MODULE 2: EFFECTIVE COMMUNICATION SKILLS LEARNING OBJECTIVES: 1. Understand the importance of communication, different means to communicate with patients, families and team members, and the barriers to communication 2. Develop active listening skills 3. Appreciate the value and uses of silence 4. Reflect on own communication style and strategies to improve communication 5. Understand the volunteer’s responsibility to protect the patient’s and family’s confidentiality and privacy COMPETENCIES: At the end of module two, volunteers will be able to: • Define the basic principles and purposes of communication in hospice palliative care • Describe what enhances or interferes with communication • Describe and practice different means of communicating with patients and families, including listening and empathy, silence and being present, and humour and laughter (when appropriate) • Communicate effectively with other members of the care team • Identify effective communication strategies to support clients and families, and to cope with difficult situations • Describe and implement practices to ensure the patient’s and family’s confidentiality and privacy.
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1. WHAT IS EFFECTIVE COMMUNICATION? As a hospice palliative care volunteer, communication is central to your role. Being there to help individuals and families discuss their fears and share their feelings is one of the most precious gifts you can offer. Your conversations and shared moments have the potential to help patients and families: • Feel less isolated • Cope better with fears and concerns • Find a sense of meaning. You also have to be able to express yourself well to communicate with the person, the family and other members of the care team. The word communication comes from the root "common". To communicate effectively, people must speak a "common" language of words and body language. They must be able to listen, and to know when to speak and when to be silent. As a volunteer, your goal is to develop the skills, perspective and energy to accept 100% of the responsibility for communication: for understanding what the other person is saying to you and for ensuring the other person understands what you are saying. To do that, you do not have to be an expert on all the mysteries of life and death. You simply When we talk, more than 80% of the “message” is in how we say it, not what we say.
Be available and “present” Give your undivided attention Listen without interruption and with empathy Respect silence.
need to be honest, open and non-judgmental in your conversations and develop a sense of trust with the family and other members of the care team. Think about the way you communicate. Are you comfortable being silent? Do you ask open-ended questions that encourage people to talk? Do you give
person,
people
time to answer? Are you an active listener? 2. BARRIERS TO COMMUNICATION There are five key barriers to communication in a hospice palliative care situation: 1. Poor listening skills . If people feel they are not being listened to, then there is no communication.
2. Stress . People often do not communicate well when they are in a crisis situation. If they are feeling ill or in pain, their attention may be focused inward and they may not hear what is said to them.
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3. Language and culture . Culture affects the way individuals and families communicate. Words and gestures can mean different things to people from different cultures. For example, eye contact is an important part of Anglo-European cultures but in other cultures it can be disrespectful. Language can also be a barrier, particularly when people don’t understand one another’s language or have to speak through an interpreter who may not convey the full intent of what was said. 4. Intense feelings . When people are emotional, they are more likely to mishear or misunderstand, and less likely to speak clearly themselves. 5. Lack of information and secrecy . If information is being kept from some people, then communications can become confused. Five Tips for Effective Communication 1. To get a conversation started, ask open-ended questions that cannot be answered by “yes” or “no”. Give the client and/or family member some time to respond and listen actively . It may take time before the person decides to trust you or how much he or she wants to say. 2. Be comfortable with pauses in the conversation. Pauses may mean that the client is thinking about something sensitive or is tired. Let the silence last. Do not rush in to fill the void. 3. Be yourself . Don't try to be a social worker, counsellor or therapist. Encourage clients to share stories about their lives and don’t be afraid to respond with humour. Laughter is “the best medicine” and an important way of coping with threats and fears. 4. Try not to give advice . Instead, reflect the person’s own thoughts back to him or her. This can help the person look at the situation in a new way. 5. When you don't know what to say or do, say or do nothing . Being there and honestly saying you don't know the answer is more supportive than pat answers. However, if a patient or family members asks for information about services or resources and you don’t know the answer, contact the hospice palliative care program.
3. ACTIVE LISTENING AND EMPATHY The first step in communication is listening to one another. Without listening there is little communication, and without communication there is little love. Each of us needs
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desperately to be listened to and to be loved by another who can listen to us and love us just as we are. 3 Most people would say they are good communicators but, for many, that means being a good
“talker”. In hospice palliative care, it’s important to know when to talk and when to listen. The main role of the volunteer is to be a “listener”. Real or active listening is a difficult and demanding discipline that requires energy and concentration. It involves paying attention to the person's total message, both what’s said (the
If we do not listen to the needs of others, how can we possibly know what those needs are? If we project our views on them, we are satisfying our own needs.
verbal messages) and what isn’t said (the non-verbal messages). Active listening is open and objective, and does not judge or evaluate. The listener must make an effort not to just hear what he or she wants to hear. Instead, he or she must focus on the other person's needs. Here are some guidelines for active listening: Clear your mind. To really focus on the person, you need to keep your own thoughts from wandering. Be silent. Silence is more than staying quiet or not interrupting when someone is speaking. Before you start to talk, pause to allow the speaker to catch his/her breath or gather his/her thoughts. He/she may want to continue. This short break gives you time to form your response and helps you avoid the biggest barrier to listening: listening with your answer running. If you are making up a response before the person is finished, you miss the end of the message that often contains the main point. At the same time, use common sense. For example, pausing for
several seconds when someone has asked for assistance with moving may be inappropriate. Make eye contact. Try to be at eye level with the client. If your client is in bed or sitting down, do not stand over them while you talk. Make eye contact – it demonstrates interest and attention. Whether or not you look directly at the client
Not every person who is dying experiences peace and/or acceptance. However, your visits will go a long way to helping the person reach this goal if you are able to offer compassion, love and acceptance.
depends on the client’s comfort level. Cultural considerations come into play. In most cases, looking at the other person while he/she speaks demonstrates your attention and helps keep your mind from wandering. Sit beside a person at a 45-degree angle, if possible, to allow him or her to break eye contact with you if they wish. If appropriate, go for walks with the person who will stop and look at you when he or she wants to make eye contact.
3 Buckman R. (2001). Communication skills in palliative care: a practical guide. NeurolClin. Nov;19(4):989-1004.
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Relax and be open. You can communicate openness with facial expressions and body positions. Uncross your arms. Sit comfortably and informally. Sit beside the person (sitting right in front of them may be intimidating) and remove any physical barriers, such as a pile of books. Watch your non-verbal responses. A look of boredom or disapproval on your face can keep the other person from finishing what he or she wants to say. Be compassionate. Someone who is dying will experience a variety of emotions. Sometimes the person may be angry or frustrated and direct that anger toward the people around them. Try to respond with understanding and compassion. Keep in mind that the anger is not personal. It is part of the response to the illness. Encourage them to express their fears and concerns; this will help them know that you understand their thoughts and feelings and are willing to journey with them. Listen without interruption. Let the person lead the conversation. If he or she wants to recount favorite stories - even if you’ve heard
Your presence, not your words, mean the most. There is no magic formula, no magic words. Just being present for that moment will go a long way to helping the person heal, if not physically, then at least emotionally.
them several times before - listen with enthusiasm.Note key words or phrases as person talks so you can respond when it’s
the
your
turn. Listen for more than the words. Observe the way the person talks – the inflection in the voice, his or her enthusiasm or lack of it. Watch facial expressions and be aware of body language. All of these are essential parts of the message and conversation. Send acknowledgements. Let the speaker know you are still there and interested by nodding your head or saying things like “Uh uh” and “OK”. Use touch -- but only with permission . Communication through touch can be very effective. Holding a person’s hand or giving a comforting pat on the arm can mean a great deal to someone fighting fear and loneliness. However you must ask permission first. It can be as simple as asking the person if you may hold his/her hand or “give them a hug”. It is essential to obtain this “consent” from the client and/or family member before touching. EIGHT STRATEGIES FOR LEARNING TO LISTEN 1) We cannot listen until we stop talking. 2) Be silent in an active way. Be open and active, receptive and alive. Keep your mind from wandering. Your body language and eye contact will reveal how attentive you are. 3) Be patient. Sometimes it takes time for someone to reveal him or her self to you. We often have to listen to people’s more superficial concerns before we are allowed into the deeper levels of the human soul.
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4)
Talking about deep feelings requires privacy and time.
5) There are no quick and easy answers. Simply respond, reflect and express understanding and empathy. 6) Listening is a skill that can be learned, but it requires practice and it sometimes involves sharing ourselves. 7) We will only hear from others when they know that we can and will keep their confidence. 8) Whenever you find yourself arguing or interrupting, recognize that it is usually because the conversation has hit a sensitive spot. But arguing will shut down communication. Don’t be afraid of tears. Tears help heal, and bottling up one’s emotions is unhealthy. When the person is crying, you don’t have to say anything; you can just hold the person’s hand.
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Listen When I ask you to listen to me and you start giving advice you have not done what I asked.
When I ask you to listen to me and you begin to tell me why I shouldn’t feel that way, you are trampling on my feelings.
When I ask you to listen to me and you feel you have to do something to solve my problem, you have failed me, strange as that may seem.
Listen! All I asked was that you listen.
Not talk or do - just hear me.
Advice is cheap. 50 cents will get you both Dear Abby and Bill Graham in the same newspaper. And I can do for myself; I’m not helpless. Maybe discouraged and faltering, but not helpless.
When you do something for me that I can and need to do for myself, you contribute to my fear and weakness.
But, when you accept as a simple fact that I do feel what I feel, no matter how irrational, then I can quit trying to convince you and get about the business of understanding what’s behind this irrational feeling.
And when that’s clear, the answers are obvious and I don’t need advice. Irrational feelings make sense when we understand what’s behind them.
Perhaps that’s why prayer works, sometimes, for some people, because God is mute, and He doesn’t give advice or try to fix things. He just listens and lets you work it out for yourself.
So, please listen and just hear me.
And if you want to talk, wait a minute for your turn, and I’ll listen to you.
Anonymous
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4. WHEN THERE’S A PHYSICAL BARRIER TO COMMUNICATION COMMUNICATING WITH SOMEONE WITH A SPEECH IMPAIRMENT When talking with someone with a speech impairment: • Speak normally. You don’t need to raise your voice. • Be patient. • Ask the person to repeat him or herself. They will know their speech is hard to understand. • Ask if they can say it a different way or give you a clue in other ways • Ask if there is someone close by who can help interpret for you. COMMUNICATING WITH SOMEONE IN A COMA 4 Coma is a state of unconsciousness. Someone who is in a coma cannot be roused by touching, shaking or calling; however, that does not mean that the person cannot hear and understand your voice or feel your touch. Coma is not always permanent nor does it mean that death is near, even in the terminally ill. Some people will slip in and out of coma; some will suddenly just wake up. Whatever the cause or duration of the coma, you must keep trying to communicate with the person. To do that, you have to become aware of both your own and the other person’s inner feelings and perceptions. You need to look for tiny clues about how the person is feeling such as changes in breathing pattern, tiny facial changes, changes in rigidity of the person’s body. Once you are sensitive to these clues you will be able to send and receive messages. Trust your “sixth sense” or intuition. Speak normally . Tell the person what you see and feel. Encourage him or her to feel what he or she is feeling. Use touch as a way of communicating . Placing your hand on the person’s chest and breathing when he or she breathes will help you to tune into the person’s inner world. (Tell them that you will be placing your hand on their chest before you do it.) Remember that a coma is an inner experience . Do not try to make the person come out of it. The inner experience is part of dying and for most people it is a necessary experience. Be relaxed and calm inside yourself . You do not have to communicate all the time. The person experiencing the coma has less awareness of the external environment.
4 KFL&A Palliative Care Education Project, as presented in Hospice Kingston Volunteer Training Manual, Hospice Kingston, Ontario.
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Avoid saying anything negative . Continue to express words of love and encouragement. Remember that the person in the coma can perceive your touch, tone of voice, and inner feelings. TECHNIQUES THAT HELP COMMUNICATION AND EMPATHY: Giving recognition Good morning, r. Smith You've written some letters today. I notice you've chosen your favourite music for today. Giving information My name is.... I'm here because I'll be taking you to the... Giving broad openings How do you feel? Is there something you'd like to talk about? Where would you like to begin? Accepting I understand... I agree... I hadn't thought of that... Using silence Yes, Uh-huh, Hmmm, nodding. Offering general leads
Go on and then? Tell me about it.
Placing the event in time
What seemed to lead up to...? Was this before or after...? When did this happen...?
or in sequence
Making observations
Are you uncomfortable when you...? I notice you are biting your lips. Tell me when you begin to feel anxious. How would you describe your pain?
Encouraging description
Restating Client : I seem to hear the clock strike every hour at night. Volunteer : You have difficulty sleeping? Note: When using restating, do not overdo the obvious. Only restate complex statements or those that seem to have an unspoken message behind them. Reflecting Client : Do you think I should tell the doctor? Volunteer : Do you think you should? Attempting to translate feelings Client : I can't talk to you or to anyone. It’s a waste of time. Volunteer : Do you feel no one understands? Client : I'm way out in the ocean. Volunteer : Do you mean you feel abandoned?
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Seeking clarification
I'm not sure that I follow. What would you say is the main point of what you said? This point seems worth looking at more closely. Next time this family problem comes up, what might you do to handle it? What could you do to let your anger out harmlessly? I'll sit with you a while. I'm interested in making you comfortable. Perhaps you and I can discover what might reduce your anxiety.
Focusing
Encouraging a plan of action
Offering self
Requesting an explanation
Why do you think that? Why do you feel this way? What made you do that? TECHNIQUES THAT HINDER COMMUNICATION AND EMPATHY:
Offering false reassurance
I wouldn't worry about... Everything will be all right. You're coming along fine.
Expressing judgement
That's good. I'm glad that you... That's bad. I'd rather you wouldn't...
Advising
I think you should... Why don't you...?
Disagreeing
I definitely disagree with... I don't believe that. Client : I'm nothing. Volunteer : Of course you're something. Everybody is somebody.
Defending
No one here would lie to you. But Mrs. B. is a very capable caregiver. It's for your own good. Keep your chin up. Just listen to your doctor...he knows Client : I'd like to die. Volunteer : Did you have any visitors today?
Making stereotypical comments
Introducing an unrelated topic
Using jargon Sympathizing Story-telling Correcting
I hear you saying that …
Oh, you poor thing.
That reminds me of the time … That’s not how it happened.
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Educating
This could turn into a positive experience for you if you just … WHAT WILL I TALK ABOUT? 5 Conversation Starters Talk about the person’s room or home – such as cards on display, plants, pictures, furnishings, views from windows, colour or style of décor, garden and/or surroundings.
As a volunteer, you may be anxious about what you will talk about with the dying person, particularly when you first meet. Here are some tips to get the conversation started: • Before your visit, review the information on the person’s likes, dislikes and any sensitive topics that you should avoid. • Remember to ask open-ended questions. • Be prepared to share information about yourself do not be afraid to describe your own feelings when appropriate. • When you arrive, “take the temperature of the room” by asking family members how
Ask about the person and family – siblings, children, grandchildren, family achievements, education and reminiscences. Ask about their life story – where they were born, their childhood home, pets, family life when they were young, special friends, historical events they lived through, hurdles and heartbreaks, and favourite occasions. Discuss what’s happening now or this week – the weather, current events, how their week was, family members’ activities in the past week and any planned outings. Explore social interests – hobbies, favourite pastimes, sports, travels, jobs, friends, movies and community involvement. Talk about thoughts and feelings – their dreams, fears, hopes and expectations for themselves and their family members (psycho-spiritual issues).
and
the
person is and how he or she is coping.
• When greeting the person, introduce yourself -- something you may have to do several times with some clients. • Be yourself.
5 Adapted from Hospice of Waterloo Region Volunteer Training Manual: The Art of Conversation
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