Communication in medical practice

Workplace Communication Relationships

Effective communication demands that the parties involved in communication have a shared and clear appreciation of the various definitions and parameters about which information is being exchanged. Workplaces are witness to generally five types of communication relationships: Collaborative, Negotiative, Competitive, Conflictive and Non-recognition.

Fundamental obstacle to effective communication

Non-recognition relationship blocks any meaningful exchange by refusing to acknowledge that one or more of the players in the desired exchange has no rights whatsoever.Conflictual relationship is a situation in which the parties recognize each other but are no longer able to work towards a win-win result and resort to verbal abuse and physical violence instead. These types of relationships present a fundamental obstacle to effective communication.

Collaborative and negotiative relationship

In the collaborative relationship the needs and positions of all the parties are clearly defined and understood and everyone involved shares the will to succeed, as well as information, equipment, accommodation and logistic arrangements, for example. The negotiative relationship has much in common with the collaborative scenario except that some needs and positions may not have been defined clearly enough and require discussion and trading to reach a mutually acceptable outcome.

How credibility and trust develop over time

What can studying communication skills What can studying communication skills offer us as medical practitioners?offer us as medical practitioners?

Increased nurse Job Satisfaction Increased nurse Job Satisfaction Decreased Conflict Within The Consultation Decreased Conflict Within The Consultation More Accurate And Efficient Interviews More Accurate And Efficient Interviews Better Clinical Hypothesis Generation Better Clinical Hypothesis Generation Increased Patient Satisfaction Increased Patient Satisfaction Increased Patient Understanding And Recall Increased Patient Understanding And Recall Improved Compliance And Disease Outcome Improved Compliance And Disease Outcome Decreased Medico Legal Complaints Decreased Medico Legal Complaints Actual Savings In Time Actual Savings In Time More Structure And Control Of The Difficult Consultation More Structure And Control Of The Difficult Consultation

Treatment Outcome:Treatment Outcome: Effective diagnoses and treatment depends not only on Effective diagnoses and treatment depends not only on identifying physical symptoms of illness, but also on the identifying physical symptoms of illness, but also on the nurse’s ability to detect and respond to verbal and non-nurse’s ability to detect and respond to verbal and non-verbal cues, to elicit all relevant information (physical verbal cues, to elicit all relevant information (physical and psychosocial), relevant to diagnoses and treatment. and psychosocial), relevant to diagnoses and treatment. PatPatient’s Adherence:ient’s Adherence:A poor communication skill is related to poor compliance. A poor communication skill is related to poor compliance. Communication skill training has a positive influence on Communication skill training has a positive influence on patient compliance with prescribed medication. patient compliance with prescribed medication. Effective Effective communication enables nurses/Nurse and other health communication enables nurses/Nurse and other health professions to pass on relevant health informationprofessions to pass on relevant health information, and , and to motivate patient to pursue healthier lifestyle. This is a to motivate patient to pursue healthier lifestyle. This is a very important part on very important part on health promotion.health promotion.nurse’s Competence & Self-Assertion: nurse’s Competence & Self-Assertion: Research has also shown that better nurse’s patient’s Research has also shown that better nurse’s patient’s communication can also contribute to the clinical communication can also contribute to the clinical professional and personality (self-confidence) aspects.professional and personality (self-confidence) aspects.

Patient’s Satisfaction. Patient’s Satisfaction. Many researches have also shown a significant Many researches have also shown a significant relationship between the clinician’s interpersonal skills relationship between the clinician’s interpersonal skills and patient’s motivation and satisfaction. When the and patient’s motivation and satisfaction. When the nurse dominates the interview, verbally and emotionally, nurse dominates the interview, verbally and emotionally, the result is always leads to dissatisfaction of the the result is always leads to dissatisfaction of the patients and their relatives. This may also be related to patients and their relatives. This may also be related to the patient’s expectation about the role of the nurse.the patient’s expectation about the role of the nurse.Patient’s satisfaction plays a major role in assessing Patient’s satisfaction plays a major role in assessing quality medical care in the newly adopted health system quality medical care in the newly adopted health system (manages care) in the USA.(manages care) in the USA.Cognitive SatisfactionCognitive Satisfaction: How satisfied is the patient with : How satisfied is the patient with their understanding of the diagnoses, treatment, and their understanding of the diagnoses, treatment, and prognoses. This is related to the nurse’s prognoses. This is related to the nurse’s Verbal Verbal Behavior.Behavior.Emotional Satisfaction:Emotional Satisfaction: This is related to the nurse’s This is related to the nurse’s non-verbal behaviornon-verbal behavior. The ability to show care and . The ability to show care and concern by tone of voice, eye gaze, facial expression, concern by tone of voice, eye gaze, facial expression, body movement and posture.body movement and posture.

INTERVIEWING INTERVIEWING AND AND

COMMUNICATION COMMUNICATION SKILLSSKILLS

CORE COMMUNICATION CORE COMMUNICATION SKILLSSKILLS: : Core communication Core communication skills covers three skills covers three dimensions:dimensions:

•• nurse -patient interpersonal nurse -patient interpersonal skillsskills

•• Information gathering skillsInformation gathering skills•• Information giving skills and Information giving skills and

patient educationpatient educationAdvanced Communication Advanced Communication

SkillsSkills•• Skills for motivating patient Skills for motivating patient

adherence to treatment plansadherence to treatment plans•• Other applications of core Other applications of core

communication skills in communication skills in specific situations.specific situations.

Information gathering skillsInformation gathering skills

A critical part of all nurse-patient interactions involves A critical part of all nurse-patient interactions involves eliciting information from patient. The core skills which are eliciting information from patient. The core skills which are needed to needed to facilitatefacilitate the process of information gathering the process of information gathering are skills which help to are skills which help to facilitatefacilitate the patients’ involvement the patients’ involvement in the medical interview in away that enables the nurse to in the medical interview in away that enables the nurse to arrive at an accurate diagnosis of a patient’s problem or arrive at an accurate diagnosis of a patient’s problem or symptoms.symptoms.Using an appropriate balance of open to closed Using an appropriate balance of open to closed questionsquestionsOpen questions invite an extended answer, not a Open questions invite an extended answer, not a “Yes/No” response. Generally questions such as “Please “Yes/No” response. Generally questions such as “Please tell me about your pain” are better at eliciting information tell me about your pain” are better at eliciting information than closed questions such as “Is it a stabbing pain?”. than closed questions such as “Is it a stabbing pain?”. Open questions are particularly useful patients are being Open questions are particularly useful patients are being asked to describe their problem; which they should be asked to describe their problem; which they should be allowed to do minimal interruption early on in the allowed to do minimal interruption early on in the consultation.consultation.

SilenceSilenceYou need to learn to use silence appropriately as a way You need to learn to use silence appropriately as a way to encourage express themselves more fully, raise to encourage express themselves more fully, raise difficult topics and remember importantdifficult topics and remember important

Clarifying patient expectations about the consultationClarifying patient expectations about the consultationYou need to clarify with the patient what their You need to clarify with the patient what their expectations are consultation, and should avoid making expectations are consultation, and should avoid making premature conclusions about the reason person’s visit to premature conclusions about the reason person’s visit to the nurse. This may helps to reveal cases where the the nurse. This may helps to reveal cases where the symptom the patient is not in fact the patient’s main symptom the patient is not in fact the patient’s main concern, and will also help to avoid inaccurate diagnosis concern, and will also help to avoid inaccurate diagnosis of the patient’s complaints.of the patient’s complaints.

Clarifying the information given by the patientClarifying the information given by the patientYou need to clarify the meaning of what the patient is You need to clarify the meaning of what the patient is saying and the nurse perceives from the patient’s non-saying and the nurse perceives from the patient’s non-verbal communication in order to he/she understands the verbal communication in order to he/she understands the patient fully.patient fully.

Sequencing of eventsSequencing of eventsAfter eliciting a broad description of the patient’s After eliciting a broad description of the patient’s situation, students need to help the patient to sequence situation, students need to help the patient to sequence events and experiences in order to develop a logical of events and experiences in order to develop a logical of the patient’s situation.the patient’s situation.

Directing the flow of informationDirecting the flow of informationWhile it is important that patients be allowed the While it is important that patients be allowed the opportunity to communicate at the same time the student opportunity to communicate at the same time the student needs to learn to maintain control of the interview, by needs to learn to maintain control of the interview, by guiding the interview content towards a diagnosis of the guiding the interview content towards a diagnosis of the problem.problem.

SummarizingSummarizingSince a lot of information can be exchanged in Since a lot of information can be exchanged in consultations, you should be able to summarize the main consultations, you should be able to summarize the main issues raised during the consultation and should ensure issues raised during the consultation and should ensure that a shared understanding of these.that a shared understanding of these.

Information giving Information giving skills and patient skills and patient

educationeducationThe medical interview usually involves the nurse in providing The medical interview usually involves the nurse in providing information to the patient about their illness or problem, and when information to the patient about their illness or problem, and when appropriate the nurse will give inform and advise about the appropriate the nurse will give inform and advise about the proposed treatment plan or treatment options.proposed treatment plan or treatment options.Providing clear and simple information Providing clear and simple information by monitoring jargon, and by by monitoring jargon, and by checking the patient’s understanding before (“What do you know checking the patient’s understanding before (“What do you know about asthma?”) and during (“Have I made myself clear?”) the about asthma?”) and during (“Have I made myself clear?”) the explanation process.explanation process.Using specific advice with concrete examples.Using specific advice with concrete examples. Abstract or general Abstract or general advice/inform should be exemplified in terms that make sense to the advice/inform should be exemplified in terms that make sense to the patient “Don’t use acidic foods for example steer clear of fried patient “Don’t use acidic foods for example steer clear of fried things”.things”.Putting important things first. Putting important things first. Research suggests that what is said Research suggests that what is said first is remembered. A nurse should say first what it is most first is remembered. A nurse should say first what it is most important for the patient to recallimportant for the patient to recall

Using repetition. Using repetition. Repetition should be used carefully to a Repetition should be used carefully to a level appropriate to patient. Often it is best to recycle level appropriate to patient. Often it is best to recycle information using slightly different words, in case the information using slightly different words, in case the formulation has been only partly understood.formulation has been only partly understood.Summarizing. Summarizing. This is an important interview-closing skill This is an important interview-closing skill (see above). Sum should be brief, and repeat the main (see above). Sum should be brief, and repeat the main points agreed in language, which is unambiguous clear. points agreed in language, which is unambiguous clear. Patients may also be invited to repeat the nurse’s Patients may also be invited to repeat the nurse’s instruction to ensure that they shared understanding.instruction to ensure that they shared understanding.Categorizing information to reduce complexity and aid Categorizing information to reduce complexity and aid recall. recall. Where the information to be conveyed is complex, Where the information to be conveyed is complex, or where there is a lot to be said, it should be clearly b or where there is a lot to be said, it should be clearly b down into manageable units which are clearly signaled to down into manageable units which are clearly signaled to the patient, using markers s “there are three things we the patient, using markers s “there are three things we need to think about ... firstly/secondly/thirdly etc”.need to think about ... firstly/secondly/thirdly etc”.

Using tools:Using tools: Complex information could well be Complex information could well be accompanied by a series of heading and accompanied by a series of heading and diagrams. Some nurses offer tape recorders of diagrams. Some nurses offer tape recorders of their consultations to patients where the their consultations to patients where the information has been intellectually demanding information has been intellectually demanding and psychologically distressing.and psychologically distressing.Checking patient understanding of what has Checking patient understanding of what has been said. Repeating instructions, using been said. Repeating instructions, using diagrams, written instructions, and sometimes-diagrams, written instructions, and sometimes-technical aids to explain difficult concepts are technical aids to explain difficult concepts are useful. The student must be competent in useful. The student must be competent in summarizing the information given and in summarizing the information given and in checking patient understanding by asking the checking patient understanding by asking the patient to repeat what heard and understood.patient to repeat what heard and understood.

Skills for motivating Skills for motivating patient adherence to patient adherence to

treatment planstreatment plans

The list below includes skills for the promotion of behaviour. Realistic The list below includes skills for the promotion of behaviour. Realistic compliance with treatment plans may require patients to make compliance with treatment plans may require patients to make significant changes in their diet, lifestyle or daily routine on a short significant changes in their diet, lifestyle or daily routine on a short term or long term basis.term or long term basis.Providing a rationale for behavior changeProviding a rationale for behavior changeProviding examples of role modelsProviding examples of role modelsAllowing opportunities for verbal rehearsal of the details of the Allowing opportunities for verbal rehearsal of the details of the treatmenttreatmentFeedback (positive reinforcement of constructive behaviour changes Feedback (positive reinforcement of constructive behaviour changes already achieved since earlier consultations)already achieved since earlier consultations)

Finally, Finally, nursesnurses should be aware about the clincial, communication and should be aware about the clincial, communication and

interpersonal skills that are required when dealing with difficult interpersonal skills that are required when dealing with difficult patients,(e.g., overdependent, dramatizing and exaggerating, patients,(e.g., overdependent, dramatizing and exaggerating, aggressive, and antisocoial personalitaggressive, and antisocoial personalit..

Children who are either “neglected” or “rejected”Children who are either “neglected” or “rejected” Children who have problems making friends, thoseChildren who have problems making friends, those who are either “neglected” or “rejected” who are either “neglected” or “rejected” sociometrically,sociometrically, often show deficits in social skills. One often show deficits in social skills. One of the most commonof the most common reasons for reasons for friendship friendship problems problems is behavior thatis behavior that annoys other children. Children, like annoys other children. Children, like adults, do not likeadults, do not like behavior that is bossy, self-behavior that is bossy, self-centered, or disruptive. It iscentered, or disruptive. It is simply not fun to play with simply not fun to play with someone who doesn’t sharesomeone who doesn’t share or doesn’t follow the or doesn’t follow the rules. Sometimes children whorules. Sometimes children who have learning problems have learning problems or attention problems can haveor attention problems can have trouble making friends, trouble making friends, because they find it hard to understandbecause they find it hard to understand and follow the and follow the rules of games. Children who getrules of games. Children who get angry easily and lose angry easily and lose their temper when things don’t gotheir temper when things don’t go their way can also their way can also have a hard time getting along withhave a hard time getting along with others. others.

Social competence deficits and peerSocial competence deficits and peerrejectionrejection

Exclusion from a Exclusion from a normal normal peer group can deprivepeer group can deprive rejected rejected children of opportunities to develop adaptive socialchildren of opportunities to develop adaptive social behaviors. behaviors. Evidence compiled from studies using child interviews,Evidence compiled from studies using child interviews, direct direct observations, and teacher ratings all suggestobservations, and teacher ratings all suggest that popular that popular children exhibit high levels of socialchildren exhibit high levels of social competence. They are competence. They are friendly and cooperative and engagefriendly and cooperative and engage readily in conversation. readily in conversation. Peers describe them asPeers describe them as helpful, nice, understanding, helpful, nice, understanding, attractive, and good atattractive, and good at games. Popular and socially games. Popular and socially competent children are ablecompetent children are able to consider others’ perspectives, to consider others’ perspectives, can sustain their can sustain their attentionattention to the play task, and are able to to the play task, and are able to “keep their cool” in“keep their cool” in situations involving conflict. They are situations involving conflict. They are agreeable andagreeable and have good problem-solving skills. Socially have good problem-solving skills. Socially competentcompetent children are also sensitive to the nuances of “play children are also sensitive to the nuances of “play etiquette.”etiquette.”They enter a group using diplomatic strategies,They enter a group using diplomatic strategies, such as such as commenting upon the ongoing activity and askingcommenting upon the ongoing activity and asking permission permission to join in. They uphold standards of equityto join in. They uphold standards of equity and show good and show good sportsmanship, making them goodsportsmanship, making them good companions and fun play companions and fun play partners.partners.

Children who are Children who are rejected by peers often rejected by peers often havehave difficulties focusing difficulties focusing their attention and their attention and controlling theircontrolling their behavior. behavior. They may show high They may show high rates of noncompliance,rates of noncompliance, interference with others, interference with others, or aggression (teasing or or aggression (teasing or fighting).fighting). Peers often describe Peers often describe rejected classmates as rejected classmates as disruptive,disruptive, short-short-tempered, unattractive, tempered, unattractive, and likely to brag, toand likely to brag, to start start fights, and to get in fights, and to get in trouble with the teacher.trouble with the teacher.

AAggressive childrenggressive childrenNot all aggressive children are rejected by theirNot all aggressive children are rejected by their peers. peers. Children are particularly likely to become rejectedChildren are particularly likely to become rejected if they if they show a wide range of conduct problems, includingshow a wide range of conduct problems, including disruptive, hyperactive, and disagreeable behaviorsdisruptive, hyperactive, and disagreeable behaviors in in addition to physical aggression. addition to physical aggression. Socially competentSocially competent children who are aggressive tend to children who are aggressive tend to use aggression in ause aggression in a way that is accepted by peers (e.g., way that is accepted by peers (e.g., fighting back whenfighting back when provoked), whereas the aggressive provoked), whereas the aggressive acts of rejected childrenacts of rejected children include tantrums, verbal insults, include tantrums, verbal insults, cheating, or tattling.cheating, or tattling. In addition, aggressive children are In addition, aggressive children are more likely tomore likely to be rejected if they are hyperactive, be rejected if they are hyperactive, immature, and lackingimmature, and lacking in positive social skills.in positive social skills.

The effect of The effect of illness and illness and

hospitalizationhospitalizationPhysically isolated Physically isolated Surrounded by strangersSurrounded by strangersVisiting hoursVisiting hoursProcedures that are intimateProcedures that are intimateAt first very dependent – then At first very dependent – then learn to move back to learn to move back to balance of balance of independence/dependenceindependence/dependence

Principles of Principles of effective effective

managementmanagement

Whatever health services may offer, most of the Whatever health services may offer, most of the day to dayday to day responsibilities for the care of chronic responsibilities for the care of chronic illness fall on patientsillness fall on patients and their families. and their families. Planners and organisers of medical care mustPlanners and organisers of medical care must therefore recognise that health care will be most therefore recognise that health care will be most effective if it iseffective if it is delivered in collaboration with delivered in collaboration with patients and their families. patients and their families.

Principles of effective Principles of effective managementmanagement

ToTo enable patients to play an active role in enable patients to play an active role in their care, healththeir care, health services must not only services must not only provide good medical treatment but alsoprovide good medical treatment but also improve patients’ knowledge and self improve patients’ knowledge and self management skills. management skills. ThisThis can be done by supplementing can be done by supplementing medical care with educationalmedical care with educational and and cognitive behavioural interventions.cognitive behavioural interventions.

Common elements of effective Common elements of effective chronic illness managementchronic illness management

Collaboration between service Collaboration between service providers and patientsproviders and patientsA personalised written care planA personalised written care planTailored education in self Tailored education in self managementmanagementPlanned follow upPlanned follow upMonitoring of outcome and Monitoring of outcome and adherence to treatmentadherence to treatmentTargeted use of specialist Targeted use of specialist consultation of referralconsultation of referralProtocols for stepped careProtocols for stepped care

Collaboration with patients and Collaboration with patients and familiesfamilies

To win the collaboration of patients and To win the collaboration of patients and their families, thosetheir families, those providing care providing care need to elicit, negotiate and agree on a need to elicit, negotiate and agree on a definitiondefinition of the problem they are of the problem they are working on with each patient. working on with each patient. TheyThey must then agree on the targets must then agree on the targets and goals for management andand goals for management and develop an individualised collaborative develop an individualised collaborative self management plan.self management plan. This plan This plan should be based on established should be based on established cognitive behaviouralcognitive behavioural principles and on principles and on the evidence relating to the the evidence relating to the management ofmanagement of the chronic condition.the chronic condition.

Principles of Principles of collaborationcollaboration

Understanding of Understanding of patients’ beliefs, patients’ beliefs, wishes, and wishes, and circumstancescircumstancesUnderstanding of family Understanding of family beliefs and needsbeliefs and needsIdentification of a single Identification of a single person to be main link person to be main link with each patientwith each patientCollaborative definition Collaborative definition of problems and goalsof problems and goalsNegotiated agreed Negotiated agreed plans regularly plans regularly reviewedreviewedActive follow up with Active follow up with patientspatientsRegular team reviewRegular team review

Plan for Plan for collaborative collaborative

self careself care

1 Assessment1 AssessmentAssess patient’s self management beliefs, Assess patient’s self management beliefs, attitudes, and knowledgeattitudes, and knowledgeIdentify personal barriers and supportsIdentify personal barriers and supportsCollaborate in setting goalsCollaborate in setting goalsDevelop individually tailored strategies and Develop individually tailored strategies and problem solvingproblem solving

Plan for collaborative self carePlan for collaborative self care

2 Goal setting and personal action plan2 Goal setting and personal action planList goals in behavioural termsList goals in behavioural terms Identify barriers to implementationIdentify barriers to implementationMake plans that address barriers to progressMake plans that address barriers to progressProvide a follow up planProvide a follow up planShare the plan with all members of the Share the plan with all members of the

healthcare teamhealthcare team3 Active follow up to monitor progress and 3 Active follow up to monitor progress and

support patientsupport patient

Encouraging Encouraging self careself care

Active self care is critical to the Active self care is critical to the optimal management of chronicoptimal management of chronic illness. Interventions to optimise illness. Interventions to optimise self care are based on cognitiveself care are based on cognitive behavioural principles.behavioural principles. They They start with an assessment of start with an assessment of patients’ attitudes andpatients’ attitudes and beliefs beliefs about their illness and their about their illness and their chosen coping behaviours.chosen coping behaviours.This assessment then guides the This assessment then guides the provision of provision of information, theinformation, the resolution of misunderstandings resolution of misunderstandings and misinterpretations, andand misinterpretations, and collaborative goal setting. These collaborative goal setting. These are agreed between patient andare agreed between patient and members of the healthcare members of the healthcare team.team.