THE ART OF

1. THE ART OF Presented by Shelly Parker

2. Objectives • Understand the various types of communication • Understand the importance the role of nursing plays in patient/family communication • Recognize communication strategies to improve the level of interactions with patientsand families • Gain knowledge of the Hildegard Peplau Theory of Interpersonal Relations • Identify QSEN competencies and ANA standards related to communication

3. Introduction • Effective communication in nursing is crucial to ensure the correct information is being conveyed from nursing to patients and their families. The communication from the initial assessment can make an impact on the patient’s hospital experience and confidence in the health care setting. Breakdown in communication in the health care setting can lead to negative patient outcomes and serious safety issues. Communication is critical in all nursing aspects.

4. Nursing communication • Nurse to patients/families/visitors • Nurse to physician and other health care professionals • Phone conversation/orders • Assessments/Admissions/Discharges • Education • Rounding • Nursing reports • Documentation • Patient complaints • Handoffs • Incident reports • Meetings

5. Definition • Webster’s Dictionary defines communication as “the exchange of information between individuals through a common system of signs, symbols or behaviors.” • It is the act of transforming information from one place to another (Webster’s dictionary, 2013)

6. Forms of Communication • Verbal • Non-verbal • Written:

7. 3 Points of effective communication in nursing Sender: Making sure the information is being sent Message: Information being sent Receiver: Making sure the information is received Note* It is very important for a nurse to also determine how the patient perceives the message that was sent and received. (Classroom videos, 2012)

8. Verbal • Act of conveying information or a message by oral communication • It is about what you say and how you say it!

9. Verbal • Introduce yourself and purpose • Use appropriate tone of voice appropriate for situation (avoid monotone) • Think before you speak • Timing is important • Avoid interrupting • Use open ended questions/clarify to verify understanding • Use language that is appropriate to the patient/family • Avoid judgmental statements • Show interest in the conversation (using “yes” and “uh-huh) • Avoid disruptions unless urgent • Avoid verbal discussions about patients in earshot to prevent hurt feelings and distrust

10. Non Verbal • Non Verbal Communication “ is any way that is used to express thoughts, feelings, or emotions without speaking. The human body is extremely susceptible to this type of communication, as 80% of the messages we send and receive are done so without ever saying a word. Nonverbal communication skills are a vital part of our everyday lives.” (Wood, T., 2009)

11. Nonverbal • Body posture • Facial expressions • Eye contact (take culture into consideration) • Nodding • Smiling • Leaning in • Providing the appropriate space • Touch • Manage stress in non verbal interactions

12. Written • Emails • Texts • Documentation • Be professional • Important to remember there is a good chance an electronic messages may be read by others • Be precise and clear in your message • Read back what you have written before sending • Avoid writing when emotional or upset • Use approved abbreviations that are universal

13. Listening Skills Listening helps understanding of what is being said but it also makes the patient feel heard and allows appropriate assessment of the patient. Active: Giving attention through verbal and nonverbal cues Passive: Hearing while not fully concentrating or attending to the person. Results in poor communication

14. Building trusting relationships • Use effective communication skills • Honesty • Avoid judgment • Follow through on any promises made to the patient/family • Warm and sincere • Empathetic

15. Potential barriers to communication • Lack of communication skills • Lack of experience • Fear of saying the wrong thing or not knowing what to say • Disagreements of patient/family decisions • Not having enough information or getting too much information • Cultural differences/language • Non speaking/hearing patients • Being judgmental/applying labels • Stress • High acuity and staffing issues/work overload • Lack of resources • Inadequate feedback

16. How to break “bad news” to a patient • Be emotionally prepared • Create an environment that has low stimulus to prevent interruptions and distractions during discussion • Start the conversation by asking patient how they are feeling • Provide information honestly and openly and at a level they can understand and repeat information as needed • Give time and opportunity to receive the information • Ask the patient if they would like someone else there for support • Assess what they have been told and how much they have taken in • Assess medical understanding and emotional state (Classroom videos, 2012)

17. How to break “bad news” to a patient • Establish how much they want to know as this can vary from one patient to the next • Have relevant information available • Encourage patient to express feelings • Give them time to digest the information and do not be afraid of silence rather than filling gaps • Ask if they questions • Ask if they want help in talking to other family members • Discuss treatment options and resources • Before finishing conversation check on comprehension and arrange for ongoing support. (Classroom videos, 2012)

18. Communication Strategies • Ask-tell-ask: Tool to determine what a patient knows, what they want to know and if they wish to discuss it. • Ask open ended questions • Allow time for response • Clarify responses • Answer questions (Peereboom, K., Coyle, M., 2012)

19. SOLER • S: Squarely face the patient at eye level • O: Open body posture (avoid crossing arms) • L: Lean toward the patient to show interest • E: Eye contact to show attention and focus on the patient • R: Relaxed posture to make the patient feel comfortable (Peereboom, K., Coyle, M., 2012)

20. NURSE • N: Naming the emotion, for example, “Are you feeling sad?” • U: Understanding, communicating and understanding of the emotion. For example, “I can understand why you are feeling sad right now.” • R: Respect, acknowledges patient’s ability to overcome challenges. Example, “I am impressed with your ability to face your feelings.” • S: Support, giving support for the present and future. Example, “I will work with you to meet your goal for pain management.” • E: Empathy shows interest for the patient’s situation. Example, “You said you are worried about your family, tell me more.” (Peereboom, K., Coyle, M., 2012)

21. Safety Initiatives involving communication Joint Commission national safety goals for 2014 • Improve staff communication • Identify patients correctly • Use medications safely • Use alarms safely • Identify patient safety risks • Prevent mistakes in surgery (The Joint Commission, 2014)

22. Quality “The current challenge in health care is to create an environment in which open and transparent communication is the norm rather than the exception. One way to do this is by adopting strategies that have been successful in other industries.” Safety Culture environment SBAR Bedside reporting Handoffs Huddles Nurse-Physician Intentional rounding Daily safety calls (DCI) (Chapman, K. 2009).

23. Theory Base Interpersonal Relationship Theory According to Peplau, nursing is therapeutic because it is a healing art, assisting an individual who is sick or in need of health care. Nursing can be viewed as an interpersonal process because it involves interaction between two or more individuals with a common goal. In nursing, this common goal provides the incentive for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing as a result of the interaction. Hildegard Peplau 1909-1999 (Nursing Theories, 2011)

24. Theory is based on therapeutic nurse-client relationship • A professional and planned relationship between client and nurse that focuses on the client’s needs, feelings, problems, and ideas. • Roles of the Nurse in the Therapeutic relationship: stranger, resource person, teacher, leader, surrogate and counselor • Four Phases of the therapeutic nurse-patient relationship: • Orientation • Identification • Exploitation • Resolution (Nursing Theories, 2011)

25. Uncertainty Reduction Theory (URT) • In 1975, Charles Berger and Richard Calabrese created Uncertainty Reduction Theory "to explain how communication is used to reduce uncertainties between strangers engaging in their first conversation together” • Focuses on how human communication is used to gain knowledge and create understanding. • The beginning of relationships are fraught with uncertainties, therefore one wants to reduce those uncertainties. • Interpersonal communication is the primary means of uncertainty reduction (University of Twente, 2014)

26. Root cause analysis • Problem Ineffective communication skills consistently utilized by nursing staff • Data Collection Patient Satisfaction scores • Possible contributing factors Lack of education and mentoring Lack of resources Lack of accountability

27. Root cause analysis • Root causes Lack of education and mentoring programs to assist nurses to be self learners and develop comfort in communication skills to enhance the patient experience and reduce potential safety issues. • Solution recommendations Develop educational programs in entry level nursing programs All health care facilities to develop ongoing communication education Consistent rounding with patients for feedback on communication of nursing staff and recommendations for improvement • Evaluate outcomes Improved patient satisfaction scores

28. Quality reporting • What is the purpose of the HCAHPS Survey? • The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey, also known as the CAHPS® Hospital Survey or Hospital CAHPS®, is a standardized survey instrument and data collection methodology that has been in use since 2006 to measure patients' perspectives of hospital care. • National standard for collecting and public reporting information that enables valid comparisons to be made across all hospitals to support consumer choice. • The HCAHPS sampling protocol is designed to capture uniform information on hospital care from the patient’s perspective. (Centers for Medicare and Medicaid Services, 2013)

29. HCAHPS • 3 goals Designed to produce comparable data on patients' perspectives of care that allows objective and meaningful comparisons among hospitals on topics that are important to consumers. Designed to create incentives for hospitals to improve quality of care. Enhance public accountability in health care by increasing transparency. (Centers for Medicare and Medicaid Services, 2013)

30. HCAHPS • 27 survey items • Examples: • Communication with nurses • Communication with doctors • Responsiveness of hospital staff • Pain management • Communication of medications • Discharge information • Overall rating of hospital • Recommendation of hospital

31. QSEN • Patient-center Care • See situations through the patients eyes • Support patients values • Understand patients backgrounds • Information, communication and education • Continuously analyze and improve own level of communication skill in encounters with patients • Safety • Reduce risk of harm through both system effectiveness and individual performance • Promote standardized team processes • Promote culture of safety through communication of concerns and safety issues (QSEN, 2014)

32. ANA Standards • Assessment • Emphasis on holistic data collection • Identify barriers of communication to develop individualized plan • Recognizes personal values and beliefs system • Communication • Able to assess own communication skills • Collaborates communication with other disciplines in delivery of care • Promotes communication and resolves conflict • Leadership • Commitment to lifelong learning • Utilize skills to promote respect, trust and dignity • Communicates effectively (American Nurses Association, 2010)

33. Communication Exercise/Conclusion • Perform the exercise • Questions: • Do you feel communication worked effectively? • What communication skills did you use effectively? • Where do you feel your communication skills could have been improved? • What did you learn from this exercise?

34. Questions • Thank you!

35. References • American Nurses Association [ANA] (2010). Nursing: Scope and Standards of Practice (2nd Ed.). Silver Spring, Maryland • Centers for Medicare and Medicaid Services, (2013). HCAHPS: Patient perspective of health care survey.Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html • Chapman, K. (2009). Improving communication among nurses, patients and physicians. Retrieved from: http://journals.lww.com/ajnonline/Fulltext/2009/11001/Improving_Communication_Among_Nurses,_Patients,.6.aspx • Peereboom, K., Coyle, N. (2012). Facilitating goals-of-care discussions with patients with life- limiting disease-Communication strategies for nurses. Retrieved from: http://www.nursingcenter.com/Inc/cearticle?tid=134421

36. References • QSEN. (2014). QSEN Institute. Retrieved from: http://qsen.org/competencies/graduate-ksas/ • The Joint Commission. (2014) 2014 National patient safety goals. Retrieved from: http://www.jointcommission.org/hap_2014_npsgs/ • Wood, T. (2009). Non verbal communication. Retrieved from: http://www.accuconference.com/resources/non-verbal-communication.aspx