2.1. Effective communication.

        Communication is important when dealing with others. How you communicate will affect how others feel and behave, which, in turn, can make your job difficult or easy. Learning how communication happens and some basic techniques will enable you to provide better care to your client. Communication is the process of sending and receiving a message. It consists of verbal and non-verbal communication. Verbal communication has to do with words, whether they are written, read, or said aloud. Words should be simple and clear so that people understand correctly. Remember that words may have different meanings to different people. Non-verbal communication, more commonly called ‘body language,’ sends a message too. We send messages with our facial expressions, tone of voice, gestures, posture, eye contact, and touch. Communication is misunderstood when the verbal and non-verbal (body language) messages are different. If you say one thing and your body is sending a different message, people get confused. Most people, when they get conflicting messages, will believe what they see. You have probably heard the phrase “actions speak louder than words.” That really applies in this situation. You need to be aware of your own body language as well as others.’

        Communication concepts

Principles of positive communication.

Types of communication

        Communication involves the imparting or interchanging thoughts, opinions, or information among people by speech, writing, or signs. People communicate in different ways. How effective is your communication style? Are you giving away thoughts you don’t mean to?

Verbal

        Verbal communication entails the use of words in delivering the intended message. The two major forms of verbal communication include written and oral communication.

        Written communication includes traditional pen and paper letters and documents, typed electronic documents, e-mails, text chats, SMS and anything else conveyed through written symbols such as language. This type of communication is indispensable for formal business communications and issuing legal instructions.

        Communication forms that predominantly use written communication include handbooks, brochures, contracts, memos, press releases, formal business proposals, and the like. The effectiveness of written communication depends on the writing style, grammar, vocabulary, and clarity

Oral/Verbal Communication

        The other form of verbal communication is the spoken word, either face-to-face or through phone, voice chat, video conferencing or any other medium. Various forms of informal communications such as the grapevine or informal rumor mill, and formal communications such as lectures, conferences are forms of oral communication. Oral communication finds use in discussions and causal and informal conversations. The effectiveness of oral conversations depends on the clarity of speech, voice modulation, pitch, volume, speed, and even non-verbal communications such as body language and visual cues.

        Verbal communication makes the process of conveying thoughts easier and faster, and it remains the most successful form of communication. Yet, this makes up only seven percent of all human communication!

Nonverbal Communication

        Nonverbal communication entails communicating by sending and receiving wordless messages. These messages usually reinforce verbal communication, but they can also convey thoughts and feelings on their own.

        Physical nonverbal communication, or body language, includes facial expressions, eye contact, body posture, gestures such as a wave, pointed finger and the like, overall body movements, tone of voice, touch, and others.

        Facial expressions are the most common among all nonverbal communication. For instance, a smile or a frown conveys distinct emotions hard to express through verbal communication. Research estimates that body language, including facial expressions, account for 55 percent of all communication.

Paralanguage

        The way something is said, rather than what is actually said, is an important component of nonverbal communication. This includes voice quality, intonation, pitch, stress, emotion, tone, and style of speaking, and communicates approval, interest or the lack of it. Research estimates that tone of the voice accounts for 38 percent of all communications.

        Other forms of nonverbal communication usually communicate one’s personality. These include:

• Aesthetic communicationor creative expressions such as dancing, painting, and the like.
• Appearance or the style of dressing and grooming, which communicates one’s personality.
• Space language such as paintings and landscapes communicate social status and taste.
• Symbolssuch as religious, status, or ego-building symbols.

Visual Communication

        A third type of communication is visual communication through visual aids such as signs, typography, drawing, graphic design, illustration, color and other electronic resources.

        Visual communication with graphs and charts usually reinforces written communication, and can in many case replace written communication altogether. As the adage goes “a picture is worth a thousand words”; such visual communication is more powerful than verbal and nonverbal communication on many occasions. Technological developments have made expressing visual communications much easier than before.

        A good understanding of the different types of communication and communication styles can help you know and deal with people better, clear up misunderstandings and misconceptions, and contribute to the success of the enterprise.

        2.1. Effective communication.

Everything you do or say communicates a message.

        Good communication skills are essential. Speaking, listening, feedback, and actions are important for everything a PCW does:

• providing proper care, following directions
• showing concern, building trust
• getting along with residents, families, visitors, and co-workers reducing conflict, solving problems
• reporting observations, giving clear messages
• listening, not interrupting or judging
• explaining procedures, resolving concerns
• building relationships

         Communication simply means sending and receiving messages. However, effective communication involves more than words. Both verbal and nonverbal messages carry meaning.

        Verbal. Words. Use simple and clear words.

        Nonverbal. Body language.  Everything you do sends a message:

• facial expressions;
• gestures;
• tone of voice;
• posture;
• eye contact;
• silence touch.

        Verbal and nonverbal language must agree in order to send clear messages. The problem is that most people are not aware of their nonverbal behavior. Unless verbal and nonverbal language agree, the listener gets a mixed message. For example, if the PCW expresses care and concern, but stands with folded arms and a look of disgust, the client gets conflicting messages. Unfortunately, when messages are mixed, the nonverbal impressions speak louder than the words.

        Communicate as clearly as possible to avoid any confusion. Medical abbreviations are important for  PCWs lo know in order to understand instructions. But  do not use abbreviations when you are talking with  the clients or their families. Use words that are  easily understood.

Listening

        Active listening takes effort, self-control, and practice. Pay attention to what the other person is saying, and fight the tendency to think about your reply while the other person is talking. Avoid interrupting or finishing someone else’s sentences. Teach yourself to be patient and wait for your tum to talk.

        Clients need to feel listened to, heard, and understood. Listen for facts and listen for feelings. Ask questions when you do not understand. Being a good listener helps the PCW learn what the client likes and doesn’t like, as well as problems, concerns, interests, and needs.

Feedback

        Words have different meanings to different people, which can lead to misunderstandings. Feedback is a process to avoid confusion and to clear up any misunderstanding.

        To be sure that you understand what others say to you, paraphrase (repeat what you heard using your own words). Ask if the statement is correct. Check whether others understand what you are saying by asking questions and encouraging feedback.

Guidelines for Effective Communication

        Open your heart to the clients, and try to understand their problems, pain, and frustrations. Try to imagine what it is like to be in their situation. Take time to smile and say “hello.” Convey warmth, understanding, and interest. Small acts of kindness can brighten someone’s day.

        Communicate with people at their level of under­ standing. Use an appropriate manner, level, and pace according to individual abilities.

• Take time to listen.
• Be patient, and show respect.
• Think before you speak.
• Be aware of your body language.
• Speak clearly, and use a friendly tone.
• Use simple words and short sentences.
• Ask open questions (e.g., “how?” or “why?”).
• Paraphrase (summarize in your own words).
• Ask for clarification.
• Be alert to key words about feelings (e.g., “guilt” or “hurt”), and ask for more information.
• Avoid criticizing or judging.
• Do not interrupt.

        Good communication skills build positive relation­ ships. Keys to maintaining good relationships include kindness, caring, and understanding.

Good Communication Techniques

• Listening: Take the time to listen. Pay attention to what others are saying and ask questions. Always communicate what you are doing with the care recipient. Do not work in silence.
• Be patient: Give others the time to say what they want.
• Eye contact: Look at the person and focus on what he/she is saying. Listen with interest.
• Body Language: Be aware of facial expressions and tone of voice. Watch others for differences between verbal and non-verbal messages.
• Keep conversations and words simple and clear.
• Use feedback: Repeat what you heard in your own words.
• DO NOT do the following:

1. Argue with anyone;
2. Interrupt a conversation;
3. Appear bored or impatient;
4. Pass judgment or give advice;
5. Threaten or use harsh language;
6. Be defensive – (It is better to be open to suggestions).

Barriers to communication.

        There are many reasons why interpersonal communications may fail.   In many communications, the message (what is said) may not be received exactly the way the sender intended. It is, therefore, important that the communicator seeks feedback to check that their message is clearly understood.

        The skills of Active Listening, Clarification and Reflection may help but the skilled communicator also needs to be aware of the barriers to effective communication and how to avoid or overcome them.

        There are many barriers to communication and these may occur at any stage in the communication process.  Barriers may lead to your message becoming distorted and you therefore risk wasting both time and/or money by causing confusion and misunderstanding.  Effective communication involves overcoming these barriers and conveying a clear and concise message.

Common Barriers to Effective Communication:

        A skilled communicator must be aware of these barriers and try to reduce their impact by continually checking understanding and by offering appropriate feedback.

• The use of jargon. Over-complicated, unfamiliar and/or technical terms.
• Emotional barriers and taboos. Some people may find it difficult to express their emotions and some topics may be completely ‘off-limits’ or taboo.
  • Lack of attention, interest, distractions, or irrelevance to the receiver. 
  • Differences in perception and viewpoint.
  • Physical disabilities such as hearing problems or speech difficulties.
  • Physical barriers to non-verbal communication. Not being able to see the non-verbal cues, gestures, posture and general body language can make communication less effective.
  • Language differences and the difficulty in understanding unfamiliar accents.
  • Expectations and prejudices which may lead to false assumptions or stereotyping.  People often hear what they expect to hear rather than what is actually said and jump to incorrect conclusions.
  • Cultural differences.  The norms of social interaction vary greatly in different cultures, as do the way in which emotions are expressed. For example, the concept of personal space varies between cultures and between different social settings.
  • Physical and emotional condition changes.

        2.1. Effective communication.

The body changes with age:

        This section looks at body changes. You will also learn about the changes to specific body systems and you will gain some useful information about how to provide quality care for clients who are getting older.

Visible changes.

        Many visible changes take place with age. People grow shorter as the vertebrae may compress on to each other (the spinal column compresses). The density of bones decreases, mostly in women. Muscle tone and size decrease, the tendons become less flexible and cartilage deteriorates. These changes can cause a loss of flexibility and strength, changing the overall shape of a person’s body. Wrinkles, drier skin, decreased amounts of scalp hair and a reduction in the level of pigmentation in the skin are all common in the elderly. The skin also becomes less elastic; in other words, it doesn’t have as much stretch as younger skin. An older person’s skin gets thin, making it easier to bruise, scratch or tear. Older people perspire less, hair becomes gray and the finger and toenails grow more slowly, showing some discoloration and lines.

        Sensory changes.

        Many sensory changes occur with aging. Hearing loss occurs. Sounds in the higher frequency range (such as high-pitched voices) are lost first, and sounds must be louder to be heard. Hearing problems can contribute to isolation, anxiety and depression in the older adult and can result in behavior problems. The client may withdraw from gatherings rather than strain to listen.

As a direct care staff person, communicating with clients who suffer from a hearing loss can be difficult, but using the following ideas will make your job easier:

• Make sure that if clients wear hearing aids, they are in and the batteries are working.
• If they don’t wear a hearing aid you can do the following to communicate:
• Face the person and get their full attention before you talk.
• Decrease noises.
• Speak clearly and slowly.
• Speak at a lower pitch or your normal pitch.
• Use pleasant facial expressions and gestures.
• Remove gum and candy from your mouth.
• Keep your hands away from your face in case they follow your lips to understand what you are saying.
• Allow time between sentences and rephrase sentences if necessary.
• Use a pad of paper to write notes.

        Vision, like hearing, is another common change in older adults. Normal changes in vision include the lack of ability to see close and read. Larger print is helpful. Older persons also do not see as well at night. In general, older adults see better with twice the light that they may have needed in the past. If the light seems very bright to you, it may be just at the limit of what the older person needs to be able to see. Make sure to avoid glare however, as this will interfere with vision too.

         Sensitivity to smell and taste decrease with age. Older persons cannot taste foods the way they used to taste. This can lead to less interest in eating. If an older adult client has less pleasure when eating, this may affect what he/she eats. An older person may have a reduced appetite and weight loss. If he/she is not getting proper nutrition it may affect other body functions such as healing of wounds. Not all taste abilities decline at the same rate. The sensitivity to the taste of salt does not decrease as much as sensitivity to some other tastes, such as to sweet foods. The concern here is that this can lead to clients eating more salt than they need, and this can lead to excess fluid retention.

        The sense of touch changes. In older adults the sense of touch may decrease as skin loses sensitivity. Pressure, pain, cold and heat do not feel the same as they used to feel. Decreases in touch sensitivity may cause clients to drop things. An older adult client may not notice the temperature of water, so he/she can get burned more easily. You may find that you must frequently check the temperature of things before a client comes into contact with them. As a direct care staff person, watch for skin discoloring that is white or purple in color, open areas and for skin that is cooler to the touch.

        Cardiovascular system. This system includes the heart, lungs and the blood vessels. Circulation of the blood slows down; this can result in older clients feeling cold, especially in the hands, feet and legs. Cuts and tears to the skin may take longer to heal and require extra care. One suggestion or guidance you can provide is to encourage the client to change positions so they are not always lying down or sitting. This will help avoid skin breakdown and increase circulation. However, be sure that changes in position are done slowly so as not to cause the client to get dizzy and fall.

        Neurological system. This system includes the brain and nerve system. Cells in the brain that are lost do not reproduce, and up to 25% of brain mass can be lost in the aging process. Older people take longer to remember things, respond to questions and finish certain kinds of tasks. It is not a sign of less intelligence. Rather, it simply takes longer to make the connections in the brain than it did when the client was younger.

        Respiratory system. This system that keeps us breathing changes with age, too. It takes longer to get better after a cold or flu. It is important to watch for and report shortness of breath and swelling in the legs or feet.

        Urinary system. Prostate infections (in men) and infections in the bladder may increase, and recovery is slower. As a direct care staff person, to reduce the risk of bladder infections, teach the female client to wash her private area from front to back. Watch how much the client drinks (ideally, he/she should drink eight large glasses of water a day). Encourage the client to use the toilet every two hours to reduce the risk of accidents and infections. Watch for dark, foul smelling urine and increased urinary frequency. These may be signs of a urinary tract infection that can cause pain, burning, increased confusion and behavior problems. Report any changes in urine or toileting to your supervisor.

        Digestive system. This system breaks down food. Changes in the teeth and loss of teeth occur more with the elderly and can have an impact on ability to chew and digest food. If the teeth are not strong, soft food may be easier to chew. The client may need to drink more to help swallow.

        Muscular-skeletal system. A client’s muscles may be weaker, joints may be sore and stiff and bones may be brittle. As a direct care staff person, you may have to assist the client in getting in and out of a chair and with activities such as dressing and walking. Encourage the client to do simple exercises to keep limber. Walking and simple exercises are excellent activities to prevent stiffness and pain.

        Psychological issues and aging:

        Older people must make many adjustments. Often these adjustments are handled without any problem and the quality of life stays high. Less often, people struggle, and in some cases experience stress that reduces their quality of life. Older persons may feel afraid, confused, nervous or helpless. Generally, these reactions happen when there is a sudden and unusually negative change in the person’s life situation. When you observe any of these reactions, report them to your supervisor immediately.

        It is normal for any of us to be temporarily depressed over a loss, and this is true for an older adult. Over time we adjust and this situational depression lifts. However, depression that continues without improvement is not a normal part of aging, and it can be quite serious. People who are depressed have a much higher risk of suicide. Because depression is treatable, it is important to recognize its symptoms and report them to a supervisor who can arrange for an assessment.

        The symptoms for depression include: sadness, guilt, a sense of worthlessness, hopelessness, fatigue, tearfulness, weight loss, irritability, excessive complaints of aches and pains that have no apparent cause, anger and sleep disturbances. One of the things that makes it harder to recognize depression is that it can often occur with other diseases or conditions such as dementia, heart disease, Parkinson’s disease, stroke, diabetes and cancer. When this happens it is easy for people to assume that it is normal for someone with one of these conditions to be depressed. This is dangerous thinking and is not true. Despite having another illness, someone who is depressed should be treated for the depression along with treatment for other illnesses.

        2.1. Effective communication.

Carefully observe each client throughout your daily contacts.

        Personal Care Worker need to be alert to problems or changes in each client’s physical or emotional condition. Follow agency procedures for what to report immediately and what to report in writing. Accurate, thorough, and timely records of care and observations of each client are critical.

        All information is confidential, and records must be safely stored when not in use. Some facilities keep handwritten records, and other facilities use computerized systems.

        The HIPA A* Privacy Rule provides federal protection for personal health information. All records (written or electronic) are confidential. As a health­ team member, it is critical that you understand the facility policies regarding the safekeeping and privacy of all records.

• Health Insurance Portability and Accountability Act

         Everything in the chart is confidential.

        Keeping the information confidential is

        your responsibility legally, ethically, and morally.

Observing

        Observe each client throughout your daily contacts. Being a skilled observer helps prevent serious problems and earns the respect of the team staff. Being alert to the client and the environment reduces safety hazards and health problems. Careful observation increases your awareness of each client’s physical, emotional, and social needs.

        Learn to recognize signs and symptoms of common diseases and conditions. Detecting problems in their early stages is critical. Trust your instincts. If something seems wrong, report it.

        Be alert to emotional changes:

• Mood swings, loss of control
• Depressed, hopeless, crying, tearful
• Angry, difficult, irrational, agitated
• Disoriented, confused
• Anxious, frightened, pacing, restless
  • Decreased or increased functioning (e.g., pulse, breathing, elimination)
  • unconscious, weak, dizzy, drowsy
  • Shaking, trembling, spasms.
  • Chest pains.
  • Cold, pale, clammy, chills.
  • Hot, burning, sweating, feverish.
  • Nausea, vomiting odor.
  • Diarrhea, constipation.
  • Excessive thirst, change in appetite.
  • Change in skin color.
  • Ringing in the ears.
  • Blurred vision.

Be alert to physical changes:

• Swelling, edema rash, hives, blisters;
• Choking, coughing, wheezing, sneezing shortness of breath;

• Red or irritated areas, pus, drainage.
• Change in activity level weakness on one side.

Reporting

        Thorough and accurate reports are made to the nursing staff as often as the resident’s condition requires. End-of-shift reports to the oncoming staff provide the information necessary for continued good care. Follow facility procedures.

        2.1. Effective communication.

        How do I communicate with impaired elders? As a personal caregiver you may provide care to a client who has physical disabilities or impairments that may interfere with communication. The following are some techniques to use in those situations.

Blind or Visually Impaired Elder

• Get the person attention before talking.
• Identify yourself when entering the room.
• Say their name.
• Use common sounds, such as ringing a bell, whistling, etc.
•  Explain what you are doing as you do it.
•  Ask for feedback to check for understanding.
•  Make sure eyeglasses have up-to-date prescriptions and are clean.
•  Print in big, bold letters when necessary.

Deaf or Hearing Impaired Elder

• Make sure you face the client who reads lips.
• Use visual actions to communicate.
• Get their attention before talking to them.
•  Face them when you are talking. Maintain eye contact; avoid turning or looking away while you are talking.
•  Talk at a normal pace.
•  Raise your voice some and lower your tone. DON’T yell. Speak to the side where hearing is best.
• If necessary, use paper and pencil to write messages.
•  Get rid of other noises – TV, radio, etc.
•  Make sure hearing aides are working and are properly inserted.
•  Write down messages.
• Ask for feedback to determine understanding.

Speech Impaired, Aphasic Elder (Aphasia-Trouble speaking or understanding, often result of a stroke)

• Address the person by name.
• Keep communication simple and clear. Speak slowly and use simple words.
• Ask questions that can be answered with yes or no.
• Make message clear, emphasizing key words, limiting details.
• Eliminate unnecessary background noises (to help the client concentrate on what is being said).
• Be patient. Give the client enough time to respond to you. At least 10 seconds is the recommendation. (Time yourself for 10 seconds so you can see how long it is. You’ll be surprised!)
• Use visual devices like a message board, pictures, or gestures.
• Be supportive and positive, avoiding criticism/corrections.
• Pay attention to body language
• Ask the person to repeat if necessary, rather than pretending you understand.

Guidelines for communicating with the cognitively impaired client

Communication with the Cognitively-Impaired Client:

COGNITIVE: 

DEMENTIA IMPAIRED

        What is dementia? Dementia is a gradual decline in mental and social functioning compared to an individual’s previous level of functioning. A client may have memory loss, personality change, behavior problems, and loss of judgment, learning ability, attention and orientation to time and place and to oneself. Alzheimer’s disease is the most common cause of dementia, and we will spend more time on this as it will likely be one of the more frequent causes of cognitive impairment of residents in your facility.

        Alzheimer’s disease is a chronic, progressive debilitating illness. At first the symptoms are mild and might include difficulty remembering names and recent events, showing poor judgment and having a hard time learning new information. At this early stage the person often tries to deny their problems. Most difficulties at this time are with performing IADLs.

        As the disease progresses, the person is unable to judge between safe and unsafe conditions and will need help to dress, eat, bathe and make decisions. There may be personality changes such as increased suspiciousness. Unfamiliar people, places and activities can cause confusion and stress. The person shows less interest in others and wants to withdraw to familiar, predictable surroundings and routines. The person in later stages has difficulty performing basic ADLs.

        Some common behaviors associated with Alzheimer’s disease are rapid mood changes, crying, anger, pacing, wandering, doing things over and over, asking the same question, following people closely and inappropriate sexual behaviors.

        Cognitive impairment refers to difficulty in processing information. There are numerous diseases that cause cognitive impairment, such as Alzheimer’s, Parkinson’s, Multi-Infarct Dementia, and AIDS. All of these diseases affect the brain in different ways to cause the impairment. Care recipients with any of these conditions will require unique caregiving in order to deal with some of the problems present. The symptoms presented will vary from person to person and will depend on the stage of the disease. Some of the common symptoms associated with dementia are as follows, with some examples:

• Gradual memory loss
• Inability to perform routine tasks–dressing, cooking, cleaning
• Disorientation in time and space – don’t know what day it is or where they are
• Personality changes
• Unable to learn new information
• Judgment is impaired – doesn’t know if something is safe or is unable to make choices
• Loss of language skills – can’t remember words, etc.

        Much of the time care recipients with cognitive impairment do not know what they are doing or saying. They have little control over thoughts or behavior. You usually cannot change the care recipient and, instead, must change how you react. This is the most important thing to remember.

• The care recipient is not asking you the same question over and over and over to annoy you.
• The care recipient does not remember and that is why the question is repeated.

        Continue to answer the questions. Look for possible reasons for the repeated questions, such as the need for reassurance, acceptance, or love. Another way to look at this type of behavior is this – to the care recipient, there is no past and no future, but only the immediate present.

        Cognitive impairment (cognition means of or relating to conscious thinking) is a term that simply means someone has lost a large amount of his/her higher intellectual ability. What do we mean when we use the term higher intellectual ability? We mean the ability to think and reason, the ability to use logic. We mean the ability to communicate and the power of memory. We mean all of the mental capacity that we need in order to function as human beings in our daily lives People with cognitive impairment have difficulty in communicating. They have difficulty in understanding what is said to them. They can, at times, become confused about whom you are, and they can be confused about who they are. They can be confused about where they are, what day of the week it is, and what year it is. People who suffer from cognitive impairment do not have the ability to think clearly and logically or they may only be able to do so once in a while. There is no one single condition, illness, or disease that causes cognitive impairment. People with cognitive impairment may have had a stroke, they may be suffering from Alzheimer’s disease, they may have had a head injury, or it may not be known why they have lost the ability to be rational. The only certainty is that there has been some illness, disease or accident that has permanently damaged the parts of the brain that control the ability to think, concentrate, and reason.

        Although many people with cognitive impairment are elderly, being old does not always mean that someone has a diminished mental capacity. But regardless of why your clients have cognitive impairment, coping with this situation can be very difficult. It takes patience and compassion. Above all, as a health care professional, you must remember that these patients do not have the ability to function and think as you do. We use our powers of thought, concentration, memory, logic, and language to cope with the world around us. For these people, those skills are absent or severely damaged. As a result, they cannot understand what they see and what you say. Many times, this will leave them frightened and confused. And more importantly, it leaves them dependent on you as a professional.

        And the confusion and difficulty in communicating with these clients can be quite frustrating. So, make no mistake about it: working with a client who has a significant degree of cognitive impairment can often be very difficult. However, it is important to realize that these interactions are a two-way street; the situation is difficult for the client, as well. So when you are caring for someone who is confused, uncooperative – perhaps even aggressive – it is absolutely natural to feel frustrated. But remember: the client is doing the best he/she can and their feelings of confusion and fear are probably just as intense as your feelings of frustration.

        A PRACTICAL APPROACH TO WORKING WITH CLIENTS WHO HAVE COGNITIVE IMPAIRMENT fortunately, with the proper attitude and some simple techniques, working with in these situations doesn’t have to be painful for you or your clients. Here are some basic tools that can help you when you are working with a client who has cognitive impairment.

        Patience: You will need a lot of patience. The natural instinct when interacting with another adult is to assume that he/she is at your level of emotional and intellectual ability. This is not true of the client with cognitive impairment. This is a simple idea to understand, but many people have difficulty remembering this.

        Non-verbal communication: Most of us think of communication as what we say or the words we use. But much of our communication is non-verbal. The tone of your voice, the loudness or softness of your speech, the speed at which you talk, the way you stand, and where you stand when you speak to someone – all of these are forms of non-verbal communication. People with cognitive impairment may have lost the ability on an intellectual level to understand what you are saying. But their other senses are completely intact. They will, often, respond to how you speak to them rather than what you are saying. It is often best to stand where the person can easily see you. Making eye contact is important. Avoid touching the person until you are sure he/she won’t feel threatened by physical contact. Never pull or yank on someone if you want that person to move, change positions, stand up, etc. When you first approach someone, try and do so slowly; don’t rush at them.

        Verbal communication: You don’t have to be talk down to these people. However, until you have established otherwise, it is sensible to be gentle when talking to these clients. Speak slowly and clearly. Try and keep your language at a basic level. Give them time to process what you are saying, and try and remember that it may take them far longer than you imagine to completely grasp the meaning of what you have said. It also helps to keep your communication simple and direct. Don’t be afraid to repeat what you have said, and don’t be surprised or frustrated if you have to. And don’t forget: although you may remember something that was said to you earlier in the day or earlier in the week, these clients may forget something that was said to them just an hour ago. Constant repetition and reinforcement will help clients to remember. Do not speak quickly, and make sure that you use simple language…

        Flexibility: Perhaps nothing is more important when working with a client who has cognitive impairment than flexibility (And the opposite is also true: nothing is more harmful when working with these clients than being stubborn or rigid). What do we mean when we use the term flexible? It means simply that you adjust to the demands of the situation. It means that you are able to change your plans. It means that you realize what is/isn’t important, and that you know that getting the task done is far more important than how you do it.

        Priority setting: All too often, health care professionals see their job as a series of tasks that need to be accomplished. That is true, but working with people is very complex. Many times it is simply not possible to do everything you need to do and want to do in the way you want to and when you want to. Situations change and people change. If you are not able to clearly see what, at any given time, is the most important priority, your job will be very difficult. Ask any experienced health care professional and he/she will tell you: in order to function efficiently, it is very important to know and decide what is most important, but you also need the ability to see that the situation has changed and to understand that a new, more important priority has replaced the previous one.

        Regular routines: Because the person with cognitive impairment has difficulty remembering people, places, and situations, he/she can be helped by establishing reliable routines. If it is possible, try and arrange for the same PCW to work with the same clients. Try and find a routine for daily activities that is simple, does not change, and will be easy to remember for the client. Be careful to slowly introduce changes into the client’s daily routine, and try and explain these changes as clearly as possible. And if you tell the client that you are going to do something, make sure that you follow through on your promise. The client may surprise you by remembering what you said (e.g., you will in his/her home at 9 in the morning to help them get dressed) and may become disoriented if you do not keep your word. Example: Imagine that you need to assist a client in getting out of bed and getting dressed. You are very busy and you have a lot of other things you need to do for other clients, as well. But the client you are working with is resisting all of your efforts. He doesn’t want to get up, and he doesn’t want to get dressed. You can’t understand why, and he can’t tell you. You can try and force the issue, but when you do, he begins to get agitated. You need to determine what the most important priority is, and what the best way to accomplish that goal is. Perhaps in this situation you have more time than you think. You might be able to sit quietly with this person for a bit and give the person a few minutes in which to adjust. Perhaps you can accomplish the task in steps; this will also give the client time to adjust. Also, you might be able to move to another task with another client. It may not be important – really important – that the client get dressed right at that time you had planned. Always ask yourself: Can you change your priorities to make your day and the clients run a bit smoother?

        2.1. Effective communication.

Care of Clients with Mental Illness/Mental Retardations.

        How to care for residents with mental illness and mental retardation? The clients in your home care agency come from a variety of backgrounds, have different life experiences and have unique personalities. Some are easy-going and cheerful. Some may like to argue. Some are very active. Others are relaxed and content. In addition to the basic differences, many may also have impaired mental abilities, whether it has been a condition all of their life or a more recent onset. As a direct care staff person, it is important to have a good understanding of each resident with whom you will be working, including those who have mental deficits or impairments.

        In this session we will look at the three main causes of cognitive impairment. You will be able to identify the symptoms, describe some of the behaviors common to these conditions and identify methods of interaction that are most effective in dealing with challenging behaviors.

        Every person is different, and everyone has good days and bad days. It will be important to get to know each resident and develop your skills in working with each resident as an individual.

Mental retardation:

        What is mental retardation? A person with mental retardation has lower intellectual functioning – meaning his/her IQ is significantly below average. He/She may need help with the daily living skills needed to live, work and play in the community. These include communication, self-care, social, leisure and work skills. Mental retardation can be caused by any condition that impairs development of the brain. Some common causes of mental retardation include genetic conditions, problems during birth, alcohol and drug use by the mother, some childhood illness and exposure to toxic materials.

        The abilities of people with mental retardation vary. Most people with mental retardation are mildly affected and are able to learn new skills. With appropriate supports all individuals with mental retardation can live satisfying lives in the community.

        Clients with mental retardation have social interests and needs that match their age. Keep this in mind as you consider the music they like, the clothes they want to wear and the activities they enjoy. It is important to get to know the abilities of each person and allow as much independent decision-making as possible. It is also important not to talk to or treat a person with mental retardation like a child. She/he is an adult who likes adult activities and has adult interests.

Mental illness:

        What is mental illness? A mental illness is a disturbance in behavior, mood, thought process, social skills or interpersonal relationships. There are many different types of mental illnesses and different levels of severity.

        A client with a mental illness may be younger and in the home due to his/her care needs, or the client may be elderly with a mental illness. These will be important issues to know about each individual. A client with a mental illness may feel deep sadness, may hear voices, may be very suspicious of others, may change moods quickly or may have emotional highs and lows. These are symptoms of mental illness and not a person’s choices or bad behaviors.

        Many people with mental illness are treated with medication under the care of a doctor. These medications can greatly reduce the symptoms of the illness, but many often have unpleasant side effects. It will be helpful to you and the client if you take the time to learn what medication is being taken, and the side effects. You may also notice that there is frequently a cycle that occurs with some mental illnesses. A person can be doing quite well for a period of time, and then start to slip into some of the symptoms of their illness. This can be a challenging time for everyone. There needs to be a re-evaluation by the doctor and possibly an adjustment in medication or in the person’s program or environment. As a direct care staff person, you are part of the team that observes behavior. If you are noticing changes in behaviors, be sure to follow the home’s system for reporting and documenting. This will be very helpful to others in considering treatment options.

        2.1. Effective communication.

        Now that we have a basic understanding of three of the most frequent reasons for cognitive impairment, we will look at some basic behavior management skills.

        As stated throughout this training, you are likely to be faced with challenging behaviors on a regular basis. If you develop strong skills in managing these behaviors and in communicating effectively with clients, this will help you in dealing with difficult situations and provide better care for the clients in all aspects of your job, from helping with ADLs, to encouraging clients to take part in social activities in the home or in the community.

        “Behavior management” involves using certain techniques and ways of interacting in order to increase or decrease certain behaviors. It can be very effective, but it is not a quick fix, and it must be used consistently.

        Think of your behavior management skills as tools in a toolbox. In this toolbox you have many different and effective ways of dealing with people and behaviors. Depending on the behavior, the person and the situation, you will affect the decision about which tool to use. Sometimes it may take a few tries to figure out what will work best, and some days it will be harder than others, but we will begin by placing some tools in our toolbox.

        Remember, we are just touching on these basic principles. There is much to be gained by learning more about positive behavior techniques, and you are encouraged to seek out additional training, observe people who use these techniques effectively and take notice of your own interactions and how you can improve upon them. In addition to the basic ideas we will discuss here, residents in your care will have specific support plans developed by the care team. It is important to become familiar with these plans and use your skills to follow them.

Tool # 1 – Ask questions to figure out the reason for the behavior.

        There are many causes of behavior. If you notice a change in a client’s behavior, talk with other members of the care team to find out what might be going on. If it is an ongoing problem, first look to see what the cause might be. You may need to observe for a while to see what might be happening.

        If a client is in pain, for example, it is important to take note of things such as whether he/she had a recent fall or whether they have recently been ill. If a client is not eating enough at mealtime, this may be a problem with his/her dentures fitting okay, it may be a problem with chewing and swallowing or it may be that he/she does not like the food. Watch to see when and how much the resident eats. Watch the client’s facial expressions. Watch the resident’s reactions to the people sitting at the table. What has changed recently?

Tool # 2 – Use positive reinforcement/rewards.

        If you see a good behavior by a client, praise the good behavior. Behavior that is rewarded will be repeated.

Tool # 3 – Listen with understanding.

        When we show a person that we are interested and want to understand their feelings we are showing that we care about them as a person. We connect with them on a more personal level which can help them feel less lonely. We show this by listening to the resident and talking with the resident. Try to understand the client’s feelings.

Tool #4 – Smile and keep it positive!

        Believe it or not, a smile can go a long way when working with people. The times you feel least like smiling are when it will be the most important that you make your best effort. Take a deep breath, go into the room with a smile and be positive.

General Guidelines

        The following are some simple guidelines that should help you in dealing with care recipients who have cognitive impairments:

• Speak slowly.
• Keep conversations short and simple.
• Do NOT argue or reason with the care recipient.
• Write down instructions, keeping them simple and step-by-step.
• Do tasks one-step at a time?
• Provide objects that make things easier, such as slip-on shoes, finger foods, etc.
• Maintain a routine. Change of routine adds confusion.
• Use the memory loss to your advantage to distract the care recipient.
• Provide a safe living environment.
• Label drawers, cupboards, and doors.
• Encourage as much independence as possible.
• Approach the care recipient slowly from the front.
• Limit the choices the care recipient has to decide among.
• Play music since it is therapeutic. Make tapes.
• Use validation therapy. (Explained below).

Validation therapy.

        Accept and acknowledge when they are feeling paranoid, afraid, etc. and talk about those feelings. Don’t try to convince them their feelings are wrong.

        Look for hidden messages:

• If the care recipient makes baby crying sounds, it could mean they feel like a baby in a crib when in a bed with the side rails up.
• Looking for parents could mean they feel lonely or scared.
• Wanting to go to work could mean a feeling of uselessness.
• The care recipient cannot express any of these feeling in the usual way. You have to search for them and interpret them.

Nonverbal Communication Techniques

        Care recipient with cognitive impairment will have difficulty communicating with you and understanding your communication to them. Use the following techniques to help you:

• Use low-pitched voice.
• Use gentle touch.
• Give more time for a response.
• Approach care recipient slowly and calmly. Never display any frustrations you may feel.
• Get rid of as many other noises as possible.
• Have care recipient point to an object.
• Label drawers, etc.
• Have recognizable pictures in view.
• Cue care recipient to begin task by pointing, touching, or beginning the task for them.
• Observe non-verbal behavior for clues.

Wandering Behavior

        Your care recipient may display the behavior of wandering. This can be the result of restlessness, of a search for something, or of unexpressed feelings. Here are some techniques to help you with this behavior:

• Surround the care recipient with familiar objects.
• Remove trigger objects, such as coats or suitcases.
• Check care recipient often for hunger, thirst, or need to void.
• Keep the care recipient occupied with a task.
• Put up stop signs or barriers at exits. Cover knobs.
• Use the care recipient’s memory loss to your advantage by distracting them with something more appropriate.
• Give the care recipient something active to do.

        Repetitive and/or Inappropriate Behavior As in every other situation, remember that the care recipient does not know that what he/she is doing is repetitive or inappropriate. The part of the brain that would know this is no longer working properly. Do NOT scold or yell at them. Instead, try some of the following suggestions:

• Be non-judgmental.
• Calmly suggest a new task that is more appropriate.
•  Look for antecedents – something that always happens before the behavior.
• Plan activities to keep the care recipient occupied.
• Offer reassurance.
• Praise the care recipient when the behavior is appropriate.

        Use positive statements. Tell the care recipient what you want him/her to do, NOT what you don’t want.

        2.1. Effective communication.

WORKING WITH THE CLIENT WHO BECOMES AGGRESSIVE

        Most of us are able to sit back and assess a new situation. We can decide if we like what we see, whether or not it is safe, and if we are not comfortable, we can simply avoid it. And as we gain experience in the world, this process becomes easier because we have encountered similar situations before: the learning process has become more efficient. But for the client with cognitive impairment this is not the case. Because of their impairment, many situations – even ones they have encountered many times before – can seem new. Like everyone else, this can make them anxious, but unlike most people, they cannot draw on their past experiences to interpret what is happening now. And they cannot quickly assess what is happening because of their impairment. Not surprisingly, they feel vulnerable and afraid. And many people, in those situations, will feel they need to defend themselves and become aggressive. It can be very difficult to work with someone who is confused and aggressive. You need to keep that person safe, but you must also protect yourself and others. Fortunately, with some common sense and a little planning, you can accomplish these goals. · Do not indiscriminately use force: Using force can often backfire. Certainly, there are times when you need to physically restrain someone. But when and how to do so should be clearly outlined in the policies of the institution in which you are working. Make sure you familiarize yourself with them before these incidents happen. · Stay calm: It is natural to become excited when someone is acting aggressively. But many times, if you allow that person to express the anger, the possibility of physical violence can be avoided. Most people have a natural aversion to harming another person, so give the person who is angry the opportunity to be verbal rather than physical. · Use reason: Try and remember that the person who is acting aggressively is not doing so to harm you. That person believes that he/she is trying to protect themselves. Don’t give them another reason to feel threatened. Be quiet, rational, and calm.

DEALING WITH DIFFICULT BEHAVIOR

        Behavior may disguise a client’s need for comfort and understanding.

        How do I communicate in difficult situations? If care recipients are angry, try not to take it personally. Often, they are upset about the situation and don’t know how to handle it. Give them some space and listen to their concerns. Do not raise your voice or get defensive, this will only add to their anger. Sometimes the best thing to do is not to respond but just to listen.

        Recognizing the link between actions and needs helps build good relationships. Keep in mind that residents in long-term care are adjusting to changes in their lifestyles that affect them physically, emotionally, and socially.

        Difficult behavior may signal a need for comfort and understanding. Or it may be an attempt to be in control when a person feels powerless. For example, rather than being annoyed when a resident continua uses the call light, stop by often to offer reassurance.

        Basic psychological needs are the root of most conflict. Following are four basic needs identified by Dr. William Glasser for motivating behavior.

        Belonging:

• Loving, sharing, and cooperating.

        Power:

• Achieving, accomplishing, being recognized and respected.

        Freedom:

• Making choices

        Fun:

• Laughing and enjoying

        Difficult behavior is a symptom of a problem (e.g., anger, fear, boredom, loneliness). Look beyond the behavior for possible unmet needs. Try to recall any incidents that might have triggered an outburst in order to avoid future problems.

        In difficult situations, stay calm and reassuring. Pay particular attention to your voice (tone and volume), your posture, facial expression, and other nonverbal signals. Be willing to listen to concerns, and assure clients that you care about them.

        Coping with changes can be difficult for anyone. The elderly face significant changes that can bring a sense of loss, loneliness, frustration, fear, depression, lack of self-confidence, and many other unpleasant feelings. If a client seems upset, ask how you can help, and take time to listen.

        Consider some of the concerns that affect the elderly, and show compassion (sympathy for another’s suffering):

• Change in lifestyle, loss of independence health problems, pain, unable to sleep;
• Unmet physical and social needs;
• Longing for the “good old days”;
• Confusion;
• Loneliness;
• Lack of control;
• Financial concerns;
• Family problems;
• Facing mortality (death).

        Individuals cope with problems and frustrations in different ways. Some people take out their anger on everyone; others may be quiet and withdrawn. Some people blame everyone else for their problems; others blame themselves for everything. Some deny there is a problem; others try to find a reason or excuse for everything.

        Sometimes residents are uncooperative, demanding, threatening, rude, stubborn, or unpleasant. Do not argue or feel hurt. Be calm and supportive. Try to look beyond the behavior to the underlying need for comfort and understanding. Identify and encourage coping ·skills that help the client (and you) deal with difficult situations.

        2.1. Effective communication.

Controlling Your Feelings

        Being a Personal Care Worker can be stressful and demanding, both physically and emotionally. To stay motivated and to provide quality care, keep a positive attitude and take good care of yourself.

        When you feel overwhelmed, ask for help and be open to suggestions. Consider ways to work smarter (not harder), and use your time wisely. Balance work and your personal life. Leave personal problems at home, and leave work-related issues at work.

        Being a Personal Care Worker requires a sincere desire to help others and a genuine interest in the sick and aged. You must be able to treat all people with dignity, including people with physical, mental, or emotional problems.

        Your attitude affects the behavior and well-being of the clients. Whenever you feel frustrated, try to understand why you feel that way. Do not take out your anger or irritation on others.

        If your feelings are out of control, do whatever is necessary to secure the area, explain that you are up-set, and excuse yourself at the earliest opportunity.

        Never express anger toward the clients. Find a quiet place until you are in control of your feelings. If you are unable to cope, ask your supervisor for advice.

        Always treat clients with patience, caring, empathy (sharing another’s emotions), concern, and kind­ ness. The clients’ well being is your primary concern. If you have a problem coping with difficult behavior, ask your supervisor for help.

Set your feelings aside, and always provide the best possible care.

        Good interaction with the clients is vital. Emotional barriers can block communication and prevent positive interaction. As a PCW, it is important not to let your feelings interfere with providing the best possible care for each client.

        Everyone has the same basic needs, but each person is different than anyone else. Differences in the way people look, think, or behave sometimes cause misunderstandings, fear, or frustration. You may have negative feelings about certain beliefs, religions, races, cultures, backgrounds, or experiences. Regard­ less of your personal feelings, each client has the right to quality care.

        Listen to clients with an open mind. Respond to problems or complaints in a caring and courteous manner. Supportive feedback strengthens self-esteem and builds good relationships. Following are examples of caring responses to problems and concerns.

• Tell me more about the problem.”
• “How can I help?”
• “You seem upset, and I want to help you.”

        Avoid being defensive. People tend to lash out whenever anything threatens their self-esteem. Defensive behavior can destroy relationships and affect work performance. Respond to hurtful comments in a calm and controlled manner. Try to resolve issues without feeling angry or hurt. If you make a mistake, admit it, learn from it, and move on.

        If your supervisor offers suggestions, accept the comments without feeling defensive or making excuses. Constructive feedback is an opportunity to improve your work performance.

        Make clients feel good about themselves, and avoid situations that make them feel defensive. Create an atmosphere in which clients feel accepted and confident to talk freely about their thoughts and feelings.

        Consider your attitude toward illness and health care. As a PCW, you will interact regularly with people who depend on you for physical and emotional care. If you enjoy helping people, being a PCW is very satisfying. If not, you should consider another career for your own sake as well as the clients’ well-being.

        Avoid the following behaviors that are emotional barriers to communication:

• Acting impatient, irritated, or annoyed;
• Ignoring, acting bored;
• Threatening, shouting, or using harsh language;
• Judging or giving advice;
• Arguing;
• Interrupting;
• Changing the subject;
• Belittling;
• Being defensive.

        2.1. Effective communication.

Introduction:

         You may be thinking: Why do I need to know about the different cultural backgrounds of clients? By becoming more aware and appreciative of the cultural differences among the clients, you will be better able to show respect for individual clients, provide assistance in ways that are culturally familiar to clients and develop positive relationships with clients.

        Throughout our history, many people of many different backgrounds have come to live in the United States. Historically, a number of people have come from other parts of the world to make their home in the United States. There are people of different races. There are people practicing many different religions. Some speak a language other than English. Many have different beliefs, values, ways of communicating and ways of thinking based on their cultural background. In order to provide the best quality care and give everyone the respect they deserve, it is important to understand how culture affects the way we live our lives every day.

What is culture?

        First, let’s take a closer look at the meaning of culture. Culture is a set of values, beliefs and behaviors. Culture is the “truths” that are accepted by members of the group. Most cultural rules are not written down. We learn them from other members of the group. Culture is like the air that we breathe. It is something that we do not think about directly. We take it for granted.

        For example, in some cultures the older people are the most respected age group in society. Older people are valued for the experience and wisdom they have gained during their long lifetime. The place of honor in the family goes to the oldest person. Members of the family seek the advice of the older persons. Older people are proud of their age. This cultural belief is true in many Asian cultures like Chinese or Japanese cultures. Yet, in other cultures, youthfulness is valued more than older age. People try to stay young as long as they can. Hair coloring and plastic surgery may be used to maintain a youthful appearance. Older people are thought to be “out of touch.” Children hold the special place in the family. This belief is strongly held by many in the United States.

        We also see some differences between cultures in terms of attitudes and behaviors related to caring for older adult members of families. In some Asian and Latino cultures, for example, when parents get older they typically move in with one of their children, who are expected to care for them. Such expectations are less common in the U.S.

        Culture is very important because we tend to interpret other people’s behaviors through our own culture. We expect others to think and act the way people in our culture think and act. We even interpret their behavior through our own expectations. When people from a different culture act differently than people in our own culture, we may consider their behavior to be strange, inappropriate or even wrong. The important thing to remember is that differences in cultures are not good or bad; differences in cultures are not right or wrong. They are just different ways of doing and thinking. Direct care staff persons need to understand and be respectful of cultural differences.

Examples of cultural differences

        What are some cultural differences you might experience with personal home care clients? Many cultural differences are related to how we talk and listen. You have learned about the importance of good communication skills in earlier modules. Now we will learn about communication skills as they relate to cultural differences.

Eye contact:

        One area is eye contact. Research has shown that when Americans talk to one another, they tend to look at each other directly in the eye. This sends the message that the other person is listening to you and is interested in what you have to say. It is a sign of respect. Yet, in some cultures looking directly in the eyes of another person may be a sign of disrespect. This is particularly true when the person is speaking to someone in a position of authority, such as a doctor, a nurse or a caregiver. Direct eye contact may be interpreted as being a challenge to one’s authority. Looking down or at the floor may be a way of showing respect for the person in authority. People from Latino cultures, such as Mexico and South America, may practice this cultural behavior. Therefore, when you are giving them instructions, they may not look you in the eye while you are talking. This may be a sign of respect for your authority.

        In some Middle Eastern cultures, direct eye contact between a man and a woman is considered a sexual invitation. In general, direct eye contact should be avoided with Middle Easterners of the opposite sex.

Direct and indirect styles of communication:

        The use of directversus indirect styles of communication is another difference in cultures. Many Americans tend to use a directstyle of communication. They tend to be open, honest, direct and precise. Assertiveness is respected. If you have a problem with someone or something, it is okay to speak directly about the problem and try to get it worked out. The belief is that trusting relationships are built on openness and honesty.

        However, people in many cultures use an indirect style of communication. In these cultures, it is very important to avoid embarrassment for oneself and for the other person. Therefore, one may use a roundabout way to let the other person know there is a problem. This can be true for many people from Asian and Latino cultures. Rather than saying directly that there is a problem, the resident may hint at the problem. It will be important for you as a direct care staff person to pick up on the hint. If you are uncertain, it is best to ask questions to try to understand the message the resident is really trying to convey.

Use of the word “yes”:

        Use of the word “yes” as an answer to a question can sometimes be tricky. In some cultures, particularly Asian cultures, people may try to avoid saying “no.” The use of “no” may cause embarrassment for the other person. Therefore, a person may simply say “yes.” In this case, “yes” may not mean that the person agrees or even understands. It may simply mean that the person acknowledges your statement. To find out if the person really understands or agrees, you may need to ask more specific questions to test their understanding or agreement.

Use of first names:

        Another area in which we see cultural differences is in the use of first names. Many Americans tend to use a direct and informal style of communication. This is true even when they first meet someone or have known them only for a short time. One of the reasons for doing this is to show friendliness. Yet, in some cultures, calling someone by their first name is a sign of disrespect. Many people from Latino, Arab and African American cultures prefer the use of a title, such as Mr., Mrs. or Miss, when they are addressed. Using the title helps the person maintain a sense of dignity. A title should be used until a resident asks you to use his/her first name.

Touching:

        Another area of cultural differences is in the way we touch one another. Most Americans do not mind having someone touch their shoulder or arm as a gesture of friendliness. However, the amount of touching that is considered appropriate varies among cultures. In many Asian cultures, casual touching may be uncomfortable and should be avoided, especially in public. Yet, people from Latino backgrounds may be much more comfortable with casual touching and hugging. In fact, a Latino may offer a hug instead of a handshake as a greeting.

        Touching may also be restricted by religious rules. For example, members of the Orthodox Jewish religion are prohibited from touching members of the opposite sex in public. This rule is similar for Muslims. This rule even extends to shaking hands when meeting and greeting. Therefore, if a female direct care staff person extends her hand to greet an Orthodox Jewish or Muslim male and he does not extend his hand in return to shake hers, she should not be offended. It does not mean he has any ill feelings toward her. He may simply be practicing the rules of his religion.

Space:

        Every culture has its own unwritten standards about how much personal space feels right and comfortable. Many Americans feel comfortable when standing about an arm’s length away from the next person. In some cultures, such as the Japanese culture, an even greater amount of distance between people is desired. Yet, in other cultures, such as Latino and Arab cultures, people are very comfortable standing very close to one another.

Review of some key points about cultural differences:

        There are many differences in cultural practices. Few, if any, people will know everything about every culture. What is important is being aware that a client’s behaviors and beliefs may be different than your own. This may help you to be more sensitive. Try not to jump to conclusions and label behaviors that are different from your own as wrong or bad.

        It is important to recognize when different cultural behaviors and practices come into conflict. When you interact with other people, be aware that cultural differences may be coming into play when you experience such feelings as confusion, frustration, misunderstanding, tension or impatience. Ask questions to make sure that you understand the meaning of behavior that seems out of place. Seek additional information about the culture to gain a better understanding of the behavior.

Stereotypes:

        One thing that can stand in the way of our being respectful to others is stereotyping. Stereotypes are fixed assumptions made about all members of a certain group. Stereotypes are a rigid way of thinking that does not take into account the differences among people in a group. For example, “All older people are frail and sickly” is a stereotype. While some older people are frail and sickly, many older people are strong, active and in good health. Some other examples: “You cannot teach an old dog new tricks.” “All homeless people are drug addicts.” “All boys who live in the inner city are members of gangs.” “All females gossip.”

        We have so much information coming at us that our brains can only pay attention to a small percentage of it. Stereotypes help us sort large amounts of information into a smaller number of categories. The unfortunate part, however, is that they tend to discourage considering people as individuals rather than as faceless members of the group being stereotyped. We mistakenly begin to assume that everyone in the group has the same characteristics.

        Of course, if we stopped to think about it, we would have to admit to ourselves that stereotypes are not true descriptions of every person in a group. Even the good stereotypes are not true of everyone in a group. The stereotypes that we hold about people play an important part in how we communicate with and treat people. If you do not stop to consider the real possibility that the resident you are working with may not fit the stereotype category, you may not treat him/her in a respectful and appropriate manner. It is important to remember that there are always differences between individuals. It is always a mistake to stereotype people based on appearance.

Communicating with non-English speakers:

        The number of people in this country who speak a language other than English is growing. Communicating with people whose first language is not English can take special effort. The following guidelines can be helpful.

• Speak clearly and a little more slowly than you usually do. Sometimes we tend to speak quickly. For people who speak English well, the fast speed may not be a problem. But a slower pace will give non-English speakers more time to process your message.
• Do not shout. Raising your voice or shouting will not increase understanding. Speak in a normal tone of voice.
• Pronounce your words clearly. Avoid running words together.
• Avoid slang or jargon. Americans have many expressions that are understood by those in our culture. However, they may make little sense to those from other cultures. Examples include: “Completing that job was a piece of cake.” “Thanks a million.” “The birthday celebration was a real blast.” Expressions like these may only confuse a person who is just learning English.
• Use the written word, draw pictures or show with demonstrations. These techniques may help to increase understanding.
• Pay attention to body language. Notice the facial expression or use of arms or gestures of the person with whom you are speaking. These may help you to determine if the person understands what you are saying.
• Take time to consider how your words might be understood by someone who is not completely familiar with your language.