December 5, 2010 0

Module 3:

Communication

Developed by: Provincial Spiritual Health Care Management Network

The Spirit of Caring:

A Volunteer Education Resource

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Module 3 – Session Guide

Communication

Facilitators Overview/Outline TIME ACTIVITY RESOURCE COMMENT 5 min

What is Communication – an open discussion as to what is involved in communication

Definition from Webster’s page 2

Involve as many as possible, compile definition on white board if available

15 min

Communication in a caring relationship

Page 3 Spend time emphasizing each of the three elements

15 min

Intended and Actual Nonverbal communication

Page 4 Allow 3-4 of the trainees to respond to the question for Reflection

15 min Break 20 min

Basic principles of Communication

Page 5-7 Take time for the Horizontal Talking exercise and discussion

20 min

Communication Tips/Guidelines for “Being There”/Self Disclosure

Page 8-10

20 min Responding to Patient Frustration

Appendix 5 This is an important section and spending some time in the kick off exercise is well worth the time.

5 min Conclusion/Wrap-up Ending Quotes Page 10

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Interpersonal Communication and Listening Skills: The Essential Tool of the Spiritual Care Volunteer

Jill Taylor – Brown, Dan Knight and Larry Hirst

What is Interpersonal Communication?

The definition of communication is shared in the Webster's Dictionary as "sending, giving, or exchanging information and ideas," which are expressed in both nonverbal ways and verbal ways; or, as the Merriam-Webster dictionary says, “a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior.” The fact is we all communicate and all of the time. Most of us do it quite well in most circumstances, but all of us can struggle with it in difficult circumstances and/or if we are stressed or fearful. The caring/helping relationship with a person who may be a stranger to us can generate fear and stress which can impede interpersonal communication. But remember, it is impossible NOT to communicate. Between 80 and 90 % of what we communicate is non-verbal, and when there is a discrepancy between the verbal and non-verbal, the non-verbal will almost ALWAYS be believed. The most important aspects of interpersonal communication are: ACTIVE LISTENING and ATTENDING.

True words aren’t eloquent; eloquent words aren’t true.

Wise men don’t need to prove their point; men who need to prove their point aren’t wise.

- Lao Tzu.Tao Te Ching Verse 81

Objectives: • To understand the essential components of interpersonal communication

in a caring relationship • To recognize active listening, attending and “presence” as key

interpersonal communication skills • To become aware of the impact of non verbal communication • To enhance active listening skills

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There are three key elements to communication in a caring/helping relationship:

Research from over thirty years ago (Carl Rogers and others) has shown that no matter what the discipline, background, or education (ie whether a spiritual health specialist, a doctor, psychiatrist, psychologist, nurse or volunteer), if these three ingredients are not present the person will not feel cared for nor “helped”.

1. Authenticity – being genuine and congruent

a. Begins with being aware of self and being REAL b. Non-verbal behavior needs to match verbal behavior – if

discrepancy, non verbal will ALWAYS be believed (show by example – someone shouting “I am NOT ANGRY!!” – someone tearful saying “I’m fine” ; someone stating they very much want to be there, but are fidgety and/or have distracting behaviors).

2. Non-judgment – showing warmth and acceptance

a. Try to remain open to what is being said without thinking about whether it is good or bad, right or wrong. Try to cultivate this attitude towards others and towards yourself. Being non-judgmental allows the other person to feel “safe” and free to express themselves without worrying what you will think of them.

b. One way to cultivate a non judgmental stance is to be very aware of the language we use – both “out loud” and internal. Recognize words that contain judgment – and there are many! Be aware if you are making judgments as someone is speaking – judgments can be positive as well as negative (eg. brave, courageous, good, bad, right, wrong, fair, unfair, should, shouldn’t, etc)

3. Empathy ( not sympathy) (FEELING WITH AND NOT FOR, PITY IS A

DESTRUCTIVE EMOTION; OPPOSITE OF EMPATHY IS PITY) a. Empathy is a translation of the German term Einfühlung,

meaning to feel as one with. b. Empathy is the ability to feel “as if ” one was in that

situation. It is showing understanding from the other’s point of view: “putting oneself in their shoes” . . However, recognizing that it is “as if” , it is not the same or equal.

“ …..suffering ……no matter how multiplied…….is always individual.” Anne Morrow Lindbergh

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Every communication has both intended and actual effects (which can be unintended)

.

Intended – the intended effects are those that we planned. We may send a card to a friend with the intent to encourage the friend. Or we may ask an acquaintance “how are you?” out of curiosity for their wellbeing. , but ask it in passing and although slow down, don’t stop moving. Actual – The actual effect is the real impact of our communication. If the card is received and the friend is encouraged – our intended effect has been realized. On the other hand, although we intended to communicate that we care how our colleague is feeling, our non verbal behavior (asking the question while walking and not slowing down) may have the actual unintended effect of communicating we don’t really care how they are feeling or that we have no time to listen to how they are feeling.

Questions for Reflection 1. Can you remember a situation in which you had intended to communicate

one thing, but actually communicated another? (Facilitator should provide an example or two from his/her own experience)

2. Would you be willing to share the situation you are remembering?

Nonverbal Communication Activity How and what do we communicate non verbally? Set up an exercise in becoming more aware of non verbal communication. Have each person turn to the person beside them and take a turn talking about something (book, movie, vacation) and the other practicing listening skills. The first time instruct participants that the listener must use their best listening skills, but must not look the talker in the eye. Give one or two minutes. Then, discuss impact from perspective of both the talker and the listener. Discuss situations in which we do this, ways we compensate. Switch partners and have the other become the talker. This time have the listener make eye contact and listen but do something distracting while they are listening. Then discuss. Elicit thoughts and reactions, and other real life examples.

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The ideal “attending” posture

: F.E. L.O.R. (see Cartoon – Appendix 1)

F - Face forward E - Eye Contact (not staring – culturally based “listen” to their non verbal cues L - Lean slightly forward O - Open body posture R - Relaxed (authentic/real)

Basic Principles in Communication

1. LISTEN a. The Chinese symbol for “To Listen”: (Appendix 2) is made up of several

components– emphasize the components which are the components of active listening – focus on the other, ear, eyes, heart (ie listening with the heart), and giving “undivided attention” Speak about how rare undivided attention is in our day to day encounters with others and what a precious gift it is.

b. Active listening is not just hearing but rather listening for MEANING c. Listening involves being – your presence in the here and now is your most

important gift

1. GET THE SETTING RIGHT (adapted from Dr. Robert Buckman (2005) “I Don’t Know What to Say: How to Help and Support Someone Who is Dying”)

When considering the context for listening we need to be conscious of: a. Privacy b. Background noise c. Remember F.E.L.O.R. d. The importance of your physical position in relation to the patient

Activity Break up in pairs and practice the F.E.L.O.R attending posture with each other

BREAK

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3. ENCOURAGE TALKING

Give Sorrow words; the grief that does not speak knits up the

O’ve wrought heart and bids it break (Shakespeare – MacBeth

)

a. Show you are listening b. Ask open ended questions (discuss and elicit examples of open and

closed questions) c. Nod, “Uh-huh”, “Tell me more about…” “I am wondering if you would like

to say more about …..” d. Repeat two or three words from the last sentence e. Paraphrase to check for understanding f. Paraphrasing:

• Clarifies • Minimizes misunderstanding • Lets the other person feel heard • Helps people sort thro9ugh their thoughts • Repetition helps to build understanding

4. DON’T MAKE ASSUMPTIONS

(Cartoon – “For Better of For Worse” – Cartoon - Appendix 3)

Exercise: Horizontal Talking: A Difference in Perspective • Get together in pairs • One partner lies on the floor and the other stands • In this position, carry on a five minute conversation, then switch places • Share your experience with the group Discuss what you as a spiritual care volunteer might do to minimize the hazards of this reality?

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5. CHANGING THE SUBJECT When we are seriously ill or in a health care facility, there can be a huge sense of a loss of control. When we change the subject , it can give several unintended messages “I was not interested in what you were saying” or “You are not in control of what we are talking about”.

6. GIVING ADVICE (Advice on giving advice – DON’T)

When we give advice, in essence, we’re telling somebody else what to do. It implies we have the answers about what works and what doesn’t.

7. SILENCE

a. Silence allows for opportunity for the person to reflect and consider before responding. Especially important when person is ill as thought processes may be slower.

b. Sometimes there are simply no words to match or respond to what has been said and the most appropriate response is to be in silence together

c. When we break the silence we may be taking too much control of the conversation

8. WHEN OTHERS ARE PRESENT INCLUDE THE PATIENT IN ALL CONVERSATIONS –

do not speak to others in the room as if the patient were not even there. 9. TOUCH

a. What does this image – evoke in us regarding touch and communication? (Art by Robert Pope - Appendix 4)

b. Gender Issues related to Touch

Group brain storm exercise:

• Ask participants to remember a time when they had a concern (big or small).

• Now ask them to think about what someone else did (behaviors) or did not do that was helpful or not helpful.

• Make two columns on a flip chart or white board (or ask them to write on paper in front of them). One side “Helpful” and one side “Unhelpful”.

• List the responses as they are given under each heading. • Ask the participants “How did that make you feel?” or “What was helpful

/unhelpful about that?” Often the same item might show up on each side (e.g. touching or bringing casseroles) – this is often when giving advice shows up on the unhelpful side.

This concept is one that many volunteers struggle with

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10. HUMOR (Cartoon - Appendix 5)

a. Allows for ventilation b. Releases intense feelings c. Puts things in perspective d. It’s how we humans deal with the impossible

11. RESPECT EACH PERSON’S WAY OF COMMUNICATING

Guideline for “Being There” for the other

(Victoria Hospice Society)

1. Place yourself at the same level as the person with whom you are visiting 2. Use the person’s name regularly – hearing your name spoken is very grounding,

especially when spoken by someone who cares for you, but be natural and do not overuse it

3. Offer opportunity for privacy and uninterrupted, unhurried discussion. 4. Be yourself, be ordinary, take time to settle in, give time to settle in and build

rapport and trust 5. Observe and match your mood and behavior to the situation 6. Be guided by the person in regards to the others comfort with physical contact 7. Find common ground as you share time together 8. Heaviness, sadness, anger, frustration may need to be acknowledged before any

further issues are raised. 9. Be specific about how you can help and what this relationship is about 10. Set boundaries 11. Respond to opportunities to talk about the issues the other is concerned about 12. Be respectful and humble 13. Do not use platitudes 14. Do not make assumptions

Boundaries1

1 The section BOUNDRIES IN THE SPIRITUAL HEALTH CARE PROVIDER – CLIENT RELATIONSHIP has been adapted from the College of Registered Psychiatric Nurses of Manitoba document entitled, “Professional Boundaries in Psychiatric Nursing” printed in 2010.

Activity; Facilitator asks trainees, “Imagine that I am a patient you are visiting. During the course of the visit I tell you that a granddaughter is coming to visit tomorrow and I have no card to give her. Then I hold out a $5.00 bill and ask you to go to the gift shop for me and pick up a card.” How would you respond (go around the group)

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The core of providing spiritual health care is the relationship

between the client and the provider. Establishing and maintaining this relationship is the responsibility of the provider, not the client. Spiritual health care providers recognize that trust, respect, and empathy must always be present in the relationship. Trust is a critical ingredient in developing rapport. This trust is established through interpersonal warmth, a non-judgmental attitude, and a demonstration of understanding.

The relationship between the spiritual health care provider and the client is different than a social relationship. A social relationship with a client may already exist when the need arises to develop a therapeutic relationship. It is expected that spiritual health care providers will utilize professional boundaries

to maintain a safe and appropriate relationship.

Boundaries define and separate professional roles from other roles

. Boundaries are the limits that allow the safe connection between the spiritual health care provider and the client. A boundary violation occurs when the spiritual health care provider, whether consciously or unconsciously, uses the relationship to meet his or her own personal needs. Boundary violations can impact both the provider and the client in negative ways.

They can result in a client experiencing ambivalence, mistrust, guilt, and shame. Boundary violations can seriously undermine future therapeutic interactions and relationships. For the spiritual health care provider, boundary violations can result in feelings of guilt, shame, and remorse. Boundary violations have the potential to threaten professional integrity, and may result in personal and/or professional consequences (such as disciplinary action from the employer.) Boundary issues may pose significant ethical dilemmas for spiritual health care provider. When the spiritual health care provider is unsure, it is important to consult with peers and supervisors so that you can fully and carefully make appropriate choices.

Potential Warning Signs for Boundary Violations

• Sharing personal information or work concerns with the client. • Feeling responsible if the client’s progress is limited.

Alternate Activity: Scenario about boundaries on the Council on Palliative Care & McGill Volunteer Training Videos

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• Inappropriate physical touching that is sexual or flirtatious in nature. • Favouring or giving special attention to a client. • Keeping secrets with the client. • Giving or receiving gifts from the client. • Questioning oneself about interactions with the client.

Questions to Facilitate Ethical Decision Making (Appendix 6)

• Is this in my client’s best interests? • Whose needs are being served? • What about this situation is causing me to pause? • Will this have an impact on the relationship? • Should I consult with a peer or my supervisor? • How would this be viewed by the client’s family? • How would I feel telling a peer about this? • Am I treating this client differently? • Does this client mean something special to me? • Does this action benefit me or the client? • Would I do this for all my clients?

Self Disclosure in the Caring Relationship

Helpful and unhelpful self-disclosure

Self-disclosure is helpful when… Self-disclosure is unhelpful when … • it is short and quickly returns the

focus to the patient • it matches the intensity of the

patient’s disclosure • it is genuine • it is specific to yourself and not a

generality

• it takes and keeps the focus off the patient

• it “out does” or “one-ups” the patient

• it meets my need as opposed to the patient’s need

• it changes topic • it judges or dismisses the patients

experience

Exercise – Responding top patients scenarios (Appendix 7) Consider role playing some of the scenarios with the trainees

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Concluding Quotes:

“…it is important to approach people… gently, so gently, not forcing yourself upon them, but accepting them as they are

with humility and respect.”

Jean Vanier

§§§§§§

“Perhaps the world is one big healing community and we are all healers of each other.

Perhaps we are all angels and we do not know it.”

Rachael Naomi Remen, MD

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Appendice 1

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Appendix 2

The Chinese Symbol for “Listen”

YOU

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Appendix 3

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Appendix 4

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Appendix 5

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Appendix 6

Questions to Facilitate Ethical Decision Making

• Is this in my client’s best interests? • Whose needs are being served? • What about this situation is causing me to pause? • Will this have an impact on the relationship? • Should I consult with a peer or my supervisor? • How would this be viewed by the client’s family? • How would I feel telling a peer about this? • Am I treating this client differently? • Does this client mean something special to me? • Does this action benefit me or the client? • Would I do this for all my clients?

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Appendix 7

Responding to the patients frustration

Exercises adapted from “I Don’t Know What To Do: How to Help and Support Someone Who Is Dying” Dr. Robert Buckman (2005). You are a spiritual Health care volunteer who has been asked to provide care for Mr. Jones. Mr. Jones is 59 years old. Last year he lost his wife to ovarian cancer. Just this week, he was brought into the hospital by ambulance from work. He had had a significant heart attack that may require him to go on disability. Mr. Jones indicated that he would be happy to have a spiritual health care volunteer visit him while he was in the hospital. After the preliminaries, Mr. Jones looks at you and says, “Damn it, how much do you think a man can take. I lost my wife to cancer just a year ago, I was just getting used to being alone and now this. If I can’t go back to work I know I’m going to go crazy.” You respond, “You know, God never gives a person more than they can handle.” He looks down, then back up and says, “Why don’t you leave – I don’t need anyone telling me that God won’t give me anymore than I can handle. I just told you I can’t handle this!”

1. What might have been a better way to respond? 2. How might you respond to Mr. Jones to salvage the spiritual care visit?

Example #1 When the patient says… And you respond (taking it personally) …

“I feel awful and you’re no help!”

• “Well, I’m doing my best” • “Stop criticizing me!” • You’re not the easiest person to

help!” All of these responses lead to escalation and a rift between you and the patient

Instead

When the patient says… And you respond (not taking it personally)…

“I feel awful and you’re no help.”

• “Tell me more about how you are feeling.”

• What’s the hardest part of all this for you?”

• You sound really low (or angry, or depressed…)

Encourages dialogue and allows patient to say what is on their mind the patient Example #2

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When the patient says… And you respond insensitively…

“I’m going to die and I’m not ready.”

• “Well, you are 80 and you have lived a rich life.”

• “There’s a reason for everything.” • “Don’t talk like that – you have to

think positively about your situation.”

These statements shut the door to talking about feelings

Instead When the patient says… And you respond…

“I’m going to die and I’m not ready.”

• It’s not easy for you , is it?” • “What is the hardest or scariest

part of this for you?” • Say nothing – simply hold their

hand or reach out to the other. These responses are all attempts to stay close and encourage further conversation

around the feelings. Other difficult statements that often surface in the course of caring:

1. “Why me?” 2. “I have so many regrets.” 3. “I am just not ready to die yet.” 4. “I feel so let down by my friends.” 5. “I hate being so dependent.” 6. “I’m not sure how much longer I can go on like this?”