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EFFECTIVE COMMUNICATION

Homemaker / Companion
Non-Medical Skills Training

Angelic Hospice & Palliative Care

WINGS Ministry

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Purpose:

Communication and Interpersonal Skills [BASIC CORE] 1. Components of Effective Communication a. Communication Process b. Verbal / Non-verbal Communication c. Communication Styles 2. Attitude and Active Listening 3. Barriers of Communication a. Inadequate Listening Skills b. Other Barriers 4. Developing a therapeutic relationship a. Open-Ended Questions b. I Messages c. Reflective Responses d. Conflict Resolution e. Other Communication Tips

Objectives:

The student will: 1. Describe and explain the communication process. 2. Explain the importance of non-verbal language.

3. Identify different communication styles and explain the importance of assertive communication. 4. 5. Identify key elements of active listening Identify and explain barriers to communication.

6. Describe and explain effective techniques for therapeutic communication and conflict resolution.

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COMPONENTS OF EFFECTIVE COMMUNICATION 1. The Communication Process: Communication in homecare is the link between you, the client, and the agency. Sharing accurate information and observations with family and the agency improves the care for the client. The communication process involves the: Sender (for example, the speaker) Receiver (for example, the listener) Message Feedback The goal of communication is the acceptance of the senders message by the receiver. If the receiver understands the meaning of a message and perceives it the same as the sender, the goal of communication is achieved. The sender gets input as to how the receiver perceived the message via feedback from the receiver. If the feedback never comes or if the feedback is not what the sender expects, communication is ineffective. Effective communication happens when the intended meaning of the sender and the perceived meaning of the receiver are virtually the same. 2. Verbal Communication: Verbal communication uses words. Often we use the word verbal to mean oral, or spoken, language. But verbal communication also includes writing and different ways of expressing words. Sign language and Braille are also verbal communication. Braille is the writing system that uses raised dots to express the letters of the alphabet. 3. Non-verbal Communication: Non-verbal communication does not use words. There are several categories: facial expressions, head movements, hand and arm gestures, physical space, touching, eye contact, and physical postures. Even a person s emotions or how she dresses can influence the communication process. As much as 90% of communication can be non-verbal. Non-verbal means no words are used.

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Have you ever visited a country and didn t speak the language? How important was nonverbal communication? When verbal and non-verbal communication are combined, a stronger message can be sent. A completely different message is sent if the verbal and non-verbal do not agree. Example #1: While asking a client to sign your time sheet, you hold the timesheet and pen in your hand. Your actions support the verbal message. Example #2: You ask a person, How are you today? and she replies, I okay, but she is sobbing into a tissue. Two different messages are being sent. 4. The main types of communication styles are: Aggressive: Meeting needs of self and not of others. Passive: Meeting needs of others and not self. Assertive: Meeting need of both others and self. 1. Aggressive Communication What is aggressive communication? It may be physical, non-verbal (if looks could kill, ridicule, disgust, disbelief, scorn), or verbal (insults, sarcasm, put downs). It is used to humiliate or demean another person, for example, with profanity or blaming. Why people behave in an aggressive way They anticipate being attacked and overreact aggressively. They are initially non-assertive. Their anger builds until they explode. They have been reinforced for aggressive behavior. It got them attention and/or what they wanted. They never learned the skills for being assertive. They do not know how to appropriately communicate their wants and needs to others. They were socialized to win, be in charge, be competitive, and be top dog. Consequences They get their own way but often alienate others.

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They are often lonely and feel rejected. They receive little respect from others. They may develop high blood pressure, ulcers, have a heart attack, or other related ailments. 2. Passive Communication The word passive refers to not resisting or not acting. It comes from the Latin word to suffer. A verbally passive person keeps quiet and may withhold feedback. This makes communication harder and puts relationships at risk. When you withhold needed information and create an atmosphere of uncertainty, the other person does not really know what you think or feel no one is a mind reader. It can lead to misunderstandings, strained relationships and suffering. Why people behave in a passive way They believe they have no rights. They fear negative consequences (someone being angry, rejecting, or disapproving of them). They mistake being assertive as being aggressive. They do not know how to communicate their wants, and assume others should know these. They were socialized to always be compliant, accepting, accommodating, non-demanding, and selfless. Consequences They avoid conflict but often appease others. They lose self esteem. They develop a growing sense of anger and hurt. They may develop headaches, ulcers, backaches, depression, and other symptoms. What is passive-aggressive communication? Passive-aggressive behavior is often used when we try to avoid doing something, but we do not want to cause a conflict. We may just try to postpone or procrastinate. Passive-aggressive communication is subtle and may appear underhanded and manipulative. This can include forgetting, pouting, silent treatment and manipulative crying.

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3. Assertive Communication Assertiveness is the ability to say what you want to say, but still respect the rights of others. When you are assertive, you are honest about your opinions and feelings. At the same time you try not to criticize or put others down. Assertive communication is respectful of both the sender and the receiver of the message. As a direct care worker, you should strive to use assertive communication at all times. It is respectful of yourself and others It recognizes your needs as well as others. You are not a doormat, and you are not a bully. It is constructive, honest, open direct communication because you: have options, are proactive, value yourself and others, stand up for yourself without excessive anxiety, and accept your own and others limitations.

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ATTITUDE AND ACTIVE LISTENING 1. Attitude Influences: Attitudes influence our communication in three ways: Attitudes toward ourselves (the sender). Attitudes towards the receiver. Attitudes of the receiver towards the sender. Attitudes toward ourselves determine how we conduct ourselves when we transmit messages to others: Unfavorable self-attitude ~ receivers notice uneasiness Favorable self-attitude ~ receivers notice self-confidence. When favorable self-attitude is too strong ~ receivers sense brashness and overbearing attitude. Then our communication loses much of its effect with the receiver. Attitude toward the receiver or the receiver s attitude toward the sender also influences our communication. Our messages are likely to be very different when communicating the same content to someone we like than to someone we dislike. We also structure our messages differently when talking to someone in a higher position than ours, in the same position, or in a lower position, regardless of whether we like them or not. The words may be the same, but how you deliver them may affect how the message is understood. Are you assertive or defensive? Angry or thoughtful? 2. Active Listening: Listening is one of the most important skills you can have. How well you listen has a major impact on your job effectiveness, and on the quality of your relationships with others. We listen to obtain information. We listen to understand. We listen for enjoyment. We listen to learn.

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Given all this listening we do, you would think we'd be good at it! Clearly, listening is a skill that we can all benefit from improving. By becoming a better listener, you will improve your productivity, as well as your ability to influence, persuade and negotiate. What's more, you'll avoid conflict and misunderstandings. All of these are necessary for any workplace success! The way to become a better listener is to practice "active listening". This is where you make a conscious effort to hear not only the words that another person is saying but, more importantly, try to understand the complete message being sent. Becoming an Active Listener There are five key elements of active listening. They all help you ensure that you hear the other person, and that the other person knows you are hearing what they say. 1. Pay attention. Give the speaker your undivided attention, and acknowledge the message. Recognize that non-verbal communication also "speaks" loudly. y Look at the speaker directly. y Put aside distracting thoughts. Don't mentally prepare a rebuttal! y Avoid being distracted by environmental factors. y "Listen" to the speaker's body language. y Refrain from side conversations when listening in a group setting. 2. Show that you are listening. Use your own body language and gestures to convey your attention. y Nod occasionally. y Smile and use other facial expressions. y Note your posture and make sure it is open and inviting. y Encourage the speaker to continue with small verbal comments like yes, and uh huh. 3. Provide feedback. Our personal filters, assumptions, judgments, and beliefs can distort what we hear. As a listener, your role is to understand what is being said. This may require you to reflect what is being said and ask questions.
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y

Reflect what has been said by paraphrasing. "What I'm hearing is." and "Sounds like you are saying." are great ways to reflect back. Ask questions to clarify certain points. "What do you mean when you say." "Is this what you mean?" Summarize the speaker's comments periodically.

Tip: If you find yourself responding emotionally to what someone said, say so, and ask for more information: "I may not be understanding you correctly, and I find myself taking what you said personally. What I thought you just said is XXX; is that what you meant?". 4. Defer judgment. Interrupting is a waste of time. It frustrates the speaker and limits full understanding of the message. y Allow the speaker to finish. y Don't interrupt with counter arguments. 5. Respond Appropriately. Active listening is a model for respect and understanding. You are gaining information and perspective. You add nothing by attacking the speaker or otherwise putting him or her down. y Be candid, open, and honest in your response. y Assert your opinions respectfully. y Treat the other person as he or she would want to be treated.

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BARRIERS TO COMMUNICATION 1. Poor Listening Skills Poor listening skills contribute to ineffective communication. Listening involves not just hearing the message, but the ability to understand, remember, evaluate and respond. Be an active listener! Steps to improve your listening skills Be quiet. Pay attention to what the other person is saying. Stop all other activities. Focus on the speaker. Look and sound interested. Do not interrupt the speaker. Let the speaker finish, even if it takes a long time. Do not try to think of a response while the person is speaking. Do not finish sentences that the speaker begins. Listen for feelings. Clarify what the speaker has said. Ask open ended questions that encourage the speaker to continue. 2. Other Barriers There are numerous other barriers to communication. Avoid the following: Giving advice. Making judgment. Giving false reassurances about your clients physical or emotional condition. Focusing on yourself. Discussing your own problems or concerns. Discussing topics that are controversial such as religion and politics. Using clichs or platitudes (for example, Absence makes the heart grow fonder).

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Recognizing Barriers Activity

Identify and explain barriers to communication using the following example scenarios. 1. agreeing with the patient: makes it difficult for the patient to later change of modify his opinions 2. agreeing with the patient: P: Im just jumpy- I get like this sometimes. I guess its because I didnt get too much sleep last night RN: yes when you dont get a good nights sleep it does make you edgy 3. belittling the patients feelings: implies that the patients feelings are not unusual, thus denying the importance they have for him 4. belittling the patients feelings: patient: "whats there to talk about? first they say they have to operate, and then when Im beginning to feel better, I get this infection, RN: I know just how you feel 5. changing the subject: takes the lead in the conversation away from the patient, thereby blocking what the patient wishes to discuss. 6. defending: suggests that the patients criticisms are unfounded, and that he has no right to express his thoughts and feelings 7. defending: RN: "you have a fine doctor, Mr. Iverson. we have lots of his patients. he always take every precaution" 8. disagreeing with the patient: may anger the patient and put him on the defensive or cause the patient to refrain from further expression of thoughts and feelings. 9. disagreeing with the patient: Patient: "you'd think my doctor could have prevented me from getting phlebitis but he's too busy to care about whats happening to me" RN: "you're wrong, Mr. Iverson. of course he cares" 10. expressing disapproval: indicates that the patients feelings and actions have not been accepted 11. expressing disapproval: Patient: "I dont know. I hate to have my boyfriend see me looking like this. just thinking about him coming to visit makes me nervous" RN: " You really should stop worrying. that may be whats keeping you from getting the rest you need, and after all no one expects you to look your best when your in the hospital" 12. giving advice: P: buts its kind of hard having to watch what I eat, and tying to be careful about what I do RN: you should take up a good hobby, something you can do without much physical strain. 13. giving advice: indicates that the nurse is imposing her/his judgements rather than accepting the patients feelings and actions

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14. giving approval: Patient: "Maybe I should find a hobby or something. I try not to get discouraged; I know I shouldnt let it get me down." RN: "thats the right attitude it really doesnt help to worry about it." 15. giving approval: tends to focus conversation on the nurses values rather than the patients and implies that the nurses concept of right and wrong will be used in judging the patients behavior 16. making stereotyped comments: leads the patient to respond in like manner, thus keeping the conversation at a superficial level 17. requesting the explanation: requires the patient to analyze or explain his feelings, and may thereby threaten the patient 18. stereotyping: P: how are you feeling this morning Mr. Patterson RN: thats good 19. using reassuring clichs: tends to minimize the significance of the patients feelings, and conveys a lack of understanding or interest 20. using reassuring clichs: Patient: well, I havent been able to work for quite awhile now, and the doctor says I might not ever work as a carpenter again" RN: "it must be difficult for you right now, but Im sure everything will be alright"

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DEVELOPING A THERAPEUTIC RELATIONSHIP Good communication between the HOMEMAKER / COMPANION and the client is important to provide services that meet the needs of the person. Therapeutic communication is a process designed to involve the client in conversation that is beneficial to her or his physical or mental well-being. Useful techniques: Use open-ended comments to encourage conversation. This keeps a person from just answering yes or no. Learn more about the person to meet the person s needs. Use paraphrasing or reflective responses to clarify information (explained below). Use this method to direct the conversation to specifics. 1. Open-Ended Questions Use open-ended questions. This lets others engage in the conversation and share information. It gives them the chance to tell you what is important to them. Closed-ended questions are answered by yes or no: Did you eat breakfast today? Are you feeling okay? Better: Open-ended questions ask for details: What did you ha ye for breakfast today? Could you describe how you are feeling today? 2. I Messages Use I messages instead of You messages. You-messages can put the blame on the others, but an I-message is assertive. It shows that you take responsibility for your own feelings. You-message: You make me worry when you dont talk to me. Better: I message: I feel worried when I cannot communicate with you. 3. Reflective Responses Using reflective responses can help the speaker clarify his or her own meanings. There are several specific techniques you can use. Restate what the speaker has said: So you think that you don t get enough sleep. Pay attention to feelings: It seems you are upset about this.

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Dont guide the conversation or make suggestions. Dont say, Perhaps you should... 4. Conflict Resolution Sometimes a client or family member gets upset when you are in the home. It is important for you as the HOMEMAKER / COMPANION to not get angry. You must be polite and professional, and you must respond in a way that is not threatening. Use listening skills and therapeutic communication techniques listed above. Listen intently. This lets the person know that what he has to say is very important. If the person knows that what he has to say has value, he/she will begin to diffuse anger. Do not respond with anger or become defensive. Empathize. See it from his/her perspective. Then, once he sees you are an ally, not an enemy, fill him in on your challenges, feelings, roadblocks, and/or perspective. Put your own emotions on hold. Take a few minutes of time out, if needed. This lets you calm down and gather your thoughts. 5. Other Communication Tips Stick to the point at handdon t add, And another thing... Turn a negative into a positive. Set limits. Understand that people respond with different emotions to the same situation. Do not react when you feel your emotions are rising: Listen first. Speak in I and I want. Own your feelings no one can make you feel something. Feelings are not right or wrong they just are.

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Therapeutic Communication Techniques Activity

Self-challenge to use and master at least seven (7) techniques in one month TYPES OF QUESTIONS Open Ended Questions: Begin with what, how, when, where, can you tell me. Inquiries in which the received can respond in whatever direction is most appropriate for him/her at the time. Encourages the most spontaneous answer. Ex: How are you today? Closed Ended Questions: Begin with do, is, are, will. Responses are usually limited to yes or no or other one word response. Useful when wanting a short, direct answer. Avoid when trying to get client to expound on an issue. Ex: Are you feeling better today?

Thirty-One Therapeutic Techniques:

1. Focusing Questions: Targets certain are on which the nurse wishes the client to provide more detail. (Can also refer to this as a Directing Question). Ex: Can you describe how you felt when you became so anxious? 2. Validation: A question to verify that the listener has heard the sender accurately. (Arnold & Boggs refers to this as restating). Ex: Are you say.. or What Im hearing you say is___________. Is that accurate? 3. Clarification: A question that asks the client to expand or simplify a previously spoken message. Asks the client to be more specific or to say it in a different way to eliminate any confusion. Ex: Can you explain.., Can you help me understand, How do you mean? or Im not sure I understand. 4. Reflecting: Restates a portion or all of what client has just said. Focuses on feelings of client. Used to emphasize a portion of clients message, to express doubt in a questioning tone, or to continue on that topic. Caution: If overused, listener sounds like a parrot echoing everything client says. May seem disinterested or mechanical. Ex: You feel no one understands you. 5. Paraphrasing: Similar to reflecting, but the nurse re-phrases clients message in her own words focusing on the cognitive aspects. It invites client to continue with his/her thoughts. Ex: Client: This wound isnt getting any better, no matter what the doctor does. Nurse: Youre not noticing any improvement in spite of the various treatments.
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6. Sequencing: Places events in chronological order for listener understanding or to help client explore cause and effect relationships. Ex: When did you first begin to feel your life had lost its meaning? 7. General Leads: Short words or phrases to encourage the client to elaborate on the issue he/she is discussing. Ex: uh-huh, I see, Yes, Go on. May be nonverbal, nodding, facial expression, gesture. 8. Silence: A pause in which the listener provides the client to gather his thoughts and/or for the listener to observe non-verbal communication. The listener remains attentive, accepting, and expectant but without intruding into the clients thoughts. Also useful in times of powerful emotion. It if becomes extended, re-open conversation with open- ended question. Ex: Whats going on with you right now? 9. Summarizing: Used at the end of an interaction to review important issues of prior to transition to a new topic. 10. Verbalizing Implied Thoughts or Feelings: The nurse voices thoughts or feelings which the client may have alluded to or hinted at, but of which he/she may not be fully aware. Helps client clarify and process feelings and thoughts. Should always be validated. Ex: From what youve said it sounds like you really felt betrayed. Is that how you felt? 11. Acknowledging Feelings: A responding skill that communicates to clients that their feelings are understood and accepted. Provides safe, non-threatening environment so client feels secure in continuing to verbalize. Ex: I can just imagine how frightened you must have been! 12. Giving Information: Providing information that may be helpful to a client or which has been requested. Ex: Client: I cant wait to get home to watch football with a tall, cold beer. Nurse: I wonder if youre aware that the mediation youre taking shouldnt be combined with alcohol. 13. Seeking Information: When the nurse requests data from a client about feelings, events, attitudes, beliefs, symptoms, etc. Ex: How are you feeling? 14. Sharing Observations: Verbalizing an observation focused on the clients physical and/or emotional state designed to increase the clients selfunderstanding. Ex: You seem upset.
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15. Voicing Doubt: In a tentative or questioning tone of voice, the nurse verbalizes concern about the veracity or accuracy of something the client has said. Ex: Its difficult for me to believe that just one beer made you drunk enough to pass out. 16. Confrontation: In a caring, calm, respectful manner the nurse clarifies specifically the clients incongruent thoughts, feelings, behaviors or unacceptable behaviors. Articulates why the behavior is a problem, requests a behavior change and encourages a change by matter-of-factly explaining the positive consequences of changing behavior and/or the negative consequence of not changing behaviors. It assists clients self- awareness and enforces boundaries. Ex: When you smoke in the presence of oxygen, Im afraid an explosion will result and youll be injured. Please limit smoking to the designated smoking area. Otherwise, Ill have to remove your cigarettes or call security. 17. Touch: A powerful listening response which conveys empathy used to support a client who is overwhelmed with deep emotion, pain, loneliness, sensory deprivation, confusion, fear or anxiety. It must be used judiciously and with observation of clients response to the touch. Some clients may be offended or misinterpret touch. Touch must be appropriate in location, frequency, and pressure. 18. Humor: Used Judiciously after rapport and trust have been developed in the nurse- client relationship, humor can help clients appreciate the absurdities and incongruities of life, defuse an intense situation, distract from painful feelings or physical pain. 19. Immediacy: Involves focusing on the current interaction of the nurse and the patient in the relationship. It is a significant dimension because the patients behavior and functioning in the relationship are indicative of functioning in other interpersonal relationships. Immediacy involves sensitivity to the patients feelings and a willingness to deal with these feelings rather than ignore them. As with the other dimensions, high-level immediacy responses should not be suddenly presented to the patient. The nurse must first know and understand the patient and have developed a good, open relationship. Ex: Patient: The staff here couldnt care less about us patients. They treat us like children instead of adults. Nurse: Im wondering if you feel that I dont care about you or perhaps I dont value your opinion? 20. Reframing: Help client to see things from a different perspective, providing an opportunity to modify their outlook, feelings or emotional state, thereby promoting

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client control and emphasizing client strengths. Examples are helping clients to find a positive aspect in a negative situation or finding meaning in a difficult situation. Ex: Client: I never thought Id have a heart attack; Im so depressed. Nurse: Your wife said you always overwork yourself. Can you see anything positive about this crisis in your life? 21. Feedback: Information given in an empathetic manner about the others behaviors, actions, attitudes, and ideas. It should be given with an I message describing the nurses reaction to the client, be specific versus general, clear, honest, with appropriate timing and it should enhance the goals of the relationship. 22. Setting Limits: Establishing boundaries for behaviors. Consequences of going beyond those limits are explained and enforced. Ex: It is inappropriate to our relationship for you to speak to me in this manner. If it happens again Ill not be able to provide nursing care for you. 23. Boundaries: The definition and separation of the self from others by differentiating between behaviors which are and are not appropriate and acceptable. Ex: Client: Id like to take you out to dinner after Im discharged. Nurse: Thats a generous offer, but our relationship is strictly professional so Ill have to decline. 24. Redirecting: Distracting a client from undesirable behavior to re-focus on a healthier, more acceptable behavior. This is a time when it is appropriate and desirable to change the subject. Ex: Client in a nursing home and confused: I have to go to work now. Nurse gently leads client to dining area: Tell me about your career while we have breakfast. 25. Offering Self: Making self available to listen to the client. Ex: Lets sit over here and talk about whats going on with you. 26. Emotional Catharsis: Occurs when the client is encouraged to verbalize feelings, thoughts, behaviors, attitudes or beliefs that are troubling the client 27. Coaching: Assisting a client verbally and/or non-verbally (pantomime desired action) to carry out tasks with which he/she is having difficulty. Often helpful with confused client. Ex: Client is having difficulty figuring out how to dress himself. Nurse: Mr.____, first put on your underwear. Good. Now your T-shirt. O.K. Now your slacks, etc.

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28. Self-Disclosure: Honest personal statements about the self (nurse) intentionally revealed to a client when the nurse has experienced feelings, situations, or experiences to which are similar to those of the client. It is ONLY APPROPRIATE when it lets the client know he/she is understood, deepens trust in the nurse-client relationship, lets the client see the nurse as a normal human being, and augments an empathetic response. It should never be long, lack pertinence to the clients situation, upstage or embarrass the client, or re-focus the interaction on the nurse. Ex: Nurse: Youre really having a difficult time with this divorce. I can still remember how alone and scared I was when I divorced. Is that how youre feeling? 29. Confirming Responses: Responses that acknowledge the validity of clients feelings and enhance self-esteem. Overlaps with other therapeutic techniques. 30. Disconfirming Responses: Any communication that discounts, contradicts, minimizes or denies the clients feelings and lowers self-esteem. Includes many of the blocks to therapeutic communication. 31. Offering Alternatives: Helping the client consider and explore additional options. Ex: Have you thought of., Would it be useful to consider.., Some people have found it helpful to.., What else could you do?

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Therapeutic Communication Techniques

June

Sun

Mon

Tue

~ July 2011 ~ Wed

August

Thu

Fri
1 Focusing Question

Sat
2 Validation

3 Clarification

4 Reflecting

5 6 Paraphrasing Sequencing

7 General Leads

8 Silence

9 Summarizing

10 Verbalizing Implied Thoughts / Feelings 17 Touch

11 12 Acknowledging Giving Feelings Information

13 Seeking Information

14 15 Sharing Voicing Observations Doubt

16 Confrontation

18 Humor

19 Immediacy

20 Reframing

21 Feedback

22 23 Setting Limits Boundaries

24 Redirecting

25 Offering Self

26 Emotional Catharsis

27 Coaching

28 SelfDisclosure

29 Confirming Responses

30 Disconfirming Responses

31 Offering Alternatives

Notes: Express your independence to Speak Life and spark up a Therapeutic Conversation or two or ten or thirty. You keep count of the methods shared during July. Then rejoice in the number of times you have open the door to JOY by using your communication skills.

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TEST YOUR SKILLS 1. Describe the elements of the communication and explain the process. y ____________________________ y ____________________________ y ____________________________ y ____________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

2. Explain the importance of non-verbal language. _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

3. Identify different communication styles and explain the importance of assertive communication. y _______________________________ y _______________________________ y _______________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

4. Identify the key elements of active listening. y ________________________________ y ________________________________ y ________________________________ y ________________________________ y ________________________________
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5. Identify and explain three (3) barriers to communication. y ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ y ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ y ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

6. Describe and explain three (3) effective techniques for therapeutic communication and/or conflict resolution. y ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ y ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ y ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

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References:
Principles of Caregiving Fundamentals AZ Department of Health and Human Services Being a Homemaker Home Health Aide: sixth edition Ebrite, Lou Jean; Zucker, Elana Mosbys Essentials for Nursing Assistants: fourth edition Sorrentino; Remmert; Gorek

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