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- 1. COMMUNICATING THROUGH BARRIERS CHAPTER 5 Copyright © 2020 by Elsevier, Inc. All Rights Reserved
- 2. Learning Objectives 1. Discuss communication through language barriers and the use of interpreters. 2. Discuss communication and interaction with patients who have auditory and visual impairments. 3. Explain stress, the body’s physiological response to stress, common coping mechanisms, and actions health care professionals can take to help the stressed patient. 4. List best practices to address “challenging” patients and guidelines for responding to workplace violence. 5. List strategies to discuss sensitive topics with patients. 6. Discuss signs a patient may be a victim of intimate partner violence or abuse and communication issues unique to these patients. Copyright © 2020 by Elsevier, Inc. All Rights Reserved
- 3. INTRODUCTION Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Ability to communicate is essential • Pt communication barriers • Language differences • Sensory impairments • Poor hearing, poor eyesight • History of abuse • Stress, anger, and anxiety • Many pt will have a combination of barriers • Main reasons for poor clinical outcomes
- 4. LANGUAGE BARRIERS (1 OF 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Limited English proficiency (LEP) • 8.5% of the US speaks English “less than very well” • Pts are more likely to be misdiagnosed • Pts have difficulty providing medical history • Pts have issues adhering to instructions • Bilingual HCP are in high demand
- 5. LANGUAGE BARRIERS (2 OF 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Legal Responsibility • Discrimination on basis of national origin is prohibited under CRA Title VI • HCP must offer interpreter • Provide translated materials free of charge • Use of an Interpreter • In-person interpretation, face-to-face • Ad hoc interpreters – any untrained interpreter present during clinical encounter • Calling in trained interpreter is safest • If you use an interpreter, speak in short, clear sentences and wait for pt response • Always document in detail
- 6. LANGUAGE BARRIERS (3 OF 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Remote interpreter services – translating services are done via phone or video, not in person • Cost effective and close to in-person • Video remote interpretation (VRI) is even more effective since it mimics in-person more • As technology gets even better, streaming live video on wireless device is very convenient
- 7. SENSORY BARRIERS (1 OF 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Sensory barriers – any impairment of one or more of the senses, sight, hearing, smell, touch, taste • American and Disabilities Act (ADA) of 1990 prohibits discrimination and mandates that all health agencies make accommodations to ensure effective communication with pt • Visual impairments (anopia) • Ensure pt area is well lit • No tripping hazards • Easy-to-read signage
- 8. SENSORY BARRIERS (2 OF 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Auditory impairments (anacusis) • Otosclerosis – hardening of structures of the ear, sometimes from wax build-up, correctable • Sensorineural – involving hearing centers of the brain, hearing loss is profound • Mixed deafness – combination of both types, harder to diagnose and treat • Presbycusis – common in older pts • Face pt • Speak clearly and in short sentences • Use visual aids if needed
- 9. PATIENTS AND STRESS (1 OF 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Stress is a side effect of illness • Lack of basic needs (Maslow’s hierarchy) creates stress • Unresolved stress can lead to many physical issues • Eustress – positive or good stress • Pushing through stress can make one be more resourceful or creative • Fight-or-flight response – a physiological reaction intended to give body energy to respond to threats
- 10. PATIENTS AND STRESS (2 OF 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Coping mechanisms • Either active or avoidant • Maladaptive coping mechanisms • Using drugs or alcohol increases stress • Coping mechanisms commonly seen in health care: • Compensation • Displacement • Fantasizing • Humor • Projection • Rationalization • Regression • Repression • Suppression • Undoing
- 11. PATIENTS AND STRESS (3 OF 3) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Patient Interactions • HCP must try to relieve stress from pt • Create relaxing environment • Sit face-to-face, speak slow and calmly • Help pt adjust priorities and be more realistic • Be available for questions • Stay positive and encourage laughter • Relaxation techniques include stretching, breathing exercises, visualization, meditation, body exercises
- 12. “CHALLENGING” PATIENTS AND FAMILY MEMBERS (1 OF 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Pts and family may be uncooperative and hostile • Health care can change feelings of pt • Finances, poor family support, wait times, may lead to negative interactions with HCP • HCP may be defensive, listen less attentively • “Challenging” pts can create negative outcomes • As HCP, explore possible explanations for behavior • Be patient and confront issue head on with pt • Listen intently, gently set boundaries, document • If pt becomes more aggressive, get another HCP
- 13. “CHALLENGING” PATIENTS AND FAMILY MEMBERS (2 OF 2) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Workplace violence – violence acts directed toward persons at work or on duty • Can be physical or verbal abuse • HCP more likely to experience due to interactions with “challenging” or “difficult” pts • 80% of violence towards HCP due to pt interaction • Steps to take if found in dangerous encounter • Ensure clear path to the door • Cautiously and firmly warn pt of behavior • Call for help from coworker or even 911
- 14. DISCUSSING SENSITIVE TOPICS Copyright © 2020 by Elsevier, Inc. All Rights Reserved • HCP and pt may have anxiety and uncertainty • Ensure pt they are in safe, private, environment • There are exceptions to confidentiality • Child and elder abuse • Some sexually transmitted infections • Be aware of body language • “Normalize” the issue through broad statements • E.g., “Many people find it difficult to talk about their sexual concerns, so I find it important to ask all of our patients about it” • Ask closed-ended questions to promote clarity
- 15. PATIENTS EXPERIENCING ABUSE (1 OF 4) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Abuse - a misuse or maltreatment • Physical, verbal, emotional, psychological, sexual or economic • Intimate partner violence (IPV) physical, sexual, or psychological harm by a current or former partner or spouse • Look for signs: injuries, trauma • Ask questions when pt is alone • S.A.F.E. method of questioning
- 16. PATIENTS EXPERIENCING ABUSE (2 OF 4) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Child Abuse • mandatory reporters - states require HCPs and others to report suspected child abuse • Review signs of child abuse • Communicating: • Speak at child’s level • Speak in private • Determine need for safety • Be honest with child • Do not criticize family • Assure the child that it is not his or her fault • Child “did the right thing” by telling
- 17. PATIENTS EXPERIENCING ABUSE (3 OF 4) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Elder Abuse • Misuse of medications or physical restraints • Force-feeding or failure to feed • Lack of clothing, shelter and medical care • Recommended every elderly pt be screened • If HCP is trusted, pt will disclose any abuse • Be aware of caretaker’s behavior during pt interview • Older Americans Act (OAA) is a federal regulation protecting adults 60+ from abuse • Provides education and research resources
- 18. PATIENTS EXPERIENCING ABUSE (4 OF 4) Copyright © 2020 by Elsevier, Inc. All Rights Reserved • Bullying – repeated aggression among adolescents based on a power imbalance • Can be based on physical characteristics, social standing, ethnicity, gender ID • Cyberbullying: social media, chatrooms, text • Being bullied can affect health • Increased anxiety • Depression or PTSD • Self-harm or suicidal thinking • Counsel parents if suspected • Child must be made aware that it is not their fault • Many states have laws to prevent bullying
Editor's Notes
- Miscommunication can lead to terrible outcomes. Misdiagnosis is 1980 led to a pt becoming quadriplegic and family awarded $71 Million.
- Legal Responsibility: The Civil Rights Act of 1964 (CRA) requires that any health care provider or health care organization that participates in a federal program, such as receiving reimbursements for providing services to Medicare or Medicaid patients, must provide equal access to medical services Interpreter: Decreases length of stay, missed follow-ups and overall expenses for the HCP Ad hoc interpreters can be family, friends, caregivers, even another pt from the waiting room if necessary – these interpreters are sometimes better than those trained by facility as they may know pts medical history and lifestyle habits. Avoid using a minor unless in an emergency
- Legal Responsibility: The Civil Rights Act of 1964 (CRA) requires that any health care provider or health care organization that participates in a federal program, such as receiving reimbursements for providing services to Medicare or Medicaid patients, must provide equal access to medical services Interpreter: Decreases length of stay, missed follow-ups and overall expenses for the HCP Ad hoc interpreters can be family, friends, caregivers, even another pt from the waiting room if necessary – these interpreters are sometimes better than those trained by facility as they may know pts medical history and lifestyle habits. Avoid using a minor unless in an emergency
- Visual impairment pts: Escort pt by having them take your arm and do not pull or push the pt Describe pt’s special layout if needed Explain each procedure and inform pt if you need to touch them Guide dogs are permitted to go wherever the pt goes
- Auditory impairment pts: Pts may be unaware of their condition as it’s gradual Looks for signs of impairment since pt may be unaware or deny – flat, slurred speech, frequent requests to repeat yourself, complete misunderstanding of what you are saying, tendency to dominate conversation (they may be unaware you are speaking) Interacting with these pts: Alert patient (maybe tapping on arm) before speaking Allow pt to see your facial cues Speak clearly and slowly and lower than normal pitch – short sentences Use chalkboards or note pads, magic slates, if pt cannot understand
- Stress – is undeniably bad, but good stress exits that can make us work more efficiently Unresolved stress can lead to many physical symptoms: headache, gastro issues, anxiety/panic, exhaustion, memory loss, insomnia Fight-or-flight – -the heart beats faster to pump blood faster -respiratory rate increases to increases the oxygen supply in the body, which will all help supply glucose to muscles to make them work more efficiently. -Blood pressure rises to force blood into the tissues needed to fight or to run away. Pupils dilate to bring in every available visual image for processing. Digestion slows so that available energy is used for survival -pupils dilate Parasympathetic system is opposite, allows us to rest and digest – calm and soothe body Maslow’s pyramid from chapter 4 – are our basic needs met (food, shelter, finances, cared for and loved) We use coping mechanisms to manage stress Either active or avoidant Maladaptive coping mechanisms Using drugs or alcohol, often increases stress
- Coping methods most important in healthcare: -Compensation – Example, pts with impaired vision can develop stronger hearing -Displacement – Example, caregiving may rage at you when anger cannot be directed to pt -Fantasizing – daydreaming as a means of escape -Humor – laughing at ourselves in a situation to lighten situation -Projection – attributing own unacceptable motives towards another person -Rationalization – Justifying behaviors -Regression – returning to earlier stage to escape stress -Repression – involuntarily rejecting painful thoughts -Suppression – Deliberately refusing to acknowledge stressor, may be appropriate if not affective health care -Undoing – attempting to cancel out unacceptable behavior with one more acceptable
- Relaxation techniques (examples) -Stretching: stretch from top of head to toes, relieving muscle tension, yoga -Breathing: Sit or stand with hands of abdomen and good posture, hold breath for a few seconds, breathe deeply -Visualization: Picture a positive scenario in your mind -Meditation: Like visualization, setting aside 5 to 10 minutes to relax mind and body -Exercise: Releases endorphins (natural mood elevators), may help sleep and anxiety
- Pt feelings changes from health care: Anger Anxiety Frustration Depression (especially in chronically ill pts)
- A structured series of questions regarding STDs will help provide details of pt’s sexual history. Short example of approach to STD conversation in pt interview: Shawna: Have you ever had an STD? Mr. Sims: No, I don’t think so. I’ve never been tested though. Shawna: Are you worried you might have an STD? Mr. Sims: Yes, a little. Shawna: We can test you if you like. Would you like to be tested today? Mr. Sims: Okay. Shawna: Is there anything you’d like to tell us about your sexual health or history?
- Family violence is a comprehensive term that addresses abuse throughout the life cycle. Family violence includes partner abuse, child abuse, and elder abuse. Abuse is generally defined as a misuse or maltreatment Examples of abuse: Physical – pushing, hitting, physically trapping or impeding movement Verbal/Emotional – criticizing, degrading, blaming, attacks on self-esteem Psychological – isolating you from family and friends, controlling, invading private space Sexual - Forcing or demanding of sex, refusing to use safe sex Economic – forbidding you from working, controlling money, preventing work through other means (citizenship) 37% of women and 31% of men experience IPV Signs of IPV: Repeated injuries or bruises Unusual marks, scars, or rashes Bite marks Swelling or pain anywhere on the body, including the genital area Venereal disease and genital abrasions or injuries Unexplained fractures Repeated accidental injuries Black eyes or wearing dark glasses Makeup worn to hide bruising Asking questions about IPV: (SAFE method) S for Safe – pt feel safe A for Afraid – afraid of partner F for friends or family – could you tell friends or family comfortably E for Emergency plan – is there a safe place to go in an emergency if felt life in danger
- Child abuse mandatory reporters: Social workers School personnel HCP Counselors, mental health professionals Child care providers Medical examiners and coroners Law enforcement Some states even require photo processors, animal control and college admin to report child abuse. Many signs of child abuse: Previous reports Conflicting stories by parents Suspicious stories of injuries Repeated ER visits for injuries Bruising on buttocks, back and abdomen, or on any child too young to walk or crawl Elbow, wrist and shoulder discolorations Erratic school attendance Poor hygiene Malnutrition Dental neglect
- Elder abuse also includes, forging signature to steal money or possessions, neglect, abandonment, failure to pay nursing home if legally obligated to do so Signs during screening: physical marks, withdrawal from normal activities, sudden change in finances, bedsores Suspicious behavior by caretaker: lack of concern, closely monitoring interaction, refusing to leave room, hostility
- Examples of bullied groups: Most bullied children say that they are bullied because they are different or marginalized, such as having a disability or chronic disease ---being overweight or underweight -being a member of a religious or ethnic minority -identifying as a gender or sexual minority (Kann, et al., 2016) (McClowery, 2017) Consequences of being bullied: Lowered academics Increased anxiety Low self-esteem Depression Deteriorated physical health Self-harm or thoughts of suicide Alienations Absenteeism www.stopbullying.org/laws/key-components/index.html