Traditional Social Work Practice and Intervention Skills

The social service worker needs to demonstrate appropriate empathy, non-judgmental acceptance, and respect for the older adult. We must be a good listener, objective and always be unbiased in the interpretation of the information that was heard. Always keep the residents information confidential and protect the Resident Rights. You are the resident advocate. Good communication skills and counseling are a very important part of your job.

COMMUNICATION

Communication is the exchange of information with others. You must have a "sender" and a "receiver".
Communication is only successful when both the sender and the receiver understand the same information as a result of the communication.
Communication is one of the most basic and fundamental skills of our existence.
When we struggle to communicate with those closest to us it can be both frustrating and painful. It alters our everyday way of life.

When communicating with Residents, remember;

• Always greet the resident by his or her preferred name. Never call them "honey or baby"
• Identify yourself
• Focus on the proper topic to be discussed
• Face the resident while speaking, avoid talking into space
• Talk with the resident while giving care
• Listen and respond when the resident speaks. Praise the resident, smile often.
• Encourage the resident to interact with you and others
• Be courteous
• Tell the resident when you are leaving the room.

Touch is a form of non-verbal communication.

One of the basic needs of all human beings is the need for nurturing caring touch. Yet, due to common social attitudes, many elderly experience touch deprivation.

Research has shown that among hospitalized patients, the psychotic and the elderly were touched the least.
Those with worn bodies and wrinkled skin are no longer "beautiful" in the eyes of the world. They are, in fact, often considered "untouchable." Frequently, even the elderly accept this form of stereotyping and therefore do not expect to have their touch needs met.

This is unfortunately, since expressive touch has been shown to make a significant difference in the way elderly perceive nursing care.

Click on this website to learn more about good communication Good Communication 

Attitudes that promote communication

Courtesy and respect

Keep in mind that the resident has the right to make decisions regarding his/her own care and that this is the resident's home. 

• Examples: "Please" "Thank You" should be used to both staff and residents.
• Use resident's preferred name when speaking with him/her.  Never call them "honey or baby"
• Knock on door prior to entering the resident's room or other occupied room and identify yourself
• Focus on the proper topic to be discussed
• Keep emotions under control
• Respond in a professional manner to the residents, visitors, and staff.
• Remember to not take things personally due to a resident's actions or words.  Be professional and be the bigger person.
• Show empathy
• Put oneself in the other person's place to better understand how they may be thinking or how they feel.
• Show consideration to both residents and co-workers.

Actions and responses that promote effective communication between SSD and residents

• Identify self by name and job title
• Provide opportunity for resident to express thoughts, opinions, and feelings.
• Listen carefully to expressed thoughts and feelings and tone of voice.
• Listen attentively to resident's comments.
• Listen and respond when the resident speaks. Praise the resident, smile often.
• Encourage the resident to interact with you and others
• Allow enough time for communication.  With aging, the individual often needs more time to process information.
• Block out other distractions, hold their hand and express acceptance of resident's thoughts or concerns.
• Repeat back what the resident has said to summarize and validate
• Look at the resident speaking; make eye contact, unless this disrespects the resident's cultural expression.  Avoid talking into space
• Express acceptance of residents and their thoughts
• Observe resident's nonverbal behavior during interaction.  Be aware of own nonverbal communication.
• Body position or posture
• Facial expression
• Body activity, such as restlessness or turning away
• Listen carefully to expressed thought and feelings, and to tone of voice
• Look at person speaking, block out other distractions.  Make eye contact, unless this disrespects the resident's cultural expression. Express acceptance of residents and their thoughts
• Repeat back what the resident has said to summarize and validate.
• Focus on concerns of the resident
• Understand the residents personal history, past behaviors, and patterns
• Don't talk about SSD’s personal situations or personal problems
• Don't criticize other staff or the facility

Also be aware of others personal space which is an area in which each person considers their territory.  If another person enters this space without this desired; it makes them feel uncomfortable. The amount of space for comfort is determined by each individual.  Realize that you will be working with the resident in their personal space, but be sensitive to their space even though you need to cross that barrier.

• Be aware of barriers to effective listening and communication that the residents may experience
• Environmental distractions such as resident and staff talking or moving about can affect their communication experience, even a television that is on or ringing of the phones.
• Hearing impairment or visual impairment (more care strategies will be discussed later in this unit)
• Difficulty processing information
• The resident may have confusion or decline in mental alertness
• Fatigue may impair the resident's willingness to talk
• Difficulty expressing speech (aphasia, dysphasia) as a result of disability such as a stroke (CVA)
• Inability to understand language used for communication
• The resident may have a primary language other than English.
• Be aware of barriers to effective listening and communication that the SSD may experience.
• Environmental distractions, as described above
• Not concentrating on what the resident is saying, thinking about unrelated matters.
• Not understanding differences in (or having negative feelings toward) culture, ethnic, lifestyle, or religious expression
• Inability to understand language used for communication
• Diversity may become barriers due to the lack of unfamiliarity, lack of acceptance or personal prejudices

Sometimes life itself is difficult and we tend to, at times, have personal issues or problems outside of work.  Remember to leave your problems, issues, or distractions in your personal life at the door.  It is difficult to juggle both personal life and your job but you need to be fully available mentally to the residents because a personal distraction will affect your communication with the residents as well as your co-workers.  Same goes for your work life and taking it home, it is best, if at all possible, to separate the two so you can be effective in both areas.  This can be a big challenge to overcome but being aware that it can be a barrier gives you the upper hand to tackle that challenge successfully.

Always focus on the resident concerns.  It's not about you; it's about the resident needs. Understand the resident's history and past behavior patterns. This will help you understand the resident's behavior in a more professional way.  When you take yourself out of the equation and focus on the resident you will be successful. 

Identify and use actions and responses that promote effective communication between SSD and resident's family and friends.

• The same general concepts of good communication as stated above apply also for family and friends as well as residents.
• Family may need suggestions about how to "visit" with resident.
• Providing information
• A designated person, usually the nurse, communicates information such as change in medical status or change in doctor's orders. 
• Behavior or communication between resident, family, and staff may reflect distress from changes in the resident's situation.  Examples:
• Family may express guilt or grief at placing resident in the facility
• Resident may express anger or sadness from placement in the facility or from functional changes due to illness
• Resident and family may not understand the residents health problem or facility expectations
• Resident or family may be concerned by matters outside of the facility, such as finances.
• The SSD should avoid involvement in family arguments.

Listening to family members concerns and requests, and taking these request to the appropriate person help promote a good relationship. Always show kindness,patience/empathy and not interfering in family business. Maintain resident confidentiality with the family and direct them to the appropriate person, such as charge nurse, for any medical information. Sometimes family members have difficulty communicating with their loved one due to anger or guilt of placing the resident in the nursing home. The resident may have concerns of money, pain, the future or separation from family. Whatever the reason, this can be a difficult time for family and resident to have a healthy conversation.

Communicating with resident who has a vision or hearing impairment

Make sure the resident has their hearing aid and it is in working order if they own one. Remember to speak using a low; slow voice when resident is hard of hearing. Use nonverbal communication when needed.  Always approach the resident from the front.

• Approach resident with vision/hearing impairment from within field of vision, usually from the front.
• Sit or stand at the same level as the resident.
• With a resident who has a hearing impairment, speak slowly and clearly using a low-pitched voice.  Use nonverbal communication to provide cues.

Communication with the resident who has cognitive impairment or confusion:

Typical behaviors for long term confusion

• Loss of ability to care for self
• Unable to recognize familiar persons or surroundings
• Memory loss, particularly for recent experiences
• Impaired  judgment
• Not knowing self or others
• Talking incoherently
• Forgetfulness
• Not paying attention or understanding when someone else is speaking
• Sleep disorders
•  Hallucinate, visual, and auditory
• Wandering about, not oriented to person, place and/or time
• You will find many symptoms of confusion. Every resident may show a different symptom of confusion, some more than others
• Psychosocial implications of confusion
  • Be frightened, unhappy, bewildered
• Be unaware of environment; thus not sense danger
• Have reduced intellectual and emotional contact with others
• Have less self expression
• Have less independence
• Feel insecure
• Withdraw, be tearful
• Express suicidal thoughts
• Misinterpret care tasks because of history, experience in past, or personal "boundaries"
• Express hopelessness, helplessness
• Decreased social inhibitions
• Social inhibition is a conscious or unconscious limitation by a person or it can be the behavior that the person may consider offensive in a social setting. Inhibitions can serve necessary social functions, reducing or preventing certain antisocial impulses from being acted on.
• Inhibitions vary greatly from person to person, and may be closely linked to a person's confidence. An extreme lack of inhibition may be antisocial and a symptom of a mental disorder. On the other hand, a high level of inhibition may also create personal problems, including an inability to feel or express certain emotions.
• Beginning approaches for communicating with a resident who is confused
• Approach the resident from within his/her field of vision
• Speak and act in a calm, friendly manner. Avoid sudden and loud actions
• Use short, simple words and sentences.  Offer simple choices
• If the resident does not understand a spoken request, try to demonstrate the request
• Follow a consistent routine
• If the resident is unwilling to participate in care or in an activity, do not force him/her to participate.  Arguing with a confused resident is ineffective communication and does not show respect
• Use discretion techniques

As you are beginning working in a long term care setting you will realize that a resident who is confused or has behavior problems will be affected just by the approach and the reaction to that approach can have lasting effects throughout the day.  Following these simple steps can greatly affect the resident for the day as well as the other resident's in the facility.  It is in the best interest of the resident to have a good approach and communication process which will make your job and their environment much easier.

• Practice looking friendly- Your attitude/mood is contagious, felt by all, even if you share it verbally only with other staff.
• Make your verbal and nonverbal messages the same.
• Stand in front and make eye contact.
• Assume an equal or lower position, especially if the resident feels powerless.
• Move slowly.
• Approach from the front, not the side or behind, within his/her field of vision
• Avoid overwhelming the resident physically or verbally (approaching an anxious
• Resident with three or more people may lead to a catastrophic reaction).
• Treat the resident as an elder or peer, not as a child.
• Trigger automatic responses.
• Identify symbolic behaviors and their meaning- the cup the resident wishes to hang onto often after meals may be symbolic for having coffee with friends and relatives and be a source of security and comfort.
• Use lots of touch, if the resident enjoys it, and allow time for the resident to touch you.

Verbal Approaches

Use short, simple words and sentences.  Offer simple choices

• If the resident does not understand a spoken request, try to demonstrate the request
  • Use concrete, exact, positive phrases; repeat the same phrase.
• Break tasks down into single instructions like walk forward, stop, turn around, and sit down.
• Make a suggestion if the person is unable to make a choice.
• Use a calm, soft, slow voice pattern, friendly manner.
• Ask one question at a time and WAIT for a response.
• Do not argue or try to reason.
• Keep your promises, so promise only what you will be able to do.
• Include the person in your conversation.
• Identify the person's vocabulary and use it--if he uses the word potty for bathroom, then staff should use that word.
• Acknowledge the person's feelings and help her name it if she has difficulty-for example: You look sad. Do you miss your daughter after she leaves?
• Give directions within attention span.
• Tell resident your name with each interaction
• Cue resident to events: "it's time for you to go to the dining room for dinner."
• Use the resident's name in talking with him/her and determine chosen name, do not use grandma or grandpa or pet names.
• Use reality orientation if resident has memory retention and recall.
• Use validation techniques rather than arguing with resident - reminisce, ask questions using who, what, when, where and how. Never ask "why" questions.
• Click here  to read about validation and Naomi Feil.
• Again, concentrate on residents needs not the staff needs. Always keep in mind it's not about you it's all about the resident and their needs.
• Difficult behaviors can be more easily understood if the SSD remember that:
• All behavior has meaning: It is most important to remember that all behavior has meaning, even if it's sometimes hard to determine what that meaning is. People with Alzheimer's Disease don't follow logic and can be very difficult to understand.
• There is always a cause for a behavior and a result of the behavior: Behavior always has a cause and a result. For instance, a person may start to pace for multiple reasons. He may have a generalized feeling of anxiety or he may be searching for something. The behavior's result can be anything from a decrease in the feeling of anxiety to finding a way out of the house in order to search further
• Behavior does not occur in a vacuum: There are always outside influences that modify behavior. They can come from people or from the environment. For instance, a person with Alzheimer's Disease who is a resident of a nursing facility might become agitated when a message from a staff member is heard over the loudspeaker. Since these influences change from moment to moment, behavior also may change from moment to moment.

Confidentiality

Confidentiality is a term that indicates preserving the privacy of the persons in which you care for. This will mean that all information related to them will be kept in strict confidence for use only by the team of care providers. This includes information gained verbally or from resident or client records.

All information is considered confidential when it pertains to medical care and client records. Patient confidentiality and privacy are a very important aspect within our jobs in the healthcare industry. Each and every day we place our trust into the hands of our patients. Maintaining confidentiality will ensure quality care by showing that your patients can count on you for maintaining privacy and respect for their care and their medical records. With legality issues so much on the rise today, we should always be ever so mindful to the problems at hand when confidentiality issues are violated. Smart charting, and adherence to company policy and procedures will go along way in protecting you legally as you do your best to give high quality care to your patients.

Confidentiality issues are also a standard of practice related to ethical and professional healthcare.  Breach of confidentiality is sharing information verbally or in written form regarding a resident or client with someone who is not on the care team of the resident or client, or who does not have a release of information form from the resident or client.

Indiscretion is an action in which you inadvertently share confidential information. There is no bad intent associated with an indiscretion. 

What is considered confidential?

Information and actions that are confidential and private include, but are not limited to the following:

• Age
• Sex
• Race
• Religion
• Marital status
• Occupation
• Health information
• Social security number
• Insurance information
• Health conditions and problems
• Lab tests and X-rays
• Blood work
• MRI and CT scan
• Any diagnostic procedure done on the patient
• Any physical contact that involves examination Personal care
• Toileting and dressing

Remember, often times it is not WHAT we say, But rather HOW we say it, and more importantly.. WHO we say it to. Never forget that lives are affected by breaching confidentiality.

Responsibilities of Healthcare Workers with Private and Confidential Information.

Guidelines for protecting private and confidential information include the following:

• Discuss resident and client information ONLY in a place that is away from other residents, families and visitors. Report should not be given at the nurses station, as this is not a private area, with much opportunity for information to be overheard.
• Never discuss patients in an elevator, in a hallway, cafeteria, or any other public place within or outside of the facility. Discuss resident information only with appropriate staff.
• Do not ever release information to media or newspapers.
• Don’t release information to the police without first alerting a supervisor. Instead refer them to an appropriate manager.
• Do not keep a copy or make copies of resident information.
• Destroy all end of shift report sheets after use.
• Any item with a residents name or identifying medical information should NEVER be placed in general trash receptacles. They should be shredded for appropriate disposal of confidential information.

Responsibilities regarding private and confidential information include:

Know your expected limits: Check your job description. Ask your supervisor to clarify anything you do not understand. Never discuss information that you are unsure of, and be sure of who you are sharing this information with. Not all friends and family are authorized to know information regarding your resident or client’s condition.

• Be on the alert for breaks or leaks. Be particularly mindful of when private information becomes casual chatting. 
• Practice care that is private and behavior that guards confidence. 
• Report to your supervisor. The best working relationships are those in which you keep your supervisor well informed and on top of things that are going on.
• Keep open lines of communication between your superior and yourself.
  

Patient privacy and confidentiality generally refers to a patient's right to:

• Decide what personal health information can be shared with others
• Decide how that information can be shared, and with whom it may be shared
• Not have information about resident or client discussed in areas where others could overhear

Privacy also refers to the right to have physical privacy (curtains pulled)

Patient confidentiality generally refers to a patient's trust that health information will only be shared with those who need to know, and in order to provide appropriate care.

For care to be appropriate authorized health care staff need full access to a patient’s medical record. But, patients may withhold important information if they fear it will not be kept private and confidential. By ensuring patient privacy and confidentiality, your facility will help patients feel a sense of trust and help assure them they will receive appropriate care.

Protecting patient privacy and confidentiality is vital to your organizations mission. It helps increase patient's satisfaction and sense of dignity. It helps ensure that patients get the most effective care.