Interpersonal skills
Therapeutic communication
Our interpersonal skills are key in therapeutic work. We communicate through what we say, our tone of voice, facial expressions, body language, our appearance and our actions. Individuals living with stroke can find it difficult to make use of all these aspects of communication, as they may be impaired by their brain injury. They may have difficulties interpreting aspects of human interaction. In some patients, the ability to express and/or recognise emotion can be affected, therefore, we need to ensure we communicate in a way that helps our clients make sense of the information.
Interpersonal skills are important for patients whose cognition or communication has been affected by stroke. We need to make sure that we take into account the emotional experience of having a stroke, being in hospital or undergoing rehabilitation. This section describes how we can improve our interactions with patients by putting them at the centre of their care.
Some rules for effective communication
Thinking about the case of Bob, we know that he has some difficulties with comprehension. He also has some difficulties with memory. There are a few things that we can do to help patients in this situation, such as paying attention to their facial expression, summarising and clarifying things.
The right level
Pitch what you have said at the right level for the person. This means not merely simplifying what we say. Listen to the words the patient uses, and use the same words: if they say “high blood pressure”, say “high blood pressure”, if they say “hypertension”, say “hypertension”. By using their terminology we make sure that the patient feels listened to and understood, and does not feel belittled.
Pay attention to body language
Observe the person and read their facial expression and body language. Doing the same routines day in and day out can make us forget that this is all new to a patient. Thinking of Bob, he feels very unsafe in the hoist, but does not want/can’t voice this. You might notice this when looking at his facial expression or tension in his body. When noticing it you can ask the patient how they are feeling or tell them they appear uncomfortable or worried about something if that is what you are observing. There may be a simple solution which would not only improve their wellbeing and experience of care, but also make your job a lot easier.
Jargon
Avoid using jargon! Those of us who work in health and social care are used to medical terms and abbreviations that others do not understand. Use as little jargon as possible with patients and carers/relatives. When using medical terminology, explain it and check out understanding e.g. “can you tell me what you understand of that”. Also, do not assume a patient understands everything if they have previously worked as a nurse or medic, as stroke may be completely new to them. Also don’t assume they understand even if they are using the correct terminology! You can find a list of questions in the toolkit that help you to check how much your patient understands about stroke.
Break into chunks
Bob has some difficulties understanding and remembering. He would struggle if we gave him a lot of information at once, for example about medication, rehabilitation, risk factors etc. Decide what is most important to tell the patient at this time or consider what they feel their immediate needs are, and leave other things for later. We need to make sure to break information down for all our patients but particularly for those with cognitive difficulties – remember this is potentially their first experience of a hospital ward or stroke.
Check out understanding
Watch the person’s non-verbal communication as you converse with them. Do they seem to pay attention and understand, or do they seem distracted and look puzzled? When you observe signs of confusion, stop and ask what they understand about what you have just said. For example “Did I explain that right? Can you explain back to me what I just said so I can make sure?” Correct anything they have misunderstood, or repeat/change your use of language to strengthen the message.
Stop and summarise frequently
Frequently stop and summarise what has been said to you: “Let me see if I understood that correctly, so you said…”. This way the patient feels listened to, and can give you the opportunity to make sure that you understand what they are saying to you. It can be particularly helpful to stop and summarise when you are talking to someone who has a tendency to go off topic. By summarising the main, important points, you can bring their focus back to the issue at hand.
Repeat as necessary
Lots of repetition is important, as we often just remember bits of a conversation. Use different ways, re-wording to explain things if the person does not seem to understand. Sometimes it helps to use metaphors, similes, or images, or to draw pictures and diagrams.
Use written/ pictorial aids
If someone has memory difficulties, you could encourage them to write down the important points, or do this for them if they are unable to do it themselves. You might also want to use pictures to see if this helps. Some people might want to use their phone to make notes.
Chit – Chat
Making day-to-day conversation is fine – in some situations. You may use chit-chat to:
· put the person at ease
· find out about the person
· distract the person when they feel anxious
· normalise the situation
· make the person feel valued (like a person, not a patient).
However, be careful of boundaries. Do not disclose anything personal or anything which may unhelpfully change the way the person sees you (as a trustworthy professional); for example, you would not want your dentist to tell you he is feeling a bit shaky after having too much to drink the night before as he prepares to drill your teeth. How and when you ‘chat’ informally to patients may depend on your role. The rule of thumb in ALL contact with patients is to ask – “is this at least harmless, and better still, is it therapeutic?”
Consider the case of Bob; you may wish to distract him from a nursing task he finds difficult by chatting about your children. However, Bob might get distressed at this, as he cannot see himself playing with the grandchildren ever again. When using chit-chat in this way, look out for non-verbal signs and listen to how the person responds, giving them space to voice their feelings, thoughts and images.
Don’t try to contradict or reassure at this stage – just let them explore their feelings, worries and concerns and provide an empathic listening approach and containment of their feelings. Jumping in too quickly at this stage (when we don’t actually know the outcome ourselves) with reassurance can feel humouring for the patient. Equally, you don’t need to jump in with medical explanations at this stage. Just listen, and convey that you are trying to understand how they might feel. It is ok to acknowledge the uncertainty, whilst carefully interjecting a little optimism and determination. One of the key components in the art of good communication is timing. Knowing when to listen, when to reassure, when to gently challenge or contradict, and when to try to move the person forward.
Ignoring
When in the company of patients, even if they seem unaware or unreceptive, DO NOT TALK AS IF THEY ARE NOT THERE. When you are working with a patient, always address them in your conversation. Talk through what you are doing, chat about what is going on outdoors, what is for lunch on the ward. Do not have a conversation with a colleague that excludes the patient.
Being positive, optimistic and realistic – a difficult balance
Positivity and optimism is a very important issue, and it becomes clear when you speak to stroke survivors a couple of years after their stroke. Some patients are angry that they have been told ‘all will be fine’, but who have not returned to their pre-stroke functioning. Equally, patients might have made more progress than initially predicted, and they feel angry and upset that they were given a poor prognosis or that they had been discouraged at their initial diagnosis and early rehab.
Immediately after the stroke, patients need hope for recovery. Without hope, there may be no reason to engage in rehabilitation. If Bob for instance will not be able to run around with the grandchildren, why have physiotherapy? We need to avoid hopelessness and disengagement from rehabilitation. After all, can we know in the early stages of recovery just how much progress an individual will make?
We need to strike a balance of maintaining hope while not giving unrealistic expectations. How this is best approached depends on the patient. Some patients do not want to keep being told that things will get better if it may not be true. On the other hand, there are some patients who do not want to hear that things might never get any better. We need to ask the patient what is important to them and work towards this goal. We need to establish where the patient feels they are at and what they feel is likely to be the expected outcome. If they lack true awareness (because it is early days for them too) and their goal is unlikely to be achieved, we need to revisit it when they are ready and together help the patient come realise their own potential and set more realistic timely goals.
Never set a strict deadline for recovery (e.g. the level you are at 18 months post stroke is where you will stay forever). Without hope, patient’s will often not engage in rehab and without rehab, they are unlikely to recover further. Telling a patient that they are ‘at the end of the line’ can end up being a self-fulfilling prophecy.
Barriers to Interpersonal Effectiveness
The environment
Think about how the ward looks and feels through the eyes of a patient or visitor: it can be busy, noisy and sometimes smelly. Descriptions used by patients include “daunting”, “horror” and “terror”. This, together with the uncertainty about what will happen now, can raise anxiety levels considerably. Most of us would prefer talking in private about our worries and anxieties. Therefore, if you need to discuss something of a sensitive nature with patients or relatives, if possible go to a quiet room where there are fewer distractions and your conversation and your patients care can remain confidential.
Our own circumstances/stress levels/priorities
Our jobs can be stressful, and this, coupled with personal life experiences can create a great deal of anxiety. Imagine your partner losing their job. At such a time we may find it difficult to be compassionate with a patient or relative. It is important to be aware of your own mental health and wellbeing. Ultimately, coming to work when you are overly stressed can have a negative impact not only on yourself but also the patients you are caring for. You may be able to put some strategies in place to help yourself but speak to colleagues about this if you can (see section on Self Care for Staff).
Our own personal style
We all have very different personalities and ways of communicating. Valuing our differences is important, and it wouldn’t do if we all went around communicating in exactly the same way. However, for some patients we might need to be a little different, for example more (or less) upbeat. Think about your own individual communication style and how you can adapt it to suit your style and the patient’s character and needs.
Patient characteristics
Think of a patient you really like because they are friendly or thoughtful. Now think of a patient you do not like working with. Not every person is rewarding to work with, maybe because they seem demanding, complain a lot, have a very different lifestyle to your own or simply irritate you. It is important to be aware of and reflect on this. Is there anything you can do differently to meet this person’s needs, to make sure they receive the appropriate care? Sometimes it is helpful to acknowledge difficulties together with the person and think of ways around this. A good relationship is helpful when providing care or rehabilitation for a patient, so if necessary, consider moving staff around to avoid personality clashes.
Having considered how we can improve talking to people and providing information, the next section is concerned with how counselling skills can help us improve our attitude towards patients to support them better.
Core Counselling Skills
When we talk about counselling, we generally mean providing help and assistance for resolving personal or psychological problems. However, the core skills of counselling are not limited to therapy, but are helpful in all everyday interaction. Carl Rogers (1957) talked about the core counselling conditions empathy, genuineness, warmth and unconditional positive regard as essential for a therapeutic relationship.
Empathy
Empathy is the ability to “stand in the patient’s shoes”. Being empathic allows us to gain an understanding from the perspective of the patient.
Genuineness
To be genuine means to be ‘real’, natural and open, to spontaneously and willingly share your own experiences and feelings and not just ‘act’ your job role. This should be done carefully and sparingly. Being genuine does not mean that you should share all of your thoughts/feelings with a patient; it simply means that the thoughts and feelings that you do express should be real and genuine.