CHUSE Clinical Communication Pre-disposing Activity

Welcome to the CHUSE Clinical Communication Active Learning Activity

Completion of this activity is achieved by reading the content on this page and by accessing and reading the linked websites provided.

This information will prepare you for your practical sessions and testing in your upcoming CHUSE Clinical Communication course.

After reading the content on this page, please complete the Pre Course MCQ herePlease note that the “Contextual Dimensions Of Rural And Remote Practice” reading is optional and that it will not be tested in the MCQ.

Please contact us if you are having trouble accessing any of the resources.


Communication is a bit like Magic……..

Some people seem to have been born magically as good communicators.  There are not many of these…unless you have this magic, read on…

Some people think they are good communicators, they say they communicate everything to others very clearly. But this is only one way communication. And in any case, what is clear to them may be “as clear as mud” to others.

Some people know they are not very good at communicating.   Learning about communication is one thing – but if you learn the correct ingredients, put everything into the cauldron, stir it around, and hope some magic will come out…but sometimes all that comes out is a frog, or worst still, an ugly toad!

So this article is going to try and make communication a bit easier…so that out of your cauldron, you can create a communication prince….…or princess.

How hard can it be??

Terry Pratchett wrote some great stories about witches and wizards. They were very clever stories and very funny. But they contained a lot of wisdom.… Pratchett wrote that   “communication is essentially “100% recycled words”.  But getting the words and the face and body expressions right in different situations can be very tricky.

Most of you will have learnt good skills in communicating with both Aboriginal people and non-Aboriginal people in this area of Australia. We know you will have some great stories about communication that works, and communication that really does not work. When we meet you in the course, we would like you to share some of those skills and stories with each other, and with us.

Even in an emergency situation, you should continue to practise those skills.

However, in an emergency situation, things can happen very quickly. There are some techniques which are important to use (on top of your already great skills), so that poor communication does not cause any issues or catastrophes. Here are some of the techniques:

General Communication tips (with some classic quotes from Terry Pratchett to keep you entertained):Active listening.

  • Unless you have actually “heard” the question or the response you won’t be able to reply appropriately.
  • It often helps to use clarifying questions to ensure you have understood everything correctly.
  • Sometimes it is useful to rephrase to ensure that your partner in the conversation knows they are being heard.
  • Did you notice the word “partner”?

Use direct and indirect questions appropriately.

  • There is a time for both. You need to know and when to use direct questions and when to use indirect questions.
  • Often using a direct question with an Aboriginal person may not be the best way. What may happen if you do this?
    • No matter who you are talking with, direct or leading questions may generate short or incomplete answers.
  • For example, if you say “Do you have pain here?” the person may answer – “Yes”.
  • But if you say “Please tell me about your pain”, you may find out a lot more information. (See the resources below for more details)

Practice the 3 C’s: Closed loop, Cite names, Clear instructions.

  • For example, if you are running an emergency response with an inexperienced team, you may need to say:
  • “Corey, please take over the chest compressions 100 per minute, and Jen, please provide 2 breaths via mask every 30 compressions. Ok let’s confirm who is doing what.”
  • (See the Crisis Resource Management videos below for some more examples of this type of clear, concise communication).
  • When you are doing this don’t follow this description from Terry Pratchett…

“In an instant he became aware that the tourist was about to try his own peculiar brand of linguistics, which meant that he would speak loudly and slowly in his own language.”
 Terry Pratchett, The Color of Magic

Use non-verbal cues appropriately and pick up on other’s non-verbal cues: Eye contact (or not), body position, tone of voice, facial expressions are all important and must match to the words you are delivering. See the video for exaggerated examples from Friends.

 Be aware of (and use) Graded Communication (how to be assertive when you have concerns).

  • Graded assertiveness: The four levels (and some possible words) are:
    • Probe (also nicely called a ‘hint’) “I’m just not sure…”
    • Alert (or offer alternative) “Could we double check?”
    • Challenge. “Is there a reason for…?”
    • Emergency action “For the safety of the patient, we must…!”
  • It is important to know when to use this technique, but also important to know when someone else is using it.
  • Graded communication should be noted, acknowledged and appropriately addressed both to prevent deterioration in communication between parties and also for the safety of the patient.

 “There are times in life when people must know when not to let go. Balloons are designed to teach small children this.”
Terry Pratchett

Use Checklists especially in a crisis to help you remember the vital things:

  • ISBAR or SBAR or ISoBAR are all about keeping the communication concise and to the point and are very effective communication tools

“Chaos is found in greatest abundance wherever order is being sought. It always defeats order, because it is better organized.”
Terry Pratchett, Interesting Times: The Play

Keep your stress levels in check

  • You need to be aware when you are becoming stressed and ensure that you try and manage that stress.  Something that can help is Prioritising your tasks.
  • Divert non urgent tasks (such as answering the phone in the middle of a crisis), and communicate that non-urgent tasks will be dealt with later.
  • Focus your team and fall back on your rehearsed ways of clearly communicating in a crisis.

“Pets are always a great help in times of stress. And in times of starvation too, o’course.”
Terry Pratchett, Small Gods

Signposting can make things more obvious. For example, if you are debriefing after an incident, signposting can be useful.

  • A bit like the introduction sentence to a paragraph “ now I will talk about x and then later we will talk about y”– it lets people follow where you are in the conversation.
  • Although you may not need this technique in every situation!

“Some things are fairly obvious when it’s a seven-foot skeleton with a scythe telling you them”
 Terry Pratchett, Hogfather

Communication Resources and Checklist links

  • With parents tips for communicating with parents
  • General guide to improving effective communication. Actually a very helpful article with links to many other communication resources (though do take the exercising your middle ear muscles advice with a grain of salt).  Takes you through the steps of effective communication.
  • Very good resource on active listening
  • Non-verbal skills resource
  • Handling complaints – aimed at practice managers but a whole heap of articles on complaint management, managing difficult patients

Crisis Resource Management

  • Review article from the EMA 2011. Very good summary of the principles.
  • CRM video drilling it down to 5 things to concentrate on in CRM in simulation – you may need to watch it in fast forward but it is an exaggerated example of what you need to do in particular some good demonstrations of closed loop communication for those struggling with the concept.

Please watch the following videos with some great tips on communication in difficult encounters and breaking bad news. Note that watching these videos is optional and that the audio is not very loud.


“It’s still magic even if you know how it’s done.”
Terry Pratchett, A Hat Full of Sky


Please accept our apologies for any background noises.

Please accept our apologies for any background noises.


Contextual Dimensions Of Rural And Remote Practice

Primary Sourse: Qld Department of Families (2003) Lighthouse Project Report: A Framework for Learning in Rural and Remote Professional Practice

1. RURAL AND REMOTE PROFESSIONAL PRACTICE

Working and living in rural and remote communities can be very challenging professionally. Emilia Martinez – Brawley describes it as essential for the rural and remote practitioner to add substance to generic practice skills by knowing how ‘the rural context uniquely affects the interface between individuals and their surroundings’. (cited in O’Sullivan p 33)

2. CONTEXT OF RURAL AND REMOTE PRACTICE

 When we look at rural and remote communities we are particularly conscious of the interaction between the practitioner and client(s) as well as how they both interact with the community(Munn, 1989) Practice and practitioners in a rural and remote setting are not merely influenced by the rural and remote context, they are integral parts of that context (Cheers, 2000: 220). This contextual complexity is multi-layered and multi-faceted, involving complex sets of interrelationships and interdependencies. In examining the complex contextual, systemic and relational demands of rural and remote practice the practitioner may more fully understand the situation in its uniqueness and wholeness. Emilia Martinez-Brawley (cited in Cheers, 2003) calls this ‘integrative thinking’ because the practitioner is attempting to integrate “the various elements of the human encounter’. These include: the cultural, social, physical, political, economic and spiritual contexts and the human relationships in which the job is embedded.

To facilitate an examination of this contextual complexity five contextual dimensions have been identified as separate entities for descriptive purposes, but in reality they constitute different reference points in a holographic reality (O’Sullivan et al, 1997). (Model 1 below) Each dimension provides a different point of reference for viewing each individual community with its unique sets of issues and relationships that impact on practice. All of the dimensions of the Context:

  • Community Interactions;
  • Community Acceptance;
  • Knowledge and Understanding of Community;
  • Community-oriented practice; and
  • Self and Community;

and their integral parts are enfolded in one whole reality and need to be considered in seeking a full understanding of an issue or event or in determining an appropriate intervention.

MODEL 1

CONTEXTUAL DIMENSIONS OF RURAL AND REMOTE PRACTICE

COMMUNITY INTERACTIONS

Coping with loss of anonymity and increased visibility

In large urban communities there is a different relationship between the practitioner, client and community, which is usually distinguished by greater anonymity for both the worker and the client with practitioners spending their working hours dealing with people they rarely come across in other roles. Influences of communities where you practice can be less compelling where the organisational imperatives are down the corridor; where you can retreat to your office; and where at day’s end you go home to your place in another community.

In rural and remote communities, the community is where you live and work, and an ability to cope with the loss of anonymity is critical to effective rural and remote practice. Working without anonymity is not the exclusive domain of rural and remote workers. Urban practitioners who work with their own cultural community eg: Aboriginal practitioners or Torres Strait Islander practitioners have greater visibility in their practice and experience many of the challenges confronting rural and remote practitioners.

Managing personal and professional boundaries

The greater the visibility, the more practitioners relate with people both personally and professionally. This visibility leads to greater informality in the professional role and rural and remote practitioners are often required to be open and frank in their relationships, and to share more of their private self with their clients (Lonne, 1990:32). What they do personally and professionally, affects how people view and respond to them. The practitioner is part of the comprehensive network of mutuality which binds the community together, requiring a modification of the degree of freedom of both worker and the client (Cheers 2000). Boundaries become blurred and client-worker relationships may be multiple and may even be reversed much more frequently than in urban settings.

Maintaining confidentiality and avoiding conflict of interest

It is well recognised that the complex ethical issues surrounding service provision in rural and remote communities is further compounded with this blurring of boundaries, the personal becoming enmeshed with the professional (Cheers, Lonne). Due to the high visibility of both practitioner and client maintaining confidentiality is difficult, especially when mixing with clients socially. Information about people is often commonly known. In small communities there is often a distrust of ‘outsiders’ and suspicion of formal services and scepticism about guarantees of confidentiality. It can be particularly difficult for new workers to know who is “trustworthy” (McAullife:193)

Small communities often have active ’gossip’ networks that can constrain people in their ability to seek assistance from local networks, and particular care needs to be exercised in giving feedback to others about clients, always obtaining consent from clients if outside consultation is needed. Sometimes clients choose to seek assistance from services in another town rather than risk disclosure in their community. Managing ‘secrets’ within a rural and remote context becomes very draining over a lengthy period of time for practitioners who may experience a strong sense of isolation and lack of support when dealing with the issue. (McAullife: 193)  Confidentiality issues also impact on families because they will frequently be there when clients make contact at home or in the street.  There are no simple answers to these ethical concerns and seeking support and advice is critical to sound ethical decision-making.

COMMUNITY ACCEPTANCE

 Being visible and building relationships

The sensitive and demanding nature of rural and remote practice further compounds the challenge of managing community interactions and boundary issues. A constant juggling of the need to participate in, and be accepted by community, and maintain some balance in the boundaries between personal and professional life is frequently identified as one of the most significant challenges confronting rural and remote practitioners, particularly new graduates who were experiencing difficulty adapting to the rural and remote lifestyle. Some practitioners adopt strategies such as maintaining a personal life separate from the community either by leaving the community on weekends or becoming reclusive or socialising exclusively with work colleagues.

Building trust and demonstrating a commitment to the community

Strategies such as those adopted for managing boundary issues are counter to the need to gain acceptance by the community. Being out in the community, being visible, becoming known and building relationships that demonstrate a personal commitment to the community can be critical to effective practice and adjustment to rural and remote living. Bob Lonne’s research (2000) reported that finding the right balance between involvement in community activities, being accessible and visible in the community, and maintaining personal privacy is one of the factors that has a significant impact on the length of time a practitioner will stay in a rural and remote position.

Articulating role and managing community expectations

Practitioners constantly face the challenge of distinguishing between the personal and the professional. With absence of adequate resources they are often required to work beyond that which would be expected of them in an urban setting as there is no effective alternative. The stress is compounded by their inability to provide the necessary services to clients. Even if they are able to distinguish between the personal and the professional, some clients and other service providers do not always accept the line of demarcation. Without support and guidance practitioners who are inexperienced or new to rural and remote living can be apt to take some time to recognise and adjust to these dynamic relationships. (Lonne,)

 Being authentic and interacting respectfully

With the inherent distrust of ‘outsiders’ in many small communities, an authentic approach that is respectful of all people and sensitive to the community culture is essential to gain acceptance and engage effectively with clients. It may be necessary to adapt the style and medium of communication and be mindful of community protocols, particularly in Aboriginal communities and Torres Strait Islander communities. A further consideration is the importance of recognising the strengths of the community and to avoid being seen as an ‘expert’ and a threat to community institutions that have traditionally provide services. At the same time, however, the practitioner has a role in assisting the community to identify its own needs and set up better structures for meeting them. To this end the worker needs to gain acceptance and establish personal credibility within the community before their own professional competence is credible.

KNOWLEDGE AND UNDERSTANDING OF COMMUNITY

Knowledge of Impact of Social Contexts of Practice

All practice is socially embedded in as much as it exists within broader social settings and alongside other social practices. These external social contexts constitute an environment which may impact culturally, historically, intellectually, economically and politically on practice.

 Understanding of community dynamics

Rural and remote communities have political dimensions. They are locations of power struggles, factional disputes, status hierarchies and oppression. Practitioners cannot insulate themselves from these as they might in an urban setting. (Cheers, 2000: 223) They need to research and understand the dynamics of the community; map communities and read the political climate eg; gatekeepers; power brokers; identify ‘grass roots’ contacts and informal or existing helping networks. It is also important to know which issues unite and which divide a community and the pace of change the community will accept. This will vary from place to place and time to time. They also need to develop an awareness of small town and agency dynamics and where the practitioner fits into the structure. To obtain support for a new initiative, practitioners will need to establish strong working relationships with key people and generate support for the issue across a wide cross-section of the community.

Knowledge of local values, life-styles and traditions

Knowledge of local values, life-styles and traditions are particularly important in knowing and understanding the client’s interaction with the local community. Are they silenced or disempowered? Cheers (1985, 2000) contends that in rural and remote communities there are community induced family problems eg: problems caused by community dynamics such as scapegoating, social isolation, labelling or problems that are supported or in some instances reinforced by the local community ie: domestic violence, aggressive child-rearing practices. When community factors are the cause, changing them must be part of the response.

COMMUNITY-ORIENTED PRACTICE

Brian Cheers introduced the concept of community-oriented practice. He sees it as not a method, a theory or a model but an attitude that a practitioner has towards living and working in a rural and remote community. The framework does not share the traditional emphasis on professional distance and the steadfast separation between professional and personal ‘selves’ (2000: 221). Whilst many urban workers, especially those who work in a community development role in distinct communities, also practise in this way, it is apparent it is a key characteristic of successful rural and remote practice. (Lonne,) The need for a different model or style of service delivery and interaction particularly when working with Aboriginal communities and Torres Strait Islander communities is often cited by experienced rural and remote practitioners as a requirement for effective practice.

Establishing and using formal and informal community networks

Rural and remote communities are seen to uphold conservative social traditions which value and rely heavily upon informal helping networks. The rural and remote practitioner needs to be aware of these traditions and possess the skills necessary to nurture, strengthen and expand such resources. They must be mindful of the potential power differential between themselves and the informal networks, working with them as partners not client systems. (Lynn, 1990, Pucket et al, 1992) This integration of professional skills with informal helping systems and networks is often viewed as being both culturally appropriate and a necessity. For instance, because rural and remote communities are seen to be resource deprived areas, the practitioner needs to be able to utilise informal helping networks to assist service users. However, volunteer services should not be seen as doing the work of professionals because it is cheaper, but that they are doing work that is integral to building the resilience of the community (Lynn, 1992). Practitioners need to know how and to whom informal help is offered, in order to offer sensitive, complementary service.

Consulting with and being responsive to community

Engagement with community is essential in ensuring that practice is responsive to local needs, priorities and circumstances. Practice takes place within a particular cultural context which provides meaning to social issues and guidance in how services should be provided. Martinez-Brawley refers to rural and remote practice needing to be indigenous. This means it must acknowledge, work with and reflect the value and knowledge base of the local people, it must respond to their definition and interpretation of their needs and it must deliver services in culturally appropriate ways.(cited in Lynn, 1990; Cheers, 2000).

Being flexible and adaptable using generic practice methods within a generalist framework

As there are usually few specialist services, practitioners are expected by their communities to respond to a wide range of issues across a number of fields of practice. They are required to be flexible and adaptable both professionally and personally ie: can be innovative and creative at finding solutions; have a capacity for lateral thinking ’can think outside of the box’ and know the resources, both formal and informal, to call upon.  People in rural and remote communities expect to transact with the same person at multiple levels, the relationship being as important as the service.

Developing collaborative, cross-sectorial multidisciplinary relationships

Another reality is the need for professionals to work more closely and collaboratively with professionals of differing disciplines to achieve the optimal outcomes for individuals, families and communities. This approach though often driven by the absence of specialist discipline specific resources, as has already been argued, is more culturally compatible with rural and remote life. Such an approach goes beyond networking and requires skills and attitudes appropriate to working in multidisciplinary teams and across professional networks and an appreciation of the value of this activity.

SELF AND COMMUNITY

Awareness of own values and sensitivity to, and acceptance of difference

Professional values may conflict with dominant local values in communities where patriarchal structures and attitudes are at odds with social justice principles (Cheers, 2000) and can create considerable inner conflict. Although opportunities to challenge dominant local values do arise, practitioners frequently must accept, without necessarily agreeing with, the values and norms of people in the community because not to do so, may have consequences for future practice. There will however, be occasions when it is necessary to take on an advocacy role and challenge community values/belief systems around such things as family violence or to promote the agency value stance, which ultimately is a reflection of a broader community stance, for example, on child abuse. The level of community acceptance and perceived credibility of the practitioner, as well as their knowledge and understanding of the community, will significantly influence the level of support they will gain in challenge the dominant view. In establishing strong working relationships with key power brokers, and generating sympathy for the issue across a wide cross-section of the community by strategies such as media activities and public meetings, the process of change can begin.

Managing personal and professional isolation

Professional practice in rural and remote areas is often conducted in relative isolation without the level of professional and personal support available to urban colleagues.  Practitioners are often extended greater autonomy than their urban colleagues, so that those with initiative, confidence and a willingness to learn about life and work in the particular community, often enjoy the opportunity to approach the job in the manner they choose. But working more autonomously in this context has its down side. One of the major problems is ‘burnout’. Practitioners in these settings often are required to work with minimal supervision and support. They are often required to provide both locally based and visiting services, travelling long distances to isolated areas. In a study undertaken by the Victorian Department of Human Services (Gibbs,2002 ) the metaphor ‘sink or swim’ was used by a number of participants to describe how they reflected upon early days in rural practice. Supervision experience emerged as pivotal in shaping their experience. The multiprofessional approach discussed earlier was seen as “a strategy for overcoming professional isolation as much as a way of fostering a more collaborative and integrated ‘intersectorial’ approach to service delivery.”

Practitioners who enjoy the rural and remote lifestyle and desire to live in the community in which they work, better manage the social, physical and at times, emotional isolation. Practitioners who move from large provincial cities or urban areas are often prone to relocation and adjustment problems given their distance from personal and professional supports and their generally poor preparation for rural and remote practice. (Lonne & Cheers, 2000) If poorly supported in the adjustment process, some can experience psychological distress and problematic adjustment which may prompt a decision to leave earlier than intended.

Awareness of safety issues related to increased visibility, geographic conditions and outreach service

In rural and remote areas environmental factors impact on service delivery and capacity in a number of ways. Geographical isolation has major implications for the safety and wellbeing of workers. The provisions of outreach services requires practitioners, who are often young and female, to travel long distances in often isolated and poorly serviced locations with poor, if any mobile service which a significant issue if the car is not fitted with a satellite phone. In periods of excessive rain practitioners can be required to navigate difficult and seemingly dangerous road conditions to deal with urgent matters. Bush skills and the physical capacity and skill to be able to drive and maintain off road transport and sustain rugged conditions are considered essential but rarely part of the consideration on appointment or included in induction. The requirement in some locations to fly into small communities and stay in very basic accommodation with minimal security, highlights the importance of building relationships and gaining acceptance by the community. When there is a high turnover of staff in these locations there is often limited opportunity for such relationships to be established.

The high visibility of practitioners also presents safety issues when engaged in dealing with very complex and sensitive matters. When conflicts arise and emotions are high, practitioners are very vulnerable both personally and professionally When living in a small community the stress caused by threats of violence from a client who knows much about the practitioners’ personal circumstances is difficult to manage appropriately. The impact of client initiated violence on practitioners is the subject of much current research and organisational initiatives aimed at reducing the occurrence and impact of such incidents on rural and remote staff.