Ch. 10 Person-Centered Communication

Foundations and Definitions of Person-Centered Care

• Conceptual Definition: Person-centered care is defined as providing healthcare services that respect and meet the specific needs of patients and their caregivers to promote positive outcomes and perceptions of quality.

• Core Emphasis: It focuses on treating every patient as a unique individual rather than a specific diagnosis or clinical condition (Kwame & Petrucka, $2021$).

• Nurses' Role in Integration: Nurses must acknowledge the lived experiences and personal knowledge of patients. This involvement requires integrating the patient's values, preferences, and needs into all aspects of the care plan.

• Collaboration and Trust: Actively engaging patients in planning and decision-making fosters trust, collaboration, and shared responsibility for health outcomes (Johnsson et al., $2018$).

• The Role of Communication: Communication is the primary vehicle for achieving person-centered care. Effective communication must be both "personal" (authentic connection) and "explanatory" (making information clear and meaningful).

• Opening Dialogue: Nurses use open-ended questions and empathetic listening to invite patients to share feelings, thoughts, and concerns.

• Strengthening Therapeutic Relationships: Using plain language and adapting methods to explain health conditions and treatment plans strengthens the relationship between nurse and patient.

• Addressing Barriers: Delivering compassionate care requires identifying and minimizing barriers such as bias, cultural differences, sensory impairments, and language discordance.

Implicit Bias: Development, Impacts, and Healthcare Disparities

• Definition of Bias: An unreasonable judgment that is not based on facts (Merriam-Webster, $2021$).

• Implicit Bias (Unconscious Bias): Refers to deeply ingrained stereotypes and attitudes that influence human thoughts and actions without deliberate awareness (Gordon, $2017$).

• Biological and Developmental Origins:

  • Infants naturally develop a preference for the familiar, distinguishing "family" (safe) from "others" (potentially threatening).

  • The human brain manages massive amounts of data by unconsciously categorizing people and assigning judgments with positive or negative associations (Narayan, $2019$).

• Stereotypes: Generalized beliefs about groups arising from limited experiences, environment, media portrayals, or anecdotes.

• Impact on Nursing Care: Implicit biases can lead to less compassion and less investment of time/effort in certain patient therapeutic relationships, adversely affecting professional assessment (Narayan, $2019$).

• Healthcare Disparities Examples:

  • Cardiovascular Care: Significant gaps based on gender exist. Men often receive immediate attention and quick interventional cardiology for chest pain, while women are more frequently asked about stress levels and given medications (Shaw et al., $2017$).

  • COVID-19: Disparities related to African-Americans have been documented (Wright & Merritt, $2020$).

  • Cardiac Arrest: Poverty-stricken individuals have a lower rate of return of spontaneous circulation in out-of-hospital cardiac arrests (Gaddam & Singh, $2020$).

• Common Targets of Bias: Individuals with higher weight, older people ($65$ and older), LGBTQIA+ individuals, illegal drug users, those with mental illness, and people of specific races or religions (Gopal et al., $2021$).

• Documented Negative Outcomes: Inadequate assessments, inappropriate diagnoses/treatment decisions, reduced time in patient care, and discharges with insufficient follow-up (FitzGerald & Hurst, $2017$).

Strategies for Bias Awareness and Mitigation

• Lifelong Quest: Learning about different social identities is a continuous process through courses, books, videos, and workshops.

• Self-Reflection: Nurses must reflect on clinical situations to assess for personal bias. Mindfulness increases the likelihood of becoming aware of these deeply rooted attitudes.

• Bias Assessment: Utilizing tools like the "Project Implicit" assessment to discover unconscious associations.

• Self-Intervention Strategies (Table $10.1$):

  • Counterstereotypic Imaging: Purposely identifying and replacing biased images with positive ones of group members who counter stereotypes (IHI, $2017$).

  • Emotional Regulation: Reflecting on "gut feelings" like fear or dislike to intentionally replace them with empathy and compassion (Joint Commission, $2016$).

  • Habit Replacement: Framing biases as habits and using a personal toolkit to replace them with individualized care (Devine et al., $2012$).

  • Increasing Opportunities for Contact: Developing relationships with members of outside groups to dissolve stereotypes.

  • Individuation: Mindfully seeing patients as unique individuals rather than members of a stigmatized group.

  • Mindfulness: Calming thoughts to stay in the present moment and act compassionately (Burgess et al., $2017$).

  • Partnership Building: Intentionally framing encounters as a collaboration between equals.

  • Perspective Taking: Purposefully thinking about what the patient is thinking and feeling to stimulate caring.

  • Stereotype Replacement: Acknowledging stereotypical responses and committing to response with compassion in the future.

Social Identity and the ADDRESSING Framework

• Social Identity Definition: An individual’s sense of self based on membership in social groups (e.g., race, ethnicity, gender, religion, socioeconomic status).

• Personal vs. Social Identity: Personal identity involves unique characteristics, whereas social identity is shaped by shared group affiliations and societal meanings.

• Components of Social Identity:

  • Language spoken,

  • Religion/Spiritual beliefs,

  • Gender identity,

  • Socioeconomic status,

  • Age,

  • Sexual orientation,

  • Nationality and Ethnicity,

  • Geography and Educational background,

  • Life experiences and Living situation,

  • Employment and Immigration status,

  • Ability/Disability.

• Intersectionality: People typically have multiple overlapping social identities that are closely intertwined.

• The ADDRESSING Framework: A model for recognizing different social identities that influence patient experiences and interactions.

Principles of Effective Communication Adaptation

• General Sensitivity Suggestions (Brooks et al., $2019$):

  • Introduce yourself by name and role.

  • Address patients formally (Title and Last Name) until informed otherwise.

  • Ask specifically how the patient would like to be addressed and record it in the chart.

  • Acknowledge visitors and family members at the bedside.

  • Maintain at least an arm's length of physical distance initially.

  • Observe patient nonverbal cues (eye contact, touch, space) and follow their lead.

• Language Maturity: Avoid terms like "wheelchair bound"; use "a person who uses a wheelchair" instead.

• Nonjudgmental Integration: If a patient’s practices or beliefs are safe, the nurse should attempt to integrate them into the care plan, even if they do not personally agree.

Guidelines for Medical Interpretation

• Federal Mandate: Facilities receiving federal funds (Medicare/Medicaid) must provide professional interpreters under Title $VI$ of the Civil Rights Act and the Affordable Care Act.

• Clinical Benefits: Professional interpretation is linked to fewer errors, shorter hospital stays, lower $30$-day readmission rates, and higher satisfaction.

• Restrictions on Family: Family members should NOT serve as interpreters because they may lack medical terminology knowledge, may edit sensitive information, or the patient may withhold details from them.

• Interviewer Guidelines (Juckett & Unger, $2014$):

  • Allow extra time for the conversation.

  • Document the interpreter's name in progress notes.

  • Face the patient directly and speak in a normal tone of voice (do not talk to the interpreter).

  • Use the first person ("I") rather than third person.

  • Avoid idioms (e.g., "under the weather"), slang, jargon, or jokes.

  • Speak in short sentences or paragraphs.

  • Use the "Teach-Back" method by asking the patient to repeat instructions.

Visual and Hearing Impairments

• Visual Impairment Signs: Difficulty walking, trouble finding items, or lack of eye contact.

• Communication Strategies for Vision:

  • Identify yourself when entering the room and ask before touching.

  • Orient the patient using the bed as a reference.

  • The Clock Method: Identify food locations on a tray (e.g., milk at $2:00$, potatoes at $3:00$, meat at $9:00$).

  • Minimize glare and provide high-contrast labels or large-print materials.

• Hearing Impairment Strategies:

  • Minimize background noise.

  • Speak clearly in a slightly louder voice with a steady, deeper pitch.

  • Position yourself $2-3$ feet away and facilitate lip-reading by facing the light.

  • Do not turn away while speaking.

  • Gain attention via touch before starting to speak.

Impaired Speech and Aphasia

• Aphasia Definition: Communication disorder caused by brain damage (stroke or head injury) impacting language expression and understanding.

• Types of Aphasia:

  • Expressive Aphasia: Difficulty putting thoughts into words; the patient knows what they want to say but cannot say it.

  • Receptive Aphasia: Difficulty understanding spoken language; the patient can speak but cannot comprehend.

  • Global Aphasia: Damage to multiple areas (Wernicke’s and Broca’s); results in inability to say more than a few words or repeat phrases/sounds and extreme difficulty comprehending.

  • Broca’s Aphasia: Most common type; patient understands speech but speaks in short, effortful phrases (e.g., saying "Bathroom, Go" instead of "I would like to go to the bathroom").

• Communication Methods:

  • Phrase questions for "Yes" or "No" responses.

  • Use alternative methods: writing tablets, communication boards, or eye-blinking.

  • Ensure call lights are marked for speech difficulty.

Cognitive and Substance Impairment

• Cognitive Impairment: Includes conditions like Down syndrome, Autism, or fetal alcohol syndrome.

  • Use active listening to determine patient priorities.

  • Speak clearly at a steady pace; avoid speaking so slowly that it sounds patronizing.

• Substance Impairment: Drugs/alcohol can alter the capacity to think and reason.

  • Maintain "unconditional positive regard" and a non-judgmental attitude.

  • Use a Relational Inquiry approach to understand patient agency.

  • Speak in short, simple sentences focused on the priority health issue until the substance effects dissipate.

Emotional Distress, Violence, and Trauma-Informed Care

• Managing Distress: Use open-ended questions like "Tell me about how you are feeling" and permission statements to normalize emotions (e.g., "Patients often feel angry when diagnosed").

  • Use silence and active listening; do not change the topic to avoid discomfort.

• Trauma-Informed Approach: Assume all patients may have experienced trauma (abuse, war, natural disasters).

  • Always explain every step of what you are doing.

  • Always ask permission to touch.

  • Provide the patient with options/choices for the first topic of discussion to restore control.

Sexual Orientation and Gender Identity (LGBTQIA+)

• Definitions:

  • Sexual Orientation: Physical/emotional desire on a continuum.

  • Gender Identity: Inner sense of being a man, woman, neither, or both.

  • Gender Expression: Outward demonstration (clothing, hairstyle, mannerisms).

• Clinical Disparities: Discrimination has led many to delay healthcare. Higher rates of substance abuse and suicide are linked to persistent bias and stigmatization (Cole, $2018$).

• Nonbinary: Individuals who do not fall into the binary categories of male or female.

Developmental Considerations and Age Categories

• Pediatrics:

  • Neonate: $24$ hours to $28$ days old.

  • Infant: $28$ days to $1$ year.

  • Toddler: $1-2$ years.

  • Preschooler: $3-5$ years.

  • School-age: $6-12$ years.

  • Adolescent: $13-17$ years.

• Strategies for Young Children:

  • Use a relaxed tone and gestures.

  • Demonstrate procedures on dolls or stuffed animals.

  • Involve parents as a secondary data source; ask how they know (e.g., "How do you know the baby is in pain?").

• Strategies for Adolescents:

  • Address them first, before the parents.

  • Offer private time to speak alone without parents.

  • Avoid demeaning "child-talk."

  • Use permission statements to normalize self-consciousness and fear of judgment.

• Older Adults ($65+$):

  • Allow extra time for processing and answering.

  • Treat the patient and caregiver as a "dyad" if necessary, but prioritize the patient as the main focus.

  • Direct questions to the patient first, even if a caregiver is present.