9 Communication, assessment and planning care
• To consider the importance of communication, assessment and care planning for older people in the practice setting
• To enable students to explore the tools and frameworks that form part of the assessment and care planning process with older people in practice
• To enable students to identify effective strategies for communication, assessment and care planning with older people in the practice setting
Introduction
We ask you to consider the role of communication, assessment and care planning in terms of establishing and maintaining high-quality person-centred approaches to patient care with older people, and it would be timely prior to reading this chapter to read Chapter 8 on the core philosophies. These core philosophies of care are a central tenet of assessment, care planning and communication and we refer to respect for individuality and using person-centred care approaches as an integrated part of assessment, care planning and communication throughout this chapter, thereby giving you the opportunity to think about how philosophies of care are translated from conceptual models into foundations of care and care practices with older people. In this way, we add another piece to the complexity of the ‘holistic’ jigsaw of caring for older people.
Introduction to communication
We all use various forms of communication which may be defined as spoken (oral), written or non-verbal communication. It is rarely transparent or uncomplicated. It shapes and transforms the world, establishes who we are and who others are in relation to us (Crawford et al 2006). However, for the most part, communication is a taken-for-granted part of our daily lives and one which we probably do not spend a great deal of time thinking about. For example, we may not always be aware of the many complex skills that we use in everyday communication encounters yet this is the very essence of how we establish and maintain relationships with those around us. Equally, it is hard to imagine how we would communicate if some of these taken-for-granted skills were no longer available to us, for example not being able to hear what is being said or to see the person with whom we are holding a conversation.
Within the context of health care, communication is a core, if not the core, aspect of nursing practice and we all need to develop excellent communication skills in order to develop therapeutic relationships with patients and clients and to be competent nurses (McCabe & Timmons 2006). Moreover, communication is not purely confined to the immediacy of the nurse–patient–client relationship but also includes carers, relatives and friends and at an organisational level. There is a need to develop and maintain effective communication strategies and understanding across many different disciplinary boundaries.
Moreover, it is only through effective communication that we as nurses are able to work with patients, clients and carers to identify their needs as individuals and to plan care appropriately, and as Faulkner (1996:2) has observed:
However, while we all recognise the importance of effective or ‘good’ communication skills, there are a number of factors which may inhibit effective communication in practice. In the following section we consider some of the issues that can impact on the quality of communication from the particular perspective of older people.
Quality of communication and the older person
As we noted earlier, communication is not just concerned with language, it is inherently bound within the wider context of the attitudes and the values that individuals hold. Negative attitudes and stereotypes towards older people may impact significantly on how individuals communicate with an older person, for example ignoring older people during a conversation or using inappropriate terms of address. This in turn has the potential to impact on the way in which an older person may feel about themselves and ultimately their self-esteem. Moreover, poor communication and pervading stereotypes of older people may profoundly affect the quality of care and treatment that older people receive. Blomqvist (2002), for example, found that the effective management of older patients’ persistent pain and pain relief in the clinical setting was inhibited by a number of factors including poor communication.
Negative attitudes towards older people and the impact on communication is an enduring theme in many publications, reports and studies relating to older people. For example, The National Service Framework (NSF) for Older People (Department of Health 2001) has identified the need to communicate effectively with older people as a central facet in the development of person-centred approaches to care and the eradication of age discrimination.
Brown & Draper (2003) have highlighted that older people may experience what they describe as a ‘mismatch’ between an older person’s ability to communicate and others’ perceptions of this ability. They suggest that this mismatch may lead to the use of inappropriate language, for example language used in health encounters with older people that may be ‘patronising’ or ‘infantilising’. The authors further suggest that this can exert a significant and negative impact on older people’s psychological and physical health.
Language is very powerful and the theme of ‘infantilisation’ has been explored elsewhere by Kitwood (1997) within the field of dementia care. As we considered earlier, personhood is clearly linked with status or ‘standing’ through the context of relationships, and Kitwood used the term ‘malignant psychology’ to describe the impact of a number of depersonalising tendencies that he observed during care encounters, one of which he described as ‘infantilisation’. Kitwood gives an example of this term where older patients in a dementia setting were described as ‘the babies’.
Efraimsson et al (2003) also illustrate the power of language and communication in their study which explored the interactions taking place during a discharge conference involving an older person. In this Swedish study, the authors video-recorded the discharge case conferences and used discourse analysis (this is a method of analysis that enables researchers to describe both the structure and content of a particular interaction) to explore the older person’s experience of the discharge planning case conferences. The authors found that the older person was often spoken ‘about’ in the third person during the conference discussions and that the content and structure of the meetings was mainly controlled and influenced by the professionals present rather than acknowledging the wishes of the older person or their family.
Different forms of communication
Communication has a number of elements, and while the way in which we shape communication encounters (for example, our attitudes, language and posture) are a central tenet of this process, there are a number of sensory barriers that may also impact on the ability and quality of effective communication with older people. Sensory loss is not uncommon among older people and can result from the ageing process or occur as part of an illness (for example, changes in vision, hearing or speech) and this needs to be taken into consideration when working with older people. We would also stress that sensory loss is not a necessary part of ageing, however the link between sensory loss and communication difficulties is well established. Heine and Browning (2004) also highlight that dual sensory loss, for example hearing and sight, affects a number of older people and again can have a significant impact on psychosocial functioning.
We can enhance and promote effective communication with older people through a range of approaches and Box 9.1 explores a number of ways in which communication with older people can be optimised in everyday encounters. These are not exhaustive and you may also wish to add some effective strategies that you have used from practice. You may also wish to consider how these strategies may have helped you in earlier encounters. You will observe or will have observed your mentor and other practice staff carrying out assessments. You may also have carried out nursing assessments with an older person yourself under supervision while on your placements.
Box 9.1 Maximising communication opportunities