Communication in healthcare

Relational aspects of health care are important to patients. They value good communication and time to ask questions. Better professional-patient relationships will improve trust and health outcomes. (Office for Public Management 2000)

Every nurse, whatever their stage of training or experience, is already skilled in communication. Nurses routinely communicate with patients, families and colleagues as part of their work, and with countless others in their life outside work. Because of the everyday nature of communication, this chapter will often appear to state the obvious but there is strong evidence that communication difficulties underlie some of the most difficult and important problems in healthcare (Audit Commission 1993; Healthcare Commission 2007). The Essence of Care benchmarks of patient-focused healthcare in the NHS were modified 2 years after the original publication to include communication as a key focus (Department of Health 2003). The teaching of communication skills to nurses has been criticised (Chant et al. 2002) and it has been argued that communication should be one of the ­high-priority topics for audit in the nursing profession (Currie and Watterson 2008).

The National Service Framework (NSF) for Children (Department of Health 2003b) lists the ­following communication skills shown as necessary for staff working with children in hospitals.

• How to listen to and communicate with children, young people, parents, carers, and the need to understand the extent and the limits of children’s comprehension at various stages of development.
  
• Recognition of the role of parents in looking after their children in hospital.
  
• Providing information that is factual, objective and non-directive about a child’s condition, likely prognosis, treatment options and likely outcomes.
  
• Giving bad news in a sensitive, non-hurried fashion, with time offered for further consultation away from the ward environment.
  
• Enabling a child and family to exercise choice, taking account of age and competence to understand the implications.

Good communication, and in particular empathy, can have a direct effect on patients’ health. Rakel et al. (2009) assigned some patients suffering from colds to see doctors who (following training) made a special effort to be empathic. Other patients saw a doctor making no special effort. Patients seeing empathic doctors had less severe colds, recovered more quickly and even showed measurable changes in their immune system. Note that empathy should not be confused with sympathy. Sympathy is when you show someone you feel sorry for them. Empathy is when you have ­convinced someone that you have genuinely understood (not guessed or assumed) some part of what they are feeling or experiencing. The importance of checking you have understood is demonstrated by Wheeler et al. (1996), who found that when student nurses, and even their clinical instructors, rated their empathy, it bore little relationship to the empathy perceived by their patients. In short, if we tell someone ‘I know just how you feel’, we almost certainly don’t.

In paediatric respiratory healthcare, as in other health specialties, communication problems have been identified as being of crucial importance. For example, in clinics for children with asthma, Butz et al. (2007) found that the majority of parents and children struggled to communicate basic symptom information to health staff without prompting.

General communication problems

The following are some of the many ways in which spoken communication can go wrong.

• Person listening doesn’t understand and knows it (but might find it hard say so).
  
• Person listening thinks they understand what the person speaking really means but doesn’t.
  
• Person being spoken to is not listening. (There could be many reasons for this.)
  
• Person listening is offended, bored or shocked.
  
• Person speaking is unsure what to say.
  
• Person speaking finds it hard to put thoughts into words.
  
• Person speaking thinks person listening has understood but they haven’t.
  
• Person speaking changes or limits what they say, because they’re worried what the person listening will think or how they will react.
  
• Person speaking doesn’t care whether the person listening understands.

In each of the above, the ‘person speaking’ could be a patient, a nurse or another colleague and similarly the listener. Note also that the examples could apply to written communication by replacing ‘speaking’ with ‘writing’ and ‘listening’ with ‘reading’.

Improving communication

Because communication is natural and instinctive, we usually do it automatically, unaware of the complex and sophisticated skills that we are using. It is often only when we sense communication is failing that we are forced to think about it, and it can start to feel unnatural, difficult, stressful, frustrating and even give rise to a sense of helplessness.

The aim of this chapter is to provide practical ideas on how to get past these difficulties, by developing new understanding and skills which encourage better communication, using examples in the context of paediatric respiratory nursing. Like improving any skill (e.g. driving), changing how you communicate is likely to feel awkward and hard work at first but should become more familiar and easier with practice. ‘Common sense’ might suggest that some people are naturally good communicators while others are not, and that this cannot be changed. In fact, there is good evidence that health professionals can improve their communication skills with training (Connolly et al. 2010; Lewin et al. 2001).

In business, communications training is very often focused on ‘getting your ideas across’. However, in patient-focused support, it is at least as important, if not more so, to learn to actively listen and understand patients, their carers and other professionals.

Key ideas to improve communication

The following are key tips for improving communication with patients, carers and others. The first one, listening, is the most important.

• Listen actively, so that you are thinking hard about what the child or parent is trying to communicate.
  
• Be genuinely but respectfully curious, and develop the attitude that a wide range of responses, or a change of mind, would be acceptable and reasonable.
  
• With families, make it clear that different family members will often see things differently and that’s OK.
  
• Avoid leading questions (‘Have you done all your treatment?’ versus ‘How much of your treatment have you done?’).
  
• Avoid unintended judgemental attitudes to parents, children or young people.
  
• Make explicit that it’s OK to ask for clarification
  
• Avoid or explain jargon. Remember that words that are common and easily understood by yourself and other trained colleagues may be jargon to families.
  
• Check understanding (‘How would you explain what I’ve told you to a friend?’).

Communication with parents

In general, the younger a child is, the more a health professional is likely to communicate via the parents. The older a child is, the more a health professional should communicate directly with the young person themselves.

Parents often have real difficulties in communicating with their children. One of the indirect benefits of communicating honestly, empathically and effectively with parents is that you are teaching, by example, how parents might communicate more effectively with their children.

Communication with colleagues

Most of the ways to improve communication (for example, active listening) also apply to working with colleagues. Clarity of brief spoken and written information to other nurses, doctors and other colleagues can be improved by structuring what is said using the mnemonic SBAR – Situation, Background, Assessment, Recommendation (NHS Institute for Innovation and Improvement 2010).

School is a key environment for children. Effective communication between nurses and school staff (including teaching assistants) is recognised as crucial to management of respiratory diseases such as childhood asthma (Office for Public Management 2004).

Written communication

Written communication can be a useful alternative, or addition, to spoken communication but it is important to recognise that around 16% of adults in the UK lack ‘basic literacy’ (Department for Education and Skills 2003).

Most of us tend to use more complex words and grammar when we write, compared with when we speak. Complicated writing, with jargon and long, hard-to-read sentences, is actually quite easy to write. It may even impress some people but it often fails in its main aim of communication. On the other hand, clear and brief English looks simple but often requires a lot of effort to do well.

The Plain English Campaign (2001) has published a number of free guides to writing clearly for the widest possible audience, including one specifically for medical information .This includes a glossary of medical terms with plain English alternatives. Even commonplace medical terms can usefully be replaced with everyday alternatives without sounding condescending (e.g. ‘fracture’ can be replaced with ‘broken bone’). This makes it easier to read for adults, children and those with reading or learning difficulties. It is also easier to translate accurately into other languages (see below).

Differences in language

English is not the first language at home for 6% of the UK population (Office for National Statistics 2006). When families speak a different language to the nurses caring for them, this clearly magnifies many of the problems already described and adds some new ones but many of the ideas already discussed will help, whether attempting to communicate directly using the patient’s limited English or using an interpreter (see below). In particular:

• use simple language, with as little jargon as possible
  
• provide written information – either prepared leaflets or hand-written at the time. Many families will have friends, family or a support worker who can translate for them
  
• check understanding by asking the patient or carer to say (or demonstrate) what they have understood (e.g. about how to take medication or use a device)
  
• remember it is with the family that you want to communicate and establish a working relationship, so when using an interpreter, look at the family (not the interpreter) throughout.

The National Register of Public Service Interpreters has a useful guide to working with interpreters, which is available online (Corsellis 2003).

Differences in culture

There is evidence that parents from different ethnic backgrounds tend to have different beliefs and understandings of illness, including asthma (Cane et al. 2001). Differences included beliefs about diet and the extent to which they had deferential trust in ‘western’ medicine. Awareness of these trends may help nurses to be alert to possible differences in understanding but they should never be assumed to apply to any individual child or parent, as the range of attitudes and beliefs within any ethnic or religious group is almost certainly greater than the differences between any two groups as a whole. If you think an attitude or belief might be important then ask but ask in such a way that is curious about them as individuals:

Nurse: Some parents I see think their child’s illness gets worse when they eat certain kinds of food. Do you think Amjal’s illness changes when he eats different foods?

Communication skills in the context of nursing

The above communication issues and skills, along with some new ones, are illustrated below in a number of scenarios frequently encountered in paediatric respiratory nursing. Because of the personal nature of these encounters, all the case examples are created from a mixture of clinical experience rather than from individual patients and their families.

Introductions: first meeting a child and family

A woman, a man, a 7-year-old girl and a 4-year-old boy are in a paediatric asthma clinic and have already seen the doctor, before being asked to see the nurse (in order to be shown how to use a new inhaler).

Nurse [to the girl]: You must be Sally.

Sally nods shyly.

Nurse [to the woman]: And you must be Mum.

Woman:That’s right.

Nurse [to Sally]: And is this your little brother?

Sally: Uh-huh

Nurse [to the man]: And I take it you’re their Dad?

Man [embarrassed]: Um …

Woman: Well he’s Billy’s dad but not Sally’s.

Initial introductions can hugely influence how well the rest of a meeting and future conversations will go. After very briefly introducing yourself, it’s important to check who everyone in the room is. It is often helpful to ask a child to tell you who other people are. Children will often be too shy to say much at first but by asking them, you are starting to engage them. The adults will usually fill in the silences. In the above scenario, the nurse mistakenly assumed the man was Sally’s dad. It might have been better if the nurse had asked Sally, ‘And who’s this?’. Sally would then have had the chance to say ‘Billy’s dad’ or if she said nothing, then a glance to either Mum or Billy’s dad would hopefully prompt them to explain.

At an initial meeting, you are likely to have your own agenda of getting more information and explaining things to the family. Before getting involved in this, it is helpful to check what the family’s agenda is. Ask them if there’s anything in particular they want to find out today and either answer it briefly or agree to tell them later. Emphasise there’s a lot to take in and it’s always OK to ask.

Getting information: open and closed questions

Nurse: Are you feeling better?

Teenage boy: No.

This nurse has begun with a ‘closed’ question, i.e. one that has a very limited number of answers – in this case ‘yes’ or ‘no’. Answers to closed questions usually give very little information. In this case the answer is ambiguous, as we don’t know if the boy feels he’s not completely better or not improved at all. A corresponding open question would be ‘How are you feeling today?’ which could be answered in many ways, giving more information. Even a grunt would give the information that he doesn’t want, or feel able, to say!

Table 16.1 Open and closed questions

Health professionals are often justifiably criticised for using too many closed questions but this criticism can lead to an oversimplified view that ‘open questions are good’ and ‘closed questions are bad’. In practice, both are useful in different ways, as shown in Table 16.1.

The following exchange shows a nurse thoughtfully using a mixture of open and closed questions – adapting the type of question not just according to the information she needs but also to how the conversation is going.

Nurse: Did you come on the bus today? [simple closed question to help relax patient]

Teenager: Yeah.

Nurse: What have you been up to over the past week? [an open question to find out more]

Teenager: Nothing. [open question hasn’t really worked. Perhaps teenager isn’t yet relaxed enough to get into conversation where he has to think what he wants to say. Maybe try something easier to answer]

Nurse: Did your asthma give you much trouble this last week? [a closed and focused question]

Teenager: A bit. [two-word answer – we’re getting somewhere!]

Nurse: What was the worst thing about having asthma this past week? [a more open question again but still focused on the health issue]

Teenager: [after a pause] I had to stop playing football with my mates when I got a wheeze.

Nurse: What did it feel like? [an open question again]

Teenager: Tight and aching – like there was a strap around it. [useful information about patient’s experience of asthma]

Nurse: What did you do?

Teenager: I took a couple of puffs of my blue inhaler.

Nurse: How much did that help?

Teenager: It helped a bit but I still felt too out of breath to carry on playing. [NB: If the nurse had asked ‘Did it help?’ that would have invited a yes/no answer, and produced less information.]

Giving information

Giving information is one of the important roles of nurses, often supplementing or explaining information given by medical doctors. Words that are familiar to health professionals may be jargon to patients and their families. Parents of children with long-term conditions can become very knowledgeable, through frequent consultations, accessing the internet and talking to other parents. But the risk remains that they have misunderstandings (or different understandings) which nurses might not be aware of, leading to unforeseen problems in their care. Key points to remember include:

• make sure that the child or parent you are speaking to is in the right frame of mind to listen
  
• use ordinary-language (Plain English) alternatives to technical words where possible
  
• when patient/family are going to need to understand medical jargon, explain it in simple terms
  
• repeat information as necessary
  
• provide information in written form (either from leaflets,or brief hand-written notes)
  
• check understanding using open rather than closed questions.

Nurse [after taking time to explain to a parent how to use a new device]: Do you understand that OK?

Parent: Yes.

The parent’s ‘yes’ response to this closed question may mean they understand how to use the device in the way the nurse intended but it could also mean many other things including:

• they think they understand it but have actually missed or misunderstood a crucial point
  
• they don’t really understand it but are embarrassed to admit it
  
• they don’t really understand it but don’t want to be a nuisance by asking
  
• they don’t really understand it but are keen to get home before the rush hour.

One alternative would be to ask the parent to repeat what you’ve said but that gives the sense of challenging and potentially humiliating the parent. Also, repeating parrot-fashion may not indicate proper understanding.

A better way to check understanding by asking an open question. A particularly helpful one is ‘How would you explain this to a friend (or partner, parent)?’. This is less threatening because the person is being asked to explain to someone else, rather than prove their own knowledge. But because this requires the person to interpret and explain what you’ve said, you get a much better idea of their understanding.

Painful or distressing procedures

Preparation

The term distressing procedures has advantages over the more usual painful procedures for two reasons.

• A number of potentially distressing procedures involving little or no physical pain are used in paediatric respiratory medicine. Examples include oxygen masks, inhaler spacers with masks in small children and computed tomography (CT) scans. These can all provoke anxiety, fear and distress. Although most of the following refers to examples involving pain, most of the understanding and management described below apply equally well to these and other ‘painless’ procedures.
  
• Even in procedures that do involve some pain, it is often not the main cause of anxiety or distress (Duff 2003).

The reassurance that ‘it won’t hurt’ rarely works in children, because:

• children don’t believe it (and they are often entirely justified in this)
  
• whether the procedure involves significant, slight or no pain at all, other factors are often responsible for most of their anxiety, including loss of control.

However, pain is often a major cause of distress, so nurses should be vigilant for any indication of pain and anticipate it in children at all times (Royal College of Nursing 2009). A review by the Healthcare Commission (2007) concluded that too few nurses were trained in the effective management of pain in children.

Procedural pain can, of course, be anticipated, and there are a number of ways of helping children to cope. Physiological interventions, such as local anaesthetic (e.g. EMLA^® cream or ethyl chloride vapo-coolant spray), ‘gas and air’ (Entonox^®; Vater and Hessel 2000), sedatives (e.g. midazolam) and ultimately general anaesthetic, can be effective. Although relatively safe, sedatives and general anaesthetics have additional risks for children with respiratory disorders (Malviya et al. 1997).

Specialist psychological techniques, in particular cognitive behavioural therapy (CBT) (Powers 1999) and hypnosis (Liossi 2002), are also demonstrably effective in reducing, and even overcoming, procedural pain. However, specialist psychological techniques require highly trained and skilled psychological practitioners. As well as being in short supply, these techniques are often only needed when a child’s earlier encounters with medical procedures have been poorly managed. It is clearly much better to avoid or minimise this level of distress in the first place, so children do not become so fearful that it becomes a major problem.

Even when children have had difficult previous experiences, nurses can be very effective in helping them to manage procedures with only brief and mild distress by using skilled and sensitive communication. Nurses are in a key position to ensure that best practice is followed. This requires skilled communication not only with children and their carers but also with nursing and medical colleagues, who may need educating and persuading to implement these procedures.

Is pain really the problem?

Although in clinical practice local anaesthetic appears to be effective, there is evidence that when distraction is used, EMLA cream is no more effective than placebo (Lal et al. 2001). Similarly, Ramsook et al. (2001) found that coolant spray was no more effective than placebo for venepuncture and cannula insertion in children. Both studies found wide variation in the reaction of children in both treatment and placebo groups. Note that this does not indicate that these local anaesthetics were ineffective in practice. Rather, as anaesthetics and placebo were equally effective, it demonstrates that the anaesthetics’ effectiveness is not due to their chemical (or cooling) effect. It seems likely that the widely observed benefit is actually due to the way the staff administer the cream or spray (real or placebo), communicating confidence and reassurance to the child.

Advance preparation: setting the scene

If it is known days or weeks in advance that a child will have to have a procedure, and may be distressed, nursing staff, together with parent/carers, have the opportunity to help the child prepare beforehand. The immediate question arises as to whether to (a) warn and prepare the child well in advance to help them become calm and more able to cope with the distress of the procedure or (b) say nothing in advance so they don’t build themselves up into a state of anxiety, which could be avoided by ‘just getting it over with’ quickly when the procedure has to be done.

As is often the case, clinical experience as well as ‘common sense’ suggests that both can be true. Box 16.1 presents some arguments for and against preparation. The arguments against preparation are often given by parents who are wary of warning their children of difficult procedures.

The evidence is that preparation is effective, particularly if it focuses on developing a child’s ability to distract themselves from the procedure (Powers 1999).

Immediate preparation: when it’s got to be done now

Whether or not there has been time for advance preparation of the child, there are several ways to minimise the distress to the child, as well as making the process quicker and more pleasant for staff. The Royal College of Nursing has produced a practical guide for nurses taking bloods which is available online (Royal College of Nursing 2006).

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