional. Holistic care is fundamental in achieving family/Person-centred practice in any healthcare service and thus should be an aim of every health professional.

HOLISTIC CARE INCLUDES CONSIDERATION OF CONTEXT To provide holistic care it is important that health professionals consider the interrelating aspects of the whole Person/s regardless of the presence of an obviously dominating aspect at any one time. It is also important to remember that individuals with whom health professionals communicate develop within diverse and multiple contexts. Recognition of these contexts is essential when communicating (Harms 2007, Harms & Pierce 2011, Milliken & Honeycutt 2004, Purtilo & Haddad 2007, White 2006; see Chs 6 & 10). Some consider these contexts to be physical, financial, cultural and social (family or kinship groups, friends, colleagues or acquaintances), while others consider them to also include a spiritual element (Colbert 2003, Taylor 2006). Regardless of their composition, these contexts provide experiences that promote positive or negative responses within the cognitive, spiritual and psychological functioning of the individual. Such responses ultimately affect the physical and social aspects of the individual (Colbert 2003, Golman 2006) and, therefore, all of these contexts require the attention of health professionals.

THE REQUIREMENTS OF HOLISTIC CARE There are currently many health professions, each with their particular expertise and focus. An awareness and understanding of the various health professions is important to ensure holistic care and positive outcomes (Selimen & Andsoy 2011). Openness to the involvement of multiple health professionals when assisting individuals, regardless of the presence of an inter or multidisciplinary team, increases the potential for holistic and positive outcomes (White 2006).

• • •

•

State the aspect(s) upon which your particular health profession focuses. How can you ensure holistic care for those seeking your assistance? Divide a page into two, top to bottom.  On one side, make a list of every health profession you know.  On the other side, list the aspect(s) upon which that health profession focuses. If you are not sure, do some research and then list the aspect(s).

Compare your list with two others and adjust it according to the contents of the other lists, requesting clarification where necessary. • How can you use this list to ensure holistic care that empowers the individual to achieve their goals and transform their functioning?

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Each of the individuals below is awaiting a diagnosis relating to physical symptoms, however, this is what they express: • A 43-year-old regularly expresses anxiety about their diagnosis. • A 17-year-old expresses stress because of matriculation assessments. • A 7-year-old just wants to continue playing weekend sport. • A 54-year-old male with an intellectual disability wants to marry his 22-year-old girlfriend who also has an intellectual disability. • A 28-year-old overeats constantly because of fear. • A 45-year-old expresses disappointment that their same-gender partner of 20 years has been unfaithful recently. • A 76-year-old expresses distress over their lost cat. • A 52-year-old expresses confusion because of their dementing parent. • A 39-year-old expresses despair because of their dying child. • A 60-year-old is depressed because they cannot attend their religious group. • A 32-year-old has just given birth to her first (much-awaited) child. She has been told the child has Down syndrome and she expresses devastation.

• • •

Decide how to best acknowledge and fulfil each person’s need. What would your health profession do to assist each person? Decide whether it is appropriate for one health professional to meet all the needs of every person they see. • How can you ensure holistic care for these people?

Holistic care requires consideration of the whole Person, however it also requires care of self (Geist-Martin & Bell 2009). This therefore requires reflection and self-awareness within while practising as a health professional. This awareness will guide and promote necessary change. Holistic care also requires health professionals to assume responsibility for themselves – for their thoughts, words, actions and related outcomes. This, of course, requires health professionals to balance their personal and professional needs (Dossey et al 2005a, 2005b). Holistic care requires health professionals to acknowledge the effects of their professional encounters and seek assistance as necessary. Such care of self will develop and strengthen holistic communication (Portillo & Cowley 2011). Using the information contained in this chapter and the beliefs held within the group, list ways of achieving holistic healthcare. Consider the following questions when compiling this list: • Can an individual health professional achieve holistic care alone? • Can traditional medical intervention alone achieve holistic care? • Can CAM alone achieve holistic care? • How can a health professional from a profession typical of either the medical model or CAM model achieve holistic care? • How important are traditional indigenous treatments for an indigenous Person/s? Why? • How important are traditional Eastern treatments for a Person/s with an Asian background? Why? • Do all aspects of the whole Person/s require attention to achieve holistic care? Why?

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Holistic communication Holistic communication requires health professionals to apply the principles of effective communication to every individual within the context of their practice. These individuals include other health professionals (some in the same team and others not), support staff and people seeking assistance. Holistic communication requires a willingness to communicate about contexts, experiences, thoughts, emotions, needs and desires, because in so doing the health professional will relate to all aspects of the whole Person/s (Brill & Levine 2005, Crotser & Dickerson 2010, Milliken & Honeycutt 2004, White 2006; see Ch 8). When communicating holistically it is important to understand that the individual perspectives of each Person/s (Gordon et al 2006, Harms 2007, Harms & Pierce 2011), as well as previous and present events, affect the choice of topics of communication, the interpretation of events and messages during communication, and the results of communication. Holistic commuWhat is your emotional and nication requires health professionals to consider elephysical response to the following ments of the particular context of the interaction, questions? because these will affect the quality and success of • Can you tell me where I can the communication (Salmon & Young 2011). The perform my daily prayers while immediate context involves the resources associated I am here? with the service (both people and objects) and the • Can you talk with me about my various aspects of the individual at the time. It is religious beliefs? necessary for health professionals to consider and • Can I ask my family to bring me a care for these aspects within themselves as well as copy of the writings of my faith? within those with whom they communicate (Devito • May I keep my placenta please? 2009, Purtilo & Haddad 2007, Stein-Parbury 2009; • I must go back to where I was born to ‘finish off’ (die). When can see Ch 6). I go? Purtilo & Haddad (2007) note that it is essential • Can I use the medicine made by my to understand that the Person/s seeking assistance Elder (Aboriginal or Torres Strait will attribute a different significance, most often a Islander) or tohonga (Maori)? greater significance, to their need than the health • Can I use herbal remedies as professional. They will generally be aware of their well? need from a physical perspective and this may be the • Can you tell me where I can have an reason they are seeking assistance. The Person/s will abortion? My husband and I are not also perceive the emotions, thoughts and social expeready to have children. riences associated with their need. In addition, many • Can I also have acupuncture while will also perceive a spiritual element depending on having your treatment? their background and beliefs. Awareness of variations • Can I also have physiotherapy while in the level of significance and influence of the having acupuncture? aspects, perspective and context of the individual will • You won’t tell my father he is dying, will you? It is not our way. assist the health professional to communicate holistically (Hartog 2009). Dossey et al (2005b) state that holistic commu• How should health professionals nication requires genuine and sincere care that respond to these requests? acknowledges the uniqueness of each individual. It • Is there anything they should do in requires a flow of expression and interchange between response to these requests? people and significant beings – pets, nature, God/ life force and others around them. Dossey et al

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(2005b) admit the importance for individuals of recognising and understanding that humans share their humanity. Humans, regardless of race, culture, gender, age, status, intelligence, material possessions or any other factor, share the same needs and concerns. Recognition of this fact assists health professionals to accept diversity and communicate holistically, thereby creating collaborative relationships in practice (Milliken & Honeycutt 2004). Effective and holistic communication with any individuals relating to the health professions requires understanding of all involved individuals, that is, both self and the Person/s. It requires a holistic understanding of the constituent aspects of the person (Brill & Levine 2005) and knowledge of the roles of the various health professions. While holistic communication requires an investment of time, it is essential for effective communication.

Chapter summary The whole Person/s comprises physical, cognitive, emotional, spiritual and social aspects. It is important for health professionals to synthesise all five aspects when communicating with another Person/s. During such communication, holistic care recognises that the needs of a Person/s seeking assistance may arise from more than the physical aspect. It considers underlying causes of the presenting symptoms and, as necessary, refers to other health professionals. This requires a clear understanding of the roles of other health professionals and how to contact or refer to particular services. Communicating with the whole Person/s requires a willingness to communicate about individual needs, different perspectives of various experiences, thoughts relating to the condition of the Person/s and their aspirations and goals for the immediate and long-term future. Holistic communication requires that health professionals remember the principles of effective communication when relating to every Person/s involved in their practice.

FIGURE 11.1â•… The aspects of the whole Person impact on communication.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

REVIEW QUESTIONS 1. What are the five aspects of the whole Person/s? i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ iv. _______________________________________________________________ v. _______________________________________________________________ 2. What are the three meanings of holistic care? i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 3. What does holistic care seek to achieve? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. What does holistic care require? i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 5. Why is it important to have knowledge of the role of other health professions? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 6. What does holistic communication require? i. _______________________________________________________________ ii. _______________________________________________________________

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iii. _______________________________________________________________ iv. _______________________________________________________________ v. _______________________________________________________________ 7. With whom do health professionals communicate? i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ 8. What should health professionals be willing to communicate about? i. _______________________________________________________________ ii. _______________________________________________________________ iii. _______________________________________________________________ iv. _______________________________________________________________ v. _______________________________________________________________ vi. _______________________________________________________________

REFERENCES Bertakis K D, Franks P, Epstein R M 2009 Patient-centered communication in primary care: physician and patient gender and gender concordance. Journal of Women’s Health 18(4):539–545f Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Cegala D J, Post D M 2009 The impact of patients’ participation on physicians’ patientcentered communication. Patient Education & Counseling 77(2):202–208 Colbert D 2003 Deadly emotions: understand the mind body spirit connection that can heal or destroy you. Thomas Nelson, Nashville, TN Crotser C B, Dickerson S S 2010 Women receiving news of a family BRCA1/2 mutation: messages of fear and empowerment. Journal of Nursing Scholarship 42(4):367–378 Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Dossey B M, Keegan L, Gussetta C 2005a Holistic nursing: a handbook for practice, 4th edn. Jones & Bartlett, Sudbury, MA Dossey B M, Keegan L, Gussetta C 2005b A pocket guide for holistic nursing. Jones & Bartlett, Sudbury, MA 163

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Geist-Martin P, Bell K K 2009 ‘Open Your Heart First of All’: perspectives of holistic providers in Costa Rica about communication in the provision of health care. Health Communication 24(7):631–646 Golman C 2006 Social intelligence: the new science of human relationships. Hutchinson, London Gordon R, Druckman D, Rozelle R et al 2006 Non-verbal communication as behaviour: approaches, issues and research. In: Hargie O (ed) The handbook of communication skills, 3rd edn. Routledge, New York, pp 73–120 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Hartog C S 2009 Elements of effective communication: rediscoveries from homeopathy. Patient Education & Counseling 77(2):172–178 Lin Y, Tsai Y 2011 Maintaining patients’ dignity during clinical care: a qualitative interview study. Journal of Advanced Nursing 67(2):340–348 Liu K P Y, Chan C H, Hui C W Y 2000 Clinical reasoning and the occupational therapy curriculum. Occupational Therapy International 7:173–183 Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Portillo M C, Cowley S 2011 Working the way up in neurological rehabilitation: the holistic approach of nursing care. Journal of Clinical Nursing 20(11/12):1731–1743 Punwar A J, Peloquin S M 2000 Occupational therapy: principles and practice, 3rd edn. Lippincott, Williams & Wilkins, Baltimore Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Reed K L, Sanderson S N 1999 Concepts of occupational therapy. Lippincottt, Williams & Wilkins, Philadelphia Salmon P, Young B 2011 Creativity in clinical communication: from communication skills to skilled communication. Medical Education 45(3):217–226 Selimen D, Andsoy I 2011 The importance of a holistic approach during the perioperative period. AORN (Association of periOperative Registered Nurses) Journal 93(4):482–490 Sims-Gould J, Wiersma E, Arseneau L et al 2010 Care provider perspectives on end-oflife care in long-term-care homes: implications for whole-person and palliative care. Journal of Palliative Care 26(2):122–129 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Taylor B J 2006 Reflective practice: a guide for nurses and midwives. Open University Press, Maidenhead White G 2006 Talking about spirituality in healthcare practice: a resource for the multi-professional healthcare team. Jessica Kingsley, London

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ANSWERS TO REVIEW QUESTIONS CHAPTER 11â•… Communication with the whole Person/s Answers to the following questions provide a summary of this chapter. 1. What are the five aspects of the whole person? i. Physical aspect ii. Cognitive aspect iii. Emotional/psychological aspect iv. Spiritual aspect v. Social aspect. 2. What are the three meanings of holistic care? i. Inclusive care that embraces traditional medicine or interventions ii. Complementary and alternative medicine iii. Considering the whole person using a variety of interventions depending on the needs of the individual. 3. What does holistic care seek to achieve? It seeks to achieve healing by considering the whole Person and identifying the cause of the problem. 4. What does holistic care require? i. Mutual respect, which assumes equality in the therapeutic relationship ii. Collaboration with the Person to establish goals and make decisions about their care and their future life iii. A facilitation and empowering role because the responsibility for change lies with in the Person/s. 5. Why is it important to have knowledge of the role of other health professions? Knowledge of the role of other health professions allows referral as necessary and facilitates family/Person-centred practice. 6. What does holistic communication require? i. Recognition that every individual is unique, while sharing their humanity, and thus needs to be accepted and to be able to function at some level in their daily life ii. Reflection that enhances self-awareness about responses and needs while practising as a health professional



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iii. Care of self: responsibility for my own thoughts, words and actions and any interventions I prescribe for that Person/s iv. A work-life balance that manages the needs of the individual health professional v. Recognise the effects of any demanding or challenging professional encounters and seek assistance as necessary. 7. With whom do health professionals communicate? i. Other health professionals ii. The Person/s and all relevant or significant others seeking assistance iii. Support staff. 8. What should health professionals be willing to communicate about? i. Relevant and particular contexts ii. Recent and past experiences and their perspective of these events iii. The thoughts of the Person/s iv. The feelings of the Person/s and how they are affecting the functioning of the Person/s v. The most pressing needs of the Person/s vi. The desires and goals of the Person/s for their future.

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CHAPTER 12â•…

Non-verbal communication

CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Explain and give examples of non-verbal communication • Discuss the significance of non-verbal communication • Examine the benefits of non-verbal communication • List and explain the results of non-verbal communication • Recognise and synthesise the components of non-verbal communication • Recognise types of communication for those who cannot use spoken words • State the basic requirements for the use of alternative communication devices.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Non-verbal communication is, as the name implies, communication without words. It encompasses the environment, manner and style of communicating, and the internal values of the people communicating (Holli et╯al 2008). Non-verbal communication includes the behaviours that accompany words (Burgoon & Hoobler 2002). Crystal (2007) states that even though non-verbal messages carry meaning, they are less flexible and adaptable than verbal modes of expression. While this may be true, non-verbal cues significantly influence the meaning of a sent message (sometimes communicating more than 80 per cent of the meaning) and as such are often more important than the spoken words (Egan 2010). Body language is the general name given to non-verbal cues. Body language includes gesture, facial expression, posture, eye contact, gait and clothing. However, there are other non-verbal elements of speech relating to the voice. The technical name for nonverbal characteristics of the voice is suprasegmental features. There are two types of suprasegmental features: prosodic and paralinguistic. The prosodic features of the voice include volume, pitch and rate of speech, which combine to create the unique ‘rhythm’ of a language. The paralinguistic features (also called paralanguage) of the voice use other vocal effects to convey meaning; they include emphasis (see Ch 1), timely pauses and tone, as well as laughing, whining, moaning and other non-verbal sounds (Crystal 1997). Suprasegmental vocal characteristics along with body language can change meaning, and thus are worthy of recognition and examination when considering non-verbal communication.

The significance of non-verbal communication Mehrabian (1981, 2009) indicates that the words carry a small proportion of the meaning of a message. The suprasegmentals of a message and body language deliver most of the meaning. However as it is impossible to separate verbal and non-verbal messages (Knapp & Hall 2009), it is important that the non-verbal cues support rather than contradict the verbal messages. If the voice or face is preoccupied or upset and the words contradict this message, the Person/s will experience confusion. In short, body language and the spoken language must send the same message to avoid misunderstanding and negative outcomes. This indicates that health professionals must use both verbal and non-verbal forms of communication consciously and with care, regardless of the relative significance of either in delivering the meaning (Boynton 2010, Knapp & Hall 2009).

THE BENEFITS OF NON-VERBAL COMMUNICATION Burgoon & Hoobler (2002) indicate that skill in interpreting and using non-verbal behaviour increases the attraction, popularity and psychosocial wellbeing of an individual. However, they also indicate that skilful use of non-verbal behaviours increases the likelihood of manipulating other people. Thus, individuals who are skilful in using non-verbal communication can be influential in assisting and supporting as well as in deceiving other people.

The effects of non-verbal communication Non-verbal behaviour regulates or adjusts verbal communication (Collins et╯al 2011, Egan 2010, Esslemont 2010). It can: • Substantiate or reiterate the meaning of the words (e.g. yelling Yeah! at a football game is often reiterated by throwing arms up in the air or jumping up and down); 166

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• Contradict or complicate the meaning of the • • • •

words (e.g. stating I am OK with a faltering voice and quivering lip may indicate the opposite meaning to the words); Reinforce or accentuate the meaning of the words (e.g. saying No thanks along with specific non-verbal gestures and body positions, such as covering a cup with a hand, makes the message very clear); Influence the response of the Person/s regardless of words (e.g. avoiding eye contact may indicate a desire to evade interaction, or holding up a hand may indicate a need to stop an interaction); Decrease anxiety and facilitate expression of opinions, feelings and concerns (Weaver 2011); or Express feelings (Knapp & Hall 2009).

Non-verbal communication can achieve positive and negative results. • List the positive and negative results of the non-verbal behaviours listed opposite. • Consider the results from the perspectives of both parties – the sender and the receiver. • How might a health professional ensure their non-verbal and verbal messages send the same message?

The components of non-verbal communication ENVIRONMENT The environment communicates clearly the level of interest in, and care for, the Person/s (Brill & Levine 2005; see Ch 10). Seating arrangements in a cosy room that promote appropriate levels of connection communicate careful attention to the needs of those using the room. Health professionals who focus, rather than being distracted by responding to every other event in the service, deliver specific messages that develop trust and positive outcomes (Marcinowicz et╯al 2010).

•

BODY LANGUAGE

Discuss the different meanings of standing while waving both arms frantically above the head. When have you done this or seen others do it? • How does context assist the interpretation of body language?

Body language is a worldwide component of communication. There are particular rules for the use of body language that vary from culture to culture. The interpretation of body language must consider the context and the particular circumstances of the communicating people. The physical appearance and the apparent care the health professional has taken with their appearance communicate particular messages. Conscious consideration of those messages assists the health professional to communicate respect, equality and acceptance.

Facial expression Facial expressions can be powerful additions to words and generally express emotions. Facial expressions can also convey messages without the use of words (Purtilo & Haddad 2007). Some individuals have expressive faces while others rarely use their face to express their emotions. Some comedians are excellent examples of people who, when performing, rarely use facial expressions to communicate their emotions (i.e. the classic ‘deadpan’

•

Do you use your face to express your emotions regularly? • How successfully do you express your emotions with your face?

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delivery). Individuals with expressive faces must take care not to demonstrate emotions they regret when communicating. Health professionals should consciously use and control facial expressions to express respect, empathy and attention (Marcinowicz et╯al 2010). It is important to understand there are cultural variations in the use of facial expression to convey messages. These variations include both how the face is used and the meaning of particular facial expressions.

• • • • •

Each member of the group chooses an emotion (e.g. happy, sad, embarrassed, tired, angry, frustrated, disgusted, anxious, confused, peaceful, lonely, bored, sleepy, interested and so forth). Do not tell anyone in the group your chosen emotion. Each person uses their face to express their chosen emotion. The other group members write down the name of the person and the emotion they are expressing on a piece of paper. When everyone has expressed their emotion, check the interpretations of the emotion. How many were incorrect? How could you vary your facial expression to more accurately express the emotion? How many variations of the same emotion were there? What are the implications for a health professional if different people assume different emotions from similar facial expressions?

Eye contact

•

Eye contact in some cultures signals interest and attention, while avoiding eye contact can indicate the opposite (i.e. disinterest). Eye contact can regulate turn-taking in an interaction and indicate the nature of the relationship between the people communicating. Using eye contact can assist the health professional to assess the feelings or functioning of the Person/s while communicating (Marcinowicz et╯al 2010). There are cultural variations in the use of eye contact. Some Aboriginal and Torres Strait Islander Peoples may communicate discomfort or pain by turning their heads to avoid any possibility of eye contact. Some cultures have different rules or beliefs about eye contact relating to gender, age and status, and may avoid eye contact in particular situations.

In pairs, look each other in the eye. How long can you continue this until you feel uncomfortable? Continue beyond the point of discomfort. What was the result? • Discuss the variations in comfort with eye contact. What does this mean for a health professional?

Gesture Gestures vary from individual to individual and convey attitudes, feelings and ideas. They do not necessarily require words. Gestures can use the entire upper limb or one finger; using an arm to wave or a finger to wave conveys very different meanings. Folded arms can communicate lack of openness or unhappiness, a tapping foot along with folded arms communicates impatience, and looking at a watch while tapping a foot with folded arms has a different meaning again (i.e. anger). In these cases the action clearly communicates the meaning without words. Understanding subtle as well as obvious gestures is essential for effective communication (Purtilo & Haddad 2007). When working with people from different cultures, it is

Choose five common gestures (e.g. waving). Do they have the same meaning every time they are used? If not, explore the factors that change the meaning?

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appropriate for a health professional to state the conventions of gesture in their own culture and ask for the convention in the culture of the Person/s seeking assistance. For example, the health professional might say When we do this, it means this; what does it mean to you? Asking such a question of the Person/s will assist understanding and build rapport. If gestures can change meaning within a single culture due to context, it is inappropriate to assume that the gestures of one culture have the same meaning in another culture. Specifically asking about the meaning of particular gestures in the relevant culture is often conducive to the development of the therapeutic relationship.

Space or proximity The use of space or proximity while interacting is important because it communicates interest (Mohan • Communicate in pairs with one et╯al 2004, 2008) and, in some cultures, the nature of person sitting and the other standing the relationship. In some South Pacific cultures, the for about four minutes. Swap authority figure must always be at a higher level than positions and repeat the exercise. others. Generally, however, it is important to attempt to • Discuss how each person felt in the different positions. communicate on the same level with the Person/s. That • What are the implications of these is, if they are sitting it is beneficial to attempt to sit as feelings for the health professional? well. The distance between two interacting people communicates interest in the interaction and can indicate the intimacy of the relationship. The comfortable distance between standing individuals while relating varies from country to country. Cultural differences can result in individuals from a country with a small acceptable space ‘chasing’ individuals from a country with a larger acceptable space around a room, as the first steps into the personal space of the second and the second moves away. Until they realise what is causing the constant movement they will both experience discomfort during the interaction, one because they are standing too far apart and the other because they are too close to the other person.

SUPRASEGMENTALS: PROSODIC FEATURES OF THE VOICE Volume The volume of a voice refers to whether the voice is loud or soft. Some individuals have voices that seem loud even when the person thinks they are speaking softly. Such voices are distinctive and can often be heard clearly from a distance or among other noises. Different situations require changes in volume depending on the context and the environmental noise conditions. Some individuals lower their volume when they are nervous, while others will raise their volume when nervous. Using appropriate volume is very important when speaking with a Person/s because this demonstrates the characteristics of a caring health professional. Many Aboriginal and Torres Strait Islander Peoples speak with a low volume when discussing personal or important information and may be uncomfortable with loud

•

Are you ever asked to change your volume when speaking? • Are there particular circumstances that make you speak more quietly or more loudly? Divide a page into two columns. Title one column ‘Increase volume’ and the other ‘Decrease volume’. Make a list of the possible times when you might need to adjust the volume of your voice as a health professional. Explain the reason for adjusting the volume in each situation.

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Say each of the following sentences while increasing your pitch at the end of the statement. Discuss the changes in meaning. • It’s ten o’clock now. • That’s your artwork.

•

Has anyone ever asked you to change your speed of speaking? • Are there particular circumstances that make you speak more quickly or more slowly? What are these circumstances? How might you always ensure appropriate speed?

volume in such situations (Australian Government Department of Health and Ageing 2004).

Pitch Pitch refers to the frequency of the voice, which makes the voice sound low or high. Pitch changes the style of expression and communicates feelings. Variations in pitch change meaning and may give greater force or intensity of feeling to spoken words (Crystal 1997, 2007). In some cultures, variations in pitch can also indicate the opinion of the speaker. Pitch falls or rises depending on the starting point of the voice. Various languages use falling or rising pitch to indicate meaning. For example, changes in pitch can mean the difference between a statement and a question. In some South Pacific groups, however, raising the pitch at the end of a sentence is a common feature of the language and does not indicate a question.

Rate

The speed or rate of speaking also affects comprehension. Different communities and cultures use particular • List possible emotions that might rates of speaking, and most people within those comaffect the speed of speaking. munities adopt the rate that represents the norm. Some Discuss the idea that the rate • cultures value rapid speech while others consider of speaking changes the persuasiveness of spoken words. slow speakers to be competent speakers (Devito 2009). Decide whether speed is the only Within a particular culture, however, some people natuvoice characteristic that affects rally speak more quickly or slowly than the majority. persuasiveness. Speaking in public or in situations that create negative emotions may affect the speed of speaking; in turn, this may limit the ability of the listener to concentrate, which will decrease their understanding. It is important for health professionals to be aware of situations that potentially affect the rate of their speech, and to consciously adjust their rate in these situations to ensure adequate comprehension. Another situation that might require an adjustment in speech rate is when the health professional is communicating with someone who has limited skills in the language of the health professional. In this situation, using a slower than usual speech rate may facilitate understanding for the listener.

SUPRASEGMENTALS: PARALINGUISTIC FEATURES OF THE VOICE Volume, pitch and rate combine to create rhythm while speaking. However, there are other important non-verbal characteristics of speech.

Emphasis Emphasis is a characteristic of the voice that can be used to change meaning. Emphasis refers to the stress placed on words within phrases or sentences. When used skilfully, it is a powerful communication tool. However care must be taken when using emphasis to communicate meaning, because it can easily produce negative effects in addition to positive effects. You did what? stresses the action and can have a positive or negative meaning. 170

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You did what? stresses the person and again may indicate disbelief that has a positive or a negative meaning.

Pauses Pauses when speaking occur within sentences as well as in conversations. They provide opportunities for taking a breath or for ‘looking up’ from papers if referring to notes. They provide opportunities for thinking in both the speaker and the listener. Pauses allow the speaker to compose their next sentence and the listener to process, understand and perhaps consider any questions they might want to ask the speaker. A speaker may pause in response to non-verbal cues given or not given by the listener. Such a pause allows the speaker to decide whether to clarify the words or to ask if the listener requires clarification, or, in some cases, to ask whether they are listening. Different cultures view pauses or silence differently (Vainiomaki 2004). Some interpret them negatively, while others consider them essential when attempting to become familiar with an unknown individual. Cormier et╯al (1986) suggest it is best to avoid pauses of over 10–15 seconds in length, because long pauses may create feelings of discomfort. However in some Aboriginal and Torres Strait Islander cultures, pauses and silence facilitate communication and informationprocessing (Eckermann et╯al 2010, Harms 2007, Harms & Pierce 2011); in these cultures, pauses of less than several minutes can feel uncomfortable. Pauses associated with vocalisation (e.g. ah or um) may communicate uncertainty (Devito 2009) or a level of incompetence. It is best for health professionals to avoid such vocalised pauses. It is important for health professionals to communicate confidence when speaking, whether through words, non-verbal cues or silence, because this assists the listener to trust and feel confident in the accuracy of the message.

•

Have a group member say each of the following statements. Then change your emphasis to indicate a change in meaning. In some cases, the emphasis may give the phrase the opposite meaning.  Well that’s a nice shirt.  You’re so clever.  Have you finished yet?  Well do you want a cup of tea?  That colour really suits you.  Well that was good wasn’t it? • Decide what each statement means with different emphases. • Indicate where to place the emphasis to change the meaning.

• • • •

• • • •

Tone Emphasis and tone may occur together. Tone is associated with quality of voice, and it is the manner of expressing words that indicates feelings, attitudes or thoughts about a particular topic. Tone is usually expressed through changes in pitch, volume or duration of a word. The tone of voice can be used to change meaning in particular circumstances. Tone of the voice usually affects the entire utterance, unlike emphasis, which usually affects a few words.

• • •

How do you respond to pauses in conversations? How do you feel if you have verbally shared something personal and there is a pause with no response? What do you do in such situations? How do you feel if someone has shared something personal with you and you simply have to stop, process and consider while they are waiting for a response? What would you say in this situation? Is a pause an appropriate response when you do not know what to say or how to respond? What might be an appropriate response in this circumstance? Is a pause or silence appropriate when someone has asked a question and is waiting for a response? What might be appropriate if you need time to consider your answer? Suggest situations when a pause might occur or be required for a health professional. Suggest possible responses to these situations.

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•

Have a member of the group say each of the following statements. Then change your tone to indicate a change in meaning.  Do you really want that?  What do you think you’re doing?  Have you finished yet?  Why is this here? • Decide how tone of voice changes the meaning of these statements. • If something is important for the safety of the Person/s, is it appropriate for the health professional to use a particular tone of voice to indicate that importance? For example, when talking about using or cleaning a device, taking medication, doing exercises, ‘keeping’ to a diet. • Suggest a situation in which a health professional might appropriately use tone to enhance meaning?

While non-verbal behaviours are powerful communicators of various emotions and ideas, it is easy to misunderstand them. It is therefore essential to validate perceptions of non-verbal messages because these vary from individual to individual and from culture to culture. Requests for validation allow the Person/s to either state or deny the emotions and ideas they are experiencing at that moment. They sometimes remind the Person/s of the power of their non-verbal messages, and encourage them to take responsibility for their nonverbal behaviours and the associated emotions or ideas. Different individuals use non-verbal cues in different ways. Some use them consciously, while others use them unconsciously. Many individuals have been surprised while watching themselves on video to see their nonverbal use of their body or voice. Unconscious hairtwirling, arm-crossing, upper lip-stroking or nail-biting while concentrating may be a habit so unconscious that the person is surprised when they see themself doing it. Health professionals must learn to observe and interpret non-verbal messages, but must also be aware of their own non-verbal behaviours (Esslemont 2010, Friess 2011). They should use non-verbal messages to communicate their exact meaning. This mandates that the words and the non-verbal messages have the same meaning.

Communicating with the Person/s who has limited verbal communication skills When communicating with the Person/s who finds verbal communication difficult, it is necessary to use devices and forms of communication that do not rely on verbal transmission. Augmentative and alternative communication (AAC) refers to systems of communication for people who find speaking difficult or are unable to speak. Such communication systems may help reduce frustration levels and thus decrease the use of disturbing behaviours to communicate. Augmentative and alternative forms of communication include the use of symbols, aids, strategies and techniques to transmit and receive messages through either electronic or non-electronic means (Beukelman & Mirenda 2006, McNaughton & Beukelman 2010). Augmentative communication refers to non-verbal forms of communication that highlight the spoken word through simultaneous gestures or signs (e.g. finger spelling, keyword signing [e.g. Makaton], sign language [e.g. Auslan]), or by pointing to objects or pictures. Alternative communication uses forms of communication to replace the spoken word (e.g. an electronic device using visual communication software). Individuals who experience difficulty communicating because of physical or cognitive limitations may rely on AAC to transmit and receive information. The use of AAC will assist such individuals to interact socially and engage in the activities of their choice. Such individuals can use one or a combination of several forms of AAC to process and understand information as well as express themselves. Some individuals use AAC until speech 172

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develops, or to supplement attempts at vocalisation. For others AAC is a permanent means of communication that can assist comprehension and self-expression. Successful use of AAC requires competence in the dominant language of the environment; social competence in the expected norms of communication; competence in operating the particular system; and an ability to compensate for the ignorance of communication partners who are unfamiliar with the particular system. Understanding the norms of personal interaction and communication are necessary for effective communication. They include ‘competence as to when to speak, when not, and as to what to talk about, with whom, when, where, in what manner’ (Hymes 1972, p 277). Most individuals absorb these norms as they ‘grow up’ in a particular culture or society and use them skilfully yet unconsciously whenever interacting. Augmentative and alternative forms of communication are generally visual in nature. (Any individual who finds it difficult to process auditory information may benefit from using visual forms of communication.) Visual forms of communication are useful because they are concrete and do not usually require abstract thought. They are also stable, lasting longer than the spoken word. The use of a symbol or sign that resembles a real object also makes accurate assumptions possible for the person receiving the message. If possible, it is beneficial for AAC devices to be flexible and portable, allowing the individual to use them in a variety of situations. Such devices are generally individualised to the needs, wants and emotions of the particular individual. Augmentative and alternative forms of communication can function to give directions, provide single-step pictures for completion of activities, or facilitate choices of activities. They can take many forms, for example: • A community request card containing a picture of a particular type of burger and can of drink; • A notice board containing a pictorial representation of the schedule for the day; • A ‘chat book’ that introduces an individual who communicates regularly with a variety of people – the book might include pictures of their likes and dislikes, family, hobbies, social experiences and the events of the previous week; • A pictorial shopping list displaying pictures of the goods needed for the next week; • An activity choice board or book that allows an individual to choose the activity they would prefer to perform after completion of the current activity. These are the less technical forms of AAC. However, such systems can also take the form of electronic devices that may provide vocalisation in addition to visual forms of messages. Health professionals will find AAC systems to be useful when relating to the Person/s who has difficulty communicating using spoken words. They encourage self-expression and often increase independence. Augmentative and alternative communication creates a connection with those around the individual by increasing the likelihood of communicative exchanges.

Chapter summary Non-verbal communication refers to communication without words, and it is often more important than spoken words when deciding the meaning of a message. There are two main elements of non-verbal communication. The first is body language, which includes facial expression, eye contact, gesture and proximity. The other element is the suprasegmental features of the message, which refers to the non-verbal characteristics of the voice; they include volume, pitch, rate, emphasis, pauses, tone and non-verbal sounds such as 173

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laughing or moaning. Communicating with the Person/s sometimes requires the health professional to communicate using alternative forms of communication, including electronic devices or graphic representations of actions or objects. In all interactions however, non-verbal communication can have negative and positive results. It is therefore important that non-verbal messages complement verbal messages. Health professionals must be aware of the variations in meanings of non-verbal cues and of their personal manner of using the elements of non-verbal communication.

FIGURE 12.1â•… The power of non-verbal messages.

REVIEW QUESTIONS 1. What does non-verbal communication encompass? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 2. What are the four major components of non-verbal communication? i. ii. iii. iv.

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3. How much of the meaning of a message do the words carry? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. What are the benefits of using non-verbal behaviour skilfully? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 5. What are the effects of non-verbal communication? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. Give three examples of three of the four components of non-verbal communication. • Component 1:___________________________________________________________ i. ii. iii. • Component 2:___________________________________________________________ i. ii. iii. • Component 3:___________________________________________________________ i. ii. iii.

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7. Explore the four components of non-verbal communication. • Choose one aspect of the environment and explain how a health professional might use that aspect to achieve positive results when communicating.

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• Choose two forms of body language and explain how a health professional might use those forms to achieve positive results when communicating.

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• Choose two forms of prosodic features and explain how a health professional might use those forms to achieve positive results when communicating.

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• Choose two forms of paralinguistic features and explain how a health professional might use those forms to achieve positive results when communicating.

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8. Context can affect the meaning of non-verbal behaviour. Give an example of how context might affect the interpretation of non-verbal behaviour. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

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9. Culture can affect the use of non-verbal communication. Give two examples of ways of using non-verbal behaviour to communicate messages in different cultures. i. ii. 10. Consider your own non-verbal behaviour. Do you have friends or family members who tell you that you express yourself non-verbally without realising you are doing it? For example, do you play with your hair, use a strong tone of voice when you are not angry, fidget or fiddle when listening, or sit in a disinterested manner when you are actually listening and interested? If so, is this something that could be detrimental to your role as a health professional? How could you learn to control the behaviour? If you have never had someone tell you about your non-verbal messages, ask a friend if there are particular times when you send non-verbal messages that may deliver a different message to the intended one. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

REFERENCES Australian Government Department of Health and Ageing 2004 Providing culturally appropriate palliative care to Aboriginal and Torres Strait Islanders: resource kit. Commonwealth of Australia, Canberra (The Mungabareena Aboriginal Corporation assisted in the preparation of this resource kit.) Beukelman D R, Mirenda P 2006 Augmentative and alternative communication: supporting children and adults with complex communication needs, 3rd edn. Brookes, Baltimore Boynton S 2010 Non-verbal communication. Journal of the Irish Dental Association 56(5):234–235 Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson Education, Boston Burgoon J K, Hoobler D 2002 Nonverbal signals. In: Knapp M L, Daly J A (eds) Handbook of interpersonal communication, 3rd edn. Sage, Thousand Oaks, CA, pp 240–299 Collins L G, Schrimmer A, Diamond J et al 2011 Evaluating verbal and non-verbal communication skills in an ethnogeriatric Objective Structured Clinical Examination (OSCE). Patient Education & Counseling 83(2):158–162 Cormier L S, Cormier W H, Weisser R J 1986 Interviewing and helping skills for health professionals. Jones and Bartlett, Boston Crystal D 1997 The Cambridge encyclopedia of language, 2nd edn. Cambridge University Press, New York 177

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Crystal D 2007 How language works. Penguin Books, London Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Eckermann A, Dowd T, Chong E et al 2010 Binan Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont, CA Esslemont I 2010 Doctors’ non-verbal communication…. British Journal of General Practice 60:575:453–453 Friess E 2011 Politeness, time constraints and collaboration in decision-making. Technical Communication Quarterly 20(2):114–138 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Hymes D 1972 On communicative competence. In: Pride J B, Holmes J (eds) Sociolinguistics. Penguin Books, London, pp 269–293 Knapp M, Hall J 2009 Nonverbal communication in human interaction, 7th edn. Wadsworth, Boston, MA McNaughton D B, Beukelman D R (eds) 2010 Transition strategies for adolescents and young adults who use ACC. Brookes, Baltimore Marcinowicz L, Konstantynowicz J, Godlewski C 2010 Patients’ perceptions of GP non-verbal communication: a qualitative study. British Journal of General Practice 60(571):83–87 Mehrabian A 1981 Silent messages. Wadsworth Thomson, Belmont, CA Mehrabian A 2009 Non-verbal communication. Aldine Transaction Publishers, Piscataway, NJ Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Vainiomaki T 2004 Silence as a cultural sign. Semiotica 150:347–361 Weaver D 2011 Introduction to communication in social care. Nursing and Residential Care 13(2):60–64

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ANSWERS TO REVIEW QUESTIONS CHAPTER 12â•… Non-verbal communication Answers to the following questions provide a summary of this chapter. 1. What does non-verbal communication encompass? Non-verbal communication encompasses the environment; the manner and style of communicating and the values of the people communicating. 2. What are the four major components of non-verbal communication? i. The environment ii. Body language including gestures, facial features, posture, gait and clothing iii. The prosodic suprasegmental features of the voice including volume, pitch and rate of speaking iv. The paralinguistic suprasegmental features of the voice include emphasis, timely pauses, tone and non-verbal sounds such as laughing, whining, moaning and so on. 3. How much of the meaning of a message do the words carry? The words carry as little as 20% of the message. 4. What are the benefits of using non-verbal behaviour skilfully? Skilful use of non-verbal cues can increase the attractiveness, popularity and psychosocial wellbeing of an individual. 5. What are the effects of non-verbal communication? Non-verbal communication can reiterate, contradict, accentuate the meaning of the words. It can also produce particular action regardless of the words. 6. Give three examples of three of the four components of non-verbal communication. • Component 1: The environment i. The use of heating or cooling to regulate the temperature in a waiting area ii. The types of chairs available and how they are arranged in a treatment area iii. The use of screens or doors to exclude distractions and promote privacy. • Component 2: Body language i. The neat clothing and hairstyle of the health professional ii. Facial expressions that express respect, empathy, care and attention iii. The use of eye contact varies in different cultures – some use it to indicate interest and respect, others avoid it to indicate the same.



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• Component 3: Prosodic features of the voice i. The volume of the voice can create discomfort if someone feels it is too loud ii. The pitch of the voice can indicate a question or particular feelings iii. The normal speed of talking varies in different cultures and the rate of speaking can indicate particular emotions. 7. Explore the four components of non-verbal communication. • Choose one aspect of the environment and explain how a health professional might use that aspect to achieve positive results when communicating. The way health professionals position themselves when communicating can demonstrate interest and a sense of equality. • Choose two forms of body language and explain how a health professional might use those forms to achieve positive results when communicating. Facial expression and gestures can demonstrate respect, empathy and caring, which promote positive outcomes. • Choose two forms of prosodic features and explain how a health professional might use those forms to achieve positive results when communicating. A health professional can vary the volume of their voice and the rate of their speech to demonstrate respect and cultural competence with particular people. • Choose two forms of paralinguistic features and explain how a health professional might use those forms to achieve positive results when communicating. When communicating with some Aboriginal and Torres Strait Islander Person/s a health professional can use long pauses and a reassuring tone to create feelings of comfort and to facilitate understanding and trust. 8. Context can affect the meaning of non-verbal behaviour. Give an example of how context might affect the interpretation of non-verbal behaviour. The amount of noise in a particular context (whether limited amounts or large amounts) can require a change in the volume of the voice. Non-verbal message of seeming tired may be an indication of the heat in the room. 9. Culture can affect the use of non-verbal communication. Give two examples of ways of using non-verbal behaviour to communicate messages in different cultures. i. In some cultures eye contact can signal turn-taking and the nature of the relationship between the people communicating ii. The same gestures can have different meanings in different cultures, which can cause confusion and misunderstandings if the health professional does not acknowledge this reality.

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10. Consider your own non-verbal behaviour. Do you have friends or family members who tell you that you express yourself non-verbally without realising you are doing it? For example, do you play with your hair, use a strong tone of voice when you are not angry, fidget or fiddle when listening, or sit in a disinterested manner when you are actually listening and interested? If so, is this something that could be detrimental to your role as a health professional? How could you learn to control the behaviour? If you have never had someone tell you about your non-verbal messages, ask a friend if there are particular times when you send non-verbal messages that may deliver a different message to your intended one.



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CHAPTER 13â•…

Conflict and communication

CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Recognise the mutual benefits of communicating appropriately during conflict • Identify the typical causes of conflict • Understand the importance of evaluating severity of emotions during conflict • Demonstrate some awareness of their own patterns of dealing with conflict • Discuss the different responses to conflict • Outline the characteristics of assertive communication • Demonstrate ways of communicating assertively in difficult situations.

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•

How do you feel about Disagreeing with someone  Presenting a point of view that is different to a popular view  Saying no to a request  Discussing an emotionally charged topic? • Consider your answers to these questions. Your answers indicate the reality of how you face potentially difficult situations involving conflict. 

Most communicative interactions are relatively straightforward and, although they may require concentration and energy, do not present major difficulties. However, wherever people interact, difficulties in communication are inevitable; including conflict (Bowe & Martin 2007, Brill & Levine 2005, Devito 2009). Conflict involves a disagreement or clash between people; such communicative interactions are not only difficult, they are also potentially unpleasant. It is beneficial for health professionals to develop understanding of and skills in managing conflict – both to achieve effective communication and to develop skills and confidence when communicating (Almost et╯al 2010). It is advantageous if health professionals feel confident to resolve situations of conflict calmly and appropriately for the mutual benefit of themselves and the vulnerable Person/s.

Conflict during communication CAUSES OF CONFLICT Conflict while communicating can involve: • Disagreement about supply and understanding of information, reasons for decisions, supervisory feedback (Higgs et╯al 2005, 2010, Weissman et╯al 2010) • Differences in ideas, principles or even in people (Weissman et╯al 2010) • Differences in ideas about the way to organise things (Stein-Parbury 2009) • Different understanding of the same words (Purtilo & Haddad 2007) • The perceptions of the relative value of certain procedures (Holli et╯al 2008, Weissman et╯al 2010) • The order of priority or importance of particular tasks (Weissman et╯al 2010) • Not understanding expectations (Eckermann et╯al 2010, Mohan et╯al 2004, 2008). These are some of the differences that may result in conflict and thus potentially a difficult communicative interaction. Conflict may occur between the health professional and the Person/s, but it may also occur between the health professional and their colleagues (Almost et╯al 2010). Conflict in itself does not cause difficulty; it is the management of conflict that produces negative or positive results (Rakos 2006). Gaining positive results from situations of conflict requires self-awareness and self-control (Devito 2009).

• • • • • •

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How could an understanding of your blocks to listening and barriers to emotions assist communication during conflict? How could this understanding contribute to changing the way you communicate during conflict? How could the need to always be right affect communication during conflict? How could the need to appear knowledgeable affect communication during conflict? How could being judgemental affect communication during conflict? How could feelings of insecurity affect communication during conflict? Will explicitly noting these tendencies in yourself or in others assist you to respond appropriately when communicating in difficult situations in the future? If you have these tendencies, will you need to do more than recognise them? That is, will you need to act to overcome these tendencies when communicating?

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IDENTIFYING EMOTIONS DURING CONFLICT In order to understand how to communicate appropriately during conflict, it is important to identify the severity of the emotions in all communicating parties during the conflict. This recognition will assist in deciding how to control or resolve the conflict. The severity of the emotions associated with the conflict may also indicate the effort and action required to resolve the conflict (Kassing 2011). If the emotion is simply one of uneasiness or awkwardness, it is probably not too serious. The uneasiness may indicate totally unrelated causes (e.g. tiredness, hunger or lateness). A simple question to clarify the reason for the lack of ease may quickly resolve the awkwardness (e.g. Are you feeling all right today?). Alternatively, a statement to recognise or explain the uneasiness (e.g. I am sorry, I have just been to the funeral of a close friend) will assist in clarifying and potentially reducing the conflict in the situation. Another emotion associated with conflict when communicating is irritation. Irritation or annoyance can occur during an interaction when the potential outcome of the interaction appears unsatisfactory to at least one of the people communicating. In this situation the use of questions (e.g. You seem irritated today – is there something upsetting you?) or an ‘I’ statement or question (e.g. I feel irritated because you said you would be on time today and you were half an hour late again or Are you upset because of something I have done?) can be powerful in highlighting and potentially resolving a difficult communicative event. Despite the use of ‘I’, these responses focus on the problem. They can clarify the cause of the emotion and potentially resolve the irritation in the Person/s. Another result of difficult communicative interactions can be misunderstandings (see Ch 16). A misunderstanding occurs when there is a failure to understand or correctly interpret the meaning of words, ideas, intentions, associated feelings, non-verbal behaviours or actions. This may occur because of different ways of understanding and resolving conflict in different cultures (Eckermann et╯al 2010). Such situations can cause confusion, dissatisfaction and discouragement in all communicating parties. The failure in understanding is not always easy to resolve if there were associated emotional responses. However, if one party feels misunderstood it is possible the other communicating individuals will also feel misunderstood. Honestly acknowledging the misunderstanding, admitting any mistake and apologising is a powerful course of action that can resolve the conflict. This action often allows the other Person/s, if they choose, to apologise and say it is all right. Remembering that each individual is in control of their emotional responses, and can choose what they will feel, is important for the health professional in such circumstances.

CHOOSING TO IGNORE In some situations it is important to identify the purpose of expressing the emotions. Recognising the reason for the passionate expression of any negative emotion may assist the health professional to determine and perhaps adjust their response. Such expressions of emotion may cause discomfort for those present in the room. In these situations it is important to assess whether ignoring the expression is the appropriate course of action. Sometimes an individual simply needs to express their emotions with a minimal response from another individual. It may be difficult to evaluate and respond with the correct action. The action might be to quietly leave the room and close the door or perhaps remain quietly in the room until the Person/s has expressed the emotion. Whether or not the health professional chooses to ignore, in situations similar to these it is best for health professionals to avoid responding emotionally, nor should they absorb blame if they are

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not responsible. Dealing appropriately with expressions of emotion will assist the Person/s and the resolution of the situation.

Resolving negative attitudes and emotions towards another •

In the health professions, why is it important to overcome negative thoughts and attitudes towards an individual? • How can an individual overcome negative attitudes and thoughts about a Person/s? Consider what has helped you change your mind about someone towards whom you initially felt negative.

What is your natural tendency or usual way of responding?

•

Do you avoid conflict at all costs by remaining silent and saying nothing? • Do you remove yourself from conflict as quickly as you can? • Do you do anything to appease the person and stop the conflict? • Do you retaliate and fight to win? • Do you defend the attacked opinion, idea or person? • Do you become involved in the expressed emotion? • Do you think negatively about a person and avoid that person wherever possible? • Do you find a way of compromising to resolve the conflict? Which of these reactions promotes feelings of satisfaction for everyone? If your natural tendency promotes a feeling of ‘losing’ in an interaction, how might you change this tendency to achieve protection of your rights and the rights of the Person/s?

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Sometimes negative attitudes and prejudice towards another can cause constant stress when thinking about or communicating with that individual. Such responses may occur between the health professional and the Person/s, but they can also occur among colleagues. The opinion that creates this stress may seem justified because of the attitudes or actions of the Person/s. It will, however, be a source of constant strain. This strain could negatively affect every working relationship connected with that Person/s, and would certainly affect the thoughts and ultimately attitudes of the stressed health professional (Brinkert 2010). In order to avoid habitual unproductive ways of relating to that Person/s it is important to quickly resolve such emotions. Unresolved stress in a relationship can result in a breakdown in both communication and the relationship. This suggests that resolving the attitude and associated emotions creating the stress is important. Recognition of the source of the attitude of the health professional can assist in resolving the emotions associated with the other Person/s. Investment of time to understand the Person/s and the factors that stimulate a negative response in the health professional can promote a positive attitude and assist the health professional to relate in a positive manner. A focus on the positive attributes of the Person/s, as well as similarities shared in experiences or values, can also assist in changing a negative attitude. Appropriate management of conflict situations is essential in the health professions. It requires awareness, preparation and commitment to resolution of unresolved emotions on the part of the health professional.

Patterns of relating during conflict There are always underlying requirements that must guide communicative interactions in the health professions, whether or not the interactions involve conflict. During any type of communication, but particularly during conflict, it is important to focus on the needs of the Person/s. Remember that they have

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a right to feel and to express their differences of opinion or their emotions. However they do not have a right to ‘abuse’ another person, regardless of the strength of their emotions. Respect for and protection of the rights of self and the Person/s (Tyler et╯al 2005) as well as the need for family/Person-centred goals (Unsworth 2004) must guide all communicative responses during conflict. Understanding the difference between aggressive, passive and assertive responses assists health professionals to protect their own rights and the rights of others while achieving positive results from conflict. Awareness of these differences empowers health professionals to develop the skill of asserting rather than reacting with a fight or flight response. Assertiveness skills assist in the confident and constructive management of conflict situations.

AGGRESSIVE The individual with an aggressive pattern of relating during conflict expresses their perceptions, opinions and feelings in a manner that intimidates or attacks other communicating individuals. Their manner expresses the desire to be right and make everyone else agree with them, thus indicating they are right; or it expresses a desire to achieve what they want regardless of the feelings of others. Aggression expresses the desire to ‘win’. This manner precipitates two major reactions in listeners: fight (aggression – I will win this) or flight (escape from the uncomfortable situation and emotions).

PASSIVE The individual who relates passively during conflict does not express their perceptions, ideas or opinions. The belief that they do not have the right to express or feel anything is the basis of this response. Limited confidence, self-esteem and self-respect produce passive responses. In turn, encountering regular and repeated passive responses from an individual may negatively affect and ultimately destroy the confidence, self-esteem or self-respect of their communicative partner. This person too may eventually relate passively in every communicative event due to limited confidence, self-esteem and self-respect.

ASSERTIVE The assertive individual expresses their perceptions, ideas or opinions in a manner that respects the worth and rights of others to have and express perceptions, ideas or opinions. Assertion affirms the interests and rights of the self and the other (Craig & Banja 2010). It facilitates positive communication outcomes and strengthens relationships (Devito 2009, Rakos 2006), and thus is the preferred manner of responding during difficult communicative interactions (Alberti & Emmons 2001).

Bullying When practising as a health professional it is possible to experience or observe bullying. Health professionals may bully each other or bully the Person/s, or family members may bully the Person/s receiving the intervention. It is uncomfortable to experience or to observe bullying. It is one form of conflict within the workplace and creates feelings of intimidation. It usually begins because of ineffective communication and establishes an uncomfortable environment or atmosphere (Crossman et╯al 2011). It can negatively affect the motivation, health and wellbeing of particular individuals (Losey 2011, Ttofi 2011) as well as potentially affecting intervention outcomes. It can originate from insecurity in 183

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Label the following responses as aggressive, passive or assertive.

Tom and Jenny are deciding which people they will each assist of those just referred to them.

•

I am familiar with people who have that difficulty, but all right, you can see them. (Thinking: I’ll struggle with these people – I have no idea what I will do with them, but hey, what does it matter?) • I am experienced with people with these difficulties so I am assisting them. • I would prefer to assist these people and you prefer them as well, so why not divide them and help each other with ideas for assisting the people with the difficulties we are unsure about?

Jean and Fred are choosing which piece of equipment to buy.

• •

I am familiar with X and it has the best results. We are buying X. Mmm, X is good, but I was reading about Y (the latest development) – research seems to indicate it has great results. Why don’t we look at the budget to see if we can afford both? If not, perhaps we can do some research and see if we can buy one now and one later. • Oh, all right, we can buy X. (Thinking: Who cares what is the best or what I want anyway!) Create assertive ways of responding to the following: • You are angry because a colleague promised to assist you with something and instead they read research articles all day. • You are struggling with a task and a colleague is watching you struggle without attempting to assist you. • You have one day of leave promised and now, without explanation, the decision has been reversed and you have heard that someone else has leave that day instead of you. • A person is yelling and swearing at you and you have no idea why they are yelling or what the problem is. • A person seeking your assistance appears not to be listening to you.

Think of a situation in which you regularly communicate passivity or aggression. How could you respond in a more mutually satisfying manner that reflects awareness of the rights and dignity of everyone communicating?

particular individuals who may find communicative interactions difficult and compensate for these feelings by intimidating or threatening people who create uncomfortable feelings in them (Hayes 2011, Healey 2011). Bullying typically includes negative verbal and non-verbal messages, which are difficult for everyone observing those messages. Bullying may take the form of repeatedly stating negative or threatening things to a person or about a person. These statements are usually designed to create a negative view of the person in an attempt to intimidate

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them or to destroy their reputation (Crossman et╯al 2011). Bullying may also include passive responses including failure to respond (‘the silent treatment’), ignoring requests or failing to follow instructions or communicate information (Tracy et╯al 2006). A health service experiencing bullying can be depressing and very negative for everyone in the service. This book is unable to explore the wide range of possible bullying scenarios or the many ways of managing these scenarios because of the many variations. However most health services have policies and procedures to manage bullying within the workplace. Some have a designated person to contact if there is bullying in the workplace. If experiencing bullying it is important to avoid ‘gossiping’ about the ‘bully’ but rather seek the assistance of an experienced health professional. Such assistance should encourage development of strategies to respond assertively and to manage the resultant feelings of injustice and of being misunderstood. If observing bullying, it is equally important to discuss the situation with an appropriate, experienced person in order to avoid acceleration of the bullying and assist the relevant individuals to resolve the issues and cease the bullying behaviour. It is important that the person prone to bullying is given assistance to resolve the feelings that produce their bullying behaviour. Consideration and application of how to communicate assertively when experiencing bullying may assist, however resolution of the resultant negative emotions is essential to ensure a positive atmosphere in the particular health service.

How to communicate assertively The following points are suggestions of how to use assertive behaviour when communicating. • Establish and focus on the problem, not the emotions (Higgs et╯al 2005, 2010). • Remain calm and avoid responding in an emotional manner (Harms 2007, Harms & Pierce 2011). • Avoid placating with Calm down, you’re OK. • State the facts about the situation; do not evaluate or judge (Devito 2009). • Listen carefully, allowing the person to finish each sentence (McLean 2011). • Use ‘I’ statements (Mohan et╯al 2004, 2008). • Take responsibility for your feelings and actions (Holli et╯al 2008). • Be aware of your non-verbal behaviours; use a relaxed body position (McLean 2011). • Use normal speed and tone of voice (Devito 2009). • Avoid talking slowly because this may appear patronising. • Observe carefully the non-verbal behaviours of the upset person. • State how the problem affects you, not how you feel about the situation. • If appropriate, gently and calmly repeat a question or statement until the person hears and responds (e.g. Shall we talk about how to solve this now?). The timing of such questions is significant and may negatively or positively affect the situation (Higgs et╯al 2005, 2010, Rakos 2006). • Emphasise collaboration, asking for an indication of the person’s thoughts throughout the discussion. • Seek achievable solutions that require specific action within a particular timeframe.

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•

Use the above points in ‘How to communicate assertively’ while role-playing the following cases. It may assist if the players choose names for their roles. • During each role-play, have observers classify every statement or question according to the behaviours listed in ‘How to communicate assertively’.

Role-play 1 Person 1: You are the supervisor of Person 2. You feel angry because Person 2 is always late in completing their work and it reflects badly on you. Person 2: You do your best every day with limited assistance and do not really understand the problem. The work will be done, just maybe not on time.

Role-play 2 Person 1: You are a young health professional seeing Person 2 for the first time. They have previously received assistance from your health service, but the health professional who saw them is no longer available. You sense they are disappointed and do not really want to see you. Person 2: You are disappointed that you have to see Person 1 because you had a good relationship with the previous health professional. You really do not want to see Person 1 because they seem too young, but you do not want to hurt their feelings.

Role-play 3 Person 1: You are the supervisor of Person 2, a student who has been discussing confidential matters in the dining hall. During their orientation you outlined confidentiality, ethical practice and legislation. You indicated what these meant in practice and asked questions to clarify their meaning. Person 2: The needs of some of the people assigned to you are overwhelming and there has been no time to talk about this except during lunch.

Role-play 4 Person 1: You are a health professional who feels Mrs Stathos can continue living in her home. You have consulted all the health professionals assisting Mrs Stathos and intend to organise various supports (weekly home care and shopping, daily nurses for showering, meals on wheels) and attendance at a weekly program to maintain her in her home. Person 2 has requested an appointment with you, and you feel he disagrees with you. You intend to show him how Mrs Stathos can stay safely and independently at home. Person 2: You are married to Mrs Stathos’ daughter. You know how forgetful and dependent Mrs Stathos has become because your wife has been caring for her, often staying with her overnight. You are really angry that this young health professional (Person 1) thinks they know what is best for your family; you think they have no idea. You intend to make sure Mrs Stathos is placed in residential care – not in a nursing home but in a ‘village’ with her own unit.

Role-play 5 Person 1: You are a health professional who has been assisting Terry, a young man with paraplegia. You have been working consistently with him and his motivation to walk again is maintaining his mood. You are furious with a new colleague (Person 2) because they have just told him it is unlikely he will walk again. You have experience with people like Terry, and in the past you have seen young men with worse damage than Terry walk (with assistive equipment, but walking independently of another person) against all the medical odds. You feel this colleague is ignorant and should not have spoken to Terry. Person 2: You are new to the Spinal Injuries Department and heard the doctor say that Terry would probably not walk again. You feel it is important to be honest so you tell Terry he will probably not walk again. You cannot see why Person 1 is upset.

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Chapter summary It is important that the health professional develops strategies and skills to manage conflict situations in an effective and resolute manner. Recognition of the emotions causing the conflict begins the process of resolution (Milliken & Honeycutt 2004). Perceptions of the emotions behind the conflict require validation through honest statements or questions relating to these perceptions. Validation of perceptions promotes a clearer understanding of the cause of the conflict in the person expressing the emotion (Egan 2010). It allows disengagement from the argument and a focus on possible resolution of the emotions and the problem. Questions asked with an appropriate tone of voice (see Ch 12) can diffuse the expression of strong emotions, for example, You are obviously upset; can you tell me about the problem? or Do you want to tell me why you are shouting? Such questions allow focus on solving the problem rather than focus on the emotions that are creating the argument or emotional behaviour. Resolution of conflict in difficult situations is facilitated by acceptance of differences, compromise and assertive collaboration with a calm focus on problem solving (Devito 2009). It is important for the health professional to develop confidence in managing interactions involving conflict. Such confidence develops with self-awareness, self-control, appropriate supervision and mentoring, specific instruction in conflict management, understanding of possible management strategies and, ultimately, experience.

FIGURE 13.1â•… Exploring emotions can diffuse conflict.

REVIEW QUESTIONS 1. Define conflict. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

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2. State the major cause of conflict. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3. What is your natural tendency when communicating during conflict?

Suggest at least two ways of overcoming this tendency if it is unproductive. i. ii. 4. List the causes of misunderstandings. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5. Describe ways of resolving each emotion during conflict. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. Describe ways of resolving your negative attitudes towards particular people. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7. In your own words, describe one of the ways of responding during conflict. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

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8. In your own words, list five ways of communicating assertively and provide examples of each. i. ii. iii. iv. v.

REFERENCES Alberti R, Emmons M 2001 Your perfect right: assertiveness and equality in your life and relationships, 8th edn. Impact, Atascadero, CA Almost J, Doran D M, Hall L M et al 2010 Antecedents and consequences of intragroup conflict among nurses. Journal of Nursing Management 18(8):981–992 Bowe H, Martin K 2007 Communication across cultures: mutual understanding in a global world. Cambridge University Press, Melbourne Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Brinkert R 2010 A literature review of conflict communication causes, costs, benefits and interventions in nursing. Journal of Nursing Management 18(2):145–156 Craig K, Banja J D 2010 Speaking up in case management, part I: ethical and professional considerations. Professional Case Management 15(4):179–187 Crossman J, Bordia S, Mills C 2011 Business communication for the global age. McGraw-Hill, Sydney Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Eckermann A, Dowd T, Chong E et al 2010 Binan Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont, CA Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Hayes R 2011 Rising above bullying: from despair to recovery [electronic resource]. Jessica Kingsley, London Healey J 2011 Dealing with bullying. Spinney Press, Thirroul Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Kassing J W 2011 Stressing out about dissent: examining the relationship between coping strategies and dissent expression. Communication Research Reports 28(3):225–234

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Losey B 2011 Bullying, suicide, and homicide: understanding, assessing, and preventing threats to self and others for victims of bullying [electronic resource]. Taylor & Francis, Hoboken McLean S 2011 The basics of interpersonal communication, 2nd edn. Allyn & Bacon, Boston Milliken M E, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Rakos R 2006 Asserting and confronting. In: Hargie O (ed) The handbook of communication skills, 3rd edn. Routledge, New York, pp 345–381 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Tracy S, Lutgen-Sandvik P, Alberts J 2006 Nightmares, demons and slaves: exploring the painful metaphors of workplace bullying. Management Communication Quarterly 20(2):102–123 Ttofi M M 2011 Health consequences of school bullying [electronic resource]. Emerald, Bradford Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney Unsworth C A 2004 Clinical reasoning: how do pragmatic reasoning, worldview and client-centredness fit? British Journal of Occupational Therapy 67:10–19 Weissman D E, Quill T E, Arnold R M 2010 The family meeting: causes of conflict. Journal of Palliative Medicine 13(3):328–329

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ANSWERS TO REVIEW QUESTIONS CHAPTER 13â•… Conflict and communication Answers to the following questions provide a summary of this chapter. 1. Define conflict. Conflict is a disagreement or clash between people. 2. State the major cause of conflict. Differences in opinion, perceptions, values or understanding. 3. What is your natural tendency when communicating during conflict? Suggest at least two ways of overcoming this tendency if it is unproductive. i. I tend to say ‘Yes’ to any request, which is sometimes OK and sometimes not OK. I need to feel confident and OK about saying ‘I am sorry I am unable to do that at this time’ and perhaps make suggestions of someone who might be able to help. This requires self-awareness and acceptance that different people have different ideas. ii. When someone disagrees with me I get angry and scream at them. I need to think things through and be willing to see the other point of view and feel OK about people not agreeing with me. This needs me to be comfortable with not controlling other people and their ideas, and to not be afraid that if they do not agree with me that they will reject me – which they usually do if I scream at them! So I am ‘setting people up’ to do what I am afraid of, because I have to be right all the time to feel OK about myself. 4. List the causes of misunderstandings. Misunderstandings can occur because one of the people communicating does not assume the same meaning of a word, idea, intention, feeling, non-verbal behaviour or action. 5. Describe ways of resolving each emotion during conflict. It can help to recognise and name the emotion thereby allowing the person to ‘own’ the feelings or deny them – it can ‘clear the air’ and produce more positive feelings. 6. Describe ways of resolving your negative attitudes towards particular people. It is important to identify the origin of the negative attitude and then resolve and change the attitude. It can help to identify possible reasons for their reactions and responses. It can also help to think of the positive characteristics of the person. 7. In your own words, describe one of the ways of responding during conflict. There are three ways of responding: aggressively, passively or assertively. Responding assertively is the best way. It means to express what I want, think and feel without dominating or being dominated by the other person. My response would affirm the responses of the other person even if I do not agree or they do not agree with me.



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8. In your own words, list five ways of communicating assertively and provide examples of each. i. Work out what the problem is and focus on that, not on my feelings. ii. Do not blame another person for my own emotional responses. iii. Think about my body position and the expression on my face so that I communicate interest and not boredom or irritation. iv. State what the effects of the problem are in this situation not my feelings about the situation or problem. v. Ask the upset person to work with me to try to find a solution to the situation or problem, not just express strong emotions about it.

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CHAPTER 14â•…

Culturally competent communication CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Define culture and culturally competent communication • Clarify the importance of culturally competent communication • Discuss the impact of cultural identity upon communication • Demonstrate understanding of the notion of cultural safety in practice • Describe factors affecting culturally competent communication • Explain the impact of cultural difference upon communication • Develop useful strategies to achieve culturally competent communication • State some of their personal cultural assumptions and expectations • List the necessary steps required for the use of an interpreter • Give a basic description of the culture of their particular health profession • Recognise and understand the culture of disease or disability.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

The use of the word competent is not meant to intimidate or overwhelm, but rather to encourage readers to begin the journey to becoming confident and competent communicators wherever there is diversity.

INTRODUCTION Effective communication requires the health professional to understand that there are different ways of ‘doing and being’ (Wilcock 2006). These ways of ‘doing and being’ result in many different patterns of daily life (Brill & Levine 2005). The values and beliefs of groups generate these patterns or traditions (Purtilo & Haddad 2007). Culture is the word commonly used to describe the learned patterns of perceiving, interpreting and adapting to the world that develop from within the context of a group or community (Canon 2011, Fageeh 2011). Thus, ‘culture’ influences every person and every activity, every day (Devito 2009). Despite this influence, culture is often quite invisible to the members of the originating group (Martin 2009, Ramsden 2002). This chapter may begin the process of exploring cultural competence, however it is important to note that becoming a culturally competent communicator is an experiential process requiring a lifetime (Suarez-Balcazar & Rodakowsi 2007). As such, the chapter cannot provide an exhaustive understanding of appropriate work practices with people from all cultural groups, but it can provide awareness of the cultural diversity in the world and ways to embrace, accept and understand this diversity. It is this diversity that mandates the need for culturally competent communication in health services (Arrendondo et╯al 2008, Lewis et╯al 2009). Before beginning this journey, it is important to remember that no culture ranks more highly than any other culture, they are merely different (Black & Wells 2007). This chapter seeks to present a model that may guide health professionals to develop culturally competent communication and explore this with the Person/s. Health professionals, during daily practice will relate to individuals from both ‘large’ and ‘small’ cultures (Holliday et╯al 2010). A ‘large’ culture is one that has extensive membership and considerable impact upon its members in all aspects of life. The culture of a nation is an example of a ‘large’ culture. A ‘small’ culture is one that has a smaller membership and usually affects the lives of the members only when fulfilling roles expected by that small group culture. Thus, ‘small’ cultures may have a limited impact on the everyday lives of the members. An example of a ‘small’ culture is a particular health profession, health service or a sports group. Therefore health professionals will experience cultural differences with the Person/s, whether they are from other • List examples of ‘small’ cultures in countries, other socioeconomic groups or other your life. ‘small’ cultures. They will also experience cultural • Consider how these ‘small’ cultures differences with other health professionals. These difhave affected your world view and ferences develop within particular group settings and daily life. potentially affect the outcomes of communication and services.

Defining culture It is important to examine and understand culture to assist the health professional to achieve culturally competent communication. The concept of culture has changed over time (Goddard 2005) and there are currently many ways of explaining this notion. Purtilo

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& Haddad (2007) present culture as a broad concept that embraces all aspects of life, including customs, beliefs, technological achievements, language and the history of a group of similar people. Devito (2009) states culture relates to the ‘specialised lifestyle of a group of people’. Tyler et╯al (2005) suggest culture to be the ‘shared and systematic ways of living’ within a particular society. Similarly, culture can be described as a system of beliefs, values and behaviours that characterise a particular group (Berryman-Fink et╯al 2009, Egan 2010, Purtilo & Haddad 2007, Stein-Parbury 2009). Thus culture has material and non-material aspects that affect daily life (Beltram 2011). None of these descriptions of culture are contradictory; they all suggest that culture relates to group membership and is an expression of some kind of similarities or shared meaning within that group. Groups might express their culture through their particular beliefs, spirituality, language, family roles, ways of living and working, expectations, dress, artefacts, artistic expression, attitudes, food, remedies, identity and non-verbal behaviours, as well as through the value they place on their land (Kinébanian & Stomph 2010, Mohan et╯al 2004, 2008, Parbury 1986, Smith 2008, UNESCO 2002). Each generation shares these patterns of behaviours and understanding with each new generation.

Cultural identity affecting culturally competent communication Cultural identity is unique to each individual and develops from group membership. This however is not simple as every individual has membership within various groups, and each group contributes to a unique cultural identity as each group has a unique culture (Holliday et╯al 2010). Group members develop particular identities that relate to the values, traditions, beliefs and expectations associated with membership of that group. Examples of such groups include families, sporting teams, special interest groups, religious groups, school groups, class groups, activity groups, and so on. Membership of many groups affects the overall identity of every individual because of the unique common experiences and expectations of each group. Thus each person has a unique identity that reflects their cultural or ethnic origins. However, cultural identities are complex and rarely static as changes in cultural practice, beliefs and values affect these identities, and individuals adapt to the changes around them (O’Toole 2011). This complexity indicates that health professionals should abandon any stereotypical idea of other cultures or of individuals from those cultures (Peiris et╯al 2008). An awareness of the complex nature of cultural identity (both of the health professional and • What influences your personal and the Person/s) is essential when communicating with cultural identity? people from diverse backgrounds (Anoosheh et╯al Why have particular groups had more • 2009). This awareness facilitates acceptance of the influence than others? uniqueness of every individual and their differing perceptions of the world.

Defining culturally competent communication To achieve culturally competent communication it is important for health professionals to understand that cultures differ (Tyler et╯al 2005). It is also important for health

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• • • • •

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professionals to understand that each person has diverse experiences, world views, beliefs, attitudes and values that affect their understanding of power and privilege (Eckermann et╯al 2010, Miller et╯al 2004). This understanding is especially important for health professionals because the relationship between the health professional and the Person/s has an inbuilt power imbalance that can affect communication. This reality is especially relevant in communicative interactions with individuals from various indigenous cultures because many have experiences that negatively affect their expectations of the relationship with any health professional. Their perceptions of power and privilege in combination with their experiences of this relationship (with its inbuilt power imbalance) may suggest to many indigenous people that they should not trust a health professional (Eckermann et╯al 2010). It is this reality, evident wherever there are indigenous people relating to health services, that led to the development of the notion of cultural safety. This concept developed because of the power imbalance in health services in New Zealand during the mid-nineteen nineties (Papps & Ramsden 1996). However it is relevant to every health professional working in any health service. The notion of cultural safety embraces all diverse groups regardless of age, gender, sexual preferences and disability. The discussion around this notion identifies the Define safety. power, prejudice and attitude in the health profesWhat generally creates a feeling of safety? sional that can negatively impact on health service What might create the feeling of safety outcomes. It is not merely about creating safety for in health practice? the Person/s in health services. It highlights the What might limit the experience of importance of allowing the Person/s respect and safety in health practice? acceptance that embraces differences and values their How might you avoid these limitations opinions (Barnett & Kendall 2011). Cultural safety when practising as a health considers everyone unique and empowers each indiprofessional? vidual (Eckermann et╯al 2010). It provides opportunities for the Person/s to contribute and exercise some power over the health intervention process (Ramsden 2001, 2002). The notion of cultural safety highlights the importance of tactful and compassionate acceptance of the different cultures represented by the individuals relating to the health professional. Dean (2001) states it is impossible to be ‘completely culturally competent’ in every culture, perhaps unless born into that culture. Even then individual interpretation and expression of the culture produces both material and non-material changes to the culture. In the health professions the concept of cultural competence relates to making ‘sound, ethical and culturally appropriate decisions’ during daily practice (Black & Wells 2007, p 33). Regardless of their level of competence, the health professional must be open to and accepting of the different cultures encountered during practice. Culturally competent communication involves being aware of, sensitive to and appreciative of the cultural variations common among individuals and groups, and mandates respect for these variations (Camphinha-Bacote 1999, Eckermann et╯ al 2010, Egan 2010, Mohan et╯ al 2004, 2008). It invites the health professional to acknowledge the validity of the other culture (Bowe & Martin 2007) rather than ridiculing or trivialising it. Culturally competent communication requires knowledge, mutual respect and negotiation (Purtilo & Haddad 2007) to achieve effective communication and thus outcomes specific to the needs of the Person/s and the skills of the health professional.

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Why consider cultural differences? Cultural differences produce a diversity of behaviours, but they also produce the health beliefs and behaviours of individuals (Canon 2011). These health beliefs and behaviours can profoundly affect expectations and the ultimate outcomes of any health service (Purtilo & Haddad 2007). What are your health beliefs and Individuals vary in their responses to physical and behaviours? psychological distress; these variations affect the • What would you do if you had: responses of both the health professional and the  A cold for more than a week? Person/s. It is often particular health beliefs that reg Prolonged nausea? ulate these responses. It is initially surprising to  Neck or back pain? realise that different people have different beliefs and  Anxiety attacks? behaviours associated with their health. It is impor A toothache? tant to resist applying personal health beliefs to those  Feelings of euphoria and highly relating to the health professional because this will irregular behaviour? negatively affect communication. • Who would you go to if you had a health concern?

A model of culturally competent communication There are many closely related factors contributing to culturally competent communication. They are intimately tied together and constantly affect each other. This model presents these factors in a bow to remind the health professional of these factors and the need to accommodate or, if affecting them personally, to control these factors during their practising day.

Culture Personal Identity & Stereotypes Ways of Doing, Language/s & Dress World Views, Values & Beliefs Ethnicity Physical Appearance Personality Expresses These

Expected Roles Clubs & Groups

Humble

Self/Other-Aware

Organisations Respectful & Institutions Open

n

Family

Able to Act

Expectant

tio ica n u s mm Norm o C

National & State Policies

Motivated

Peers

Society

Area Health Service or NGO Individual Health Service The Health Professional & Person/s affect and inform and are affected by the above

Co m Ex mu pe nic cta at tio ion ns

FIGURE 14.1â•… A model of culturally competent communication for health professionals.

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The central and pivotal ‘knot’ of the bow is the health professional who has the responsibility to achieve culturally competent communication. The health professional must demonstrate particular characteristics to achieve culturally competent communication. It is awareness of these characteristics that allow the health professional to consistently demonstrate them and thus communicate effectively where there is diversity. Motivation to display these characteristics is foundational to achieving effective communication. Selfawareness is essential in all communicative events and thus is the beginning of culturally competent communication (Tervalon & Murray-García 1998). This self-awareness contributes to being other-aware or aware of the Person/s encountered in practice, and can liberate the health professional to communicate with cultural competence. It also promotes humble awareness that no one is better than another person, but rather merely different. Self-awareness and humility can also encourage the health professional to accommodate difference and thus be expectant of positive communication outcomes while interacting with the culturally different Person/s. This expectation will non-verbally communicate hope to the vulnerable and possibly fearful Person/s, and therefore promote development of the features of Person-centred practice. These characteristics contribute to the ability to demonstrate respectful attitudes and behaviours that are mandatory in the health professions (Barnett & Kendall 2011). The above characteristics ensure an open health professional committed to culturally competent communication. However such communication is rarely possible when the health professional is unable to act either because of cultural norms or an inability to communicate because of cognitive or physical causes or differences in language. There are strategies that can overcome the last few causes of an inability to act, however it is more difficult to overcome the cultural reasons that limit the ability to act for a particular health professional. The knot of the bow also includes the group contexts surrounding and influencing the individual. It indicates that each health professional and Person/s develops and exists within the context of various social groups. These groups influence the ability to achieve effective culturally competent communication. Membership of these groups produces particular roles that may contribute to the development of skills relating to communication, and can influence effectiveness while communicating. The family group has a lasting effect on communication styles and competence and typically ‘prepares’ the health professional and Person/s for competence in settings where there are differences. Other groups that affect the health professional and Person/s include the wider society, which has norms and expectations that influence the family and thus their members. The related norms and experiences of interacting with peer groups, such as sports groups, single purpose clubs such as chess or quilting • Choose two of the listed social clubs, or licensed clubs also influence expectations contexts that affect communication. of communication. The organisation or institution • Consider each context separately and has considerable effect on the expectations and behavanswer the following questions:  What are some of the iours of the health professional. These contexts are communication norms and not limited to the employing organisation or instituexpectations you developed from tion, but relate to any group with whom the health membership of these social professional or Person/s must relate to successfully contexts? perform their roles and fulfil their responsibilities.  Consider how these norms and They often mandate culturally competent commuÂ� expectations affect your nication and may provide support to produce such competence for communication. communication. All of the above contribute to the development of skills in communication. 196

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The left-hand loop of the bow is the inherent factors influencing the health professional. They are influential when communicating in diverse situations. The culture of a person, as mentioned above, is often invisible or assumed and the health professional may not be able to articulate actual expectations of their culture. However it does affect their personal and cultural identity and may contribute to particular assumptions or stereotypes that influence their communicative ability. It will determine their particular ‘ways of doing’ or living their everyday life, whether private or professional. It will initially determine the languages they speak, they way they dress, and will produce their values and beliefs and world view. The ethnicity of an individual is often obvious and although not always conclusive, it can determine their physical appearance. These factors are both material and non-material (Beltram 2011) and, while some are less obvious, they affect the health professional. However the health professional will interpret and express these factors according to their individual personality. These factors affect the health professional and the Person/s, along with their expectations of culturally competent communication.

Language Words, non-verbal behaviours and intention can have different meanings among people from the same culture and can cause difficulties in communication. For example, asking someone for dinner for some means a meal at midday, for others a meal around 5.30 p.m. and still others a formal meal after 8 p.m. It is not surprising then that individuals from different cultures experience communication difficulties because of variations in meanings of words and non-verbal behaviours (Dressler & Pils 2009). For example, directional nods and shakes of the head have different meanings in different cultures, so this can cause miscommunication (see Ch 16). The right-hand loop of the bow is the external factors that influence the health professional, their practice and the Person/s. While these factors do guide health professional behaviour, the health professional can also influence these external factors. The National and State Policies guide and support each area health service and relevant non-government organisations (NGO). These policies determine expectations for communication and behaviour amongst all health professions, whether in the private or public sector. In turn, the area health service or NGO supports particular health services. This support can include such things as recruiting, training and networking. The individual health service supports and directs the health professional, identifying norms and expectations for communication and behaviours. It also supports the Person/s indicating their rights and expectations of expressions of satisfaction or complaint. The health professional and the Person/s interact and communicate within the context of the above factors. They can, however, through collaborative agreement affect and inform all of the above even at the level of policy. The health professional can achieve this through active involvement with their national professional body. The ends of the ribbon facing the person before they tie the bow are the norms and expectations of communication that are the underlying component of culturally competent communication: the expectations and norms of communication. When the ribbon is tied in a bow, they form the tails. They are important and in the context of the health professions affect all elements of the bow – or features of the model.

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Understanding context Understanding a particular context can promote effective communication (Bowe & Martin 2007). The context of the Person/s can affect communication and mutual understanding. Similarly, the context of a health service is confusing and unfamiliar for many individuals within their own culture, but for someone from a different culture it is often frightening (Hasnain et╯al 2011). It is important to understand that the particular contexts affect the expectations of each communicating individual – both the Person/s and the health professional – and thus the effectiveness of communication.

Ethnocentricity When an individual believes their particular method or way of approaching a situation is superior and indeed the best way, they are ethnocentric. Purtilo & Haddad (2007) state that ethnocentricity is a common phenomenon in health professionals and can negatively affect communication. The behaviour in the scenario outlined above was ‘strange’ in a Western culture, and there were negative responses from various health professionals. Some were direct expressions of personal biases and attitudes, while others were personal attitudes expressed through health service regulations. In most situations it is important, but in such

A man from a different culture is admitted to hospital with a stroke (cerebrovascular accident). His family are absent. The health professionals are curious as they settle the man into the ward. His language skills seem adequate because he asks appropriate questions and responds appropriately when asked to do something. However, he sits by the bed quietly and passively; he does not look around or relate to anyone. Around 4.30 p.m. people of varying ages from the same culture arrive and the health professionals assume they are family. The man suddenly seems happy and takes an interest in what is happening. These people have brought woven mats, food, plates and utensils with them. In an out-of-the-way corner in the ward, they place the mats on the floor and serve the food onto plates. One person – an older lady – sits by the man and assists him with his meal. The rest of the family sit on the mats on the floor and eat together, including the man in all the interactions while talking quietly in their own language. They are obviously all enjoying themselves.

• • • • •

What are the possible explanations for the behaviour of this man? Do you think it strange? What are the possible explanations for the behaviour of this family? Do you think it strange? How would you respond to this behaviour? One response is to ask to join them on the floor – suggest other appropriate responses.

List the possible ways of responding. What are the possible consequences of these responses? • What is a culturally competent response?

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situations it is essential, to consider more than the behaviours by looking below the surface to the multifaceted and complex reasons for the behaviours (Krepp cited in Purtilo & Haddad 2007). Different situations and countries have different services available. This family came from a country where hospitals do not provide many services, thus the family were expecting to do everything for the person in hospital, including supplying meals, providing clothes and assisting with showering and toileting. In addition, their culture values mealtimes as social occasions and therefore they could not imagine their relative having a meal alone. In this culture, a person is alone when they are among strangers. Understanding cultural differences in this situation provided explanations for the ‘strange’ behaviour and facilitated a compromise that met the needs of all involved in the care of this culturally different man and his family.

•

Consider the previous scenario and outline the:  Needs and expectations of the Person/family  Needs and expectations of the health professionals  Expectations of the health service. • Brainstorm ways of compromising to be culturally competent while still completing the required routines of health professionals and meeting the occupational health and safety requirements of the health service.

In situations presenting cultural differences, it is important to accept and appreciate diversity (Egan 2010). If the health professional merely recognises the differences this may separate and distance. Perception and appreciation of the similarities, however, will promote connection and development of rapport. In such situations it is important that culturally different individuals experience acceptance and understanding, not fear and misunderstanding.

A southern European family lives with several generations in four adjacent houses. The retired father, Giuseppe, is recovering from surgery that established he has inoperable brain tumours. He currently requires assistance to complete simple self-care tasks. The health professionals involved are reluctant to suggest how long he might live. Each health professional (HP) has different thoughts about what should happen. • HP1 suggests he should go to a hospice to die. • HP2 suggests he needs more time to recover from surgery. • HP3 suggests placing him in a high-dependency unit. • HP4 says that his daughter cannot see her mother managing if Giuseppe goes home. • HP5 suggests that with the right assistance he could die at home. • HP6 suggests that talking to the family is important. • HP7 suggests that asking Giuseppe might be a good idea. → • HP8 says that Giuseppe should not be told that he will die soon (his prognosis).

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• •

Consider each response and decide what the health professional believes, values and fears. Which of the responses do you consider is the one that suits the family? The family conference includes health professionals 1, 4 and 5 as well as several members of the family, including his wife Roma, his eldest son, his youngest daughter and the wife of his youngest son. The aim of the conference is to establish where Giuseppe will go upon discharge. Each health professional explains the options. The first discusses hospice care and states they feel that would suit them all. The second indicates they understand that certain members of the family are concerned about managing if Giuseppe goes home and supports this view. While both these health professionals are explaining the options, his wife is crying uncontrollably. The third health professional outlines the possible assistance that is available if Giuseppe goes home, carefully explaining the possible difficulties but stating that Giuseppe may be more independent when he recovers from the surgery. As the third health professional explains, Roma begins to listen and stares at this health professional. When this health professional finishes, Roma stands and says in broken English That is what we want – Giuseppe to come home. She states this emphatically and says it will mean that he can die at home. A family argument ensues with some family members supporting Roma and others supporting the idea of Giuseppe being told what is happening and going where he can receive expert care. Suggest ways to manage this situation so that Giuseppe and his family receive familycentred care.

• •

What do you feel you would want if Giuseppe was your husband? Or father? What does this feeling indicate about your personal values?

Managing personal cultural assumptions and expectations It is relevant to remember that cultural differences do not only occur between people from different countries, but also between people from different socioeconomic backgrounds, contexts, states or provinces, indigenous groups, religious groups, occupations, societies, and families. Cultural variations can even occur between different health professionals. In fact there is a limitless number of variations. Cultural differences occur in everyday life in material and non-material ways (Beltram 2011) including practices relating to handshakes, greetings, what to talk about, what to avoid talking about, the meaning and use of colours, personal space, eye contact, humour, music and songs, ways to wash and dry clothing, food (including its value, ways to prepare it, timing of meals and how to arrange the place of eating), habits of personal hygiene/ personal cleaning rituals, bed linen and ways of arranging a bed, spirituality and religious practices, expression of beliefs and values, understanding and meaning of the land, artistic expression and so forth. The list is extensive and could fill many pages. In the health professions it is important to understand that for particular individuals there are differences that might affect the outcome of the health service (Jirwe et╯al 2010). Wosket (2006) states consideration of cultural difference is essential when planning outcomes for individuals and groups. When establishing goals, it is easy to apply the cultural values, assumptions and expectations of the health professional, but this does not produce family/Person-centred practice. 200

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At a local health service, an older man holds the door open for a mother with a baby in a stroller and a toddler. The young mother is thankful but hurries past him mumbling something about being late. He walks slowly behind the mother to the desk to register his arrival. The person at the desk is polite but their non-verbal communication indicates they are unhappy with the mother. The elderly man smiles and states his name and appointment time. The receptionist looks up and says politely You are very late Sir – we assume you are not coming unless you ring to indicate you are going to be late.

•

Discuss and suggest possible reasons why the health service staff would assume someone was not coming if they were very late. • Why do you feel they have assumed the man has access to a phone when in transit? • What are their cultural expectations? The older man sits down next to the mother. They both watch the receptionist ring the health professional who was scheduled to see the mother and hear her say Yes she is here, but she was late last time she came and she was told to ring if she was going to be late. I just don’t think she really cares about your schedule.

•

What is a culturally competent way to respond to individuals such as this man and young mother? • What is it about the cultural assumptions and expectations of the health service staff that make it difficult to demonstrate culturally competent communication?

•

Suggest possible explanations for the lateness of these individuals. The mother looks at her children, one asleep in the stroller and the other curled up on the floor. She quietly says She has no idea how hard it is to organise two little ones, rely on a bus service that is always late and is 10 minutes walk from my unit, change buses twice and then walk 10 more minutes to actually reach the front door of this place. The older man smiles and looks at both children. He looks at his watch. How late are you? He enquires. The mother says quietly What is the time? She looks to see it is 9.30 a.m. Oh, I left home in plenty of time, but the first bus was 20 minutes late and they were digging up the path from the bus stop closest to here, so it took longer to get here. I am 45 minutes late. I couldn’t help it, I don’t have a mobile phone, we can only afford one between the two of us, and my husband takes it so he can ring during the day to see how we are. He’s out on the road a lot. How late are you? The older man smiles and says About 25 minutes. I don’t like to be late, but this morning I found it hard to get going, there is a bit more pain than usual, and I stopped to help a little boy who I have not seen before, whose cat had run up a tree. I knew the cat would be fine, but the boy was worried about his cat so I retrieved it for him. Both cat and boy seemed happy, but obviously our friend here isn’t! I don’t have a mobile phone either. My children bought me one, but I found someone who needed it more than me – her family could pay for the calls but not buy the phone – so I asked my kids if it was all right for me to give it to that person. They said it was OK. They weren’t surprised at all, they said. • Suggest other ways of responding to these latecomers.

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Both people in the scenario above have good explanations for their tardiness. When a health professional considers more than the superficial characteristics of an individual, they can explain behaviour that seems strange or unacceptable at the time. Health professionals often originate from particular socioeconomic backgrounds that use cars to travel from place to place, and thus they may apply particular cultural assumptions and expectations to those seeking their assistance. It is important that health professionals attempt to avoid applying these assumptions and expectations to any Person/s in order to achieve family/Person-centred practice.

Strategies for demonstrating culturally competent communication It is important for health professionals to expand, maintain their understanding of and accept cultural differences across the myriad of cultures they experience every day (Harms 2007, Harms & Pierce 2011), including the cultures within different health professions. Many strategies contribute to positive experiences in cross-cultural communication (Mihalic et╯al 2010).

Consider your beliefs and attitudes Write your honest answers to the following questions (adapted from Devito 2009). • Equality of genders: Do women and men really have equal opportunities? • Family: Are your personal priorities more significant than family or kinship priorities? • Religion: Does it provide the ultimate guide for living and the concepts of right and wrong? Alternatively, is it simply a social construct? • Group versus individual performance: Do you prefer to perform with a team or are you too competitive and prefer to perform alone? • Money: Is it an important component of any major decision you make or is it something you do not consider when making major decisions? • Relationship permanency: Do you feel relationships are forever or do you feel as long as there is more good than bad in them then they are sustainable? • Expression of negative emotions: Do you feel it should occur freely or that this should never occur in public? • Work habits: Do you prefer to work as much as possible or do you prefer to take every opportunity to enjoy yourself? • Time orientation: Do you consider time and attempt to be prompt or do you live in the moment and are not concerned about time? • A just world: Do you believe that good behaviour leads to good events in life or do you believe good and bad happen to everyone? These questions highlight some of the differences in culture that might cause difficulties when communicating. Honest answers to these questions will assist you to understand your own beliefs about some aspects of culture. Consider and write down how your beliefs in these areas can affect your communication.

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SELF-AWARENESS The first step in achieving culturally competent communication is to critically evaluate personal and individual cultural values, beliefs and traditions (Balcazar et╯al 2009, Holli et╯al 2008, Purtilo & Haddad 2007). It is difficult to be a culturally competent health professional if you are unaware of personal biases. If unaware of personal cultural biases, it is impossible to confront any tendency to stereotype (see Ch 7), and this limits the potential to understand and accept different cultures.

PERSONAL COMMITMENT TO UNDERSTANDING DIFFERENCES The requirements of effective communication are the basis of culturally competent communication (Purtilo & Haddad 2007). Commitment and willingness to implement these requirements will assist health professionals to adopt appropriate strategies when communicating with people from cultures different to their own. Such commitment will assist the health professional in predicting the requirements of communicating with individuals from different cultures.

EXPOSURE AND LEARNING The best way to communicate across cultures is to become familiar with the relevant culture(s) (Devito 2009). There are many ways to achieve this familiarity, including reading books and articles written by individuals from the culture about the culture, watching relevant movies (beware of bias), reading information on the internet and socialising with friends from the culture. Another way to achieve familiarity with a culture is to approach the culturally different Person/s with an open, accepting attitude and express interest within the context of the practice (Seth 2010). Asking questions about traditions, as well as styles of communication, can increase understanding. This understanding provides the knowledge of the culture that can produce appropriate and sufficient skill for culturally competent communication. Discussion about the cultural differences as the health professional conducts their interventions, can be reassuring for both the individual and the health professional. Purtilo & Haddad (2007) suggest that the health professional should recognise the differences and consider the interaction an opportunity to learn about the other culture. It is important when considering cultural differences to also account for the individual, because often there are individual variations that limit the application of a general understanding of any cultural norm.

INVESTMENT OF TIME TO NEGOTIATE MEANING AND ENSURE UNDERSTANDING There is a certain amount of insecurity about communicating with someone who is from a different culture, speaks a different language, or has differing values, beliefs and traditions, even when it is only a different health language and belief. Investment of time and energy to understand the individual is imperative (Siegel et╯ al 2011). There is no reason to be afraid because, while it is important for the health professional to restructure their world view to accommodate and understand the differences, they do not necessarily need to profess, internalise or assimilate these differences in their everyday life. Cultural understanding simply allows the health professional to demonstrate respect of the world view, which will assist in developing rapport and fulfilling the needs of the Person/s. 203

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ANTICIPATION OF DIFFICULTIES Marianna is a 5-year-old Fijian girl with no English. The interpreter informs the health professional that Marianna appears to understand only ten words of Fijian. Marianna appears friendly but unsure about the strange place, people and behaviours. An interpreter taught the health professional a few Fijian words this child understands: hello, goodbye, thank you, please, toilet, wee, sorry, help.

•

How might the health professional form a connection with this unsure 5-year-old? • What are the immediate aims of the health professional in such a situation?

There are a variety of possible difficulties within any communicative interaction. Anticipation of these difficulties may assist the health professional to develop appropriate responses (Berryman-Fink et╯al 2009). The health professional can overcome some of the difficulties associated with achieving culturally competent communication by being aware of personal cultural attitudes (Balcazar et╯al 2009), the aspects of that culture and the factors that affect culturally competent communication. A major difficulty in intercultural communication can be the lack of a common language. This creates apprehension for both the health professional and the Person/s. An open and relaxed demeanour will assist any attempt to connect with the individual despite the lack of a shared language. When communicating without a common language, anticipating the need for an interpreter is paramount.

Using an interpreter When considering use of an interpreter to achieve culturally competent communication, it is important to first note that there are different types of interpretation (Bowe & Martin 2007). The interpreter translates information while it is being presented during simultaneous interpretation. This type of interpretation does not usually occur when translating for one person, but often occurs when there is a group of listeners. Simultaneous interpretation is common when interpreting for groups of people who have a hearing impairment. This type of interpretation is demanding because the interpreter speaks at the same time as the speaker, and must concentrate and listen carefully to interpret. Sequential interpretation allows the speaker to present a small portion of the information then the interpreter translates this portion. During this type of interpretation, only one person speaks at any one time. Sequential or consecutive interpretation is the usual form of interpretation for interactions in the health professions (Higgs et╯al 2005, 2010). There are also two styles of interpretation. Transliteration is the exact translation of each word or • What difficulties might arise when sound spoken, regardless of meaning; such utterances using an interpreter? often have limited meaning. Interpretation is the • When using an interpreter, who do you translation of the meaning of the utterance regardless predict will most easily develop rapport with the Person/s? of the spoken sound or word. There are particular steps required to use an inter• How could the health professional use the interaction to build rapport? preter effectively. This process requires skill, concentration and careful planning, just as the act of interpreting itself requires skill, concentration and specific knowledge of both languages. Many interpreters, unless particularly trained in the use of medical terminology (Stein-Parbury 2009), may find medical or technical words unfamiliar so it is best to avoid using professional jargon. 204

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It is important to understand that professionally trained interpreters are not always available. In remote areas interpreters may not be available at all, while in other areas there are interpreters of only a limited number of languages. In some areas telephone interpreters are available; they usually require an appointment made in advance. It is possible to use colleagues as interpreters if available, but remember that colleagues are rarely trained for interpreting and thus may require additional allowances while interpreting. In some situations health professionals might use family members to interpret. This practice is not always recommended and can cause family tension. The use of an adult family or community member might be appropriate for information about progress or the need for the toilet, for example, but it can be inappropriate to use such an individual to give complicated information or information relating to a diagnosis, prognosis or the future.

ESSENTIAL STEPS WHEN USING AN INTERPRETER 1. Establish the purpose of the interaction that requires an interpreter. 2. Schedule and book an appropriate time for everyone required for the interaction. It is important to organise an interpreter in advance. Allow time to brief the interpreter concerning the purpose of the interaction before the commencement of the interaction with the Person/s. Interpreters can be late for good reason so briefing them by telephone may be necessary. 3. Prepare the questions and information for discussion. When using an interpreter it is easy to forget a point or deviate from the original plan. It is therefore important to organise the points carefully to ensure coverage of all necessary information. 4. Clarify any areas of uncertainty in the mind of the interpreter. It is important to establish a signal to indicate when an item of information is too long. All people involved in the interaction should know the meaning of this signal. 5. Introduce everyone. Remember the health professional and the Person/s are the focus of the interaction. Take care to concentrate on developing rapport with the Person/s not the interpreter. Introduce the purpose of the interaction to the Person/s. 6. Speak to and look at the Person/s not the interpreter. It is important that the interpreter connects with the Person/s; however, development of a relationship between them is unnecessary and may detract from the purpose of the interaction. They may have an immediate rapport because they share a common language and this will assist the Person/s to relax, but it is important to focus on the purpose of the interaction because the interpreter is available for a limited time. Maintain control of the interaction – the interpreter is there to assist not to conduct the interaction. 7. Use small chunks of information not long sentences. Make the points clear and minimise jargon or colloquialisms to avoid misinterpretation or reinterpretation of the content. It is important to keep a mental note of what has been covered and what is yet to be covered as the interaction progresses. 8. Observe the non-verbal reactions of the Person/s carefully. 9. Ask questions in response to these non-verbal reactions, for example, You appear unhappy about that – am I right? What do you need to know or how can we help you to feel happier? Because it is often difficult to know exactly what has been communicated, asking questions to clarify and verify understanding throughout the interaction is essential when using an interpreter (Harms 2007, Harms & Pierce 2011). 205

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10. Remember to ask the Person/s to summarise the information to demonstrate their understanding. Include time to answer any unrelated questions or address any concerns. Remember the importance of disengagement in the development of a therapeutic relationship with the Person/s.

• •

Consider the reasons for and against using a family member as an interpreter. When might it be appropriate to use a family member? (e.g. when asking about matters such as improvement in symptoms, or the need for toothpaste!). • When might it be inappropriate to use a family member? (e.g. when giving bad news).

The culture of each health profession Consider the particular perspective of your health profession. Write a brief outline of that perspective for at least three of the following concepts. State the role of your profession when relating to each of these concepts: • The concept of the Person/s and their role in their own healing • The concept of family/Person-centred practice • The concept of health and illness • The concept of pain • The concept of disability.

•

What is your experience with disease or disability? • Which diseases or disabilities cause you the most discomfort when you consider working with people who have that disease or disability? Consider both physical and psychosocial diseases and disabilities, for example, someone who is dying, someone with schizophrenia and someone with an intellectual disability.

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Individual health professions have underlying philosophies, values, assumptions, beliefs, expectations and habits specific to that profession. These generate particular knowledge and behaviours in the everyday activities of each health profession. Thus, each health profession has a ‘culture’ specific to that profession. These cultures generate differences between health professions. Each profession has a particular concept of the Person/s, and the role of the Person/s and the profession in the healing process (Milliken & Honeycutt 2004). Each profession has a particular understanding of various concepts (e.g. pain, disability, illness, health, wellbeing) and each has a particular role when relating to these concepts relevant to the particular profession. While there are variations in values and beliefs, many professions value family/Person-centred practice and all share the common value of mutual respect and developing rapport.

The culture of disease or ill-health The culture that may be the most difficult to understand unless experienced personally is the culture of disease or ill-health, whether chronic or acute, sudden or gradual. During their working week, health professionals consistently relate to people who live in this culture of disability. Achieving competent communication that accommodates this culture is challenging but as rewarding as communicating competently with individuals from different cultures.

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Chapter summary Culture refers to the material and non-materials aspects of a group. These aspects represent the values and beliefs of a particular group that generate patterns of behaviour. While a health professional can never understand a culture completely unless they are part of it, it is important that they are open to and accepting of the different cultures encountered during practice. The model presented in this chapter provides a guide for each health professional as they consider how to be culturally competent communicators in their daily practice. It highlights particular characteristics that enhance communication in culturally diverse situations. It also identifies inherent and external factors that impact on the health professional and therefore require consideration when communicating with Person/s. Culturally competent communication can be achieved through consideration of this model along with investment of time to negotiate meaning and achieve mutual understanding. Where this requires the use of an interpreter, there are particular steps required to ensure effective communication.

FIGURE 14.2â•… Accommodating and embracing diversity facilitates effective communication.

REVIEW QUESTIONS 1. What must a health professional who is committed to culturally competent communication understand?

2. Define ‘culture’.

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3. What are some of the differences that affect culturally competent communication?

4. How do members of a culture express the cultural characteristics of the culture?

5. List three factors that affect culturally competent communication and give examples of each factor. i. ii. iii. 6. What promotes openness to cultural diversity in a health professional?

7. List some strategies that assist health professionals to avoid applying their personal cultural biases when communicating with culturally different people.

8. Outline the ten steps for effective communication while using an interpreter. i. ii. iii.

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iv. v. vi. vii. viii. ix. x.

9. List some of the values and beliefs of your health profession and give a behavioural example of each.

10. Outline your experience with the culture of disease or disability. Indicate how this experience, if any, assists your understanding of this culture.

REFERENCES Anoosheh M, Zarkhah S, Faghihzadeh S et al 2009 Nurse–patient communication barriers in Iranian nursing. International Nursing Review 56(2):243–249 Arrendondo P, Tovar-Blank Z G, Parham T A 2008 Challenges and premises of becoming a culturally competent counsellor in a socio-political era of change and empowerment. Journal of Counselling Development 86:261–268 Balcazar F E, Suarez-Balcazar Y, Taylor-Ritzler T 2009 Cultural competence: development of a conceptual framework. Disability and Rehabilitation 31(14):1153–1160 Barnett L, Kendall E 2011 Culturally appropriate methods for enhancing the participation of Aboriginal Australians in health-promoting programs. Health Promotion Journal of Australia 22(1):27–32 Beltram R 2011 Cultural dimensions of occupation analysis. In: Mackenzie L, O’Toole G (eds) Occupation analysis in practice. Wiley-Blackwell, London, p 66–80 209

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Berryman-Fink C, Verderber K S, Verderber R F 2009 Inter-act: interpersonal communication concepts, skills, and contexts, 12th edn. Oxford University Press, Oxford Black R M, Wells S A 2007 Culture and occupation. AOTA Press, Bethesda, MD Bowe H, Martin K 2007 Communication across cultures: mutual understanding in a global world. Cambridge University Press, Melbourne Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Camphinha-Bacote J 1999 A model and instrument for addressing cultural competence in health care. Journal of Nursing Education 38:203–207 Canon E 2011 Tips from an accidentally ‘interculturalist’. Cross-Cultural Communication 7(1):112–121 Dean R 2001 The myth of cross-cultural competence: families in society. Journal of Contemporary Human Services 86:623–630 Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Dressler D, Pils P 2009 A qualitative study on cross-cultural communication in post accident inpatient rehabilitation of migrant and ethnic minority patients in Austria. Disability and Rehabilitation 31(14):1181–1190 Eckermann A, Dowd T, Chong E et al 2010 Binaŋ Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont CA Fageeh A A 2011 At crossroads of EFL learning and culture. Cross-Cultural Communication 7(1):62–72 Goddard C 2005 The lexical semantics of culture. Language Sciences 27:51–73 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Hasnain M, Connell K J, Menon U et al 2011 Patient-centered care for muslim women: provider and patient perspectives. Journal of Women’s Health 20(1):73–82 Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Holliday A, Hyde M, Kullman J 2010 Intercultural communication: an advanced resource book for students. Routledge, New York Jirwe M, Gerrish K, Emami A 2010 Student nurses’ experiences of communication in cross-cultural care encounters. Scandinavian Journal of Caring Sciences 24(3):436–444 Kinébanian A, Stomph M 2010 Diversity matters: guiding principles on diversity and culture. World Federation of Occupational Therapists (WFOT), Amsterdam Lewis A, Bethea J, Hurley J 2009 Integrating cultural competence in rehabilitation curricula in the new millennium: keeping it simple. Disability and Rehabilitation 31(4):1161–1169 Martin K J 2009 Student attitudes and the teaching and learning of race, culture and politics. Teaching and Teacher Education 26(5):1224–1225 210

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Mihalic A P, Morrow J B, Long R B et al 2010 A validated cultural competence curriculum for US pediatric clerkships. Patient Education & Counseling 79(1):77–82 Miller J, Donner S, Fraser E 2004 Talking when talking is tough: taking on communications about race, sexual orientation, gender, class and other aspects of social identity. Smith College Studies in Social Work 74:377–393 Milliken M E, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne O’Toole G 2011 What is occupation analysis? In: Mackenzie L, O’Toole G (eds) Occupation analysis in practice. Wiley-Blackwell, London, p 3–24 Papps E, Ramsden I 1996 Cultural safety in nursing: the NZ experience. International Journal of Quality Health Care 8:491–497 Parbury N 1986 Survival: a history of Aboriginal life in NSW. Ministry of Aboriginal Affairs, Sydney Peiris D, Brown A, Cass A 2008 Addressing inequities in access to quality health care for indigenous people. Canadian Medical Association Journal, 4 Nov 179:985–986 Doi:10.1503/cmaj.081445 Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Ramsden I 2001 Defining cultural safety and transcultural nursing. Nursing New Zealand 7(1):21–26 Ramsden I 2002 Cultural safety and nursing education in Aotearoa and Te Waipounamu. New Zealand Council of Nursing, Auckland Seth T 2010 Communication to pediatric cancer patients and their families: a cultural perspective. Indian Journal of Palliative Care 16(1):26–29 Siegel C, Haugland G, Reid-Rose L et al 2011 Components of cultural competence in three mental health programs. Psychiatric Services 62(6):626–631 Smith J D 2008 Australia’s rural and remote health: a social justice perspective, 2nd edn. Tertiary Press, Melbourne Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Suarez-Balcazar Y, Rodakowsi J 2007 Becoming a culturally competent occupational therapy practitioner. OT Practice 12:14–17 Tervalon M, Murray-García J 1998 Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved 9(2):117–125 Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney UNESCO 2002 Declaration on Cultural Diversity. UNESCO, Paris, France Wilcock A A 2006 An occupational perspective of health, 2nd edn. Slack, Thorofare, NJ Wosket V 2006 Egan’s skilled helper model: developments and application in counselling. Brunner-Routledge, London

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ANSWERS TO REVIEW QUESTIONS CHAPTER 14â•… Culturally appropriate communication Answers to the following questions provide a summary of this chapter. 1. What must a health professional who is committed to culturally appropriate communication understand? They must understand their own cultural identity and the associated biases. 2. Define ‘culture’. Culture is the patterns that develop from a particular group. 3. What are some of the differences that affect culturally appropriate communication? Different languages, different meanings of non-verbal cues and uses of non-verbal communication, different perceptions of power and privilege. 4. How do members of a culture express the cultural characteristics of the culture? Members of a culture express their culture through what they value, their beliefs, by performing particular traditions and activities, by the clothes they wear, the food they eat as well as their expectations of behaviours of those around them. 5. List three factors that affect culturally appropriate communication and give examples of each factor. i. Levels of self-awareness can affect communication across cultures. Being aware of your own cultural norms, values, beliefs and expectations can assist you to avoid being judgemental of people with different norms, values, beliefs and expectations. ii. Humility: acknowledging that no one is better than another person – but that there are differences, i.e. avoiding being ethnocentric. iii. Some cultures have particular rules about who ‘can do what’ in different circumstances, so being allowed or not allowed (because of cultural norms) to do something in a particular situation can affect communication. 6. What promotes openness to cultural diversity in a health professional? A willingness to accept differences and a desire to understand those differences promote openness to cultural diversity. 7. List some strategies that assist health professionals to avoid applying their personal cultural biases when communicating with culturally different people. It is helpful if the health professional is aware of their own culture and the attitudes, beliefs and expectations associated with their own culture. They may also need to adjust their worldview to allow for differences in values, beliefs and expectations. The heath professional should also examine any stereotypes they might hold that relate to the particular culture of the Person. They should allocate time to become familiar with the culture of the Person.

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8. Outline the ten steps for effective communication while using an interpreter. i. Be sure of the purpose of the interaction that needs an interpreter. ii. Book the time well in advance and, if necessary, brief the interpreter over the phone beforehand. iii. Prepare an outline of everything you need to communicate during the time with the interpreter. iv. Make sure the interpreter understand the purpose and the information – and decide on a signal that indicates there is enough information that needs interpreting. v. Make sure everyone knows everyone else, introduce everyone and keep the focus on the Person. vi. Remember you are talking to the Person – so look at them and talk to them. Avoid allowing the interpreter to dominate the interaction, they are there to assist. vii. Present small amounts of information at one time, avoid using jargon or colloquialisms. viii. Carefully observe the non-verbal cues of the Person. ix. Ask questions in response to any non-verbal cues. Regularly ask if they understand or have any questions. x. Have the Person summarise the information to indicate they understand and allow time for questions or clarification. Remember to finish the interaction appropriately. 9. List some of the values and beliefs of your health profession and give a behavioural example of each listed value. This is difficult to give a short answer to as it depends on the actual health profession. An example might be: Some professions expect the Person to listen and do exactly as they are instructed – the behaviour associated with this expectation would probably be to give short instructions and expect the Person to comply whether or not they are in the room. Other health professions expect the Person to be an integral part of the health process and thus would spend time asking for information, explaining processes and discussing various possibilities to determine what might be the best course of action for the particular Person. 10. Outline your experience with the culture of disease or disability. Indicate how this experience, if any, assists your understanding of this culture. I have experienced being a Person/patient and thus have some understanding of what it is like to be in a health service environment with limited control over what, when and how you do particular activities, even your personal care.

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CHAPTER 15â•…

Communicating with Indigenous Peoples CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Employ the four Rs: Remember, Reflect, Recognise and Respond to reflect Reconciliation and to empower all interactions with Indigenous Peoples • Appreciate the importance of using terms appropriately when communicating with Indigenous Peoples • Apply the general principles of effective communication when communicating with Indigenous Peoples • Analyse and recognise the importance of cultural identity • Analyse the relevance of the pre- and post-contact states of Indigenous Peoples • Appreciate and synthesise the factors affecting the establishment of cultural safety when working with Indigenous Peoples • Apply specific communication principles relevant to Indigenous Peoples • Recognise potential barriers to effective communication when communicating with Indigenous Peoples.

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Note: It is not possible to be an expert in all cultural practices. The author as a nonIndigenous Person is far from being an expert, nor is this chapter able to make experts of non-Indigenous readers. However, it can begin the exploration of communicating with and assisting Indigenous communities who have diverse practices that are different to those of the health professional. This chapter will potentially begin the journey for some and continue it for others in understanding and embracing the communication needs of Person/s who were the original inhabitants of a region or country, that is, Indigenous Peoples.

Correct use of terms History and attitudes dominate relationships with indigenous groups around the world. This often means that non-indigenous colonists and their descendants demonstrate attitudes and use terms that are discriminatory and offensive to the relevant indigenous peoples. It is important then that health professionals avoid causing offence by ensuring they understand the current terms that are appropriate when relating to indigenous peoples. While this is not always true in many countries, in Australia the terms used evolve continually when describing Aboriginal and Torres Strait Islander Peoples (NSW Department of Health 2004). This provides a challenge for every Australian health professional to know the most current descriptive terms, as the appropriate use of terms is essential for the development of therapeutic relationships and family/community-centred practice. Using the current terms also contributes to positive experiences that will ensure Indigenous Peoples continue to seek assistance from health services.

Suggest ways an Australian health professional might ensure appropriate use of terms and avoid offending an Indigenous Person/s when communicating with them.

The 4 Rs for reconciliation: Remember, Reflect, Recognise, Respond Indigenous Allied Health Australia has suggested four relevant words and related actions beginning with ‘R’ to assist anyone relating to Indigenous Peoples. These words suggest reflection and, in some instances, actions to assist any health professional in any country interacting with Indigenous Peoples. Remember, Reflect, Recognise and Respond challenges any health professional when communicating with any individual, however they are particularly important when assisting Indigenous Peoples.

REMEMBER As mentioned above, the events of history around the world (often based upon stereotypical attitudes) when indigenous peoples were assumed to be inferior are not only regrettable, but also in many cases have created inappropriate and difficult situations for indigenous peoples. The reality of these events has resulted in sub-standard conditions for many indigenous peoples around the world. It is important to remember and 213

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reflect upon these events, not to create a sense of guilt, but rather a sense of understanding and awareness of the historical difficulties. These events continue to affect some Indigenous Peoples in the present as they attempt to relate to health services (Eckermann et╯al 2010).

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Remember the events of history relating to the Indigenous Peoples in your country. • How do you think you and your family would have responded if you had been in their place? • Given that you would have had limited methods of resisting:  How would you feel if you had been separated from your family and sent away?  How would you feel if you were forced to do menial labour with minimal pay? • How do you think the Indigenous Peoples in your country felt?

REFLECT Remembering is vital, however without reflection it can be futile. Reflection about these events produces understanding and the ability to demonstrate respect and empathy in order to develop trust and a therapeutic relationship. This can take time when assisting Indigenous Peoples (Eckermann et╯ al 2010). As it is these characteristics of practice that affect final outcomes of the health service, it is vital that health professionals reflect upon these historical events. It is sobering to note that there are still people alive in some countries (Australia being one country) that remember the violence experienced by indigenous peoples. It is equally sobering to realise some Indigenous Peoples in some communities continue to experience this prejudice and violence today.

RECOGNISE The events of history in many countries have radically reduced the number of Indigenous Peoples in the area. However for the generations who remain, it is important to recognise the resilience of Indigenous Peoples. This characteristic produced people originally well adapted to and sustaining their surrounding environments, and in the present it produces people who attempt various ways to not only survive but to thrive in their current situations.

RESPOND An appropriate response requires constant collaborative practice that reflects true reconciliation. This practice requires time and perseverance to establish mutual understanding (Eckermann et╯al 2010). Remembering, reflecting and recognising have the potential to promote responses that enhance the characteristics discussed in Section 1 of this book. These characteristics are essential in health professionals committed to family/ Person-centred practice and in the case of Indigenous Peoples, community-centred practice. There is no definitive formula for relating to Indigenous Peoples, however the four Rs provide a foundation for any health professional relating to Indigenous communities. Recognition and application of the general purpose of health professionals when communicating will ‘build upon’ these Rs and assist in achieving effective communication and positive outcomes. There are also specific principles useful in all communicative circumstances that will therefore be beneficial when communicating with Indigenous Peoples. Before exploring these principles, it is important to consider the reality of cultural identity. 214

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The complexity of cultural identity Cultural identity is complex because each individual is a member of many different groups that have a unique culture. In each of these groups, every individual has a particular identity that is unique to that group (Anngela-Cole et╯al 2010, Holliday et╯al 2010; see Ch 14). The nationality of the individual provides a particular cultural identity that accompanies values, traditions, beliefs and expectations (of self and others) specific to that nation. Membership of other groups – families, clans (in New Zealand iwi = tribe and hapu = sub-tribe), communities, sporting groups, religious groups, educational groups, employment groups, and political groups – creates additional List the groups of which you are a aspects of cultural identities that relate to and affect member. Choose two of these groups: the national and/or cultural identity of each person. • How has membership of each group shaped how you view yourself? Membership of each group provides a connection through common experiences and expectations that • How has membership of these groups affected how others see you? are unique to the group. However each member has a different, unique identity. People with Indigenous descent also have unique identities that reflect their original group or nation. Their connection to the values, beliefs, traditions and expectations of that group influences their cultural identity and their appreciation of that identity. Levels of identity and connection vary for many Indigenous People. If an individual has lived their entire life with their kinship group at a traditional birthplace, their cultural identity will strongly reflect their national group. Traditional knowledge and customs will guide their daily life. If an individual was separated from their birthplace and kinship group at some point, their cultural identity may reflect other influences as well as the influence of their national origin. An Indigenous Person/s who lives in a large metropolis may or may not take pride in their cultural identity. They may have only vague expectations of adhering to cultural traditions and customs, although they may acknowledge particular spiritual and relational values and beliefs. In Australia, although the cultures of Aboriginal and Torres Strait Islander Peoples are different, there are common core values shared across the country. These values include family and kinship, caring and sharing, and a spiritual connection with and love of the land (Country). While Maori have less variation in their distinctive groups, they share a sense of connection to space and belonging. This is reflected in Tūrangawaewae – a place to stand, a place to belong to, a seat or location of identity. In most countries there is a broad range of connection with and adherence to traditions among indigenous peoples. In Australia, for example, many rural Aboriginal and Torres Strait Islander Peoples have replaced walking with horses or motorised forms of transport. However, the same people continue to value the land (Country) along with their traditional ceremonies and singing. In New Zealand, many Maori have absorbed ‘ways’ from the dominating culture of the colonists. However, they still believe in and use traditional remedies to augment or replace the health practices of the dominant culture. In the Pacific, various indigenous peoples may use modern equipment to fulfil the traditional occupation of fishing. However, the same people continue to make traditional mats for use in their houses and for particular occasions. In many places in Asia, indigenous peoples use mobile phones to communicate but still plough their fields using buffalo. In many places in northern Canada, the skidoo has replaced the traditional use of the dog sled for transport and sometimes even hunting. However, the same people still create unique 215

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clothing that reflects membership of their particular kinship group. It is important to remember that the culture of all indigenous peoples is neither static nor uniform. Each culture and individual within that culture is continually changing and adapting to the influences upon themself or their community. The complexity of cultural identity indicates it is important that health professionals recognise the factors affecting that identity. It is also essential that health professionals acknowledge there are variations within Indigenous Peoples that prohibit the stereotypical labelling of any individual because of their nationality. Aboriginal and Torres Strait Islander Peoples clearly exemplify this fact, as they are two distinct groupings. The Torres Strait Islander Peoples have an origin, culture and identity distinct from the many Aboriginal nations that originated in the mainland and Tasmania. These many Aboriginal groups also have languages, cultures and identities that are distinct from each other and from those of the Torres Strait Islander Peoples. There is a long history of stereotyping of many Indigenous Peoples. Indigenous Peoples may also stereotype non-Indigenous People and sometimes even other Indigenous individuals or groups. It is the responsibility of the health professional to consider their own tendency to stereotype and adjust their knowledge and attitudes to avoid stereotyping any Indigenous Person/s. It is also important that the health professional behaves in a manner that will reduce the tendency of some Indigenous Peoples to negatively stereotype non-Indigenous health professionals (Eckermann et╯al 2010).

Principles of practice for health professionals when working with Indigenous Peoples CREATING CULTURAL SAFETY FOR INDIGENOUS PEOPLES IN HEALTH PRACTICES Understanding the concept of cultural safety is essential when relating to indigenous peoples from any country. Practice that respects, supports and empowers the cultural identity and wellbeing of an individual produces cultural safety (Nursing Council of New Zealand 2002). Such practice is more than mere awareness or sensitivity, it mandates collaboration with the Indigenous community. It allows them to have the power when receiving health interventions – it is Community-centred practice. It also requires action that results from critical reflection about the personal values of the health professional (DiGiacomo et╯al 2010, Stein-Parbury 2009) and evaluation of their personal attitudes and beliefs. It requires the health professional to acknowledge and accept that their own values and beliefs may be different to those of the Indigenous Person/s they assist in their daily practice (Eckermann et╯al 2010). This acknowledgement and acceptance should assist the health professional to avoid imposing their own values onto the Indigenous Person/s. Culturally safe practice also requires awareness of and reflection about the culture and values of the particular health service. It is important that the health professional evaluates how their values, attitudes and beliefs and those of the relevant health service affect the Indigenous Person/s they assist in their daily practice (Fenwick 2001). It is equally important for health professionals to evaluate the quality and outcomes of the assistance Indigenous Person/s receive from their health service. Such evaluation requires awareness and appreciation of the perceptions and lives of Indigenous Person/s, their kinship groups and their communities. These perceptions develop while receiving assistance, whether past or present, and should contribute to any evaluation of a health service. The histories of the relationship of indigenous Person/s with the Europeans who 216

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have colonised their country also affect these perceptions. The result of such reflection and evaluation should be the achievement of cultural safety for Indigenous Person/s because of adjustments and improvements in the health service and the practice of the health professional (Fried 2000). In contrast, lack of cultural safety exists when any individual behaves in a manner that challenges, denies, diminishes, demeans or disempowers the cultural identity and wellbeing of any individual within a health service (Nursing Council of New Zealand 2002).

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What actions or words demean or deny your identity? How do you feel when this happens? What might you do to avoid doing this to an Indigenous Person/s?

Emilia is a 5-year-old Australian girl with blonde hair and blue eyes who has come to you for assistance. You have developed a good relationship, based on respect, trust and rapport, with her mother, Jill. Your assessment of Emilia indicates the choice of school will be significant and could affect her learning and thus her future. Her mother feels safe and comfortable with you and discusses the pros and cons of the local schools with you. She indicates that one school, a distance away, has extra funding for children with an Indigenous background. You are unsure of the meaning of this comment – you have not noticed any indication of heritage on Emilia’s record or file and the appearance of Jill and her three children suggest there is no Indigenous background. You assume Jill is concerned that if Emilia attends that school she will not have the assistance she requires because of the presence of an Indigenous cohort. You say it would not be good for Emilia to experience reverse discrimination because of her ethnicity (i.e. to miss out because she does not have an Indigenous background). Jill bristles and coldly explains that her mother was taken from her family post-contact with Europeans and thus Jill did not know until recently she had an Aboriginal heritage. She states a family that was discriminatory against people with her background raised her mother, and thus she now has to adjust to the fact that she is one of the people about whom she previously thought negatively. While her husband, who she married before she discovered this fact, says it makes no difference to him, she struggles to establish her identity and often avoids disclosing her heritage. This makes her reticent to place Emilia, despite her eligibility, at the school that has specific funding for children with an Aboriginal background. You are generally an accepting person and have good friends who have an Indigenous background. You regret your assumptions and offensive comment. You are aware that you could have been assisting Jill to resolve her struggle, experience acceptance and establish her cultural identity.

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What could you have done to ensure cultural safety for Jill and her three children? What will you do now to retrieve the relationship and encourage her to continue bringing Emilia for assistance?

Note: When treating children it is essential that the health professional assist the family, not just the individual child, because it is the context of the family that usually dominates 217

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the development of the child. In addition, it is the parents who know the child better than anyone and are invaluable in providing a true picture of the child and their abilities. There are a number of factors contributing to the creation of cultural safety for Indigenous Peoples that require examination.

THE IMPORTANCE OF HISTORY As mentioned above, the awareness and understanding of pre- and post-contact history is a factor that contributes to the creation of cultural safety. For many Indigenous Peoples (particularly those who are older) it is highly significant, because historical factors have created negative perceptions and mistrust of non-Indigenous or mainstream health systems (Australian Government Department of Health and Ageing 2004). Thus, pre- and post-contact history requires close consideration.

Pre-contact history Pre-contact with Europeans, many indigenous groups in various places around the world existed in harmony with their spiritual and physical environments and in varying levels of harmony with each other for generations upon generations. Each group had their own traditional languages, culture, specific identity including dress, spiritual explanation of their existence, rules of behaviour including expectations of the individual and the group, kinship rules, remedies, methods of artistic expression, methods of providing food and water, and laws governing their daily lives. The groups (although rarely hierarchical in Australia) had designated leaders or groups of members who understood and protected their values, traditions and laws. As protectors of these values, traditions and laws, these leaders had particular levels of wisdom and understanding and thus were often the decision makers for the group and the individuals within the group. In Australia pre-contact there were around 250 distinct groups of Aboriginal and Torres Strait Islander Peoples with their own language, culture, identity, kinship rules, boundaries and laws for relating to other groups (Australian Government Department of Health and Ageing 2004). Aboriginal groups had inhabited Australia for approximately 50╯000 years pre-contact. These groups did not always relate well to each other and some still experience tension today. In New Zealand pre-contact there was one Maori language. However, more than one group existed and these groups did not always experience harmonious relations. The Maori inhabited New Zealand for approximately 300 years before the arrival of Europeans. While there was a treaty (te Tiriti O Waitangi:The Treaty of Waitangi) in 1840 between the Maori and particular non-Indigenous People, that treaty was not ratified by the non-Indigenous colonial government of the time. This meant that the rights of the Maori were not recognised, although it became impossible to ignore their organised existence. This resulted in post-contact stress that in many ways results in inequality today.

Post-contact history In many cases, when European contact occurred with the indigenous peoples of a region or country, the indigenous groups were not structured or organised in ways recognisable to the non-indigenous people. In many places in Australia ‘contact’ resulted in violence, devastation through loss of access to their traditional food sources (Eckermann et╯al 2010) and introduced diseases or deliberate attempts to kill and/or control these groups. This control often placed members of ‘non-compatible’ groups together in reserves or 218

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missions. Lack of understanding, multiple incorrect assumptions and misplaced social theories (Harms 2007, Harms & Pierce 2011, Smith 2001) by non-Indigenous People post-contact often resulted in histories that established negative expectations in the minds of the affected Indigenous Peoples. For example, in Australia there was deliberate segregation in society that also occurred in hospitals. Hospital staff often placed Aboriginal and Torres Strait Islander Peoples on the verandah or in unneeded areas of the hospital to keep them separate from non-Indigenous People. Many older Aboriginal and Torres Strait Islander Peoples still remember such actions, which contribute to current negative expectations. These expectations continue in many places today because of continued discriminatory attitudes and behaviour by many non-Indigenous People. In many sectors of Australian society, however, there has been a slow awakening and recognition of the social, emotional, spiritual and cultural damage caused post-contact to Aboriginal and Torres Strait Islander Peoples. In New Zealand, there has been a similar awakening reflected in the Treaty of Waitangi Act 1975, which recognises the effects of colonisation on the Maori and has resulted in various changes for the benefit of the Maori. Knowledge and understanding of pre- and post-contact history is important in the creation of cultural safety. However, genuine Remembering and Reflection creating synthesis of the history and an appropriate Response (including awareness of the personal bias of the health professional) to this history is essential when communicating with Indigenous Peoples.

OTHER FACTORS Many factors affect feelings of cultural safety; some of these factors relate to cultural differences. Some have greater impact on health service delivery than others, but all are significant in the creation of cultural safety. The following points in this section have been adapted from the Australian Government Department of Health and Ageing 2004. • It is important to understand that communication styles vary. For example, the use of eye contact for some Aboriginal and Torres Strait Islander Peoples and for Maori (Metge & Kinloch 1978) can be a sign of disrespect rather than a sign of attentive listening. However, others may avoid eye contact if they feel ashamed or feel they are being patronised. Some will not look at a person of the opposite gender. Some Indigenous Peoples may feel it is unnecessary to answer a question when the answer is obvious. Some may also consider it impolite to answer a question immediately, and thus they will pause before answering a question. The use of direct questions in some cultures (not just Indigenous cultures) is rude and thus when requesting personal information it is best to ask open questions (see Ch 4). In many cases telling a story of someone with a particular difficulty may elicit information about the needs of the Person/s. It is important to accept and accommodate differences in communication style wherever possible. • It is important to understand that many Indigenous Peoples define the notion of family differently to non-Indigenous People. For example, Aboriginal and Torres Strait Islander Peoples, Maori and many Pacific Islanders may call and consider someone a brother, sister, uncle or auntie when, if related, they are only distantly related in a non-Indigenous context. In some Indigenous groups a community Elder may have such a place (name) within a family group. • Equally important is understanding there are differences in concepts of spirituality among Indigenous Peoples. For many, spirituality includes a special relationship with the land or with nature. It is possible for each Indigenous Person/s to have 219

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unique spiritual requirements that are integral to the provision of healthcare, whether the requirements are related to a special custom or the expectation of particular behaviour when someone is ill. For example, a particular person in the ‘family’ is expected and expects to care for a relative with a life-limiting illness. This person may consider caring for this relative more important than employment, and thus if they are unable to continue working while caring for this ill person they will resign from their employment without a second thought. It is important to understand that kinship obligations (for Maori reflected in the concept of whanaungatanga, an obligation of giving and receiving) may result in large numbers of people either visiting or accompanying the Person/s. Accommodating this factor may mean provision of a particular area or room for the Indigenous Peoples accompanying the Person/s. Expectations of particular behaviour may also relate to kinship obligations. For example, when a mother is ill among the Aboriginal and Torres Strait Islander Peoples, most often the eldest daughter expects to fulfil the role of carer. Also important is the reality that Indigenous Peoples experience differences in life circumstances, family histories and community. Many Indigenous Peoples live in imposed poverty with living conditions that a non-Indigenous Person would not tolerate. Therefore, many Indigenous Peoples experience diseases related to poverty. Life expectancy may be shortened in many Indigenous communities, with general levels of health below the average for the non-Indigenous population. For example, in Australia the Yawuru people of the West Kimberly country (Western Australia) commonly experience a premature death of one of the members of the community, often on a weekly basis (ANTaR 2007). Aboriginal and Torres Strait Islander Peoples typically have life expectancies that are 20 years less than those of the total Australian population. The death rates in the 35–54-year age group are five to six times higher than in the general population (Australian Bureau of Statistics & Australian Institute of Health and Welfare 2003). Such facts exist for many Indigenous Peoples (for facts relating to Maori, see Durie 1998) and often result in unresolved grief and a sense of loss, for both past and present, in Indigenous communities. Recognition of this reality is important for the creation of cultural safety. It is important to remember that Indigenous Peoples will react differently to people and the healthcare environment. Some Indigenous Peoples find it difficult to seek assistance, or to continue to seek assistance, because of factors such as separation from the people in their communal group; arrangement of the environment and rooms in health services and thus restrictions on particular types of behaviour; and unfamiliar people who apparently do not understand or want to understand their customs and often their previous experiences with health services. This can affect the creation of cultural safety. Any person with a different cultural background will be affected by differences in education and language. For many rural and remote Indigenous Peoples, English is a second, third or sometimes fourth language and thus they may require an interpreter (see Ch 14), preferably from an organisation dedicated to that particular Indigenous group. If there is no known organisation dedicated to the appropriate Indigenous group, it is essential to remember that the Indigenous Person/s will have their own sociolinguistic and sociocultural expectations that will affect the interaction (Bowe & Martin 2007, Eckermann et╯al 2010). It is also important to note that many Indigenous Peoples have their own dialect of the language of the

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non-Indigenous colonists. In Australia, Aboriginal and Torres Strait Islander Peoples have a particular dialect of English that is in many cases a significant part of their cultural identity (Aboriginal English in the Courts 2000). The use of their own dialect without an interpreter may contribute to pauses of varying lengths as the Person/s silently translates the message into their dialect to facilitate understanding. Acceptance of variations in the dialects of English may be important for creating cultural safety. Understanding that Indigenous Peoples may have different attitudes, understanding and approaches to illness, health, death and disability contributes to establishing cultural safety. Some indigenous groups in Asia believe particular disabilities are a punishment for wrong behaviour, thus disability brings shame. Generally, it is unacceptable for individuals with disabilities to relate in public in such cultures. Some indigenous groups in the Pacific and Australia attribute disease and death to sorcery or curses rather than biomedical causes. It is interesting to note that the word ‘health’ may not always have a direct equivalent in some languages of the Aboriginal and Torres Strait Islander Peoples. For Aboriginal and Torres Strait Islander Peoples, ‘health’ is often about wellbeing. Wellbeing is not related to illness, but rather to connection with kinship groups and, for many, connection with traditions and the land. For many Indigenous Peoples, having the same gender health professional to assist them contributes to their cultural safety. In many cases the Indigenous Person/s may not attend repeat appointments if they have a health professional of the opposite gender assisting them. Establishing cultural safety for Indigenous Peoples requires an understanding that different values and ‘ways of doing and caring’ in rural and remote areas may result in behaviours that seem foreign and sometimes unacceptable to the values and ways of the non-Indigenous health professional. These ways of caring have been practised for thousands of years and, if accepted and creatively accommodated rather than rejected, can produce cultural safety and remove a reluctance to access non-Indigenous services. Another cultural difference that affects cultural safety is traditional methods of managing illness and death (Healing Our Way 2005). Such methods are often foreign to non-Indigenous health professionals. However inclusion of such practice in the care of Indigenous Peoples (e.g. the use of traditional healers and foods) can contribute to their spiritual, emotional, psychological and often physical comfort. The impact of the imbalance of power in the relationship between the health professional and the Indigenous Person/s is a crucial factor affecting the creation of cultural safety. This imbalance occurs even when there is no cultural difference, because of greater familiarity of the health professional with the health system and the particular health profession. When assisting Indigenous Peoples, however, this imbalance is heightened in many cases because of social, economic and educational advantage on the part of the health professional. Previous government policies relating to Indigenous Peoples have influenced the expectation of a power imbalance from the perspective of Indigenous Peoples. This in turn influences the potential development of therapeutic relationships and the creation of cultural safety. It is important that the health professional behaves in a manner that respects and accommodates and in some instances advocates for cultural differences in order to create a collaborative balance of power rather than a dominating one. 221

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• Appropriate training in understanding cultural differences for all staff in a health

service contributes to achieving cultural safety. However it is the application of this training that produces both safety and competence. • Investing time to learn about cultural differences and discovering ways to accommodate these differences and include them in practice will contribute to cultural safety and positive outcomes. All the above factors affect the creation of cultural safety for Indigenous Peoples. They require consideration and accommodation when providing health services for indigenous peoples from both the southern and northern hemispheres. These factors provide a foundation for the principles that guide the practice of a health professional when assisting Person/s with indigenous backgrounds.

Which of the above factors affecting feelings of cultural safety do you feel are most important to you?

•

In groups of four, divide the factors affecting feelings of cultural safety among the group to ensure consideration of all the listed factors. • Suggest ways that your health profession or health service might accommodate each factor. • Suggest ways that an individual health professional might accommodate each factor.

Factors contributing to culturally safe communication with Indigenous Peoples Many of the factors that contribute to the creation of cultural safety also influence the effectiveness of communication. However, the following factors relate specifically to communication with Indigenous Peoples. • The direct and confident ‘professional’ manner encouraged in non-Indigenous health professionals may be offensive to some Indigenous Peoples, especially when discussing sensitive information. In such situations, a softly spoken, informal manner is more appropriate. An established relationship based on respect and rapport encourages effective communication with Indigenous Peoples. • When referred a Person/s with an Indigenous background, it is important to consider the correct people to approach or to include if giving important information about the future of the Person/s. Include all appropriate people in discussions about the intervention plan and where appropriate the discharge plan. As mentioned, when a mother is ill it is often the eldest daughter who needs to know the medication or intervention regimen, not the person herself. It may be important to approach a local Elder (Kaūmatua [male] or Kuia [female] Maori Elder) before initiating contact or have an Elder present when discussing future intervention or discharge (Clarke et╯al 1999). • Establish how to contact the local community Elder or relevant organisation connected specifically with the cultural background of the Person/s. Establish communication links with the specialist organisation, either at an institutional level 222

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• • •

•

•

•

•

•

or a personal level, depending on the situation. Seek the advice or direct involvement of an Indigenous health worker as they are trained specifically to liaise between the Person/s and the health professional to ensure understanding and accommodation of the communication and cultural needs of the Person/s to promote quality health services. The Indigenous health worker, while trained in health, is typically a member of the community in which they work and thus has ‘first hand’ experience and understanding of the cultural expectations of the Person/s. They also know who should be involved and how to engage the Person/s and relevant services. Avoid making assumptions based on appearance, living conditions, people present, and commitment to traditional beliefs and customs. Remember the person who is entitled to give consent may not be present despite the presence of a close relative. Use an Indigenous health worker or medical liaison officer from the particular Indigenous group if communicating complex information or bad news. Isaacs et╯al (2010) & Millis et╯al (2010) state that collaboration is a key factor of successful communication opportunities with Indigenous Peoples. Clarify with the interpreter before the discussion the appropriate terms for particular concepts. For example, death and dying are words that may not be used in some Indigenous communities. Open communication that embraces differing communication styles contributes to culturally safe communication. It is important to avoid imposing any particular values, expectations or ways of performing tasks onto the Indigenous Person/s. It is also important to avoid correcting the spoken expression of Indigenous Peoples, including children, because this indicates lack of acceptance of their particular dialect and a desire to impose the dialect of the health professional. Ask about the cultural background of the Person/s or family and community. Ask the Indigenous health worker for information about specific communication behaviours and relevant cultural needs. Accommodate these differences where possible. Explain the requirements of the health service and remain open to possible ways of complying with these requirements while accommodating the cultural needs of the Person/s or community. Sometimes the questions asked by health professionals are offensive to an Indigenous Person/s because of the nature of the questions or the gender of the person asking the questions. Questions may appear silly if the answers seem obvious. It is important for health professionals to state the need to ask many questions in an apologetic, concerned manner. Explain that everyone seeking assistance from this health service usually answers these questions and the information will not affect their access to services. Reassure them of privacy and confidentiality of the collected information. Listen. Skills in listening are essential when communicating; however, many Indigenous Peoples feel that non-Indigenous People do not take the time to listen (Clarke et╯al 1999, Harms 2007, Harms & Pierce 2011). This reality may originate in the different uses of silence and questions/answers in some Indigenous cultures. Consider the method of providing information that will maximise understanding. Many Indigenous cultures use storytelling as a means of sharing information. Using a story about a person with a particular condition or difficulty may allow the Indigenous Person/s to understand the requirements of the health professional or to recognise their own condition and related needs. For example, telling a story about 223

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someone with diabetes and their experience of the relevant intervention may allow the Indigenous Person/s to see they too have diabetes and to understand how to control that condition. • Allow sufficient time for processing of information. Verify understanding of the information given and seek clarification where required about that information from an Indigenous member of staff or person from the relevant Indigenous organisation (Australian Government Department of Health and Ageing 2004). Remember some Indigenous Peoples may be translating the information into their own dialect or language and thus may require longer to process information. • Invest time to establish trust (it may take longer than expected depending on the previous experience of the Person/s with health professionals) and a therapeutic relationship with the Person/s and the members of the community who care for them. Many Indigenous Peoples are accustomed to non-Indigenous People talking and filling the silences (Harms 2007, Harms & Pierce 2011, Metge & Kinloch 1978). Therefore, establishing a relationship may require investment of time to sit quietly and listen or simply sit. • Provide time for discussion and explanation during all stages of the assistance process. Where possible include an Indigenous health worker or medical liaison officer of the same cultural background. • Observe and validate non-verbal cues. Where direct questions are not the cultural norm, suggest a possible interpretation of the non-verbal cues and wait for a response. For example, if an Indigenous Person/s has their eyes averted or head turned away, the health professional might ask a specific question in a nonconfronting, non-patronising manner. For example, I can see you are not happy (frightened etc); are you feeling pain? This manner of questioning validates their feelings and allows them to feel and agree or disagree with the assumption. For some Indigenous Peoples, however, if the health professional has made the correct assumption about the cause of the non-verbal cues they will not answer because the answer seems obvious. Remember non-verbal cues may have particular meanings that are different to those of the health professional. • Silence has a particular role in many Indigenous communities. It is a positive element of communication that facilitates learning about a person through thought and observation. Silence is an acceptable part of communicating. It allows time for processing information, ‘feeling’ those around them and understanding the environment. • Indigenous peoples may communicate discomfort through silence and this has particular implications for a health professional. The silence may indicate physical pain. However, Which of the above factors affecting it may also indicate that it is inappropriate to communication are least familiar to you? respond to particular questions or comments from a person of the opposite gender. As mentioned, silence may also represent Choose the five factors least familiar translation time. to the group and decide how a health Lack of response may possibly indicate an • professional might accommodate each inability to physically hear the message and this factor. requires particular action on the part of the health professional.

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Barriers to culturally safe communication Many Indigenous Peoples have experiences that suggest most non-Indigenous health professionals have limited knowledge of or lack of interest in Indigenous cultures, and are generally not interested in accommodating Indigenous cultures (Bailie et╯al 2010). These experiences often result in Indigenous Peoples avoiding seeking assistance from non-Indigenous health services. They may also result in the Indigenous Person/s not returning for repeat assistance. The following are causes of culturally unsafe communication identified by Indigenous Peoples that provide barriers to effective communication. • The presence of stereotypes and preconceptions may govern the behaviour of both the health professional and the Indigenous Person/s. • Failure to explore the actual meaning of words or behaviours is a barrier to effective communication because words may have a different meaning for the Indigenous Person/s. For a non-Indigenous Person, ‘home’ may mean a house, but for an Indigenous Person/s they are at home when they are with their kinship group, whether or not that group is in a house. Failure to explore the meaning of words can limit communication in the same way that failure to explore the meaning of particular behaviour can limit communication. For example, exploration of the meaning of silence, averted head and/or eyes, non-attendance, repeated attendance after discharge, or failure to complete the required at-home tasks may assist the health professional to provide appropriate assistance and develop rapport. • Failure to understand that some Indigenous Peoples provide the answer they think the health professional desires. Indigenous Peoples may do this because they do not understand the request or because of multiple repeats of the same question. • Failure to listen patiently and quietly. • Failure to observe and explore non-verbal behaviours in a culturally appropriate manner. • Failure to clarify understanding. • Responses that are clichés or automatic and therefore do not acknowledge the language and/or cultural needs and differences between the Indigenous Person/s and the non-Indigenous health professional. • Use of inappropriate pamphlets or written information. Using written information with visual images and no jargon or technical terms is important when communicating with most people seeking assistance, and especially with Indigenous Peoples. It is important to seek the advice of Indigenous health workers or medical liaison officers when preparing any written information for Indigenous peoples.

Chapter summary Many factors affect communication with Indigenous Peoples. These factors arise from separate and shared experiences of Indigenous Peoples and often non-Indigenous People. It is important that health professionals consider the relevant factors when communicating with Indigenous Peoples to ensure culturally safe practice, effective communication and family/community-centred practice.

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FIGURE 15.1â•… Equality produces positive results.

REVIEW QUESTIONS 1. What is the purpose of using appropriate terms to describe their groups when relating to Indigenous Peoples?

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 2. Explain why each individual has a unique cultural identity.

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 226

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_____________________________________________________________ _____________________________________________________________ 3. Define cultural safety.

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 4. List the five main steps that create culturally safe practice when working with Indigenous Peoples. i. ii. iii. iv. v. 5. Identify eight factors that contribute to the creation of cultural safety for Indigenous Peoples. Give original examples of how a health professional might accommodate each of these factors in practice. i. ii. iii. iv. v. vi. vii. viii.

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6. Choose and explain ten factors that contribute to the creation of culturally safe communication for Indigenous Peoples. Give examples of ways of communicating that will create effective communication with Indigenous Peoples. i. ii. iii. iv. v. vi. vii. viii. ix. x. 7. List seven barriers to the creation of culturally safe communication. i. ii. iii. iv. v. vi. vii. 8. Describe how a health professional might overcome at least four of the barriers to culturally safe communication. i. ii. iii. iv.

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REFERENCES Aboriginal English in the Courts 2000 Department of Justice and Attorney-General, Queensland Government. Online. Available: http://www.justice.qld.gov.au Jan 2012 Anngela-Cole L, Ka’Opua L, Busch M 2010 Issues confronting social workers in the provision of palliative care services in the Pacific Basin (Hawai’i and the US-affiliated Pacific Island nations and territories). Journal of Social Work in End-of-Life & Palliative Care 6(3/4):150–163 ANTaR: Australians for Native Title and Reconciliation 2007 Liyarn Ngarn (feature film with Patrick Dodson, Peter Postlethwaite, Archie Roach and Shane Howard). ANTaR, Australia Australian Bureau of Statistics & Australian Institute of Health and Welfare 2003 The health and welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. Commonwealth of Australia, Canberra Australian Government Department of Health and Ageing 2004 Providing culturally appropriate palliative care to Aboriginal and Torres Strait Islanders: resource kit. Commonwealth of Australia, Canberra (The Mungabareena Aboriginal Corporation assisted in the preparation of this resource kit) Bailie R, Si D, Shannon C, Semmens J et al 2010 Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples. BMC Health Services Research 10(1):129–141 Bowe H, Martin K 2007 Communication across cultures: mutual understanding in a global world. Cambridge University Press, Melbourne Clarke A, Andrews S, Austin N 1999 Lookin’ after our own: supporting Aboriginal families through the hospital experience. Aboriginal Family Support Unit, Royal Children’s Hospital, Melbourne DiGiacomo M, Davidson P M, Taylor K P et al 2010 Health information system linkage and coordination are critical for increasing access to secondary prevention in Aboriginal health: a qualitative study. Quality in Primary Care 18(1):17–26 Durie M 1998 Whaiora: Maori health development, 2nd edn. Oxford University Press, Auckland Eckermann A, Dowd T, Chong E et al 2010 Binaŋ Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Fenwick C 2001 Pain management strategies for health professionals caring for central Australian Aboriginal People. Australian Government Department of Health and Aged Care, Canberra Fried O 2000 Providing palliative care for Aboriginal patients. Australian Family Physician 29:1035–1038 Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Healing Our Way: Aboriginal Health and Community Protocols 2005 Discipline of Aboriginal Health Studies, Faculty of Health and Medical Sciences. The University of Newcastle, Australia (Learning Production Group Education Services, USD CD–ROM 2005 release) Holliday A, Hyde M, Kullman J 2010 Intercultural communication: an advanced resource book for students. Routledge, New York

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Isaacs A N, Pyett P, Oakley-Browne M A et al 2010 Barriers and facilitators to the utilisation of adult mental health services by Australia’s Indigenous people: seeking a way forward. International Journal of Mental Health Nursing 19(2):75–82 Metge J, Kinloch P 1978 Talking past each other: problems of cross-cultural communication. Victoria University Press, Wellington Millis J E, Francis K, Birks M et al 2010 Registered nurses as members of interprofessional primary health care teams in remote or isolated areas of Queensland: collaboration, communication and partnerships in practice. Journal of Interprofessional Care 24(5):587–596 NSW Department of Health 2004 Communicating positively: a guide to appropriate Aboriginal terminology. NSW Department of Health, Sydney Nursing Council of New Zealand 2002 Guidelines to cultural safety, the treaty of Waitangi, and Maori health in nursing and midwifery education and practice. Nursing Council of New Zealand Smith L T 2001 Decolonising methodologies: research and Indigenous Peoples. University of Otago Press, Dunedin Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney

FURTHER READING Child and Youth Health Inter-government Partnership (CHIP) 2005 Healthy children – strengthening promotions and prevention across Australia: national public health strategic framework for children 2005–2008. Australian Government Department of Health and Aged Care, Canberra Ellis R, Simms S (eds) 2005 Indigenous health promotion resources: a national information guide for Aboriginal and Torres Strait Islander health workers, 5th edn. Aboriginal and Torres Strait Islander Health Worker Journal, Matraville, Australia Hazlehurst K 1996 A healing place: Indigenous visions for personal empowerment and community recovery. Central Queensland University Press, Rockhampton NSW Department of Community Services 2009 Working with Aboriginal people and communities: a practical resource. Sydney. Online. Available: http:// www.community.nsw.gov.au January 2012 Rolfe S A 2002 Promoting resilience in children. Australian Early Childhood Association, Watson, Australia Social Health Reference Group for National Aboriginal and Torres Strait Islanders 2004 Social and emotional wellbeing framework for Aboriginal and Torres Strait Islander Peoples’ mental health and social emotional wellbeing: 2004–2009. Australian Government Department of Health and Ageing, Canberra

WEBSITES AND/OR ORGANISATIONS NOTE: These largely Australian websites have been found to be useful and reliable. Many of these associations or organisations also represent the equivalent health profession in New Zealand as there is currently no related association there. Australian Indigenous Doctors Association (AIDA) Australian Indigenous Psychologists Association (AIPA) 230

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Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) Indigenous Allied Health Australia (IAHA) Indigenous Dentists Association of Australia (IDAA) National Aboriginal and Torres Strait Islander Health Worker Association (NATSIHWA) http://www.yarrahealing.melb.catholic.edu.au http://www.aiatsis.gov.au http://www.justice.qld.gov.au/AboriginalEnglish.htm http://www.natsiew.nexus.edu.au (see Topics: Health) Useful and reliable information relevant to health professionals in New Zealand http:// www.atns.net.au/glossary.asp An Agreement in Principle or Heads of Agreement (AIP/HA) is an agreement entered into between the Crown and a claimant group that is part of the process for the historical settlement of grievances under the Treaty of Waitangi (1840) (extended definition). A site relevant to communication and the law in New Zealand can be found on the Health and Disability Commissioner website: http://www.hdc.org.nz/ A relevant New Zealand site relating to privacy and confidentiality can be found on the Privacy Commissioner website: http://www.privacy.org.nz/ health-information-privacy-code/

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ANSWERS TO REVIEW QUESTIONS CHAPTER 15â•… Communicating with indigenous peoples Answers to the following questions provide a summary of this chapter. 1. What is the purpose of using appropriate terms to describe their groups when relating to Indigenous Peoples? Using terms appropriately demonstrates respect and promotes development of trust and a therapeutic relationship. 2. Explain why each individual has a unique cultural identity. Each individual has a unique cultural identity because they belong to many groups with their own ‘cultural’ expectations and norms that affect the identity of each individual combining to make that identity unique. 3. Define cultural safety. Cultural safety acknowledges the power imbalance between the health professional and the Person/s and mandates that the Person/s have the right to influence and contribute to the design of their health care. 4. List the five main steps that create culturally safe practice when working with Indigenous Peoples. i. It is essential to respect, support and empower the cultural identity of and wellbeing of the Person/s. ii. This is only possible after critical reflection of my personal values and critical evaluation of my personal attitudes and beliefs about Indigenous cultures. iii. Consider the cultures and values of the relevant health service and those professionals working in that service. If those values will negatively affect the service offered to Indigenous Peoples then the relevant health professionals should be encouraged to change those values to accommodate and respect Indigenous Peoples. iv. The health professional should consider how their cultural beliefs and values affect the Indigenous Peoples and seek to learn about their ways to facilitate appreciation of their lives and appropriate interventions. v. It is also important that the results of any interventions provided for Indigenous Person/s are evaluated from the perspective of the Indigenous Person/s to assess their cultural relevance and thus success. 5. Identify eight factors that contribute to the creation of cultural safety for Indigenous Peoples. Give original examples of how a health professional might accommodate each of these factors in practice. i. Learn about and reflect upon the historical events that are relevant to the Indigenous Peoples in my country/area. Understand that these events have left a lasting negative legacy that is the direct cause of the health condition of many of the Indigenous Peoples today. O’Toole 2e. © 2012 Elsevier Australia

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ii. Understand that communication styles vary from culture to culture, thus not expecting the Person/s to use your style. iii. Culturally safe practice with Indigenous Peoples requires an understanding that the person is part of a group and should be seen in that context. iv. Indigenous People/s generally have a specific understanding of spirituality and generally relate to their spirituality in daily life. Understanding and incorporating this aspect into their healthcare contributes to a culturally safe service. v. Understand there are particular kinship obligations that will affect particular expectations and behaviours among Indigenous People. vi. Indigenous People react differently to the healthcare environment and may require particular cultural factors that make it more comfortable for them. vii. To be aware of the reality that many Indigenous People live in poverty with deprived living conditions that result in a higher incidence of disease and a shortened life expectancy. This encourages health professionals to work towards creating culturally safe health services to improve these conditions. viii. Rural Indigenous Peoples are different to their urban counterparts and they may be more connected in their daily lives with their traditional customs and beliefs. Some may have limited education and thus be illiterate and may not understand or speak the standard English dialect. 6. Choose and explain ten factors that contribute to the creation of culturally safe communication for Indigenous Peoples. Give examples of ways of communicating that will create effective communication with Indigenous Peoples. i. To avoid using the direct and confident professional manner the health professional might sit alongside the Indigenous Person and introduce themselves and their role quietly and in a friendly informal way that indicates interest and a desire to assist, then wait quietly for a response. ii. It is important to contact the relevant Elder and include them in any interactions with the Indigenous Person/s. iii. To avoid assumptions based on appearance and environmental conditions about the connection of the person with their traditional beliefs and customs, it is important for the health professional to reflect about and identify any possible assumptions they might make based on appearance and the state of the living conditions and consciously avoid making such assumptions. It might also be useful if there is a trusting relationship for the health professional to respectfully ask the Person/s about their traditions and customs and how they affect their daily life. iv. Seek the assistance of an appropriate medical health worker when interacting with the Indigenous Person/s and seek clarification of your understanding of the content of the discussion. Such a person can interpret words, non-verbal cues and customs.

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v. Adopt an open style of interacting that is accepting of the Person/s and their dialect. That means not correcting their expression or sentence structure, but simply seeking to achieve mutual understanding based upon respect. vi. Take the time to listen and sit quietly with the Person/s and members of their community. This investment of time will develop trust and mutual understanding of cultural ways and customs. vii. Explain that some of the questions you need to ask may seem silly or may appear offensive, but you have to ask them anyway. Apologise for this and ask them if it is OK to ask these questions. Explain everyone coming to this health service is asked the same questions because the answers assist the health professional to meet their needs. viii. Arrange the room so there is privacy while interacting and tell them specifically how you will maintain confidentiality relating to all their personal information. ix. Establish links with the relevant organisation and/or Elder to ensure everyone understands the intervention or medication regimen, but also to ensure the person who has the role of performing these regimens fully understands them. x. Consider the most appropriate method of providing information as sometimes using story telling or visual versions of the information with culturally appropriate pictures or expressions allows culturally safe communication. 7. List seven barriers to the creation of culturally safe communication. i. Stereotypes and preconceptions ii. Not exploring the meaning of particular confusing words or behaviours iii. Not taking the time to listen patiently and to relate quietly iv. Not noticing non-verbal cues and assuming their meaning instead of exploring their meaning v. Not taking the time to clarify meaning and validate understanding vi. Responding to events and questions with clichés or ‘pat’ answers that do not consider the cultural implications of the questions or comments vii. Using pamphlets or written information that is full of jargon or technical words that do not have any meaning to the Indigenous Person/s or that are written in the standard English dialect that makes it difficult for a speaker of a non-standard dialect to understand. 8. Describe how a health professional might overcome at least four of the barriers to culturally safe communication. i. The health professional must be aware of their own biases and tendencies to make assumptions because of appearances or living conditions, and work hard to accept the people as they are – rather than judging them and making particular assumptions.

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ii. The health professional must take the time to explore the meaning of not only particular words, but also non-verbal cues and often silence or limited response to questions. iii. The health professional must ensure that the Indigenous Person has not simply provided the answer they thought was expected by the health professional. This can be done by ensuring the appropriate Elder is present, and asking them to validate the information provided in the answers. iv. The health professional must design pamphlets and brochures with local Indigenous People to ensure they are designed, expressed and visually communicative of the correct information.

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CHAPTER 16â•…

Misunderstandings and communication CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Define and explain a misunderstanding • Explain the factors contributing to understanding • Describe some possible causes of misunderstandings • Develop useful strategies to reduce misunderstandings • Explain the steps for effectively resolving misunderstandings.

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Communication that produces misunderstandings All health professionals must learn to manage communicative interactions when there is a failure to achieve mutual understanding about words or events. In such cases they must respond in a reasonable and calm manner (Holli et╯al 2008), even though interactions involving misunderstandings are often uncomfortable. Misunderstandings may produce feelings of anxiety and regret and, if serious enough, feelings of guilt or unfair judgement. Everyone experiences feelings of discomfort, anxiety and regret because of misunderstandings. Guilt, while a self-defeating emotion, is a typical reaction if lack of care on the part of the health professional causes a miscommunication. However, the health professional may feel misjudged if incorrectly blamed for a misunderstanding. Both the health professional and the Person/s may experience negative emotions because of misÂ� understandings. When experiencing misunderstandings, it is essential to remember the characteristics of effective communication. It is interesting to note that communicating with care and the best intentions do not guarantee underConsider a time when you experienced standing (Bowe & Martin 2007, Tyler et╯al 2005). The a misunderstanding. perspective of the Person/s may affect the interpreta What was the cause of the • tion of a kind intention. For example, assisting misunderstanding? someone after observing them struggling to com Were you the person who failed to • plete a task may produce anger rather than exprescommunicate clearly or were you sions of thanks if the Person/s was intent on proving the person who failed to clarify they could independently complete the task. Conthe meaning? versely, not assisting a struggling Person/s may also • What were the consequences? elicit anger. A means of avoiding such situations is to • How did you feel? use a question or gesture designed to establish the • Did you feel tempted to blame the other person? desire or lack of desire for assistance. Similarly, if the • What could you have done to avoid Person/s expects a particular intervention that is the misunderstanding? outside the role of the health professional, this may What did you learn from this • cause miscommunication and requires immediate experience? clarification. Misunderstandings decrease levels of • What will you do next time to avoid trust and may severely affect the therapeutic relationa misunderstanding? ship. This has implications for the health professional, the Person/s and the ultimate outcome of the service. It is clear that a misunderstanding might generate negative emotions, but the various factors that contribute to misunderstandings are not always clear. However, it is important to comprehend the various factors affecting mutual understanding in an attempt to prevent misunderstandings.

Factors affecting mutual understanding Many factors affect the ability of communicating individuals to achieve mutual understanding. Some of these factors include language, word usage, making assumptions about meaning, the context and the time invested in negotiating meaning. The possibility of misunderstanding increases if communicating individuals come from different cultures. Misunderstandings, however, may also occur between individuals from the same cultural groupings. 233

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Mutual understanding increases, although it is not guaranteed, if the interacting individuals can communicate competently in a common language. Understanding is enhanced when individuals share the same meanings for particular words. Difficulties can arise if one person does not know the various meanings of a particular word (see Ch 1) and thus does not recognise that word in a particular context. Lack of word recognition prevents understanding. In many languages, sounds and/or words can carry multiple meanings (Harms 2007, Harms & Pierce 2011, Nunan 2007), and this can make it difficult to understand the sound or word in an unfamiliar context. This may occur with the use of professional jargon, technical words or very long monologues, but can also occur when communicating with a person who has learnt the language of the interaction after their first language (Bensing et╯ al 2010). Mutual understanding is also influenced by assumptions individuals make about meaning. Assumptions can develop because of experience, Give examples of each of the following knowledge and understanding of the situation and five factors that could produce context. The probability of achieving mutual undermiscommunication: culture, language, standing may be decreased if some of the indiassumptions about meaning, context viduals communicating are unfamiliar with the of the health profession and context of context of the communication, or they communicate the words. outside the expectations of the context (Nunan 2007). Of the factors that limit the achievement of mutual understanding, it is necessary to consider which of these are relevant to the health professions. Health professionals relate regularly to individuals from different cultures (see Ch 14). Misunderstandings between people from different cultures may occur because of expectations as well as the meaning of particular behaviours and words. Openness, understanding and acceptance of the differences will assist those communicating to achieve mutual understanding. It is the responsibility of the health professional to demonstrate openness and acceptance because of the vulnera� bility of the Person/s. Among health professionals there is not always a common language. A health professional that specialises in a particular area may use jargon that a health professional from a different specialty might struggle to understand. For example, someone working in medical radiation science may not understand the terminology used by someone working in occupational rehabilitation. Individuals seeking assistance, even when they speak the local language, may not understand any health-specific jargon. If they are unable to recognise a particular word in the health context, they may misinterpret the meaning. The individual struggling to understand a word will often assume the meaning if they feel uncomfortable about asking for clarification. Similarly, some Aboriginal and Torres Strait Islander Peoples will not express an inability to understand because experience tells them the health professional will not listen (Eckermann et╯al 2010). In all situations the health professional has responsibility to negotiate mutual understanding. However, if misunderstandings do occur it is important that the health professional takes responsibility to repair the misunderstanding, regardless of the cause. Misunderstandings occur wherever people interact, thus the health professional will benefit from considering such events carefully to understand the causes and how to avoid them in the future (Higgs et╯al 2005, 2010).

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Causes of misunderstandings The factors affecting mutual understanding – culture, language, word meanings, assumed meanings and context – can also contribute to misunderstandings. There are additional factors that can cause misunderstandings, however, and these are examined in this section.

ATTITUDES Misunderstandings can occur because of the negative attitudes of the interacting individuals. Non-verbal communication of judgemental attitudes may assume greater strength from the perspective of the Person/s than is actually felt by the health professional. The negative emotions associated with these attitudes can create misunderstandings. It is important that the health professional, through reflection and self-awareness, fosters an attitude of openness and acceptance towards individuals who might not meet their criteria of what is acceptable. For example, vulnerable individuals from a different culture must experience an accepting, open attitude from the health professional regardless of the language they speak and their potentially differing values. It is important that an attitude of respect, empathy and inclusion, as well as an attitude that focuses on the goals of the vulnerable individual, saturates every encounter between the health professional and the Person/s. Health professionals with such underlying attitudes will naturally communicate to avoid misunderstandings. It is difficult to control the attitudes of those around the health professional. However, maintaining a positive and accepting attitude can influence the attitudes of others. A health professional with an appropriate attitude will positively affect the Person/s, contributing to avoidance of misunderstandings and fulfilment of positive outcomes.

EMOTIONS Emotions can both positively and negatively influence the outcome of communication. It is easy to perceive feelings of frustration, intolerance, impatience and anger in another person, and such emotions can significantly compromise communication (Mohan et╯al 2004, 2008). Unresolved emotions – whether in the health profesConsider an interaction in which your sional or the Person/s – can negatively affect any negative emotions limited your ability to communicative interaction. Failure to give adequate concentrate or understand. Perhaps you attention to emotions both before and during interreacted emotionally to something that actions can cause misunderstandings. When attemptwas said and were unable to hear the ing to repair or resolve a misunderstanding, it is rest of the conversation, resulting in important for the health professional to give appromisunderstanding. priate consideration to the emotions causing the misunderstanding.

RELEVANCE OF CONTEXT TO DETERMINE MEANING The use of context to determine meaning varies from culture to culture, and this cultural variation can cause misunderstandings. Some cultures use verbal and non-verbal messages to construct meaning, while other cultures construct meaning using these messages as well as context. In such cultures the context refers to the circumstances (including the circumstances of the interacting people) or events that form the environment within which the communication occurs. In these cultures the context may have greater weight

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than the verbal or non-verbal messages. In cultures that rely on context to determine meaning, the speaker, their role, their manner of communicating and their relationship to the listener(s) combine to influence the meaning; the actual words spoken may be irrelevant to the meaning of the message. Still other cultures use varying combinations of context and constructed messages to determine meaning. Hall • What is important when relating to (1997) refers to high-context and low-context cula Person/s who uses context to tures according to their use of context to establish determine meaning? understanding. It is important to understand that • Should the health professional adjust some cultures use context to determine meaning their manner of communicating? because this affects the communication style of Explain why or why not. people from such cultures and may explain any misunderstandings.

EXPECTATIONS OF STYLES OF COMMUNICATION

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Styles of communication vary across cultures and families. This reality rarely requires consideration unless communicating with individuals who expect a different style. Some cultures expect information to be organised in particular ways with the major points clearly expressed first (more direct). Others seem to avoid the major point initially, only reaching it after extensive circular discussion (indirect) (Bowe & Martin 2007). Thus confusion may result between individuals from culHow could direct and indirect tures that organise information in different ways. communication styles influence Another style of communicating relates to the understanding in the practice of tolerance of ambiguity (Bowe & Martin 2007). This the health professional? tolerance is higher in people who have a tendency How could the health professional towards an indirect style of communication. Some compensate for either style? cultures, societies and families communicate through implied meaning – one person suggests an implied perception of a concept or idea and another then Decide what style of communication implies similar or alternate perceptions. This style your culture uses – an implicit style, of communicating is difficult to grasp if it is not explicit style or combination of both. the style of the culture of the health professional. Give examples of each style. State the However, while to a novice this style appears circonditions and the type of subject that cular and difficult to follow, the communicators regulate the use of each style. are able to achieve mutual understanding. In contrast, a less ambiguous style of communicating involves explicit statement of points and exploration of these points. The words used to communicate directly reflect the meaning. In this style, unless there is an unconscious agenda, the communicators say exactly what they think, feel and desire. Some cultures and families use both implicit and explicit (some call them ambiguous and clear) styles of communicating, depending on the circumstances. The health professional does not necessarily need to adjust their style to that of their communication partner. However, it is beneficial to be aware of the style of the Person/s, acknowledge that style and explicitly explain the style that will govern the communicative interactions with the health professional. This may reduce the possibility of misunderstandings.

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EXPECTATIONS OF THE EVENT OR PROCEDURE The expectations an individual might have of a health service will influence their understanding within that service. For example, if a Person/s expects to receive something that will immediately remove their symptoms, it may be distressing to learn they must have further investigations. It is important that health professionals clearly explain their service and the expected results of and reasons for particular procedures and events (see Chs 3, 14 & 15). The vulnerable individual may not understand the situation or the procedures well enough to know which • List the characteristics of a clear questions to ask. Therefore, it is the responsibility of explanation. the health professional to explain rather than assume • Choose one of the following health service contexts: acute, rehabilitation, the Person/s knows how and why something might community, health promotion, happen. For example, everyone involved in a family occupational rehabilitation or private conference should understand the purpose of and the practice. usual process employed during a family conference. Write a clear explanation of the context • This allows the Person/s to clarify their expectations and the kinds of ‘events’ that occur in and/or to demonstrate their understanding of the that context. procedure. Clear explanations will assist in avoiding misunderstandings due to particular expectations.

EXPECTATIONS GOVERNED BY CULTURAL NORMS Every culture and society, and most families, have norms that affect communicative behaviours. Such norms govern what is said and when it is said according to particular situations. Lack of understanding of or familiarity with cultural norms can cause miscommunication (Sims 2010). It is not possible for any health professional to learn every norm for every culture (Dean 2001), society or family. However, it is important that health professionals are aware of the existence of cultural norms related to communication. This understanding can explain variations in communicative events and empower the health professional to make allowances for these variations. Particular cultures, social groups and families have norms that govern the topic of social conversation in particular situations. Some freely discuss politics, salaries and sex, and openly ask the age of a person, while others avoid these topics. Some freely discuss spiritual beliefs and values, while others avoid discussing spiritual or religious topics. Some freely express emotions, while others avoid expression of emotions. Some cultures use specific combinations of words to fulfil a social function. For example, in English, How are you? fulfils the function of acknowledging and greeting a person. In most cases it is not a request for information about the health of a person but simply says hello. In Chinese, Where are you going? or Have you eaten? may fulfil the same function. Understanding that different combinations of words may fulfil different functions is important and can assist the health professional to avoid misunderstandings.

Strategies to avoid misunderstandings There are specific communicative behaviours that can assist in avoiding misunderstandings. Most individuals have a desire to share meaning with those communicating (Bowe & Martin 2007) and will usually concentrate and struggle, if necessary, to understand. This is both an encouragement and a warning to the health professional. It is encouraging because it indicates that those seeking assistance will want to understand and in many 237

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cases will try to understand. The warning is that in a service with limited resources, the health professional may not invest the time required to achieve adequate understanding. The temptation to provide information quickly and allow the Person/s to assume the meaning, especially when they are striving to achieve this meaning, is dangerous. This action does not guarantee mutual understanding.

REDUCING THE INCIDENCE OF MISUNDERSTANDINGS The following are suggestions that will reduce the incidence of misunderstandings (Bowe & Martin 2007, Tyler et╯al 2005). • Plan and prepare for the interaction. Read reports, records and relevant research related to the condition and needs of the Person/s. It is important when referring to reports, records or referrals to avoid the creation of assumptions and opinions about the needs of the Person/s. Remember the overall aim of the health professional is fulfilment of family/Person-centred goals and practice. • Understand the communication expectations of the Person/s involved in the interaction. • If communicating with a Person/s from another culture, become familiar with the needs, cultural expectations and language level of the Person/s. Schedule an interpreter if necessary (see Ch 14) however avoid complex tri-lingual interactions (Fatahi et╯al 2010). If using an interpreter, ensure they are assigned based on linguistic background not ethnicity or nationality. • Know and understand the information for discussion and organise it clearly and carefully. • Speak clearly and avoid a rapid rate of speech. • Minimise misunderstandings of words and sentences.  Be specific: avoid words that do not communicate specific information (e.g. this, that, then, things, some, many, over there).  Choose the words carefully, giving consideration to other possible meanings and anticipating potential assumptions and conclusions.  Avoid using jargon or technical terms without a clear explanation of such words.  Avoid using colloquialisms or everyday sayings specific to a local dialect or language (e.g. He’s on the road, Go with the flow, A lot, Take it easy). • Observe the effect of the information on all communicators, including the health professional, throughout the interaction (Jegatheesan et╯al 2010). • Ask for confirmation of understanding throughout the interaction. • Ask for a summary of the information to determine the level of understanding. Give explanations if misunderstandings are apparent. • Reflect upon the interaction after completion. Reflection can assist health professionals to understand themselves, the other Person/s and the components of the communication. It can assist the health professional to prepare for future communicative interactions and avoid future misunderstandings. • When communicating within the many health professions, fostering teamwork, improving interdepartmental communication and encouraging positive relationships may also minimise misunderstandings (Seavey 2010). Misunderstandings are inevitable wherever individuals interact. It is important that the health professional understands the causes of misunderstandings and develops confidence to manage misunderstandings. Such confidence will develop through experience, reflection, discussion and understanding of possible management strategies. 238

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Resolving misunderstandings The experience of misunderstanding affects individuals in different ways. As a health professional, the major concern is the effect of misunderstandings on the emotions of the Person/s. It is also important for health professionals to take care of themselves; however, resolution of the emotions of the health professional must occur separately to the resolution of the emotions of the vulnerable Person/s. The control of any frustration, impatience or intolerance on the part of the health professional is essential when there is a misunderstanding. Vulnerable individuals receive and interpret such emotions quickly, which may contribute to further misunderstanding. In situations of misunderstanding, clarification of the information may resolve the negative emotions associated with the misunderstanding. Resolution of the emotions resulting from the misunderstanding may accelerate the ability of the vulnerable Person/s to understand the previously misunderstood information. It is important that the health professional decides which to consider first – the resolution of the emotions or the understanding of the information. The existence of a therapeutic relationship will facilitate this decision; however resolving the emotions may facilitate underRefer to the ‘Reflection’ activity at the standing. The major aim of the health professional at beginning of this chapter: ‘Consider a this point is to resolve the misunderstanding. time when you experienced a misunderstanding’. It is important in every communicative interaction to remember the components of effective • Was that misunderstanding resolved? • Was it resolved satisfactorily? If so, communication. If the health professional comoutline or list the steps used to municates according to these components, their resolve it. action will achieve appropriate resolution of any Could you use these steps in every • miscommunication. Restoring communication is situation? How could they be adapted essential for achieving the ultimate purpose of the for use in any situation? health professions – fulfilment of family/Personcentred goals.

STEPS TO RESOLVING MISUNDERSTANDINGS These steps will assist the health professional in resolving misunderstandings. 1. Be aware that there is a misunderstanding. This is not always immediately obvious. However, as soon as it becomes obvious the health professional has a responsibility to act to overcome the cause of the misunderstanding and thus achieve effective communication. 2. Control any negative emotions associated with the misunderstanding. If possible, resolving negative emotions before restoring communication is the most appropriate option. Time constraints may make this difficult or impossible, thus learning to control negative emotions is beneficial. The major emotions for the health professional to communicate are regret that the communication failed and a desire to achieve effective communication. 3. Take responsibility for the misunderstanding regardless of the cause or problem. It is more probable that the vulnerable Person/s will accept the actions of the health professional if the health professional willingly assumes responsibility for the misunderstanding. 4. Understand what caused the misunderstanding. Understanding the cause will assist the health professional to compensate and avoid further misunderstandings because of that cause. It may also assist the health professional to consider and predict other 239

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possible causes. Preparation and planning should assist the health professional to avoid further misunderstandings. It is essential to understand that isolating the cause of the misunderstanding is not a substitute for action to resolve the misunderstanding (Brill & Levine 2005). 5. Make a conscious decision to restore communication to achieve mutual understanding. This will assist the health professional to persevere to overcome the barriers to understanding. It will potentially resolve the misunderstanding and restore trust and effective communication. 6. Focus on the restoration of understanding, not on the cause of the misunderstanding. If the health professional focuses on restoring communication it will assist in controlling the negative emotions associated with the misunderstanding.

Chapter summary Misunderstandings may occur for many reasons and can affect the outcomes of health services. They are the opposite of mutual understanding. The factors affecting achievement of mutual understanding include language, word choice and recognition of the meaning of that word in the particular context and assumptions about the meaning of words and that the Person/s has understood regardless of the reality. The health professional must recognise that personal attitudes and emotions may adversely affect communication, as the Person/s will perceive any judgemental attitudes or negative emotions. Thus the health professional must invest time to reflect to achieve self-awareness of any judgemental attitudes or negative emotions. They must also invest time to acknowledge and resolve the emotions of the Person/s to avoid misunderstandings. Health professionals must acknowledge that the expectations of the Person/s and the limitations of the role of the health professional may also cause misunderstandings. This acknowledgement will empower them to ensure mutual understanding in every interaction. Commitment to the components of effective communication will empower the health professional to successfully manage misunderstandings and restore effective communication.

FIGURE 16.1â•… Clear expression gathers required information.

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REVIEW QUESTIONS 1. Define ‘misunderstanding’.

2. List the factors that affect mutual understanding.

3. Give examples of how two of these factors can affect communication.

4. Give original examples of each cause of misunderstandings.

5. In your own words, list four ways to reduce the incidence of misunderstandings. i. ii. iii. iv.

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6. List the six steps that will assist the health professional to resolve misunderstandings. i. ii. iii. iv. v. vi. 7. Suggest reasons for the importance of each step listed in Question 6. i. ii. iii. iv. v. vi.

REFERENCES Bensing J M, Verheul W, Jansen J et al 2010 Looking for trouble: the added value of sequence analysis in finding evidence for the role of physicians in patients’ disclosure of cues and concerns. Medical Care 48(7):583–588 Bowe H, Martin K 2007 Communication across cultures: mutual understanding in a global world. Cambridge University Press, Melbourne Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Dean R 2001 The myth of cross-cultural competence: families in society. Journal of Contemporary Human Services 86:623–630 Eckermann A, Dowd T, Chong E et al 2010 Binaŋ Goonj: bridging cultures in Aboriginal health, 3rd edn. Elsevier, Sydney Fatahi N, Nordholm L, Mattsson B et al 2010 Experiences of Kurdish war-wounded refugees in communication with Swedish authorities through interpreter. Patient Education & Counseling 78(2):160–165 Hall E T 1997 Beyond culture. Anchor Books, New York Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne 242

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Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Holli B B, Calabrese R J, O’Sullivan Mailett J 2008 Communication and education skills for dietetics professionals, 5th edn. Lippincott, Williams & Wilkins, Philadelphia Jegatheesan B, Fowler S, Miller P J 2010 From symptom recognition to services: how South Asian Muslim immigrant families navigate autism. Disability & Society 25(7):797–811 Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Nunan D 2007 What is this thing called language? Palgrave Macmillan, Basingstoke Seavey R E 2010 Collaboration between perioperative nurses and sterile processing department personnel. AORN Journal 91(4):454–462 Sims C M 2010 Ethnic notions and healthy paranoias: understanding of the context of experience and interpretations of healthcare encounters among older Black women. Ethnicity & Health 15(5):495–514 Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney

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ANSWERS TO REVIEW QUESTIONS CHAPTER 16â•… Misunderstandings and communication Answers to the following questions provide a summary of this chapter. 1. Define ‘misunderstanding’. Failure to achieve mutual understanding about words or events. 2. List the factors that affect mutual understanding. The factors affecting the achievement of mutual understanding include: language; choice of words; assumptions about meaning, context; the time invested in negotiating meaning; and sometimes whether or not the people interacting come from different cultures. 3. Give examples of how two of these factors can affect communication. Language: If the people communicating do not share a common language there can be misunderstandings because they cannot use words everyone understands. Choice of words: If you choose a word that has various meanings it is possible for the other person to assume a meaning that is different to your meaning, which will create a misunderstanding. 4. Give original examples of each cause of misunderstandings. Attitudes: Negative or judgemental attitudes can be unintentionally communicated and this can cause misunderstandings. Emotions: Allowing feelings of impatience or frustration to influence communication with the Person. Context: A non-verbal message such as nodding or shaking your head have different meanings in different cultures. 5. In your own words, list four ways to reduce the incidence of misunderstandings. i. Observe any non-verbal cues and seek to clarify or validate their meaning. ii. Understand that there are different styles of communicating and explain the style that will be used with the health professional. Understand the style and expectations of communication from the Person perspective. iii. Be sure you know and understand the information you want to communicate. Use clear explanations and instructions that are verbal and written with illustrations that help to clarify the meaning. Organise an interpreter if necessary. iv. Reflect upon the interaction, considering what created mutual understanding and what created misunderstanding. Consider ways to avoid misunderstandings in the future, for future interactions. O’Toole 2e. © 2012 Elsevier Australia

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6. List the six steps that will assist the health professional to resolve misunderstandings. i. Acknowledge there is a misunderstanding and take actions that achieve mutual understanding. ii. Control any negative attitudes or emotions, and express regret that the interaction has caused misunderstandings. iii. Regardless of the cause of the misunderstanding, take responsibility for the misunderstanding, apologise and resume the interaction. iv. Identify the cause of the misunderstanding, but you still need to resolve the misunderstanding. v. Make a conscious decision to restore the lines of communication, which will assist in restoring trust and the therapeutic relationship. vi. Focus on the restoration of the interaction, which is to achieve mutual understanding. 7. Suggest reasons for the importance of each step listed in Question 6. i. Acknowledging there is a misunderstanding empowers the health professional to take actions that achieve mutual understanding. ii. If the health professional controls their own judgemental attitudes and negative emotions, they can achieve effective communication and positive family/Personcentred outcomes. iii. Taking responsibility for the misunderstanding and apologising for the misunderstanding will reassure the Person/s and make them feel less vulnerable. It will also contribute to restoring the therapeutic relationship and allow the Person/s to resume the interaction without negative emotions. iv. Identifying the cause of the misunderstanding allows the health professional to plan and prepare for any future interactions with that Person/s, and can contribute to resolving the misunderstanding. v. If the health professional does not make a conscious decision to restore the lines of communication because they are very busy, it may mean there will be limited trust and no therapeutic relationship with that Person/s and therefore negative or limited outcomes. vi. If the health professional does not focus on restoring the interaction there will be limited mutual understanding. It will affect the involvement of the Person/s and the overall result of the communication.

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CHAPTER 17â•…

Ethical communication

CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Explain the importance of ethical communication • List and understand the characteristics of ethical communication • Appreciate the ethical responsibility of health professionals when communicating about their professional life • Consider and develop strategies that ensure ethical communication and practice.

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Ethical communication is essential in any health profession. Ethical communication relates to appropriate behaviour when communicating and is necessary for the maintenance of harmonious, productive and beneficial therapeutic relationships (Donkor & Andrews 2011). The ability to communicate ethically requires motivation, character • Discuss what is right and what is and self-awareness (Dossey et╯al 2005a, 2005b, Tyler wrong when communicating. et╯al 2005). Awareness of and commitment to ethical Consider potentially inappropriate communication may depend on the familial, social and topics, places of communicating, styles of communicating and cultural background of the health professional (Egan reasons for communicating. Your 2010, Harms 2007, Harms & Pierce 2011). Violation answers here should consider more of ethical responsibilities when communicating has than personal preference. serious consequences for both the person seeking assis• Use the ideas raised in this tance and the health professional (Egan 2010). Thus, it discussion to list the possible is important for the health professional to know the fundamental elements of ethical rules or codes of behaviour expected by the governcommunication in the health ment, their profession and their particular health service professions. (Higgs et╯al 2005, 2010, Purtilo & Haddad 2007). This chapter examines some of these expectations and rules. Mohan et╯al (2004, 2008) state that most health professionals, while being aware of ethical requirements at a theoretical level, rarely consider them during everyday practice. However, it is not awareness or consideration of ethical requirements alone that produces ethical communication. It is the knowledge of, commitment to and application of these requirements into communicative behaviours that creates an ethical communicator. Devito (2009) considers every communicative act to have the potential to be constructive or destructive. This reality indicates that every communicative interaction in the health professions, if ethically sound, has the potential to create and sustain constructive therapeutic relationships (Rider & Keefer 2006). The main purpose of this chapter is to outline the characteristics of, and strategies to achieve, ethical communication.

Respect regardless of differences An overall characteristic and value of the health professions is respect of all people, whether for those seeking assistance or those working alongside the health professional (see Ch 2). Every health professional must respect the rights of all individuals. These rights include equal opportunities, equal consideration and equal treatment regardless of status or condition (Harms 2007, Harms & Pierce 2011). Ethical communication requires health professionals to express unconditional positive regard for all human beings (Purtilo & Haddad 2007, Rogers 1967; see Ch 8). These are fundamental requirements for achieving the ultimate purpose of the health professions – family/Person-centred practice (see Ch 2). Expression of unconditional positive regard for all human beings is ethical and is in accordance with the Universal Declaration of Human Rights (United Nations 1948),

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How do you demonstrate respect for someone who is quite different from you? For example, someone who:  Lives on the street  Works the streets  Will only wear/not wear designer clothes  Hates/loves football  Has a different religious code to you  Believes terrorism is/is not appropriate  Has a different political allegiance?

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the Human Rights Council (United Nations 2006) and the Convention on the Rights of Persons with Disabilities (United • List the values or beliefs a person Nations 2006). The challenge for the health profesmay have that make it difficult for sional is not usually in respecting rights, however, but you to demonstrate respect. in respecting the actual Person/s. • What can you do to ensure you Demonstration of respect for others requires health demonstrate respect regardless of professionals to first respect themselves. Respecting and such differences? valuing self begins with an awareness of the thoughts about self that affect self-image and self-esteem; some of these thoughts may have their origin in comments made by others. Regardless of their origin, these thoughts require reflective consideration and adjustment (Backus & Chapian 2000). If health professionals find it difficult to value and respect themselves, it is imperative they seek expert assistance to maximise their potential to be effective communicators. Health professionals demonstrate respect through verbal and non-verbal communicative behaviours. Such behaviours automatically reflect the underlying values and beliefs of an individual (Brill & Levine 2005, Tyler et╯al 2005). Thus critical awareness of personal values and beliefs is essential for establishing and practising ethical communication (Harms 2007, Salladay 2010, 2011, Smudde 2011).

Honesty The truthful statement of thoughts, feelings and desires is the common understanding of honesty. The New Shorter Oxford English Dictionary on Historical Principles (1993) suggests that honesty is a characteristic, not merely a linguistic or social occurrence. Words such as ‘honourable character’ and ‘uprightness of disposition and conduct’ imply that honesty is about more than truthful statements; it is an underlying characteristic of an individual. The dictionary presents the opposites of honesty as being cheating, stealing and lying. These definitions provide ‘food for thought’ that may assist the health professional when considering honesty. They suggest that honesty is a characteristic that generates honest statements and produces consideration of the needs of all interacting individuals. Honest responses from a health professional are important. Many people seeking assistance are able to recognise a verbal or non-verbal response that does not reflect honesty. Such responses affect the level of trust in the relationship, and if detected

You are very busy today, with more than the usual number of appointments. The young Person you are assisting is the same age as you and has similar interests. They are usually optimistic and relaxed when they attend, but today they suddenly begin to tell you about their feelings of depression and all the things that are going wrong in their life. A holistic communicative approach alone, without consideration of the therapeutic relationship that is essential for positive outcomes, dictates that you should stop, actively listen, empathise and, if appropriate, seek permission to refer the Person to another professional. However, you are extremely busy and not interested in hearing any more because you have problems in your life too! You do not want a reminder of these things while at work, nor do you want to fall behind today because you have a personal appointment immediately after work. → Besides, there are other people waiting to see you.

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Consider the possible ways of responding. Discuss the potential outcomes of each response. What is an ethically appropriate response? Which needs are the appropriate ones in this situation – the needs of the Person or those of the health professional?

potentially create anxiety in the Person/s concerning reasons for the lack of honesty (Wenger & Vespa 2010). It is important to consider particular situations and questions that could cause difficulty for the health professional and prepare possible responses (Higgs et╯al 2005, 2010). This consideration will assist in the development of a therapeutic relationship and contribute to family/Person-centred practice. If the health professional genuinely seeks the wellbeing of those with whom they interact, sensitive honest responses will develop trust and safety for all communicating individuals.

Clarification of expectations

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What do you need to consider before responding to the following?  Someone is reluctant to follow a treatment regimen.  Someone is unhelpful when you have asked for their assistance.  Someone is dismissive when you have asked them a question.  Someone relates differently from their previous interactions.  Someone shares that they are lonely and depressed but asks that you tell no-one.  Someone requests your assistance and what they are asking is inappropriate.  Someone waiting for results asks Do I have cancer? You know they do, but the doctor wishes to inform the Person. • Consider other possible situations that require honest responses.

When entering a new situation or environment, most individuals strive to understand that situation or environment. They may feel tentative or insecure and thus appreciate a friendly health professional who demonstrates genuine interest and concern. In such situations, it is reassuring for the Person/s to know what to expect and how to gain answers or assistance through either verbal or written information. Asking the Person/s to voice their expectations of the service allows clarificaDiscuss different ways of responding to tion of any uncertainties and can also serve to reassure the above situations with care, respect the Person/s. and honesty. There are various ways of communicating about the available services and the rights of the Person/s. Verbal and written explanations of rights and procedures, with opportunity for clarification, are usually successful and potentially improve the outcomes of both the communication and the service.

Consent AGREEMENT ABOUT INFORMATION In an attempt to achieve ethical behaviour from staff, particular health services use signed agreements that outline privacy and related issues. All Person/s are asked to sign such agreements. These agreements are explicit statements of the usually implied rules that guide the relationship between the health professional and the Person/s. Such rules assume that health professionals will never seek to harm the Person/s and that they will always seek to assist and fulfil appropriate goals for that Person/s (Purtilo & Haddad 247

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Discuss the following. As a health professional, what do you feel the Person/s should know about your expectations and their rights before they receive your assistance? • What do you feel such a Person/s would like to know about their rights and the services available when they seek your assistance? • What would you like to know about their expectations of your service?

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2007). Signed agreements may provide information about the service, what to expect when receiving assistance, the responsibilities of all stakeholders and guidelines for lodging a complaint. They usually make statements about responsible use of gathered information based upon the assumption that every individual has a right to privacy (Mohan et╯al 2004, 2008). For more information relating to privacy see If you sign an agreement to protect relevant government websites. In Australia, see Austrayour privacy, what would you expect lian Government policies and acts such as the Privacy Act that to mean about the information 1988, Disability Services Act 1986 and Commonwealth Disability you provide to different health Strategy 2003. For a similar policy in New Zealand see professionals about your needs or the New Zealand Government Privacy Act 1993. These acts condition? often state that the health service agrees to protect Would you feel it was appropriate for privacy. They may indicate that health professionals a particular health professional to might share revealed information with other health discuss your information with professionals but only for the benefit of the Person/s, another person? If so, with whom never for illegal or inappropriate reasons. and why? Would you like to have access to It is important to remember that the Person/s will and explanation of any notes or be more willing to provide information if the health reports the health professional(s) professional has explained how the information will be wrote about you? used and why it is necessary for them to have this What are the implications of your information (Harms 2007, Harms & Pierce 2011, answers for a health professional? Stein-Parbury 2009). To encourage sharing of information, health professionals must act to indicate they are worthy of trust (Brill & Levine 2005).

Read and discuss excerpts from Malone’s (2003) ‘A fully informed consent letter’ article titled Ethics at home: informed consent in your own backyard at the end of this chapter. • What are the implications of this letter for:  The health professional?  The Person/s signing the informed consent letter? • What might health professionals do to limit the potential gap in understanding between themselves and the Person/s signing the letter?

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INFORMED CONSENT Although the ‘informed consent’ type of agreement often refers to research involving humans (Malone 2003), within the health professions it usually refers to procedures associated with a particular health profession. This type of agreement requires the health professional to provide clear information about the procedure, the associated risks and the expected outcome of the procedure (Purtilo & Haddad 2007). Informed consent is an attempt to give the vulnerable individual a sense of control in a situation where they often feel they have little power, control or autonomy. In many places there are legal requirements to provide such information at an appropriate level of complexity for all Person/s.

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Confidentiality PROTECTING SHARED INFORMATION

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The Person/s seeking assistance requires a safe ‘space’ in which to express their feelings, thoughts and concerns. The basis for that safe place and the expression of concerns is a trusting therapeutic relationship (Brill & Levine 2005, Stein-Parbury 2009). It requires the health professional to state explicitly what they intend to do with the shared information. Some of the information given by the Person/s is required for the development of appropriate interventions and should be available for all involved health professionals. However, there will also be information shared that does not contribute to their overall treatment. It is not essential to share this information. Sometimes it is not obvious whether the information is necessary for the success of the overall goals. Awareness of the necessity of information increases with experience. A relatively inexperienced health professional who is unsure about why someone is sharing particular information might be advised to ask the Person/s two questions. First, Are you telling me this for a reason? meaning Is there any action required because of this disclosure or do you simply trust me? Second, the health professional might ask whether it is acceptable to pass the information on to a more senior health professional, for example, Do you mind if I tell X what you have told me? These questions will promote awareness in the Person/s about the type of information they are sharing and the reason for sharing it. This may be particularly important when a young person shares information with a young health professional of the opposite gender. The possibility for attachment, whether romantic or not, is real and is best avoided because it can be destructive for both the Person/s and the health professional. A guiding principle for deciding what information to share with other health professionals should be whether the information affects the health and wellbeing of the Person/s seeking assistance.

•

PROTECTING ETHICAL RESPONSIBILITY Health professionals have ethical responsibility to protect information about the Person/s. This refers to information both read and heard. Such information belongs exclusively in the professional context – records, files, experiences, feelings and memories of

• • •

Why is confidentiality important for everyone in a healthcare setting? Are there any contexts that are more sensitive than others and require greater confidentiality, or do all contexts require the same level of confidentiality? Is a health professional obliged to share everything they hear from the Person/s? How should you decide what to share? A Person shares with you that they feel suicidal and asks you to tell no-one. What should you do? List ways that guarantee confidentiality for the Person/s. Consider:  Reports and records  Meeting a good friend who asks about a Person/s you are assisting  A difficult encounter that leaves you drained emotionally at the end of the day  Frustration with other health professionals.

•

Sometimes a Person/s says they do not want anyone else to know the shared information and might ask You won’t tell anyone this, will you? or say Please don’t tell anyone else. How would you respond and why? • Is there any information that does not affect the health and wellbeing of the Person/s?

Discuss the following scenario. You meet an ex-classmate after work. You naturally talk about your experiences at work. They ask about a Person/s you are assisting by name – a close relative of theirs. How will you respond? This is a ‘small’ city but you want them to value you, and you also want to be respected and successful in your profession.

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shared information all belong at work. It is also important to remember that failing to protect confidentiality can destroy any trust between the health professional and any Person/s, including colleagues, as well as potentially have legal ramifications, possibly including the risk of deregistration.

PROTECTING THE HEALTH PROFESSIONAL There are many times when health professionals simply need to ‘unload’ the thoughts and feelings associated with the information gathered from a particular Person/s or from an entire day. The emotions and thoughts associated with a particular interaction or several interactions over a day require some form of resolution. Accumulation of these emotions can produce cynicism and burnout (Rupert & Morgan 2005). Discussing the emotions with someone pro• Is it appropriate for the health vides an opportunity for resolution and dissipation of professional to talk to a close and the intensity of the emotions. Sometimes a particular trusted family member if they need Person/s makes a deep impression in the mind of the to ‘offload’? What are the ethical health professional, and thus the health professional issues here? Who is an appropriate may require time and discussion to process the depth person for the health professional to of and the implications of this impression. talk to? Should the health

•

professional ever use names? What are the implications when working in a small city or town?

Answer honestly the following questions: • How easy do you find it to talk about others when they are not present? • How easy do you find it to tell someone directly what you think of them – either positive or negative thoughts? • How easy do you find it to believe things said about other people, whether you know the people or not? • Is what you say about other people usually positive or negative? • If negative, can you isolate the reason why you often say negative things about people? Are you jealous? Are you naturally judgemental? Have you been hurt by these people? Are you responding to something that someone else has said about these people? • How do you feel when you discover someone has been talking about you – saying things, whether true or not, without you knowing?

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PROTECTING THE PERSON/S FROM GOSSIP Words once said are very difficult to retract, regardless of the intention of the words. Words cause an immediate emotional or cognitive reaction, and it is often impossible to change those emotions even with an explanation of the intended meaning. This means that the health professional must take care when they say anything about any of the people with whom they are working – colleagues or otherwise.

Boundaries ROLES Ethical communication requires definite understanding of the limits of the role of each health profession and the relationship between the Person/s and the health professional. Each health profession has a particular role. Regardless of the level of knowledge of the health professional about the interventions of other health professions (Milliken & Honeycutt 2004), it is important that they practise within the limitations of their particular profession-related knowledge and skills. This is important for ethical, safety and insurance reasons.

RELATIONSHIPS The limitations of the therapeutic relationship relate to the whole Person/s. There are physical, emotional, social, cognitive and spiritual reasons for health

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professionals to practise within particular boundaries or limits. These limits include time, friendship and dependency boundaries (Brill & Levine 2005, Harms 2007, Harms & Pierce 2011, Purtilo & Haddad 2007). Each encounter with a Person/s seeking assistance should have time limits. These limits allow the Person/s a change and the health professional to assist others and complete the requirements of their role. Practising within the boundaries of the health professional role means understanding the role to be that of a ‘therapist’ not an intimate friend. If the health professional needs to have a real ‘friendship’ with a Person/s they assist, this is an abuse of the role and can potentially damage the vulnerable individual (Heron 2003). That health professional must ask themself whether the relationEgan (2010) and Harms (2007) suggest that to be therapeutic you have to ‘come ship is fulfilling their needs rather than those of the close’. Person/s. Being friendly within the role is essential • How do you achieve this while but is different to connecting in a personal and intimaintaining boundaries? mate manner. How do you achieve this without • Many of the people health professionals encounter developing reliance and dependence? will share personal and intimate information. This self-disclosure from the Person/s seeking assistance assists them and assumes a particular understanding of confidentiality. If self-disclosure occurs between people of opposite genders, the health professional may misinterpret the meaning of this disclosure. They • If someone asks you personal questions, what should you do? For may assume it is simply an expression of emotions at example, Do you do drugs? Do you the time and not understand that there are expectahave children? Do you have a tions of a deeper relationship that the health profesgirlfriend/boyfriend? sional is unable to reciprocate. Dependence may How do you decide whether or not to • develop along with an expectation of exclusion of all answer? What criteria should you use? others from the relationship, which removes any therapeutic benefits (Egan 2010, Purtilo & Haddad 2007).

SELF-DISCLOSURE It is sometimes appropriate for health professionals to share their own experiences, but only in particular circumstances. Self-disclosure on the part of the health professional should only occur to promote a connection with a Person/s or to demonstrate understanding and particular strategies (Harms 2007, Harms & Pierce 2011). Selfdisclosure should never occur to move the focus to the health professional or to make the health professional appear connected and knowledgeable. It should only take place to encourage and maintain the relationship (Devito 2009) – in this case, the therapeutic relationship. Sharing information about self can develop rapport. In New Zealand, a normal process that develops rapport for the Maori is disclosure about their iwi (tribe). In other cultures, disclosure about birthplace or immediate family is the norm. People from certain cultures may benefit from the health professional disclosing particular kinds of personal information. This information might be about family, country or town of origin, events or experiences, but is not usually about deep emotional experiences or emotional reasons for their demeanour. Some individuals are more comfortable than others with sharing personal details (Vogel et╯al 2006) and thus the comfort level of the health professional may assist in deciding the appropriate level of self-disclosure. 251

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OVER-IDENTIFICATION Over-identification can cause difficulties in the therapeutic nature of a relationship (Purtilo & Haddad 2007). Over-identification may occur when a health professional has experienced a very similar situation to the Person/s, for example, when assisting someone who has a child, sibling or parent with a disorder the same as that of the health professional. When a health professional over-identifies they can be anxious to share their experiences to indicate a connection, thereby focusing on themself. Emotional competence (Heron 2003) becomes important when the health professional experiences overidentification. Emotional competence means that the health professional will not allow their own experiences or emotions to affect the assistance they offer to the vulnerable Person/s. If the health professional is not able to function with emotional competence, the resultant self-focus is detrimental to the therapeutic relationship because it fulfils the needs of the health professional rather than the Person/s (Heron 2003, Purtilo & Haddad 2007).

Ethical codes of behaviour and conduct There are principles and in some cases legislation that guide and direct the behaviour of all health professionals (Collins 2004). These principles are usually the basis for the specific code of ethics adopted by individual health professions. If a particular health profession does not have a code specific to their practice, government policy exists to guide their practice in ethical conduct. For example, in Australia, see the Queensland Government Public Sector Ethics Act 1994, the Queensland Health Code of Conduct 2006 and the NSW Health Department Code of Conduct, Appendix 27 2007. In New Zealand, see The Health and Disability Commissioner Act 1994 and the Health Practitioners Competence Assurance Act 2003. The legislation, principles and ethical codes do not define the word ‘ethical’, nor do they necessarily provide exact answers to all ethical dilemmas experienced during practice (Banks 2006). They do however provide guidelines that assist a practising health professional. It is important to • Using the code of ethics specific to understand that a code of ethics can produce rigid your profession, list behaviours that doctrinarian attitudes that are insensitive to the rights reflect this code. of others (Taylor 2006). This is never the intention of • List characteristics of communication such a code and health professionals should use their that conform to this code. code of ethics to encourage and empower individuals, not to paralyse them.

Chapter summary Ethical considerations are important when communicating within the health professions and they relate to specific and correct behaviour, often mandated by a specific health profession or a government. Such behaviour requires respect of self and the Person/s, regardless of similarities or differences, which is communicated both verbally and nonverbally during any interaction. Honesty is also important as the Person/s can generally detect lack of honesty, which may create anxiety about the reasons for the lack of honesty. A Person/s who is new to a health service requires information about their rights, the service and any procedures or expectations (in some cases including consent forms), along 252

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with details about how any disclosed information will be managed to maintain confidentiality. There are also ethical boundaries in both the roles and relationships of health professionals that limit self-disclosure and over-identification on the part of the health professional. Ethical considerations in communication ensure positive outcomes for all people involved in a health service.

FIGURE 17.1â•… The components of ethical communication.

REVIEW QUESTIONS 1. What does ethical communication achieve in a health service? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 2. Explain why some health professionals might not consciously apply ethical requirements in their practice? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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3. Why must a health professional fulfil ethical requirements? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4. A health professional must provide certain information to fulfil ethical requirements. • What information must a health professional provide? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ • What forms can this information take? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ • What characteristics must this information have? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 5. What must a health professional ensure when communicating ethically? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 6. What must a health professional remember to achieve ethical communication? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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7. Define emotional competence and explain how it assists a health professional to achieve ethical communication. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 8. What are the requirements of the code of conduct relevant to your health profession? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

REFERENCES Australian Government 1986 Disability Services Act. Online. Available: http:// www.austlii.edu.au/au/legis/cth/consol_act/dsa1986213 19 Jan 2012 Australian Government 1988 Privacy Act. Online. Available: http://www.comlaw.gov.au 19 Jan 2012 Australian Government 2003 Commonwealth Disability Strategy. Online. Available: http://www.facs.gov.au/internet/facsinternet.nsf/disabilities/cds_introduction.htm 19 Jan 2012 Backus W, Chapian M 2000 Telling yourself the truth, 20th edn. Bethany, Minneapolis, MN Banks S 2006 Ethics and values in social work, 3rd edn. Palgrave Macmillan, Basingstoke, UK Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston Collins D 2004 The balancing act: self determination versus duty of care. In: Brown R (ed) Living, striving, achieving: an Australian perspective on disability. Life Activities, Newcastle, Australia Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston Donkor N T, Andrews L D 2011 Ethics, culture and nursing practice in Ghana. International Nursing Review 58(1):109–114 Dossey B M, Keegan L, Gussetta C 2005a Holistic nursing: a handbook for practice, 4th edn. Jones & Bartlett, Sudbury, MA Dossey B M, Keegan L, Gussetta C 2005b A pocket guide for holistic nursing. Jones & Bartlett, Sudbury, MA Egan G 2010 The skilled helper, 10th edn. Thomson, Belmont, CA Harms L 2007 Working with people: communication skills for reflective practice. Oxford University Press, Melbourne Harms L, Pierce J 2011 Working with people: communication skills for reflective practice. Oxford University Press, Don Mills, Ontario 255

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Heron J 2003 Helping the client: a creative, practical guide, 5th edn. Sage, London [reprinted] Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Malone S 2003 Ethics at home: informed consent in your own backyard. International Journal of Qualitative Studies in Education 16:797–815 Milliken M A, Honeycutt A 2004 Understanding human behavior: a guide for healthcare providers, 7th edn. Thomson Delmar, New York Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne New South Wales Health Department 2007 Code of Conduct. Online. Available: http:// www.health.nsw.gov.au/pubs/a/ar9697/a2700.html 19 Jan 2012 New Zealand Government 1993 Privacy Act. Online. Available: http:// www.legislation.govt.nz 19 Jan 2012 New Zealand Health and Disability Commissioner 1994 The Health and Disability Commissioner Act (Amended 2003). Online. Available: http://www.hdc.org.nz 19 Jan 2012 New Zealand Ministry of Health 2003 Health Practitioners Competence Assurance Act. Online. Available: http://www.moh.govt.nz/hpca 19 Jan 2012 Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Queensland Government 1994 Public Sector Ethics Act. Online. Available: http:// www.legislation.qld.gov.au/ 19 Jan 2012 Queensland Health 2006 Code of Conduct. Online. Available: http:// www.health.qld.gov.au/about_qhealth/cc.asp 19 Jan 2012 Rider E, Keefer C 2006 Communication skills competencies: definitions and a teaching toolbox. Medical Education 40:624–629 Rogers C 1967 On becoming a person. Constable, London Rupert P A, Morgan D J 2005 Work setting and burnout among professional psychologists. Professional Psychology: Research and Practice 36:544–550 Salladay S A 2010 Ethical problems: communication, getting the nod. Nursing 40(4):18–19 Salladay S A 2011 Ethical problems: communication under surveillance. Nursing 41(4):12–13 Smudde P M 2011 Focus on ethics and public relations practice in a university classroom. Communication Teacher 25(3):154–158 Stein-Parbury J 2009 Patient and person: interpersonal skills in nursing, 4th edn. Churchill Livingstone Elsevier, Sydney Taylor B J 2006 Reflective practice: a guide for nurses and midwives. Open University Press, Maidenhead The New Shorter Oxford English Dictionary On Historical Principles 1993 Oxford University Press, Oxford Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney

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United Nations 1948 Universal declaration of human rights. Online. Available: http:// www.un.org/Overview/rights 19 Jan 2012 United Nations 2006 Convention on the rights of persons with disabilities. Online. Available: http://www.un.org/disabilities/default.asp?id=150 19 Jan 2012 United Nations 2006 Human Rights Council. Online. Available: http:// www2.ohchr.org/english/bodies/hrcouncil 19 Jan 2012 Vogel D, Wester S, Heesacker M et al 2006 Gender differences in emotional responses: do mental health trainees overestimate the magnitude? Journal of Social and Clinical Psychology 25:305–332 Wenger N S, Vespa P M 2010 Ethical issues in patient–physician communication about therapy for cancer: professional responsibilities of the oncologist. Oncologist 15:43–48

FURTHER READING Australian Government 1999 National standards on ethical conduct in research involving humans. Commonwealth of Australia, Canberra Australian Human Rights Commission 2011 Disability standards and guidelines. Online. Available: http://www.humanrights.gov.au/disability_rights/standards/ standards.html 19 Jan 2012 New South Wales Department of Ageing, Disability and Home Care 2006 Stronger together: a new direction for disability services in NSW 2006–2016. NSW Government, Sydney The New Zealand Ministry of Health 2000 The New Zealand health strategy, Chapter 5. Online. Available: http://www.moh.govt.nz/moh.nsf 19 Jan 2012 United Nations Enable. About us: secretariat for the convention on the rights of persons with disabilities. Online. Available: http://www.un.org/disabilities 19 Jan 2012 United Nations Enable. Standard rules on the equalization of opportunities for persons with disabilities. Online. Available: http://www.un.org/disabilities 19 Jan 2012

USEFUL WEBSITES Codes of conduct (mainly Australian) for some health professions Ambulance: Ambulance Service of NSW 2007 Code of conduct. Online. Available: http://www.ambulance.nsw.gov.au 19 Jan 2012 Dental Hygiene: International Federation of Dental Hygienists 2003 Code of ethics. Online. Available: http://www.ifdh.org 19 Jan 2012 Dietetics: Dietitians Association of Australia 2006 Statement of ethical practice. Online. Available: http://www.daa.asn.au 19 Jan 2012 Nursing and Midwifery: Australian Nursing and Midwifery Council 2005 Code of professional conduct for nurses in Australia. Online. Available: http:// www.anmc.org.au 19 Jan 2012 Occupational Health and Safety: Safety Institute of Australia. Occupational health and safety professionals code of conduct. Online. Available: http://www.sia.org.au 19 Jan 2012 Occupational Therapy: Occupational Therapy Australia 2001 National code of ethics. Online. Available: http://www.ausot.com.au 19 Jan 2012

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Osteopathy: New South Wales Osteopaths Registration Board 2001 Code of conduct for board members. Online. Available: http://www.osteoreg.health.nsw.gov.au 19 Jan 2012 Physiotherapy: Australian Physiotherapy Association 2001 Code of conduct. Online. Available: apa.adusol.com.au 19 Jan 2012 Podiatry: Podiatrists Registration Board 2005 Code of professional conduct. Available: http://www.podreg.health.nsw.gov.au; Podiatrists Board of Queensland 2007 Code of conduct. Online. Available: http://www.podiatryboard.qld.gov.au 19 Jan 2012 Radiography/Radiation Therapy: Australian Institute of Radiography 2007 Guidelines for professional conduct for radiographers, radiation therapists and sonographers. Online. Available: http://www.a-i-r.com.au 19 Jan 2012 Social Work: Australian Association of Social Workers 1999 Code of ethics. Online. Available: http://www.aasw.asn.au 19 Jan 2012 Speech Pathology: Speech Pathology Australia 2000 Code of ethics. Online. Available: http://www.speechpathologyaustralia.org.au 19 Jan 2012 Traditional Medicine: Australian Traditional-Medicine Society Ltd 2006 Code of conduct. Online. Available: http://www.atms.com.au 19 Jan 2012

Informed consent This extract from an original article by Malone (2003) relates to a research study involving postgraduate students as subjects. While many health professionals do not partake in research projects, the principles of informed consent are the same. Health services require any Person/s receiving assistance to sign a form indicating their responsibilities and the responsibilities of the health service. Many require signing of an ‘informed consent’ form. This means that the Person/s has been informed about and understands the implications of any interventions or procedures. There are many assumptions behind such letters, as the following extracts indicate. It is important to consider the ethical implications of such assumptions when requesting a signature from a vulnerable Person/s seeking assistance. NOTE: The repeated dots indicate removed text. The words in italics were not included in the original letter but have been added to highlight the difficulties associated with such letters. They indicate the potential meaning of the words in the letter – a meaning that was not evident until the project had been completed. Reproduced from Malone S 2003 Ethics at home: informed consent in your own backyard. International Journal of Qualitative Studies in Education 16:797–815 by permission of the publisher (Taylor & Francis Ltd, http://www.tandf.co.uk/journals 19 Jan 2012)

A FULLY INFORMED CONSENT LETTER Dear Graduate Student: I am a doctoral candidate from ……… doing dissertation research. The purpose of my proposed study is to develop an understanding of how doctoral students learn to write the accepted language, or discourse, of their discipline. ……… I am interested in looking specifically at doctoral students in mathematics education. The study will last for one semester (approximately 15 weeks). As a part of the project I would like permission to collect data from you in three ways. Observations: I would also like an opportunity to observe your involvement in activities related to writing. ……… I am also interested in observing such activities as 258

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collaborative writing with a group on a class project, a peer review of some of your writing as part of the composing process, or a discussion between you and a professor about a piece of writing; you might be able to direct me to other relevant activities as well. [My presence in your class and continuing requests to be present in these other situations will initially make you very uncomfortable ……… In the class, you will never really know how to think of me – but you will not dare to bring up this issue because the professor has agreed to let me in and you will believe that expressing concern or discomfort will put you in the position of resisting her/him. You and s/he will say and do and think about things that you never would have except for my presence in your lives – it will change the nature of the class, perhaps in some negative ways.] After our initial interview, we will decide together which of your semester’s writing projects I will examine in depth ……… I might also ask for samples of writing you produced before the semester in which the study takes place, in order to determine a baseline by which to judge your writing development. [My assurance that this is something we will decide together might mislead you to think that you will have more power in this situation than you will actually have; it is highly unlikely that either of us will have time for you to be very involved in many of the decisions, especially those regarding the interpretation and rendering of the data.] Other than the possible inconvenience posed by the extra printing, I do not believe your participation in this study will pose any risks for you. [Except for putting you into a position of extreme vulnerability in your relationships with your professor and your fellow graduate students.You also might learn things about yourself that will be painful; you will almost certainly share with me or discover things that you will not want anyone else to know about you and you will have to trust me to not do things that will hurt you. It is probable that I will not always know what might hurt you.] ……… You will have the opportunity to read the report before it is made public and to see how any data from your case study are used. [The potential for ‘harm’ will continue even beyond the data collection phase and into the reporting phase; that harm could include your discomfort with things the study – and my interpretations – reveal about you. Even your feedback on the report and on how I have represented you will end up being ‘data’, to be interpreted along with the rest of it.] ……… If you agree to participate, please sign the form below. Participation in this project is completely voluntary and you may withdraw at any time. [In reality, you are very unlikely to feel free to withdraw from this study once you’ve begun – you would be too concerned with what others, particularly your professor, would think and the repercussions of such a decision. You probably are not even free to volunteer – you have been drafted, coerced by your professor’s decision to work with me and, possibly, to some extent, by your own position as a graduate student or novice researcher. In short, you will not have a great deal of personal autonomy, given the political realities of the situation.] If you would like additional information, please feel free to contact me at ……… Thank you for responding to this request. Sincerely ………

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ANSWERS TO REVIEW QUESTIONS CHAPTER 17â•… Ethical communication Answers to the following questions provide a summary of this chapter. 1. What does ethical communication achieve in a health service? It maintains harmonious, productive and beneficial therapeutic relationships. 2. Explain why some health professionals might not consciously apply ethical requirements in their practice? Different familial, social or cultural backgrounds may produce particular expectations of practice. 3. Why must a health professional fulfil ethical requirements? It is usually a legal requirement of both governments and health services. 4. A health professional must provide certain information to fulfil ethical requirements. • What information must a health professional provide? Information about the rights of the Person/s and the services their practice provides, what the Person/s can expect and who they can contact for answers to questions. Also provide a contact phone number and an indication of protection of their information (privacy). • What forms can this information take? Verbal or written form. • What characteristic must this information have? Clear explicit explanations in language that is easy to read about how the health professional will manage the information they obtain from the Person/s. 5. What must a health professional ensure when communicating ethically? Confidentiality. 6. What must a health professional remember to achieve ethical communication? All information and feelings relating to their work should remain at work. Thus they must debrief with someone from their workplace after emotionally intense experiences. They must also remember the limitations of their professional role. Avoid inappropriate self-disclosure and over identification. 7. Define emotional competence and explain how it assists a health professional to achieve ethical communication. Emotional competence requires the health professional to avoid over-identifying and therefore allowing their own experiences and emotions to become the focus of their interaction with the Person/s. 8. What are the requirements of the code of conduct relevant to your health profession? ANSWERING THIS QUESTION REQUIRES A COPY OF THE CODE OF CONDUCT OR ETHICS RELEVANT TO EACH PARTICULAR PROFESSION. O’Toole 2e. © 2012 Elsevier Australia

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CHAPTER 18â•…

Remote communication

CHAPTER OBJECTIVES Upon completing this chapter, readers should be able to: • Define and discuss remote communication • List types of remote communication typically used in the health professions: written reports, databases, telephone, video/teleconferences and the Internet • Describe the characteristics of remote communication • Explain the advantages of remote communication • Justify the principles for use of remote communication • Explain and discuss the limitations of remote, online collaboration tools • Develop strategies for appropriate use of remote communication including written information, telephones, video/teleconferences, email, search engines, professional chat rooms and social networking sites.

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Remote communication involves communication that is not face-to-face or that occurs over large distances. For more than 50 years health professionals have consistently used written reports and telephones as common forms of remote communication. Written reports and telephones traditionally communicated information about appointments, expectations, interventions, results, needs, future plans and various other issues related to the Person/s. Today, however, worldwide technological changes allow health professionals to communicate electronically through video/teleconferences and the • Consider the amount of time you Internet (Higgs et╯al 2005, 2010, Mohan et╯al 2004, spend using remote communication. 2008, Purtilo & Haddad 2007). Such electronic forms How many hours a day do you spend communicating via telephone of communication are called computer-mediated comcalls, text messages, the Internet munication (CMC) and are typically forms of remote (email and chat rooms including communication. social networking sites) and Skype While there are advantages and disadvantages of (or other forms of instantaneous new and old forms of remote communication, it remote video interaction and appears that remote communication is a permanent typing)? feature of the twenty-first century. Why do you use these particular • Societies, professions, families and individuals forms of remote communication? respond differently to remote forms of communication. Which of these forms of remote • Remote forms of communication potentially increase communication experience the most the convenience and speed of communication (De Ville disruption that is out of your control? 2001, Kirkwood et╯al 2011), however these are not the • Do you think everyone in your town only factors that determine responses to remote forms or city would spend a similar amount of communication. Each form of remote communicaof time each day using remote tion has specific characteristics that influence responses communication? to it. These characteristics include convenience, control, • Do you think most people have access to the technical forms of speed of delivery, preparation time, level of formality remote communication? and thought required, reusability, the absence of non• With which form of remote verbal cues to complement meaning, irreversibility, communication do you feel most legal implications, security and access to appropriate comfortable? Why do you think this technology (Armfield et╯al 2010). Many of these charis so? Does everyone you know feel acteristics are desirable for health professionals however; the same? some have implications worthy of consideration (Mohan et╯al 2004, 2008).

Characteristics of remote forms of communication for the health professional There are a number of characteristics of remote forms of communication for the health professional that require consideration (see Table 18.1). It is interesting to consider the characteristics of each form of remote communication typically used in the health professions. The often-popular electronic forms are not always as available or as reliable as many suggest (Devito 2009). Many countries and rural areas do not have technological resources available, or they have unreliable access to such resources. Thus it can be difficult to achieve effective communication when relying only on electronic forms of remote communication in the health professions. Convenience, immediacy and cost are factors increasingly important in health services due to rising demand for and, in many places decreases in, resources and funding. 261

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TABLE 18.1â•… Characteristics of remote forms of communication for the health professional Characteristic

Telephone

Video/teleconference

Email

Written report

Networking sites

Convenience

Y

Y

Y

S

Y

Control for caller/sender

Y

Y

Y

Y

Y

Immediate delivery time

Y

Y&N

Y

N

Y

Quick preparation time

Y

N

Y

N

Y

Formality required

S

S

N

Y

N

Thought required

S

Y

S

Y

N

Reusability

Y

N

Y

Y

Y

Permanent record

N

S

Y

Y

Y

Non-verbal cues present

S

Y

N

N

S

Legally binding

S

S

Y

Y

Y

Availability

Y

S

S

Y

S

Reliability

Y

S

S

Y

S

Security

S

N

N

Y

N

Privacy

Y

N

N

Y

N

Key: Y = definitely a characteristic; S = sometimes a characteristic, depending on the situation; N = not usually a characteristic.

•

List the remote forms of communication typically used in the health professions. • List the advantages and disadvantages of each of the remote forms of communication. • Suggest ways to overcome the disadvantages. Explain why the following statement is or is not so: ’Direct personal contact is a necessary component of remote communication.’

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Most health services adopt practices that increase efficiency and improve outcomes. Thus many are adopting electronic methods for storing and accessing records, sharing techniques, and communicating within and beyond the health service (i.e. internal and external email) (Brill & Levine 2005). Many health services and professions promote electronic forms of networking for support and professional development of employees (Ashar et╯al 2010, Ellis et╯al 2004, Maeder et╯al 2010). However the nature of the health professions suggests that direct personal contact will always be a necessary component of remote communication. There is discussion about the ‘paperless’ modes of communicating because some health professionals still prefer hard copies of information (Purtilo & Haddad 2007). It is interesting but difficult to predict the preferred form of remote communication for health professionals of the future.

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TABLE 18.2â•… Principles that govern professional remote communication Use:*

Avoid:*

• • • •

• • • • •

Polite forms of words and constructions Formal language and expression Clear explanations of any jargon or technical terms** Correct spelling and grammar – always check before sending • Concise, accurate and clear statements – one idea to one sentence

Abrupt, impolite messages Colloquial or everyday expressions Unexplained use of jargon Spelling and grammatical errors Long and rambling sentences

NOTE: *While ‘use’ and ‘avoid’ statements are repetitive and directive, they attempt to clarify meaning and avoid misunderstandings. **Technical terms are words that may have one meaning in everyday use but assume a different meaning in the context of professional communication.

Principles that govern professional remote communication There are important principles that govern remote communication among health professionals (see Table 18.2). These principles relate directly to the characteristics of an effective health professional (see Ch 6), but are sometimes forgotten in remote (especially email) forms of communication (Bevan et╯al 2011, Boucher 2010, Devito 2009, Ellis et╯al 2004, Higgs et╯al 2005, 2010, Mohan et╯al 2004, 2008, Tyler et╯al 2005, Yao et╯al 2010). The principles governing remote communication are especially important in health services that do not have support personnel to assist with preparation of documents. When individual health professionals compose and prepare written forms of remote communication, it is beneficial to ask a colleague to proofread the document (for spelling and grammatical errors, appropriate levels of civility and formality, and clarity and accuracy) before sending. These principles or ‘points to remember’ govern all types of remote communication. In combination with these principles, the following strategies guide the use of the types of remote communication commonly used within the health professions.

Documentation: written reports, medical records and letters CONSIDER THE AUDIENCE OR READER When writing in the health professions it is essential to consider who will read the document. If a report or letter is for several ‘audiences’ it is appropriate to use language and constructions suited to the individual least familiar with the health professions. Thus, if a specialist and the Person/s will both receive copies of a document, it is important to either use commonly understood terms or explain all jargon and technical terms. If the document will be read only by other health professionals, it is beneficial to explain only those terms that are not commonly known or are specific to a particular health profession. It is important to remember that medical records may be requested as evidence in court.

Abbreviations Abbreviations commonly occur in documents in the health professions because they reduce the time required to complete a report or entry. Abbreviations specific to the health professions are common in medical records (e.g. Ax = assessment, Rx = treatment). It is 263

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important to use only commonly known abbreviations. Different health services may use variations of abbreviations. Some have prepared lists to be used by employees, so it is important to become familiar with the abbreviations specific to a particular health service. Not all abbreviations used will be specific to the health professions. A common form of abbreviation not restricted to use in the health professions is an acronym (e.g. CMC). When using an acronym it is essential to also write the full meaning of the letters the first time the acronym appears. In some cases health professionals can invent previously unknown abbreviations (e.g. therapeutic use of self = TuoS) and thus it is important to document such meanings clearly.

Formatting It is important to comply with the requirements of the particular health service when formatting any written document. A report or letter should be printed on the letterhead of the health service. The advantage of this convention is that the contact details of the service will automatically be included on the paper. Reports and letters should include: • The date • A salutation (e.g. Dear …); use the family name of the person to avoid offence • A clear reason for the letter (e.g. Re: Name of person or reason) before the first paragraph – something to draw the attention and focus of the recipient (Mohan et╯al 2004, 2008) • A clear statement of the reason for the letter or report in the first paragraph • Well-organised points. Separate each new point into paragraphs or use bullet points or numbers to make the report or letter easy to read. Use examples of behaviours or needs to validate and verify the stated points (Higgs et╯al 2005, 2010). • A concluding paragraph that indicates required future action or details of future events • An appropriate salutation related to the tone of the letter before your signature (e.g. Yours sincerely, Thanking you) • A signature with the name of the person signing typed below before it is sent to the relevant reader(s).

Points to remember

• It is important to distinguish between fact and opinion in all written records. The

results of a standardised assessment tool do not require qualification, however it is important to use appropriate words to indicate the recording of opinion based upon observation (e.g. It appears…, It seems…). • Do not forget to read, correct and file all reports and letters before sending them. • Remember to sign a letter before sending it.

DATABASES Many health services use electronic forms of notes, records and files (databases) for recording information about the Person/s. It is important that the health professional learns and conforms to the expectations and requirements of the health service regarding databases. It is also important for the health professional to remember the principles for recording information presented in this chapter.

Telephones A telephone conversation allows the use of suprasegmentals – the non-verbal features of the voice – for negotiation of meaning. It is best to avoid using the telephone to deliver 264

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bad news, explain a complicated procedure or solve a complicated problem (Purtilo & Haddad 2007). There are important strategies that will assist in the achievement of effective telephone communication.

STRATEGIES FOR USING A TELEPHONE Answering a call Many health services have a method of recording information about callers and it is important to use the designated system. However there are some principles that guide the actions of the health professional when answering a telephone call. • When answering a call it is important to state your name and the name of the health service. • If possible, find the person and connect them with the caller. • If the person is unavailable, record the name of the person, time they rang, their number and the purpose of their call in the designated system. Ask them to spell their name if necessary and read their telephone number to them to check the accuracy of the number before • Decide if there is any other consideration that will make terminating the call. answering a call during a working • Tell the person calling you will pass the day either more professional or information to the relevant person, explain the clearer for the caller. person is very busy and thus encourage them to • Consider the perspective of the call again if they have not heard from the person caller and list reasons for each of within a particular time frame. If possible suggest the above points. a time when they might be available to take a call. • Thank them for calling, using their name.

Making a call

• Prepare for the call – gather all appropriate documents, a pen and a piece of paper or diary before making the call.

• It may be beneficial to compile a list of points (checklist) for coverage during the call to avoid wasting time.

• State your name and place of work, the purpose of the call and the name of the required person for the conversation.

• Exercise patience if there is a delay in locating the required person; it may be

• • • • • • • •

helpful to do something that is not demanding while waiting. When connected, ensure the delay does not affect your attitude or tone of voice (Mohan et╯al 2004, 2008). (If receiving a call, apologise for any delay caused and maintain pleasant responses if the caller is a little impatient.) If the person is unknown it is advisable to begin with a formal tone and reduce the formality with the development of rapport. Articulate carefully to produce clear speech. Avoid talking when the other person is talking. Clarify all points and confirm understanding of important points. Listen carefully and if necessary take notes. Give feedback to indicate understanding, whether of agreement or otherwise. Remember there is only the voice to influence meaning and therefore the conversation may require explicit verbalisation of any non-verbal behaviour or emotions (Ellis et╯al 2004, Mohan et╯al 2004, 2008). Allow time for discussion of additional points if required by the other person. 265

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• Remember to thank the person when finished and say goodbye. • It may be important to provide written confirmation of the conversation (Mohan et╯al 2004, 2008).

STRATEGIES FOR USING SHORT MESSAGING SERVICE (SMS) Health services are increasingly using the short messaging service (SMS) that accompanies a mobile phone to confirm information or appointment times. Thus it is important to consider the content of such messaging. When communicating using an SMS as part of a health service it is important to: • Use the name of the person who should be receiving the SMS • Avoid using abbreviations typical of an SMS • List the possible points for inclusion • State each point clearly and succinctly, where in an SMS to a Person/s to confirm necessary using punctuation to indicate each their appointment. point • Together write and agree upon the • Use a name (either your name or the name of content of such an SMS. the health service) at the end of the SMS so they know who sent the message.

STRATEGIES FOR USING AN ANSWERING SERVICE OR VOICE MAIL When recording the message to advise there is no-one from the service available to answer the call, it is important to: • State the name of the service for the caller and state there is currently no-one available to answer the call. • Provide instructions for how to leave a message, for example, After the tone, state your name and number and the date and time of your call and then hang up. • State that someone will respond to the call as soon as possible. • Thank them for calling (this could also be stated at the beginning of the message). When leaving a telephone message it is important to:

• State your name and place of work, the purpose of the call and the name of the

person who should receive the message. State the return phone number carefully, perhaps twice, to allow easy transcription of the message (Mohan et╯al 2004, 2008). • Articulate carefully to produce clear speech. • Avoid speaking rapidly or running words together. • As a reminder, record details of the date and time of the call in your diary or another relevant place. When receiving a recorded telephone message it is important to:

• Write the message in a particular place, recording the date and time of receipt of

the message (e.g. diary or phone message book). Avoid pieces of paper because they are easily lost. • Phone the person to indicate receipt of the message and the relevant response (Purtilo & Haddad 2007). Indicate action taken by marking the received message in some manner.

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Video/teleconferencing or using Skype Video/teleconferencing or using Skype involve the use of technical devices that allow either a simultaneous visual or telephone connection for multiple people from multiple sites. These connections allow communication without individuals leaving their workplace (Dixon 2010, Ellis et╯al 2004). A tele- or Skype conference is not particularly anxiety provoking because it simply requires people to sit and talk. Some people at a remote site during such a connection may need to do something to assist their concentration or focus, as they may be unable to see the people at the other sites. Taking notes about the details of the conversation or required action as a result of the conversation may assist this potential for boredom or limited concentration. A videoconference uses a camera and this can produce consternation for some individuals. Such consternation usually reduces with exposure to the videoconferencing process.

BENEFITS Communicating in this form is beneficial for: • Networking • Health professionals in remote settings • Saving time • Reducing travel costs • Allowing non-verbal behaviours to establish meaning • Sharing ideas with previously inaccessible individuals • Receiving assistance for problem solving • Sharing new procedures with remote sites or professional development.

STRATEGIES FOR USING VIDEO/TELECONFERENCING

• When conducting a video/teleconference introduce each site. If the interacting • • • • •

individuals are unknown to each other, allow time for the individuals to introduce themselves and their roles. If the individuals are known, name those present and restrict introductory details to new people. When conducting a teleconference remember to have the individuals identify themselves each time they speak. When conducting a videoconference it is essential to include all the connected sites in the discussion and the presentation of ideas or procedures.  Ask for confirmation of visual, auditory and cognitive understanding.  Ask for comments or questions from all sites. When conducting a videoconference it is important to repeat anything not in range of the microphone. This is especially important during question time. When finishing a video/teleconference say goodbye to each site separately. Encourage people leaving the conference to indicate they are leaving before terminating the connection. If they know they have a limited time less than the scheduled time at the beginning of the conference or as they are about to terminate the connection, they should indicate their intention to terminate the connection. This is important as it advises those remaining in the conversation whether or not there were technical complications or a deliberate termination of the connection.

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The Internet EMAIL People often forget that email is neither private nor secure (Brill & Levine 2005, Snyder 2010, Snyder & Cistulli 2011). It is possible to forward any email anywhere. As an email passes through a server, a copy appears on that server and is held there whether deleted from or remaining in an inbox. There are also problems of access relating to email. Not all sites or individuals have reliable access and some may simply not have access to this technology (Rennie et╯al 2010). Despite these drawbacks, people often prefer email because it allows the sender and receiver control of their time and ideas (Tyler et╯al 2005). There are important strategies and ‘points to remember’ that will assist in the achievement of effective email communication. • Decide on the purpose of the email. • Use the appropriate tone for the audience; the tone (polite and friendly with an appropriate level of formality) and content of professional emails should be different to that of personal emails (Mohan et╯al 2004, 2008). • Remember that every email is a legal document. • Include a title in the subject box. The title indicates the content of the email and can capture the attention of the recipient. • Use a salutation (e.g. Dear …). The use of a given name will depend upon the purpose of the email and the relationship with the recipient. Use Hi … thoughtfully in professional emails. • Use well-constructed sentences to assist the person reading the email. • Explain critical comments carefully and politely. • Use careful constructions to avoid appearing abrupt and even rude (Devito 2009). • Use careful constructions to avoid ambiguity (Tyler et╯al 2005). • Describe any emotions because these are unseen (Higgs et╯al 2005, 2010). • Describe any relevant non-verbal cues because these are also unseen. • Avoid capital letters because they are considered equivalent to SHOUTING! • Compose requests for clarification politely, giving reasons for the need for clarification (Higgs et╯al 2005, 2010). • Avoid abbreviations (Higgs et╯al 2005, 2010) or emoticons (Devito 2009) in professional emails. • Write what you mean and proofread before sending (Ellis et╯al 2004). • Use a final salutation or signature appropriate to the tone and purpose of the email (Tyler et╯al 2005). A computer-generated signature is beneficial for professional emails because it ensures that role, position and contact details accompany every sent email. • Ensure the email is going to the right person before sending! • Use an explanatory sentence when including an attachment to confirm the contents of the attachment. • Reduce the size of large attachments by saving them in a compressed format. When creating or saving an attachment in a particular format remember that the recipient may not have the software required to access the attachment (Tyler et╯al 2005). • Check for the correct address if an email is undeliverable. Undeliverable emails may also mean that the inbox of the recipient is full. • Reply to every email that is not a mass ‘company’ email; acknowledgement of receipt is polite and reassuring for the sender. 268

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Email is convenient and in many cases imme�diate. It allows control and is beneficial in augmenting faceto-face contact with those who interact with the health professional (De Ville 2001). However, there are disadvantages that require careful consideration when communicating remotely using email.

•

Using the above bullet points, compile a list of advantages and disadvantages of using email. • Suggest realistic ways of overcoming the disadvantages.

SEARCH ENGINES The use of search engines to locate information and practice-related research is common in the health professions where there is appropriate technology. The value of a search engine lies in the number of websites to which it can connect the searching individual. Locating the required websites can be frustrating until an appropriate word or combination of words typed into the search engine provides a satisfactory connection. It is important to consider the reliability of a website when sourcing information from individual sites (Tyler et╯al 2005). It is relatively simple to construct a website, so there are multitudinous websites with particular agendas and biases. When seeking evidence for practice or assessment tasks it is possible to access websites that are less than reliable and not always reputable. Thus it is important for health professionals and students to exercise care when using any information obtained from a website.

Online collaboration tools PROFESSIONAL CHAT ROOMS AND WIKI SPACES There are particular protocols that govern all Internet-based chat rooms; the basis of these protocols is a desire for and commitment to respectful communication. Professional chat rooms and wiki spaces allow worldwide exploration of alternative protocols, procedures and management strategies (Meenan et╯al 2010, Mills et╯al 2010). When relating to health professionals from other cultures through chat rooms, it is important to remember the factors affecting culturally appropriate communication (see Chs 14 & 15).

SOCIAL NETWORKING SITES Social networking is currently a major pastime for many people. These sites are often accessed and used while completing other tasks and as such do not always have the full attention of the participants. They can facilitate creativity as well as social engagement (Goggin & Hjorth 2009) and are useful for both personal and teaching purposes (DiVerniero & Hosek 2011). Many people in this busy world use such sites as a social outlet and often the only connection point with particular people. This in fact means that individuals from particular sites invite other people to join those sites and thus it is often difficult to know who has access to those sites. In fact your employer or a future employer might be on a site, which means they can observe and evaluate you, perhaps making judgements on your credibility (Kirkwood et╯al 2011). Certainly there is evidence that student opinions of their instructors decreases if the instructor discloses ‘too much’ personal information (DiVerniero & Hosek 2011). However, such sites provide an easy interface to share information about personal and professional life and/or social events. They can also be liberating for people who experience social anxiety (Kang & Hoffman 2011). There are implications for the use of these sites for every health professional, which do not relate to cyber-bullying. Postings on any social networking site, like emails, are not only permanent but also may have legal implications. Such postings exist in a public domain and are widely available, in fact they are potentially there for everyone to see 269

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(DiVerniero & Hosek 2011, Mazer et╯al 2009). This reality can have long-term consequences for every health professional using these sites. Another factor affecting the use of social networking sites is that the postings on such sites are open to personal interpretation. This interpretation may result from the particular emotional wellbeing of the person interpreting the posting at that time and may not reflect the intention of the person posting the comment. This personal interpretation, if discussed elsewhere whether innocently or not, can easily create misunderstandings. This can produce potential confusion and negative emotions in other people and ultimately potentially harmful consequences for the person posting the comment. A final-year health professional student was completing a professional placement as part of a health professional degree. During this placement around week two of a ten-week placement this final-year student mentioned on a social networking site that they were not enjoying the particular context of their placement because of the time pressures. These pressures meant there was limited time for developing a therapeutic relationship or providing actual treatment. After the completion of their placement a health professional who worked at the site of this placement was talking to another second-year student from the same training institution. This student mentioned that from a posting on a social networking site it was obvious that the final-year student had not enjoyed their ten-week placement at her health service, and that other students had decided that if possible they would avoid ever completing a placement at that site. The health professionals at the site were both surprised and concerned, as the final-year student seemed to have an honest relationship with the immediate supervisor and the rest of the team and had not mentioned anything to indicate lack of learning or enjoyment during the placement. When this information was communicated to the final-year student, they were amazed that their posting could be interpreted in that manner. They had really enjoyed their placement and had learned a great deal about being a health professional and would definitely recommend it to any other student. They admitted the posting had indicated their personal struggle with an unfamiliar context, but had never intended to mean the site produced a difficult placement, one to be avoided by other students. The initial personal struggle of the final-year student with an unfamiliar and fast-paced context had been interpreted as an indication of a ‘bad’ placement site rather than the reaction to an unfamiliar setting and pace of practice.

• •

What could the final-year student have done to avoid this situation? Suggest guidelines for the use of social networking sites relating to professional practice.

In this case, the final-year student decided the best course of action for future contributions to any social networking site was to implement the advice of the media. This advice states that everyone should avoid posting any comments relating to anything about their workplace but especially feelings about or interactions from their workplace on any social networking site. Many people using social networking sites do not remember their postings are permanent and can have professional and possibly legal implications, whether or not they are removed from view. In addition, it seems that people posting on such sites do not remember that the interpretation of others using the site can adversely affect the meaning and thus the focus of any posting. Even though any interpretation is the responsibility of the interpreter, it may not be linked to the person interpreting but rather to the person 270

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making the original posting. It is this person who will hold the legal responsibility of the posting and any resultant discussion of the posting.

Chapter summary Remote communication is a permanent fixture in the health professions and has legal implications. It can take the form of reporting in hard copy and digital format or use of the Internet to communicate relevant information. There is also increasing use of video/ teleconferencing to physically separated sites. Remote communication, while convenient and immediate, can have particular disadvantages that require the consideration of any health professional communicating through remote means. It is important for health professionals to use remote forms of communication appropriately and politely to benefit from the advantages of this form of communication. Health professionals using social networking sites must avoid posting anything, whether feelings, opinions or events relating to their workplace. Remote communication can save time, can connect people who might be isolated without this form of communication, and can provide the latest relevant information and procedures for interested health professionals.

FIGURE 18.1â•… Remote communication has particular components.

REVIEW QUESTIONS 1. Using your own words, define remote communication. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

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2. List the types of remote communication typically used among health professionals. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 3. State the advantages of remote communication. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. Suggest ways of overcoming the disadvantages of remote communication. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 5. Focus upon written or digital documents. • Explain why is it important to consider the recipient of written/digital information. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • Provide original examples of the two major types of abbreviations. i. ii. • Outline an effective written report or letter, or digital entry to a database. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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• List the things to remember before sending a report or submitting an entry into a database. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 6. Focus upon using a telephone. • What is it important to do when answering a telephone call for a health service? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • What is important when preparing to communicate professionally over the telephone? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • Briefly describe an effective telephone conversation. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • List the things to remember when using an SMS to confirm information or appointments. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • List the things to remember when using an answering service. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

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7. Focus upon video/teleconferencing. • Outline the benefits of video/teleconferencing. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ • Briefly, describe an effective videoconference. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 8. Focus upon email. Categorise each point listed in the ‘Email’ section of this chapter into one of three categories: Civility

Practicality

Reality

The

They

They

9. Focus on chat rooms or social networking sites. List things to consider when posting onto a social networking site or chat room. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

REFERENCES Armfield N R, White M M, Williams M L et al 2010 Clinical services and professional support: a review of mobile telepaediatric services in Queensland. Studies in Health Technology & Informatics 161:149–158 Ashar R, Lewis S, Blazes D L et al 2010 Applying information and communications technologies to collect health data from remote settings: a systematic assessment of current technologies. Journal of Biomedical Informatics 43(2):332–341 Bevan J I, Jupin A M, Sparks L 2011 Information quality, uncertainty, and quality of care in long-distance caregiving. Communication Research Reports 28(2):190–195 274

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Boucher J L 2010 Technology and patient–provider interactions: improving quality of care, but is it improving communication and collaboration? Editorial. Diabetes Spectrum 23(3):142–144 Brill N I, Levine J 2005 Working with people: the helping process, 8th edn. Pearson, Boston De Ville K A 2001 Ethical and legal implications of e-mail correspondence between physicians and patients. Ethics Health Care 4(1):1–3 Devito J A 2009 The interpersonal communication book, 12th edn. Pearson, Boston DiVerniero R A, Hosek A M 2011 Students’ perceptions and communicative management of instructors’ online self-disclosure. Communication Quarterly 59(4):428–449 Doi:10.1080/01463373.2011.597275 Dixon R F 2010 Enhancing primary care through online communication. Health Affairs 29(7):1364–1369 Ellis R B, Gates B, Kenworthy N 2004 Interpersonal communication in nursing, theory and practice. Elsevier, London Goggin G, Hjorth L 2009 Waiting to participate: introduction [online]. Communication, Politics & Culture 42(2):1–5 Higgs J, Ajjawi R, McAllister L et al 2010 Communicating in the health sciences. Oxford University Press, Melbourne Higgs J, Sefton A, Street A et al 2005 Communicating in the health and social sciences. Oxford University Press, Melbourne Kang T, Hoffman L H 2011 Why would you decide to use an online dating site? Factors that lead to online dating. Communication Research Reports 28(3):205–213 Doi: 10.1080/08824096.2011.566109 Kirkwood J, Gutgold N D, Manley D 2011 Hello world, it’s me: bringing the basic speech communication course into the digital age. Communication Teacher 25(3):150–153 Doi:10.1080/17404622.2011.579905 Maeder A, Hovenga E J S, Kidd M R et al 2010 Telehealth and remote access. Studies in Health Technology & Information 151:239–254 Mazer J P, Murphy R E, Simonds C J 2009 The effects of teacher self-disclosure via Facebook on teacher credibility. Learning, Media and Technology 34:175–183 Meenan C, King A, Toland C et al 2010 Use of a wiki as a radiology departmental knowledge management system. Journal of Digital Imaging 23(2):142–151 Mills J E, Francis K, Birks M et al 2010 Registered nurses as members of interprofessional primary healthcare teams in remote or isolated areas of Queensland: collaboration, communication and partnerships in practice. Journal of Interprofessional Care 24(5):587–596 Mohan T, McGregor H, Saunders S et al 2004 Communicating as professionals. Thomson, Melbourne Mohan T, McGregor H, Saunders S et al 2008 Communicating as professionals, 2nd edn. Cengage Learning, Melbourne Purtilo R B, Haddad A 2007 Health professional and patient interaction, 7th edn. Saunders, Philadelphia Rennie E, Crouch A, Thomas J et al 2010 Beyond public access? Reconsidering broadband for remote Indigenous communities [online]. Communication, Politics & Culture 43(1):48–69

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Snyder J L 2010 Email privacy in the workplace: a boundary regulation perspective. Journal of Business Communication 47:266–294 Snyder J L, Cistulli M D 2011 The relationship between workplace e-mail privacy and psychological contract violation, and their influence on trust in top management and affective commitment. Communication Research Reports 28(2):121–129 Tyler S, Kossen C, Ryan C 2005 Communication: a foundation course, 2nd edn. Pearson & Prentice Hall, Frenchs Forest, Sydney Yao J, Wan Y, Givens G D 2010 Using web services to realize remote hearing assessment. Journal of Clinical Monitoring & Computing 24(1):41–50

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ANSWERS TO REVIEW QUESTIONS CHAPTER 18â•… Remote communication Answers to the following questions provide a summary of this chapter. 1. Using your own words, define remote communication. Remote communication is when people are interacting but are not in the same room or physical space. 2. List the types of remote communication typically used among health professionals. Telephones, reports, teleconferences or videoconferences or Internet. 3. State the advantages of remote communication. Convenient, saves time and money, does not need a lot of preparation and is mostly immediate. 4. Suggest ways of overcoming the disadvantages of remote communication. You can overcome the legal implications and the fact that remote communication is often permanent by being very careful about how you phrase yourself and what you say. You can overcome the lack of non-verbal messages by using words that indicate your emotional responses at the time. The inconsistent access to electronic forms of remote communication in some areas means you need to plan your day to use it when it is available – if you have it some of the time. If you have no access at all, then you will need to travel to somewhere that does have access. 5. Focus upon written or digital documents. • Explain why it is important to consider the recipient of written/digital information. Considering the people who will read the report helps the health professional to use words that the reader will understand, rather than using their particular jargon. • Provide original examples of the two major types of abbreviations. i. Those specific to their health profession or health professions generally ii. Acronyms or commonly known abbreviations, e.g. Road = Rd. • Outline an effective written report or letter, or digital entry to a database. Effective reports or letters that are NOT digital should be written on the letterhead of the health service and should include the date, who it is for – Dear Mrs, Dr, Mr, Ms followed by RE: with a brief statement of the focus of the letter or report. The first paragraph should have a clear statement for the reason for the letter. Whether a hardcopy or a digital entry, the ‘report’ should include a clear list of the relevant points – using dot points or new paragraphs for each new point, if appropriate, and a concluding paragraph or section with the recommended action or future plans. A hardcopy report should conclude with a greeting or salutation that is appropriate to the tone of the letter. All reports or medical records should include your signature and, where appropriate, your name typed below the signature. O’Toole 2e. © 2012 Elsevier Australia

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• List the things to remember before sending a report or submitting an entry into a database. Check the sentences make sense and flow so they follow each other in a logical order; check spelling and grammar before sending it. Make sure you only include facts but, if including your opinion of observations, use word that indicate this. Words like: from observation it appears, it seems, and so forth. Make sure before sending or submitting it you have signed it! 6. Focus upon using a telephone. • What is it important to do when answering a telephone call for a health service? Make sure you state your name and the name of the department or particular service before passing the call onto the relevant person. If that person is not there, use the appropriate system to record the caller’s details, tell the caller the information will be given to the person, but if they have not heard from them in a few days, to call again at a particular time because the person is very busy. Thank them for calling and say goodbye to them using their name. • What is important when preparing to communicate professionally over the telephone? Make sure you have all the information you need close, as well as a pen and paper or diary. Make a list of the points you need to cover during the conversation. After connecting clearly state your name and who you want to talk to – sometimes you need to state the reason for the call. Speak clearly. • Briefly, describe an effective telephone conversation. State your name and who you want to talk to clearly and state the reason for the call. Be patient if it takes time to find and connect with the particular person. Speak clearly, stating the reason for the call while using a formal tone and avoid talking while the other person is talking. Listen carefully to make sure the person understands what you are saying and make sure you give feedback that reflects your understanding of what they have been saying – and if necessary explicitly state the consequences of the feelings associated with the conversation (e.g. I am finding that difficult). Allow time for discussion of any further information or questions and ensure you say goodbye. In many case it is important to provide written confirmation of the content of the conversation. • List the things to remember when using an SMS to confirm information or appointments. Using the name of the person who should be receiving the message allows a response of either ignoring it or indicating it is the wrong number if the person receiving it is not the correct person. It also allows the recipient to deliver the message to the person if they know that person. Using abbreviations could create confusion or misunderstandings. Using your name to sign the SMS tells the person who to contact if they cannot attend or if they have any questions.

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• List the things to remember when using an answering service. It is important to: state your name clearly, enunciating carefully so you are easily understood; provide details of your number and, if appropriate, when to call; if appropriate, state or record the reason for calling; thank the person for calling or for their time. 7. Focus upon video/teleconferencing. • Outline the benefits of video/teleconferencing. They allow people to connect with other health professionals without leaving their workplace or travelling long distances. They also allow the inclusion of non-verbal messages and sharing of problem-solving ideas and new procedures. • Briefly, describe an effective videoconference. At the beginning name and introduce each site. Make sure each person identifies themself each time they speak during a teleconference. Ask for confirmation of understanding. Ask for comments or questions from each site. If the group is large repeat anything said that is not in range of the camera or microphone. Make sure everyone indicates if they are terminating the connection before completion of the scheduled time. 8. Focus upon email. Categorise each point listed in the ‘Email’ section of this chapter into one of three categories: Civility

Practicality

Reality

Appropriate tone and content Use an appropriate salutation Construct content carefully to be polite Language must be polite Avoid capitalisation of words Use a final salutation appropriate to the tone and purpose of the email Acknowledge receipt of the email with a thank you

Decide on the purpose Place a title in Subject Use full sentences for clarity Explain everything carefully and clearly Avoid abbreviations Proofread before sending to check spelling and grammar Check the email is going to all the relevant people Explain any attachments

Every email is a legal document Emotions are unseen so they can be ambiguous as they describe non-verbal information Do not use capitals for whole words Make sure the email address is correct It’s important to confirm the content of the email

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9. Focus on chat rooms or social networking sites. List things to consider when posting onto a social networking site or chat room. Postings on social networking sites are permanent and they have legal standing that could have long-term implications for the person posting the comments. It is important to consider the possible ways of interpreting a posting as different interpretations can lead to misunderstandings and confusion. You really have no idea who has access to the site and they many read any derogative comments about themself or others. This behaviour may adversely affect the reputation of the health professional posting the comment and potentially may affect their relationships with more than the person about whom they are commenting.

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The Focus of Communication in the Health Professions: Person/s

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Introduction Small group activity Person/s experiencing strong emotions Person/s behaving aggressively Person/s experiencing extreme distress Person/s reluctant to engage or be involved in communication or intervention Person/s experiencing depression Person/s in different stages of life A child An adolescent An adult A person who is older Person/s fulfilling particular life roles Person/s fulfilling the role of a colleague Person/s fulfilling the role of carer for Person/s Person/s fulfilling the role of parent to a child requiring assistance Person/s fulfilling the role of single parent to a child requiring assistance Person/s fulfilling the role of a student Groups in the health professions Person/s experiencing long-term conditions Person/s experiencing post traumatic stress disorder and complex PTSD Person/s with decreased cognitive function Person/s experiencing a life-limiting illness and their family Person/s experiencing a mental illness Person/s experiencing long-term (chronic) or multiple physical conditions Person/s experiencing a hearing impairment Person/s experiencing a visual impairment Person/s in particular contexts Person/s experiencing an emergency Person/s experiencing domestic abuse Person/s speaking a different language to the health professional References Further reading

278 279 281 281 284 286 289 291 291 294 298 300 303 303 305 307 310 313 315 320 320 323 326 330 333 336 339 342 342 345 348 351 351

Introduction Government health departments around the world list the rights of the Person/s when seeking assistance from health services, including the right to experience effective communication. The Communication Bill of Rights (www.scopevic.org.au) developed in Victoria, Australia, is an example of a document about this right. While this bill is introduced in the context of communication with people who have a hearing or intellectual impairment, it is applicable to all people regardless of their abilities, race, gender, status, religion, sexual orientation, condition, emotions, stage of life and role. There are various versions of a communication bill of rights in different countries around the world. In the health professions the rights of every communicator are based upon the steps that contribute to family/Person-centred practice (see Ch 2). They include the right to understand and be understood (negotiate and experience mutual understanding or to share meaning), express, learn, choose, interact and contribute, along with the right to say no. Health professionals will practise according to these rights if they conform to the code of conduct relevant to their particular health profession or to the relevant government health department (see Ch 17).

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The aim of Section 4 is application of knowledge and consolidation of the skills required by health professionals for effective communication. This section can facilitate exploration and application of the principles and skills discussed in the first three sections of this book. Health professionals communicate with Person/s from diverse backgrounds that have multifaceted issues and varying needs. A health professional must remember to consider the whole Person/s, including the environmental constraints on the Person/s. They must also remember the basic components of healthcare that provide the foundation for assisting any Person/s (see Fig 2.4). These components should be familiar at this stage in the book and are hopefully now ‘old friends’ to any health professional committed to effective communication. This section contains particular scenarios that facilitate exploration of the needs of the Person/s in the scenario and development of communication skills. They provide a guide for effective communication and are not considered to be conclusive – but rather provide a foundation of suggestions that potentially promote consideration of particular points when communicating as a health professional. After consideration of some factors contributing to effective communication, there are details of a male and a female scenario or Person/s that represent particular needs or realities of life. Thus the scenarios reflect the Person/s potentially encountered in health professional practice. They encourage exploration of the needs and realities of such Person/s.

Small group activity Exploration of Section 4 should begin with around 15 minutes of small group discussion that considers the points listed below in relation to the particular scenario. The entire group can later note any extra information learnt from the content of the particular scenario.

SCENARIOS Section 4 contains 24 different scenarios (including a male and a female case) that represent typical people and situations a health professional may encounter in their working life. The scenarios should not promote stereotypes or stereotypical ways of communicating, but rather should encourage health professionals to place the family/Person/s at the centre of their practice and avoid assumptions about any Person/s. When considered in depth, these scenarios can prepare the health professional to communicate effectively with similar Person/s in similar situations. The scenarios would best be used during problem-based tutorials or group discussions. Most cases can be examined using role-plays; however discussion points have been included for each case in which it seems inappropriate or difficult to ‘play’ the roles. The contributions of group members can be invaluable if they are comfortable to share their knowledge and experience. Regardless of the method used to explore each scenario it is important to begin by first defining the emotion, the life stage, the role, condition or context. A discussion of what it might mean to experience the specific need or life reality and the potentially associated feelings can follow the definition. The role-plays or consideration of the discussion points should occur after exploration and discussion of the scenarios to ensure participants are well informed and able to relate to the details of the male or female case. 279

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Guidelines for discussion prior to exploring each case scenario

• As a group decide upon a definition of the need or life reality. • Decide what it might mean to be experiencing that need or life reality. • List the specific behaviours that might reflect the need or life reality. • List the individuals most susceptible to these needs or life realities. • Suggest the emotion typically associated with these needs or life realities, which can

produce difficulties when relating to a health service. • Suggest possible events or environments that might produce the need or life reality and explain why. • List principles for effective communication to remember when communicating with a Person/s experiencing these strong emotions. Give reasons for the need to remember these principles. • Suggest strategies for communicating with a Person/s who is experiencing these strong emotions. Decide why you might see such a Person/s in your particular health profession. • Consider and explore the content of each scenario. • Compare the initial answers with the content of each scenario, noting any additional thoughts or ideas. NOTE: The content does not intend to be comprehensive but merely provide the foundation for developing knowledge and practising required skills for achieving effective communication in the health professions. PROCEDURE IF USING ROLE-PLAYS AFTER COMPLETING THE ABOVE

If it is not possible to role-play these scenarios, consider and explore the possible responses and communication strategies that will achieve effective communication and family/ Person-centred practice. • In small groups, assign the roles to group members and role-play at least one of the cases. • The people playing the roles consider (not discuss) the communication strategies that will best achieve effective communication. • The observers note the:  Words used and their effects  Non-verbal behaviours of all communicators and their effects  Style of communication used and the effects  Characteristics of communication that were the most effective. • Then, as a group:  Discuss the results, noting both successes and elements that require improvement. Check that the ‘actors’ were aware of their non-verbal behaviours.  Note whether different people interpreted the non-verbal behaviours and the effects of communication differently. Discuss the implications of any variations in interpretation.  Consider the feelings of each Person/s in the role-play. Explore what caused their feelings. If the feelings were resolved, consider what caused this resolution.  If possible, repeat the role-play with different people playing the roles until everyone has played one of the Person/s. • When everyone who desires to assume a role has completed the role-play, discuss the observations, emotions and outcomes of the role-plays and devise strategies to 280

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assist effective communication and family/Person-centred practice in similar situations. PROCEDURE IF USING DISCUSSION POINTS AFTER COMPLETING THE ABOVE GUIDELINES

• Establish the meaning of jargon-specific words before the discussion. • Decide the most appropriate course of action for the health professional. • Together devise strategies that will assist effective communication in a similar

situation. • Small groups might discuss one scenario and then share their ideas with a group that has discussed a different scenario. To conclude the exploration of each scenario, it may be useful to summarise in point form successful strategies for communicating with a Person/s experiencing the particular emotion, stage of the lifespan, role, condition or context. NOTE: The scenarios are fictitious, so if any of the scenarios cause discomfort and emotions of identification it is essential to seek assistance and resolution. Resolution of discomfort will ensure a consistent ability to provide the best care for both ‘self’ and the Person/s during practice. Upon completing consideration of the 24 scenarios in Section 4, readers should be able to apply knowledge and consolidate the required skills to communicate effectively with Person/s with particular needs or who are experiencing particular life realities. These Person/s scenarios incorporate those experiencing particular emotions including: demonstrating aggression, extreme distress, reluctance to engage in communication or intervention, and depression. They also identify Person/s in particular stages of life including childhood, adolescence, adulthood and older people, along with Person/s in particular roles including colleagues, carers, parents, single parents, students, and roles relating to group membership. The scenarios also facilitate exploration of Person/s with particular conditions including those with a disorder related to trauma, decreased cognitive function, life-limiting illnesses, mental illnesses, chronic or multiple physical illnesses, and impairment of hearing and/or sight. Finally the scenarios present Person/s in particular contexts including experiencing an emergency, domestic abuse and communicating with Person/s from a culture and language that is different to that of the health professional.

PERSON/S EXPERIENCING STRONG EMOTIONS Small group discussion is more appropriate than role-plays when considering scenarios that incorporate Person/s experiencing strong emotions.

Person/s behaving aggressively (Key words: angry, aggressive, assertive, violent)

Definition of aggression Consider anger at one end of a continuum and violence at the other end, with aggressive behaviour in between. A person who behaves aggressively may demonstrate anger initially and violence ultimately. 281

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A person who behaves aggressively is someone who: Exhibits apparently unprovoked behaviours that threaten those around them Feels vulnerable and out of control Wants their ‘own way’ and will intimidate or threaten to fulfil their desires May confuse aggression with assertion May believe aggressive behaviour is the only way they can ‘win’ or achieve their desired results • … and so on (this list is not exhaustive).

• • • • •

Behaviours related to aggression An aggressive person might: • Be verbally abusive and loud when interacting • Threaten (verbally or in writing) to physically harm someone or something • Use non-verbal gestures to indicate feelings of aggression.

Individuals most susceptible to behaving aggressively A common belief suggests that individuals who behave aggressively are found mostly in mental health settings. This is not always true because aggressive behaviour can occur anywhere. Individuals may be susceptible to behaving aggressively because of: • Eroded self-esteem • Emotional trauma (e.g. disappointment, loss, frustration, bewilderment) • Unresolved anger or frustration • Stress • Unfulfilled desires • Inability to understand a situation or event. People who behave aggressively may have an emotional reason (e.g. unfulfilled desires) to which they respond with aggressive behaviour. However, such people do not always behave aggressively in the environment that provides the trigger for their emotions.

Possible reasons for aggression Individuals may become aggressive because of: • Loss of something important (e.g. family, employment, health) • Unexpected events • Excessive use of addictive substances or withdrawal from addictive substances • Reaction to medication • Chronic pain • Forgetting to take or deciding not to take medication.

Principles for effective communication with a Person/s behaving aggressively When communicating with a person who behaves aggressively it is important to: • Respond with patience and understanding • Empathise with the person, not necessarily with their feelings • Use active listening and careful observation 282

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• If appropriate, focus on the problem and possible solutions • Avoid responding to the aggressive statements or threats with aggression – do not retaliate

• Demonstrate interest, attention and concern through non-verbal behaviours

• Remember the principles of assertive communication (see Ch 13); however, some

people may become more aggressive if you attempt to discuss what they are expressing at that time • Validate if appropriate • Avoid confronting if they are violent • Always remember safety of self and others • Position self closest to the door • Use emergency call buttons or duress alarms if necessary and available. If there is a risk of violent behaviour it is important to: • Inform the immediate supervisor of the possible risk • Wherever possible have another health professional present • Ensure the health service knows the exact whereabouts of the health professionals who work with the person, whether on- or offsite • Plan the interaction carefully considering the safety of all involved individuals • Be alert for the safety of everyone involved and if necessary remove self and others from the scene • Stay close to the door or exit • Avoid attempting to physically connect with the person • Call the police if necessary.

Strategies for communicating with a Person/s behaving aggressively

• Remain calm to maximise observation and problem-solving skills. • Ask them to ‘tell you their story’ to explain their strong emotions. This may allow

them to calm themself. • If the person is still in control, state they are being inappropriately aggressive. This may stop the behaviour, potentially providing an opportunity to become calm. • Be aware of non-verbal behaviours and remove yourself if the person is expressing extreme agitation. Among group members, brainstorm ways to respond verbally so you can remove yourself safely. • Engage the person in consideration of their plans for the future and how they might fulfil these plans.

See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is John. You are a 35-year-old man who had an accident at work 5 years ago. You have been experiencing chronic lower back pain since that time. You were on

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modified duties for 2 years and have not been employed full time during the past 3 years. You have seen four doctors and several physiotherapists, chiropractors, podiatrists, massage therapists and rehabilitation providers. You are very frustrated and fail to see how this recent referral will achieve anything different. You feel your divorce a year ago was a result of your pain over the past 5 years. You want to see more of your two children but your pain makes this difficult. Person 2: You are the health professional. The referral indicates this man is prone to aggressive behaviour. You want to avoid aggressive behaviour in order to develop a therapeutic relationship and some appropriate goals.

Scenario two: The female and the health professional Person 1: Your name is Jessi. You are a 16-year-old girl who always passively allows other people to have what they want, regardless of what you may want. You do this because you desperately want to have a ‘place’ in a particular group at school. However, now you cannot control the emotions resulting from repeated hurt, frustration and bewilderment because of your non-assertive responses to those around you. You now respond aggressively to everyone, even your closest friends and family. Person 2: You are the health professional doing a routine assessment and check-up with Jessi. Her responses are aggressive and rude. • How should you complete the check-up?

Person/s experiencing extreme distress (Key words: overwhelming emotion, fear, anxiety, grief, frustration)

Definition of extreme distress An extremely distressed person is someone who is experiencing overwhelming negative emotions including sadness, anxiety, fear and loss.

Behaviours related to extreme distress An extremely distressed person might: • Express the depth of their emotions silently through non-verbal behaviours • Express emotion uncontrollably through paralinguistic means (e.g. crying or sobbing) • Depending on their personality, withdraw from contact with others.

Individuals most susceptible to extreme distress Individuals may be susceptible to extreme distress because of: • Strong emotions, including fear, anxiety and grief • Enduring chronic situations such as war or displacement from safety • Conditions causing chronic pain • Loss, including loss of control over their circumstances.

Possible reasons for extreme distress Individuals may become extremely distressed because of: • The impending death of a child, sibling, spouse or parent • An accident 284

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• An attack • Lack of understanding of events or the environment.

Remember there are cultural variations in the expression of emotion. A particular culture might consider extreme emotional expression to be an appropriate response to something that another culture might consider a minor event.

Principles for effective communication with a Person/s experiencing extreme distress When communicating with a person who is extremely distressed it is important to: • Empathise and validate • Listen actively – encourage them to say whatever they need to say • Be silent if appropriate • Comfort in an affirming and encouraging way that does not fulfil the needs of the health professional.

Strategies for communicating with a Person/s experiencing extreme distress

• Be willing to sit in empathic silence. • Avoid mind reading. • Be aware of the appropriate use of touch. • Consider whether gender-specific care might be important (i.e. male to male and female to female).

• If a young person, remember environmental factors (see Ch 10) when

communicating. Young people are often more susceptible to situations that cause distress, and if distressed can have less ability to control their emotions. • If an Indigenous person, involve an appropriate Indigenous health worker. • Remember to debrief confidentially if required to maintain ‘self’.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is David and you are a 40-year-old father of three children. Your eldest son is in the final stages of leukaemia. No-one really knows when he will die. The emotions you feel make it difficult to continue working and supporting your wife, who is also overwhelmed by the situation. You are extremely distressed but desperately trying to appear OK whenever you are with your son or with members of your immediate family. The energy involved in maintaining this appearance is exhausting, but you feel it is necessary. You are now sitting in a waiting area, waiting to see a health professional for an unrelated reason. Although it is only 8.30 a.m. you can only sit with your head in your hands. You would really like to cry, but are not accustomed to crying in public places. Person 2: You are the health professional. You have a busy day ahead and the first person for the day is someone who is new to your service. When you enter the waiting area and see → a man sitting with his head in his hands, you wonder what is wrong and why he looks like

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that at 8.30 a.m. You wonder whether this person works night shifts or is unwell. You discover this man is the person you are scheduled to see. • How will you respond?

Scenario two: The female and the health professional Person 1: Your name is Alice. You are a 16-year-old girl who was born with a deformity of your spine, which produces high levels of pain. You have limited success managing your pain with medication, but use medication episodically under careful supervision. You find the level of pain you experience limits your ability to join your peers in various age-related activities, which at the moment is causing you extreme frustration. Person 2: You are the health professional who has been attempting to assist Alice to increase her involvement in age-related activities. She is demonstrating extreme levels of distress today and has been crying uncontrollably whenever you speak to her. • What will you do?

Some health services offer services for distressed people and thus the health professionals working in such services will often encounter extremely distressed people. However, it is possible for all health professionals to encounter distressed people in the course of their working life, regardless of the particular context of the health professional. When relating to such people it is challenging but essential to communicate in a manner that fulfils the needs of the individual(s) and considers the communicating people.

Person/s reluctant to engage or be involved in communication or intervention (Key words: uncertain, avoidant, reluctant, resistant)

Definition of reluctance to engage A person who is reluctant to engage or be involved is someone who may be: • Unwilling to be or do in a particular situation, environment or context • Unsure about the situation, environment or context • Unsure about something particular in the situation, environment or context • Unsure about someone in the situation, environment or context.

Behaviours related to feeling reluctant to engage A person who is reluctant to engage or be involved might: • Verbally or non-verbally refuse to engage, be involved or collaborate • Deny there is a problem • Take action that appears cooperative, but resist non-verbally • Express themself through aggression and sometimes violence • Avoid looking at the health professional by turning their head away • Withdraw as far from the health professional as possible.

Individuals most susceptible to feeling reluctant to engage Individuals who may be susceptible to feeling reluctant to engage or be involved include: • Children • The elderly 286

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• Individuals scheduled for complicated procedures • Individuals attending a health service for the first time • Individuals who are unfamiliar with something or someone in the health service • Individuals with a previously negative experience of a health service • Individuals with inability in some area(s). Possible reasons for reluctance to engage Individuals may be reluctant to engage or be involved because of: • Apprehension from the unfamiliarity of the situation, environment or context • Feeling afraid about possible events in the situation, environment or context • Previous experience of negative emotions in that particular situation, environment or context, or in a similar one • Reluctance to move because of pain or discomfort • Not being in the situation, environment or context by choice, but because (i) of an emergency, (ii) of a forced admission (Community Treatment Order) into a mental health institution, or (iii) their family might be ‘pushy’ • Not accepting or denial of their need • Feeling unsure about the expectations of the situation, environment or context • Not understanding what they are being asked to do or say • Not understanding the particular role or expectations of the health professional • Feeling they are unable to perform the required tasks or requested actions • Being physically unable to perform the required tasks or requested actions. In common with all Person/s the health professional meets, reluctant people are feeling vulnerable for many different reasons.

Principles for effective communication with a Person/s reluctant to engage When communicating with a Person/s who is reluctant to engage or be involved it is important to: • Make introductions • Listen actively • Validate • Question sensitively • Provide clear information in various forms • Take care to ensure all non-verbal messages are positive • Confront false beliefs and attitudes (if appropriate) to emphasise reality.

Strategies for communicating with a Person/s reluctant to engage

• Remain calm • Check they understand the language you are speaking • Consider your non-verbal behaviours – avoid overbearing or intimidating body language

• Validate their responses • Clearly explain the reasons for each occurrence • Clearly explain the expectations or expected events • Clarify wherever there is uncertainty • Ask if they do or do not want something, and if possible do that to reassure them • If violent, indicate their behaviour is inappropriate and call for assistance. 287

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Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional NOTE: When working with children it is important to remember that the parents and siblings are part of their environment, and thus must be considered when gathering information. The parent is usually the expert in terms of knowledge about the skills and behaviour of their child. Person 1: You are a 10-year-old boy called Carl and you need assistance from a health professional. As you arrive with your mother for the first appointment you are reminded of the last time you went to see a health professional. That person was not friendly – they kept talking to your mother, not to you, and they physically hurt you. You do not want to relate to the health professional because they look just the same as the last one. You stand behind your mother and cling to her, hiding your face in her back. You refuse to look at the health professional or respond to any of their attempts to talk with you. Person 2: You are Carl’s mother. You are very surprised at Carl’s behaviour because he does not usually behave like this and you have no idea why he is clinging to you. You have no idea how to respond to promote a relationship between Carl and the health professional. Person 3: You are the health professional. You know 10-year-old boys do not usually relate in this manner and you would like to tell him to ‘get over it’ and act his age! However, you remember the three steps in effective communication and wish to apply these to this boy and his mother who are seeking your assistance.

Scenario two: The female and the health professional Person 1: You are a 79-year-old lady who prefers to be called Mrs Jones. You love attending for treatment and try to be very cooperative despite the discomfort you sometimes feel because of the treatment. You often require assistance to find the toilet and are easily disoriented when trying to find the exit after treatment. One day you could not actually find your car in the parking lot. You are anxious to hide the fact that you have been experiencing more confusion lately because you do not want to be made to leave your home, where you have lived for 30 years. You manage well when at home in your familiar environment. You always say you are fine when you are at home – that there really is not a problem – whenever the health professionals suggest they contact the home-care organisation. You do not want anyone in your house – you just want to be able to stay there and be independent. Person 2: You are the health professional. You have noted the regular disorientation Mrs Jones exhibits when attending for treatment. You note that Mrs Jones appears to take pride in her appearance because she is always well dressed and clean. But you are wondering whether her appearance is an attempt to pretend that things are OK. You are concerned about her safety and think Mrs Jones might require some assistance at home. You ask her if she would like you to contact the appropriate organisation to arrange some assistance with cleaning and meals at home.

There are many reasons for reluctance to engage on the part of the Person/s. A health professional may require more than a warm, friendly persona to achieve positive outcomes. The health professional may require specific communication skills and strategies to encourage the Person/s who is reluctant to engage in order to achieve family/Personcentred practice. 288

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Person/s experiencing depression Interesting facts: Different types of depression require different management. Depression can take different forms and have different affects depending on the time of life. Rates of depression in women are twice as high as they are in men. (Key words: depression, depressed, common)

Definition of depression Depression is a mood disorder recognised by a lack of interest in previously enjoyable activities and/or limited feelings of pleasure in life. It may include feelings of helplessness and hopelessness.

Behaviours related to feelings of depression Men who are depressed may experience fatigue, irritability, sleep problems, and loss of interest in work and hobbies. They may exhibit anger, aggression, violence, reckless behaviour and substance abuse. Men experiencing depression are at a higher suicide risk, especially older men. Women are more prone to experience feelings of guilt, sleep excessively, overeat and gain weight. Adolescents will often be irritable when experiencing depression. They may be hostile, grumpy or easily lose their temper. Unexplained aches and pains are also common in young people with depression. They may experience difficulties at home and school, indulging in drug abuse and self-loathing. People experiencing depression may: • Sleep a lot or have very little sleep • Lack interest in eating or eat too much and gain weight • Have difficulty concentrating, making decisions and remembering things • Engage in escapist behaviour including substance abuse, reckless driving, dangerous sports • Be angry, short-tempered and irritable, sometimes aggressive • Demonstrate self-loathing attitudes and language.

Individuals most susceptible to feelings of depression

• People feeling worthless • People with limited social contact • People who have lost a significant other

• People constantly feeling they make mistakes

• People feeling guilty • People overcommitted financially • People experiencing loss of employment • Women who have recently given birth • People experiencing constant pain • Individuals feeling high levels of fatigue.

Possible reasons for feelings of depression

• Loneliness • Lack of social support • Recent stressful life experiences • Family history of depression • Marital or relationship problems

• Financial strain • Early childhood trauma or abuse • Alcohol or drug abuse • Unemployment or underemployment • Health problems or chronic pain. 289

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Principles for effective communication with a Person/s experiencing depression

• Demonstrate unconditional positive regard • Validate • Employ active listening • Clarify their understanding of any discussed procedures or information • Use positive non-verbal messages • Confront false beliefs and attitudes (if appropriate) to emphasise reality • Where appropriate provide information about depression • If they are not receiving specific assistance, explain where they can receive assistance. Strategies for communicating with a Person/s experiencing depression

• Relate consistently • Do not ignore any attempts they make to discuss their depression • Remain willing to discuss their feelings if they initiate the conversation • Reinforce the truth about their abilities and their life • Provide regular encouragement and positive affirmation • Sensitively challenge negative self-talk. Avoid saying things like: • It’s all in your head • We all go through times like this • Look on the bright side • You have so much to live for why do you want to die?

• What’s your problem? Just snap out of it • What’s wrong with you? • Shouldn’t you be better by now? • I can’t do anything about your situation.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: You are a 17-year-old young man named James who lives in a rural setting. You are preparing for your final school exams, which will decide your future. You are friendly and helpful and this year you are school captain. The staff and the students at the school affirm you, even those in the primary or junior school. You usually achieve well in all your subjects at school and enjoy playing for the school soccer team. You have recently been feeling overwhelmed by all the responsibilities you have at school, find it difficult to motivate yourself to attend school and have been consistently avoiding soccer training. You do not seem to enjoy it anymore, even though Coach wants you to ‘try out’ for the state team in a few weeks. You are really not interested anymore and have begun to think that life is not worth living. You have not told anyone this and find it hard to talk about how you are currently feeling. However recently you have been experiencing pain in your right knee and your mother has insisted you see a health professional for assistance with your knee. Person 2: You are the health professional seeing a young man called James for the first time. You have heard of James and know he is the captain of the local regional high school. You know he is an excellent soccer player and a state coach is visiting town in a few weeks to assess the local outstanding soccer players, so you are eager to help him with the pain in his knee, so he can → continue playing soccer and maybe even join the state team.

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Scenario two: The female and the health professional Person 1: You are 29-year-old Rachel who has recently given birth to your first son, Jackson. He is a bonny, cute baby who is developing well – but he keeps you awake at night, produces an amazing amount of extra work and seems to eat constantly and need his nappy changed and then washed ‘every time you turn around’. You are finding it very difficult to understand why he cries all the time and you need more sleep. You usually pride yourself in keeping a clean and tidy house and are currently unable to find basic things like bills to pay, because the house is so messy. There is a constant pile of washing and the kitchen is always full of dirty dishes as your husband works long hours and travels an hour to work every day. Some days you wish you could just crawl away and ignore everything, but that makes you feel guilty and a failure because you are unable to manage all the demands on your time. This little baby that constantly demands your attention and needs so much is making you wish you could ‘run away’. You have a community nurse coming today to monitor the development of the baby and how you are managing breast-feeding – you feel hopeless because the house is so dirty and messy. Person 2: You are the health professional who must visit Rachel and her baby today. You notice the mess in the house and wonder how Rachel is managing. You also wonder if she has any postpartum depression.

PERSON/S IN DIFFERENT STAGES OF LIFE An individual in any of the four of the different stages of life – child, adolescent, adult and a person who is older – may present with particular attitudes and associated needs. When assisting such Person/s it is important to remember the abilities and events typical of these stages.

A child (Key words: child, children, childhood, dependent, under-age) When assisting children it is essential to remember the parent is the expert about the child. They are familiar with the skills and abilities of the child and if they indicate the child can do something you do not witness, they will probably be correct. It is important to avoid talking about children when they are present. Whether the child can understand the words or not, they are able to understand non-verbal cues and thus will respond with a particular emotion or behaviour.

Definition of a child For the purpose of this section, a child is a person aged 0–16 years.

Behaviours related to being a child The behaviour of a child will depend on their age, their personality, their culture, the experiences of their upbringing, the stability at home, their sense of security, the reason for the referral and the presence of a significant adult. 291

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A child might be: • Quiet and non-engaging • Shy and hiding • Crying and clinging • Happy but initially untrusting

• Looking to their parent for assurance • Angry and aggressive • Curious and wanting to explore. • Distractible and avoidant.

Children most susceptible to experiencing difficulties when attending a health service Such children include those who: • Have a history of negative experiences in life • Are very young and are not accustomed to separating from a parent • Are from a different cultural background • Are unfamiliar with healthcare settings • Are experiencing physical or emotional pain • Are very ill • Have a previous negative experience with a health professional • Are a victim of an accident, attack or natural disaster • Have communication difficulties • Have a visual or auditory impairment.

Possible emotions a child might experience when attending a health service A child might experience emotions related to: • Fear and anxiety • Physical or emotional ‘pain’ from any source, causing frustration and despondency • Boredom • Isolation and displacement.

Possible reasons for these emotions

• Awareness that they are different to other children • They may be experiencing physical pain • Uncertainty and discomfort because of lack of familiarity with the environment, people and procedures

• Difficulties at home, school or in the neighbourhood. Principles for effective communication with a child When communicating with a child it is important to: • Make introductions at a different language level for the parent compared to the child • Demonstrate empathy • Carefully observe the responses of the child • Validate their perceptions (it may be necessary to validate the perceptions of the parent if the child is unable to communicate) • Make appropriate use of non-verbal behaviour – if there is no common language, non-verbal or visual communication is essential to develop rapport and a therapeutic relationship • Allow time for the child to trust you; to feel comfortable and safe 292

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• Monitor the language level – use simple explanations and provide warnings about upcoming events and termination of the session

• Touch only if appropriate • Establish boundaries and expectations for behaviour • Relate consistently with consistent expectations • Practise holistic communication • Disengage, and if appropriate, with indication of a future meeting • Ensure family-centred practice. Strategies for communicating with a child

• Talk directly to the child. • Where possible either ‘go down’ to their level or raise them up (if safe) to your level.

• Avoid talking about the child with the child present. • Explore toys and activities that are meaningful to the child and use them to engage, comfort and relax the child.

• Provide a safe environment. • Understand the culture of the child. • Understand the familial, social, physical, cognitive, cultural and spiritual background as well as the expected developmental level of the child.

• Tell the child what will happen and when it will happen. Give adequate warning about when the session will finish to facilitate smooth transition from the completion of the session to leaving the room. • Respond to the non-verbal behaviours of the child with verbal questions or reflective comments about the observations. • Avoid touching the child wherever possible or ask permission to touch the child from the child and the parent. • Avoid distractions and use silence if appropriate to encourage concentration and focus.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the trained volunteer Person 1: You are Mohammad, a 12-year-old Sudanese boy whose family has taken refuge from the Sudan. You have learnt some English, but still do not understand many of the behaviours of those around you, and you cannot read or write English yet. Your older brother was killed just before your family left the Sudan. Your father does not have a job yet and your mother works until late at night for little pay washing dishes in a Chinese take-away shop. You do not feel accepted at school, even by the other Sudanese who have been there longer than you and often tease you in Arabic. Your little sister seems happy and has several friends. You have been feeling angry and you have begun to verbally abuse teachers and the other boys from the Sudan at school. You do not enjoy relating to anyone other than your family. Person 2: You are a trained volunteer for the local multicultural centre and you run a group for → ‘at-risk’ boys with refugee status. This afternoon is the first time you will meet Mohammad.

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You know he is sometimes violent, but that is all you know. Many of the at-risk Sudanese boys are violent. You want to assist Mohammad to settle and integrate.

Scenario two: The female and the health professional Person 1: Your name is Elise and your 2-year-old daughter, Jenny, has just been diagnosed with an intellectual disability. She is your only child and has been a joy to your immediate family. You are confused and unsure. You are afraid of the future and while you wait to see the health professional you become sad and teary. You watch Jenny play on the floor at your feet. What does this mean for her future? She is so beautiful and you had such wonderful plans for her future. Person 2: You are the health professional who must assess Jenny’s abilities. When you enter the waiting area you call Jenny’s name and notice a woman flinch and look up. She smiles at you and lifts Jenny from the floor. How will you relate to Jenny and Elise in this initial session? What are your communication priorities? • Elise does not want Jenny to leave her lap and nor does Jenny want to leave it. How will you encourage them both?

Children are often the focus of a specialty health service. However health professionals from many contexts may need to relate to children. It is both challenging and rewarding to work with children, for whom particular skills are required to ensure effective communication and family-centred practice. NOTE: There are many groups and associations that provide information and support for parents of children with particular conditions (e.g. Autism Association, Royal Institute for Deaf and Blind Children).

An adolescent (Key words: adolescence, adolescent, teenager)

Definition of an adolescent An adolescent is someone who is: • A youth • Between childhood and maturity • Growing up or maturing • Experiencing physical changes in their body that indicate development to maturity • Experiencing emotional insecurity, social and cognitive challenges, and often spiritual independence. The age of maturing varies depending on gender and ethnicity. In some cultures there are expectations of particular genders at a certain age. Once these expectations are met, regardless of age, the individual assumes the role and responsibilities of an adult and is considered an adult in all aspects of their existence. In most Western cultures, age determines the arrival of adulthood. Individuals regardless of gender assume some of the responsibilities of adulthood from 14 years onwards (e.g. paid employment at 14.9+ years, driving a car at 17–18 years) but are not considered 294

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adults until they reach 18–21 years (when they can purchase cigarettes and alcohol). It is not the emotional, intellectual and social maturity of the individual that officially indicates the arrival of adulthood, but rather age.

Behaviours related to being an adolescent An adolescent may: • Engage in high-risk behaviours • Exaggerate their actions (act out) to gain attention • Withdraw and keep to themself • Behave in ways that create direct conflict with their values in order to maintain a position in a social group • Be verbally abusive and argumentative • Experiment with various substances • Behave in a happy and carefree manner.

Adolescents most susceptible to experiencing difficulties when attending a health service Adolescents susceptible to experiencing difficulties when attending a health service include those who: • Are different to their peer group • Do not want to receive assistance from a health professional • Are from a different cultural background • Are unfamiliar with healthcare settings • Have difficulties adjusting to the changes occurring in their body • Experience physical or emotional pain • Have a previous negative experience with a health professional • Are a victim of an accident, attack or natural disaster • Have a visual or auditory impairment • Have an intellectual disability.

Possible emotions an adolescent might experience Emotional responses in adolescents are complex and often unpredictable for both the individual and those around them. An adolescent may experience extremes of emotion including: • Anger • Feelings of inadequacy • Loneliness • Feeling like they ‘do not fit’ • Confusion • Hatred of their appearance • Isolation • Insecurity • Restlessness • Anxiety • Conflict and stress • Feelings of unimportance • Feelings of rejection • Boredom • Dissatisfaction • High energy.

Possible reasons for these emotions An adolescent undergoes complex changes in their physical, emotional, cognitive, social and spiritual self during adolescence. An adolescent may experience extremes of emotion because of: 295

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• Hormones • Social pressures • School pressures • Home pressures

• Cultural differences • Dominating need for social interaction. • Focusing on their own needs • Their friends.

Principles for effective communication with an adolescent The principles of effective communication apply to all individuals seeking assistance. However it may be more difficult to communicate using these principles when relating to an adolescent unless the health professional is aware of the needs of the adolescent, and self-aware about the effects of their own experience of adolescence. When communicating with an adolescent it is important to: • Be self-aware – of own experiences, values and beliefs • Practise holistic communication • Understand and be sensitive • Demonstrate unconditional positive regard • Demonstrate respect • Adhere to ethical boundaries • Accommodate cultural differences • Confront inappropriate self-talk, values and beliefs • Observe their non-verbal behaviours.

Strategies for communicating with an adolescent

• Aim at family/Person-centred practice. • Establish a safe environment, both emotionally and physically. • Use of a holistic approach is vital because the physical symptoms may be covering

underlying needs. • Be aware of personal limitations – the health professional does not need to meet all the needs of every adolescent seeking their assistance. • Relate consistently with consistent reactions and explanations. • Be committed to and compassionate for the person, not necessarily their behaviour. • Demonstrate understanding and interest through the use of activities they find meaningful. • Be aware of the non-verbal behaviours of all communicating individuals. • Explicitly state the expectations of behaviour. • Establish clear boundaries.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Jake. You are 17 years old and in your final year at school. You have found adolescence difficult. It has been difficult to concentrate and therefore learn at school. You are not sure why your parents insisted you stay at school because you rarely pass your exams. The teachers do not really understand you and only one or two seem to care. You have some → great friends and do outlandish things together – not life-threatening things, just ‘out-there’

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fun things. Recent assessments indicate you have attention deficit hyperactivity disorder (ADHD) and you have begun to take medication for this. You do not like the medication because, although it makes you calm and gives you greater control, you no longer feel you are yourself. You love working outside in gardens and have begun working in the grounds of a local health service, mostly during your school holidays. Person 2: You are a health professional who often has lunch in the grounds of the health service. You have begun chatting with one of the new grounds-people, Jake, and find he lacks confidence and a sense of self-worth. While this is typical of many adolescents, you feel there is more about Jake than typical adolescence. You have decided to befriend, encourage and affirm him so you often have lunch with Jake. • Do you need to be able to encourage and affirm Jake? Why? • How can you encourage and affirm him?

Scenario two: The female and the health professional Person 1: Your name is Ruth and you are a well-known local 15-year-old with a promising career in surfing. You are the leading junior female surfer in the country. You were excited when you signed a contract with an international surfing label for sponsorship and promotions. You are popular with teachers and students, and your parents often tell you how proud they are of you. You have applied yourself at school and at the local surf club. You love surfing and at every opportunity you are at the beach on patrol or on your board. In a recent and unusual shark attack you lost your right arm below the elbow. The experience was very traumatic, but you have other things to concern you. What about the contract you have with the surf label? And your surfing career – what happens now? You are devastated because surfing is your life and you cannot image surfing without your lower arm and hand. You were hoping to be school captain in a few years but think no-one would nominate someone without an arm. You are right-handed and you cannot image how you will ever write without your right hand. You are sure that boy you like in the surf club will not even look at you now. You were looking forward to driving; you often imagined driving up the coast with your board on top of the car and not a care in the world. How will you ever drive a car without your right hand? You have so many questions and fears. All your parents can say is You’re alive – that’s all that matters! You wish you could find someone who understands your fears and could answer your questions. However you do not enjoy talking about or feeling negative emotions, so you need convincing to openly discuss your feelings. Person 2: You are a health professional and also a senior member of the surf-lifesaving club of which Ruth is an active member. You have been mentoring Ruth for some years and, while you are devastated by the attack, you know Ruth has greater needs than you. You have been spending time with Ruth but feel helpless. You know of another young woman who surfs without an arm because of a car accident, and you have contacted her to organise a time to meet with Ruth. You go to see Ruth to tell her about the other woman and arrange a time to meet, but first you want to be sure that Ruth is willing to talk about her experience and associated feelings.

Adolescence can be an uncomfortable time for most people, the adolescent and those around them. Adolescents feel vulnerable because of their stage of development. If an adolescent requires the assistance of a health professional, their feelings of vulnerability may multiply exponentially and thus the health professional must communicate using all of the principles of effective communication.

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An adolescent values their peer group and thus, wherever possible, it can be beneficial to include individuals of the same or similar age in the assistive process. Adolescents with similar experiences can be very therapeutic for an adolescent who requires assistance from a health professional.

An adult (Key words: Adulthood, independence, responsible, decision maker, adult, financially independent)

Definition of an adult An adult has completed their growth and development, and assumes responsibility for their own needs and often the needs of those dependent upon them. In some cultures adulthood is defined according to age, in other cultures according to achieving particular skills and assuming specific responsibilities.

Behaviours related to being an adult An adult may: • Assume responsibility for their own needs • Make decisions independent of other people • Manage their own time to meet all responsibilities • Demonstrate competence in daily life • Be competent in areas of chosen employment • Take initiative in daily activities, including leisure activities • Cohabit with a partner and raise children.

Adults most susceptible to experiencing difficulties when attending a health service Adults with: • An unexpected illness or emergency • Pain of unknown origin • Previous negative interactions with a health professional or health service • An ill significant other • A partner in labour • Limited knowledge of the health service environment • Limited knowledge of the roles of particular health professionals.

Possible emotions an adult might experience when relating to a health professional The emotions an adult might experience include: • Confusion • Despondency leading to depression Fear • • Anger Frustration • • Disappointment.

Possible reasons for these emotions

• Change in life situation • Illness of a family member • Desire to protect significant others 298

• Overwhelming financial commitments • Retrenchment • Inability to achieve goals.

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Principles for effective communication with an adult When communicating with an adult it is important to do the following: • Friendly but professional introductions • Clarify understanding • Honesty • Validation and encouragement • Empathy • Calm and clear explanations • Respond to non-verbal messages and • Affirmation questions • Appropriate assertion if in conflict Acknowledge strengths and difficulties • • Well designed written information. • Active listening

Strategies for communicating with an adult

• Remember the whole person and use holistic communication principles. • Do not forget any significant others – use a family/Person-centred approach. • Use non-verbal messages to communicate acceptance. • Allocate (invest) time to answer questions and clarify meaning or future events. • Ensure you ‘follow up’ their concerns and respond in a timely manner. • Consider the need for gender specific care if they are distressed and seeking comfort. • Retain professional boundaries while maintaining a demeanour of equality.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: You are Joe and your wife has just left you for another man. She and her new partner have relocated to the UK for work reasons. You have a large mortgage and two children. Sally, your four-year-old daughter, misses her mother and cries a lot. Nathan, your nine-year-old son, has begun acting out at school and is very sullen when at home. You are struggling to work and care for the children. Your job consumes 12 to 15 hours a day and does not leave you either energy or time to spare. However your income allows you to hire a housekeeper who comes every day to prepare meals and organise and clean the house. Your parents are also helpful and spend time with the children some days. Sally has caught an infection from her 2 days at preschool and is running a fever and coughs through the night – she cries and asks for her mother several times each night. You are exhausted and are wondering if you should resign from work and try to care for the kids. It is 11 pm and you decide to take Sally to the after hours doctor. You wake Nathan to come with you, as you do not want to leave him in the house alone. Nathan screams and yells he is old enough to stay home alone – and says he wants to stay in bed. The three of you are finally at the surgery – there is about a one-hour wait, however a heath professional comes to do a preliminary questionnaire before you see the doctor. You do not want to answer questions – besides you would not know, your wife knew all the immunisation and medical history questions – you just want to see the doctor and get the children back in bed (not to mention yourself!), which you make quite clear! Person 2: You are the health professional who does a verbal questionnaire about medical history when there are more than four people waiting to make it quicker for the doctor. You have just begun your shift, so feel fresh and relaxed, and thus are happy to chat to gain the answers. This man → however is not very cooperative and tests your patience and skills in gathering information.

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Scenario two: The female and the health professional Person 1: You are Julie and two weeks ago you lost your job. As the sole breadwinner for the family you would like to find other employment relatively quickly. You were not worried initially as you have substantial savings that will cover the cost of living for a few months – provided there are no unexpected expenses! You know you will find another job soon because you have a soughtafter skills set. However your husband, who has an acquired disability that means he cannot work, wants to cancel the family holiday to Europe as he is concerned about how the family will manage when the savings are gone, and the trip will consume a large portion of those savings. You received a rejection for a job application this morning, but you have two others pending so you are trying to feel positive. On the way home from taking the children to school, your car developed a major problem with the gearbox and had to be towed to your mechanic. The mechanic looked at it and thinks it will cost several thousand dollars to make the car roadworthy. You are currently sitting in the waiting room of your local doctor because Melanie, your daughter, has a very high temperature and has been sent home from school. She has been complaining about aches and pains for a few months and while previously you thought it was not serious, you are beginning to wonder if she might have something major wrong. This will cause a problem as your health insurance was connected to your employment and lapsed when you lost your job. This is the first time you have been really worried about your lack of employment and thus you sit very quietly looking at your sleeping daughter, struggling to hold back the tears. The person that has just entered the room sits opposite you and asks you why you are there. There is no one else in the room and Melanie is asleep, so you decide to tell her your story. Person 2: You are a heath professional working in the community for the doctor. You need a signature and a quick word with the doctor about someone you saw yesterday. You are not dressed in a uniform, however as a heath professional and an employee of the doctor you can see the woman opposite you is struggling to compose herself. There is no one else in the room, so you ask her name, and tell her you noticed she is very upset and wonder if you can assist her.

A person who is older (Key words: ageing, elderly, senior, over 65, frail-aged)

Definition of a person who is older An older person may be someone who: • Experiences the constraints of ‘age’ when moving, thinking, relating or feeling regardless of their chronological age, joint stiffness or hair colour • Has reached the age of retirement • Is eligible to join a Seniors organisation.

Behaviours related to being an older person An older person – in common with any person – might exhibit idiosyncratic behaviours typical of their personality, interests, culture, upbringing, generation and life experiences. Older people may not exhibit ‘age-related’ behaviours of any kind – they may live full, independent and meaningful lives. However, an older person who requires the assistance of a health professional might: • Insist on doing a task without assistance and without fear for their safety, regardless of their ability

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• Request assistance even when they are able to complete something independently • Request information repeatedly due to difficulty hearing or remembering • Request glasses and/or written information in large print • Repeat the same information on different occasions • Attempt to monopolise the time of the health professional with complex new needs at every session • Be uncooperative and sullen • Be well-adjusted and enjoy attending the health service.

An older person most susceptible to experiencing difficulties when attending a health service An older person susceptible to experiencing difficulties when attending a health service includes those who: • Have negative experiences of health services • Have never experienced a health service before • Are experiencing some cognitive or hearing loss • Deny they require assistance • Have limited function and participation • Are in pain • Have recently experienced loss of someone or something close to them.

Possible emotions an older person might experience An older person might experience emotions related to: • Fear and anxiety about the future • Fear and anxiety about death and dying • Grief and sadness • Confusion and deteriorating abilities • Depression • Loneliness.

Possible reasons for these emotions

• Previous negative experiences • Chronic diseases and/or multiple conditions • Pain • Feeling that they want to die • Feeling that they do not belong anywhere and cannot offer anything anymore. Principles for effective communication with an older person When communicating with an older person it is important to: • Make introductions • Demonstrate respect • Demonstrate empathy • Provide clear written information with pictures if necessary to clarify meaning • Listen actively • Provide encouraging comfort • Confront inappropriate beliefs and thoughts where appropriate. 301

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Strategies for communicating with an older person

• Use a holistic approach. • Ask them what they would like to be called – they might prefer to be addressed as

Mr, Mrs or Miss rather than their given name until they feel the health professional is not a stranger. • Treat an older person as an equal, regardless of their age, gender, cultural background or abilities. • Listen to and remember their story.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Ron and you are an active 78-year-old man who swims every morning. Since your wife died you have independently cared for yourself and even assisted in caring for your two granddaughters. You have recently had a fall while doing the shopping and currently you require regular treatment for a knee injury. You are not enjoying the change in your functioning and are anxious to return to swimming every day. During your treatment you are polite but do not really enjoy requiring the assistance of anyone. You are accustomed to assisting others, not having them do things for you. This young health professional is very nice but too young to know very much about anything. Person 2: You are the health professional. You have developed a working relationship with Ron and have been attempting to establish how he feels about his recent fall, because you would like to refer him to another health professional who can give him some information about avoiding falls in the future.

Scenario two: The female and the health professional Person 1: Your name is Elsie. You are an 84-year-old woman who lives alone. Despite a coccygeal fusion, osteoporosis of the upper vertebrae of your spinal column and bilateral arthritis of the hands, you have continued to spin, knit and sew. Until recently you were very active, attending line dancing and playing bowls several times a week. However, you pulled a muscle in your leg while line dancing 6 months ago and have not been the same since. You had to stop line dancing and playing bowls. Then, a month ago, just as you were recovering from your leg injury and thinking about returning to line dancing, you pulled a muscle in your shoulder while cleaning your light fittings. You are fiercely independent and despite having a gold card with the Department of Veterans’ Affairs (DVA) you have never thought of using it for assistance. You see a physiotherapist at present who has asked you to consider a home-care assessment to determine whether you might benefit from assistance with your housework and washing. Person 2: You are a health professional who knows Elsie very well and have been asked to convince her to accept home-care for her safety.

People who are older bring a wealth of experience and wisdom to every interaction. Unless experiencing cognitive decline, they do not usually require variation in the style of communication. As for all individuals, effective communication with an older person requires respect, empathy, rapport, empowerment, collaborative involvement in their treatment and, of course, person-centred practice. These characteristics should be evident in the relationship of the health professional with every older person, regardless of any decline in the physical, social, cognitive or emotional competence of that person. 302

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PERSON/S FULFILLING PARTICULAR LIFE ROLES Individuals may fulfil many roles during their lives, for example, colleague, carer, parent, single parent, student and role of group member. These roles make particular demands upon the individual, which may have a variety of effects depending on their stage of life. Health professionals experience various groups in their role and thus the final scenario relating to roles is about the groups found in the health professions. This scenario is unique and thus there are unique steps to follow for the related small group activity.

Person/s fulfilling the role of a colleague (Key words: team, multidisciplinary team, interdisciplinary)

Definition of a colleague in the health professions A colleague in the health professions is: • Any other professional whether inside or outside the health service who works with the health professional to assist vulnerable people • Any other worker who supports the health professional to assist vulnerable people.

Attitudes and/or behaviours expected of a health professional A health professional should be: • Professional • Ethical • Reliable • Respectful • Punctual • Caring • Interested in people • Committed to caring • Sacrificial

• Willing to assist • Self-aware • Thoughtful • Diligent • Supportive of colleagues • Reflective • Reflexive • Accepting of differences • Observant.

Attitudes and/or behaviours not expected of a health professional A health professional should not be: • Self-serving • Self-focused • Non-reflective or non-reflexive • Personally ambitious • Lazy • Judgemental

• Sexually predatory • Resistant • Uncooperative • Slovenly • Racist • Sexist.

Possible emotions a colleague might experience A colleague might experience emotions related to: • Frustration • Betrayal • Grief and loss • Isolation • Disappointment • Feeling unvalued • Feeling misunderstood • Feeling inadequate. 303

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Possible reasons for these emotions A colleague might experience these emotions because of: • Personal experiences that occur outside the work context in family or social relationships • Decisions made by the employing institution • Their own attitudes and behaviour at particular times • The attitudes and behaviour of other colleagues • Unmet expectations • Accidents either at work or in their personal life • A person dying either at work or in their personal life • Attempts to fulfil the unclear expectations of others • Limited resources and pressure of work.

Principles for effective communication with a colleague When communicating with a colleague it is important to: • Use holistic communication • Confront • Listen actively • Empathise • Validate • Show sensitive honesty Clarify • • Give encouraging comfort Understand • • Be assertive.

Strategies for communicating with a colleague

• Demonstrate colleague-centred communication. • Balance acceptance of the colleague with confrontation that empowers them to change inappropriate attitudes and behaviours.

• Do not assume understanding of the behaviour of a colleague. • Demonstrate unconditional positive regard despite the differences. • Use ‘I’ messages to communicate both your negative and positive emotions to a colleague.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional colleague Person 1: Your name is Ian and you are a single parent with three school-aged children. You are often called to emergencies with the children and find it difficult to balance life with work. You love your work as a health professional and have excellent relationships with your colleagues and the people you assist. You work efficiently and always have positive results. Person 2: You are new to this health service and you are Ian’s immediate supervisor. You have noticed that he often arrives late and leaves early without explanation. He works efficiently when he is at work and everyone thinks very highly of him. He appears to have excellent relationships with everyone, as well as positive outcomes. You have a supervision meeting with Ian scheduled for today. • What are your aims for this session and why? → • Role-play the session when you have established those aims.

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Scenario two: The female and the health professional colleague Person 1: Your name is Paula and you have a very busy day of work scheduled in your health service. A colleague notices your schedule and offers to assist you. You are quite surprised because this colleague often appears to avoid work. Together you agree that they will do some easy administration tasks due today that your supervisor has allocated to you. You clarify when they must be done, how to do them and where to place them upon completion. Throughout the day you notice your colleague chatting and reading a novel and you hope they have done those tasks. You have no time to do them yourself. At the end of an exhausting day, you are with this colleague and your supervisor asks for the tasks the colleague had agreed to complete. You look at the colleague, who looks away, and say you have not had time to complete them. The supervisor is not happy that you have not completed these specific tasks and says they hold you responsible. The colleague listens and says nothing. You are angry because you had no time to complete them today. You are now in the room with the colleague, you feel angry and you … (decide what to do). Person 2: You are the colleague who offers to assist then chooses to chat and read instead, thinking that you will get to those tasks later. As the day disappears you think I can do them tomorrow. You watch the supervisor talk to Paula but you cannot see the problem – you said you would do them and you will try to remember to do them tomorrow. You find it difficult to understand why Paula is angry.

Health professionals have a responsibility to care for themselves, their colleagues and the Person/s. Reflection is beneficial in achieving this care in a manner that considers the needs of all communicators within the health professions.

Person/s fulfilling the role of carer for Person/s (Key words: carer, legal and informal, long term, caregiver, guardian)

Definition of a carer A carer is someone who cares for a person with atypical health full time or for more than a designated number of hours each day. (The designated number of hours varies according to legislation.) Carers might be: • Spouses, daughters, sons, siblings, close friends of the same or opposite gender, and sometimes neighbours • A person who is paid to provide care, by either the government or the family of the person who requires care.

Behaviours related to being a carer The behaviours of a carer will vary according to the age of the carer and the condition of the person requiring assistance. A carer might: • Act as an advocate for the person, always indicating their needs and desires • Be constantly doing things for the person, regardless of the abilities of the person • Exhibit non-verbal behaviours that appear opposite to their verbal messages. 305

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Possible emotions a carer might experience A carer might experience emotions related to: • Fear • Inadequacy • Anxiety • Desperation • Confusion • Loneliness • Depression • Denial of the problem Grief • • Isolation: no one can understand Anger • • Hopelessness.

Possible reasons for these emotions A carer might experience these emotions because of: • Spending all their time caring for the person • Social isolation • Responsibility and stress • Limited knowledge about and skill in caring • Loss of hope • Confusion about the implication of recent needs that have resulted in seeking assistance from a health professional • Fear of and anxiety about the future.

Principles for effective communication with a carer When communicating with a carer it is important to: • Demonstrate empathy and sensitivity • Make introductions • Listen actively • Give encouraging comfort • Validate • Answer any questions clearly and honestly • Provide clear and well-organised information about the health service and any services or organisations that will provide assistance and support.

Strategies for communicating with a carer

• Do not avoid the issues – be prepared to respond to the obvious and stated needs of the carer.

• Be prepared to respond to the non-verbal behaviours of the carer – they may send a different message to their words.

• If necessary, refer the carer to other appropriate health professionals or organisations. • If appropriate, confront the fears and feelings of the carer.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Steve. You are 39 years old and married to Marie, who was diagnosed with multiple sclerosis (MS) 7 years ago. You have recently reduced your hours of work to assist → Marie with the maintenance of the house, her personal care and mobility, as well as your

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two children. Marie was falling at home while you were at work, so you reduced your hours to be with her when she most requires assistance. You accompany Marie to every appointment with the health professionals and you know them all quite well. You sit in the waiting area, feeling tired and distressed by Marie’s recent deterioration. You are not sure but you think you need to resign from work and live on your savings and a carer pension. You find it increasingly difficult to fulfil all the roles you have, and you are not sure how you will manage when Marie finally dies. You stop, shocked at the thought – you would rather call it ‘passing on’. Your religious beliefs have been very important to how you manage your emotions and friends from church have been supportive, often cooking meals, doing housework and mowing the lawns for you. However, you are very tired and feel like you need a rest. Person 2: You are the health professional responsible for the needs of Marie, a person with MS. Marie is being seen by a health professional with different expertise today and you have decided to use the time to talk with her husband, Steve.

Scenario two: The female and the health professional Person 1: Your name is Genevieve and you are the main carer for your 6-year-old son, Damien, who has cerebral palsy (CP). Damien is a boy with a wonderful sense of humour who is confined to a wheelchair. Although you usually anticipate what he wants, he communicates using sounds, gestures and an augmentative communication system. You are also providing meals and some house maintenance for your ageing father who lives in the next street. You are tired and wondering how you can continue to care for both your son and your father. So much with Damien takes so long; you want to encourage him to feed himself and do some of his dressing himself, but it takes much longer when you give him time to do things for himself and you do not feel you have the time. Person 2: You are a health professional who has not met Genevieve before, but have been working with Damien on school days. Genevieve has arrived early today and you go to meet her. You are committed to family/Person-centred practice and want to find ways to encourage Damien to feed himself at least a few teaspoons of food every day instead of being fed everything.

Person/s fulfilling the role of parent to a child requiring assistance (Key words: parents, foster-parents, role models, family, legal guardian, uncertain)

Definition of a parent A parent is someone who: • Has been part of creating the ‘child’ • Is legally responsible for the ‘child’ • The ‘child’ views as their parent or parent figure – their protector, provider and model. A ‘child’ is someone who has a parent and may be of varying ages.

Behaviours related to being a parent with such a child The behaviours related to being a parent will depend on the age of the child. Such behaviours are often related to the feelings the parent is experiencing. 307

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When the ‘child’ is young a parent might be: • Protective and even angry on behalf of the child • Anxious to understand everything related to the child • Controlling of the child • Able to coax the child into engaging and being involved in the process • Able to reassure the child and provide safety for the child. When the ‘child’ is an adolescent a parent might be some of the above and/or: • Protective and overbearing • Accusatory, depending on the cause of the need for a health professional. When the ‘child’ is an adult the behaviour of the parent might depend on the quality of the relationship with the ‘child’ and the nature of the reason the ‘child’ is seeking assistance from a health professional.

Parents in these situations most susceptible to experiencing difficulties when attending a health service The parents susceptible to experiencing difficulties when attending a health service may be those who: • Are young • Have an intellectual disability • Have addictions • Are unfamiliar with the health system • Have unrealistic expectations • Have children with long-term difficulties • Have previously negative experiences of health services.

Possible emotions such a parent might experience A parent might experience emotions related to: • Fear • Guilt • Anxiety • Resignation • Uncertainty • Being lonely • Desperation • Feeling inadequate • Denial • Grief. • Shock

Possible reasons for these emotions The possible reasons for emotions in a parent will depend upon the age of the child and the severity of the condition for which the child requires assistance. However the emotions, regardless of their cause, are as significant as those of the child and require management by the health professional. Family-centred practice is particularly relevant to practice associated with children aged 0 to 16 years. Children exist in the context of the family and should not be assisted without reference to and consideration of that context. Parents may experience negative emotions because of: • Concern for the continued health, wellbeing, participation, functioning and safety of the child • Feeling guilt and responsibility for the condition • Loneliness and isolation • Fear of and anxiety about the future 308

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• Confusion about the meaning of their life if something happens to the child • Inadequacy and desperation • Grief for lost opportunities related to career, friendships, family and siblings, in the case of a long-term condition.

Principles for effective communication with a parent in this situation When communicating with a parent it is important to: • Demonstrate empathy and sensitivity • Make introductions • Provide and explain information • Provide clear and well-organised information about any services or organisations that will provide assistance and support • Listen actively • Schedule time for discussion and answers to pertinent questions • Give encouraging comfort • Validate • Disengage.

Strategies for communicating with a parent in this situation

• Invest time with the parent as well as the child to develop a therapeutic relationship. • Clearly explain and clarify their understanding of the procedures and events regularly – avoid assuming they understand everything.

• Respond to their non-verbal messages. • Acknowledge and use the expertise and knowledge the parent has about the child.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Theo. You are the 72-year-old father of 48-year-old Christopher who has recently been diagnosed with motor neurone disease (MND). You are anxious about the wellbeing of your eldest son who has managed your concreting business for many years. Christopher has been a great son, especially since your wife, Anna, died 4 years ago. He has provided for his wife and your five grandchildren, managed the business expertly and, like you, loves concreting. You have no idea what MND means and you just want your son to go back to his life of participation and providing. Person 2: You are the health professional who Theo sees monthly and you have noticed recently that he is not himself. Whatever is troubling him seems to be affecting the way Theo cares for himself so you would like to explore this and see if he requires some form of intervention.

Scenario two: The female and the health professional Person 1: Your name is Sally. You are a mother of two girls with a husband who is often away for extended periods with his job. Your eldest daughter, Suzie, is 8 years old. She seems to have → difficulty learning and appears to be aggressive at school. Your younger daughter, Katie,

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is 6 years old. They both attend the same school and the behaviour of Suzie at school embarrasses Katie, who is becoming aggressive towards her older sister at home. You have no idea how to help either of your children and feel desperate. Suzie is gentle and loving at home so you cannot understand her behaviour at school. You attend a health service regularly so decide to ask the health professional there for assistance. Person 2: You are the health professional who has been seeing Sally for some time and feel you have a positive therapeutic relationship with her. She has always been cooperative and friendly. You have no idea about the difficulties her children are experiencing, but when she explains you decide you would like to help even though it may not be your area of expertise.

Parents of children, who require the assistance of a health professional, regardless of the age of the children, require a supportive and therapeutic relationship along with their children. The needs of the parents may or may not be different, but the parents are a vital component of the context of the person seeking the assistance of the health professional. Similarly, when parents are receiving assistance from a health professional the children will have similar needs and emotions to those listed in this section. In such situations the child of the person, whether adult or not, is an integral part of the context of the person and will therefore require consideration and effective communication.

Person/s fulfilling the role of single parent to a child requiring assistance (Key words: parenting alone, one-person parenting, sole responsibility, unsupported)

Definition of a single parent A single parent: • Is someone who is attempting to raise the child(ren) alone • Often has no-one with whom they can share the care of the child(ren) • Is often working full-time as well as managing the needs of the child(ren), sometimes without the support of extended family.

Characteristics single parents may expect of themselves Single parents may expect themselves to be: • Competent to meet all the needs of their child(ren) • Able to manage regardless of life events or circumstances • Good at problem solving • Determined • Able to persevere.

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Possible emotions a single parent might experience A single parent might experience emotions related to: • Struggle • Insecurity • Fear • Feeling discouraged • Inadequacy • Frustration • Anger • Anxiety Envy • • Scepticism Resentment • • Constant tiredness • Feeling overwhelmed • Desperation • Depression • Stress • Loneliness • Grief • Isolation • Exhaustion.

Possible reasons for these emotions A single parent might experience these emotions because of: • Feeling rejected through divorce or separation • Any unexpected event • Responsibilities and stress related to their role • Demands of the child(ren) • No respite or rest • Financial burdens • Friends appearing to ‘have it easy’ • Having no sense of being valued • Considering the needs of the child(ren) above their own needs.

Principles for effective communication with a single parent in this situation When communicating with a single parent it is important to: • Listen actively • Establish boundaries • Encourage • Confront • Give information • Disengage.

Strategies for communicating with a single parent with a child requiring assistance

• Avoid critical comments about their parenting. • Imagine how you would manage if you were in their situation. • Set achievable goals.

See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Paul is a single parent to his three children. His wife died 3 years ago and he has managed to care for the children since then. The schools the children attend have after-care facilities but Paul finds this too expensive for three children. Each of the children is allowed one

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extracurricular activity. Craig (15 years old) plays soccer, Lara (14) plays the piano and Lacey (10) settled for tap dancing because her father said horse riding was too expensive and too hard to organise. Paul manages a department store and relies on his eldest child, Craig, to care for the younger girls until he arrives home from work each day. The younger children, Lara and Lacey, do not enjoy the time before their father returns home from work because Craig orders them to do chores around the house while he plays computer games or watches television. Their father is always tired when he arrives home and thanks Craig for the completed chores. Craig does not say he did not do them and enjoys his father’s appreciation. Sometimes one of the girls makes a meal, but often Paul prepares the evening meal and then supervises their homework. They have a routine that allows everyone to fulfil their responsibilities at home, work and school. Organising extracurricular activities and sport is challenging and exhausting, but parents of friends of the children often drive them home. Today Paul receives a call from Craig’s principal requesting an interview with Paul to discuss Craig’s progress. Two hours after receiving that call, a teacher from Lacey’s school rings to say Lacey has fallen at school and needs medical attention. As Paul drives to the school he wishes his wife was alive just so he could have someone with whom to talk. The teacher has assured him Lacey is all right so he is not prepared for the swelling on her forehead or the blood on her arm. He wonders why he thought it was just a scratch and a bruise. Lacey is barely conscious but seems to know he is there. At the hospital Paul waits quietly by his youngest daughter, holding her hand. He misses his wife, especially at times like these because she was so good with sick people. He has no idea how he will manage if Lacey needs extra time and attention, because he only just manages now. He thinks about Craig. That 15-year-old needs more attention than I give him, he thinks. He remembers how hard it was to be fifteen and how many temptations there were when he was growing up. He realises he has not had the time to talk with Craig about this the way his father did when he was about twelve. So much of his energy goes in just getting the basic things done each day. Someone comes to take Lacey for an X-ray; Lacey does not notice that Paul does not go with her. Another health professional arrives to ask a few questions and to see what Paul needs. • If you were that health professional, what questions would you be required to ask? • Answers to some of these questions would lead you to ask further questions – what might they be? • How important might the story of Paul and the children be for achieving the goals associated with Lacey’s care?

Scenario two: The female and the health professional Jenna is a 33-year-old woman who is a single parent to 6-year-old Jonah. Jonah is currently receiving speech pathology, occupational therapy and physiotherapy for delayed speech, attention deficits and gross motor coordination. A podiatrist has made arch supports for Jonah and this has helped his gross motor performance in some areas, but he needs assistance to develop his muscle tone and strength. Jenna and her husband separated 5 years ago. Jonah always spent the weekends with his father until recently, when his father moved interstate. Jenna found that the break from caring for Jonah on the weekends helped her manage during the week. It also meant she did not have extra expenses on the weekends because Jonah’s father paid for the movies and other expensive activities Jonah liked doing on the weekends. Since that time, Jenna and Jonah seem tense when they are together and they often yell at → each other out of frustration. Jenna says she hates yelling, but she gets so frustrated when

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Jonah will not listen to her. Jenna says she is really struggling with being alone. She finds it difficult to be responsible for Jonah without a break because he has particular needs all of the time. She is unsure how to manage the frustration and anger she feels most of the time. She is not always frustrated with Jonah, just with their situation. • If you were a health professional involved with the care of Jonah, how would you approach this situation? • What are the aims of communication with Jenna?

As a large group, share the main points discussed by each small group about these scenarios. Consider various strategies that may increase the effectiveness of the communication in a similar situation.

Person/s fulfilling the role of a student (Key words: studying, learning, professional practice, clinical experience, applying theory)

Definition of a student in the health professions A health professional student is someone who is not fully qualified in their chosen health profession. Students usually visit clinical settings to consolidate theory and learn skills, and may become excellent health professionals in their particular profession. They might be observing, practising or consolidating, but ultimately they are connecting theory with practice. Being a student means individuals might: • Feel underpaid and overworked! • Feel isolated if away from family • Find balancing work and study hard • Feel pressure to party and abuse alcohol • Feel inadequate • Feel pressure to achieve high grades.

Behaviours related to being a student A student might: • Observe enthusiastically • Attempt to compensate for inadequacy • Engage in risk-taking behaviours • Not ask questions • Chatter about irrelevant things.

Possible emotions a student might experience A student might experience emotions related to: • Insecurity • Frustration • Loneliness • Anxiety • Fear • Pressure • Lack of confidence • Feeling overwhelmed. • Disappointment 313

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Possible reasons for these emotions A student might experience these emotions because of: • Lack of knowledge or skills • Pressure to perform and achieve • Feelings of inequality • Social isolation – away from family • Financial pressure and struggles • Different learning styles • Relationship issues • Peer pressure • Poor self-management skills • Imbalance in the activities of life • Different personality types.

Principles for effective communication with a student When communicating with a student it is important to: • Make introductions – to everything! • Consider their non-verbal behaviours • Demonstrate respect and empathy • Understand • Be consistent in communication • Confront when necessary • Provide information • Listen actively • Give encouraging comfort • Disengage.

Strategies for communicating with a student

• Provide clear and detailed information about the expectations of the student while they are on placement.

• Avoid making assumptions about what they know and their life experience. • Become familiar with their learning style and manner of managing information. • Provide immediate and specific feedback in a format that reflects their learning style. • Communicate positive and negative feedback clearly with suggestions of definite behaviours to improve. Be specific.

• Address the causes of their issues not the symptoms. • Adjust your communication style to be approachable – being friends with students is acceptable.

• Avoid intimidating facial expressions and behaviour. • Allow them time for processing information. Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Ryan and you are a third-year student completing a 5-week clinical placement. You were punctual and relaxed on the first day but each day since then you

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have been late and you appear anxious. On the Friday of the first week you lose a medical record required by another health professional. This becomes a major issue because the record for this person is required in court on Monday. Person 2: You are the supervisor responsible for Ryan and, as such, you are responsible for the lost record. Respond to Ryan to achieve the best outcome for all involved individuals.

Scenario two: The female and the health professional Person 1: Your name is Sharon and you are a 19-year-old student health professional. You are currently on placement at a health service with five other students from different health professions. This health service provides activities and education for people who are high functioning but have a history of mental illness. You have been enjoying the placement. You relate well to the various people who attend the service for assistance. You are young, attractive and naturally friendly to everyone. The other students are from other cities and you invite them to the pub after work. A particular male who attends the centre for assistance, Tom, is present when you make the arrangements and assumes he is included in the arrangements. When you arrive at the pub Tom is there waiting for you. You think he is there with his mates. You say Hi and then ignore him, not realising he is there to join you. Some of the other students notice he leaves in a distressed state. You do not worry, saying It’s a free world – he can do what he likes and so can I. I meant no harm; he should have known the arrangements were only for the students. Person 2: It is Monday morning and you are the student supervisor for this health service. Several qualified staff have heard that Tom was admitted to hospital on Friday night. One of the students feels guilty because she knew Tom was in the room when Sharon arranged to go to the pub, and she knew it was not appropriate to make the arrangements in the presence of a person seeking the assistance of the centre. This student has told you everything that happened at the centre and the pub. You ask to speak with Sharon privately to hear her side of the story and to ensure she does not behave in this way again.

Student health professionals are the future of their profession. They deserve and require effective communication and opportunities to develop their skills in communication as well as specialised assistance to successfully complete their program.

Groups in the health professions (Key words: groupwork, group dynamics, group growth) The health professional might encounter two major kinds of groups during their practising life. The first type of group is one in which they are a member of a team or group of people. Such multidisciplinary or interdisciplinary teams may be found in public or private health services. Such teams aim to help those seeking their assistance. These teams may consist of people with different roles and different skills. The people may work for the same health service or for different services. As a member of a multidisciplinary team, it is important to understand the workings of a group and the possible experiences groups may provide. The second type of group often has therapeutic or educational goals, and is one in which the health professional may be the leader or facilitator of the group. 315

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Each of these groups require trust, commitment to group goals and participation in group activities from all participants, whether group members or group leader. Groups have a life of their own and, while beneficial, require particular knowledge and skills to maximise the benefits.

GROUPS IN THE HEALTH PROFESSIONS • • • • • • • •

Decide what types of groups occur in the health professions. List the stages of growth in a group. List the emotions typically experienced in a group. List the expectations of group behaviour (group norms) for a multidisciplinary health professional team, considering the possible needs of group members and the health service. List the expectations of group behaviour (group norms) for a therapeutic group, considering the possible needs of group members. List principles for effective communication to remember when communicating within a group. Give reasons for the need to remember these principles. Suggest strategies for communicating effectively within a group. Relate the strategies to the goals of your particular health profession. Check your answers against the information below, noting any additional thoughts or ideas (of the group or from the information below).

Types of groups offered in health services Health services may offer: • Educational groups • Therapeutic activity groups • Life skills groups • Healthy lifestyle groups • Condition-specific groups (e.g. stroke groups, autism groups) • Therapeutic play groups • Craft groups • Staff development groups • Professional development groups • Support groups • Seniors’ groups • Leisure groups (e.g. non-professional sporting, music, dancing and drama groups).

Stages of group growth Groups experience growth and change as group members become familiar with each other. Initially group members experience uncertainty and possibly limited trust, they then experience differing levels of conflict as the members adjust to ways of relating within the group, and finally most groups achieve working relationships that facilitate group cohesion and productivity. Group members establish their roles and patterns of 316

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TABLE S4.1â•… Stages of group growth Tuckman & Jensen (1977)

Schutz (1973)

Mosey (1996)

Forming

Inclusion

Orientation

Storming

Control

Dissatisfaction

Norming

Affection

Resolution

Performing

Production

Mourning

interrelating as they develop an understanding of self and of other group members. The development of trust and ‘working’ group relationships facilitates fulfilment of group goals. Various theorists describe the stages of group growth (see Table S4.1). Some describe groups with psychosocial goals and others describe groups with task-oriented goals. Each of the theorists in the table describe group stages using words that indicate groups will experience tension followed by ease of relating that facilitates positive outcomes. It is important to remember these stages whether you are a member of a group or the leader of a group. Johnson & Johnson (2009) describe a group as having a leader who guides the group into productivity. The stages they describe often occur when the group is task-oriented. However being a task-oriented group does not mean the group will be free of tension, because time is required to establish mutual understanding and commitment to the goals of the group. The stages take place as follows: • Defining and structuring procedures • Conforming to procedures and getting acquainted • Recognising mutuality and building trust • Committing to and taking ownership of the goals, procedures and other members • Functioning maturely and productively • Terminating.

Emotions typically experienced in a group Yalom & Leszcz (2005) describe the therapeutic factors of groups that create particular emotions for all group members. While the dynamic of interdependent relationships within groups is challenging, they indicate that therapeutic factors occur because of the existence of the group and because of the complex interplay of the experiences typical of group membership. They highlight eleven primary factors that create particular emotions and demonstrate the therapeutic nature of groups. These therapeutic factors include the instillation of hope and the feeling of universality, both of which develop from the fact that other group members have similar experiences. Another therapeutic factor occurs because of feelings that arise from regular expression of experiences and feelings (catharsis) and the sharing of various types of information. Groups allow members to relate with selflessness (altruism) as they develop understanding of the feelings and needs of others through interpersonal learning. This provides opportunity to develop socialising techniques by observing and imitating the positive behaviour of other group members. Groups 317

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provide opportunity for positive group experiences that contribute to group cohesiveness and override possible negative experiences of family groups. They provide opportunity to understand existential factors relating to responsibility, because group membership requires particular behaviour to avoid unpleasant consequences.

Overall group aims There are always overall goals for the existence of a group, whether the group is a health professional team or a therapeutic group. It is important that each group member understands and is committed to these goals. Health professional teams may have mission statements, and therapeutic groups will always have an overall aim. Clear explanation of the overall aim(s) is important to ensure appropriate expectations and behaviour from all group members. Both types of groups assemble for meetings, which have particular goals that contribute to the overall aim of the group. A therapeutic group may have a specific number of meetings and thus a limited group life.

Events of specific group sessions and associated emotions Each group session contributes to the growth of the group and thus the movement through the stages of group development. The events within each session will elicit particular emotions for group members. The structure and preparation of each session will assist in management of any negative emotions associated with the session. The events typical of a group session are as follows: • Welcome and aims: Discussing the aims of the particular session allows group members to leave the events of everyday life and focus on group members and the forthcoming group events. This stage is important because it relaxes group members and allows them to remember their ‘place’ in the group and the ‘place’ of the other group members. • Warm-up: A warm-up allows group members to re-connect with the group norms and goals, and with other group members. • Main activities: The main activities usually fulfil the aims of the overall purpose of the group and the aims of the particular session. • Warm-down/wrap-up: A wrap-up allows group members to reflect upon the events of the group and their relative success in achieving the aims of the session. It allows group members to reflect on the effect of the group session upon themselves and other group members. It also allows disengagement from the group members until the next group session.

Group norms: expectations of group behaviour Group norms are the values that govern behaviour within a group. They are essential in any group because they promote cooperation and cohesion between individuals with different personalities, skills, knowledge and opinions. A group norm is the shared agreement and acceptance of rules that govern behaviour within a group. Norms include expectations regarding acceptable appearance when attending the group, punctuality, expression of emotions, acceptance of group members and confidentiality. A norm can also govern the rate, quality and method of producing outcomes if the group has a task focus. Explicit discussion of group norms in the initial stages of the group process facilitates openness concerning the expectations of particular behaviour within the group. 318

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Principles for effective communication within groups When communicating within groups it is important to: • Remember that non-verbal behaviour is very powerful and can be easily misinterpreted in a group • Give non-judgemental encouragement to all members • Respect, accept, encourage, and use all other elements of effective communication.

Strategies for communicating as a group leader

• Be well prepared with the required equipment and material to facilitate the group effectively and efficiently.

• Clarify and clearly state the group goals. The goals must be relevant and easily • • • •

implemented, create positive interdependence, and encourage commitment from group members. Establish and state group norms and revisit them whenever necessary. Encourage open and accurate expression of ideas and feelings without judgement. Encourage participation, inclusion, acceptance, support and trust of each group member. If appropriate, share the leadership among all group members.

See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion.

Scenario one: A 2-day team development group A health service has about twenty-four staff members who work full time and part time within the service. The person in charge has noticed there are difficulties in the relationships among many of the staff. They have organised a 2-day team-building experience to attempt to develop trust and cohesion among the staff. They expect everyone to attend, including the administration staff, the cleaners, the people who work in the grounds and all health professionals. There is a mixed reaction on the first day because some people feel the cleaners should not be there and others feel the administration staff should not be there. • Decide who should be there and explain why. • How do you think the person in charge should manage these responses, which are contrary to the purpose of the 2 days?

Scenario two: An education group A group educates its members about their condition and how to manage the condition. It runs for 6 weeks for 112 hours each week. You facilitate the group and have other health professionals attend at different times to provide a holistic consideration of the particular condition. • Choose a condition relevant to your health profession that could require an educational group. • Using the specifications listed above (i.e. 6 weeks for 112 hours per week) decide upon the overall goals of such a group, the possible aims of each session and the content. • Indicate whether you will include any other health professionals in the overall program. If so, devise the information and instructions you might give them as a guide for their involvement in the group.

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PERSON/S EXPERIENCING LONG-TERM CONDITIONS Person/s experiencing post traumatic stress disorder and complex PTSD Post traumatic stress disorder (PTSD) is caused by exposure to traumatic events and complex PTSD (C-PTSD) by prolonged exposure to traumatic events. (Key words: trauma, life threatening, emotional illness, devastating life events, helplessness, fear, hopelessness)

Definition of PTSD Post traumatic stress disorder (PTSD) is an emotional illness that is classified as an anxiety disorder. It is usually associated with a horribly frightening, life-threatening, or an otherwise highly unsafe, experience. Women are twice as likely to experience PTSD than men, while ethnic minorities are also more likely than men to develop PTSD. It is estimated that up to 40% of children have experienced at least one traumatic event in their life. Children may exhibit symptoms of PTSD in quite different ways to adults and can experience learning difficulties. A diagnosis of PTSD requires the persistent presence of three groups of symptoms: 1. At least one symptom of experiencing reoccurring memories of the traumatic event, for example, nightmares, flashbacks. 2. At least three symptoms demonstrating avoidance (phobia) of places, people and experiences that trigger the memories and/or a numbing of emotional responses to emotional situations. 3. At least two persistent signs of hyperarousal must exist for at least a month, for example, sleep disturbance, limited or poor concentration, irritability, unexplained anger, blackouts, poor memory, as well as hypervigilance (excessive watchfulness) for possible threats to their safety. The combination of these symptoms must cause significant distress or functional impairment. PTSD may negatively affect the social and emotional development of a child, whether they experience or observe the traumatic event.

Behaviours typical of a Person/s with PTSD People experiencing PTSD may: • Avoid places or people that remind them of the traumatic experience • Detach or distance themselves from people, even avoiding social interaction with significant others • Overuse addictive substances, for example, cigarettes, alcohol, marijuana • Have difficulty remembering particular appointments • Have difficulty sleeping • Experience lack of interest in previously enjoyed activities • Have difficulty regulating emotional responses, but may avoid expressing emotions • Have suicidal ideation that affects their ability to interact • Express feelings of hopelessness and/or helplessness • Avoid making plans for the future • Seek assistance for a seemingly unrelated condition, such as depression, substance abuse, manic depression or an eating disorder.

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Susceptibility to PTSD Different people consider different things to be traumatic. As individuals define traumatic experiences differently, different people will respond differently to the same traumatic experience. People who might develop PTSD include: • People who live in war zones or locations that regularly experience traumatic events • People with an emotional condition prior to experiencing a life-threatening or horrifying event • People with limited social support who experience a traumatic event • Children and adolescents with learning difficulties may develop PTSD after a traumatic experience • People who experience violence in the home • People who experience, even through observing, an horrific event or emergency • People who experience a similar event (although less traumatic) that trigger memories of the traumatic event.

Possible emotions a Person/s with PTSD might experience A person with PTSD might experience: • Anxiety • Fear • Uncertainty • Guilt

• Difficulty regulating emotions • Persistent depressive emotions • Persistent overwhelming negative emotions.

Possible reasons for these emotions

• Re-experiencing or re-living the traumatic event • Repeated and consistent nightmares or visual representation of the event • Difficulty sleeping creating extreme fatigue • Isolation and limited social support • Blaming themself for the event • Receiving extremely disturbing news, for instance a diagnosis of a severe condition. Principles for effective communication with a Person/s experiencing PTSD When communicating with someone with PTSD it is essential to consistently demonstrate all aspects of family/Person/s-centred practice: • Be self-aware of your personal experience in resolving or not resolving your own emotions relating to any traumatic event/s in your own life • Demonstrate unconditional positive regard • Employ active listening • Use positive non-verbal messages • Clarify their understanding of any discussed procedures or information • Confront false beliefs and attitudes (if appropriate) to emphasise reality.

Strategies for communicating with a Person/s experiencing PTSD Person/s with PTSD require specialised psychological intervention and often medication to reduce the severity of the symptoms: • Provide education about the illness and include the significant others • Include significant others in discussions and, where appropriate, interventions 321

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• Listen and discuss the particular traumatic event if they initiate this conversation • Reinforce reality and discuss any negative thought patterns • Seeks advice from their treating psychologist if unsure of how to proceed • Ensure consistency by maintaining regular contact with other health professionals assisting the Person/s with PTSD

• Reinforce appropriate strategies to manage the symptoms, including management of sleeping difficulties

• Encourage positive thoughts about self and positive lifestyle habits • Encourage talking with others they trust for support • Reinforce their chosen relaxation techniques when discussing their life challenges • Reinforce principles of conflict resolution for their significant others • If they are not receiving specific assistance, explain where they can receive assistance • Educate all relevant parties about PTSD and strategies to manage the symptoms.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: You are 37-year-old Tom who was previously a member of a national sports team. You are currently sitting in the waiting room waiting for an appointment with a health professional. You are wondering what you will tell the health professional today as last week they indicated that during the next appointment they wanted to talk with you about other ways to manage your symptoms. While waiting, your mind goes over a traumatic event that occurred some years ago. During this event you witnessed a severe car accident that caused the death of your beautiful wife, Beth, and your adorable 3-year-old son, Jordan. While you found this very traumatic at the time and experienced extreme amounts of guilt, you no longer relive the experience of trying but failing to remove Jordan who was screaming uncontrollably from the car. You have resumed your life and are now happily married to Mel. You are expecting your first child together in a few weeks. Since you were told that this baby might have Down syndrome you have begun experiencing nightmares again, in which you relive trying but failing to save Jordan. You have not told Mel about the nightmares, but she has begun asking you if everything is all right, saying you seem more withdrawn. She has also commented on the fact that you no longer take your morning jog, something you did everyday regardless of your location or the weather, or watch the cricket, something you previously loved doing with her. You have begun experiencing aches and pains, so you have been seeing a health professional who has been assisting to resolve the symptoms. However when one symptom resolves another seems to begin. As the health professional acknowledges they are ready for you, you remember that today they want to talk about other ways of resolving your symptoms. You are doubtful there is another way and do not really want to talk about your current emotional state. You believe your symptoms have a physical origin and do not relate to your current emotional distress. Person 2: You are the health professional who has seen Tom several times for a simple and treatable condition, which seems to resolve with the appropriate intervention. However, Tom keeps returning indicating he has developed new symptoms or similar ones that require your assistance. You are wondering if there is something else troubling Tom, and last week mentioned to Tom that you want to explore other options, rather than provide the usual → intervention at his next appointment.

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Scenario two: The female and the respite volunteer Person 1: Your name is Cindy and you are an only child. You are a 14-year-old girl who watched your father try to murder your mother a few months ago. Your father is now in prison, your mother is in hospital with fractured C3 and C4 vertebrae, and your grandparents live in the UK. The foster family you currently live with are caring, but you miss your mother. You visit her in hospital daily and she is always appears pleased to see you, but she is not able to relate to you because of immobility, pain and emotional shock. Whenever you try to sleep at night you see the attempted murder scene all over again, and if you do sleep you usually cry yourself to sleep. At school you keep to yourself, you tell yourself it is because you do not want anyone except the principal and two teachers to know about the event. However, at the moment anything makes you cry and you find this embarrassing. In addition, you simply feel like you do not want to relate to people, so you say no when your friends ask you to go to the local shopping mall with them (something you previously loved doing with them). The shopping mall has bad associations for you since this traumatic event, as it was a family trip to that mall that triggered the event. You keep reliving it and it reminds you of how much you miss your mother. Person 2: You are a trained volunteer assigned to provide respite for foster families. You usually enjoy this role and develop very good relationships with the adolescents for whom you provide respite. However Cindy is very difficult to relate to – she is either emotionally withdrawn or cries with little provocation whenever you are with her. The foster family suggest this experience is not the first distressing experience for Cindy, but she will not talk to them about her previous life. You have a day scheduled with Cindy before she goes to the hospital and are thinking it might be good to go to the local shopping mall together.

Person/s with decreased cognitive function (Key words: dementia, Alzheimer’s disease, intellectual disability (mental retardation), addictive behaviours) It is important to note that children with decreased cognitive function due to Down syndrome or an intellectual disability do not fall into the same category as someone who has lost cognitive function because of ageing, head injury or addictive behaviours. Such children have specific needs but are able to learn and are very able in many areas. Alternatively, in most cases people experiencing a loss of cognitive function find it difficult to compensate for that loss after a particular level of deterioration.

Definition of decreased cognitive function A person with decreased cognitive function may be experiencing a mild, moderate or severe decrease in cognitive function. A person with a mild decrease in cognitive function is someone who may: • Function independently • Choose to participate in the activities they perform well and enjoy • Perform their self-care activities • Assist others in basic tasks they enjoy performing • Understand others and express themself to facilitate understanding • Develop and use compensatory strategies to participate and function • Learn and thus remember with repetition and perseverance 323

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• ‘Work’ in a structured environment with varying levels of support • Enjoy social interaction.

A person with a moderate decrease in cognitive function is someone who may:

• Function with greater levels of assistance • Know what they enjoy performing but may have difficulty making choices • Perform some self-care activities independently (e.g. dressing and toileting; may require a reminder to bathe)

• Not always use words to communicate, but may understand others • Learn simple tasks with repetition and visual cues • Be able to ‘work’ in a supported workplace with repetitive activities • Enjoy social interaction with particular familiar people.

A person with a severe decrease in cognitive function is someone who may:

• Require assistance with all personal care needs and with all other activities, except

activities relating to mobility • Require constant supervision if they tend to wander and become lost • Be incoherent and unable to consistently communicate; however, may respond randomly to particular people, pictures or objects • Recognise familiar people they see constantly, but not consistently recognise others • Be repetitive in the sounds they make and in their behaviours • Be violent at particular times and sweet and passive at other times.

Behaviours related to being a Person/s with decreased cognitive function The behaviours of a person with decreased cognitive function will vary according to the severity of the decrease in function. A person with decreased cognitive function might: • Be illogical, irrational and unpredictable • Be perfectly happy sometimes • Repeat particular behaviours • Ask the same irrelevant questions repeatedly • Become easily distressed without provocation • Wander for no reason • Be violent – although not all individuals with a decrease in cognitive function will be violent • Behave in socially unacceptable ways.

Individuals with decreased cognitive function most susceptible to experiencing difficulty when relating to a health professional A person with a moderate decrease in cognitive function is most likely to experience difficulty when relating to a health professional. In groups, discuss and explain why.

Possible emotions a Person/s with decreased cognitive function might experience A person with decreased cognitive function might experience emotions related to: • Confusion and fear because of a change in routine • Unfamiliar environments and/or people, which may cause disturbed behaviour • A lack of connection with reality. 324

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Principles for effective communication with a Person/s with decreased cognitive function When communicating with a person with decreased cognitive function it is important to: • Demonstrate respect • Demonstrate empathy and understanding • Be consistent • Have a sense of humour • Give clear instructions with visual cues if necessary • Practise holistic communication.

Strategies for communicating with a Person/s with decreased cognitive function

• Invest time to develop a therapeutic relationship. • Do not take anything personally that the person might say to you or about you. • Consider the whole person. • Communicate gently and consistently. • Avoid expressions of anger and frustration. • Communicate with patience and a ‘go-with-the-flow’ attitude. • Aim to maintain a feeling of safety, happiness and comfort for the person wherever possible.

• Remember they are generally unable to change the way they relate, how they behave and what they say.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Fred. You are 75 years old and you live alone in a large house. The major outing you have each week occurs when a bus collects you to attend a group for older persons. You are worried about where your wife has gone and what happened to the custard tarts you were going to eat with your cup of tea. Person 2: You are the health professional who has Fred in a weekly group. Fred is a friendly man, however recently he has begun repeatedly asking you what happened to his wife who died 10 years ago and if you have eaten his custard tarts. Because Fred lives alone, you are very concerned about his safety and his ability to care for himself. You know his daughter visits daily, cleans his house and provides him with a hot meal. However you are still concerned about his safety. Have a conversation with Fred and decide if he may be safer in the familiarity of his own home than elsewhere.

Scenario two: The female and the health professional Person 1: Your name is Sarah. Your mother, Irene, is 82 years old and is currently in a rehabilitation unit because she recently had a right cerebrovascular accident (CVA). Prior to the stroke your mother and father, Harry, lived together in their house for 35 years. While your father is frail, he is mentally able and has been successfully caring for your mother with your support. You realise your mother has decreased cognitive function that was present before the stroke and has been worsened by the stroke, and that it might be suitable for her to be placed somewhere for →

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people with her stage of dementia. However, you are worried about how your father will manage emotionally if they are separated in this permanent manner. Person 2: You are Irene and you have little control over your behaviour. You often wander and disappear to be found undressing and trying to get into bed with any man you can find on a bed. Some of the males in the ward think it is amusing, while others find it disturbing. Person 3: You are 86-year-old Harry. As Irene’s husband of 53 years, you really want to continue caring for her. You do find her exhausting and are aware that you are not as strong as you have been. You feel you can continue caring for her with the support and assistance of your daughter. Person 4: You are the health professional who needs to speak with the family, including Irene, to determine whether she will return home or go to a high-dependency ward of a nursing home.

Working with individuals with decreased cognitive function can be both challenging and rewarding. However such work – even on an occasional basis – does not suit all health professionals.

Person/s experiencing a life-limiting illness and their family (Key words: life-limiting illness, critical care, terminal illness, death, grief, loss, palliative care)

Facts about people who know they are dying and their families A person who knows they are dying and the members of their family or circle of friends will experience emotions according to the ‘cycle of grief’. Kubler-Ross (1969) and Kubler-Ross & Kessler (2005) suggested stages of grief; however, it is now recognised that people who know they are dying can experience the emotions typical of a particular ‘stage’ at various times throughout the process of the disease. They do not experience them in order, nor do they move through the emotions as though they are stages. They may experience them repeatedly before they reach acceptance. The emotions include denial, rage, resentment, envy, bargaining, depression and finally acceptance. It is important to note that an individual experiencing loss of any kind may experience these emotions while attempting to grieve and adjust to the loss. Family members or friends of a person who is dying usually experience the cycle of grief and the related emotions. People who have a life-limiting illness often receive services from palliative care units. These units generally follow national policies, standards and guidelines specifically developed for palliative care situations (see Palliative Care Australia [www.pallcare.org.au] or New Zealand Palliative Care Strategy [www.moh.govt.nz/moh.nsf/pagesmh/2951]). The World Health Organization (WHO 2008) states that palliative care is an approach that improves the quality of life of people and their families facing the problems associated with a life-threatening illness. This is achieved through the prevention and relief of suffering by means of early identification and impeccable assessment, as well as treatment of pain and other problems (physical, psychosocial and spiritual). WHO (2008) states that palliative care aims to assist people with life-limiting illnesses to experience quality of life until the moment of their death. Palliative care should provide 326

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relief from pain and other distressing symptoms. It should affirm life but regard death as a normal part of life. Palliative care should neither hasten nor postpone death. Palliative care considers the whole person and integrates psychological and spiritual care for the benefit of the person and their family members. Palliative care is committed to supporting the family during the course of the illness and after death.

Core values of Palliative Care Australia (www.pallcare.org.au)

• Dignity of the person, caregivers and each member of the family • Respect and empowerment of all of these individuals • Compassion for all involved individuals, regardless of age • Equity in access to services • Excellence of provision of care • Family-centred practice. Definition of a life-limiting illness

A person with a life-limiting illness is someone who has 0–6 months to live. This may be due to: • Cancer • A progressive neurological disorder • End-stage cardiac, renal or respiratory disease • AIDS • Other degenerative diseases • Experiencing a serious accident, attack or natural disaster • Experiencing an unexpected and serious life-threatening medical occurrence (e.g. cerebrovascular accident [CVA] or cardiac arrest [CA]).

Behaviours a Person/s experiencing a life-limiting illness might exhibit A person experiencing a life-limiting illness will exhibit a range of behaviours that might include: • Acting as though nothing is wrong one day and being totally withdrawn the next • Being quiet and thoughtful one day and chatty the next • Forcing themself to do something regardless of their pain or fatigue • Sleeping excessively because of pain medication, fatigue and depression • Being unable to sleep and thus being awake all night • Being short-tempered and dismissive towards carers and health professionals • Being teary sometimes • Wanting to discuss spiritual issues or beliefs about life after death.

Possible emotions a Person/s experiencing a life-limiting illness, their family members and friends might experience A person might experience emotions related to: • Bargaining (If I do this it will cure me) • Denial • Rage • Resentment • Envy • Depression • Anxiety

• Confusion • Fear • Despair • Hopelessness • Desperation • Acceptance • Peace or agitation. 327

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A person experiencing a life-limiting illness may experience physical, emotional, social, cognitive and spiritual distress. Physical distress may include: • Pain • Oedema • Fatigue • Disfigurement • Anorexia • Loss of strength and range of movement • Restlessness • Bladder and bowel disturbances • Breathlessness • Neurological dysfunction. Psychological or emotional distress may include or be caused by: • Sadness • Despondency • Shock • Loss of emotional control Uncertainty • • Role changes Fear • • Loss and grief • Anxiety • Change in self-esteem • Depression • Change in body image. Social distress may include: • Isolation • Family conflict • Lack of support • Inability to manage social situations • Financial issues • Inability to perform community-based or home-based tasks. • Carer stress Cognitive distress may include: • Negative self-talk • Decreased cognitive function. Spiritual distress may include: • Search for meaning • Is there life after death? • Crisis in faith • Religion What is death? • • Paranormal experiences What will death be like? • • Review of priorities • What about my life? • Review of values. Family members and friends may experience a range of emotions for many reasons also related to the components of the whole person.

Principles for effective communication with a Person/s experiencing a life-limiting illness, their family members and friends When communicating with a person experiencing a life-limiting illness, or with their family and friends, it is important to: • Be self-aware – of your own values, beliefs and needs relating to experience of or thought about life-limiting illnesses • Demonstrate respect • Show empathy and compassion • Be silent when necessary • Listen actively • Be sensitive to non-verbal behaviours and voice • Touch if appropriate – hugs can be good • Demonstrate ethical behaviour • Provide company for the person dying or for a family member or friend • Use an interdisciplinary approach – you cannot do it alone • Always behave with integrity and honesty.

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Strategies for communicating with a person experiencing a life-limiting illness or with their family and friends

• A family-centred approach is essential when someone is dying. • A holistic approach is also vital when a person is dying. • Be committed to and aware of the quality of life of the person. • Be willing to discuss the practical aspects of dying. • Be aware of personal limitations – the health professional does not need to meet the needs of every person seeking their assistance.

• Consider the need for debriefing at various times with other team members.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is James and you are a 47-year-old pastry chef. You love working in your local bakery and have lots of friends who come into the shop. You contracted a virus 8 months ago, which you thought was from walking for half an hour to work at 2 a.m. every day. However the cough did not improve and you began to lose weight rapidly. After 4 months of having the terrible cough, the local doctor sent you for tests. You knew deep down there was something seriously wrong, but you did not want to think about it because it was less than a year since your mother had died unexpectedly. Then, 2 months ago the doctors told you that you have final-stage cancer, an aggressive form of cancer that is in the major organs of your body and your lymphatic system. You know you have a limited time to live, but you do not know how long. You are home from hospital and you are struggling to get through each day. You try to do something every day – you go for a walk or talk to the neighbours, but you need to sleep a lot. Although you want to remain positive for the sake of your brothers and sister, it is very difficult to remain positive and you just want it all to end. You are confused, and while you want to think about dying you are not sure what it means, what it will feel like and what will happen to you when you die. You have questions but no-one who you feel you can ask about them. Person 2: You are a health professional who lives next door to James. You see him over the back fence most days and try to encourage him to talk about what he is feeling and the things he wants to discuss. You are willing to talk about whatever he wants, even the spiritual issues he is facing.

Scenario two: The female and the health professional Person 1: Your name is Janice. Your mother died of breast cancer when she was 42 years old, a few years ago now. She was diagnosed, had treatment, lived for 5 years, then had a relapse and died 4 months after the recurrence of the cancer. The doctor has just told you that you have breast cancer. You are sure there was a mix-up with the pathology sampling and ask for more tests. It just is not true. Person 2: You are the health professional who has to tell Janice the result of the extra tests is positive – she does have breast cancer.

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Many individuals who seek the assistance of a health professional experience a sense of grief and loss – not always about their life, but about their identify and their ability to function or participate in life. Health professionals who understand this reality can communicate more effectively with people experiencing a life-limiting illness, as well as people experiencing a loss of any kind.

Person/s experiencing a mental illness (Key words: mental illness, psychiatric, DSM-IV-TR, mental health)

Definition of a mental illness A person experiencing a mental illness is someone who for various psychosocial reasons is unable to manage the demands of life. People with particular conditions require assistance from a mental health service from time to time. Some of these conditions include anxiety, personality disorders, psychosis, paranoid schizophrenia, bipolar disorder, post-traumatic stress disorder, depression, alcoholism, drug addiction, obsessive compulsive disorder, phobias and combinations of the above.

Behaviours related to a Person/s experiencing a mental illness A person attending a mental health service may behave in a variety of ways depending on their condition, compliance with medication, current stability, the predictability of events in their life and their consistency of participation in health-sustaining behaviours. A person experiencing a mental illness might be: • Withdrawn with no desire or ability to relate • Aggressive and sometimes violent • Repetitive in actions or words • Behaving in a manner that does not indicate connection with reality • Perfectly coherent and conversant.

Individuals most susceptible to experiencing a mental illness The individuals susceptible to experiencing a mental illness include people who: • Have addictions • Have experienced previous episodes of any mental illness • Have a reduced sense of worth or self-esteem • Self-harm • Are suicidal • Believe someone is attempting to hurt them • Say they hear voices that tell them what they should do.

Individuals with a mental illness most susceptible to experiencing difficulty when relating to a health professional

• Those who are acutely unwell • Those who have ceased taking their medication • Those who have been admitted against their will.

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Possible emotions a Person/s with a mental illness might experience A person with a mental illness might experience emotions related to: • Rejection • Having always been told they were not good enough • Hopelessness • Changing cultures • Feeling of failure • Having no place to belong • Negative self-talk Feeling under-valued • • Addiction Loss of any kind • • Loss and grief • Never being ‘able’ or competent • Hallucinations • Paranoia • Failure to take medication • Cognitive dysfunction • Reactions to medication.

Principles for effective communication with a Person/s experiencing a mental illness When communicating with a person experiencing a mental illness it is important to: • Make introductions • Confront if appropriate • Demonstrate respect • Listen actively • Show appropriate honesty • Demonstrate unconditional acceptance. • Give clear explanations

Strategies for communicating with a Person/s experiencing a mental illness

• Explore and resolve your own personal biases relating to mental illness. • Understand that the person is vulnerable. • Remember the person is not always aware of the consequences of their behaviour. • Do not take comments the person makes personally. • Do not believe the accusations of the person about anyone else. • Therapeutic groups can be effective. • Outline clear and consistent expectations. • Set clear and consistent boundaries. See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Matthew is a 28-year-old man who is addicted to alcohol and currently in hospital for detoxification. He has developed a good relationship with a male student health professional. They have very different backgrounds but are the same age and share common interests. The student visits Matthew one morning to find him writhing in pain, sweat pouring off his brow and looking terrible. Matthew seems desperate and surprises the student by grabbing his wrist. Matthew is trembling and he says that the doctor caring for him has not been assisting him. He pleads for a ‘drink’, saying all he needs is one – just one would get him through this and he would never touch another drop. The student feels sorry for Matthew; he knows Matthew has had a very tough life and feels he → has suffered enough. He wants to help Matthew to stop him from suffering.

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A nurse sees the student leaving Matthew’s room and says You have to be careful of alcoholics when they are at this stage – they will do anything for a drink. This comment seems unfeeling and callous to the student, who simply thinks that Matthew has suffered enough. • What would you do? • How would you feel if you were the student health professional? • What would you think if you learnt the student gave Matthew a drink? • What would you think if you learnt the student was so disturbed by this situation he over-used alcohol himself that night?

Scenario two: The male and the health professional Rod is a 56-year-old secondary school teacher who loves teaching mathematics. However, he has recently found the behaviour of some of the 15-year-olds upsets him and makes him angry. He is usually patient and understanding, able to relate well to the needs of young people. He is finding his impatience disturbing and has begun to think it means he is not a good teacher. He begins to feel discouraged about his ability to teach and to relate appropriately to the students. He believes he no longer has the ability to teach successfully and begins to feel he must find another profession. He feels he is too old to retrain so he applies for a curriculum development position, but is unsuccessful. Several weeks after this, his mother and twin brother suddenly die in a car accident. He now often feels hopeless and alone. These emotions continue for over a year. He is constantly tired and finds it difficult to sleep. When asked if he is feeling unwell, he simply states he is tired. His wife, colleagues and friends notice he is withdrawn with limited affect. His wife notes that he seems depressed and suggests he seeks assistance. He says he is fine, however several weeks later he unsuccessfully attempts suicide. • What do you think? What would you do if you were Rod? • How would you communicate with Rod? • What do you feel is important when communicating with people similar to Rod?

Scenario three: The female and the health professional Sally is a 20-year-old woman with a history of treatment for anorexia. She is no longer haunted by the thoughts that caused the anorexia and is enjoying studying to be a health professional. She has recently begun to experience what she describes as panic attacks. She says she knows she can successfully complete the courses in the program, but finds herself having these attacks whenever she thinks about the amount of work she has to complete. She says she has trouble breathing and her heart races, her palms become sweaty and she wants to vomit. The symptoms usually pass after a few hours, but they are occurring more frequently and lasting longer. She decides to ask a close friend for advice about this. • What would you say to Sally? • How would you relate to Sally? • What elements of communication do you feel are important when relating to Sally?

There is a particular stigma associated with people who experience mental illness. Both the media and social misconceptions support and sustain this stigma. However it is not the symptoms and behaviours associated with mental illness that are the focus of the health professions, but rather human beings with particular needs and desires. NOTE: It may be necessary to consider any stigma you personally feel about people experiencing a mental illness. It is essential you change that response to a positive one when interacting with people experiencing a mental illness. 332

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Person/s experiencing long-term (chronic) or multiple physical conditions (Key words: amputations, arthritis (for example, psoriatic, rheumatoid or osteoarthritis), particular cardiac and/or respiratory conditions (for example, cardiomyopathy or chronic obstructive pulmonary disease), cirrhosis of the liver, diabetes, some neurological conditions, cerebrovascular accidents, traumatic or acquired brain injuries, persistent renal disease, surgery induced conditions. These are a few examples of the long-term or chronic conditions a Person/s may have when relating to health professionals.

Definition of long-term or multiple physical conditions A long-term or chronic condition is one that is of long duration with little change in symptoms or function, or it may be a condition with slow progression. Individuals with a long-term condition often develop other conditions related to their chronic condition, that is a comorbid condition.

Behaviours typical of a Person/s with long-term or multiple physical conditions Personality, age and culture can affect responses to having a long-term or chronic condition. Person/s with a long-term or chronic condition may: • Seek opportunities to pursue particular activities • Withdraw from social interaction and demonstrate depressive symptoms • Enjoy spending time with particular friends or members of their family • Complain repeatedly, often about their pain or limitations • Be reluctant to relate to or engage with health professionals • Avoid the activities or movements that might exacerbate their symptoms • If diagnosed with such a condition at a young age, show resilience and adaptation to their limitations, demonstrating minimal limitations in daily life • Demonstrate behaviours similar to those experiencing loss.

Susceptibility to acquiring long-term or multiple physical conditions

• Varies depending on the hereditary status of previous generations and current family members, predisposing factors, age and in some instances gender

• Arthritis may result from particular infections • Individuals who engage in extreme sports or extreme behaviours may acquire a long-term physical condition.

Individuals with long-term or multiple physical conditions most susceptible to experiencing difficulty when relating to a health professional

• Individuals who are experiencing constant pain with limited relief • Individuals with a long history of relating to health professionals • Individuals new to a service who have been referred because of evidence of a new condition or because of geographical relocation.

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Possible emotions a Person/s with long-term or multiple physical conditions might experience

• Frustration • Distress • Depression and despondency

• Resignation • Anxiety about the future • Positive acceptance.

Possible reasons for these emotions

• Chronic pain • Repeated medication trials • Feeling like ‘a guinea pig!’

• Acceptance of little improvement • Lack of certainty about their future • Lack of positive things to anticipate.

Principles for effective communication with a Person/s experiencing long-term or multiple conditions

• Clear and warm introductions that engender trust • Active listening and validation • Empathy through verbal acknowledgment of their condition and associated symptoms

• Honesty without removing hope • Affirmation of their achievements • Encouragement • Clarify and confirm their understanding of all procedures and future events. AVOID SAYING

• You’ll be OK • Don’t worry, I’m sure things will get better soon. Strategies for communicating with a Person/s experiencing long-term or multiple physical conditions As with any person, it is essential the health professional consistently demonstrates the characteristics of effective communication alongside family/Person-centred practice whenever interacting with the Person/s or the significant people in their lives. • Suggest strategies to them and their significant others to manage the many symptoms associated with their condition/s. • After actively listening and validating their emotions, if appropriate, reinforce relevant strategies when the person appears distressed about a particular symptom. • Engage them in conversation about positive experiences they have had since you saw them last. • If appropriate involve any significant children in their interventions.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: You are Hilton, a 76-year-old Aboriginal man married for 35 years to Deidre, a nonIndigenous Person. You have a daughter who is a successful sociologist and academic,

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a son-in-law who is a mechanic and three grandchildren aged 5, 7 and 11. In your youth you were an Olympic class athlete and very active, swimming and jogging every day along with playing competition squash. You have worked all your life as a mechanic and really love this work. Many years ago you were diagnosed with diabetes and are now insulin dependent, however this has not previously affected your daily life. Ten years ago you suddenly developed multiple physical disorders that limited your physical activities and reduced your level of fitness. These conditions include psoriatic, rheumatoid and osteo arthritis, high blood pressure, a left-sided stroke and a large hernia. These have resulted in many surgical procedures and admissions to hospital. Some of the procedures included bilateral knee-replacements and removal of around 30 cm of your bowel. You live for your three grandchildren: the eldest is school captain this year, and you love attending things at the school whenever possible because you are so proud of your granddaughter. However your pain levels have made this difficult in the last few months. You are currently recovering from a shoulder replacement after eight months of pain from a fall and an unsuccessful shoulder reconstruction. You have not been told what to expect and your arm is not recovering at the rate you had expected from comments made by the surgeon: You will not know yourself, you will have a perfect shoulder after this. You are feeling sore, uncertain and depressed, and you find the pain difficult to tolerate at night. You are expecting a visit from a health professional today, but you are becoming impatient with health professionals (even though you are usually very patient) who relate to you from their stereotypes of Aboriginal people and who also indicate they think you should be back to ‘normal’ when you are not – despite taking the precautions and doing all the exercises. Person 2: You are a health professional going to visit Hilton, an Aboriginal man who you have never met before. You are sure his shoulder will be almost back to normal as that is the expected recovery rate for shoulder replacements. When you arrive a lady answers the door, takes you into a man who has skin that is too pale for him to be an Aboriginal and, even though this man has a wrapped shoulder indicating he could be Hilton, you ask to see Hilton. They look shocked and indicate the person in front of you is Hilton. You feel embarrassed and wonder how you can overcome the possible offence you may have caused them and develop some rapport.

Scenario two: The female and the health professional Person 1: You are Caroline and you have epilepsy, which you developed as a child. You are a shy, modest person who does not usually like meeting new people. You have been married to Mick, a bioscientist, for 25 years. He married you knowing you had epilepsy and always said that did not worry him. In the last 25 years your cognitive functioning has deteriorated because of the severity and uncontrollable nature of your seizures (you have endured many tests and regimens to try to control them – to limited effect). You are currently able to manage the necessary household tasks and you make a wonderful lasagne, considered by your in-laws to be very authentic Italian lasagne. Mick always assists you with the shopping, and you sometimes become disoriented if you leave the house alone. You have become more childlike in some of your responses and you often find your mother-in-law, Maria, very frustrating and unreasonable in her demands of Mick. Mick is the eldest son of an Italian family. When you married him you did not realise that meant his mother would live with you if something happened to his father and Maria was not able to manage in her own home. Maria also has decreased cognitive functioning that makes her quite demanding and often appear rude. Maria found it very difficult that Mick married you as you were not Italian, and when she realised you had epilepsy she tried to persuade Mick not to marry you. She finally accepted you into the family and speaks fondly about you to everyone. You are currently in hospital because there have been some recent changes in treatment of your type of epilepsy, but that means more tests and you are experiencing fear and confusion. You have been → through many tests before and there has been little change, and you feel this admission

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is also hopeless and a waste of time. You are also very agitated because you have been placed in a ward with two men and you find that very difficult. You wish Mick could be with you all day and count the minutes until he arrives every afternoon. You sometimes find yourself thinking even a visit from Maria would be better than being in this room with these noisy men, who do not always close the door when they go to the toilet and each have the television on different channels. You are scheduled for the longest and most tiring test today and thus are feeling more vulnerable than usual. You do not want to talk to anyone except Mick, and are determined you will not relate to the unfamiliar health professional who has just come to talk with you. Person 2: You have not previously met Caroline but have to gather some information about her history before she has the test. You realise she may be frustrated with all the health professionals asking her questions, but you have not had time to check her records and want to build rapport and understand Caroline as you will be relating to her after her discharge.

Person/s experiencing a hearing impairment (Key words: hearing loss, deafness, hard of hearing, deaf, industrial deafness, Auslan, New Zealand Sign Language, American Sign)

Definition of a hearing impairment A person with a hearing impairment is someone who: • Finds verbal or aural communication difficult because of an inability to hear • Finds comprehension of cultural cues difficult to understand because of a hearing impairment.

Behaviours typical of a Person/s experiencing a hearing impairment A person with a hearing impairment will exhibit different behaviour according to the age at which they developed their impairment, whether they grew up in the deaf community or a hearing population, whether they have learnt to lip-read, and whether they can read and write. A person with a hearing impairment might: • Often communicate with strong non-verbal gestures and facial expressions • Make intense efforts to be understood that may appear aggressive • Appear rude or inappropriate if they do not hear many auditory cues (the social or cultural cues of hearing people may have different meaning or no meaning to a person with a hearing impairment) • Demonstrate behaviour typical of mistrust • Behave in a stubborn manner.

Individuals most susceptible to a hearing impairment The individuals susceptible to experiencing a hearing impairment are: • Unborn babies with family members who are deaf – hereditary • Babies who do not develop appropriately in utero – congenital • Babies who have undetected meningitis • Premature infants who receive antibiotics with ototoxic side effects • Individuals who experience trauma to the head or neck 336

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• Individuals who experience an industrial accident • Children with recurring undetected or untreated ear infections • Individuals who do not wear earmuffs in areas of high noise • Older people who experience age-related hearing loss • Individuals from countries that do not have occupational health and safety standards to protect their hearing • Individuals from countries or regions within countries that have limited health services.

Possible emotions a Person/s with a hearing impairment might experience

• Anger • Frustration • Rejection • Fear

• Confusion • Vehemence and stubbornness • Isolation • Anxiety.

Possible reasons for these emotions A person with a hearing impairment might experience these emotions because of: • Seeing what is happening but not being able to hear or understand everything • Having people shout at them because they think speaking loudly will assist their ability to hear • People talking too quickly and/or with unclear articulation when they are trying to lip-read • People talking to the hearing people in a situation but not including the person with a hearing impairment • People speaking or signing to an interpreter rather than to the individual with the hearing impairment.

Principles for effective communication with a Person/s experiencing a hearing impairment When communicating with a person experiencing a hearing impairment it is important to: • Show patience and perseverance – keep trying to achieve understanding • Avoid responding with frustration • Clarify understanding – avoid making assumptions about the meaning • Validate • Disengage – this is very important • Avoid using humour, as subtle nuances of language associated with humour are difficult to perceive, understand or explain • Use predictable and well-articulated speech if the person is lip-reading.

Strategies for communicating with a Person/s experiencing a hearing impairment

• Use alternative methods of communicating if you do not share a common language. • If working with individuals who have a hearing impairment on a regular basis, consider learning the appropriate sign language for your country (e.g. Auslan [Australian Sign Language] for Australia and some of the Pacific). • Try to communicate even if you do not understand.

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• Use written words or pictures wherever possible. • If communicating with someone who lip-reads, stand directly in front of them, articulate clearly and speak at a steady pace.

• Do not assume they want to have good hearing, because lack of hearing may be part of their identity.

See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of family/Person-centred practice.

Scenario one: The male and the health professional Simon is a 10-year-old boy who was diagnosed with a severe hearing impairment at the age of six. The hearing impairment was discovered during a routine medical check-up at school. By that time Simon had been labelled as having a behaviour problem, because he would never sit still to listen in class and was always the last to finish any work. His written work was good when he could copy, but he was never able to write a story or read words. Simon has always been a child who loves to move and thus he rarely played games that required hearing. He rarely spoke before attending school but seemed to understand spoken words and instructions. He is a loving boy and has a supportive mother who trained as a teacher’s aid to assist him with his schoolwork. He has recently had cochlear implants, which have restored 70 per cent of his hearing in both ears. However Simon is still behind other children his age with his schoolwork and requires constant assistance with his work. • How will you relate to Simon? • What will be your goals in communicating with him?

Scenario two: The female and the health professional Rhonda is a 24-year-old beautician. She was born without hearing to parents who could hear. They did not consider that Rhonda should learn sign language and insisted she learn to lip-read and verbalise. They sent her to a non-specialist local school with her siblings. Rhonda learned to read and write as well as lip-read. She is intelligent and thus is able to compensate for her hearing impairment by guessing the meaning of situations if she cannot actually understand. She is determined and studied hard to become a beautician. She is very difficult to understand when she speaks and, in an attempt to be understood, she often repeats words. She is confident but very moody when others are talking without including her. According to the culture of the hearing population, her non-verbal behaviours are exaggerated and often appear rude. • How will you relate to Rhonda? • What will be your goals when communicating with her?

There are many different sign languages worldwide. Within Australia there are two main dialects of Auslan. The northern dialect is based on French Sign Language and the southern dialect on British Sign Language. New Zealand Sign Language was adopted as the official sign language of New Zealand in 2006. Sign languages are languages in their own right, unrelated to the spoken language of the people who live in the same country. (Auslan, for example, is not the same as Signed English, which uses a sign to represent each English word.) Users of sign languages use signs to indicate particular meanings and may express a whole concept with one sign, where it might take many words to express the same concept in a spoken language. Each sign language also has alphabet signs for finger spelling. Many use a two-handed method of spelling letter by letter. However American Sign uses a

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one-handed finger-spelling system. Alphabet signing/finger spelling is a small component of signing for sign language users, only used if needing to communicate an English name or word, or with people who are not fully competent in the sign language. Sources of information on hearing impairment are listed in Table S4.2. TABLE S4.2â•… Sources of information on hearing impairment Australia Australian Hearing Auslan Sign Bank (Royal Institute for Deaf and Blind Children)

www.hearing.com.au www.auslan.org.au

New Zealand Deaf Association of New Zealand Inc National Foundation for the Deaf Inc

www.deaf.co.nz www.nfd.org.nz

United States of America National Association of the Deaf American Sign Language

www.nad.org www.aslinfo.com

United Kingdom Royal Society for Deaf People

www.royaldeaf.org.uk

Individuals who are born with a hearing impairment into a hearing population have a very different identity to individuals born deaf into a community of deaf individuals (’the Deaf community’). The Deaf community believe that being deaf is part of their identity and are sometimes vehement about maintaining that identity. Thus, they may choose not to have cochlear implants despite the possibility of being able to hear.

Person/s experiencing a visual impairment (Key words: visual loss, blindness, blind, visual impairment)

Definition of a visual impairment A Person/s with a visual impairment is someone who: • Is unable to experience the world visually because of a loss of visual acuity – the ability to see clearly • Has less than 6/60 corrected visual acuity in both eyes • Has a field of vision constricted to less than ten degrees of arc around the central fixation in either eye.

Behaviours related to a Person/s experiencing a visual impairment A person with a visual impairment will exhibit different behaviour according to the age at which they developed the visual impairment – whether they were born with no sight or lost their sight at a later age, whether they experienced special education specifically designed for people with visual loss, and whether they can read and write. A person with a visual impairment might: • Move confidently with particular self-controlled assistance • Move timidly when in an unfamiliar environment 339

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• Have limited facial and non-verbal behaviours, depending on the situation • Show well-adjusted behaviour and ease of mobility. A person who is losing their vision slowly might:

• Walk close to a wall • Have poor posture • Move hesitantly or with short steps • Squint or tilt their head • Spill or knock over food and other items • Bump into objects • Look closely at items such as print • Request changes in lighting • Be sensitive to light • Easily become lost • Be unable to find items • No longer recognise people by sight • Demonstrate altered emotional states, such as anxiety, tearfulness, frustration and embarrassment

• Stop taking care of their appearance • Stop socialising in a group • Stop reading or sewing • Stop participating in activities. Individuals most susceptible to a visual impairment The individuals most susceptible to a visual impairment are those who: • Have a family disposition to blindness • Have degenerative eye conditions • Have congenital causes • Experience trauma to the head or face • Experience an industrial accident • Have repeated and untreated eye infections • Are children with poor nutrition • Are children who live in environmentally deprived situations • Do not wear goggles in designated work areas • Are from countries that do not have occupational health and safety standards to protect their sight • Have diabetes • Are children with juvenile diabetes • Are from countries or regions within countries that have limited health services.

Possible emotions a Person/s experiencing a visual impairment might experience A Person/s with a visual impairment might experience emotions related to: • Interest or curiosity • Sadness • Insecurity • Envy • Confusion • Resentment • Frustration • Helplessness • Fear • Determination. 340

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Possible reasons for these emotions A person with a visual impairment might experience these emotions because of: • Other people assuming they know their needs • Other people assuming they must require assistance because they are blind • Strangers feeling sorry for them • Hearing things but being unable to see them • Hearing threatening sounds to which they cannot respond because they cannot see the cause • Having limited control when in unfamiliar situations.

Principles for effective communication with a Person/s experiencing a visual impairment When communicating with a person experiencing a visual impairment it is important to: • Touch – remember to ask permission first • Validate • Clarify • Ensure use of physical contact to demonstrate your presence if using silence • Provide information – use Braille or computer technology if appropriate • Disengage.

Strategies for communicating with a Person/s experiencing a visual impairment

• Identify yourself – do not assume the person will recognise you by your voice. • Speak naturally and clearly. Loss of eyesight does not mean loss of hearing. • Continue to use body language. This will affect the tone of your voice and give a lot of extra information to the person.

• Use everyday language. Do not avoid words like ‘see’ or ‘look’ or talking about everyday activities such as watching television or DVDs.

• Name the person when introducing yourself or when directing conversation to them in a group situation.

• In a group situation, introduce the other people present. • Never channel conversation through a third person. • Never leave a conversation with a person without saying you are doing so. • Use accurate and specific language when giving directions, for example, The door is on your left rather than The door is over there.

• Avoid situations where there is competing noise. • Always ask if they require assistance – do not assume they do. • In dangerous situations say Stop rather than Look out. • Relax and be yourself. • Do not assume you know what they want or what will help them. Ask them. See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of effective communication and family/Person-centred practice.

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Scenario one: The male and the health professional Person 1: Ronny lives in a rural area. He is 64 years old and last week received the diagnosis of trachoma after experiencing conjunctivitis for some time. He lives with his extended family. There is only one income to support seven people. He is happy but finds his fading vision disturbing because he is not as mobile these days and loves watching the local children play in the schoolyard next to his house. He finds it difficult to watch television but has it turned on for company when the others are away. Person 2: You are the health professional who needs to have a conversation with Ronny and collaborate to set achievable goals. You know that his visual loss may be permanent. • What is important for Ronny? • What might you need to know in order to assist him to maintain meaning in his life?

Scenario two: The female and the health professional Person 1: Your name is Tania and you are a 24-year-old woman with an Indigenous background. You are a well-respected early intervention teacher who manages a local preschool. You love everything about your job – the paperwork, the children, the parents, seeing the children develop skills and grow taller, as well as having them proudly display their work before they leave each day. The parents, staff and children say you have excellent skills in observing and interpreting the non-verbal cues of children, parents and staff. However, you have recently lost your vision after an accident and have not been able to work. Your boyfriend of four years – now your fiancé – is supportive but you sense he is afraid and unsure of your future together. Person 2: You are meeting Tania for the first time and you want to assist her to establish some appropriate short-term and long-term goals.

Sources of information on visual impairment are listed in Table S4.3. TABLE S4.3â•… Sources of information on visual impairment Australia Vision Australia

www.visionaustralia.org

New Zealand Royal New Zealand Foundation of the Blind

www.rnzfb.org.nz

PERSON/S IN PARTICULAR CONTEXTS Health professionals assist vulnerable people experiencing a range of contexts.

Person/s experiencing an emergency (Key words: emergency, recent, near-death experience, accident, disaster, attack, trauma)

Definition of a Person/s experiencing an emergency A person who experiences an emergency is someone who has recent experience of adverse bodily harm because of an accident, attack or natural disaster. 342

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Behaviours related to being a Person/s experiencing an emergency A person who experiences an emergency might be: • Impatient and angry, even aggressive • Irrational and incoherent due to shock • Chatty and apparently unconcerned • Quiet and unresponsive • Frustrated – expressed verbally or non-verbally • Completely passive.

Individuals most susceptible to emergencies The individuals most susceptible to emergencies are anyone who lives, breathes and moves, regardless of age, racial group and gender! However, people may be especially susceptible to emergencies if they: • Play sport or perform extreme sports (e.g. mountain climbing, abseiling) • Drive • Work with machinery, whether in cities or rural areas • Are involved in violent encounters.

Possible emotions a Person/s with an emergency might experience A person who experiences physical or emotional harm because of an emergency may feel: • Fear • Anger • Shock • Guilt • Despondency • Impatience • Disbelief • Frustration from being asked to answer the same questions by different health professionals • A lack of control over the events around them.

Principles for effective communication with a Person/s experiencing an emergency When communicating with a person who experiences an emergency it is important to: • Demonstrate empathy to build a therapeutic relationship • Validate • Make introductions • Provide and explain information • Remember that such people are often in pain and may be impatient and angry if asked the same questions repeatedly; instead, make statements to verify the gathered information • Recognise that shock can affect the cognitive functioning of an individual • Recognise that the person may respond differently to their actual feelings if medicated for pain • Verify or clarify the interpretations of perceptions 343

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• Comfort and reassure through encouragement – they may be afraid of the implications of the emergency for their future

• Remember that the person may experience social isolation in hospital if they were airlifted from a rural area

• Remember the person did not intend to have or cause the emergency. Strategies for communicating with a Person/s experiencing an emergency

• Consider the whole person – they will have more than physical needs. • Observe the non-verbal behaviours of the person closely and ask for verification or clarification of the interpretations of those. • Gather information from notes and other health professionals rather than the person experiencing health professionals repeatedly asking the same questions. If unsure about the accuracy of the information, make statements and ask for verification; this allows the person to simply nod or affirm in some manner. • Give non-verbal cues or visual indication of what is happening or what the person needs to do. • Express sensitivity and compassion regardless of the cause of the emergency. • Remember the family members of people seriously hurt because of an emergency – they are often terrified, have feelings of helplessness and require information.

See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Malcolm. You are a 28-year-old man who shattered your right tibia and fibula playing football. You are no longer in the acute ward but you remember your experience in emergency vividly. You arrived in an ambulance, were hurriedly transferred to a cubicle in emergency with the curtains drawn and left alone in pain for what seemed like hours. Thirsty and exhausted, you realised you wanted to go to the toilet. You were not comfortable calling for help. Finally, a nurse came in with a tray. Without introducing himself, he asked particular questions and filled in a form. Then, without explaining what he was doing, he rolled up your sleeve. You pulled your arm away, not sure what was coming next. He grabbed the tray and left. As he disappeared through the curtains you quickly said you needed to go to the toilet. You heard the nurse say The one with the broken leg is uncooperative and wants a bottle. Sometime later a different nurse arrived with a bottle. Every person who came in after that asked you the same questions. There were several hours of waiting and your lower back was hurting. A doctor finally arrived. She examined you and asked the same old questions. She explained you would need surgery, which would take place in about an hour. There were no explanations of anything and no time to ask questions or find out what happened to your expensive football boots. Your parents were an hour away and you had just terminated your relationship with your girlfriend of five years. You thought about how you were studying full time and working part time doing deliveries. You lay in emergency worrying →

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about how you would pay your rent, drive your car and continue your studies. You felt lonely and unloved. You are now attending a rehabilitation service and find it difficult to trust most health professionals because of the treatment you received on that first day, the day you broke your leg during that tackle. You are meeting a new health professional today. You are not interested in another change – it will mean more of the same questions. Person 2: You are the health professional assigned to assess Malcolm. You have heard he is not trusting and, although motivated to improve, he is often sullen and reluctant to develop a relationship. Consider how you will manage this situation before beginning the role-play.

Scenario two: The female and the health professional Person 1: Your name is Rachel and you are a solicitor in a big law firm. You are 40 years old and divorced, with two children aged 12 and 14 who live with you every alternate week. Your parents are ageing and quite frail. While you were driving to work a young driver drove through a red light, hitting the driver’s door next to you. You fractured four ribs and your right femur and lost some teeth in the accident. You are now in an emergency department. You are very worried about your children and the future, including paying the mortgage for your recently purchased beautiful new apartment. You cannot think clearly or remember what has happened since the accident. Fear, anxiety and pain limit your ability to concentrate and understand what is happening around you. Person 2: You are the health professional who must explain a procedure or future event to Rachel.

Not all health professionals relate to people who experience emergencies immediately after the emergency. However many will communicate with people who remember the experience of an emergency, either as a victim or an observer. Such individuals require communication that considers the various aspects of their lives influencing their everyday roles, participation and functioning.

Person/s experiences domestic abuse (Key words: domestic violence, domestic abuse)

Definition of domestic abuse Domestic abuse occurs when individuals in a family experience physical or emotional abuse in direct or indirect forms from a member of the same family. Domestic abuse can take the form of: • Physical aggression, that is an attack causing physical harm • Emotional manipulation or accusatory blaming • Deprivation of needs by controlling money • Isolation from friends and family • Constant expectation of explanations of behaviours and whereabouts. Both men and women experience domestic abuse, however the majority of people experiencing domestic abuse are women. Domestic abuse can occur in heterosexual and homosexual relationships. Another form of abuse is elder abuse. This abuse may occur in families or aged-care facilities. Elder abuse can be as undetected and destructive as domestic abuse.

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Individuals who experience domestic abuse have many needs. They need first to understand that women or men generally, and them specifically, do not have to submit to abusive interactions. They will not benefit from discussion about suspected domestic abuse until they attain this understanding. Once individuals accept that they do not have to remain in an abusive relationship, they will require particular assistance from an appropriate service. They will require a safe place to live, appropriate care for any children, financial assistance and child support, a means of becoming financially self-supporting and, possibly, legal protection. Many people who experience domestic abuse find it difficult to leave because they believe there will be change in the abusive person. The abusive relationship usually includes patterns of alternating abuse with expressions of love and promises to change and never abuse again. Fear of the abuser committing suicide, of trying to kill them or hurting the children, or fear of being alone, may stop a person from leaving an abusive relationship. If they do actually leave the relationship, they require ongoing counselling to overcome the erosion to their self-image that results from an abusive relationship.

Behaviours related to being a Person/s experiencing domestic abuse A person who experiences domestic abuse might: • Always act to satisfy the people around them, especially their partners • Accept any abusive or violent behaviour they experience • Avoid mentioning their experiences regardless of the associated depth of emotion • Find it difficult to make decisions • Be passive in relationships and not mention their own needs • Show behaviour that is not assertive or acknowledging of their needs • Always take the blame when things do not go according to plan • Stay in an abusive relationship because of fear for the children or fear of being alone • Always be looking at the time – not wanting to be late or away too long • Blame themself for having provoked the abuse.

Possible emotions a Person/s experiencing domestic abuse might experience A person who experiences domestic abuse might experience emotions related to: • Fear • Anxiety • Uncertainty • Feeling unlovable • Poor self-esteem • Insecurity • Feeling deserving of the abuse • Depression • Anger • Isolation Guilt • • Denial of the problem Mistrust of men and/or women • • Ambivalence.

Possible reasons for these emotions A person experiencing domestic abuse may experience these emotions because of: • Negative self-talk • Feeling that women deserve abuse • Their partner using non-verbal behaviour to control • Their partner often threatening to harm • Their partner constantly ‘putting them down’ 346

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• Their partner not allowing them access to their money • Their partner not allowing them to do paid work • Their partner stating they are not a good parent • Their partner controlling who they see and what they do • Their partner destroying their property • Their partner saying they deserve the abuse • Their partner threatening suicide • Their partner threatening to hurt the children. Principles for effective communication with a Person/s experiencing domestic abuse When communicating with a person experiencing domestic abuse it is important to: • Be reliable and worthy of trust • Create a safe place • Confront inappropriate beliefs • Listen actively • Observe their non-verbal communication • Validate their emotions, not their situation • Provide clear information.

Strategies for communicating with a Person/s experiencing domestic abuse

• It is essential to build rapport. • Be careful if using touch to communicate. • Deal with the specific issues. • Affirm their strengths. • Communicate to externalise the problems. • Set achievable goals. • Use same-gender health professionals. • Refer to appropriate services. • Avoid criticism of their skills.

See the Introduction to Section 4 for instructions about how to use these scenarios for group discussion. Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Jan loves wine and often drinks a bottle of wine over lunch and with the evening meal. She is a friendly person whose partner, Greg, gives her everything she wants to keep her happy and away from alcohol. She often screams and swears at Greg and even chases and hits him with whatever she can find at the time. Greg comes in for regular check-ups and has just come in for treatment. He has a broken right arm and states he broke his arm falling off a ladder more than a month ago. The next time Greg comes in he has a black eye and a hand-shaped bruise on his now-healed broken arm. He states he ran into a door, but has no answer when asked about the shape of the bruise on his arm. He quickly covers it with his sleeve. →

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• • •

How should you relate? What should you say? Do your goals change?

Scenario two: The female and the health professional Alicia lives in a caravan (trailer) park with her three children and husband, who is a labourer at the local shipbuilding yard. He is often tired and angry when he returns from work. He expects everything exactly as he wants it when he arrives home, and regularly hits Alicia if things are not as he wants. She has presented to your health service with a back injury and has bruises on her back that suggest she was hit. She maintains she hurt her back from a fall, but does not remember the details. You suspect domestic abuse. • How should you relate? • What are the major aims of relating? • What do you wish to communicate?

Health professionals who suspect domestic abuse of adults or children have a duty of care to report this suspicion. It can be beneficial to discuss any suspicion with a more senior or experienced health professional in order to plan strategies for relating and the requirement to report. The realities of domestic abuse are complex and the person experiencing the abuse may believe they deserve the abuse. They may believe that removing themself would have far worse consequences than remaining in the relationship. Counselling to achieve skills in assertiveness may assist, although assertiveness may simply escalate the levels of violence. Communicating with people who experience domestic abuse is challenging. It requires understanding and affirmation of the person to achieve effective communication.

Person/s speaking a different language to the health professional (Key words: speaker of languages other than English [LOTE], non-native speaker [NNS], non-English-speaking background [NESB], culturally and linguistically diverse [CALD], English as an additional language or dialect [EALD])

Definition of a Person/s speaking a different language to the health professional A person who speaks a different language to the health professional is someone who is unable to communicate verbally or in written form in the language of the health professional.

Behaviours related to being a Person/s speaking a different language to the health professional A person who speaks a different language to the health professional might: • Demonstrate apparently aggressive non-verbal behaviours • Demonstrate apparent comprehension even when they do not understand 348

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• Attempt to solve problems alone, with inadequate information • Avoid asking for assistance because of embarrassment • Sit quietly and avoid indicating they do not understand • Expect the services to be the same as they are in their own culture. Possible emotions a Person/s speaking a different language to the health professional might experience A person who speaks a different language to the health professional might experience emotions related to: • Fear about communicating in another language • Confusion and vulnerability, even though they normally understand conversational English • Inadequacy because they understand general English but not the English of the health professional • Frustration because of trying to understand but not being sure that they do.

Possible reasons for these emotions A person who speaks a different language to the health professional may experience these emotions because of: • Regular breakdowns in communication • Apparently aggressive non-verbal behaviours from those around them • Regular misunderstandings • Differences in cultural and social expectations • Age and gender differences • Cultural differences.

Principles for effective communication with a Person/s speaking a different language to the health professional When communicating with a person who speaks a different language to that of the health professional, it is important to: • Demonstrate empathy • Respect cultural differences • Establish rapport to build a therapeutic relationship • Negotiate meaning to achieve mutual understanding • Constantly clarify the understanding of the person • Avoid making assumptions • Consider the potential meaning of the non-verbal behaviours of the person – do not assume the non-verbal behaviours have the same meaning in both cultures.

Strategies for communicating with a Person/s speaking a different language to the health professional

• Use an interpreter – remember to speak to the person not the interpreter (see Ch 14).

• Ask questions about what is appropriate in their culture. You could ask the interpreter or family members who are fluent in your language.

• Avoid using non-verbal or visual cues unless you are certain of their meaning. • Explain how and why things are done in this health service. • Wherever possible avoid using family members or friends to interpret. 349

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• Wherever possible use a same-gender health professional. • Wherever possible provide all information in translated written form, ensuring the translation is the correct form of the language of the person.

• Have a known person introduce any new health professionals that will assist the person.

• Learn a few simple words and phrases of the language of the person (e.g. hello, thank you, please, goodbye, how are you?).

• Avoid presuming they understand. • Avoid presuming the health professional understands. • Have a sense of humour.

Remember the principles of effective communication and family/Person-centred practice.

Scenario one: The male and the health professional Person 1: Your name is Ahmed and you are a 45-year-old Middle-Eastern man who requires assistance from a health service. You speak very limited English and feel insecure about this unfamiliar place. Although you do not usually speak to unknown women, especially in public places, you spoke to a woman who was wearing a uniform. You hoped she might speak Arabic and you tried to speak to her. She seemed confused when she looked at you and obviously did not understand Arabic. Person 2: You must assess and devise some goals for a new person seeking assistance. He is a Muslim man who you think appears arrogant and rude. You observed him speak to the female cleaner who, although she does not speak fluent English, cannot speak Arabic. She appeared shocked and confused and you assume the man was rude to her. However, you are unsure because you may be misinterpreting his non-verbal behaviours or his tone of voice.

Scenario two: The female and the health professional Person 1: Your name is Kyoko and you are a 20-year-old woman from Japan. You have been studying English and have basic conversational skills. You are planning to become a health professional when you complete your English studies. You would prefer to see the health professionals in Japan but you will not be in Japan for another 10 months, so you are sitting timidly in a health service waiting room. You remember the first time you came to this service – you were very embarrassed and distressed that a young male health professional assessed you. Although he explained everything, your English skills were not proficient enough to understand. You remember crying very quietly. The young man, Matt, did not notice until you were leaving, when a lady waiting asked Matt what he had done because you were crying. When he noticed he seemed to be concerned; he thought he had physically hurt you. The next time you came he introduced a female health professional and an interpreter. You were able to apologise for crying and to explain that you would feel more comfortable with a female health professional assisting you if possible. This situation developed your confidence and they were able to answer all your questions. Matt was able to explain everything he did the last time and then what would happen next time. Since then, you have been seeing Rochelle and she has been assisting you. Person 2: You are Matt. Kyoko is a lovely young lady who has been receiving assistance for several weeks. The beginning was difficult but using an interpreter really helped for her second visit. Having Rochelle work with her also made a difference. However, today Rochelle is away and you have to see Kyoko. You are concerned and enter the waiting area with a little trepidation.

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S4 » THE FOCUS OF COMMUNICATION IN THE HEALTH PROFESSIONS: PERSON/S

REFERENCES The focus of communication Compic & Scope Victoria n.d. Communication Bill of Rights, CAN 004 280871. Communication Resource Centre, Compic & Scope, Box Hill, Melbourne. Online. Available: www.scopevic.org.au/index.php/cms/frontend/resource/id/68 20 Jan 2012 Groups in the health professions Johnson D W, Johnson F P 2009 Joining together: group theory and group skills, 10th edn. Merrill, Boston Mosey A C 1996 Psychosocial components of occupational therapy. Lippincott-Raven, Philadelphia Schutz W C 1973 Elements of encounter. Joy Press, Big Sur, California Tuckman B W, Jensen M A C 1977 Stages of small group development revisited. Group and Organisation Management 2(4):419–427 Yalom I D, Leszcz M 2005 The theory and practice of group psychotherapy, 5th edn. Basic Books, New York Life-limiting illnesses Kubler-Ross E 1969 On death and dying. Routledge, London Kubler-Ross E, Kessler D 2005 On grief and grieving: finding the meaning of grief through the five stages of loss. Simon & Schuster, London New Zealand Palliative Care Strategy. Online. Available: www.moh.govt.nz/moh.nsf/ pagesmh/2951 20 Jan 2012 Palliative Care Australia. Online. Available: www.pallcare.org.au 20 Jan 2012 World Health Organization 2008 Online. Available: www.who.int/cancer/palliative/ definition/en/ 20 Jan 2012

FURTHER READING Groups in the health professions Cohen M B, Mullender A (eds) 2003 Gender and groupwork. Routledge, New York Finlay L 2002 Groupwork. In: Creek J (ed) Occupational therapy and mental health, 3rd edn. Churchill Livingstone, London, p 245–264 Greif G L, Ephross P H (eds) 2005 Group work with populations at risk, 2nd edn. Oxford University Press, New York Haight B, Gibson F 2005 Burnside’s working with older adults: group process and techniques. Jones & Bartlett, Sudbury, MA Kueschler C F 2011 Group work: Building bridges of hope. Whiting & Birch, London Malekoff A 2004 Group work with adolescents: principles and practice, 2nd edn. Guilford Press, New York Malekoff A 2006 Making joyful noise: the art, science, and soul of group work. Haworth, New York Manor O (ed) 2010 Groupwork and mental health. Groupwork monographs. Whiting & Birch, London Preston-Shoot M 2007 Effective groupwork, 2nd edn. Palgrave Macmillan, Basingstoke Steinberg D M 2011 Orchestrating the power of groups: beginning, middles and endings (overture, movements, and finales). Whiting & Birch, London 351

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Life-limiting illnesses Australia & New Zealand Society of Palliative Medicine. Online. Available: www.anzspm.org.au 20 Jan 2012 White G 2006 Talking about spirituality in health care practice: a resource for the multi-professional health care team. Jessica Kingsley, London Helpful journals relating to life-limiting illness: Bereavement Care Cancer Journal Critical Care Medicine Critical Care Nursing Clinics in North America European Journal of Palliative Care International Journal of Palliative Nursing Journal for Community Nurses Journal of Pain & Symptom Management Journal of Palliative Care Nursing and Residential Care Palliative Medicine Psycho-oncology Qualitative Health Research Topics in Geriatric Rehabilitation.

352

Glossary

Aboriginal or Torres Strait Islander Peoples  The original inhabitants of the continent of Australia. An Aboriginal or Torres Strait Islander is a person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander and is accepted as such by the community in which they live. Active listening  Listening that responds to the verbal and non-verbal messages sent in a manner that indicates interest and acceptance. It enables the health professional to assist, enjoy, influence, observe and understand.

COMMUNICATION: CORE INTERPERSONAL SKILLS FOR HEALTH PROFESSIONALS

Aggressive communication  Communication in which perceptions, opinions and feelings are expressed in a manner that intimidates or attacks the other communicating individual(s). Alternative communication  Non-verbal forms of communication to replace the spoken word, for example, an electronic device using visual communication software. Ambiguity  A situation in which something can be understood in more than one way and it is initially not clear which meaning is intended. Assertive communication  Communication in which perceptions, ideas or opinions are expressed in a manner that respects the worth and rights of others to have and express perceptions, ideas or opinions. Attitudes  Unconscious values and beliefs. Augmentative and alternative communication (AAC)  Systems that allow non-verbal methods of communication, including visual and computer-assisted devices. Augmentative communication  Non-verbal forms of communication that highlight the spoken word through simultaneous gestures, signs, pictures and key-word  signing. Background  The environment in which a person grows and matures, and develops their values and beliefs. Barrier  Anything that stops or restricts something from happening; can restrict function and/or participation in a particular area. Beliefs  Principles or doctrines that a person or group considers true. Bias  An unfair preference or dislike of someone or something. Body language  Non-verbal communication that includes gesture, facial expression, posture, eye contact, gait and clothing. Clan  A group of families related through a common ancestor or through marriage. Clarifying  To make something clear, either by asking questions to ensure understanding or by explaining any unclear information. Cliché  A phrase or statement that is overused and does not communicate care or understanding. Cognition  The process of perceiving, processing, storing and retrieving information, as well as thinking and planning with intuitive thought and perception. Collaborative partnership  A partnership that requires the contribution of each person to achieve a satisfactory and appropriate outcome. Comforting  The process used by the health professional to ensure the person seeking assistance feels encouraged, affirmed and empowered to continue meeting the chaÂ� llenges they face. Community: health profession  All people who are qualified in a particular health profession. Community: health service  All people who work in or attend a particular health service. Community: Indigenous  Local Aboriginal or Torres Strait Islander Peoples or Maori, or people from their place of birth. Complementary and alternative medicine (CAM)  Treatment that does not usually conform to ‘traditional’ medicine or the medical model. Computer-mediated communication (CMC)  Electronic forms of communication. Confidentiality  Keeping information within a particular context; involves keeping information private. Conflict  A struggle or clash between two different or opposite ideas, thoughts, people or principles; can be physical, psychological, social or spiritual. 354

GLOSSARY

Confronting  The act of challenging and sometimes disagreeing with inappropriate attitudes and beliefs in order to clarify and examine these attitudes and beliefs and ultimately change them. It is neither intimidating nor judgemental. Consent  To give permission or approval for something to happen, usually in writing. Context  Surrounding factors that affect meaning; can be situational and environmental. Control  The ability to manage or direct the events in life. Cross-cultural communication  Occurs when people from different cultures interact with the intention of reaching mutual understanding. Cultural assumptions  Opinions about patterns of behaving, beliefs and values that are culturally determined. Cultural competence  To understand the customs, beliefs, values and behaviours of a particular culture. Cultural identity  Characteristics that a person recognises as belonging uniquely to their own culture. Cultural norms  Standard patterns of behaviour that are considered normal in a particular culture. Cultural safety (security)  Achieved through practice that respects, supports and empowers the cultural identity and wellbeing of an individual and allows the person some control over or contribution to their health interventions and outcomes. Cultural sensitivity  Achieved through practice that accommodates the cultural identity, needs and practices of different cultures. Culture  Traditions and patterns of behaviour that develop in a particular group because of the values and beliefs of that group. It influences every aspect of life. Culture: disease/illness  Individuals with illness experience adjustment to their beliefs, values and daily habits or ‘ways of doing’. Culture: health professions  Each health profession has particular values, beliefs, traditions and underlying principles that are unique to that profession. Cultures: large  Cultures with a large membership, or a nation. Cultures: small  Cultures with a small membership. Customs  Actions that people from a particular group always perform in particular ways in particular circumstances. Defenses (defense mechanisms)  Adaptive mental mechanisms that assist the individual to continue functioning, despite the presence of uncomfortable emotions, thoughts, information or wishes, by removing them from the conscious mind. They are a method of managing thoughts and emotions that would otherwise be unmanageable. There are four defenses that occur on a continuum: psychotic, immature, neurotic and mature. Disengagement  Process that leads to the disconnection of the individuals in a communicative act. It involves satisfactory completion of an interaction. Diversity  Variety of something – cultures, opinions, beliefs etc. Dominant/primary needs  Needs that dominate relationships and may negatively impact on the relationship between a health professional and a person seeking assistance. Effective communication  All people communicating have clearly understood the exact meaning of every message, regardless of the forms of the message. Effective listening  Listening that adapts to the particular individual, their non-verbal cues and the context. Requires active engagement with the person and their message, and is a characteristic of a therapeutic relationship. Effective speaking  Requires interest in, enthusiasm for and knowledge about the topic and the ‘audience’, as well as understanding of the effect of non-verbal behaviours upon the words spoken. 355

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Efficacy  The ability to produce the necessary and desired results with efficiency and accuracy. Elders  Custodians of cultural laws, ceremonies, practices, traditions and remedies. Often the key decision makers who provide advice and leadership. Emotions  Feelings that individuals experience because of internal factors that cause negative or positive agitation or disturbance. Empathy  The direct, clear and accurate understanding and expression of the emotions of an individual. Emphasis  Stress on a particular word or phrase that may change the meaning. Empower  To give the person seeking assistance a sense of confidence to overcome the challenges they face. Environment  Factors external to the person which may be physical, emotional, social, cultural or spiritual. Equality  Balance of power in a relationship through shared opportunities and mutual demonstrations of an attitude of acceptance. Ethical communication  Requires knowledge of and commitment to the requirements that result in appropriate communicative behaviour while practising as a health professional. Ethical responsibility  Protecting information about the people seeking assistance, whether read or heard. or Acting in the interests of the person seeking assistance and in accordance with the appropriate code of ethics or conduct. Ethnocentric  When an individual believes their particular method or way of approaching a situation is superior and indeed the best way. Explaining  To make the meaning of something clear by using words that make it easy to understand. Eye contact  Occurs when communicating individuals look directly into each others’ eyes. Not appropriate in all cultures. Facial expressions  A type of body language in which the face is used to communicate meaning. Family/Person-centred practice  The needs and wishes of the family or Person are the centre of the goals and elements of practice. Function  To perform any activity of choice. Gestures  A type of body language in which meaning is expressed through the use of the arms, hands or fingers. Health  Sound condition of the mind, body, emotions and spirit that allows a person to function and participate. Health professional  An individual who works in a profession that directly affects the health of the people they assist. Holistic care  Considers all aspects of the person and their context, and allows them to have an active part in their healing. Holistic communication  Requires a willingness to communicate about contexts, experiences, thoughts, emotions, needs and desires. Requires understanding of the value and uniqueness of each individual. Honesty  A characteristic that results in an upright disposition and conduct. Humour  The ability to see that something is funny; the ability to laugh at oneself when an error has been made. Ideal health professional  An excellent example of a health professional because of exemplary thoughts, patterns, attitudes, values and behaviour.

356

GLOSSARY

Indigenous peoples  ‘First Nation’ people – those who inhabited a country or region before another group came and settled the country or region as though it belonged to them. Informed consent  To give written permission or consent on the basis of real knowledge and understanding of an event or procedure. Informing  Communicating information or knowledge to the person seeking assistance. Instructing  Teaching someone how to do something. Interpretation: sequential  The interpreter translates a small portion of the information and then waits for the next piece of information before they interpret further. Interpretation: simultaneous  The interpreter interprets at the same time as the information is presented. Interpreter  Someone who translates orally or visually what is said in one language into another language to facilitate communication. Interpreting  Translating the meaning of an utterance regardless of the word/sound spoken. Intervention  Action taken by the health professional after collaboration with the person that will change something that is happening for the person in a positive manner. Introducing  Presenting oneself, the role, the environment, the people in the environment and their role. Jargon  Words used in a particular context or profession that gives those words specific meaning known only to those familiar with the context or profession. Journal  A helpful learning tool in which to record answers to questions and thoughts about self and reactions; can promote learning about self. Judgement  An opinion of someone based on personal values and beliefs. May not always be accurate or informed and may negatively affect communication. Kinship group  People related by blood or marriage. Learning preferences  Style of learning that best suits an individual. Listening barriers  Habits that limit the ability to listen, process, remember and respond appropriately to a spoken message. Mainstream  Health services that are provided by and for the dominant cultural group, whether owned by the government or a non-government body. Maori  The people who were the original inhabitants of New Zealand. Misunderstanding  A failure to negotiate meaning; also known as miscommunication. Model  Assists in directing practice. Mutual understanding  All the people communicating understand all the factors that contribute to the meaning of the message. Nation  A community of people who live in a defined area and share a common origin, culture, traditions and language. National identity  The characteristics that a person recognises as unique to their nation. Non-judging  Avoiding forming an opinion in order to ensure positive relations with acceptance regardless of differences between the people communicating. Non-verbal communication  Communication without spoken words. Non-verbal messages  Messages sent using body language or suprasegmentals of the voice. Open communication  Accepting and accommodating differences and needs while communicating. Over-identification  Occurs when the health professional discusses a similar situation or experience to the person seeking assistance.

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Paralinguistic features of the voice (paralanguage)  Particular vocal effects that change meaning, including emphasis, timely pauses, tone, laughing, whining, moaning and other non-verbal sounds. Participation  Active involvement in activities of choice. Passive communication  Lack of expression of perceptions, ideas or opinions because the person feels they do not have the right or value to express themself in that situation. Pauses  Paralinguistic features of the voice where the speaker does not produce words; provides opportunity for thought and processing. Perfection  Always being as good and accurate as possible; reaching the highest standard in actions and words. Personal space  A comfortable distance between people when communicating or moving past each other; usually culturally determined. Person/s  Any person/s to whom the health professional relates while fulfilling their role as a health service provider. May include colleagues, other workers in the health service, the person seeking assistance and their family and friends. Physical  The part of the person that relates to the external and internal parts of the body. Pitch  Frequency of sound, which makes the voice sound low or high. Prejudice  A preformed opinion often of a negative kind, based on ignorance, irrational feelings, and uninformed or inaccurate stereotypes. Processing preferences  Style of organising information that best suits the individual. Prosodic features of the voice  Vocal effects including volume, pitch, speed and rate of speech that create the unique rhythm of a language. Psychology  Mental and emotional processes. Rapport  A connection between two people based on trust and awareness that they have a common goal. Reflection  Examination of how the reactions of the self affect interactions; uses the experience and knowledge of the self as well as theory to increase self-awareness and understand the causes of those reactions. Reflective  Describes the revisiting of uncomfortable events in order to understand them and change behaviour in similar situations in future. Reflexive  Considering how the self affects and is affected by particular events in order to evaluate and critique the self; facilitates internal change that benefits relationships with people seeking assistance. Remote communication  Communication that is not face-to-face. Respect  Unconditional positive regard for self and others regardless of weaknesses or failures, position or status, beliefs and values, and material possessions or socioeconomic level. It assumes all human beings have innate worth and value. Role  The expected function of a person given their position or membership in society and the expected behaviour that accompanies that position. Self-awareness  Awareness of the beliefs, values, thoughts, inadequacies and fears that affect and drive thoughts and responses of the self during interactions. Self-disclosure  Sharing own experiences and feelings. Self-introduction  To make the person seeking assistance aware of the health professional and the role of the health professional in that health service. Sexual  Reproductive organs and the responsibilities associated with the use of those organs; also refers to sexual preference. Silence  Absence of speaking. Social  The aspect of a person that relates to others as an individual or a group. 358

GLOSSARY

Spiritual  The aspect of a person that gives meaning to self, life and the universe. It determines the beliefs and values that motivate and sustain the person. Status  The relative ‘importance’ of someone in a particular group or in society. Stereotype  An oversimplified idea or image of one person or a group that is usually incorrect. Suprasegmentals  Elements of the voice (not words or body language) that affect the meaning of messages. There are two types: prosodic and paralinguistic features. Therapeutic relationship  A collaborative relationship between the health professional and the person seeking assistance that fulfils the needs of the person and empowers them to overcome any challenges. Tone of the voice  Indicates the feelings, attitudes or thoughts of the person about the particular topic. Touch  A non-verbal way of physically connecting with a person by using a part of the body, usually a hand, to connect with a part of their body. Transliteration  The exact translation of each word/sound spoken regardless of meaning; these interpretations often have limited meaning. Trust  Confidence in and reliance upon the health professional to provide quality service that is always in the best interests of the person seeking assistance. Unsafe cultural practice  Practice that diminishes, demeans or disempowers the cultural identity and wellbeing of an individual. Validation  The health professional confirms the existence of particular situations or emotions, whether or not they agree, and indicates that the emotional response is understandable. Value  The measure of worth, importance or usefulness of something or someone. Verification  A health professional explores their perceptions of the person seeking assistance to establish the truthfulness of the perceptions and the appropriateness of the emotions. Visual  Anything that can be seen with the eye. Volume of a voice  Whether the voice is loud or soft; can communicate particular meaning. Vulnerable  Feeling emotionally insecure and unsure about the possibility of experiencing harm. Wellbeing  A sense of feeling comfortable and safe. Whole person  A dynamic system in which every aspect of the individual affects and interacts with the other aspects simultaneously. It consists of five fundamental aspects: the physical; the emotional, including the sexual aspect; the cognitive; the social; and the spiritual. Worth  The value of someone – innate and inbuilt in all human beings.

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Index Page numbers followed by f indicate figures; t, tables; b, text in boxes.

A

AAC see augmentative and alternative communication Aboriginal misunderstandings and, 234 pauses and, 171 acceptance of Indigenous peoples, 216–217 as relationship need, 71 seeking of, 71–72 self-, 66 active listening, 126, 130f adolescents, 294–298 behaviours related to, 295 definition of, 294–295 depression and, 289 emotions of, 295, 295t principles for effective communication with, 296 scenario on, 296b–297b strategies for communication with, 296–298 susceptibility of, 295 adult, 298–299 behaviours related to, 298 definition of, 298 emotions of, 298, 298t principles for effective communication with, 299, 299t scenario on, 299b–300b strategies for communicating with, 299 susceptibility of, 298 affection, as relationship need, 71 affirmation, as relationship need, 71 aggressive behaviour, 183, 281–283 definition of, 281–283 principles for effective communication with, 282–283 reasons for, 282 scenario on, 283–284 strategies for communicating with, 283 suseptibility to, 282 agreements, signed, 247–248 Alzheimer’s disease see decreased cognitive function ambiguity tolerance, 236 assertive behaviour, 183, 185 attitude development of, for stereotypical judgement avoidance, 92–93 misunderstandings from, 235 see also unhelpful attitudes or beliefs, confrontation of

audience cultural/language background of, 7 effective communication and, 7–8 mutual understanding and, 75 written documentation and, 263–264 augmentative and alternative communication (AAC), 172 devices for, 173 health professionals and, 173 successful use of, 173 variations of, 172–173 Australian Government Department of Health and Ageing, 219–222 Australian Government policies and acts Commonwealth Disability Strategy 2003, 247–248 Disability Services Act 1986, 247–248 Privacy Act 1988, 247–248 Autism Spectrum Disorder, 115–116 awareness of culture, 198–199 of misunderstandings, 239 of Person/s, 100–122, 118f of whole person, 105–106 see also self-awareness

B

background of individuals and effective communication, 7–8, 193 and meaning of words, 6–7 barriers and stereotypical judgements, 90 and listening, 77–78, 77t, 126 and experiencing emotions, 56–59 and culturally sage communication, 225 beliefs and health, 195 and awareness of, 160, 216–217 and confronting unhelpful, 37–39 behaviours of an adolescent, 295 of an adult, 298 assertive, 183, 185 bullying, 183–185 cyber-, 269–270 of carer, 305 of a child, 291–292, 292t decreased cognitive function related to, 324 depression related to, 289 different language spoken and, 348–349 domestic abuse related to, 346 in an emergency, 343

behaviours (Continued) engagement reluctance and, 286 ethical codes of, 252 extreme distress related to, 284 of health profession colleague, 303, 303t of health profession groups, 318 hearing impairment and, 336 life-limiting illness and, 327 long-term illness and, 333 maladaptive, defense mechanisms and, 57 mental illness and, 330 of an older person, 300–301 of a parent, 307–310 of PTSD, 320 of a student, 313 visual impairment and, 339–340 see also aggressive behaviour; communicative behaviours body language, 166 as non-verbal communication component, 167–172 spoken language and, 166 Boud, D J, 49, 53, 55 boundaries, 250–252 roles, 250 therapeutic relationships, 250–251 bullying behaviour, 183–185 cyber-, 269–270 burnout, 250

C

carer, role of, 305–306 behaviours of, 305 definition of, 305–306 emotions of, 306, 306t principles for effective communication with, 306 scenario on, 306–307 strategies for communicating with, 306 chaos understanding, from reflection, 51 characteristics of discouragement, 35–37, 36t of effective listening, 127–128 of encouragement, 35–37, 36t of health professionals, 69–71, 70b–71b, 91 of remote communication, 261–262, 262t of single parent, 310 chat rooms, professional, 269 child, 291–294 behaviours related to, 291–292, 292t definition of, 291

361

INDEX child (Continued) emotions of, 292 principles for effective communication with, 292–293 scenario on, 290b–291b, 293b–294b strategies for communicating with, 293–294 clarifying questions, 34 closed questions, 32–33 language barriers for, 32 multiple choice as, 33 CMC see computer-mediated communication cognitive aspect, of Person/s, 105–106, 114–116 concentration and, 115 emotions influencing, 115 skill level of, 115 understanding and consequences and, 115 collaborative partnership, family/ Person-centred practice as, 13–14 colleague role, in health profession, 303–305 behaviours of, 303, 303t definition of, 303–305 emotions of, 303–304 principles for effective communication with, 304, 304t scenario on, 304–305 strategies for communicating with, 304–305 colour, 145 comforting, encouraging compared to discouraging, 35–37 Commonwealth Disability Strategy 2003, 247–248 communication, 4 assertive behaviour during, 183, 185 conflicts during, 180–182 cultural styles of, 219, 236 ambiguity tolerance, 236 discussion points for, 281 environments influencing, 135–151 health professions and, 13 holistic, 160–161 ICF demonstrating importance of, 12–13 with Indigenous peoples, 212–231, 226f without judgement, 89 misunderstandings and, 232–243 non-judgemental, 94–95 personal assumptions influenced by, 88–99 avoidance of, 89–90 personal skills awareness and, 75–76 with Person/s having limited verbal communication skills, 172–173 role-plays on, 279–281 scenario discussion regarding, 280–281

362

communication (Continued) skill development for, 279 with whole Person/s, 155–164, 161f see also culturally competent communication; remote communication; strategies for communicating Communication Bill of Rights, 278 communicative behaviours diversity and, 80 personality and, 81 self-awareness and, 79–81 temperaments and, 81 communication styles of Indigenous people, 219, 223 computer-mediated communication (CMC), 261 concentration, 115 conduct, ethical codes of, 252 confidentiality, 249–250 ethical responsibility protection by, 249–250 gossip protection from, 250 health professionals protected by, 250 information gathering and, 104 respect and, 104 shared information protection by, 249 conflicts, 187f aggressive individuals and, 183 assertive individuals and, 183 bullying and, 183–185 causes of, 180 during communication, 180–182 emotions during, 181 misunderstandings and, 181 natural response tendency, 182 needs, 73–74 negative emotions and, 182 passive individuals and, 183 prejudice and, 182 relating patterns during, 182–183, 184b, 186b resolution of, 187 confrontation barriers for, 38 challenges of, 39 non-verbal communication and, 38 opportunities provided by, 37–38 of unhelpful attitudes or beliefs, 37–39 therapeutic relationship needed for, 38 consent ethical communication and, 247–248 information agreement and, 247–248 informed, 104, 248, 258–259 consequences, 115 context meaning cultural barriers and, 235–236 misunderstandings from, 235–236 understanding of, 198 control, as relationship need, 71 Convention on the Rights of Persons with Disabilities, 245–246

cultural barriers context meaning and, 235–236 misunderstandings and, 234 non-verbal communication and, 32 cultural differences, 195 cultural environment, 143–146 colour, 145 personal space and, 143–145 time, 145–146 cultural identity, culturally competent communication influenced by, 193 cultural norms effective listening and, 126–127 expectations governed by, 237 misunderstandings from, 237 respect expectations of, 103–104 regarding touch, 112 cultural safe communication, with Indigenous peoples, 222–224 barriers for, 225 cultural safety, 193–194 cultural/language background of audience, 7 communication and, 219, 236 reflection and, 52 culturally competent communication, 191–211, 207f cultural identity influencing, 193 definition of, 193–194 demonstration of, 202–204, 202b difficulty anticipation and, 204 exposure and learning and, 203 insecurity and uncertainty with, 203 institution and, 196 interpreter use and, 204–206 language and, 197 model of, 195–197, 195f personal commitment to, 203 responsibility for, 196 self-awareness and, 203 culture awareness of, 198–199 definition of, 192–193 differences of, 195 of disease or ill-health, 206 health beliefs and, 195 of health professions, 206 influences of, 192 large, 192 personal assumption and expectation management of, 200–202 of Person/s, 105–106, 116–117 small, 192 cyber-bullying, 269–270

D

databases, 264 decreased cognitive function, 323–326 behaviours related to, 324 definition of, 323–326 emotions of, 324 principles for effective communication for, 325

INDEX decreased cognitive function (Continued) scenario on, 325–326 strategies for communicating with, 325–326 susceptibility of, 324 defences, 58t habitual use of, 57 immature, 57 mature, 57 neurotic, 57 psychotic, 57 defence mechanisms commonly used, 58t immature and mature, 57 maladaptive behaviour and, 57 neurotic, 57 reflection and, 56–57 as survival tool, 57 dementia see decreased cognitive function depression, 289–290 adolescents and, 289 behaviours related to, 289 communication strategies for, 290 definition of, 289–290 effective communication principles for, 290 men and, 289 reasons for, 289 susceptibility of, 289 women and, 289 Devito, J A, 192–193, 245 different language spoken, 348–350 behaviours related to, 348–349 definition of, 348–350 emotions related to, 349 principles for effective communication and, 349 scenario on, 350 strategies for communicating with, 349–350 Disability Services Act 1986, 247–248 discouragement characteristics of, 35–37, 36t classifying responses of, 36b encouragement compared to, 35–37 disease culture, 206 disengagement, 128–129 cues for, 129 disorders, effective communication influencing, 8 distractions avoiding, 140–141 documentation abbreviations and, 263–264 formatting for, 264 for remote communication, 263–264 written, 263–264 domestic violence, 345–348 behaviours related to, 346 definition of, 345–348 emotions of, 346–347, 346t principles for effective communication and, 347

domestic violence (Continued) scenario on, 347–348 strategies for communicating with, 347–348 dress or appearance, 136–137 dynamic system, whole Person/s as, 105–106, 156–157

E

education, of Indigenous peoples, 220–221 effective communication, 3–10, 82f disorders influencing, 8 emotions and, 8 factors contributing to, 4–8 within audience or receivers, 7–8 external to sender, 7 guiding principle for, 4 individual thoughts, ideas, needs and emotions and, 8 learning to, 4 mutual understanding and, 5–6, 5f, 8f with Person/s, 101 professional jargon and, 7–8 word meaning and, 6–8 see also principles for effective communication; strategies for communicating effective listening, 130f activities during, 76 barriers to, 77–78, 77t, 126 external factors for, 126 internal factors for, 126 language as, 126 reasons for, 78 benefits of, 126 characteristics of, 127–128 cultural norms and, 126–127 definition of, 124 in health profession, 17 preparation for, 126–127 reflection and, 124 requirements of, 76, 124–125 results of, 125 SAAFETY principles for, 127, 127t self-awareness and, 76–78 silence and, 113 SOLER model for, 128, 129t validation and, 124 effective speaking genuine topic interest needed for, 79 self-awareness and, 78–79 skills for, 79 Egan, G, 38, 251 Elders, Indigenous people, 222–223 emergency, 342–345 behaviours related to, 343 definition of, 342–345 emotions related to, 343 principles for effective communication with, 343–344 scenario on, 344b–345b

emergency (Continued) strategies for communication with, 344–345 susceptibility of, 343 emotional environment, 142–143, 148f external, 143 internal, 142–143 responses of, 142–143 emotions of an adolescent, 295, 295t of an adult, 298, 298t of a carer, 306, 306t of a child, 292 cognitive aspect influenced by, 115 of colleagues, 303–304, 303t during conflicts, 181 decreased cognitive function and, 324 domestic abuse and, 346–347, 346t effective communication and, 8 in emergency, 343 of health profession groups, 317–318 of health professionals, 15 of hearing impaired person, 337 holistic care and expressions of, 159 ignoring of, 181–182 irritation, 181 life-limiting illness and, 327–328 long-term illness and, 334 mental illness and, 331 misunderstandings and, 235, 239 of an older person, 301 of a parent, 308–309, 308t of a person speaking different language, 349 Person/s aspect of, 105–114 PTSD and, 321, 321t reflection and, 54, 56–59 to respect, 102 of a single parent, 311, 311t strong, 281–290 of a student, 313–314, 313t validation of, 107–108 clarification within, 107–108 visual impairment and, 340–341, 340t see also negative emotions empathy, 15f, 108–112 definition of, 108–109 expression of, 15 health professionals and, 14, 108–109 importance and result of, 110–112 needed for mutual understanding, 16 Person/s and, 110–112 as process, 108 respect and, 111 scenario on, 109–110 sympathy compared to, 109 emphasis of voice, 170–171 word meanings and, 7 empower, therapeutic relationship as, 16 see also control; power imbalance

363

INDEX encouragement characteristics of, 35–37, 36t classifying responses of, 36b discouragement compared to, 35–37 practising responses of, 37 environment communication influenced by, 135–151 cultural, 143–146 distractions and interruption avoidance and, 140–141 emotional, 142–143, 148f external, 143 formal versus informal, 142 interaction outcomes influenced by, 136 as non-verbal communication component, 167 physical, 136–141 physical ability of individual and, 141 sexuality relating to, 146 social, 146–147 spiritual, 148 temperature and, 141 word meaning influenced by, 6 equality in relationships, 93–94, 94t ethical codes, of behaviour and conduct, 252 ethical communication, 244–259, 253f boundaries and, 250–252 roles, 250 therapeutic relationships, 250–251 consent and, 247–248 expectation clarification and, 247 honesty and, 246–247 ethical responsibility, confidentiality protecting, 249–250 Ethics at home: informed consent in your backyard (Malone), 248 ethnocentricity, 198–199 event expectations of, 237 reflection model description of, 53 expectations of communication styles, 236 cultural norms governing, 237 of events and procedures, 237 of health professionals, 90–92 explaining, by health professionals, 24, 237 external environment, 143 extreme distress, 284–286 behaviours related to, 284 communication strategies for, 285–286 definition of, 284–286 effective communication principles for, 285 reasons for, 284 scenario on, 285–286 susceptibility of, 284

364

eye contact cultural variations of, 168 as non-verbal communication component, 168

F

facial expression, as non-verbal communication component, 167–168 family, 147 Indigenous peoples notion of, 219 family/Person-centred practice, 13, 15f, 21 as collaborative partnership, 13–14 goals of, 17 model components of, 18f mutual understanding and, 13f scenario on, 111b therapeutic relationships and, 17 formatting written documents, 264 formal environment, 142 friends, 147 furniture placement, 138–139

G

gender of health professional and Indigenous people, 221, 223–224 gesture, as non-verbal communication component, 168–169 gossip, 250 grief, 326 groups, in health professions, 315–319, 316b behaviour expectations of, 318 emotions experienced in, 317–318 norms of, 318 overall aims of, 318 principles for effective communication with, 319 scenario on, 319 specific sessions of, 318 stages of growth in, 316–317, 317t strategies for communication as leader of, 319 types of, 316–319 guilt, 233

H

Haddad, A, 160, 198 health professionals AAC and, 173 communication goals of, 11–19 confidentiality protecting, 250 emotions of, 15 empathy and, 14, 108–109 expectations of, 90–92 information gathering by, 31 informing, instructing and explaining by, 24, 237 misunderstanding resolution by, 239–240 mutual understanding and, 14–16

health professionals (Continued) Person/s information and, 104–118 physical environment familiarity and, 138 power imbalance with, 93–94, 94t reflection and, 49, 54 respect and, 14, 103 stereotypical judgements of, 91–92 therapeutic relationship with, 16–17 values, characteristics and abilities needed for, 69–71, 70b–71b, 91 health professions career choices in, 69 communication and, 13 culture of, 206 effective listening in, 17 efficiency and improved outcomes in, 262 groups in, 315–319, 316b as multidisciplinary team, 101 self-awareness of, 69 spiritual needs of Person/s interest from, 117 see also colleague role, in health profession hearing impairment, 336–339, 339t behaviours related to, 336 definition of, 336–339 emotions and, 337 principles for effective communication with person with, 337 scenario on, 338 strategies for communication with person with, 337–339 susceptibility of, 336–337 history of Indigenous people, 218–219 holistic care achievement of, 159 context consideration for, 158 emotional expression and, 159 requirements of, 158–159 respect and, 157–158 understanding of, 157 whole Person/s and, 157–159 holistic communication, 160–161 honesty, 246–247 Honey, P, 80–81 Human Rights Council, 245–246 humble, 196 humour appropriateness of, 56 reflection about use of, 56

I

ICF see International Classification of Functioning, Disability and Health ideas of individuals, effective communication and, 8 ill-health culture, 206 immature defences, 57, 58t Indigenous Allied Health Australia, 213

INDEX Indigenous peoples, 215 acceptance of, 216–217 cultural identity of, 215–216 culturally safe communication with, 222–224 barriers for, 225 cultural safety for, 216–218 communication with, 212–231, 226f education and language of, 220–221 Elder contact and, 222–223 family notion of, 219 healthcare and, 220 history of, 218–219 post-contact, 218–219 pre-contact, 218 illness understanding and attitudes of, 221 kinship obligations of, 220 life circumstances of, 220 Maoris, 215–216, 218–219, 251 non-verbal communication and, 224 power imbalance impact and, 221 principles of practice when working with, 216–222 reconciliation principles for, 213–214 recognise, 214 reflect, 214 remember, 213–214 respond, 214 spirituality concepts of, 219–220 stereotypical judgement and, 216 traditions of, 215–216 see also Aboriginal; Torres Strait Islander individual health service, 197 individual values reasons for, 69 from reflection, 52 self-awareness and, 69 types of, 69 informal environment, 142 information agreement, 247–248 information gathering confidentiality and, 104 by health professionals, 31 method of, 31 information management responses to, 80–81 self-awareness and, 79–81 styles of, 81 information provision listener preparation for, 25 opinion and, 25 organising of, 26 presentation of, 25 repeating and, 25 timing of, 26 as two-way process, 24–26 informed consent, 104, 248, 258–259 sample letter of, 258–259

informing, by health professionals, 24, 237 institutions, 147 culturally competent communication and, 196 instructing, by health professionals, 24, 237 interacting person’s intention, reflection model and, 53 interaction events, reflection model and, 53–54 interest groups, 147 International Classification of Functioning, Disability and Health (ICF), 12, 12f communication importance demonstrated by, 12–13 Internet, 268–269 email and, 268–269 search engines and, 269 interpretation process of, 204 sequential, 204 simultaneous, 204 interpreter culturally competent communication and, 204–206 steps when using, 205–206 interviewing, 31–35 Interruptions, avoiding them, 140–141 introductions environmental, 23 information provided by, 22 quality of, 26, 27f verbal, 21–24 irritation, 181

J

jargon see professional jargon judgement communication without, 89 stereotypical, 89–90

K

kinship obligations, 220 knowledge, mutual understanding influenced by, 7

L

language background of audience, 7 communication and, 219, 236 reflection and, 52 barriers for closed questions, 32 for effective listening, 126 misunderstandings and, 234 body, 166 as non-verbal communication component, 167–172 spoken language and, 166

language (Continued) culturally competent communication and, 197 of Indigenous peoples, 220–221 spoken, 166 see also different language spoken leading questions, 34–35 letters, 263–264 learning styles, 79–81 life-limiting illness, 326–330 behaviours related to, 327 definition of, 327 emotions of, 327–328 principles for effective communication with, 328 scenario on, 329b strategies for communicating with, 329–330 lifespan stages, 291–302 adolescent, 294–298 child, 291–294 older people, 300–302 listener, information provision preparation of, 25 listening active, 126 passive, 127 see also effective listening long-term illness, 333–334 behaviours typical of person with, 333 definition of, 333–334 emotions of, 334 principles for effective communication and, 334 scenario on, 334b–336b strategies for communication and, 334 susceptibility for, 333 lunar calendar, 145

M

maladaptive behaviour, defense mechanisms and, 57 Malone, S, 248 mature defences, 57, 58t medical records, 263–264 men, depression and, 289 mental illness, 330–332 behaviours related to, 330 definition of, 330–332 emotions of, 331 principles for effective communication with, 331 scenarios on, 331–332 strategies for communication and, 331–332 susceptibility of, 330 misunderstandings Aboriginal and Torres Strait Islander and, 234 from assumptions, 234 avoidance strategies for, 237–238

365

INDEX misunderstandings (Continued) awareness of, 239 causes of, 235–237 attitudes, 235 communication style expectations, 236 context, 235–236 cultural norm expectations, 237 emotions, 235, 239 event or procedure expectations, 237 communication and, 232–243 conflicts and, 181 cultural barriers and, 234 factors influencing, 233–234, 240 incidence reduction of, 238 language barriers and, 234 negative emotions from, 233 origins of, 233 from professional jargon, 237 reflection and, 238–239 resolution of, 235, 239–240 by health professionals, 239–240 steps for, 239–240 responsibility for, 239 from words, 238, 240f motivation, 196 multidisciplinary team, 101 multiple choice, as closed question, 33 multiple illnesses see long-term illness Mumford, A, 80–81 mutual understanding audience and, 75 effective communication and, 5–6, 5f, 8f family/Person-centred practice and, 13f health professionals and, 14–16 indication seeking of, 25 knowledge influencing, 7 respect, empathy and trust needed for, 16

N

names, respectful use of, 104 needs conflict, 73–74 needs of individuals effective communication and, 8 personal unconscious, 71–73 values conflicts between, 73–74 negative emotions conflicts and, 182 from misunderstandings, 233 responses to, 36–37, 36b, 36t self-awareness influenced by, 67–69 negative self-talk, 75 perfectionism and, 75 neighbours, 147 neurotic defences, 57, 58t The New Shorter Oxford English Dictionary on Historical Principles, 246 New Zealand Government Privacy Act 1993, 247–248 New Zealand Palliative Care Strategy, 326

366

non-government organisations (NGO), 197 non-judgemental communication, 94–95 non-verbal communication, 165–178 benefits of, 166–167 components of, 167–172 body language, 167–172 environment, 167 eye contact, 168 facial expression, 167–168 gesture, 168–169 confrontation and, 38 cultural barriers for, 32 effects of, 166–167 elements of, 173–174 exercise for, 168 Indigenous peoples and, 224 paralinguistic voice features, 170–172 power of, 174f prosodic voice features, 169–170 significance of, 166 touch as, 112–113 unconscious use of, 172

O

older person, 300–302 behaviours related to, 300–301 definition of, 300 emotions of, 301 principles for effective communication with, 301 scenario on, 302 strategies for communicating with, 302 susceptibility of, 301 online collaboration tools professional chat rooms and wiki spaces, 269 social networking sites, 269–271 open questions, 33–35 opinion, information provision and, 25 other-awareness, 196 over-identification, 252

P

Palliative Care Australia, 327 paralinguistic features of the voice See voice parent, role of, 307–310 behaviours related to, 307–308 definition of, 307–310 emotions of, 308–309, 308t principles for effective communication with, 309 scenario on, 309b–310b strategies for communicating with, 309–310 susceptibility of, 308 see also single parent passive listening, 127 pauses of Aboriginal and Torres Strait Islander, 171 cultural use of, 171

pauses (Continued) uncertainty communicated through, 171 of voice, 171 people in particular stages of lifespan, 291–302 adolescent, 294–298 adult, 298–300 child, 291–294 older people, 300–302 people with particular conditions chronic or multiple physical conditions, 333–334 decreased cognitive function, 323–326 depression, 289–290 hearing impairment, 336–339 life-limiting illness, 326–330 mental illness, 330–332 PTSD, 320–342 visual impairment, 339–342 people with particular contexts, 342–350 with different language, 348–350 domestic abuse, 345–348 emergency, 342–345 people with particular life roles, 303–319 as carers for people seeking assistance, 305–306 as colleague, 303–305 of group member, 315–319 as parents to children requiring assistance, 307–310 as single parents to children requiring assistance, 310–313 as students in health professions, 313–315 perfectionism negative self-talk and, 75 self-awareness and, 74–75 as value, 74–75 personal assumption, communication influenced by, 88–99 avoidance of, 89–90 personal communication skills, selfawareness of, 75–76 personal space, 143–145 personal unconscious needs, selfawareness and, 71–73 personality, communicative behaviours and, 81 Person/family-centred practice see family/ Person-centred practice Person/s, 12 awareness of, 100–122, 118f cognitive aspect of, 105–106, 114–116 definition of, 101 effective communication with, 101 emotional aspect of, 105–114 empathy and, 110–112 information assisting health professionals when relating to, 104–118 physical aspect of, 105–107

INDEX Person/s (Continued) physical environment familiarity and, 137–138 sexual aspect of, 105–106, 114 silence and, 113–114 social and cultural aspect of, 105–106, 116–117 spiritual aspect of, 105–106 spiritual aspects of, 105–106, 117–118 touch and, 112–113 see also whole Person/s pets, 147 physical appearance, 197 dress and odour, 136–137 restrictive codes of, 137 physical aspect, of Person/s, 105–107 physical comfort of Person and health professional, 138–139 physical environment deficits in, 141 familiarity with, 137–138 health professional, 138 Person/s, 137–138 physical appearance dress and odour, 136–137 restrictive codes of, 137 rooms, 138–139 with beds, 139 furniture placement and physical comfort, 138–139 privacy needs, 139 treatment rooms, 139 waiting rooms, 139 pitch variations of, 170 of voice, 170 positive emotional responses, 17 positive outcomes, 17 post traumatic stress disorder (PTSD), 320–342 behaviours typical of, 320 definition of, 320–322 emotions from, 321, 321t principles for effective communication and, 321 scenario on, 322b–323b strategies for communication and, 321–322 susceptibility of, 321 post-contact history, of Indigenous peoples, 218–219 power imbalance with health professionals, 93–94, 94t stereotypical judgement and, 93–94 pre-contact history, of Indigenous peoples, 218 prejudice, 94–95 conflicts and, 182 exploration of, 89b honest evaluation of, 92b principles for effective communication with adolescent, 296 with adult, 299, 299t

principles for effective communication (Continued) aggressive behaviour and, 282–283 with carer, 306 with child, 292–293 decreased cognitive function and, 325 depression, 290 domestic abuse and, 347 emergency and, 343–344 extreme distress and, 285 within groups, 319 with health profession colleague, 304, 304t with hearing impaired person, 337 life-limiting illness and, 328 long-term illness and, 334 mental illness and, 331 with older person, 301 with parent, 309 with people who are reluctant to engage, 287 with person speaking different language, 349 PTSD and, 321 with single parent, 311 with student, 314 with visual impaired person, 341 Privacy Act 1988, 247–248 probing questions, 33–34 procedure, expectations of, 237 professional jargon psychological or emotional distress, 195, 328 effective communication and, 7–8 misunderstandings from, 234 psychotic defences, 57, 58t PTSD see post traumatic stress disorder Purtilo, R B, 160, 198

Q

questioning, 39 Indigenous people, 224 timing of, 32, 40f as tool, 31–32 use of, 32 questions answering of, for self-awareness, 67 clarifying, 34 closed, 32–33 leading, 34–35 open, 33–35 probing, 33–34 regarding reflection, 55 regarding relationship needs, 72 types of, 32–35

R

rapport, 16 stereotypical judgement influencing, 92 rate, of voice, 170

reconciliation principles, for Indigenous peoples, 213–214 recognise, 214 reflect, 214 remember, 213–214 respond, 214 reflection, 48, 59f basis for, 55 beneficial questions regarding, 55 as challenge, 55 chaos understanding from, 51 cultural/language background and, 52 defense mechanisms and, 56–57 definition of, 48–49, 48f effective listening and, 124 emotions and, 54, 56–59 factors influencing, 50 health professionals and, 49, 54 individual value from, 52 misunderstandings and, 238–239 models of, 52–56, 59 event description and, 53 events during interaction, 53–54 interacting person’s intention and, 53 primary need understanding from, 52 process of, 49–50 purpose of, 52–53 reasons for, 50–52 self-awareness from, 49–50, 59, 66 as self-knowledge, 49 about using humour, 56 reflective practice, 47–64 exercise on, 67 reflexivity, 49 relationship needs, 71 acceptance as, 71 affection and affirmation as, 71 control as, 71 questions regarding, 72 small group exercise on, 73 reluctant to engage in communication, 286–288 behaviours related to, 286 definition of, 286–288 effective communication principles for, 287 reasons for, 287 strategies for, 288 strategies for communication with, 287–288 susceptibility to, 286–287 remote communication, 260–276, 271f characteristics of, 261–262, 262t databases and, 264 documentation for, 263–264 Internet and, 268–269 online collaboration tools, 269–271 principles governing, 263, 263t reports written, 261, 263–264 responses to, 261 telephone, 264–266 video/teleconferencing or Skype as, 267

367

INDEX resolution of conflicts, 187 of misunderstandings, 235, 239–240 by health professionals, 239–240 steps for, 239–240 respect challenges of, 103 confidentiality and, 104 cultural norms and expectations of, 103–104 definition of, 101–102 demonstration of, 101, 103–104, 245–246 emotional response to, 102 empathy and, 111 health professionals and, 14, 103 holistic care and, 157–158 needed for mutual understanding, 16 negative and positive responses to, 102 purpose and benefit of, 101 regardless of differences, 245–246 using names as sign of, 104 worth and value from, 101–102 roles ethical communication boundaries of, 250 stereotypical judgements and, 90–92 rooms, 138–139 with beds, 139 furniture placement and physical comfort, 138–139 privacy needs and, 139 treatment rooms, 139 waiting rooms, 139

S

SAAFETY principle, for effective listening, 127, 127t scenario on adolescents, 296b–297b on adults, 299b–300b on aggressive behaviour, 283–284 on being a child, 290b–291b, 293b–294b on carer, 306–307 communication discussion and, 280–281 on decreased cognitive function, 325–326 on domestic abuse, 347–348 on emergency, 344b–345b on empathy, 109–110 on extreme distress, 285–286 on health profession groups, 319 on health professional colleague, 304–305 on hearing impairment, 338 on life-limiting illness, 329b on long-term illness, 334b–336b on mental illness, 331–332 on older person, 302 on parent, 309

368

scenario (Continued) on person speaking different language, 350 on PTSD, 322b–323b on reluctant to engage in communication, 288 on single parent, 311b–313b on student, 314–315 on visual impairment, 342 seasonal calendar, 145 self-acceptance, 66 self-awareness, 65–87, 196 answering questions about, 67 beginning journey of, 66–69 benefits of achieving, 66, 81 communicative behaviours and information management preferences with, 79–81 conflict between values and needs, 73–74 culturally competent communication and, 203 effective listening and, 76–78 effective speaking and, 78–79 as essential tool, 66 health professions and, 69 humour, use of, 56 individual values and, 69 negative emotions and experiences influencing, 67–69 perfectionism and, 74–75 of personal communication skills, 75–76 personal unconscious needs and, 71–73 from reflection, 49–50, 59, 66 scenario on, 73 stereotypical judgement and, 92–93 values and needs conflict and, 73–74 self-disclosure, 251 self respect, 56–57, 183 self-knowledge, reflection as, 49 sequential interpretation, 204 sexual aspect, of Person/s, 105–106, 114 therapeutic relationship and, 114 shared information protection, 249 short messaging service (SMS), strategies for, 266 signed agreements, 247–248 silence, 224 effective listening and, 113 Person/s and, 113–114 simultaneous interpretation, 204 single parent, 310–313 characteristics of, 310 definition of, 310–313 emotions of, 311, 311t principles for effective communication with, 311 scenario on, 311b–313b strategies for communicating with, 311–313

Skype, 267 SMS see short messaging service social aspect, of Person/s, 105–106 needs of, 116–117 social environment, 146–147 family, 147 friends, neighbours, interest groups and sporting teams, 147 institutions, 147 pets, 147 social networking sites, 269–271 SOLER model, for effective listening, 128, 129t spiritual aspect, of Person/s, 105–106, 117–118 health profession interest in, 117 importance of, 117 systems influenced by, 118 spiritual environment, 148 spirituality and Indigenous people, 219–220 spoken language, body language and, 166 sporting teams, 147 stereotypical judgement, 89–90, 94f attitude development for avoidance of, 92–93 of health professionals, 91–92 Indigenous peoples and, 216 limitations of, 93 occurrence of, 89–90 power imbalance and, 93–94 roles and, 90–92 self-awareness and, 92–93 storytelling and Indigenous people, 223–224 trust and rapport influenced by, 92 values and, 93 strategies for communication with an adolescents, 296–298 with an adult, 299 with aggressive people, 283 with carer, 306 with a child, 293–294 decreased cognitive function and, 325–326 depression, 290 domestic abuse and, 347–348 emergency and, 344–345 extreme distress and, 285–286 as group leader, 319 with health profession colleague, 304–305 life-limiting illness and, 329–330 long-term illness and, 334 mental illness and, 331–332 with an older person, 302 with a parent, 309–310 with people who are reluctant to engage, 287–288 for person speaking different language, 349–350

INDEX strategies for communication (Continued) for person with hearing impairment, 337–339 for person with visual impairment, 341–342 PTSD and, 321–322 with a single parent, 311–313 with a student, 314–315 strong emotions, 281–290 aggression, 281–283 extreme distress, 284–286 reluctance to engage in communication, 286–288 student behaviours of, 313 definition of, 313–315 emotions of, 313–314, 313t principles for effective communication and, 314 role of, 313–315 scenario on, 314–315 strategies for communicating with, 314–315 suprasegmentals see voice susceptibility of adolescents, 295 of adults, 298 to behaving aggressively, 282 of children, 292 of decreased cognitive function, 324 to depression, 289 of emergencies, 343 to extreme distress, 284 to feeling reluctant to engage, 286–287 of hearing impairment, 336–337 of long-term illness, 333 of mental illness, 330 of older persons, 301 of parents, 308 of PTSD, 321 of visual impairment, 340 sympathy, empathy compared to, 109

therapeutic relationship (Continued) limitations of, 250–251 over-identification and, 252 sexual aspect of Person/s and, 114 thoughts of individuals, effective communication and, 8 time, 145–146 lunar calendar, 145 seasonal calendar, 145 timing of information provision, 26 of questioning, 32, 40f tone, of voice, 171–172 Torres Strait Islander misunderstandings and, 234 pauses and, 171 touch cultural norms regarding, 112 as non-verbal communication, 112–113 Person/s and, 112–113 transliteration, 204 trust needed for mutual understanding, 16 stereotypical judgements influencing, 92

T

V

telephone, 264–266 answering service and voice mail for, 266 SMS strategies for, 266 strategy for use of, 265–266 call answering, 265 call making, 265–266 therapeutic relationship components of, 17 for confronting unhelpful attitudes or beliefs, 38 as empowering, 16 family/Person-centred practice and, 17 with health professionals, 16–17

U

uncertainty, communicated through pauses, 171 unconscious personal needs, 71–73 understanding and culture, 202–204 and effective communication, 5–6, 5f, 8f unfamiliar environment, verbal introduction of, 23–24 unhelpful attitudes or beliefs, confrontation of, 37–39 therapeutic relationship needed for, 38 Universal Declaration of Human Rights, 245–246 validation effective listening and, 124 of emotions, 107–114 clarification within, 107–108 values of health professionals, 69–71, 91 honest evaluation of, 92b of Indigenous peoples, 215 needs conflict between, 73–74 perfectionism as, 74–75 from respect, 101–102 stereotypical judgement and, 93 verbal communication, limited skills of, 172–173

verbal introductions, 21–24 sample of, 21–22 of unfamiliar environment, 23–24 of yourself and your role, 22 video/teleconferencing, 267 benefits of, 267 strategies for, 267 visual impairment, 339–342, 342t behaviours related to, 339–340 definition of, 339–342 emotions related to, 340–341, 340t principles for effective communication with, 341 scenario on, 342 strategies for communication with person with, 341–342 susceptibility of, 340 voice paralinguistic features of, 170–172 emphasis, 170–171 pauses, 171 tone, 171–172 prosodic features of, 169–170 pitch, 170 rate, 170 volume, 169–170 voice mail, 266

W

Walker, D, 49, 53, 55 websites code of conduct for health professionals, 247–248, 257–258 hearing and visual impairments, 336–342, 339t, 342t Indigenous peoples, 230 life-limiting illnesses, itr, 352 WHO see World Health Organization whole Person/s aspects of, 156 awareness of, 105–106 communication with, 155–164, 161f definition of, 156–157 as dynamic system, 105–106, 156–157 holistic care and, 157–159 wiki spaces, 269 women, depression and, 289 words context of, affect on meaning, 6–7 environment influencing meaning of, 6 meanings of, 6 emphasis and, 7 misunderstandings from, 238, 240f multiple functions of, 237 World Health Organization (WHO), 11 worth, from respect, 101–102 written documentation, 263–264 written reports, 263–264

369

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