Listening better: a guide to improving what may be the ultimate staff skill.

Most people would agree that having someone listen to you makes you feel better - mentally and physically. In fact, according to Ralph G. Nichols, who is regarded as the father of listening, "The most basic of all human needs is to understand and to be understood.... The best way to understand people is to listen to them." Thus, being listened to is one of our most basic needs.

Additionally, in Abraham Maslow's hierarchy of needs, at least three of the five levels of needs he describes deal with mental and emotional needs, rather than physical needs. The need to feel a sense of belonging, a sense of self-worth, and to feel self-actualized are all needs of the mind. Listening enables us to find out what those needs are in another person so that we can then meet those needs - for how can the need to belong or to feel self-worth be met if no one wants to hear what you have to say? Listening is the window to what is on the inside.

But who has the time to listen, especially in an environment where you have many tasks to perform and everyone wants to talk to you? The listening tasks of nursing home staff indeed are varied, demanding, often difficult, and sometimes unpleasant, and yet listening can be one of the simplest and most rewarding things you, do all day. Despite its importance, until recently listening was a skill that received little attention. Now we are seeing emphasis being given to listening in many fields, from customer service to sales to management, and even in the healthcare field. Even doctors are now getting instruction in how to listen as part of their medical training.

So what is all the hoopla about? Why is listening important?

If you have ever experienced the frustration of going to your own doctor, telling him or her what the problem is, but feeling like you weren't being listened to - as though the doctor had a separate agenda from yours - you can understand the need for all healthcare workers to listen. And the frustration goes beyond the healthcare factor. You feel intimidated and powerless, your self-esteem goes down and your frustration level goes up.

And what if people won't listen to you about other matters, as well? Remember your frustration, the anger and hurt you feel when you are telling someone something important and they don't bother to listen? Listening is important because it validates our thoughts and feelings. It lets us know that someone cares about the person on the inside, not just our physical being.

The frustration of not being listened to illustrates the strong link between listening and self-esteem. When someone listens to you, you feel good about yourself. You also tend to feel pretty good about the listener, as well. Likewise, when you listen to someone, you are telling the speaker that he or she is important and that you are interested in him or her as a person. You are saying "I respect you and your thoughts. I want to understand you, and you are worth listening to, and you have things to say that are of value."

In her book How to Talk So People Listen, Sonya Hamlin points out that what determines whether people will listen:

1. Self-interest

2. Who's telling

3. How they tell it

We could probably add that a fourth factor is the consequence for not listening. So people are more likely to listen if they are personally interested, if the speaker is important to them, if the speaker is particularly effective, or if there are severe consequences for not listening. And here is where we encounter the first set of problems in listening to nursing home residents. Residents often are not easy to listen to, and there are only minimal consequences for not listening to them. Some of the specific problems of listening to nursing home residents include:

1. They talk softly, mumble, or are often difficult to understand.

2. They may be repetitive (you've already heard that story a number of times).

3. They don't have much in the way of new experiences to talk about.

4. Often they are complaining - they don't feel well; they don't want to be there; they don't like the food or the person next door or the night nurse.

5. Sometimes their thought processes are incoherent and what they say makes no sense.

6. You may hesitate to get to involved with someone you don't think is going to be around for a long time.

7. It may make you sad to listen to them.

8. There may be other noise that makes it difficult to hear them (and sometimes the "noise" is another patient).

9. There simply is not enough time to be a good listener and still get assigned tasks done.

Consequently, the four things that would normally entice you to listen may be in short supply.

So, Why Listen?

The answer to this question varies depending on the person you are listening to, the situation, and what the speaker's purpose is. Often our purpose is either to get information or to have a relationship with the speaker, but there are actually six types of listening and purposes for listening (Table 1). While there may be opportunities for all six types of listening within the nursing home environment, some will be more common than others, and some will be more difficult than others to do well.

Table 1

Type of Listening                     Purpose of Listening

Discriminative listening -            to identify, discriminate and
identifying sound (i.e., whose        distinguish
voice it is) and making fine
distinctions within those sounds,
such as distinguishing emotionally
loaded words, or hearing fear or
pain in the voice of a resident or
even in nonsensical sounds

Comprehensive listening -             to understand and get
understanding the message             information

Critical listening - analyzing and    to  evaluate
evaluating the message in order to
determine whether to accept or
reject it, agree or disagree

Appreciative listening - enjoying     to enjoy
the message or the sounds

Therapeutic listening - serving as    to empathize
a nonjudgmental sounding board

Relational listening - listening      to establish or enhance a
to small talk and pleasantries,       personal relationship so that
such as greetings, "nice weather,"    the other types of listening
"how was your weekend?" etc.          can be more successful

The staff in the nursing home has a challenge because the needs of the speakers vary so much. Listening among the staff members involves the exchange of a great deal of information that must be understood quickly but accurately, and there are consequences for not listening. Listening to residents requires patience, and while it involves some information, more often it involves relational or therapeutic listening. You are listening to have a relationship or to meet the needs of the resident. Meanwhile, listening to the resident's family members involves comprehensive listening, perhaps some critical listening, and large doses of therapeutic listening.

In order to do a good job of listening, you must first determine what your purpose is. Of course, it varies from situation to situation, and even the same speaker can change purposes often and rapidly. But first, you should decide what your purpose should be, because you will bring a different set of skills and techniques to the table, depending on your purpose. You may even want the speaker to clarify what his or her purpose is. Is he telling you about a new or more aggravated symptom, or is he venting frustration over dealing with the same pain?

Listening Techniques

While there are specific listening techniques that apply to the different purposes of listening, here are some general techniques that will make you a more effective listener and can be applied in a wide range of situations:

1. Focus your full attention on the speaker rather than dividing your attention between listening and doing. Also, rather than creating or tolerating distractions, establish or move to an environment that supports effective listening - for example, take the person to an office with a closed door, move away from other residents, close the curtain around the bed, or close the door to the resident's room. The more important the message is, the more important it is that you give your undivided attention.

2. Get on the same level as the speaker. Sit or kneel by the resident.

3. Give verbal and nonverbal feedback that demonstrates that you are listening and indicates a supportive climate. Lean forward and turn your body directly toward the speaker. Make eye contact, nod your head, smile, assume a relaxed and involved body posture, say "uh huh," and maintain a close but comfortable distance from the speaker. Also, use an open body posture avoid crossed arms and legs and a rigid or closed body posture. Touching the resident's hand, forearm, or shoulder may also be appropriate. But be careful about using the condescending "there, there" touch that is often used to give comfort to a young child (although there may be times when this, too, is appropriate). Avoid shifting your eyes, looking around the room, checking your watch, turning away from the speaker, or distancing.

4. Take the time to give some quality listening to each resident and to do some relational listening. Give listening a higher priority on your list of tasks to do. Stop doing other things, such as checking blood pressure, cleaning off a tray or straightening the room. It is important to give your undivided attention to show that you really are listening, at least for some of the time.

5. Avoid giving advice unless you are qualified and have been asked for it. Also be careful about giving inappropriate reassurance, such as "you'll be OK" when you and the resident know that he or she won't be. This tends to diminish the importance of his or her message or complaint. Instead express empathy.

6. Let residents talk about what they want to talk about, rather than correcting their perceptions and reminding them that they aren't back on the farm or in their own home. If the resident is reliving an earlier time in his or her life, ask about and converse on that topic rather than trying to bring the conversation into the here and now or guiding it to your own interests, so that you can do most of the talking.

7. Give verbal responses that support rather than evaluate the speaker. Show empathy by identifying with the speaker's emotions or problems and expressing understanding, and avoid trying to evaluate, control or show superiority.

8. Be sure you allow the other person to do his or her share of the talking. When positive rapport exists, people generally share the talking time 50/50.

9. Smile, be pleasant and use humor where appropriate.

10. Remember that often your purpose is to be a friendly or sympathetic ear. You don't have to be a brilliant conversationalist if you first ask a few well-targeted questions and then become a brilliant listener. You are providing the speaker with the opportunity to share thoughts and feelings or to talk through a problem. She does not necessarily want you to solve the problem for her.

11. When you are doing critical listening, be sure that is what you should be doing. We tend to do much more of this than we should. However, you might do critical listening to determine whether a complaint is simply an attempt to get attention or is a valid complaint that should get medical attention.

12. When you are through talking or must leave, don't just walk away. Do some "leave talking" in a positive way. Say, "I've enjoyed talking with your Ms. Redding, but I need to go see about Mr. Evans' lunch."

13. Use a technique called "empathic echo." It involves simply stating back to the speaker what your heard him or her say, but in your own words. For example, "Let me make sure I understand you. You are saying you don't feel your mother is getting enough to eat?" If there is strong emotion being expressed, it is important to echo the emotion, as well. "I can see that you are really upset. You say you have mentioned this before and the problems still haven't been taken care of?"

Table 2

Defensive Climate         Supportive Climate

1. Evaluation             Description

Rather than evaluating and judging others from your own frame of
reference, describe what you've heard in a nonevaluative way. "You
feel that the pain in your arm is worse today than it was
yesterday."

2 Control                 Problem-Orientation

Rather than trying to change others so that they will do what you
want them to do, try to reach agreement on what the problem is to be
solved and a mutually satisfactory solution.

3. Strategy               Spontaneity

Rather than manipulating others, be honest and direct, free of
hidden motives.

4. Neutrality             Empathy

Rather than being coldly detached with an "I don't care" attitude,
identify with the speaker's problems, accepting his or her feelings
and expressing understanding. NOT: "I don't care. do whatever you
want." RATHER: "I understand that these are not easy decisions to
make."

5. Superiority            Equality

Avoid exhibiting an attitude of being better than others or raising
feelings of inadequacy in others. Instead, respect the individual
worth of others and their ability to solve their own problems, but
be willing to participate in the process. (This might apply
especially to listening to the resident's family.)

6. Certainty              Provisionalism

Rather than having preconceived notions about how something should
be (what is "right"), without considering anyone else's ideas, or
being unwilling to change, try to be open to new information and
ideas, and be willing to reconsider your own behavior and attitudes
- i.e., "Would you like to explore the benefits and drawbacks of the
two treatments?"

Often physical or psychological barriers interfere with our listening effectiveness. Physical barriers include distracting noise or difficulty hearing the person; or perhaps you are too tired, upset, hungry, etc., to listen. Psychological barriers would be factors such as dislike for the person, lack of interest in the topic, biases that interfere with your ability to be objective about the person, or stress or other factors that cause your mind to wander. Barriers should be minimized or eliminated wherever possible.

Defensive vs. Supportive Climates

Another important aspect of effective listening in a nursing home environment is to create a supportive climate rather than a defensive climate. Jack R. Gibb identified six characteristics that can arouse defensiveness and six contrasting characteristics that can create supportive communication.

Often in listening to nursing home residents, you may tend to take a defensive approach (an attitude that says you know better than they do) rather than providing a supportive climate. Below is a summary of the six distinguishing characteristics of a more supportive climate and some suggestions for providing it to the residents, their family members, and other staff members (Table 2).

The rewards of effective listening to your residents and their families are many. First, you actually can learn from them. They often have a wealth of experience and knowledge. You can gain valuable information about their health, well-being, and state of mind. But perhaps more importantly, you let the residents and their families know that you care about them.

You also boost residents' self-esteem by listening. (We listen to people we care about and think are important; therefore, if you are listening to me, you must care or feel that I am important.) And one final bonus is that when you are a more effective listener, the residents, their family members, and other staff members will listen to you more effectively. After all, we tend to give back what we get.

Thus, listening is truly a gift. And the best part is that it doesn't cost anything to give. The Hallmark greeting card advertisements sum it up nicely: "When you care enough to send your very best" - first, you listen.

Sheila C. Bentley, PhD, of Bentley Consulting of Collierville, TN, is past president of the International Listening Association (ILA), an organization of professionals in the United States and 12 other countries dedicated to the study of listening and enhancement of listening skills in a variety of settings. Further information on the ILA may be obtained from the Professional Communication Dept., Alverno College, P.O. Box 343922, Milwaukee, WI 53234-3922; [phone].