Kechi Iheduru-Anderson, DNP-c, MSN, RN, CWCN. Fall 2013 · PDF fileIdentify ways to employ culturally appropriate questions ... in working with clients from diverse cultural backgrounds

Kechi Iheduru-Anderson, DNP-c, MSN, RN, CWCN.

Fall 2013

Identify 4 reasons why effective communication is important for patient safety.

Be able to apply 3 facilitators of communication to a scenario.

Distinguish essential strategies for communicating effectively with co-workers.

Identify and address cultural barriers that may affect communication in patient-nurse relationships

Identify ways to employ culturally appropriate questions that effectively elicit patient information in the clinical encounter.

Apply communication techniques to resolve conflicts in culturally sensitive ways.

Identify the SBAR method as an evidence based model.

Apply a communication technique using case scenarios.

Majority of untoward events occurring in health care settings involve miscommunication (Haig , Sutton & Whittington, 2006).

Ineffective communication is implicated as the leading cause in medication errors, delays in treatment, perinatal deaths and injuries, and wrong site surgery, and is the second leading cause for restraints, suicides, and patient transfer related events.

Patient safety is improved when communication is clear, accurate, complete, and timely.

Joint Commission National Patient Safety Goals for 2008 emphasizes the importance of effective communicationo Improve the effectiveness of communication among caregivers

Communication involves a complex process of sending and receiving verbal

and non-verbal messages.

The communication process allows for the exchange of information,

feelings, needs, and preferences.

The goal of communication is a shared meaning with a mutual

understanding of the meaning of the message.

Feedback and responses from the receiver of the message indicate

whether or not the message was communicated as intended (CCNM, 2006).

Communication is influenced by cultural values, attitudes, and beliefs, and

has its roots embedded in culture.

Communication is a critical component of nursing practice.

The Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes [Massachusetts Department of Higher Education. (2010)]

KNOWLEDGE

o K1a Describes the principles of effective communication through various means.

ATTITUDES/BEHAVIORS

o Accepts responsibility for communicating effectively.

SKILLS

o S1a Utilizes clear, concise, and effective written, electronic, and verbal communications

o S1b Applies appropriate grammar, spelling, and health care terminology

o S1c Documents interventions and nursing outcomes according to professional standard and work unit policy

Knowledge

o K2b Understands the physiological, psychosocial, developmental, spiritual, and cultural influences on effective communication.

o K2c Describes the impact of one’s own communication style on others

Behavior

o B2b Promotes mutually respectful communication

o B2c Acknowledges individual cultural and personal diversity

o B2d Supports persons’ rights to make decisions in planning care.

Skills

o S2b Assesses the patient’s readiness/willingness to communicate

o S2c Assesses the patient’s ability to communicate

o S2e Assesses barriers to effective communication (language, developmental level, medical condition/disabilities, anxiety, learning styles, etc.)

The preceding two slides are not the NOF core competencies in its entirety.

Sources: o Massachusetts Department of Higher Education. (2010). Creativity and

Connections: Building the Framework for the Future of Nursing Education and Practice: Nurse of the Future Nursing Core Competencies. And

o Maine Partners in Nursing Education and Practice. (2013). The Maine Nurse: Nursing Core Competencies.

You can read more about the nurse of the future core competencies the knowledge, behavior and skills required for the entry level nurse by visiting http://www.mass.edu/currentinit/NiNofCompetencies.asp OR

http://www.mass.edu/currentinit/currentinitNursingNurseFutureComp.asp OR

http://www.mainenursepartners.com/competencies.html

Communication is a broad term and includes the way people interact through written or oral language, gestures, facial expressions, body language, space, or other symbols.

Communication is the means by which culture is transmitted and preserved.

Both verbal and nonverbal communication are learned in one’s culture.

Communication often presents the most significant problem in working with clients from diverse cultural backgrounds (Giger

& Davidhizar, 2002).

“Effective communication :Effective communication is

communication that is comprehended (understood) by both

participants (the sender and the receiver); it is usually

bidirectional between participants, and enables both

participants to clarify the intended message” (Schyve, 2007, p. 360).

In the absence of comprehension, effective communication

does not occur; when effective communication is absent,

the provision of health care ends or proceeds only with

errors, poor quality, and risks to patient safety.

Oral/Verbal

•The most used form of communication.

•Done by phone or face-to-face. Requires good listening and speaking skills.

Written

•Written signs or symbols are used to communicate. May be printed or hand written

• via email, letter, report, memo. Iinfluenced by the vocabulary & grammar used, writing style, precision and clarity of the language used

Nonverbal

• The sending or receiving of wordless messages. It is all about the body language of speaker.

•Often, nonverbal signals reflects the situation more accurately than verbal messages.

Verbal communication is the conscious use of spoken or written word with the choice of words reflecting age, education, developmental level, and culture of the sender. o Feelings can be expressed through tone, pace, etc.

Written communication is the ability to write effectively in a range of contexts and for a variety of different audiences and purposes, with a command of the language being used. This includes the ability to tailor your writing to a given audience, using appropriate styles and approaches. It also encompasses electronic communication such as SMS, email, discussion boards, chat rooms and instant messaging.

Non-verbal communication is the ability to enhance the expression of ideas and concepts without the use of coherent labels, through the use of body language, gestures, facial expression and tone of voice, and also the use of pictures, icons and symbols.

Non-verbal communication makes up 85% of all communication, is less conscious than verbal communication.

The interesting fact about nonverbal communication is that it reflects a more accurate description of one's true feelings because nonverbal reactions cannot be controlled easily by the people. Nonverbal communication may include:

Body languageo Physical appearance,. Such as choice of color, clothing, hairstyles and other

factors affecting appearance are considered a means of nonverbal communication.

o Posture/Position and movement

o Facial expression

o Eye contact – solid with a 'smiling' face.

o Gestures with hands and arms – purposeful and deliberate.

o Speech– slow and clear.

o Vocal cues/Tone of voice – moderate to low.

o Distance or spatial territory (personal space)

o Touch

Nonverbal communication cues can play five roles:

o Repetition: they can repeat the message the person is making verbally

o Contradiction: they can contradict a message the individual is trying to convey

o Substitution: they can substitute for a verbal message. For example, a person's eyes can often convey a far more vivid message than words and often do

o Complementing: they may add to or complement a verbal message. A boss who pats a person on the back in addition to giving praise can increase the impact of the message

o Accenting: they may accent or underline a verbal message. Pounding the table, for example, can underline a message.

(Wertheim, 2008).

Silence can be uncomfortable for some Americans, but some persons in Asian cultures may view silence as a sign of respect, particularly toward elders.

“Nurses need to be aware of possible meanings of silence so that personal anxiety does not promote the silence to be interrupted or to be non-therapeutic” (Giger & Davidhizar, 2004, p. 30).

Facial expression, posture, and proximity can punctuate the spoken message.

“Transcultural communication and understanding break down when caregivers project their own culturally specific values and behaviors onto the client” (Giger and Davidhizar, 2004, P. 27).

Arms crossed on chest : Defensive/ Closed

Biting Nails: Insecurity /Nervousness

Pulling or Tugging at ear: Indecision

Sitting, legs apart : Open /Relaxed

Checking The Time / Fiddling with your fingers : Boredom

Looking down while speaking: Low self-confidence / Disinterest

Repeatedly shifting Body Weight from Foot to Foot: Mental/Physical Discomfort

This list is not exhaustive. Your body gives a lots of cues which cannot be documented or easily interpreted.

People from different cultures perceive happy, sad or angry facial expressions in unique ways,

It is important to understand cultural differences in communication

Body language and styles and types of feedback may be unique to certain cultural groups (Giger & Davidhizar, 2004, p. 24).

Many Americans value eye contact as a symbol of attentiveness and sincerity especially during conversation.o So they may interpret a lack of eye contact as shyness, rudeness,

dishonesty, or a “leave me alone” message.

Other cultural groups find eye contact difficult including some Asian people, some American Indians, and young people from the West African countries who relate eye contact to impoliteness, and an invasion of privacy.

“Many American Indians regard eye contact as disrespectful” (Giger

& Davidhizar, 2004, p. 33).

Physical/environmental barriers: Physical Barriers Noise

Time and Distance Age Defects in medium / channels

Personal barriers

Physiological barriers

Psychological barriers

Semantic/Linguistic Barriers

Social/cultural Barriers: Race/Ethnicity, Gender, and

Socioeconomic Status.

Organizational Barriers

•Poor Listening Skills, Information Overload, Inattention, Emotions, Poor RetentionPhysiological Barrier

•Physical distractions are the physical things that get in the way of communication. Telephone, an uncomfortable meeting place, and noise.

•Distractions such as background noise, poor lighting, uncomfortable sitting, unhygienic room.

Physical and Environmental Distractions

•Psychological factors such as misperception, filtering, distrust, unhappy emotions, and people's state of mind can jeopardize the process of communication.

•Past Experience

Psychological Barrier

•Social factors such as age, gender, socioeconomic status, and marital status may act as a barrier to communication in certain situations.

•Culture shapes the way we think and behave. Cultural difference leads to difference in interest, knowledge, value, and tradition.

Social/cultural Barriers

•Language, jargon, slang, etc., are some of the semantic barriers.

•Individual linguistic ability may sometimes become a barrier to communication.

•The use of difficult or inappropriate words in communication can prevent the people from understanding the message.

Semantic/Linguistic Barriers

•Unclear planning, structure, information overload, timing, technology, and status difference are the organizational factors that may act as barriers to communication.

Organizational Barriers

•Unclear messages in terms of meaning, grammar, and words may act as a barrier to communication. Stereotypes are beliefs or generalizations about characteristics or qualities

•Inappropriate communication channel, Lack of feedback

Message related Barriers

Culture

•One’s culture affects one’s understanding of a word or sentences and even one’s perception of the world

Language

•The choice of words or language in which a sender encodes a message will influence the quality of communication.

•Language differences themselves are a barrier to effective communication

•Limited English proficiency

Interaction style

•Lack of structure and standardization for communication

•Excessive use of abbreviations and acronyms

Health literacy

•Low health literacy is a barrier to effective communication

•health literacy incorporates a range of abilities: to read, comprehend, and analyze information; decode instructions, symbols, charts, and diagrams; weigh risks and benefits; and, ultimately, make decisions and take action.

Organizational culture

•Organizational culture that discourages open communication. Complexity in Organizational Structure

•Lack of defined roles and responsibilities among members of multidisciplinary teams

•Time pressures and workload.

•Unclear planning, structure, information overload, timing, technology, and status difference are the organizational factors that may act as barriers to communication.

Effective communication requires deciphering or interpreting the basic values, motives, aspirations, and assumptions that operate across cultural lines.

Communicating across cultures is challenging.

Given some differences across cultures in approaches to such areas as time, space, and privacy, there are several opportunities for miscommunication while engaged in crosscultural situations.

Nonverbal cues can differ dramatically from culture to culture. Behaviors can mean several different things for people from different cultural backgrounds.

So it is important to take age, culture, religion, gender, and emotional state into account when reading body language signals.

Perceptual Biases: stereotyping and projection, Stereotyping is

one of the most common. This is when we assume that the other

person has certain characteristics based on the group to which

they belong without validating that they in fact have these

characteristics.

When it comes to communication, what's proper and correct in

one culture may be ineffective or even offensive in another. In

reality, no culture is right or wrong, better or worse—just different.

The key to successful cross-cultural communication is to develop

an understanding of, and a deep respect for, the differences.

Perceptions

Values

Emotions

Socio-cultural background

Knowledge

Role and relationships

Environment

Space and time

Attitude: Attitude is referred to the internal predisposition of a person to act in a certain way toward a situation. The attitude of a person toward the given situation is influenced by the peers, parents, environment, life experiences, perception, and intellectual processes. A person may have the attitude of accepting, prejudiced, judgmental, negative, open and close, etc.

Sociocultural Background: Various cultures and ethnic groups display different communication patterns.

Past Experiences: Previous positive or negative experiences influence one's ability to communicate. For example, teenagers who have been criticized by parents whenever attempting to express any feelings may develop a poor self-image and feel that their opinions are not worthwhile. As a result, they may avoid interacting with others, become indecisive when asked to give an opinion, or agree with others to avoid what they perceive to be criticism or confrontation (nonassertive).

Knowledge of Subject Matter: A person who is well-educated or knowledgeable about certain topics may communicate with others at a high level of understanding. The receiver who is relatively less knowledgeable of the topic under discussion may be unable to comprehend the message or consider the sender to be an expert. As a result of this misperception, the receiver may neglect to ask questions and may not receive the correct information. For example, nurses are required to communicate with the patient in a language that is understandable to the patient (patient's native language). She is also required not to use jargons while delivering health education or some other useful information to the patient. The educational status of the patient must be taken into consideration while communicating with the patient.

Ability to Relate with Others: Some people are “natural-born talkers” who claim to have “never met a stranger.” Others may possess an intuitive trait that enables them to say the right thing at the right time and relate well to people. “I feel so comfortable talking with her,” “She is so easy to relate to,” and “I could talk to him for hours” are just a few comments made about people who have the ability to relate well with others. These persons are considered as good communicators.

Interpersonal Perception: Interpersonal perceptions are mental processes by which intellectual, sensory, and emotional data are re-organized logically and meaningfully, which determine how we perceive others. Inattentiveness, disinterest, or lack of use of one's senses during communication can result in distorted perceptions of others.

Environmental Factors: Environmental factors such as time, place, number of people present, and noise level can influence communication between people in that particular surrounding. Timing is important during a conversation; a very well-timed response catches the attention of others. The place in which communication occurs, as well as the number of people present and noise level, has a definite influence on interactions among people

Source: Review of communication process. Communication and nursing education. From http://my.safaribooksonline.com/book/...1...communication.../ch1_6_xhtml

Breakdowns in communication in healthcare are

reported to occur due to;

o Human factors; attitudes, behaviors, morale, memory

failures, stress and fatigue of

o staff.

o Distractions and interruptions.

o Shift changes.

o Gender, social and cultural differences.

o Hierarchy or power distance relationships (for example,

junior staff are reluctant to report or question senior

staff).

Difference in training of doctors, nurses and paraprofessionals.

Time pressures and workload.

Limited ability to multitask even when highly skilled.

Lack of a shared mental model regarding what is to be achieved.

Lack of organization policies and / or protocols.

Organizational culture that discourages open communication.

Lack of defined roles and responsibilities among members of multidisciplinary teams

Elements of effective

communication

Clear

Concrete

Concise

Complete

Correct/Accurate

Courtesy and consideration

Complete: The message must be complete in all respect and should convey all facts required by the receiver. It answers all questions asked to a level that is satisfactory to those involved in the exchange of information.

Concise: Wordy expressions are shortened or omitted. It includes only relevant statements and avoids unnecessary repetition. communicating what you want to convey in least possible words without forgoing the other C's of communication. Conciseness is a necessity for effective communication.

Concrete: The words used mean what they say; they are specific and considered. Accurate facts and figures are given.

Clear: Short, familiar, conversational words are used to construct effective and understandable messages. Clarity in communication makes understanding easier and enhances the meaning of a message. A clear message uses exact, appropriate, and concrete words and avoids ambiguous words.

Correctness/Accurate: The level of language is apt for the occasion; ambiguous jargon is avoided, as are discriminatory or patronizing expressions (Victoria Quality Council, 2010). Correctness in communication implies that there are no grammatical and spelling errors in communication.

Courtesy/Consideration: The message should show the sender's expression as well as respect to the receiver. The sender of the message should be sincerely polite, judicious, reflective, and enthusiastic. Effective communication must take the receiver/s into consideration. The sender should make an attempt to understand the audience, their requirements, emotions, as well as problems. Ensure that the self-respect of the audience is maintained and their emotions are not hurt.

The Joint Commission reports that investing to improve

communication within the healthcare setting can lead to:

o Improved safety.

o Improved quality of care and patient outcomes.

o Decreased length of patient stay.

o Improved patient and family satisfaction.

o Enhanced staff morale and job satisfaction

Recognize Complexity in Language Interpretation

Speaking a client’s language is essential, but it does not always guarantee effective communication between the client and the provider.

Communication is more than simply shared language; it must also include a shared understanding and a shared context as well (Health

Resources and Services Administration (HRSA), 2001).

Recognizing the linguistic variation within a cultural group;

Recognizing the cultural variation within a language group; and

Recognizing the variation in literacy levels in all language groups (HRSA, 2001).

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. [Healthy People 2010] .

Health literacy is defined by the United States Department of Health and Human Services (2000) as : “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

Health literacy incorporates a range of abilities: reading, comprehending, and analyzing information; decoding instructions, symbols, charts, and diagrams; weighing risks and benefits; and, ultimately, making decisions and taking action.

The concept is comprised of two components:

o a capacity within the individual to understand words, phrases and

concepts

o the nature or clarity of the health information that is being conveyed

Thus, health literacy is dynamic and situational. It includes

oral and written communication, as well as the ability to act

upon the information.

Strategies to Enhance Health Literacy

There are a number of strategies that can be employed to

enhance an individual’s health literacy.

For oral communication:

o use plain language

o speak slowly

o provide small amounts

o reinforce with written materials with key points circled

Literacy is the ability to read, write, and speak English and to compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential (National Literacy Act of 1991).

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (IOM, 2004).

o This includes the ability to understand instructions on prescription bottles, appointment slips, medical education brochures, consent forms, and the ability to negotiate complex health systems.

o literacy skills are a stronger predictor of health status than age, income, employment status, education level, and racial or ethnic group.

Health literacy is "the ability to read, understand, and use

health information to make appropriate health care decisions

and follow instructions for treatment."

The most important factor in health literacy is an individual's

general literacy, or "ability to read, write, and understand

written material." Other factors that contribute to health

literacy include:

o Amount of experience in the health care system;

o Complexity of information being presented;

o Cultural factors that may influence decision making; and

o How material is communicated.

The CDC online health literacy training for health professionals.

o “The goal of Health Literacy for Public Health Professionals is to introduce participants to the fundamentals of health literacy and demonstrate the importance of health literacy within public health practice.

o This course will challenge you to think about the significance of health literacy in the work you do as a public health professional. The course also provides practical steps to apply the principles and strategies of health literacy in your daily activities.”

The take the CDC online health literacy visit

http://www.cdc.gov/healthliteracy/training/index.html

Plain language is a strategy for making written and oral

information easier to understand.

It is one important tool for improving health literacy.

Key elements of Plain Language include:

o Organizing information so that the most important points come first;

o Breaking complex information into understandable chunks;

o Using simple language and defining technical terms; and

o Using the active voice. (NIH, 2013)

The following link is a computer-based plain language training from National Institute of Health (NIH).

http://www.plainlanguage.gov/resources/take_training/index.cfm

“The NIH offers a free plain language internet-based training that introduces you to the basics of plain language. It not just for medical folks. The goal of this training is to help you learn to organize your ideas, use a clear writing style, and become a more effective communicator.”

For the NIH Plain language training go to

http://plainlanguage.nih.gov/CBTs/PlainLanguage/login.asp

You will be asked to create a pass word and login to take the course.

The link below provides a short video link to On HRSATube

discussing how effective healthcare communication

contributes to health equity

o Cultural Competence Resources for Healthcare Providers

For more information on health literacy go to Quick Guide to

Health Literacy:

http://www.health.gov/communication/literacy/quickguide

/factsbasic.htm

President Barack

Obama signed the

Plain Writing Act of

2010 (H.R. 946/Public

Law 111-274) on

October 13, 2010.

TRANSLATION refers to the written word, indicating materials written in one language are translated into another.o When casually or improperly performed, this strategy can result in misuse

of some terms or misunderstanding of contextual information in the new language.

INTERPRETATION refers to the spoken word, indicating a conversation between two speakers is interpreted from one language into another by a third party (this includes sign language).o For example: family members were frequently unwilling to give bad medical

news to a relative, or to ask personal questions, or to relay embarrassing responses back to the provider.

MEDICAL INTERPRETATION is the ability to interpret the spoken conversation between provider and client within the medical context, with a specific emphasis on the ability to use and explain medical terms in both languages.

Translation involves the transfer of written language from one language (idiom) to another.

Interpretation is the transfer of verbal communication from one language to another.

Who Needs and interpreter?

o There is a growing number of persons who speak English “less than well” or who are “Limited English Proficient” (LEP)

An LEP individual is a person who;

o Does not speak English as their primary language

o Has a limited ability to read, write, speak or understand English

As a Result of Changing Demographics

To Abide by Regulatory Requirements

To Manage Risk

To Ensure Quality Service

According to American Academy of Pediatrics:

o The Untrained Interpreter makes an average of 31 errors during a

15 minute encounter

o 63% of the errors made have clinical consequences

Working with Interpreters: In this video, you will learn some

basic tips that will allow you to communicate effectively and

easily through an interpreter with a person who doesn't

speak your language.

http://www.youtube.com/watch?v=pVm27HLLiiQ

Language Assistance- Your Right to an Interpreter: This

video will explain your rights to language assistance when

accessing services from a government agency or federally

funded organization.

http://www.youtube.com/watch?v=eNC7JGqBfdw

When sharing information with patients consider the following;

o What is the patient/client preferred way of getting information

o Preferred language

o Preferred method of learning

o Literacy level

o Material and training approaches

• What language does the patient speak at home?

• What is the patient's fluency level in English?

• Does the patient need an interpreter?

• What are the patient's styles of nonverbal communication?

Nurses need to assess the cultural or social factors of their

individual patients instead of relying on generalizations

about specific ethnic groups.

Using transcultural communication techniques can help

nurses with this individual assessment.

The following slides provide basic transcultural

communication techniques from (Muñoz/Luckmann, 2005)

Approach a new patient slowly: When first meeting a new patient, approach slowly and wait for the patient to acknowledge you.

Greet the patient respectfully: Refer to the patient by title (Dr., Mr., Mrs.) and last name rather than by first name. Make sure that you are pronouncing the patient’s name correctly.

Provide the patient with a quiet setting: Provide the patient with a quiet setting where you will not be disturbed. If the patient is confined to bed, draw the curtains completely around the bed to provide privacy. Patients from some cultures may want their family present.

Sit a comfortable distance away and lean slightly towards the patient: Do not interrupt the patient. Avoid changing the subject. Nod occasionally; ask pertinent questions to draw the patient out; and—with gestures and facial expressions—indicate that you accept the patient’s feelings of anxiety, fear, or anger.

Allow sufficient time for your meeting: Try not to appear rushed or anxious to leave. Avoid fidgeting or looking at the clock. A hurried attitude on your part could offend

If your patient seems uneasy: Pull up a chair and position yourself parallel to and lower than the patient. This position helps the patient feel more in control. You may also appear to be more supportive.

o Explain: Explain to patients (especially those who are nervous or fearful) that they can and need to speak freely to you about their symptoms and fears.

Listen: Listen to what your patients are trying to tell you about their symptoms. Listen with particular care to the words a patient uses to describe a symptom. Then use those same terms, rather than medical jargon, when discussing symptoms with that patient.

Component Description

Assessment

Focus on cultural aspects of clients’

lifestyles, health beliefs, and health

practices

CommunicationBecome aware of variations in verbal and

nonverbal responses

Cultural negotiation and compromise

Become more aware of aspects of other

people’s cultures and of understanding

clients’ views and explaining their

problems

Establishing respect and rapportPortray genuine respect for clients’

cultural beliefs and values

SensitivityDeliver diverse, culturally sensitive care to

culturally diverse groups

SafetyEnable clients to derive a sense of cultural

safety

The BATHE model provides a useful mnemonic for eliciting the psychosocial context of the patient's experience with illness through asking simple questions about background, affect, trouble, and handling, and expressing empathy (Stuart & Lieberman, 1993).

o Background: The simple question "What is going on in your life?" elicits the context of the patient's visit.

o Affect: Asking "How do you feel about what is going on?" or "What is your mood?" allows the patient to report and label the current feeling state.

o Trouble: "What about the situation troubles you the most?" helps the nurse and patient focus and may reveal the symbolic significance of the illness or event.

o Handling: "How are you handling that?" gives an assessment of functioning and provides direction for an intervention.

o Empathy: "That must be very difficult for you" recognizes the patient's feelings and provides psychological support.

The LEARN model suggests a framework for listening, explaining, acknowledging, recommending, and negotiating health information and instructions (Berlin & Fowkes, 1983).

o Listen with sympathy and understanding to the patient's perception

of the problem.

o Explain your perception of the problem.

o Acknowledge and discuss differences and similarities.

o Recommend treatment.

o Negotiate agreement.

Language barriers present many challenges to the health care system.

These challenges include;

o misdiagnosis,

o decreased access to care at several entry points, from having health insurance to receiving basic, preventive, and specialty care.

o decreased patient comprehension of diagnosis, treatment and follow-up care resulting to;

• improper use of medication

• reduced quality of care, and can lead to serious complications and adverse clinical outcomes.

• increased health care costs due to inefficiencies such as unnecessary testing

A call from the mother and sister of a Spanish-speaking

man reported that he was “intoxicado.” Paramedics and

hospital personnel incorrectly interpreted this as intoxicated

or drunk, and therefore, left him alone, offering no

treatment. It turned out the man was actually having a

stroke, and this mistake resulted in him being paralyzed.

After settling out of court, the health care institution was

required to pay $71 million (Grantmakers In Health, 2003, used with copyright permission from Grantmakers In Health as cited in

CCNM, 2006).

Interpreter services should be provided when patients have

o Limited English Language proficiency (LEP),

o Hearing loss, or

o other characteristics that would make it hard for them to hear or

understand conversation, instructions, advice, or other oral

communication with health care providers or members of the health

care team.

o LEP status includes a limited ability to read, speak, write, or

understand English (Office of Civil Rights, 2003).

Patient &

Family

Rapport

Empathy

Support

PartnershipExplanation

Cultural competence

Trust

Ra

pp

ort

Connect on a social level.

Consciously suspend judgment.

See patients point of view

Consciously suspend judgment

Recognize and avoid making assumptions

Empathy

Remember that the patient has come to you for help.

Seek out and understand the patient’s rational for his/her behaviors or illness.

Verbally acknowledge and legitimize the patient’s feelings.

•Ask about and understand the barriers to care and compliance

•Help the patient overcome barriers.

• Involve family members if appropriate

•Reassure the patient you are and will be available to help

Support

Be flexible with regard to control issues.

Negotiate roles when necessary.

Stress that you are working together to address health problems.

Use verbal clarification techniques.

Check often for understanding.

Explanations

Respect the patient’s cultural beliefs.

Understand that the patient’s view of you may be defined by ethnic or cultural stereotypes.

Be aware of your own cultural biases and preconceptions.

Know your limitations in addressing medical issues across cultures.

Understand your personal style and recognize when it may not be working with a given patient.

Recognize that self-disclosure

may be difficult for some patients.

Consciously work to establish trust.

Tips to Improve Communication with Patients:

o Recognize that patients rely on their listening skills to compensate

for poor reading skills.

o Speak clearly, slowly, and with appropriate vocabulary, and avoid the

use of medical jargon.

o Verify a patient’s understanding by having them repeat what they

are to do and why.

Get the Patient Encounter Off to a Good Start

Monitor Your Body Language

Practice Effective Listening Skills

Ask Questions That Yield Information and Offer Support

Give Answers That Will Be Understood

Partner with Your Patient

Develop Cultural Competency

Provide Motivational Counseling

From Association of Reproductive Health Professionals (ARHP) at http://osbhcn.org/files/Patient%20Communication.pdf

To effectively communicate with your patients across cultural lines,

You need to critically examine your own beliefs and assumptions and continually monitor them.

One way of doing so is to use the self-assessment checklist presented in this module.

It is important to treat the patients based on your knowledge of their culture and direct experience with them rather than on what you have heard about them. o In other words, self-awareness of your assumptions and stereotypical

beliefs can help you alleviate differential treatment of your patients.

Remember that every encounter is a cross-cultural

encounter in health care.

Never make the assumption that patients who look like you

share your beliefs and practices.

Principles of patient-centered care should be applied to all

patients to encourage individuals to become an active

partner in their own health care.

Breakdown in communication was the leading root cause of sentinel events

Miscommunication plays an important role in medical errors and jeopardize patient safety.

Communication in clinical setting is highly complex and prone to error especially during patient care transitions and emergent situations.

Standardized approaches and tools may provide potential solutions to improve the quality of communication and prevent subsequent patient harm.

The use of Situation, background, assessment, recommendation (SBAR) model can facilitate effective communication among caregivers

SBAR model is a form of structured situational briefing tool.

S: situation [what you’re seeing or assessing? What is happening now, chief complaint,

acute change?].

B: background [how did the situation come about? What do you see, what do you think

is going on? What factors led to this event? Vital signs, pertinent history.].

A: assessment [what you saw or assessed that concerned you? What do you see, what

do you think is going on?], and

R: recommendation [what you think should be done? What action do you propose?

What do you think I should do?] (Monroe, 2006).

Situation: What is going on with the patient at the present time?

Background: What has happened?

o What circumstances led to this situation?

Assessment: What are the current assessment findings and how

do these findings differ from the prior shift report and recent

progress notes?

Recommendation: What action, recommendation or steps need

to occur in order to correct the current problem?

o In what time frame does this action, recommendation or steps need to

occur?

SBAR allows the nurse to express an assessment of the patient’s problem(s) in an organized, concise manner.

SBAR is a tool that will help the nurse become more organized and confident when discussing patient healthcare with other healthcare providers

SBAR helps the nurse organize information and deliver message in a consistent and concise process so that relevant information is communicated in an unemotional effective, efficient and clear manner.

It bridges the communication gap between healthcare providers and between healthcare providers and family.

SBAR creates a shared mental model for effective information transfer by providing a standardized structure for concise, factual communications among clinicians.

SBAR is memory prompt; easy to remember and encourages prior preparation for communicationo Inpatient or outpatient

o Urgent or non urgent communications

o A nurse is calling a physician

o Conversations with peers

o - e.g. Change of shift report

o Nurses are transferring patients to other facilities or to other units or levels of care

o Discussions with allied health professionals

o - e.g. Respiratory therapy - e.g. Physiotherapy etc.

o Handover from an ambulance crew to hospital or nursing home staff

o administrative team meetings and

o administrative team meetings and

The following is an example of an SBAR communication

between a nurse and a physician regarding a patient

condition change.

S: Dr. West, my name is Nancy Smith and I am the RN

taking care of your patient Sally Strait, DOB 12/10/47 who

is here for a GI bleed. Currently, she is complaining of chest

pain, looks pale and is diaphoretic.

B: Ms. Strait received 2U PRBC this am. At 2pm, she had a HCT drawn and the result was 31. Her vital signs are BP-88/52, P - 118, R – 22. Pain = 7 on a scale of 10. I applied O2 at 2L/M Via nasal cannula moments ago.

A: It appears the patient may be having internal bleeding or perhaps an MI, but I think additional tests need to be done to know for sure.

R: I would like an order for an EKG, H&H, something for increased pain and I need you to evaluate her right away. What questions do you have for me?

S: Dr. West, my name is Nancy Smith and I am the RN

taking care of your patient Joe Coffey, DOB 10/1/28. Joe

fell moments ago and now is complaining of excruciating

pain in the right hip area.

B: Joe was admitted 3 days ago s/p open chole and earlier

he got up to go to the bathroom without assistance and lost

his balance. His surgical incision has no signs of injury or

new bleeding. His vital signs are BP- 138/92, P-92, R- 16

and Pain = 9 on a scale of 10. His right foot is rotated

inward.

A:It appears he may have fractured his hip. He also only has oral pain meds at this time and I think something I.M. for now would be helpful.

R: I would like an order for a right hip x-ray, an orthopedic consult now and additional I.M. pain medication while he waits for the consultation. What questions do you have for me?

o Adopted from Arizona Hospital and Healthcare Association patient safety initiative SBAR toolkit.

o For more examples on use of SBAR visit http://www.azhha.org/patient_safety/documents/SBARtoolkit_001.pdf

The following link have more information, video clips, and tutorial

on how to effectively use SBAR in different settings and scenarios

from NHS Institute for innovation and improvement.

http://www.institute.nhs.uk/safer_care/safer_care/Situation_Ba

ckground_Assessment_Recommendation.html

http://www.institute.nhs.uk/quality_and_service_improvement_t

ools/quality_and_service_improvement_tools/sbar_-_situation_-

_background_-_assessment_-_recommendation.html

http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCo

mmunicationASituationalBriefingModel.aspx

T: Talk to each other

A: Act together to care for our residents, patients, and families

L: Listen to each other

K: Know and understand each other

TALK

Pay Attention: Put the focus of attention totally on the speaker.

Repeat conversationally and tentatively, in your words, your understanding of the speaker's meaning (paraphrase the speakers comment). This will help the speaker hear and understand his or her own meaning.

Keep the posture open.

Lean forward toward the client

Feed back feelings, as well as content.(Probe, if appropriate e.g. ''How do you feel about that?" or "How did that affect you?")

Allow silences in the conversation. Silence during communication process can carry a variety of meanings. It provides an opportunity to the communicator to explore his/her inner thoughts or feelings comfortably that will be required to facilitate the communication.

Give the speaker your undivided attention, and acknowledge the message.

Recognize that non-verbal communication also "speaks" loudly.

Look at the speaker directly.

Concentrate on what the other person is saying.

Put aside distracting thoughts.

Don't mentally prepare a rebuttal!

Avoid being distracted by environmental factors. For example, side conversations.

"Listen" to the speaker's body language. Inconsistency in verbal and nonverbal communication by the sender may lead to confusion and misunderstanding of the message on the part of the receiver

Use your own body language and gestures to convey your attention.

Nod occasionally.

Smile and use other facial expressions.

Note your posture and make sure it is open and inviting.

Encourage the speaker to continue with small verbal comments like yes, and uh huh.

Our personal filters, assumptions, judgments, and beliefs can distort what we hear.

As a listener, your role is to understand what is being said.

Restating what the other person said and showing him that you’re listening

his may require you to reflect what is being said and ask questions.

Reflect what has been said by paraphrasing. ("What I'm hearing is," and "Sounds like you are saying," are great ways to reflect back.)

Ask questions to clarify certain points. ("What do you mean when you say." "Is this what you mean?“)

Summarize the speaker's comments periodically.

Interrupting is a waste of time.

It frustrates the speaker and limits full understanding of the

message.

Allow the speaker to finish each point before asking

questions.

Don't interrupt with counter arguments.

Active listening is a model for respect and understanding.

You are gaining information and perspective.

You add nothing by attacking the speaker or otherwise putting him or her down.

Be candid, open, and honest in your response.

Assert your opinions respectfully.

Treat the other person in a way that you think he or she would want to be treated.

Avoid patronizing comments and statements.

It takes a lot of concentration and determination to be an active listener.

Be deliberate with your listening and remind yourself frequently that your goal is to truly hear what the other person is saying.

Set aside all other thoughts and behaviors and concentrate on the message.

Ask questions, reflect, and paraphrase to ensure you understand the message.

If you don't, then you'll find that what someone says to you and what you hear can be amazingly different!

To learn more about active listening go to http://www.mindtools.com/CommSkll/ActiveListening.htm

How Good a Listener are You? Visit Newline ideas to take a

quick quiz about your listening skills.

http://www.newlineideas.com/listening-skills-quiz.html

Listening Actively: Listening actively means to be attentive to what the other person is saying verbally and nonverbally.

Use Silence: Silence during communication process can carry a variety of meanings.

Observe Nonverbal Behavior of the Client

Tone and Words

Be Consistent Verbally and Nonverbally: Inconsistency in verbal and nonverbal communication by the sender may lead to confusion and misunderstanding of the message on the part of the receiver

Ask Open-ended Questions: Open-ended questions encourage the client to communicate more and more, whereas, close-ended questions discourage the communication.

Use Language Understood by the Patient

Restating and Paraphrasing: Let the client know whether an expressed statement has or has not been understood.

Reflecting: This directs questions or feelings back to client so that they may be recognized and accepted.

Focusing: This takes notice of a single idea or even a single word. For example, “You told me that, your father was suffering from a chronic illness, which type of chronic illness it was?” Here, the nurse is focusing on chronic illness as mentioned by the client about his father.

Exploring: This delves further into a subject, idea, experience, or relationship. For example, “You told me that your father was not a good person, why do you think so?”

Seeking Clarification and Validation: Strive to explain what is vague and search for mutual understanding

Encouraging Description of Perceptions: Ask the client to verbalize what is being perceived.

Making Observations: Verbalize what is observed or perceived.

Jefferson InterProfessional Education Center. (nd). InterprofessionalCommunication SBAR Module. Retrieved October 3, 2013 from http://jeffline.jefferson.edu/jcipe/learning/didactic_files/SBAR%20IPE%20teaching%20plan%20v2.pdf

COMMUNICATING WITH PATIENTS: A Quick Reference Guide for Clinicians. Association of Reproductive Health Professionals (ARHP) http://osbhcn.org/files/Patient%20Communication.pdf

Coping with differences in culture and communication in health care. Nursing Standard. http://rcnpublishing.com/doi/pdfplus/10.7748/ns2008.11.23.11.49.c6726

Factors Influencing Communication from Review of communication process. Communication and nursing education. Retrieved December 5, 2013 from http://my.safaribooksonline.com/book/medicine/9789332501461/chapter-1-review-of-communication-process/ch1_6_xhtml#X2ludGVybmFsX0h0bWxWaWV3P3htbGlkPTk3ODkzMzI1MDE0NjElMkZjaDFfOV94aHRtbCZxdWVyeT0=

Visit Institute for Healthcare Improvement (IHI) to read

Noah’s Story: Are You Listening?

Recognize the importance of clear communication with

patients and their families during a care experience.

Go to

http://www.ihi.org/offerings/IHIOpenSchool/resources/Pag

es/NoahsStoryAreYouListening.aspx or

http://www.ihi.org/offerings/IHIOpenSchool/resources/Doc

uments/Participant_Noah's%20Story.pdf

A sentinel event is an unexpected occurrence involving

death or serious physical or psychological injury, or the risk

thereof.

For more information on Sentinel events visit

http://www.jointcommission.org/Sentinel_Event_Policy_an

d_Procedures/ or

www.jointcommission.org/SentinelEvents/Statistics/

Idioms, eye contact, dialects, pacing, style of conversation

(e.g., the meaning of a loud voice or ‘‘no’’), indirect

answers, and nonverbal communication all contribute to the

fear of speaking the language. Solutions to this problem are

recommending to foreign nurses to practice speaking

English as much as possible in all settings and to adopt the

nonverbal behavior of U.S. communication such as smiling

and making eye contact while talking.

Davidhizar, R., Bechtel, G. & Giger, J.(1998). A model to enhance culturally competent care. Hospital Topics. 76, 22–26.

Health Resources and Services Administration (HRSA), (2001). Cultural Competence Works.

Giger, J., & Davidhizar, R. (2002). The Giger and Davidhizar Transcultural Assessment Model. Journal Of Transcultural

Nursing, 13(3), 185-188.

Giger, J.N., & Davidhizar, R.E. (2004). Transcultural nursing: Assessment & intervention (4th ed.). St. Louis, MO: Mosby.

Schyve, P. (2007). Language differences as a barrier to quality and safety in health care: the Joint Commission

perspective. Journal Of General Internal Medicine, 22 Suppl 2360-361

National Institutes of Health (NIH), (2013). Clear Communication: An NIH Health Literacy Initiative

Haig, K. M., Sutton, S. & Whittington, J. (2006). National Patient Safety Goals SBAR: A shared mental model for improving

communication between clinicians. Joint Commission Journal on Quality and Patient Safety 32(3), 167-75.

Monroe, M. (2006). SBAR: A Structured Human Factors Communication Technique. Health Beat, 5(3). Retrieved October

26, 2013 from www.asse.org/.../HealthBeat_Newsletter_Spring2006%20for%20Web.pdf

Arizona Hospital and Healthcare Association ( 2013). SBAR Communication Standardization in Arizona. Retrieved

October 26, 2013 from http://www.azhha.org/patient_safety/sbar.aspx

Province of British Columbia - Ministry of Health (2009). Lets Talk: A Guide For Collaborative Structured Communication.

Retrieved October 26, 2013 from

http://www.health.gov.bc.ca/library/publications/year/2010/LPNGuide_collaborative_structured_communication.pdf

Berlin, E. A. & Fowkes , W. C. (1983). A teaching framework for cross-cultural healthcare: Application in Family

Practice. THE WESTERN JOURNAL OF MEDICINE, 139 (6), 934- 938.

Hearnden, M. (2008). Coping with differences in culture and communication in health care. Nursing Standard.

23(11), 49-57.

The Joint Commission (JC), (2009). The Joint Commission Guide to Improving Staff Communication. (2 Edn).Oakbrook Terrace, IL: Joint Commission Resources.

Wertheim, E. G. (2008). The Importance of Effective Communication. Retrieved December 4, 2013 from http://www.ou.edu/cls/online/LSAL3513/pdf/unit2_wertheim.pdf

Victoria Quality Council (2010). Promoting effective communication among healthcare professionals to improve patient safety and quality of care. Retrieved December 4, 2013 from http://www.health.vic.gov.au/qualitycouncil/downloads/communication_paper_120710.pdf

Jefferson Inter Professional Education Center. (nd). Interprofessional Communication SBAR Module. Retrieved October 3, 2013 from http://jeffline.jefferson.edu/jcipe/learning/didactic_files/SBAR%20IPE%20teaching%20plan%20v2.pdf

Factors Influencing Communication from Review of communication process. Communication and nursing education. Retrieved December 5, 2013 from http://my.safaribooksonline.com/book/medicine/9789332501461/chapter-1-review-of-communication-process/ch1_6_xhtml#X2ludGVybmFsX0h0bWxWaWV3P3htbGlkPTk3ODkzMzI1MDE0NjElMkZjaDFfOV94aHRtbCZxdWVyeT0=