Chapter 4: Talking, Listening and Respect

A Common Situation

A woman in her fifties visits her father every evening after work. She comes in with the shopping, talks to him from the kitchen while she puts things away, and asks several questions at once: has he eaten, did the neighbour call, would he like some tea. Her father answers "yes" to everything, or says nothing at all, and later she finds his lunch untouched on the plate. One evening he raises his voice and tells her that nobody ever tells him anything any more. She is hurt and puzzled, because she feels that she talks to him all the time. She drives home wondering what she did wrong and whether her father is changing in a way she does not understand.

Moments like this happen in many families, and nobody in them is doing anything wrong. The daughter is busy and caring; her father may hear less well than before, may need a little more time to answer, and may feel that his life is slipping out of his own hands. In this chapter, I want to share the simple ways of talking and listening that care workers and nurses learn in their training. We will look at how to prepare for a good conversation, how to listen to the feelings behind the words, how to offer choices and protect dignity, and what to do when the person you care for says no to help or when a moment becomes difficult. None of this needs special skill. It needs a little time, a quiet place and the wish to understand.

Getting Ready to Talk

Good communication begins before the first word is spoken. First, gain the person's attention gently. Come into view from the front rather than from behind, say the person's name, and wait until the person looks at you. If the person likes it, a light touch on the hand or the forearm can help. Approaching from behind or speaking from another room can startle someone, and a startled person hears and understands less. Then sit down at the same level as the person, face to face and not too far away. When you stand over someone who is seated, you may seem bigger and more hurried than you mean to be. Sitting together also tells the person, without any words, that you have time.

Light and sound make a great difference. Many people whose hearing has weakened rely on seeing the speaker's lips and face, often without knowing that they do this. So make sure that light falls on your face. If you sit with a bright window behind you, your face turns into a dark shape and the person loses half of what you are saying. Turn off the television or the radio before you talk, and close the door if there is noise from outside. Background noise is much harder for older ears to filter out than for younger ones. A common moment is the one in the opening of this chapter: talking from the kitchen, with water running and bags rustling, is perhaps the hardest place of all to be understood.

Hearing aids and glasses only help when they are in use, clean and working. It is worth making a short daily habit of checking them: lenses wiped clean, the hearing aid charged or its battery changed, the small parts cleaned in the way that the person who fitted the aid explained. Dentures matter too, because loose or missing dentures can make speaking tiring and unclear. Many people stop wearing a hearing aid because it whistles, feels uncomfortable or makes noises too loud. If this happens, the person who fitted it can often adjust it, so it is worth going back and asking. If you notice that the person's hearing or sight seems to be changing, mention it to the doctor or nurse; a check may make daily life much easier.

When you speak, use a clear, normal voice, a little slower than usual and perhaps a little lower. Shouting does not help. A raised voice distorts the sounds of words, and it can sound angry even when it is not meant that way. Care textbooks explain that, with age, high sounds are usually the first to fade, so a calm, lower voice is often easier to hear than a loud one. Use short sentences and one idea at a time. Instead of asking three questions together, ask one: "Would you like some tea?" Then wait for the answer before moving on. Long explanations with many parts are hard for anyone who is tired, worried or living with changes in memory, which Chapter 3 described.

Give the person time to answer. Many older people need a little longer to find their words and to put them together, and a silence does not mean that the person did not hear. Many carers find it helps to count slowly in their head before speaking again. If you need to repeat something, use the same words first, because new words mean new work for the listener; only then try saying it another way. Gestures and objects help as well: holding up the cup while you ask about tea, or pointing to the coat when it is time to go out. For a person who hears very poorly, writing a few key words on a notepad or a small board can turn a frustrating conversation into an easy one.

Listening to the Feelings Behind Words

Listening is half of communication, and often it is the more important half. When an older person complains about the food, the neighbours or the weather, the words may carry a feeling that is harder to say: loneliness, fear, boredom, or the sense of losing control over one's own days. Think again of the father in the opening situation. When he says that nobody tells him anything, he may not be talking about information at all. He may be saying that he feels left out of his own life, that decisions are made around him, and that he misses being the one who knew how things worked. When we hear the feeling as well as the words, our answer can be much kinder and much more useful.

Care workers learn a way of listening that is sometimes called active listening. It simply means showing, with your whole attention, that you are listening. Stop what you are doing, look at the person, nod, and use small words such as "yes" or "I see". Let the person finish without interrupting or correcting small details. Then repeat back, in your own words, what you understood: "It sounds as if you feel that things are decided without you." Naming a feeling gently, without judging it, shows the person that you have really heard. It also gives the person a chance to say, "No, that is not quite it," and to explain more. Either way, the conversation becomes a shared one.

Not every problem needs to be solved at once. When someone we love is upset, we often want to fix things quickly, and we say "Don't worry" or "It's fine". These words are meant kindly, but they can make a person feel that the worry has been brushed aside. Sometimes the best answer is simply "That sounds hard," followed by sitting together for a while. A worry often becomes smaller once it has been said out loud and received with patience. If there is something practical to do, you can talk about it afterwards, and the person will usually be more ready to plan once the feeling has been heard.

Older people often tell the same stories again and again. A carer may hear about the first job, the house that was built, the hard winter or the children's school days many times. These stories are not empty repetition. They hold a person's sense of who they are, of what they achieved and what they survived. Listening with interest, and asking about a small detail you have not heard before, is a quiet gift. Knowing the person's life story also helps you understand their wishes today: someone who rose at dawn for forty years of work may never enjoy a late breakfast. This is the person-centred care described in Chapter 1: care built around the person's own history, values and habits, not around a fixed routine.

When memory or language is changing, as Chapter 3 described, words may become harder for the person to find or to follow, but feelings remain. A person may still understand your tone of voice, your face and the way you move long after some words have become difficult. So it helps to listen to the feeling and to answer that. An older woman who asks again and again for her mother may be looking for comfort and safety, and a warm voice, a hand to hold and a familiar object may answer her better than a correction of the facts. Body language can also speak for the person: restlessness, pulling at clothes or rubbing a part of the body may mean pain, cold, hunger or a need for the toilet. A change in behaviour that is new is worth telling the doctor or nurse about.

Choices, Privacy and the Right to Decide

One of the simplest ways to show respect is to offer choices. They can be very small: which shirt to wear, tea or coffee, a wash before breakfast or after it, the window open or closed. Each choice reminds the person that this is still their own life and their own day. For someone who tires easily or who finds open questions hard, a choice between two things is often easier than a question with no limits. "Would you like the blue cardigan or the grey one?" is easier to answer than "What would you like to wear?" Holding up the two cardigans makes it easier still. Try not to offer too many options at once, and accept the choice with good grace, even if it is not the one you would have made.

Dignity grows from many small habits. Speak to the person, not about the person. At a doctor's appointment, or when visitors come, it is easy for a carer to answer every question while the older person sits silently. Instead, turn to the person, give them time to answer for themselves, and add your own information afterwards if it is needed. Use the name or the form of address that the person prefers, and ask if you are not sure. Avoid the sing-song voice and the childish words that people sometimes use with older people without meaning any harm. The person you care for is an adult with a long life behind them, and the way we speak should always show that we remember this.

Privacy is part of dignity too. Knock before entering the person's room and wait for an answer when you can. During personal care, close the door, draw the curtain and keep the body covered except for the part that is being washed or dressed; Chapter 8 says more about this. Ask before opening the person's letters or looking through their papers. Keep private matters private: health, money and family worries should not be discussed in front of visitors or on the telephone with relatives unless the person agrees. Many older people feel that, as they need more help, they slowly lose every private corner of their life. Each closed door and each question asked first gives a little of that back.

As long as a person is able, that person has the right to make decisions about their own life: where to live, how to spend the day, who comes to visit, how to use their money and what care to accept. This remains true even when the family would choose differently. When a decision worries you, talk it through together. Give clear, simple information, choose a calm time of day when the person is at their best, and allow time to think. Involving someone the person trusts can help. Care textbooks call this supporting a person to make their own decision, rather than making it for them. When the time comes that some decisions become very hard for the person, those decisions can still be guided by what the person has said they would want. Chapter 13 talks about family conversations on future wishes.

Respect often means finding a balance between safety and freedom. Imagine an older woman who wants to keep walking to the shop at the corner on her own, while her son worries that she might fall. Forbidding it may protect her body but hurt her spirit, and she may simply go anyway. A middle way often exists: walking the route together at first, carrying a telephone, choosing a time of day with good light, or resting on a bench halfway. Sometimes respect means accepting a small risk that the person chooses with open eyes. If you are worried about whether an activity is safe for the person's health, the doctor or nurse can help you both to think it through.

When the Answer Is No

Sooner or later, most carers hear the word "no". The person refuses a bath, refuses to use a walking frame, refuses to let a care worker in, or refuses help that seems clearly needed. The natural reaction is frustration, especially when you are tired and have made the effort to arrange things. It helps to see a refusal as a message rather than as stubbornness. There is usually a reason, even if the person cannot put it into words. Common reasons include embarrassment, fear, pain, tiredness, feeling cold, not understanding what is going to happen, disliking a particular person, or the painful feeling of losing one more piece of independence. Sometimes the reason is simply that the moment is wrong.

So the first step is to try to understand the reason. Ask gently, without pressure: "What is it about the shower that you don't like?" Then listen to the answer, even if it seems small. A person who refuses to wash may be afraid of slipping, may find the bathroom cold, or may feel ashamed to be seen undressed by a son or a daughter. Watch for patterns as well. Many carers notice that a person refuses help in the late afternoon, when tiredness sets in, but accepts it easily in the morning. Others notice that the refusal comes when they are hurried. Once you know the reason, you can often remove it: a warmer room, a different helper, a slower pace or a different time of day.

If the person still says no, try again later, or change the way you ask. Coming back after a little while, with a calm face and a cup of tea, can change everything. Different words help too: "Shall we freshen up before your visitor comes?" may be welcome where "You need a wash" was not. Breaking a task into small steps makes it feel smaller, and doing part of it may be enough for today: washing the face and hands now, and the rest tomorrow. Sometimes another family member or a care worker is accepted more easily than you are, and that is not a failure on your part. Many older people find it harder to accept intimate help from their own children than from someone outside the family.

What we must never do is force. Holding someone down, pushing a person into the bath or taking away their walking stick to keep them in a chair harms trust, can cause injury and goes against the person's rights as an adult. An adult's "no" deserves respect, even when it is inconvenient. If a refusal goes on for a long time and starts to affect the person's health, for example if the person refuses to eat or drink, refuses all washing for many days, or will not take what the doctor prescribed, talk to the doctor or nurse. They have met these situations many times and can often suggest new ideas, and they can also look for a health reason behind the change.

There will also be difficult moments that have nothing to do with a refusal: anger, shouting, tears, or an accusation that hurts. When this happens, stay as calm as you can. Lower your voice, slow down and avoid arguing or trying to prove that you are right, because winning an argument rarely helps anyone feel better. Give the person some space, perhaps by stepping back a little. A gentle change of subject or of setting can help: a drink, a look out of the window, a favourite piece of music, a short walk into another room. Afterwards, try not to carry the moment into the rest of the day. The person may not remember it, or may feel embarrassed and be glad to move on.

It is natural for a carer to feel hurt after harsh words, even when we know they came from tiredness, pain or illness. Give yourself a moment too: a breath of fresh air, a glass of water, a call to a friend. If a moment ever becomes unsafe for either of you, step away to a safe place, and in danger call the emergency number. A sudden change in how the person behaves, speaks or understands, one that is new and not part of their usual pattern, is worth telling the doctor or nurse about quickly; Chapter 11 explains the signs that need urgent help. Chapter 12 talks more about the carer's own feelings and about where to turn when patience runs low.

A Question to Think About

Think of a recent conversation with the person you care for that did not go as well as you hoped. What might the person have been feeling at that moment, and what one small change, such as a quieter room, a slower pace or a choice offered, could you try next time? You might think about this quietly on your own, or you might ask the person directly what makes talking easier for them, and listen to the answer.