Communication is a pivotal part of nursing. It is through good communication that we nurses are able to establish rapport and form therapeutic relationships with our patients. I chose to take Communication and Behavior to fulfill the nursing elective requirement in the BSN program. This course focuses on communication skills, communication in relation to sensitive topics (e.g., death/dying and sexuality), and motivational interviewing for health behavior change. Before taking this course, I was fearful of being assertive wth both patients and other health care professionals. Through regular journal entries, discussion board postings, and applied coursework, I was not only able to overcome this fear, but I also honed my communication skills as a whole. Below, you may find my final paper on communication/behavior and asthma treatment adherence, as well as my journal postings.
Communication and Behavior for Asthma Treatment Adherence
 The following five journal entries were very enlightening for me. By discussing my own professional and clinical experiences, I was able to reflect on what I did right and areas I could improve on when communicating with patients in the future.
Journal Entry #1 – 6/1/2014
           When interacting with patients, I use a variety of communication skills that are tailored to each patient’s personal characteristics—such as age, gender, mood, culture, and his/her behavioral responses to the interaction. Information about these characteristics can be gathered through an assessment. I believe in communication that is patient-centered. The strongest therapeutic relationship can be formed through attentiveness to the patient’s needs when communicating. If a patient feels that the nurse has his/her best interest in mind, a trusting relationship can develop. It is very important for the nurse to focus on the patient when communicating, rather than the task at hand. Communicating with a patient must occur at all stages of care; including during interventions; for example—a nurse should not enter a patient’s room and begin carrying out doctor’s orders without explaining what she is there to do. In addition to communicating effectively when performing tasks, the nurse should also provide emotional/psychological care for the patient. Inquiring about the patient’s feelings, asking about their day thus far, and listening to any patient complaints allows the patient to feel like a real person, versus just a part of the nurse’s “work.”
The most important aspect of communicating with a patient is establishing rapport. If rapport is not established, effective communication is impossible. Establishing rapport allows for the patient to be open about his/her needs, which in turn allows the nurse to respond accordingly. Rapport can be established through attending nursing actions such as active listening, empathy, and other actions that make the patient feel cared for.
The most challenging aspect of communicating with patients, families, or colleagues is being assertive. I do not want to the person I am interacting with to mistake my assertiveness for aggressiveness. There have been cases where a patient has been very adamant in refusing care that was of importance to his health. It was challenging to maintain a professional, firm demeanor when teaching the patience about the importance of the doctor’s orders. There was a tendency for me to want to communicate with the patient from a softer, friendlier standpoint. However, at the same time, I was aware that it is necessary to maintain a nurse-patient relationship; a nurse is there to provide physical, psychological, and emotional care, not to be the patient’s friend. Aside from interacting with patients, I have found communicating the patient’s needs to the physician to be a bit intimidating. I find that I become very concerned with how the physician perceives the interaction; as the nurse, I do not want the physician to feel as if I am “stepping on his/her toes.”
Improving my communication style would involve being more comfortable with my role as patient advocate when communicating to other members of the interdisclipinary team. It would also involve becoming more assertive when communicating with patients.
Journal Entry #2 – 6/8/2014
           During my Med-Surg clinical rotation in BMCC, I was assigned to a patient that was experiencing left-sided chest pains in prison. The patient was shackled to the bed and looked very melancholy when I entered the room. I was very uncomfortable going into the patient’s room with the knowledge that he was coming from jail, and with the presence of a police officer at the door. Now, I can only imagine how the patient must’ve felt as he was still handcuffed and placed under police watch while experiencing such a health scare. However, at the time, I was more concerned with my own fear.
After introducing myself to the patient, I verified who he was by reading his arm band and asking him for his name and DOB. I also asked the patient why he was in the hospital. The patient responded to me verbally, but he did not make any eye contact, or even turn his head towards my direction except when I mentioned my name (he turned to read my ID card). I asked the patient how he was feeling, and he said he was alright, but he didn’t look alright. At this point, I could’ve further inquired about how the patient was feeling. Maybe he would’ve opened up if I said that I noticed he wasn’t in the best mood. Instead, I just began my assessment. When asking the patient about his dietary choices, he acknowledged that he does not follow his doctor’s recommendations regarding a low-sodium, low-fat diet. I asked the patient if he was aware of the consequences of ignoring his doctor’s orders. He said “yeah, I know” when I inquired and tried to do some teaching. He would cut me off at the beginning of every sentence to say that he already knew. He also stated that he wasn’t concerned with the possibilities of a heart attack or a stroke, although he was in the hospital with a complaint of chest pains. In an attempt to refrain from angering the patient, I moved on to the next item on my checklist. I believe that instead of moving on, I should have tried to find out why he was not adhering to the diet modifications. Maybe he did not like any of the recommended foods, or maybe eating a healthier diet was too expensive for him. He could’ve also not been concerned about his health for psychosocial reasons—he was divorced and did not speak to his children often. There are several possibilities as to why a patient doesn’t comply, but my self-absorption at the time didn’t allow me to inquire more. In addition to inquiring more, I should have phrased my questions in a more open-ended manner. Rather than ask if he was aware of the consequences, I should’ve asked him what he already knew about hypertension and high cholesterol, and the kinds of foods he prefers to eat. These kinds of questions might have made the patient more expressive. I also should not have judged the patient. My fear stemmed from judging the patient. I thought about the reason for why he was in jail (domestic violence), instead of thinking about how I could foster a therapeutic relationship with the patient. I believe my fear did not allow for me to empathize enough with the patient and this could’ve also led to me not pushing for answers as much as I should have.
Journal Entry #3 – 6/15/2014
           My obstetrics clinical rotation took place at New York Downtown Hospital in Downtown Manhattan. I was assigned to a young African-American mother who had just given birth to her second child the previous night. She was in her mid to late 20’s. When I first entered the room, I noticed that this woman appeared to be in high spirits. She had already started forming a very strong maternal bond with her new baby. She spoke clearly and articulated herself very well. She held her baby close to her except for when she needed to eat or use the bathroom. The patient was very receptive to me and she was open to conversation. When I introduced myself, I told her that I was aware that she had just recently given birth, and she held her baby out towards to me. I perceived this as an invitation to touch the baby, and I did. I stroked the baby’s cheek and the mother smiled.
When I received the change of shift report from the nurse, I was told that the patient had a normal vaginal delivery. Therefore, one of the items on my mental checklist for the day was to make sure she had a clear understanding of what to expect in regards to vaginal discharge, as well as making sure she can identify abnormal symptoms that require her to come back to the hospital. To begin my teaching, I asked the mother “what do you know about lochia?” Lochia is a medical term, so it was understandable that she didn’t know what I was referring to. I explained that lochia is the vaginal discharge that follows childbirth. She looked perplexed and asked me to sit with her and explain further. I was only assigned one patient for that day, so I had time to explain. I started off by explaining to her that lochia starts off bright red because of normal passage of blood for the first 2-4 days, and then I explained the subsequent progression and change of color of the discharge. The patient stated that she had never been taught about lochia, so I let her know that I would try my best to explain it to her as well as I can. She interrupted me several times to ask questions and I clarified each time, being more aware of my tendency to use medical or nursing language. The patient listened very attentively and often leaned in or placed her hand on my arm while I spoke whenever she needed to ask a question. My previous patients in past clinical rotations were not open to touch, so I was slightly taken aback at first but I recovered in a few seconds. As I started to explain the symptoms she should be alarmed by after discharge, she stopped me to grab a pen and paper, something I should have thought of before I began. In the end of the interaction, the already cheery patient was even happier than she was when I walked in, and expressed gratitude for the teaching. She smiled, shook my hand, and asked me to pronounce my name again. I felt very accomplished as a student nurse—it was my first experience with almost-successful patient teaching. I forgot to validate that the patient understood everything, so when I went back to the room to check on her at a later time, I validated her understanding by asking her a few questions.
Journal Entry #4 – 6/22/2014
I am currently enrolled in Leadership/Management of Client Care at NYCCT. I have clinical on a med-surg unit at Coney Island Hospital and the section I am in has a flexible clinical schedule. We are not assigned to patients individually, however we do interact with patients while shadowing the head nurse on rounds. While on the unit this Saturday, I noticed a patient losing control and the nurse who was assigned to that patient had given up on trying to contain the situation. The patient was an 86 year old Hispanic woman who was admitted to the hospital the previous day. She had removed her hospital gown and was walking up and down the hallway, turning any doorknobs she could reach. It seemed that she was looking for a way out. The nurse stood in the hallway with her gown in his hand, and appeared defeated. I took the gown from him and approached the patient in a calm but assertive manner, explaining to her that we need to know who is a patient and who is a visitor, and that this is why it is important for her to wear the gown. I also explained that it is okay for her to wear her own clothes if she wears the gown over it. She put her finger up to my face and said “close your mouth.” She then walked away and continued yelling and turning doorknobs.
A few minutes the later, the patient walked back over to me and began speaking Spanish. I said “no hablas espanol,” but she continued to speak to me in Spanish. Hispanic patients often misperceive me to be Hispanic as well. Normally, after explaining that I am actually African and do not understand Spanish, they speak to me in English (if they can) or we use a translator. This patient continued to speak to me in Spanish and she was very agitated. She also came very close to me when speaking. I understand that Hispanic people may come closer than others and use touch while speaking, however this patient was agitated; so her closeness made me very apprehensive. She had also put her finger up to my face earlier, so I was a bit on the defense. I still tried not to show that she was making me nervous, but I did tell her to speak to me more calmly. When she placed her hand on my wrist, I tried not to react, but another nurse who had been watching stepped in and told her “no touching! Let go! Let go!” I think that this might have added to the already growing tension on the unit surrounding this patient. The patient refused to go back into her room, so I asked the Hispanic nurse’s aide who was nearby if she could translate. The patient was saying that she gets nervous at home and whenever she does, her son drops her off at the hospital, hoping that they’ll give her a home health aide. She was saying that she is not sick and just wants to go home. This was the reason for her agitation. She felt as if the staff is holding her hostage. Before I could even explain to her that we only here to care for her and that there are protocols to follow for discharge, her agitation escalated. She saw her nurse with the hospital gown in his hand and was yelling “don’t come near me, don’t touch me!” At this point a few other nurses tried to calm her down. She ran for the door and the head nurse told another nurse to lock it. She became physically violent and the head nurse told the clerk to call hospital police. Her nurse and the one who locked the door restrained her arms on either side and walked her back to her room. They aided the nursing staff with the vest and wrist restraints and her doctor ordered haloperidol. The nurse’s aide was still there to translate. She told us that the patient says she doesn’t trust any of us, and that we are supposed to be helping her but now we are tying her to the bed.
I know that in some cases, there is little to nothing that you as the nurse can do to calm a patient down. However, this case still made me feel a total loss of control. The patient escalated while communicating with me. I felt like I failed. Maybe if I had dome or said something differently, I might have been successful in calming the patient down. I am not sure if it’s ever possible to establish trust in such a short interaction with the patient, but it seems like a lack of trust played a major role in the patient’s agitation in the first place. This was not my patient, though. I did not have a prior opportunity to establish trust and rapport with this patient. This experience showed me that I am kind of clueless as to what to do in a sudden episode like this.
Journal Entry #5 – 6/29/2014
During clinical on a medical-surgical floor, I encountered a Russian male patient who was diabetic. He was an older gentleman (around 60 years old) and he was very tall (about 6’4). He was an overweight man that carried his weight around the midsection. This patient had a very thick Russian accent that made it difficult to understand him at times. He was also very aggressive. He expressed dissatisfaction with his treatment and wanted to be discharged. He would be discharged later in the day against medical advice (AMA).
It was time to do fingersticks, and as I stated before, this patient was a diabetic. He did not adhere to a diabetic diet, he refused to get out of bed, and he refused his fingerstick and insulin. This patient also had a female family member who brought him a pack of 6 large cookies and a water bottle filled with Coke. I asked the patient how he was feeling, and he said “I’m okay, I’m okay. I’m good.” He made hand gestures that meant “get away from me.” I told the patient that I wanted to check his fingerstick and he yelled “No! That’s it! It’s good for me!” I explained that I understood he would be getting discharged later, but until discharge we would like to make sure that he remains safe. The patient continued to make aggressive hand gestures and say that he’s okay. At one point he yelled “it’s my body! It’s my health!” I stepped back and asked the patient if I may know why he did not want me to check his fingerstick and I let him know that it would not prevent him from getting discharged later. The patient got up and walked towards the hallway saying to leave him alone, and that it is his health.
Later in the day, before lunch, I went to see if he would allow me to check his fingerstick. The food trays would be coming soon, and he had gone all day without his insulin. This time I was accompanied by the charge nurse. The patient was laying back and breathing heavily. I asked him how he was feeling and he yelled again “I’m fine! I’m good! It’s good for me! Lady, I don’t understand what you are saying to me. I’m good!” At this point I pulled back and left the patient alone. He did not want his blood glucose checked, nor did he want his insulin. He just wanted to be discharged. I did not have an opportunity to find out why because he was completely closed off to any interaction with me and anyone else on the staff. We left him alone, and the charge nurse documented that he refused and told the doctor.
I think that the interaction was appropriate on my end. It was hard dealing with this difficult and sometimes aggressive patient. His size and thick Russian accent were a bit intimidating but this did not affect my interaction. I also knew when to push and when to pull back. Although we didn’t accomplish our objective with this patient, I think I communicated effectively. Some patients are just difficult no matter what; sometimes they are just frustrated and want to be left alone.
