Lecture # 214:
Communicating with Clients

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Assertiveness

Assertiveness is communication that firmly expresses what the communicator wants. Being assertive can be an effective way to let people know what you want. Of course, you may not always get what you want because other people in your care may say "No". For example, no matter what you say a person may refuse your assistance. Or, no matter how you ask, your supervisor may not approve your request. Sometimes, however, being assertive can change someone else's mind.

Stand tall, speak in a firm voice, and look into your supervisor's eyes when making a request. You can request in this way, "I need to have a day off work next week to attend to some personal business." This type of request is more specific and gives the supervisor a reason for your needing a day off from work. If you hunch over and look at the floor and say, "I don't suppose I could take some time away from work one day next week," the supervisor may think that you really do not need time away from work.

At times persons may not be assertive because they think other people may not receive their request. It may make other people angry. Also some people may confuse assertiveness with being overbearing or aggressive. In some cultures, people learn not to be assertive, and in other cultures, assertive behavior is considered to be rude, too direct, and manipulative. so use assertive communication selectively, always considering how the receiver might feel about how you send your message. Do you use assertive requests?

Meditate Word By Word On These Verses:
Mark 1:40-41 .

Situation: A person denies your request.
Assertive Action: Decide whether it is important to keep trying to get what you want and if so, keep trying.
Ineffective action: Give in right away.

Situation: You decide a denied request is worth pursuing.
Assertive Action: Tell the person you understand her position (if you do). Repeat what you want and explain why it is important. Keep your hands by your side or hold them on your lap. Speak with a firm voice, look into the person's eyes, and stand tall.
Ineffective action: Tell the person her idea is wrong or silly. Repeat what you said and demand to know why your request was denied. Make angry gestures and and pound on the table. Glare at the person and shout.

Situation: You must refuse a request.
Assertive Action: Say "no" and explain why you made the decision.
Ineffective action: Say "No, I will not listen to you anymore."

Situation: The person asks again.
Assertive Action: Listen to what the person says and say "no" politely.
Ineffective action: Shout, "Didn't you hear me? I said, 'NO'!"

Situation: The person asks again.
Assertive Action: Ask the person to stop putting pressure on you.
Ineffective action: Ask, "Are you deaf?"

Situation: The person asks again
Assertive Action: Excuse yourself and walk away.
Ineffective action: Tell the person to leave you alone.

Situation: The person asks why you do not like her personally.
Assertive Action: You say you are rejecting the request, not her.
Ineffective action: You say it is because she annoys you.

Using Effective Communication to Influence Behavior

How have you learned to eat pelmeni? How did you learn what is appropriate behavior in church, in the hospital, and with your family? Many factors influence behavior. What you say and do can influence other people's behavior in a positive or negative way. At times you may be able to influence people to increase their appropriate behaviors to increase their health and well-being. At other times you may influence them to stop or reduce inappropriate behaviors that may be harmful to others or to themselves.

Communication sends messages to let people know if their behaviors are liked or disliked. Sometimes, people respond to messages by continuing behavior that is liked and stopping behavior that is not liked. Your messages may help influence the behaviors of the people you work with.

1. How can your communication positively influence the behavior of another person?

 

 

Increasing Appropriate Behaviors
The people you work with need to follow your guidance. If cares are done correctly and regularly, we know that the person will be healthier. For example, an appropriate behavior may be to check blood sugar level three times daily. The communication called social reinforcement helps to increase the likelihood that a person will repeat the appropriate behaviors. See the following:

Type of Verbal Reinforcement Example
Praise Elena Pavlovna, your hair style looks very nice.
Congratulations, Sveta, you walked 2 meters further today than yesterday.
Appreciation Thank you, Liuda, for helping Marie to find her red blouse.
Thank you, Olga, for checking your blood sugar this morning.
Encouragement Keep trying to touch your shoulder, Dmitri Sergeevich, you are doing better every day.
You're walking better today, and I think you can walk to your room in the next few minutes.
Approval That's right, Katya, you are doing your exercises exactly right.
I think that was a good choice, Anatolii Iliich.
Recognition Let's welcome Sergei Evgenievich to our news group today. Welcome!
We thank Alla Sergeevna for the picture she painted for our museum.

Each type of verbal reinforcement helps people increase their appropriate behaviors and self esteem. This is especially true if you combine the reinforcement with an expression of approval, which may be physical such as a touch on the shoulder. Here is a formula for increasing appropriate behavior to see how verbal and nonverbal reinforcement work together to influence behavior:

VERBAL REINFORCEMENT + NONVERBAL PHYSICAL REINFORCEMENT = INCREASE APPROPRIATE BEHAVIORS

No single type of reinforcement is always successful with the same person or in the same situation because people behave in certain ways for many reasons. For example, a person may not try to walk with a walker because she doesn't understand or is afraid. If what you are doing to reinforce a positive behavior is not working, try tp figure out why the person is not responding and try a different approach.

Reducing Inappropriate Behaviors
Most of the people in your care appreciate what you do for them and try to be cooperative. At times though, a person may yell, spit, or curse at you, or someone may make a racial or sexist remark. These inappropriate behaviors could be harmful to the person or someone else, and they are difficult to handle. Some people think that those who behave in such inappropriate ways should be punished. But it is never acceptable for you to punish people in your care. An appropriate response to an inappropriate behavior always allows for safety, privacy, dignity, communication, independence, and control of environment factors. An appropriate response also never violates a person's rights. When a person in your care behaves in an inappropriate way, it is natural for you to feel upset, angry, embarrassed, or frustrated. It is understandable for you to feel this way, but not acceptable to act inappropriately.

You may need to leave the negative situation and come back when you and the person you are helping feel more calm. Then you can hopefully find out why the person was upset. By communicating in this way, you make it possible for the person to talk about what is the problem and this may stop or reduce the harmful reaction.

When a person in your care behaves inappropriately, try to ignore the behavior. Sometimes a person uses inappropriate behavior to attract attention. If you pay much attention to these behaviors, they will repeat them. If a person uses inappropriate behavior to attract attention, pay more attention to the person when his behavior becomes more appropriate.

You may have many feelings to sort out after someone behaves in an inappropriate way. If you keep your feelings bottled up inside, they can create stress and cause you to act inappropriately with other people. To help you deal with the feelings you have with difficult situations, try some of the following suggestions:

  1. Leave the room.
  2. Breathe deeply for calmness.
  3. Talk with someone.
  4. Develop a plan for responding to the person's inappropriate behaviors.
  5. Talk directly to the person and let him know that you are unhappy with the behavior, but you still care for him.

Question:
2. What should you do when a client behaves inappropriately toward you?
(One or more of the following answers may be correct.)
If it is the first time, try to ignore the inappropriate behavior.
Provide verbal negative reinforcement: say 'No' and explain the reason.
Shout, "Are you crazy, or what? Stop that right now!"
Give nonverbal negative reinforcement: excuse yourself and leave the room.

 

 

Communicating with Families
When you care for someone, you learn a great deal about him. He is the primary source of personal information. You also learn more about him through family members. By asking them questions, you can learn more about his personality, place in the family, attitudes the person has and traditions the person has had in the family.

In societies all the world over, family means many things. Traditionally, the family has meant father, mother, and children. Family usually means a connection by blood, but many people consider it much more than that. There are people who experience family in many different ways:

  1. Biological. We are related biologically or by blood to both parents.
  2. Step. We are related biologically to one parent who has remarried which gives us a step parent.
  3. Foster. We are not living with either of our biological parents, but another family has made us part of their family temporarily in their home.
  4. Adoptive. We are not living with either of our biological parents, but another family has made us a part of their family permanently. Or we are living with one biological parent, and that parent's spouse adopts us.
  5. Institutional. We are not living with either of our biological parents or in another traditional family setting. We are living in a place with other children who do not have parents or traditional families. This place is often called an orphanage.

Family is important in our world and to each of us as individuals because it helps us to meet our needs for stability, affection, education, and physical care. As we grow and mature, we may begin to consider friends and people in organizations as part of a larger family that helps us grow and mature. For example, the church has youth groups and Sunday schools, there are clubs and houses of culture that have programs for children to develop their abilities. For many individuals, this family includes a partner - husband or wife. Throughout our lives, the circle that we call family may continue to change as significant people come and go in our lives. For example, an army friend may be very close in times of service, but after discharge and return to home, the relationship may lessen. Grandparents die and their traditions cease, or they may be carried on by an aunt, uncle or your parents.

The family can be an important member of the health care team. Because families are different, some want to be participating members of the team, and others do not. You can encourage families and help them feel more comfortable by getting to know them, learning about their family history, and listening to them.

Question:
3. What did God have in mind when he created the family?

 

 

You also can learn a great deal about the person in your care by observing how the family members talk to one another. At the same time, you must stay outside of their family circle and avoid making judgments, expressing personal opinions, or taking sides when there are disagreements. For example, a person I cared for was coughing up blood. His family members were informed and he was sent to the doctor who ordered a scan of his lungs. The results of the scan were not known, but the doctor ordered our patient to see a specialist in lung diseases. The first daughter agreed with the recommendations. A second daughter phoned our facility, disagreed with the treatment program, and cancelled the appointment with the specialist saying that it was not important. By this time, the daughters were angry with one another.

The director of the retirement center called both daughters with her decision. She thought it best to talk with both daughters even though they were not speaking to one another. The director's decision was that our person needed to see the specialist because the people caring for him needed to know the diagnosis and what treatment would be appropriate for him. Since our person is 85 years old, aggressive treatment is not likely, but if treatment is palliative due to cancer, we will know how to care for him and what the limits of his care would be. Thus, the whole family even though they did not agree with one another, (perhaps this situation was a power struggle between the two daughters) was satisfied with the resolution of the problem. The director was the peacemaker and the man is getting his tests for possible cancer of the lung. We are not sure what the treatment will be, but if we have an accurate diagnosis, the doctor can recommend treatment parameters and direct the care of this man.

We are also responsible to the family. They will want to know how the person in your care is progressing in a rehabilitation program, what your person is eating, and if they are getting along with others. If your client lives at home, the family must know all of this information. At times families may feel resentful about the problems they have to face. Sometimes they complain to you simply because they have frustrations and you are in their home and provide a listening ear. To put the family at ease, be sure to explain what you are doing and why so that they may do the same treatments or exercises when you are not there. Use their care-giving suggestions, but make sure that these suggestions support the principles of good care.

Question:
4. How would you feel if a person in your care cursed and threw a glass at you? How would you respond to that person? How would you handle your feelings?

 

 

Communicating with People When Teaching

The people in our care need to learn to manage their disabilities, injuries, or medical limitations. They can adapt thier lives so they can stay healthy or comfortable. Communication skills become very important when you begin to teach them how to live with limitations.

Teachers from you school days probably talked to you from the front of the classroom, wrote on the chalkboards, and gave structured tests. They taught formally. But teaching is also an ongoing process that often happens informally through conversations or as one person watches another do things.

You have probably helped other members of the health care team teach new people what they need to know. You may intentionally teach people new activities or new ways of doing familiar activities because it is part of the daily care plan. Or you may informally teach by simply performing your daily tasks, talking with people about their concerns, and giving them new information so they can make correct choices. Through all these ways you help people understand how to adapt to the changes in their lives. You can be a good teacher by practicing your three roles: reinforcement, teaching, and observing and reporting.

Reinforcing: When you reinforce, you strengthen the memory of what has been taught to a co-worker or client. Perhaps a therapist taught your client to move and walk with a cane. You can reinforce his lessons by observing his use of the cane when he moves from one place to another.

Teaching: You may teach a client with a weak arm how to dress himself and how to use a fork again to eat food.

Observing and Reporting: You can observe how well a person is doing as well as the areas in which he needs additional teaching. You may see your client using his cane incorrectly. First you correct the client and then continue observation to be certain the lesson is learned. If the lesson is not learned, perhaps you will have to ask the therapist to re-teach the technique of walking with a cane.

The Learning Process

To communicate effectively through teaching, you must understand how people learn and how you can help their learning process.

The adults and children that you teach, as well as the family members and friends, learn better when they -

They also learn better when you -

How the Learning Process Works
Learning is an ongoing process, during which a person's knowledge, attitudes, and behaviors change. Learning is not restricted to the classroom. Every day you learn by reading, working, listening to radio and television, talking with your friends and family, and using your computer. Just as you learn from others people and their experiences, the people in your care learn from you.

When you were a child in school, you learned what the teacher and the school chose to teach you. As an adult, you make choices about what you learn, based on what is important to you. What adults learn and how they learn are affected by many things, including feelings, attitudes, knowledge, and experience.

* Knowledge
A person's learning is affected by what he already knows. For example, if Mrs. Ivanov already knew how to cook nutritious meals when she changed to a diabetic diet, she has a easier time learning to plan and prepare a new diet than someone who doesn't like to cook. However, she may have had a harder time learning if the information she received was different from what she already knew.

*Attitudes and feelings
The person's learning is also affected by how he feels about what he needs to know. For example if Mrs. Ivanov thinks that diabetes is really not a big problem in her life - if she simply does not eat sugar, she may not want to learn about proper meal planning and insulin balance.

*Experience
The person's past experience affects how he learns. For example, if someone with high blood pressure tasted a few meals with less or little salt and liked them, it is easier to teach him how to prepare foods with less salt. On the other hand, if he did not like the way low salt meals tasted, he might find it harder and need more encouragement to learn how to cook with less salt.

By talking with your client, you may discover his knowledge level, his attitude and behavior. You learn that he may need more information about his disease and its conditions, because he doesn't seem to understand how his medication affects his blood. You may find out that he is willing to try a new behavior though and monitor his salt intake.

The Teaching Process

During one of your visits to Ivan Petrovich, you try to help him transfer himself from the wheelchair to the bed. During the past few days, the therapist has been working with him to learn the transfer. You are reinforcing the instructions and encourage him to do as much of the transfer as possible. He makes several unsuccessful attempts. After the third try, he mumbles, "Oh forget it, I am sure my wife knows how to do this, I don't!" You can help Ivan Petrovich learn to do the transfer if you understand the four steps of the teaching process.

First Step - Assessing
Before you begin to teaching, you need to assess what the person already knows and feels about the information he needs to learn. You can assess several different factors such as age, past education and knowledge, present health status, and illness. Certain disease or handicaps have very specific learning needs. For example, if your client has weakness on the right side because of a stroke, you needs to help him learn to move around by himself but that this man also depends on his wife to help him. Then you may understand better what the person needs to know.

Every day, as you work with the client, you continue to observe what he knows and does not know and thus understand his ongoing needs. If Mr. Shishkin depends on his wife, perhaps he is giving the message that he needs more information or that he is frustrated.

Second Step - Planning
When you understand what the person needs to learn, you can plan how to teach. Plan how to fit the teaching into the time you spend with the client. For example, you teach him how to dress himself during his morning routine. You can bring a long-handled shoehorn so that he can put on his shoes without bending over and getting dizzy. First you teach him how to put on his pants. When he does that well, you teach him how to put on his shirt, then shoes. You save teaching him how to button his shirt because that is the most difficult part of dressing. This teaching plan becomes the guideline to make sure you communicate the information he needs.

Third Step - Implementing
Implementation is putting your plan into action. An important part of implementing your plan is choosing when to teach. Teach when you have enough time, when the "student" is feeling well, and when his surroundings are quiet for learning. For example, Mr. Shishkin has repeated difficulty with buttoning his shirt. He makes several attempts but just cannot get the button through the buttonhole. After his fourth try he says angrily, "I just can't do it! I will never to able to do it. It is hopeless!" You could say, "I am sure that you are frustrated, but I am sure you will get it. Why not take a break right now?" By recognizing that his is upset and suggesting that he can wait, you are communicating your calm and patience. Taking a break and relaxing for a short time gives the person perspective on his problems and renews his spirit.

Question:
5. Your client is getting better after having a stroke. However, she wants you to do everything for her. How can you encourage her to start caring for herself?
(One or more of the following answers may be correct.)
Exercise her arms and legs, sit her up and start her moving.
Tell her, 'You won't do anything? OK, then, I will just leave you alone and let you die.'
Tell her that God loves her and wants her to have a more independent life, then pray with her.
Put a comb, brush and toothbrush on her bedside table, then help her start to use them.

 

 

Fourth Step - Evaluating
You now can evaluate how effective the teaching was by observing the person and asking questions to find out how much he learned. For example, all week you and Mr. Shishkin have worked together on dressing. Today when you come to help him with personal care, he has already eaten his breakfast and is in the process of getting dressed. He is able to button his shirt with only a little difficulty. Evaluation shows how effective you teaching has been, if the person understands, and if you need to repeat some aspect of the teaching again. The basic evaluation question is this: "Is the person willing and able to do the task or use the information I taught him?" To find the answer to this question, you should ask the person to demonstrate what he learned. After you evaluate, you should give prompt, helpful, and realistic feedback on how the person is doing. You must also write out the evaluation of you teaching so that you know if you accomplished something.

Reinforcing What You Teach
If people in your care are overwhelmed by the amount of information you give them, use teaching skills to help them remember what you teach and communication skills to find out what they didn't understand.

Help the Receiver Remember the Message
If you have a great deal of information to teach, separate the message into several smaller parts, and ask for confirmation of understanding from the person you are teaching. Give a summary of all you have taught when you finish. If you can use pictures or some brief written materials this may also be helpful.

Encourage People to Ask Questions
To find out if people understand the information, encourage them to communicate by regularly through questions. To let them know that others may also have the same questions, you might say, "Many people ask me questions about this." and to encourage questions, praise people when they ask them by saying "That is a good question. I am glad you asked." If a person asks a question you don't know how to answer, let the person know you don't know the answer and then find it out later.

Question:
6. You notice that the daughter of one of your clients brings a box of chocolates when she comes to visit her mother. You and the client know that candy is not permitted on her diet, but she eats it anyway to please her daughter. What should you do in this situation?