Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD
After reading this chapter, the reader will be prepared to:
- Describe the various components of communication.
- Discuss the importance of communication in the therapeutic setting.
- Recognize some of the barriers to communication.
- Discuss some strategies and techniques for effective communication.
- Apply effective strategies to challenging encounters.
- Discuss team communication strategies.
- Manage conflict through communication.
“People don’t care how much you know until they know how much you care.”
— Teddy Roosevelt
“The single biggest problem in communication is the illusion that it has taken place.”
— George Bernard Shaw
COMMUNICATION: WHAT IS IT AND WHY IS IT IMPORTANT?
Communication is something that we do all day every day; even without talking, we are often communicating! As a health care practitioner, good communication becomes even more critical. Good communication provides the underpinnings for all of our clinical encounters. Effective communication has been shown to enhance patient satisfaction, patient adherence, and patient health outcomes; it also prevents medical errors and decreases malpractice lawsuits.1–3 Without good communication skills, you will have difficulty obtaining a patient history, determining an accurate diagnosis, or making effective recommendations that your patient will follow. Communication is what will enable you to develop a therapeutic relationship and to engage your patients as true partners in their own health.4 In addition, effective communication is not only essential for interacting with patients and their families, but also for working in multidisciplinary teams and managing workplace conflicts.
So, what is communication, and what makes it effective? Pollozhani et al5 define communication as an “interactional process which occurs in an environment where people share meaning verbally and non-verbally.” It is not simply a matter of transmitting information, but rather requires the reciprocal interaction of all of those involved in the process—both giving and receiving information.1 This may remind you of the concepts of intention and impact that were discussed in Chapter 1. As you know, it is important to recognize that communication is much more than simply what we say. The following are 3 components to any message being communicated:
- Verbal messages: What you say (eg, the words you choose, the jargon that is used)
- Paraverbal messages: How you say it (eg, the tone, volume, pace, inflection of your speech)
- Nonverbal messages: Body language (eg, your posture, facial expression, eye contact, space, touch)
Although not everyone agrees, it has been said that 93% of your communication is the result of nonverbal (55%) and paraverbal (38%) communication; only 7% is based on the actual words you say.6 In working with patients, clearly, the words you choose are critical; however, what is of equal importance is how you communicate your message. The nonverbal expressions that you convey as you communicate must match what you say.
STOP AND REFLECT
Think back over a time when you observed or were engaged in a miscommunication.
- What was said?
- How was it said?
- What signs did you pick up that told you there was a miscommunication?
- What was the cause of the miscommunication?
Kurtz4 describes effective communication in the doctor-patient relationship as follows:
- Being a reciprocal interaction, not a one-way communication.
- Being accurate, efficient, and nonambiguous.
- Focusing on the outcomes established between the doctor and patient.
- Being dynamic, flexible, engaging, and uniquely defined for each patient.
- Repetitive and reinforcing to achieve mutual understanding through collaboration and feedback.
When communicating with patients, your words must be clear, concise, organized, and jargon-free. If your communication is too lengthy, your patient may lose interest and your explanations will lose their impact. The words we choose, especially as health care providers, must be judgment-free if we want our patients to fully hear and understand our message(s). As health care providers, it also is helpful to choose words that break down barriers, decrease resistance, and decrease defensiveness if we want to gain the trust of our patients. Table 3-1 provides some examples of ineffective and effective verbal messages.
Nonverbal messages can be as powerful—and, at times, even more powerful—than our verbal messages. For example, if you are working hard to choose your words so that your patient does not become defensive, yet your facial expression is judgmental, then your patient will very likely become defensive despite the words you choose! Nonverbal messages come from our posture, body language, facial expression, and eye contact. Very often, we are not even aware of our facial expression when communicating with others. However, our facial expression can easily convey boredom, excitement, confusion, approval, understanding, displeasure, anger, bias, and so on.
Our facial expressions, paired with our posture and body language, provide an even more powerful message to our patients. Are you standing with your arms crossed and a scowl on your face? Do you even realize that you are scowling? What message are you potentially sending? Are you standing over your patient or sitting next to your patient face to face? What messages might you be sending from both of these positions? Are you standing at the end of the bed with your clipboard in your hand? Are you looking at your electronic medical record or writing on your clipboard? Do you keep glancing at your watch out of habit? Again, what messages might you be sending, and how do you think your patient might react? Table 3-2 provides some good examples of positive body language that help to demonstrate that you are in the moment and truly listening to your patient.7
Finally, most of us have heard the well-known saying, “It is not what you said, but how you said it!” This is the paraverbal aspect of communication. How you say or emphasize words can result in very different meanings. Windle and Warren8 provide the following excellent example on their website, Communication Skills:
“I didn’t say you were stupid.”
“I didn’t say you were stupid.”
“I didn’t say you were stupid.”
Our volume, pitch, pace, and tone can all convey unintended messages. For example, if you are frustrated because of your patient’s lack of adherence, you may raise the volume and pitch of your voice or present your message in a rather abrupt manner, all of which will reveal your frustration, whether you intend to or not. It is so easy for us, at times, to get caught up in the fast pace of the clinical setting. However, it is important to recognize that presenting your message in a fast-paced manner could suggest to your patient that you are not interested in listening to his or her story, that you do not have time, or that he or she is just one of many patients you need to see in one day. Be careful not to let your busyness impact your therapeutic relationship with your patient.
KEY POINTS TO REMEMBER
To optimize communication, ensure congruence among the following:
- Your verbal message
- Your nonverbal message
- Your paraverbal message
Make sure that your verbal, nonverbal, and paraverbal messages match!
In describing doctor-patient communication skills, Kurtz4 discusses content skills (or what physicians say) and process skills (how physicians say it), but adds the dimension of perceptual skills. Perceptual skills are those skills that allow physicians to be aware of their own thoughts and emotions during the communication. Perceptual skills are particularly critical, as they enable you to be aware of what is influencing your communication and your decision making. It is through the reflective process that was discussed in Chapter 2 that we develop those perceptual skills. For example, are you having an emotional reaction to something your patient said or did? Do you have a particular like or dislike for this patient? If so, why? How might it be influencing your thoughts and actions? Do you have a particular bias or assumption about this patient’s case? Are you distracted by the noise around you, your busy schedule, or the fact that you are not feeling well? Perceptual skills require you to reflect-in-action.
Perceptual skills are particularly important when you consider that the other side of the equation in good communication is being attuned to and listening to the receiver: your patient. Stickley and Freshwater describe listening as “an active process that involves all the senses, not just the ears…It is easy to take listening for granted and, through our own preconceptions, to fail to really listen.”7 It takes mindfulness to make sure that you are fully present to listen and not thinking about your next patient, your next treatment session, or what you are going to eat for lunch.9 To truly listen, we need to be able to stop what we are doing at the moment, suspend all judgment, take our patient’s perspective, and observe. When listening, it is not enough to hear what your patient is telling you, but you must also pay attention to what he or she is not telling you—the nonverbal and paraverbal messages.
To be a good listener requires not just good listening and observation skills, but also an awareness of self. To listen effectively you must be aware of your own inner thoughts, emotions, and distractions, and your own nonverbal and paraverbal messages. You need to silence your inner voice so that you can truly listen to your patient’s. Stickley and Freshwater note, “Listening is more than a biological function between the ears and the brain. Therapeutic listening hears the sigh developed over a lifetime or the anxiety in the tone of voice or despair in the facial expression.”7
Just as congruence is important in sending effective messages, watching and listening for incongruence in the words and actions of your patients can provide you with important information. In addition, to truly understand what your patient is telling you, you must go beyond the content to understand the emotion. In physical therapy, we often see patients who have experienced loss, are in acute pain, or are at the end of life. Communication can be emotion-laden. Allowing for silence and allowing for emotion are also critical to effective listening. Silence allows for reflection and the processing of the message and how it is being experienced. Do not feel compelled to fill the space of silence or stop the emotion; both are essential in the healing process! Using touch also can convey empathy; leaning forward and coming into close proximity can convey care and concern; and reflective listening or responding by naming the emotion can convey true understanding. Remember, it is also okay to show your own emotion when hearing or sharing bad news.
KEY POINTS TO REMEMBER
- Allow for silence and emotion; both are essential in the healing process!
- Use touch to convey empathy
- Lean in to listen
- Name the emotion to convey understanding
- Sharing emotion can be important in a therapeutic relationship
- Listening requires us to stop what we our doing, suspend all judgment, and take our patient’s perspective
- A good listener listens, observes, and is self-aware
BARRIERS TO GOOD COMMUNICATION
Since communication is something that we do all day every day, and most of us have been communicating since we were toddlers, what makes it so challenging? The biggest challenge is that some believe that communication skills are innate and do not realize that communication is a skill that can be taught and learned.5
The authors of a 1986 study on patients with headaches found that the greatest predictor of headache resolution was the patients’ perceptions that they had the opportunity to fully communicate their stories and their concerns to their physician.10 Just 2 years prior to this study, a landmark study conducted by Beckman and Frankel11 showed that physicians interrupted their patients within 18 seconds of when they began to tell their story. This trend continued, even though physicians were aware of these studies. When the study was repeated 15 years later, physicians still interrupted within, on average, 23 seconds, despite the fact that studies also showed that using a patient-centered approach did not add significantly to the length of the visit; in fact, it only added 6 minutes on average.12 More recent studies indicate that patients who feel rushed or not listened to are more likely to seek litigation.3,13–15 Interruptions and poor listening are only some of the barriers to effective communication that exist today, but there are more and they carry significant consequences.
KEY POINTS TO REMEMBER
- Effective communication is a skill to be learned and practiced.
- Patients value being able to share their concerns and tell their stories.
- Improved outcomes have been noted when patients are given time to tell their stories.
- Patients who feel rushed or not listened to are more likely to pursue litigation.
- Doctors tend to interrupt or redirect patients within 18 to 23 seconds of when patients begin to tell their stories.
- Pause, take time, and listen to what your patients say without interrupting!
Communication is a part of who we are, and many of us often pride ourselves on our communication skills. Yet, it is important to recognize that our communication must continually be refined. The challenge is that our own self-concept and self-esteem are often wrapped up in how we communicate, making it challenging at times to recognize and admit that our communication skills could use improvement.4
Besides lacking self-awareness of our communication skills, we often become so task-oriented and productivity-focused in our frenetic health care environments that we fail to recognize how our rushing or attempted multitasking may be interfering with our ability to be present in the moment with our patients, to be culturally sensitive, and to communicate effectively. Feelings of stress can also impact our communication with patients.16 As Kurtz4 notes, it is important that we maintain a focus on our perceptual skills to determine how we might actually be negatively impacting our own communication with patients.
Of course, as noted above, communication is a two-way street and we must be mindful of what might be impacting our patient’s ability to communicate effectively as well. For example, is he or she under psychological stress, fearful, or anxious? Is there a lack of trust? Is there a language barrier or is there an issue of limited literacy? Think of the environment as well, particularly when you are working with a geriatric patient. Is the area conducive to a private conversation? Is noise from a television, radio, equipment, or nearby conversations distracting or interfering with your patient’s ability to focus and process information? Is the area visually distracting? Is the environment foreign and possibly depressing for your patient? All of these factors can impact how your patient takes in and processes the information you are trying to provide.
Cultural differences can be particularly profound, as diversity is ever-more prevalent in our society. Each culture has its own norms and values; its own set of verbal, nonverbal, and paraverbal behaviors. These differences can easily lead to misinterpretation, to miscommunication, and, even worse, perhaps to errors or violations of your patient’s beliefs.17,18 People of different cultures vary in their openness to share personal information or to admit pain and discomfort. Our own personal assumptions and biases may also interfere with our ability to communicate across cultures effectively. Further, it has been found that treating people of different cultures or who speak a different language can cause stress and anxiety both in you, the health care provider, and in your patients.18 Concern that you may not fully understand your patients or that you are misinterpreting their cues can lead to anxiety. Attending to your own perceptions and the potential impact that this stress may be having on you and on your communication is essential. Lack of knowledge about a patient’s language or culture can result in poor-quality care and patient dissatisfaction.5
Learning more about your patient’s culture will serve to decrease your stress, improve your communication, and enhance your patient’s satisfaction. Status, time, space, nonverbal behaviors, importance of relationship and personalization, spiritual beliefs, and psychological vs physical distress are all issues that need to be considered when working with patients from different cultures. While cultural sensitivity and the use of interpreters are both beyond the scope of this chapter, it is important to recognize the impact that both may have on your ability to communicate effectively with patients from different cultures.18,19
Another major barrier that often occurs in complex health systems is fragmented communication.20 Communication gaps between team members, ineffective hand-offs at change of shift, and lack of communication between health care providers are true barriers to communication. These can lead to miscommunication, overlaps or gaps in plans of care, medical errors, and frustration on the part of the patient.20 Strategies that facilitate communication among team members will be discussed later in this chapter.
Remember, too, as you learned in Chapter 1, that whenever 2 people are interacting, both are bringing their own perceptions to the situation. Although the intent and impact of communication may not always match, it is important to recognize that, in any given situation, both people are experts in the message. The person behaving is the expert on the intent of the message, and the person on the receiving end is the expert on the impact of the message.
Many factors can impact the effectiveness of your communication with patients. It is good practice to try to identify potential barriers to communication by pausing to assess your inner self, your patient, and your environment before, during, and after engaging with each individual. In addition, there are a number of strategies that you can use to minimize communication mismatches, which we will explore next.
KEY POINTS TO REMEMBER
- Barriers to effective communication can result from environmental, cultural, and personal factors.
- Clarifying intentions and asking for feedback about the impact of behavior can help to minimize miscommunication.
- Potential barriers to communication can be anticipated through observation and self-assessment.
STRATEGIES AND TECHNIQUES FOR EFFECTIVE COMMUNICATION
In describing the principles and practices surrounding good doctor-patient communication, Kurtz4 notes that communication is a clinical skill that is comprised of a set of subskills that can be learned. Communication is not an innate characteristic or trait, but rather must be continually learned and refined.4,21 Finally, as Dewey notes, experience is insufficient for learning; it is just as insufficient for developing good communication skills.4,5 In fact, while some people may believe that communication is something that you develop naturally as you grow up, studies have demonstrated that communications skills can be taught and learned.5,22
Demonstrate compassionate care
Know your patient first (ie, read the chart/other documentation)
Be mindful of the environment (distractions and confidentiality)
Use reflective statements
Use summary statements
Use open-ended questions
Listen actively; probe thoughtfully
Allow your patient to speak; do not interrupt
Engage your patient in decision making
Be mindful of your nonverbal and paraverbal messages
Be mindful of your patient’s nonverbal and paraverbal messages
Be sure that your team is conveying the same message
Allow for silence
Allow for emotion
Be willing to share emotion
Be sure to have a clear plan
Repeat, reinforce, reiterate
Adapted from Nguyen TV, Hong J, Prose NS. Compassionate care: enhancing physician-patient communication and education in dermatology: part I: patient-centered communication. J Am Acad Dermatol. 2013;68(3):353.e1-8; Warrillow S, Farley KJ, Jones D. Ten practical strategies for effective communication with relatives of ICU patients. Intensive Care Med. 2015;41(12):2173-2176; and Windle R, Warren S. Communication skills. www.directionservice.org/cadre/section4.cfm. Accessed March 14, 2016.
Just like any skill, to learn effective communication you must start with knowledge; however, simply knowing how to communicate is not sufficient. To be an effective communicator requires performance, feedback, practice/rehearsal, and repetition.4
STOP AND REFLECT
Think of a time when you engaged a friend in an emotionally charged conversation. Perhaps your friend received some bad news (eg, she lost a job, she did not get into the school of her choice) and you were there to help her work through her emotions.
- What was the most challenging aspect of this conversation?
- Which of the skills of effective communication did you use?
- What other strategies did you use that were not on the list?
- How effective were you in recognizing and addressing your friend’s emotions?
- Were the skills you used sufficient?
- What additional strategies might you use if you encounter a similar situation in the future, and why?
Literature is replete with strategies to enhance communication between patients and their health care providers.3,8,21,23 Table 3-3 provides a list of practical strategies for effective communication.3,8,21
- Read the chart: Reading the chart (or other documentation) helps you to at least be familiar with your patient’s history. However, based on the chart, you may develop some assumptions; be open to modifying your assumptions.
- Set the stage: As you walk into the room, be sure to take a chair, move close to your patient, and sit down at eye level. This conveys your interest and attention. Be sure to remove all distractions (eg, turn off your cell phone, close the curtain, ask permission to lower the volume on the television). Make sure that the location is conducive to a confidential conversation. It is often nice to begin with some social conversation, as it conveys your interest in your patient as a person.
- Obtain information: Begin by asking open-ended questions and do not interrupt your patient as he or she tells you his or her story. (Although, as you will see later in this chapter, when we discuss challenging encounters, there may be times when you want to ask permission to interrupt, redirect, or prioritize the conversation.) Listen and observe carefully to be sure that you have the full message. Summarize, paraphrase, and reflect back information to ensure that you have a shared understanding of your patient’s concerns.
- Provide information and make collaborative decisions: Use jargon-free, clear, concise language to educate your patient about his or her health condition and the options available for treatment. Engage your patient in the conversation and in the decision making. Patient education will be discussed at great length in Chapter 9 of this text.
- Conclude the encounter: Summarize the shared decisions that were developed and obtain agreement from your patient. Discuss follow-up steps. Ask if your patient would like to share anything else with you before you leave. Always give your patient a few minutes to process the information and to formulate any additional questions, concerns, or comments. Don’t rush! Ask the following questions:
- “Is there anything else that you would like to tell me?”
- “Is there anything else that I can help you with?”
- “Do you have any lingering questions or concerns?”
- “Is there anything else that you would like to tell me?”
Table 3-4 presents the SEGUE framework, which is a checklist of communication skills and subskills (with some adaptation) that has been used in medical schools as a checklist in teaching communication skills.25 Having a checklist is one additional strategy to help you remember all of the subskills that comprise effective communication.
Grover23 describes certain enablers or facilitators of good communication, including reflective listening skills, trust, self-disclosure, mutuality, and empathy. Reflective listening skills are critical to developing a shared understanding. Simply paraphrasing or summarizing what your patient said provides an opportunity for you to ensure that you captured your patient’s concerns and for your patient to clarify any misperceptions or add new information. For example, if your patient says, “I am really afraid to go back to work,” you might respond, “You are afraid to go back to work?” or “Can you say more about your fear of going back to work?” This allows your patient to further clarify his or her fears. Reflecting back what you believe to be your patient’s emotions can also enhance communication by opening the door to further explanation from your patient. For example, if your patient says, “I can’t stand it. I have been coming to therapy for so long, I thought that I would have been done by now,” you might respond, “It sounds like you are really frustrated by your rate of progress. Let’s talk about the healing process.” Using reflective listening skills also conveys to your patient that you are really listening and that you care.3,23
Trust is built upon honesty and integrity in communication. The more we engage patients in the decision-making process and make them true partners in the process, the greater will be their sense of trust.23,26 Using nonjudgmental language, engaging in goal setting and problem solving, and conveying a sense of empathy, care, and concern can all enhance a patient’s level of trust. Better patient engagement can also lead to enhanced patient satisfaction, improved quality of care, and decreased costs. While self-disclosure, or the sharing of personal experiences, can also enhance communication, one must be careful not to overdisclose and to keep the focus on the patient and not on the self. Disclosing personal information in a way that suggests that you “know what the patient is feeling” is not effective and could undermine your patient’s trust. Never assume that you know what the patient is thinking or feeling; rather, be sure to obtain your patient’s perspective. Mutuality is also the result of engaging your patient as a true partner in the problem-solving and decision-making process. Rather than dictating a plan of care, cocreating a plan of care will enhance a sense of self-control, personal responsibility, satisfaction, and communication.
The term empathy is used a great deal in health care, but what is it and what can you do to display empathy effectively?27 Coulehan et al define empathy as “the ability to understand the patient’s situation, perspective, and feelings and to communicate that understanding to the patient.”27 Once again, empathy is a skill that can be developed, not just something that is innate within us. Empathy requires perspective taking, which means not only understanding your patient’s perspective cognitively, but also being able to “put yourself in his or her shoes” to understand it emotionally. But according to Coulehan et al,27 empathy also has a third component, and that is one of action; checking to confirm your understanding, which provides your patient the opportunity to clarify his or her feelings and concerns. One approach that has been used to help students and clinicians learn to recognize and address emotions and convey empathy can be expressed using the mnemonic NURSE3,28 (Table 3-5).
As previously noted, the literature is replete with strategies for improving communication, particularly patient-provider communication. Taking the time to be sure that your communication is as effective as it can be will increase your patient’s level of trust and will enhance the therapeutic relationship that you are working to develop.
CRITICAL THINKING CLINICAL SCENARIO
You are about to see a patient whom you have been seeing for the past few days. You know that the patient fell and fractured her femur. As you walk into the room, you notice that your patient is being quiet. She tells you, in a rather matter-of-fact manner,” ‘The doctors just left, they told me I have cancer and that is the reason I broke my leg.” After telling you this, she becomes teary and is just silent.
- Put yourself in your patient’s shoes. What might be going through your patient’s mind? How might you confirm your assumptions?
- What is your next step? Do you leave her alone to process the information? Do you begin to give her information about her diagnosis?
- How would you assess what your patient needs?
- What aspects of the SEGUE and/or NURSE frameworks might you consider using?
- What subskills of communication are critical in this scenario?
Use mental imagery to role play a conversation with this patient using the subskills identified in the SEGUE and NURSE frameworks.
KEY POINTS TO REMEMBER
- Effective communication between health care providers and patients is essential to patient satisfaction and quality care.
- Health care providers need to think about how, where, and when they present information as well as about the content that they wish to convey.
- Obtaining the patient’s perspective, through appropriate questions and active listening, encourages effective collaboration and enhances patient engagement.
- Taking time to elicit the patient’s feelings and providing feedback that you heard these feelings can enhance the therapeutic relationship.
- Effective communication requires performance, feedback, practice, and repetition.
- Reflective listening, building trust, self-disclosure, mutuality, and empathy can enhance the therapeutic relationship.
- Consider the SEGUE and NURSE mnemonics to provide structure to your communication and to help you demonstrate empathy.
- Effective communication requires performance, feedback, practice, and repetition.
If every one of us were born with an innate ability to communicate effectively, all of our interactions would go smoothly; unfortunately, that is not the case, particularly in health care, where emotions run high, errors happen, news is not always the best, and challenging patient encounters are inevitable. Challenging situations are often multifaceted. For example, at times, health care providers can be insecure, stressed, overworked, sleep deprived, ill, or even biased. Patients can be anxious, nonadherent, hyper-vigilant, or have chronic pain, low literacy, or psychological disorders. There may be conflicts between provider and patient goals. There also may be time constraints in any patient-provide encounter.29 All of these can lead to challenging situations, which the health care provider must learn to manage. Table 3-6 provides some examples of common challenging patient encounters and suggestions on how to effectively communicate to manage the situation.3,30,31
CRITICAL THINKING CLINICAL SCENARIO
You are the clinical instructor (CI) in an acute care setting. You have worked there for more than 10 years. You are supervising a second-year student who is in an acute care setting for the first time. Many of the patients are very ill, some with terminal diagnoses. The student tells you that he is having a very difficult time. He is worried that he won’t pass this clinical internship. He reports that he has trouble concentrating during treatment sessions because he feels “so bad” for the patients. He is afraid that someone will talk about dying and that he won’t know what to say. He is worried that he shouldn’t be asking the patients to put effort into physical therapy because “what’s the point?”
- As the CI, what do you see as the major concerns with this student?
- How might the differences in experience level affect the conversation between the CI and the student?
- How might the CI encourage this student to reflect on underlying assumptions that could be affecting his work with these patients?
- Is there anything that the CI should avoid saying or doing?
CRITICAL THINKING CLINICAL SCENARIO
It is easy to “blame” communication issues on the “other person.” However, as we noted earlier in this text, whenever 2 or more individuals are engaged in a conversation, each person brings his or her own perceptions, emotions, values, assumptions, and behaviors to the encounter. Think of a time when you were assigned to work in a group with a particular individual who, for some reason, you had a negative reaction to or with whom you just did not want to work.
- What was your reaction when you found out that you had to work with this individual?
- How did your feelings about this individual influence the way you interacted/communicated?
- What strategies did you use to manage the working relationship?
- How effective were your strategies?
Now place yourself in the role of a health care provider. What if, for some reason, you experienced the same negative emotion with a patient? How might you handle that situation?
Unfortunately, sometimes the source of the communication issue does not reside with the patient. Sometimes it is the health care provider who is frustrated or having difficulty dealing with a particular patient.29 Perhaps the provider no longer wants to work with the patient. This, too, can be stressful and must be managed so as to maintain the quality of care appropriate for the patient. Health care providers must first recognize that they cannot control their patients’ behaviors; they can only control their own. One approach to helping you manage your own stress so that it does not interfere with the therapeutic relationship you are developing with your patient is the CALMER approach29,32 (Table 3-7).
KEY POINTS TO REMEMBER
- The therapeutic environment can be stressful, and stress can impact effective communication.
- Behaviors of both health care providers and patients affect the therapeutic relationship.
- Health care providers need to reflect on their own feelings and attitudes when working with “challenging” patients.
- At times, our role is to help our patients manage their own stress.
- At times, our role is to manage our own reactions and stress; consider the CALMER framework.
- We can only control our own behavior, not that of others!
GIVING BAD NEWS
Why do most of us go into health care? Surely, our goal is to help others heal. When our patients succeed, we succeed. When our patients are happy, we are happy. Unfortunately, this is not always the case. At times, we must have difficult conversations, conversations in which we must share bad news. This is quite common in medicine, particularly in areas such as oncology, emergency medicine, intensive care medicine, and neonatology. But, even in physical therapy, there are times when we must have difficult conversations with patients. For example, we may be working with a patient with a spinal cord injury who may never walk again, a child with severe cerebral palsy who may always need assistance sitting up, an older adult patient who, after an evaluation, must be told that he or she is no longer safe to go home alone, or an athlete who must be told to stop playing his or her favorite sport. These are all difficult conversations.
It is also important to remember that bad news is “in the eyes of the beholder” and that you cannot fully anticipate your patient’s response to what you might think is bad news.33 Just as we discussed in Chapter 1, and even earlier in this chapter, each individual’s past experiences, culture, and spiritual and religious beliefs will influence how he or she might receive your message. For example, after 3 months in the neonatal intensive care unit (NICU), a parent and her child are preparing to go home. The neonatologist must inform the parents that the child experienced a significant anoxic event and that there is a high likelihood that she may have cerebral palsy. This parent might just be so thrilled to have her child alive and going home, that she may not react as the neonatologist anticipated. A few months later, after healing from her experiences in the NICU, the child’s mother might begin asking you when her child will start walking. You will have to give her an honest prognosis; yet, help this mother maintain hope for the future.
Historically, before recognizing the importance of making patients true partners in their own health care, medicine had a much more paternalistic perspective. Physicians questioned how much they should tell patients about their diagnosis and prognosis or about the potential side effects of treatment. They often wanted to shield them from bad news. In 1953, a study of 364 physicians from Philadelphia revealed only 3% always informed their patients of their diagnosis of cancer, whereas 12% never told them, and another 57% usually did not provide them with a diagnosis.34 At the time, there was concern that patients could not emotionally handle a diagnosis of cancer; they were concerned about the potential of psychological harm or even suicide. By 1979, there had been a significant shift in physicians’ attitudes toward communicating more information to their patients with cancer, with 98% of physicians surveyed indicating their general policy was to tell patients. Certainly, improved prognoses and enhanced quality of life for patients with cancer during that time improved the outlook for both physicians and patients, perhaps making the delivery of bad news slightly less devastating.
Today, it is clear that patients want information, honest dialogue with their health care providers, to know their options, and to be able to make their own quality-of-life decisions. Not only that, but in the intervening years, there has been much discussion regarding the legal and ethical responsibilities that health care providers hold not only in informing patients about their health care, but also in being sensitive to and supportive in assisting them in their decision-making process.35 The truth is that, oftentimes, patients know or at least suspect when there is bad news, and they are often relieved to have someone finally discuss it with them. Communication may actually decrease psychological stress and may increase patient satisfaction.36 However, it is important to remember that people manage news differently. It must be noted that there may be cultural differences regarding when, if, or with whom bad news is shared.37,38 Some patients prefer to hear the news when they are alone so that they have time to process the information, while others prefer not to be alone. Some patients like to make difficult decisions on their own, while others rely on the entire family unit. Some families are very open to discussing bad news, while others prefer to shield the patient from hearing bad news. Recognizing individual and cultural differences and assessing what your patient needs at any given time are critical to being an effective communicator.37
While we have come to know and value the importance of clearly communicating bad news, it remains stressful for both the patient and the health care provider. Health care providers often experience a sense of anxiety and, wishing the outlook could be better, feel a huge burden of responsibility and, at times, a sense of failure. Other challenges that can add to the stress of the health care provider are finding time to engage in difficult conversations, being able to be honest yet not crush someone’s hopes nor give them unrealistic hope, and managing a patient’s strong emotional response. Sometimes, health care providers are embarrassed because they have been unrealistic in providing a much too optimistic prognosis for a given patient in the past.35
If the conversation is avoided or even poorly done, it can leave a patient with a sense of being deceived, which can ultimately lead to mistrust. On the other hand, well done, difficult conversations can be incredibly supportive for patients and can encourage them to better plan for the future and to engage more effectively in the shared decision making necessary for a better quality of life. As previously noted, patients often already suspect when there are issues, yet are afraid to raise the question. As a result, there is silence leaving them alone with their thoughts. Opening the conversation can often be a great relief for patients. It can open the door for them to share their worries (eg, potential job loss, long-term family care, side effects or pain).35 When sharing bad news or having these difficult conversations, it is critical to remember, “The beginning of an interaction has a profound and irreversible influence on the entirety of the relationship and the process that follows…how bad news is delivered has a major impact on the achievement of positive treatment outcome.”39
So, where do you begin when preparing for difficult conversations? First, as noted, every patient will hear and react differently to what you view as bad news. Do not assume! In giving bad news, you must be prepared to respond to your patients’ emotional reactions, manage their expectations for cure or progress, give hope when there is little, involve them effectively in shared decision making, and manage the input from family and team members.35
Before beginning any difficult conversation, it is important to gather information, determine what your patient already knows, and determine what he or she wants to know. Some patients want and need all of the details up front, while others prefer to hear the details over time, when they are ready. The ultimate goal of any difficult conversation is always to support your patient in developing a shared plan of care.
Be sure to prepare for the discussion by removing distractions, ensuring privacy, and having the facts available. Determine what your patient knows, don’t assume, and only provide as much as your patient wants to hear at any given time. Give information in small doses, pausing to allow your patient to process the information. Allow for emotions, allow for silence, be empathic, and use touch appropriately. If your patient is not ready to hear all of the news at once, be sure to let him or her know that you are available to discuss the details or answer questions at any time. If your patient is anticipating bad news, it is sometimes helpful to preface the information with, “I am sorry to have to tell you this…” as it gives your patient time to prepare for the news. Engaging your patient in developing a shared plan of care can also help decrease some of his or her anxiety. Finally, of course, it is critical to check for understanding along the way.35
Fujimori et al36 developed the following mnemonic SHARE to help health care providers conduct difficult conversations more effectively:
|S||Set up a Supportive Environment|
|H||Consider How you will deliver the news|
|A||Additional information; provide only what your patient wants to know at the time|
|RE||Reassure and address Emotions|
The SHARE model was developed based on patients’ perceptions of what they want or need and what oncologists say that they need. These developers found that this model decreased patient distress, while not adding any significant time demand to the physician’s schedule.36
As noted earlier, managing your patient’s emotional response may be the most challenging aspect of these difficult conversations; however, it is also the most important. Understanding what is underlying the emotion (eg, fear of pain, job loss, family stability, death itself) will enable you to provide the right supports at the right time and will allow you to frame hope around each individual patient’s wants and desires.28,35
Effectively communicating difficult conversations, while minimizing stress and achieving expected goals, takes practice. Mental rehearsal is a strategy that you can use to help learn the various strategies for effective communication and to prepare yourself for the encounter. Through mental imagery, you can anticipate your patient’s reaction and perhaps some of the challenging questions that he or she might ask; therefore, you can be prepared to manage your responses. Remember, however, to never assume that your patient will react as you anticipate.35
Given the personal relationship that physical therapists have with their patients, and the one-on-one time they spend with patients, we are often the ones who patients open up to and confide in. We must be prepared to have those difficult conversations with our patients so that we can support them in their decision-making process.
CRITICAL THINKING CLINICAL SCENARIO
You have been treating a 3-year-old child with cognitive delays and significant motor impairment for over 1 year. You have been working on rolling over and sitting independently. You talk with the child’s mother during each session. You are surprised when the mother asks you if her child will be walking without assistance by the time preschool starts in 3 months.
- What might have triggered her question?
- How might this mother be feeling?
- Considering the various strategies discussed, how might you frame your response to this question?
- Using mental imagery, role play how you think the conversation might go with this mother. What questions might you ask her? How might she respond? What strategies will you use to manage your emotions and the mother’s emotions? What type of plan will you put in place to follow up on this conversation over the next few months?