An introduction to effective Communication in End of Life Care Before embarking on teaching communication skills you are strongly encouraged to complete rhe NHS Glos communications workbook and attend the study day. Resources and calendar of events available from – http://www.nhsglos.nhs.uk/content/services/eolc/eolc-education.html Calendar - http://www.nhsglos.nhs.uk/content/services/eolc/documents/Calendar The main eolc web page is …. http://www.nhsglos.nhs.uk/content/professionals/healthprofessionals.html Trainers in communication should be experienced, knowledgeable, trained and have the skills to do so.

Ground Rules Give time for everyone to have their say Confidentiality – stays in the room. No real names to be used for residents, relatives or other professionals Time keeping Respect each others views Mobiles Housekeeping arrangements

Aims Explore some essential skills of communication in end of life care Identify barriers to effective communication

End of Life Care Strategy - Communication All staff in health and social care, and the voluntary and independent sectors, need some training to ensure they are able to communicate effectively with people who are dying and their carers about issues surrounding end of life care (DOH 2008 p.113)

COMMUNICATE What do you understand by this word? Brainstorm Encourage everyone to contribute.

What do we want from communication? Information – delivered in a language we can understand Honesty Companionship Opportunity to reflect

Exercise 1 Why is effective communication so important in relation to end of life care? Take 5 minutes to discuss in groups why you think it is important Flip chart Central to high quality patient care Ensures all involved in care are aware of plans/wishes/needs of an individual Helps understand residents concern’s and feelings Gives time to residents – especially those who have communication problems (speech, hearing, sight) Broach sensitive subjects – e.g. losses associated with moving into a home Explain illnesses to residents and families Explain care options to residents and families Reduces confusion/lack of clarity Builds good relationships within home and external agencies (GPs, DNs, etc etc) Extra points Good skills are the same whatever the subject or with whom we are communicating with – those with communication disabilities Responding appropriately important Talking about sensitive issues can help to relieve distress Active non judgemental listening is a crucial component of good communication

Essential communication skills Listening skills Verbal Language – words used Paralanguage – how it is said, tone, pitch, clarity Non-verbal what we understand and transmit from body language Three part involvement session Listening skills – 2 people back to back. A holds a picture of a house, B has to draw it from listening to A describe it – can mention shapes and sizes only( Or talk for 3 mins (two people) and relay back to group what has been said to them – cannot make notes 2 Verbal language – Open questions Require more than ‘yes’ or ‘no’ Often start with ‘how’ ‘what’ ‘why’ or ‘tell me’ Closed questions More direct and specific Limits information given Examples ‘if your condition deteriorates do you want to stay at home?’ As apposed to ‘if your conditions deteriorates where would you most like to be cared for?’ ‘do you want your friends to visit when you are close to death?’ as apposed to ‘who would you like with you and who would you like to visit when you are close to death? ‘do you want to be resuscitated?’ as apposed to ‘is there anything you would like to avoid happening to you?’ Get attendees to say ‘how are you’ – Mandy and Maggie to try first!! See how it feels 4 Non-verbal Practicing Communication skills (15 – 20 minutes) In 2s A – describe their first day at work B – listen and demonstrate that he/she is listening and ask a question, if appropriate A – answer and carry on a describe the event B – reflect back what has been understood Switch roles after 7 – 10 minutes Learning point of this exercise is to participants listen without talking or interrupting directly or indirectly (looing at watch, out of the window) and demonstrate that they are listening Get pairs to feed back Non verbal – use the information in slide 13!!!! Gestures Illustrates speech, emotions Posture Demonstrates, emotions and mood. Supports or opposes the spoken word Eye contact Important for building satisfying relationships Facial expressions Displays emotions Touching Develops caring relationship Personal space Can feel threatened if too close &

Listening Skills Plan the environment Be Attentive Hear what an individual is saying Use appropriate body language Environment Plan – peace and quiet, no interruptions – private – do not talk in corridors etc etc Attentive – eye contact, sit at same level Hearing -

Effective skills - language Questioning –open, closed, leading and multiple Encouragement Picking up on cues Reflection Silence Clarification/Summarising Open questions Require more than ‘yes’ or ‘no’ Often start with ‘how’ ‘what’ ‘why’ or ‘tell me’ Closed questions More direct and specific Limits information given Leading questions Need to be avoided – puts words into people’s mouths e.g. ‘I suppose you are nervous…?’ Multiple questions can cause confusion and reduces time for answering e.g. ‘how are you feeling? Pain any better? Did the pills work?’ Encouragement shows an interest in the conversation – encourages continuation with the conversation Picking up on cues Residents dropping hints Requires staff having the ability to pick up on these e.g. ‘I didn’t like staying in hospital, don’t want to go back’ Reflection Promoted further discussion Silence Very powerful, gives time to assess what has been said Clarification/summarising Ensures that the meaning of the conversation has been understood

Paralanguage – Tone of voice Volume Pitch Try saying ‘are you ok?’ considering some of the above to the person next to you and see what response you have.. Tone – can change the meaning of words Volume – no need to shout Pitch – can change the meaning of a word, sentence

Non-Verbal Communication Is the message or response not expressed or sent in words Over 65 percent of the social meaning of the messages we send are communicated non-verbally. Actions speak louder than words. Think of some examples……. Demonstrate some non verbals such as aggression, impatience,

Non-verbal behaviours Personal space Facial expressions Posture Gestures Touching Personal Space Can be invasive if someone gets too close Need to sit squarely, can lean forward to encourage conversation and make someone feel understood Facial expressions Display emotions – can conflict or support (smiling, frowning etc) Posture Demonstrates attitudes, emotions and moods Supports or conflicts the words spoken Gestures Illustrates speech – hands, fingers, movements Touching Expresses emotions Can help develop a caring relationship – be careful!!

Non-verbal Communication!!

Barriers or blocks to effective communication especially at EoL Could break into 3 groups. Ask them to list all the barriers they can think of under their heading. Ourselves- Poor communication skills, poop preparation, planning Them – what do they want to know, want to hear, are they ready? Level of understanding Environmental –available time, difficult environments, lack of privacy, other people, lack of staff,

Barriers to effective Listening Feeling stressed by other concerns Environment noisy or disturbed Not feeling confident Low motivation – bored or tired Being in a hurry to pass the person on Interjecting with own experiences Formulating answers to queries before hearing exactly what is needed

‘Verbal's’ for you to avoid Mumbling Passing judgement or giving unwanted advice Interrupting Discussing your own experiences Jumping to conclusions ‘I understand’ Confusing people with multiple questions Using jargon

Useful Tools Listening skills - active not passive Use of Questions - open not closed Reflecting Back Clarifying Reinforcement/Encouragement Paraphrasing Silence Listening – to pick up on cues – concentrate Questions – provides the space for an individual to express themselves Reflecting back – promotes discussion – around a problem and leads into in depth conversations Clarifying – to ensure that meaning is understood ‘what do you mean by that?’ Reinforcement/encouragement – shows interest and understanding, encourages the person to continue Paraphrasing – summarising/interpreting Silence – very powerful – gives both parties time to assimilate (digest) what has been said

Identifying emotions… Anger Sadness Surprise Guilt Anxiety How easy is this? Could they identify these in residents, family, staff?

Remember to look after yourself too… Understand that looking after a dying person will put added strain onto you and the team Beware of your own emotions, if a specific task is difficult, find someone who can help There may be events in your life that mean you are not the best person to help this client/relative on this day – that’s ok. COMMUNICATION IS THE KEY: informal chats, supervision, reflective meetings or talking to another professional may help

Dealing with limits of your knowledge/remit Its OK to To admit you don’t know something: Who might know? How will it be followed up? Explain likely time -frame of response Its NOT OK to Block a question by: - Ignoring it - Dismissing it - ‘Jollying the client along’ Guess / say something you’re not really sure of

Issues for Individuals in your care Discuss in groups what you think the dangers are if staff do not possess effective communication skills Increased anxiety Wishes not taken into account Poor quality of care Symptoms not controlled

Scenario What would you do??? You have been caring for Mary for several months. She has become gradually more frail both physically and mentally. On this occasion, she seems quite agitated and tells you “that woman has been horrible to me. She shouts at me, hasn’t given me anything to eat and won’t let me have a bath.” What would you do??? Give the group 10 mins to discuss – split into small groups or pairs Could this be role played out the front? Try and set this up at the front between you and a willing volunteer. Try and use some of the techniques already covered. Ask them afterwards what worked well or not.

‘Hello, ward P, can I help?’ Pause for thought! A 75 year old lady rings her local NHS hospital and had the following conversation: ‘Hello, I’d like some information on a patient Mrs Tiptree. She was admitted last week with chest pains and I would like to know if her condition has deteriorated, stabilised or improved’ ‘Do you know which ward she is on?’ ‘Yes, ward P, room 2B’ ‘I’ll put you through to the nurses station’ ‘Hello, ward P, can I help?’ Just read this out…

‘Oh, thank you, I’m so pleased and happy!’ Continued…….. ‘Yes, I’d like some information on a patient Mrs Tiptree. She was admitted last week with chest pains and I would like to know if her condition has deteriorated, stabilised or improved’ ‘I’ll just check her notes. Yes, I’m very pleased to say Mrs Tiptree has improved. She has regained her appetite, her observations are stable, and following a few more checks we are hoping to discharge her tomorrow’ ‘Oh, thank you, I’m so pleased and happy!’ ‘Are you a close relative?’

no-one tells you anything at all in this place!!!!’ ‘No I’m Mrs Tiptree in room 2B, no-one tells you anything at all in this place!!!!’ Does this happen in a Care home? Can it happen in a Care Home? What can we learn from this? Should it happen?

Remember help is always at hand for you Discuss/explore and explain what help there is in this particular Care home with regard to communication Refer people on to the Glos NHS Communication workbook and skills workshop for further training. http://www.nhsglos.nhs.uk/content/professionals/healthprofessionals.html

Useful Information www.endoflifecareforadults.nhs.uk Ellershaw J, Wilkinson S (2008 edition) Care of the dying ‘A pathway to excellence’ Oxford University Press Local hospices End of Life Care Learning Resource Pack, Housing 21: www.endoflifecareforadults.nhs.uk www.nhsglos.nhs.uk/your-services/help-for-those-with-a-long-term-condition/eolc-training/