1.3 Communication Within the Health Care Team

Communicating With Staff

The resident is at the center of the health care team. As a nursing assistant, most of your duties will involve interaction regarding nursing services among other CNAs, LPNs, and RNs. It is important to establish a good relationship with coworkers to ensure quality resident care. Improper communication can affect the team’s ability to provide holistic care. The health care team will be discussed further in Chapter 2.

Good communication starts by respecting those you work with and using the communication skills previously discussed to grow a trusting relationship. Knowing and fulfilling your duties, documenting and reporting the completion of these duties, and functioning in a consistent and dependable manner are keys to creating strong, professional relationships within your team.

These expectations for good communication may seem challenging as an inexperienced nursing assistant, but they can be achieved by organizing your responsibilities and managing your time. This begins by arriving on time for your shift, being dressed appropriately, being prepared to start working when your shift starts, and reviewing your assigned residents’ plans of care at the beginning of the shift. Items to review in the plan of care include the following:

• Resident’s name and location
• Activity level and transfer status
• Assistance required for activities of daily living (ADLs)
• Diet and fluid orders (see Chapter 6 for more information)
• Elimination needs

Transfer status refers to the assistance the patient requires to be moved from one location to another, such as from the bed to a chair. Activities of daily living (ADLs) are daily basic tasks that are fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving). Diet and fluid orders refer to what the resident is permitted to eat and drink. Elimination needs refer to assistance the resident requires for urinating and passing stool. For example, a resident requires assistance to the toilet and uses incontinence pads.

After reviewing the cares you will be providing to your assigned patients during your shift, discuss a timeline with your coworkers that meets residents’ schedules and allows for the coordination of cares that require more than one caregiver. For example, one resident may require a two-person assist when transferring from the bed to the chair. Schedules for activities, treatments, labs, appointments, or other services should also be reviewed so that cares can be organized around these schedules.

As resident cares are completed, they must be documented in a timely manner and reported to nursing staff. Prepare a concise report to share with the nurse for each of your assigned clients. The report should include the time cares were provided and any observations or changes noted in the resident. Read more about documentation and reporting in the “Documenting and Reporting” section at the end of this chapter.

Communicating With the Client, Families, and Loved Ones

Therapeutic communication is a type of professional communication used with patients. It is defined as the purposeful, interpersonal, information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills that leads to patient understanding and participation.^[1] Therapeutic communication techniques have been used by nurses since Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She believed in the therapeutic healing that results from nurses’ presence with patients.^[2] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.^[3] Nursing assistants also implement therapeutic communication with patients. Read an example of a nursing student effectively using therapeutic communication with patients in the following box.

An Example of Nursing Student Using Therapeutic Communication^[4],[5]

 

Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her.

There are several components included in therapeutic communication. The health care professional uses active listening and attending behaviors to demonstrate they are interested in understanding what the patient is saying. Touch is used to professionally communicate caring, and specific therapeutic techniques are used to encourage the patient to share their thoughts, concerns, and feelings.

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. A well-known phrase from a Greek philosopher named Epictetus is, “We have two ears and one mouth so we can listen twice as much as we speak.” It is important to actively listen to patients and not use competitive or passive listening. Competitive listening occurs when we are primarily focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person or we assume we correctly understand what the person is communicating without verifying their message. During active listening, we communicate verbally and nonverbally that we are interested in what the other person is saying and also verify our understanding with the speaker. For example, an active listening technique is to restate what the person said and verify our understanding is correct, such as, “I hear you saying you are hesitant to go to physical therapy because you are afraid of falling. Is that correct?” This feedback process is the main difference between passive listening and active listening.^[6]

Touch

Touch is a powerful way to professionally communicate caring and compassion if done respectfully while being aware of the patient’s cultural beliefs. NAs commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 1.4^[7] for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Therapeutic Communication Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. Nursing assistants help patients complete activities of daily living and meet goals in their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication, health care professionals often ask open-ended questions, repeat information, or use silence to prompt patients to process their concerns. Table 1.3a describes a variety of therapeutic communication techniques.

Table 1.3a Therapeutic Communication Techniques^[8]

In addition to the therapeutic techniques listed in Table 1.3a, health care professionals should genuinely communicate with patients with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to establishing true connections with others.^[9] Communicating with empathy can be described as providing “unconditional positive regard.” Research has demonstrated that when health care professionals communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors.^[10]

Nontherapeutic Responses

Health care professionals must be aware of potential barriers to communication. In addition to the common communication barriers discussed in the “Communication Styles” subsection of this chapter, there are several nontherapeutic responses to avoid. These nontherapeutic responses often block the patient’s communication of their feelings or ideas. See Table 1.3b for a description of nontherapeutic responses.^[11]

Table 1.3b Nontherapeutic Responses^[12]

Strategies for Effective Communication

In addition to overcoming common communication barriers, using active listening and therapeutic communication techniques, and avoiding nontherapeutic responses, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows^[13]:

• What concerns do you have about your plan of care?
• What questions do you have about your daily routine?
• Did I answer your question(s) clearly, or is there additional information you would like?

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with clients include the following:

• Read the care plan carefully and access any social history available. If family members or friends visit and it seems appropriate, talk with them about the client without intruding or taking up a lot of their time together. This information helps you build trust and care for the client based on their preferences and life history. For example, you might learn the resident lived on a farm most of their life and enjoyed taking care of their horses. Striking up conversations about horses is a way to build rapport with this client.
• Review any changes in routine or in the plan of care for assisting with ADLs with the client to improve understanding and participation.
• If there are questions you can’t answer, be sure to report to the nurse so someone can follow up with the client. Check back with the client to ensure they have had their questions answered.
• Observe nonverbal communication from clients. Do they seem to interact during care, or is it something that they are merely tolerating and just trying to get through each day? Find an approach so they are comfortable with receiving care.

Adapting Your Communication

When communicating with patients, their family members, and other caregivers, note your audience and adapt your message based on characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to an individual’s age and developmental level includes the following strategies^[14]:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating.

Strategies for Communicating With Patients With Impaired Hearing, Vision, and Speech

In addition to adapting your communication to your audience, there are additional strategies to use with individuals who have impaired hearing, vision, or speech.

Impaired Hearing^[15]

• Gain the person’s attention before speaking (e.g., through touch)
• Minimize background noise
• Position yourself 2-3 feet away from the patient
• Facilitate lip-reading by facing the person directly in a well-lit environment
• Use gestures, when necessary
• Listen attentively, allowing the person adequate time to process communication and respond
• Refrain from shouting at the person
• Ask the person to suggest strategies for improved communication (e.g., speaking toward a better ear, moving to well-lit area, and speaking in a lower-pitched tone)
• Face the person directly, establish eye contact, and avoid turning away mid-sentence
• Simplify language (e.g., do not use slang but do use short, simple sentences), as appropriate
• Read the care plan for information on the preferred method of communicating (whiteboards, pictures, etc.)
• Assist the person using any devices such as hearing aids or voice amplifiers
• Report any changes to the nurse

Impaired Vision^[16]

• Identify yourself when entering the person’s space
• Ensure the patient’s eyeglasses are cleaned and stored properly when not in use, and assist the patient in wearing them during waking hours
• Provide adequate room lighting
• Minimize glare (e.g., offer sunglasses, draw window covering, position with face away from window)
• Provide educational materials in large print as available
• Read pertinent information to the patient
• Provide magnifying devices
• Report any changes to the nurse

Impaired Speech^[17]

Some patients may have problems processing what they are hearing or in responding to questions due to dementia, brain injuries, or prior strokes. This difficulty is referred to as aphasia. There are different types of aphasia. People with expressive aphasia understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. People with receptive aphasia often speak in long sentences, but what they say may not make sense. They are unable to understand both verbal and written language. Aphasia often causes the person to become frustrated when they cannot communicate their needs. Review the following evidence-based strategies to enhance communication with a person with impaired speech^[18]:

• Modify the environment to minimize excess noise and decrease emotional distress
• Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may provide automatic responses that are incorrect
• Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities
• Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, or computer)
• Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit the family’s assistance in understanding the patient’s speech)
• Ensure the call light is within reach
• Repeat what the client said to ensure accuracy
• Instruct the client to speak slowly
• Read the care plan for instructions from the speech therapist
• Report any changes to the nurse

Responding to Challenging Situations

Being a care provider is a very rewarding career, but it also includes dealing with challenging situations. Using strong communication techniques can de-escalate situations and put patients, loved ones, and staff at ease. It is impossible to predict what behavior you may encounter as a health care worker, but having a solid basis of communication techniques can prepare you to better handle unique situations.

Memory Impairment and Behavioral Health Issues

As a nursing assistant, you will likely encounter older adults with varying degrees of memory impairment. Older adults are defined as adults aged 65 years old or older.^[19] Residents with memory issues often become confused and can feel overwhelmed by everyday situations. For those with impaired cognitive functioning like dementia, it may not be possible to reorient them to the current time and place or to move them on from thoughts that are not based in the current situation. Aphasia and confusion can cause frustration that can result in agitation or aggression. Agitation refers to behaviors that fall along a continuum ranging from verbal threats and motor restlessness to harmful aggressive and destructive behaviors. Mild agitation includes symptoms such as irritability, oppositional behavior, inappropriate language, and pacing. Severely agitated patients are at immediate risk of harming themselves or others through assaultive or self-injurious behavior, and they are capable of causing property damage.^[20] Aggression is an act of attacking without provocation.^[21] Agitation and aggression will be discussed in more detail in Chapter 10, but general guidelines to prevent aggression and agitation include the following:

• Keep the environment calm and as quiet as possible.
• Build trusting relationships by learning resident preferences and routines.
• Gather information from family members and loved ones about the patient’s background and beliefs.
• Offer choices to allow the patient to communicate preferences, but do not cause them to be overwhelmed with too many decisions.
• Stick to a daily routine for ADLs, meals, and activities.
• Empathize with the resident and understand that challenging behavior is often communication of emotion due to cognitive impairment and not a choice.
• Practice validation therapy. Validation therapy is a method of therapeutic communication used to connect with someone who has moderate- to late-stage dementia and avoid agitation. It places more emphasis on the emotional aspect of a conversation and less on the factual content, thereby imparting respect to the person, their feelings, and their beliefs. Validation may require you to agree with a statement that has been made, even though the statement is neither true or real, because to the person with dementia, it feels both true and real.^[22] For example, if the resident with dementia believes they are waiting to catch the bus and is intent on doing so, sit with them by the window as if you are waiting for a bus and continue to have interaction with them until they are no longer concerned with the bus.
• Redirect behavior if appropriate. For example, suggest alternative activities such as walking around the facility, looking at photos, listening to music, or other activities the resident enjoys.
• Focus on safety for residents experiencing delusions or hallucinations. Delusions are unshakable beliefs in something that isn’t true or based on reality. For example, a resident may refuse to eat breakfast because they have a delusion that staff are trying to poison them. Hallucinations are sensing things such as visions, sounds, or smells that seem real but are not. For example, a resident may refuse to enter a room because they have hallucinations of big spiders crawling on the walls. If a patient is having delusions or hallucinations, never contradict them or tell them what they perceive isn’t real. Instead, empathize with them and do whatever is possible to help them feel safe. For example, offer to move to another area or investigate what the resident is concerned about.

Dealing With Stress

The stress response is a common psychological barrier to effective communication. It can affect the message sent by the sender or the reception by the receiver. The stress response is a common reaction to life events, such as a health care worker feeling overwhelmed with tasks to complete for multiple patients or a patient feeling stressed when admitted to a hospital or receiving a new diagnosis. Symptoms of the stress response include irritability, sweaty palms, a racing heart, difficulty concentrating, and impaired sleep. It is important to recognize symptoms of the stress response in ourselves and our patients and use strategies to manage the stress response when communicating.

There are several stress management strategies to use to manage the stress response^[23]:

• Use relaxation breathing to become aware of one’s breathing. This technique includes taking deep breaths in through the nose and blowing it out through the mouth. This process is repeated at least three times in succession and then as often as needed throughout the day.
• Make healthy diet choices. Avoid caffeine, nicotine, and junk food because these items can increase feelings of anxiety or being on edge.
• Make time for exercise. Exercise stimulates the release of natural endorphins that reduce the body’s stress response and also helps to improve sleep.
• Get enough sleep. Set aside at least 30 minutes before going to bed to wind down from the busyness of the day. Avoid using electronic devices like cell phones before bedtime because the backlight can affect sleep.
• Use progressive relaxation. There are several types of progressive relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness. Progressive relaxation generally includes the following steps:
  • Start by lying down somewhere comfortable and firm, like a rug or mat on the floor. Get yourself comfortable.
  • Relax and try to let your mind go blank. Breathe slowly, deeply, and comfortably, while gradually and consciously relaxing all your muscles, one by one.
  • Work around the body one main muscle area at a time, breathing deeply, calmly, and evenly. For each muscle group, clench the muscles tightly and hold for a few seconds, and then relax them completely. Repeat the process, noticing how it feels. Do this for each of your feet, calves, thighs, buttocks, stomach, arms, hands, shoulders, and face.

Managing Clients’ and Family Members’ Stress

Being cared for by strangers can feel very challenging to clients. Residents in long-term care settings have frequently experienced major physical and/or cognitive changes that caused a loss of their independence and sometimes some of their autonomy. Autonomy is each individual’s right to self-determination and decision-making based on their unique values, beliefs, and preferences. It is important for the nursing assistant to empathize with these losses and the new reality that residents must become accustomed to when moving into a long-term care facility. Reflect on the exercise in the following box to understand a resident’s feelings during their transition:

Clients usually become more comfortable with their new reality as they become familiar with a new routine and their new home. It is important to remember that emotions related to loneliness, feeling like a burden, and loss of independence can arise at any time. The nursing assistant can help residents adjust to their new environment in the following ways:

• Greet clients by their preferred name and introduce yourself.
• Ask clients their preferences for their care. Always communicate what you will be doing next and allow the resident to redirect or refuse care.
• Provide privacy when assisting with cares.
• Use confidentiality when documenting information or reporting to other members of the health care team.
• Treat belongings carefully and with respect and remember the client’s room is their home.
• Listen to the resident and address concerns if they arise. If you cannot adequately address the resident’s concerns, communicate these concerns to the nurse or supervisor.

Family members and other loved ones may have questions and concerns about the resident’s care. Read more information about managing their concerns in the following “Dealing With Conflict” section.

Dealing With Conflict

Health care professionals provide personal care at integral times in the lives of patients. The demands of caregiving and the associated rapid decision-making process can create stress for health care team members, patients, family members, and other loved ones. Managing care and making decisions can cause conflict among all involved. As a nursing assistant, it is important to be aware of your role and responsibility when managing conflict.

When a patient does not want to participate in care necessary to support their proper hygiene or health maintenance, the nursing assistant can use effective communication to encourage actions and promote desired outcomes. When a resident declines care, here are some actions the nursing assistant may use that respect their choices but allow care standards to be met:

• Re-approach the resident at a later time.
• Offer an alternative method. For example, a resident may not want to shower or take a bath but would be willing to have a full bed bath, allowing them to stay covered and warm throughout care.
• Remind the resident what may occur if care is not provided, such as higher risk of infection, open areas in the skin, odor, etc.
• Encourage as much control and independence as possible. Allow the resident to direct the process if able and offer as many choices as are appropriate.

Family members and other supports may have concerns about the plan of care for a resident. This may be due to lack of medical knowledge, little experience with the procedures of health care facilities, or a feeling of helplessness in regard to their loved one’s situation. The nursing assistant should listen to and acknowledge these concerns. Following confidentiality guidelines, interventions included in the plan of care can be discussed if the resident has permitted disclosure of this information. However, the nursing assistant should only disclose information when they have confirmed the resident has permitted disclosure. It may be beneficial for family members or others involved to discuss concerns with the nurse or unit supervisor and possibly schedule a care conference with the health care team to resolve their concerns. In this instance, the aide should understand that any anger directed at them may be a result of the situation rather than a reflection of anything they have personally done.

Conflicts among coworkers can also be addressed with assertive communication techniques. As discussed in the “Communication Styles” subsection, using assertive communication is the best approach to address workplace conflict and a respectful way to make one’s viewpoints known. Communication should start between the two parties that have the conflict before involving other staff. It is best to think about the situation and develop a potential solution before approaching the coworker. Frame the situation from your perspective using “I” messages. If the situation is especially tense, it may be beneficial to allow some time between the experience and the discussion to reduce stress and think more logically about the conflict. A typical time frame is to wait one day to think logically about a conflict before addressing it, often referred to as the “24-hour Rule.” If you have discussed your concerns with the coworker and offered a potential solution without any resolution in the situation, it is appropriate to notify your supervisor for additional assistance at that time. See an example of conflict resolution in the following box.