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NRMW 1000. Core Skills for Health Care Professionals Communication Skills for Midwifery Practice Part B By Richard Byrt Former Lecturer/Practioner Nursing, De Montfort University and Arnold Lodge Medium Secure Unit, Nottinghamshire Helathcare Trust. Adapted for midwifery by Jacqui Williams, Senior Lecturer in Midwifery, DMU. Examples of women are based on the lecturer’s midwifery experience and are fictitious and not intended to describe clients in local services or elsewhere. 1.Introduction This handout considers: Further aspects of communication in midwifery practice. Women with specific communication needs, especially individuals with changes to brain structure and function. Communication with individuals who are bereaved. 2. Active Listening and Empathy: Two Key Skills in Midwifery Two key skills are essential: Active listening: careful attention to the clients’ non – verbal and verbal communication, and Empathy: attempting to understand the client’s feelings and experiences, communicating this understanding to her/him; and taking practical action to help the client. (Arnold and Boggs 2007, Baughan and Smith 2009) An Exercise on Empathy Imagine you are a registered midwife and you have to break the news to a woman that the results from the antenatal screening tests are raised and further investigations are required. . Consider what communication skills you would use to break this news, and to give the woman and her partner the information they require. 3.1. Empathy and Sympathy Several authors have distinguished between empathy and sympathy (Reynolds 2005, White 1997) by stating that both empathy and sympathy involve attempting to understand the client’s feelings and experiences, but the person who is sympathetic may be overwhelmed by her/his attempts to feel the same way as the client. In contrast, the midwife who is empathetic, whilst trying to understand the woman, would have a certain amount of objectivity and be able to provide practical help and support, without being overwhelmed by the client’s feelings and experiences (Arnold and Boggs, 2007, Reynolds 2005). White (1997) illustrates this by stating that a sympathetic professional might burst into tears to demonstrate sympathy, which could be difficult for the client; but that an empathetic professional would be able to translate empathy into being sensitive to the client’s non – verbal and verbal 1 communication indicating distress; and by providing practical care and active listening to reduce this. 4.1. Carl Rogers’s Core Conditions of Client – Centred Communication Some communication skills are related to Carl Rogers’ core conditions of client – centred communication (sometimes called person – centred or humanistic communication: Freeth, 2007). Empathy is one of these core conditions and the others include “congruence [and] unconditional positive regard (Freeth, 2007, p127). The three core conditions are described in detail in Rogers (1990). Client – centred principles appropriate to midwifery are considered in Arnold and Boggs (2007) and Barker (2009). Each of the core conditions requires self awareness 4.2. Congruence Congruence includes authenticity: the professional’s “awareness of [her/his] feelings and reactions” (Byrt and Doyle 2007, p86) in response to the woman. Congruence also involves being sincere, instead of, for example, pretending interest (Arnold and Boggs 2007, Barker 2009). The latter would be manifest in a midwife stating to a woman that she/he is interested in what they have to say, whilst fidgeting and looking out of the window, longing for the shift to end. This could possibly result in the woman feeling ignored, and perhaps, angry (Arnold and Boggs 2007). Congruence also involves not being defensive: that is, dismissing what the woman says. For example, if an aggressive woman complains about the midwife a congruent response would be to listen carefully to her, and offer an apology, if necessary (Arnold and Boggs, 2007). 4.3. Unconditional Positive Regard Unconditional positive regard, includes respecting and valuing the client, as a unique individual, regardless of her/his behaviour. Congruence requires that the midwife is honest about her feelings about the woman’s behaviour, with unconditional positive regard involving a determination to work consistently with the woman, despite any difficulties that may be experienced. It includes caring for a client unconditionally, not caring only if she behaves in the way that the professional thinks she should behave (Rogers 2004): “It means that there are no conditions of acceptance, no feeling of “I like you only if you [behave in particular ways]. .. “It involves as much feeling of acceptance for the woman’s expression of negative…painful, fearful, defensive…feelings, as for her expression of…positive…feelings…with permission to have her own feelings, her own experiences”. (Rogers 2004, p184) 5.1. Presence Part of empathy involves presence, which has been defined as “the quality of being open, receptive, ready, and available to the experience of another person” (Patterson and Zderad 1976, quoted in Engebretson 2004, p235). The latter author indicates that presence involves largely non – verbal communication skills: what is important for the woman is that, besides practical 2 skills, the midwife is there to support and share the woman’s experience; and this may be more important to her than the midwife’s verbal communication. An example of presence, involving empathy: “I was in a side room as I had found out a few days that my baby had died and tomorrow I am going to be induced. I was very restless and kept waking up and it took ages to ‘get back to sleep again.’ Rashida, a Student [Midwife], noticed my light on at around 3 am and guessed I was awake, and asked if I wanted a cup of tea. When she brought it, she must have noticed something was wrong because she asked me how I felt… “I said to her, “Everyone thinks I’m coping, but I’m not!” She just sat and held my hand…. with me for a while [as] it was quiet on the ward, and we’d talk about how I was’ trying to overcome some of the fears I had for seeing the baby and what would happen when I went home. .’I still remember that time in the middle of the night and how much that Student Midwife presence meant to me”. (Adapted from Baughan and Smith 2009). 5.2. Caution in the Use of Touch Although touch can be experienced by some women as comforting or otherwise therapeutic (as was apparently the case with Rashida’s use of therapeutic touch ), there is evidence that touching clients who have experienced physical or sexual abuse can be distressing and re – awaken experiences of their earlier abuse (Gallop and Tully 2009). In addition, some clients object to touch for cultural, gender and other reasons and may misunderstand the reason for the midwife’s use of touch (Arnold and Boggs 2007). For these reasons, care needs to be exercising in using touch to comfort clients or for other reasons. 6.1. Communication in Busy Health Settings It can be argued that quality, as well as quantity, of communication is of vital importance. For example, a busy midwife might have only a minute or two to listen to a woman’s fears. However, giving that client 100% attention for a minute may add considerably to her/his psychological, physical and spiritual comfort, and ensure that she receives the care needed (Baughan and Smith 2009). Morrison (1996) concluded from his research: “…Just arriving in hospital and settling into the routines to await an uncertain future is a complicated and anxiety-provoking experience. The physical environment, the technology, the uniformed staff and the specialist language used by the staff are all influential and contribute to the feeling of crushing vulnerability experienced by many if not all patients…” (Morrison 1996, p109) 7. Clients with Specific Communication Needs Good communication skills contribute to the effective professional care of clients with particular communication needs, skills and problems. Examples include the following: 3 Individuals who do not understand or speak English. This is not a problem in itself, but the lack of adequate interpreting or translating services in some health care settings has been identified as a problem. It has also been found that, within the UK, child and adult clients sometimes receive poorer services if they do not understand or speak English. It is essential nursing practice to ensure that all clients receive a high standard of care, whether or not they understand or speak English (Peckover and Chidlaw 2007, Schott et al 2007, Tribe and Raval 2006). . People with moderate or severe learning disabilities. These individuals may be very effective at communicating in certain ways: e.g., non verbally. However, they often have problems with understanding the content of speech and expressing themselves through speech (Ferris – Taylor 2007). There are now liaison learning disability nurses who work in general hospitals and who, with adult nurses, explain procedures in ways that the individual can understand (Jones 2004): e.g., through the use of a sign language or the use of pictures and symbols (Ferris – Taylor 2007). Some individuals with mental health problems may experience difficulties in communication. For example, certain people with severe depression can find it very difficult to take in what people are saying or to respond to conversation. An individual with schizophrenia (often occurring in teenagers and young adults) could feel bombarded with voices (auditory hallucinations), which might make it difficult for her/him to concentrate on what other people, including the nurse, are saying (Barker 2009). Some mothers (and fathers) need particular care and support from the midwife in liaison with mental health professionals, because of depression, excessive stress or schizophrenia precipitated by pregnancy or childbirth (Parcells 2010). Individuals with severe depression and schizophrenia can find it helpful if health care professionals: Treat them as an individual, and treat what they say seriously, rather than labelling them: that is, seeing them only as someone with a mental health problem. Are prepared to listen and to empathise (attempt to understand) their experiences. Listening and warm interest are likely to be as important as what the nurse says. Give small chunks of information at a time if the individual has difficulty in concentrating on what is being said. (Barker 2009, Stuart 2009) In a research study, Bowers (2002) found that some mental health nurses felt able to maintain therapeutic relationships with clients with aggressive behaviours, partly because they were able to see “the whole person”, and be prepared to understand the reasons for the behaviours. (These nurses cared for the minority of people whose mental health problems are associated with aggression). 8.1 Aids to Hearing, Vision and Speech Ensure that individuals have the following, if they need them: Hearing aids – and that these are working. Spectacles – and that these are appropriate for near sight or distance. Contact lenses – and that these are correctly and comfortably inserted. 4 .Hearing, and visual aids are essential for effective communication, and individuals’ self – esteem and ability to carry out everyday tasks. (Arnold and Ryan 2007) 8.2. Avoid Speaking Over the Individual and Ignoring Them It is good practice to avoid speaking to a colleague about matters that don’t involve the woman whilst providing care. An example would be to talk about your holiday to another midwife, but not communicating with the woman, whilst you are involved in undertaking observations in labour. 9 “Pregnancy Loss and the Death of a Baby” (Schott et al 2007) Midwives will sometimes work with parents whose baby has died at birth. Sands (Stillbirth and Neonatal Birth Charity) (2010) is an organization providing support for parents whose babies have died during pregnancy or at, or soon after, birth. This organization has published “Pregnancy Loss and the Death of a Baby: Guidelines for Professionals” (Schott et al 2007). Amongst many topics, these guidelines consider communication with the parents of children whose baby has died. Examples of both insensitive and helpful communication are given. “The [doctor]…knew my baby had died. But he didn’t say anything about it all. Just laughed and chatted as though nothing bad had happened”. This contrasted with: “Everyone we came in contact that night, the midwife, the [doctors]…, they were so fantastic. They took time to talk to me. And they really showed how upset they were”. “You need someone to just sit with you and talk you through all these difficult feelings…One midwife was very good: she’d come and sit with us and talk for a little while”. (Mothers quoted in Schott et al 2007, p35f) 10. Communication with women and their partners and relatives who are bereaved The points made by Schott et al (2007) about communication with bereaved parents are “Listen…and be prepared to listen again and again. “Treat parents as individuals and accept what they say without judgement. “Acknowledge their feelings and express empathy. “Remain calm when they express strong feelings. “Avoid platitudes…and empty reassurances…” (Schott et al 2007, p29) 5 Reading List and References Empathy, Active Listening and Other Communication Skills Bowers, L. (2002). Dangerous and Severe Personality Disorder: Response and Role of the Psychiatric Team. Routledge: London. Byrne, E.J. (1997). Acute and Sub-Acute Confusional States (Delirium) in Later Life. Chapter 10 in: Norman. I.J. and Redfern, S.J. (Eds.) (1997). Mental Health Care for Elderly People. New York. Churchill Livingstone. Byrt, R. and Doyle, M. 2007. Prevention and Reduction of Violence and Aggression. Chapter 5 in: National Forensic Nurses’ Research and Development Group: Kettles, A.M., Woods, P., Byrt, R.., Addo, M. A, Coffey, M. and Doyle, M (Eds.). 2007 “Forensic Mental Health Nursing: Forensic Aspects of Acute Care”. ” London. Quay Books, MA Healthcare, Ltd. Engebretson, J. (2004). Caring Presence: A Case Study. In: Robb, M., Barrett, S., Komaromy, C. and Rogers, A. (Eds.). (2004). Communication, Relationships and Care. A Reader. Routledge, Francis and Taylor Group/The Open University. Ferris - Taylor, R. (2007). Communication. In: Gates, B. (2007). (Ed.). Learning Disabilities: Toward Inclusion. Edinburgh. Elsevier. Forchuk, C. and Reynolds, W. (2001). “Clients’ Reflections on Relationships with Nurses: Comparisons from Canada and Scotland”. Journal of Psychiatric and Mental Health Nursing. 8, (1), 45-51. Ford, K., Byrt, R. and Dooher, J. (2010). Preventing and Reducing Violence and Aggression in Health and Social Care: A Holistic Approach. Keswick. M&K Publishing. Freeth, R. (2007). Humanising Psychiatry and Mental Health Care. The Challenge of the Person – Centred Approach. Oxford. Radcliffe Publishing. Gallop, R. and Tully, T. (2009). ”The Person who Self – Harms”. In: Barker, P. (Ed.). (2nd Ed.). (2009). Psychiatric and Mental Health Nursing. The Craft of Caring. London. Hodder Arnold. Keen, T. and Barker, P. (2009). The Person with a Diagnosis of Schizophrenia. In: Barker, P. (Ed.). (2009). (2nd Ed.) Psychiatric and Mental Health Nursing. The Craft of Caring. London. Hodder Arnold. Morris, G. (2006). Mental Health Issues and the Media: An Introduction for Mental Health Professionals. Routledge, Taylor and Francis Group: London. Morrison, P. (1997) Patients’ Experiences of Being Cared For. Chapter 6. In: Brykczynska, G. (Ed.) Caring. The Compassion and Caring of Nursing. London. Arnold. Parcell, D.A. (2010) Depression, anxiety and stress during pregnancy> Jounrla of Psychiatric and Mental Health Nursing.17, (9), 813-820. Rogers, C. (1990). A Client – Centred/Person – Centred Approach to Therapy. In: Kirschbaum, H. and Henderson, V.L. (Eds.). (1990). The Carl Rogers Reader. London. Constable. 6 Rogers, C. (2004). The Necessary and Sufficient Conditions of Therapeutic Personality Change. In: Robb, M., Barrett, S., Komaromy, C. and Rogers, A. (Eds.). (2004). Communication, Relationships and Care. A Reader. Routledge, Francis and Taylor Group/The Open University. Clients with Communication Problems Caused by Changes to the Structure and/or Functioning of the Brain Arnold, E. and Ryan, J.W. (2007). “Communicating with Older Adults”. In: Arnold, E. and Boggs, K. (Eds.). (2007) (5th Ed.). Interpersonal Relationships. Professional Communication Skills for Nurses. St. Louis, Missouri. Saunders Elsevier. Baldwin, C. and Capstick, A. (eds.). (2007). Tom Kitwood on Dementia: A Reader and Critical Commentary. Maidenhead. Open University Press. Bryan, K. and Maxim, J. (Eds.). (2006). Communication Disability in the Dementias. London. Whurr Publishers. Byrt, C. et al. (2003). Making Empowerment a Reality: A Personal Account. Chapter 13 in: Dooher, J. and Byrt, R. (Eds.) (2003). Empowerment and the Health Service User. Dinton, Salisbury. Quay Books, Mark Allen Publishing, Ltd. Cobley, M. (2002). Using Outdoor Spaces for People with Dementia. A Carer’s Perspective. Working with Older People. 6, (2), 23 – 30. Hayes, N, and Minardi, H. (2002). Abnormal Psychology in Old Age. In: Woodrow, P. (ed). (2002). Ageing. Issues for Physical, Psychological and Social Health. London. Whurr Publishers. Lovegrove, B. (2002). Good Neighbours: Help or Hindrance? Nursing Older People. 14, (6), 10 – 13. Neno, R. et al. (2007). Older People and Mental Health Nursing: A Handbook of Care. Oxford. Blackwell Publishing. Norman, I.J. (2010). Person – Centred Dementia Care. In: Redfern, S, J. and Ross, F.M. (Eds.) (2010). Nursing Older People. Edinburgh. Churchill Livingstone. Oddy, R. (2003). (2nd Ed.). Promoting Mobility for People with Dementia. A Problem Solving Approach. Chapter 2: “Making Communication Easier”. London. Age Concern. Redfern, S.J. and Ross, F.M. (2010). Nursing Older People. Edinburgh. Elsevier Churchill Livingstone. Reynolds, W. (2005). The Concept of Empathy. In: Cutcliffe, J.R. and McKenna, H.P. (Eds.). (2005). The Essential Concepts of Nursing. Edinburgh. Elsevier Churchill Livingstone. Richards, D., Clark, T. and Clarke, C. (Eds.). (2007). The Human Brain and Its Disorders. Oxford. Oxford University Press. Royal College of Physicians and College of Health. (1998). Stroke Rehabilitation. Patient and Carer Views. London. Royal College of Physicians of London. White, S.J. (1997). Empathy: A Literature Review and Concept Analysis. Journal of Clinical Nursing. 6, 4, 253 – 257. Comminication with People Who are Bereaved Kubler-Ross, E. (1970). On Death and Dying. London. Macmillan. Lugton, J. (2002). Communicating with Dying People and Their Relatives. Abingdon. Radcliffe Medical Press. 7 Sands (Stillbirth and Neonatal Birth Charity) (2010). Website. www.uk-sands.org/ Schott, J. et al. (2007). (3rd Ed.). Pregnancy Loss and the Death of a Baby: Guidelines for Professionals. Shepperton on Thames. Sands Stillbirth and Neonatal Death Charity/Bosun Press. Sweet, A. (1998). Taking the Trauma Out of a Crisis. Nursing Times. 94, (33), 26-28. 8