Effective Communication and Feedback Skills

Editor's Notes

• #3: This session will present basic concepts about feedback, but will also try to look at feedback from within a clinical mentoring context.
• #5: Note that only 7 to 11% of all communication is verbal, and the rest is nonverbal. Nonverbal communication may not always match a verbal message. Differences in how messages are perceived can lead to confusion. Ask participants to provide an example of when someone says one thing but seems to feel a different way. Some examples are: Crying while saying, “I am fine.” Saying that you are listening when you are not making eye contact with the speaker and are looking all around the room while the speaker is speaking. Saying that you are not bored or tired when you are yawning.
• #6: Explain that we’re going to do a quick exercise to test our perception of nonverbal communication. NOTE: this slide is animated to reveal clip art pictures one-by-one, depicting types of nonverbal communication Use the slide animated to reveal the clip-art pictures one-by-one and ask the group to write down the emotion the person in the image is feeling. After all images have been revealed, ask participants to share what they recorded for each one. If there are different interpretations of the emotion being expressed, point this out, and mention that at times we should check our perceptions to see if we are on track; for example b y saying , “You seem a bit skeptical about this approach. Is that true?” Use the following to explain nonverbal communication and debrief this activity: We often communicate without words. For example: Drumming Storytelling Drama Visual images Written and spoken language Hand signals People use nonverbal communication signs instead of expressing themselves verbally because they may feel uncomfortable expressing emotions such as anger, boredom, confusion verbally. This relates to the mentor-mentee relationship in that she clinical mentor needs to be aware both of what the health care worker might be communicating nonverbally to him/her, and what he/she as a mentor is communicating nonverbally to the health care worker.
• #7: Effective communication means that the correct message goes from the sender to the receiver successfully, in the way the sender intended. Just because a message is sent does not mean that it was received accurately. Effective communication requires the ability of both the sender and the receiver to: Listen Pay attention Perceive what the other is trying to communicate Respond verbally or nonverbally; i.e., react Effective communication is more than just providing information or giving advice. It involves asking questions, listening carefully, trying to understand a mentee concerns or needs, demonstrating a caring attitude, and helping to solve problems.
• #8: Tell participants that they are going to discuss these three techniques in the next few slides, starting with active listening.
• #9: Ask participants to name some components of active listening. Write their responses on a flip chart.
• #10: Ask participants to use this picture to add to the list of components of active listening that you began on the last slide. Possible answers include: Make eye contact. Face the speaker. Concentrate on the speaker and what he/she is saying. Pay attention. Demonstrate interest in what is being said. Avoid distractions, like phone calls, other people, or paperwork (note that this is a factor related to the environment in which you are holding a conversation—in this picture, the pair has chosen a meeting place that is free of many distractions). Give participants a minute or two to think of a time that they had to talk to someone who was a bad listener. Ask for a couple of volunteers to share what made that person a bad listener, and how it made them feel.
• #11: Instruct participants to divide into pairs and ask each pair to decide on a speaker and a listener. Allow each person 1-2 minutes to speak, prompting participants when to switch partners. Task: Each speaker should talk for 1–2 minutes about a topic of their choice (it does not have to be work-related), while the facilitator keeps time. The listener cannot say anything, but must convey active listening using nonverbal skills. The pairs should switch roles and repeat the exercise at the facilitator’s prompting. After the exercise, discuss the following in the larger group: As the speaker, how did it feel to talk for that long without being interrupted? When you were the listener, how did it feel to listen? Why? How does this exercise apply to your mentoring?
• #12: Reflective listening builds on active listening.
• #13: Note that the sample statements include the word “you,” which emphasizes that the mentor is actively listening and reflecting back what the mentee has said. This helps to check for understanding.
• #14: Have the participants get in the same pairs as for the active listening activity. Each pair should choose a first speaker and a listener. Refer participants to the list of topics below. The speaker will talk to the listener about his/her topic for 2 minutes, while the listener should respond only with reflective listening statements. Under normal circumstances, it is natural to mix reflection with other skills, but in this exercise, practice reflecting only . Group members should switch roles after 2 minutes. Each person should practice speaking, listening, and observing. Each group member should pick one topic from the list below (it is okay for group members to use the topic if they like). Topics: Describe what makes a good friend. Describe an accomplishment you are proud of. Talk about your earliest memory. Describe the best vacation you have ever taken. Talk about a scary experience you have had that turned out well. Talk about someone you admire and why. Describe a childhood experience that you remember fondly. If you had a day to do anything you wanted, describe what you would do. Debrief: Ask participants: How natural did it feel to be a speaker? A reflective listener?
• #15: Summarizing is another skill we will practice that may be useful for communication with your mentee.
• #17: Have the participants get in the same pairs as before. Each pair should choose a first speaker and a listener. Refer participants to the list of topics below. The speaker should choose a controversial topic about which to speak (or use one of the examples below), uninterrupted, for 2 minutes. Give the participants about a minute to think about what they will say, once they have chosen a topic. The speaker can express his/her opinion, or can just choose a position to support. The listener should practice active listening, but should not respond verbally. When the speaker has finished speaking, the listener should summarize what the speaker said, taking about 30 seconds. The pairs should switch roles and repeat the exercise. Suggested topics: If no gloves are available, should health care workers (HCWs) still draw blood, manage deliveries, etc., i.e., without gloves? HCWs who test HIV-positive should not be allowed to work in the hospital. Women who are HIV-positive should not have children. HCWs should be allowed to refuse to take care of HIV-positive patients if they wish. Pregnant patients should not have a choice about HIV testing; it should be mandatory. Debrief: After all participants have gotten a chance to speak, discuss in a larger group: Was it more difficult to listen quietly when you disagreed with what your partner said? As a listener, was it difficult to summarize? As a speaker, did the listener summarize correctly?
• #18: Communication can be hindered by a number of things. This picture depicts a scene in which many barriers to communication exist. What are they? Ask participants to look at the picture on the slide, and describe any barriers to good communication that they can see in the picture. Write participant answers on a flip chart. Use the following questions to help guide the discussion: What is the clinician communicating with his body language? What is the client communicating with her body language? Add anything that participants may have missed from the following: Dirty office, with other patients’ information all over the table. Interruptions and distractions, e.g., cell phone calls. The door is open and there are people nearby who can hear their interaction, so there is no privacy to ensure confidentiality. HCW is not facing the person with whom he is meeting. Other ways of not communicating well include: Looking out the window. Looking at the clock or watch. Starting to speak to someone else. Shuffling papers. Negative nonverbal communication can have many consequences, such as: Information is not shared, understood. The client may ask fewer questions. Problem may be difficult to understand. Situation may be uncomfortable. Lack of adherence to medical appointments and/or treatment. Note that this picture depicts an HCW with a patient, not a mentor and mentee. However, the same barriers to communication could exist between a mentor and mentee. Alternatively, this is a scene that a mentor might observe in the clinic and give feedback to a mentee about.
• #19: The last slide dealt primarily with nonverbal barriers to communication. This slide lists barriers to communication that are largely verbal. These barriers to communication are avoidable. However, once barriers to communication have surfaced, a significant amount of work may be necessary to overcome them.
• #20: Explain to participants that we are transitioning into the topic of feedback. Feedback is a critical component of mentoring, but for feedback to be effective, it must be offered in a way that it can be received by the mentee. The next slide depicts a role play about providing feedback effectively.
• #21: Before the role play, identify two participants and brief them on the following role play: One participant is the mother-in-law, one is the daughter-in-law. Scenario/instructions for volunteers: The mother-in-law is eating a terrible dish that her daughter-in-law cooked for her, and must respond to the daughter-in-law’s questions about how she likes it. (Mother-in-law should nonverbally communicate to the audience that the dish is not very good.) The mother-in-law’s responses must be truthful, yet not hurt her daughter-in-law’s feelings. The mother-in-law should make positive comments such as, “The plates are lovely,” or, “The food is very hot,” in addition to feedback such as, “It’s a bit saltier than I prefer.” Be sure that the daughter-in-law asks several specific questions. Debrief: After the role play, ask, “What did you observe?” Point out that the mother-in-law was honest, yet gentle and careful in how she chose her words. Overall, the interaction was a positive one. Had she chosen different words, however, the interaction could have been very negative. Summarize the activity by explaining that the role play is an entertaining way to demonstrate that there are many different ways to communicate, and that our choice of words and how we say something can have a huge impact on whether or not the interaction is positive and effective. This is especially true when giving feedback.
• #22: Ask participants to brainstorm definitions of the term “feedback” as they understand it. Write their responses on flip chart paper.
• #24: Note that feedback can be positive or critical, but the sole purpose is to improve performance, not punish poor performance
• #25: Divide the participants into small groups of 3–4, and ask them to compile a list of factors, based on the question on the slide. After about 5 minutes, come back to a large group and record answers onto a flip chart. Possible answers : Presence of patients : The clinical mentor must not embarrass the health care worker in front of a patient. At the same time, the mentor cannot allow the health care worker to do anything that will endanger the health or well-being of the patient. This means that sometimes feedback is held back until the two can talk in private; in other cases, the feedback needs to be given immediately in a diplomatic, supportive, yet honest way. Content and style are both critical in effective communication in a health care setting. The health care worker needs to cover the right information, but also needs to present it in such a way that it can be received by the patient. Feedback from the mentor might involve saying, “The information you covered about how HIV is transmitted was accurate, but I’m not sure the patient was following you.”
• #26: How we give feedback—what we say, how we say it, when we say it—is critical to whether the feedback is effective and achieves the intended effect. Present the PITC case scenario over the next two slides. Then present the two role plays demonstrating two approaches to giving feedback in the next few slides. Refer to Worksheet 3.1 for the scenario, feedback approaches, and discussion questions.
• #29: Two facilitators should present the role play with one playing the role of a clinical mentor, the other playing the role of the nurse. The clinical mentor should have a serious facial expression and a harsh tone. Clinical mentor: “Did you realize that you asked about the three partners in a very judgmental way? Did you see how the patient reacted to your questions? It seems that you must have some personal issues related to sex outside of marriage! I’m worried that this patient will be afraid to return to the clinic in the future! This is not how we expect pretest counseling to be carried out… You need to do this better!” Nurse (embarrassed, ashamed): I’m sorry. I didn’t know what to say. [expand on this if desired]
• #30: Clinical mentor (using supportive nonverbal body language, kind expression, etc.) “ I just wanted to take a couple of minutes to talk about the last client. I really appreciate the way you engaged with the patient like you did. It was excellent that you asked about the number of partners the patient had and about condom use. A suggestion for next time would be to probe further about the condom use. For example, once the patient reported that she didn’t use condoms with her husband but uses them with one of her other partners, you could specifically ask which partner she uses condoms with—number one, number two, or number three? Ask if she uses condoms sometimes or always with that partner. Ask why she does not use condoms with number one and number two. Ask her if she thinks that she is at risk for HIV when she does not use condoms.” “ It’s also extremely important to counsel patients in a manner that doesn’t make the patient uncomfortable with you. If the patient starts to feel uneasy during the visit—like you might be judging them in some way—it’s very likely that she will not disclose information regarding her HIV risk in an honest manner. So even though you may not personally agree with someone’s behavior, our role in counseling is to give the client enough information to show the client how best to keep a low risk profile for acquiring HIV. But ultimately, the patient must make the decision about what behavior she chooses to adopt.” “ Do you have questions about what I’ve just talked about? How do you think you can practice being impartial to client’s responses about their behavior in the future?”
• #31: Use the questions on this slide (and in Worksheet 3.1) to debrief the role play Record participants’ responses on flip chart paper. Possible responses: Differences between approaches: Different tone. Different nonverbal communication techniques. More time taken in the second scenario to explain the situation to the health care worker. 1 st approach was very demanding and was not constructive, in that it did not ask the mentee to think of ways to improve. 2 nd approach gave examples of how to improve in the future, and invited the mentee to think of ways to practice the improved counseling behavior. In 1 st scenario, the health care worker only learned that he/she performed poorly, not how he/she could have improved the situation. In the second approach, the health care worker learned a more effective technique for communicating with the patient, and also learned that how he/she communicates with the patient is important, in terms of whether the information is passed effectively. Remember that the purpose of feedback is not to reprimand, but to help health care workers perform better in their jobs.
• #32: See Handout 3.2, Basic Principles of Feedback.
• #33: The positive observations are the two pieces of bread, while the suggestion for improvement is the filling tucked in between them.
• #38: Explain that this final activity provides an opportunity to practice all of the skills we’ve discussed in this session: giving feedback effectively, nonverbal communication, and active listening. Ask participants to form pairs with somebody that they don’t know well. Direct participants to Handout 3.2– Basic Principles of Feedback, and Worksheet 3.3—Feedback Scenarios. Instruct one member of the pair to play the clinical mentor, the second to play a HCW. Assign two scenarios to each pair. The task is for the mentor to provide feedback to the HCW based on one of the scenarios. Allow about 10 minutes. Switch roles, and repeat with the 2 nd scenario. Debrief the activity by asking participants: “ How did it feel to give feedback?” “ How did it feel to receive feedback?” “ Other thoughts?”