Communication Skills

Jenny LoweSt John’s Hospice

2010

Government recommendations re: communication skills Calman-Hine (1995) “Psychosocial aspects of cancer should be

considered at every stage of disease”

NHS Cancer Plan (2000) advocates joint training in communication skills & provision of psychological support

NICE (2004) All health & social care professionals should demonstrate effective information giving, compassionate communication & general psychological support

End of Life strategy(2008, p119) Core common requirements for workforce development: Training in Communication skills – basic, intermediate and advanced

Cancer network band 6 above to have Advanced communication skills training

Aims of effective communication1. To improve detection of patients’ concerns2. To improve recognition of psychological

morbidity3. To optimise tailoring of information4. To identify and meet patients’ needs re

participation in decision making process5. To reduce burnout levels in Health care

Professionals6. To reduce number of complaints and law

suits

Effective communication has been shown to improve the rate of patient recovery, pain control, adherence to treatment regimens, and psychological functioning (Stewart 1996, Jenkins et al. 1999)

Assessment of concerns

Number and severity of patients’ concerns: High levels of emotional distress Weisman & Worden 1977, Harrison et al

1994

Affective disorder Parle et al 1996

Yet up to 60% of concerns remain undisclosed in hospice setting

Heaven & Maguire 1996

80% concerns remain undisclosed in inpatient setting

Farrell et al 2005

Stress in health professionals: nurses Oncology nurses report little confidence in

knowing how much information to disclose to patients Corner 1993

Newly qualified cancer nurses found to suffer from highest levels of stress

Corner 1993, Wilkinson 1994

Burnout lowest in hospice nursesPayne, 2001

Complaints and law suits 90% complaints dealt with by official

bodies concern poor communication

30-40% of patients who have begun litigation, do not proceed if they receive an adequate explanation and apology

Lack of sensitivity of doctors is often a significant factor leading to law suitRoyal College of Physicians of London. Report of working party.1997; Vincent et al 1994

Complaints….

Many complaints by patients and their relatives relate to a perceived failure of the doctors and health care professionals to communicate adequately or to show they care, rather than to problems of clinical competence.

(DOH 2000)

What happens in consultations ?

Communication behaviours In nursing:

54 ward nurses /cancer patients (Wilkinson 1991) >54% utterances had the function of moving

away from cues (blocking) very poor or absent coverage of psychological

aspects (0.04 out of a total score of 6)

60 CNS (Heaven, Clegg and Maguire 2006) Cues explored med. 10.4% Cues acknowledged 30.7% Cues distanced 56.9%

Reasons why healthcare professionals may not elicit patients’ concerns

Fear of upsetting the patient (Pandora’s Box) Fear of causing more harm than good

Fear of unanswerable and difficult questions (eg why me?)

Fear of saying the wrong thing, getting into trouble, getting blamed

Feeling incompetent Feeling powerless/helpless

Reasons why healthcare professionals may not elicit patients’ concerns cont’d

Too busy/lack of time Fear of dealing with patients’ emotions

Threat to own emotional survival “Not my job” Failing the patient/wanting to shield

from emotional pain Being reminded of human vulnerability

– our own feelings

Reasons why patients/families may not disclose concerns

Health Care Professionals perceived as being too busy

Don’t want to increase burden Belief that HCP is primarily

concerned with physical issues. Belief that life/quality of life

depends on treatment so don’t want to complain.

Worries perceived as insignificant.

Reasons why patients/families may not disclose concerns cont’d

Fear of admitting inability to cope/ breaking down/ losing control Fear of stigmatisation by admitting

psychological problems Unable to express how they feel Worried about having their worst fears

confirmed Trying to protect staff from their distress.

Reasons for non-disclosure...

The first nurse was so sweet and nice, I did not want to hurt her by telling her all about that. Nurse ‘X’ on the other hand seemed stronger, less fragile, I felt I could tell her all my troubles.”

Hospice Patient 1990

Verbal and Non-verbal skills

Non-Verbal Behaviour/Body Language

Personal Space - Physical distance between people

Orientation - Position in room

Facial Expression - Powerful signalling tool

Eye Contact - Implies interest and concern

Posture - Cue to mood/indicative of difficulties -

Gestures - Signalling – can indicate emotional state

Touch - Therapeutic effect

Verbal Communication

LanguageParalanguage Voice quality Volume Intonation and pitch Speed Tone

Facilitating Behaviours

...use of words and gestures to encourage the patient to carry on talking; Verbal - Non-Verbal

ListeningSilencesAcknowledgementEncouragementPicking up cuesReflection

Facilitating behaviours cont’d

ClarificationEmpathyChallengeGiving informationSummarisingOpen questions

Effective micro-skills: recent advances Silence or minimal prompts most likely to

immediately precede disclosure Eide H et al 2004

Giving information reduces likelihood of further disclosure Zimmerman C et al 2003

Polarity of words important: screening Qs “Something else” more than twice as likely to elicit

further concerns than “anything else” Heritage J et al

2006

Cues A verbal or non-verbal hint which suggests

an underlying unpleasant emotion and would need clarification

Mention of psychological symptoms eg I worry Words or phrases which describe unpleasant emotional

states linked to physiological symptoms eg. it feels like a knife

Words or phrases which suggest vague or undefined emotions eg it felt odd, I cope

Verbal hints to hidden concerns eg. it took awhile Neutral or repeated mention of an important life event

eg I lost my job, I had chemotherapy Communication of a life threatening diagnosis I have

cancer

Cues…Definition... Non verbal cues:

clear expression of negative or unpleasant emotions (crying)

hints to hidden emotions (sighing, silence after a question, frowning, posture etc)

Verona Consensus Statement 2006

Del Piccolo et al (2006) Patient Education and Counselling. 61(3):473-475.

CuesCue based facilitative skills

Open questions linked to a cue are 4.5 times more likely to lead to further disclosure

Open questions not linked to cue have a 50:50 chance of being followed by disclosure

Fletcher PhD thesis 2006 (Maguire Unit)

Cues..How cues are missed / blocked Overt blocking

Pt “I was upset about being ill” Int “How’s your family”

Distancing changing time

“Are you upset now?” changing person

“ Was your husband upset?” removing emotion

“How long were you ill for?”

Plus normalising, minimising, premature advice and reassurance

Blocking behaviours – inhibit communication

Switching focus Switching time Switching person Switching topicUsing distancing strategies Giving premature advice Premature or false reassurance Passing the buck Normalising/stereotypical comments Selective attention to cues Jollying along

Blocking behaviours cont’dClosed/leading/multiple

questionsDirective questions Requesting an explanationUsing jargon

Why is it so difficult ?

Inadequate training & lack of confidence In assessing what people already know

knowledge, perceptions and feelings Integrating medical and psychological modes of

enquiry In judging how much information to give

In handling difficult reactions to the bad news Anger, distress, difficult questions

In assessing patient’s preferred role in decision making

Working Environment

Lack of support Lack of availability of help when

needed Colleagues not perceived as being

concerned about our welfare Booth et al 1999

Lack of space and time Staff conflict

How can we be more effective ?

Communication - Difficult Issues

Bad News We Break…. Diagnosis related news Treatment related news Diagnostic test related news Social news

(i.e. illness, death, unemployment) Change in disease trajectory Disease relapse Death

Breaking Bad News Aim - to slow down speed of transition.

EnvironmentAssess what the patient knows/suspects

Assess what they want to know

Fire warning shotAssess - Does the patient wish to continue

Allow Denial Explain in simple language

- Pause - check comprehension!

Elicit ALL concerns - Allow ventilation of feelings

Summarise - care plan

Follow up

Handling Difficult QuestionsClarify questionAcknowledge importance of question - Check why question is asked - (check for other reasons)Does person want an answer now?

Warning Shot/Answer - Pause

Answer - avoid false reassurance Allow expression of concerns

Invite further questionsAssure continuity of Care

Follow up

Patient not ready…Patient not ready…

Assure presence/answer Assure presence/answer to future questionsto future questions

Recognition Permission Listen to story to get as much information as

possible Focus on person’s stress/feelings Apologise Reasons - explore the reasons

non-judgemental non-defensively

Negotiate a solution Look for transition Sadness - Guilt If anger escalates,set limits,if limits refused, withdraw

Dealing with Anger

CollusionFocus on colluder Feelings/stress/strain on relationship Reasons for not being truthful Support reasons Assess pt’s questions to relatives Suggest window on knowledge Ask for permission to assess the pt Reassure no telling Confirmation if necessary

Dealing with Emotions Recognition Non verbal/Verbal Acknowledgement “I can see you’re...”

Permission “It’s ok to be ....”

Understanding “I want to find out what’s making you.....”

Empathy accept. “I can see why you’re .....because.....”

Assessment Severity and effects of....... Alteration (possible?) - Removal of stressor Cognitive Challenge Assist in coping Medication

Patients not wanting to talk

Denial - facts/feelings Check for windows/cracksIgnorance - ability to comprehend - Incorrect

informationDepression/Dementia/DisengagementTalking to someone elsePreviously dealt with - “wanting to forget”

Remember Many problems are insoluble Bad News is Bad News Illness causes many forms of pain We can’t make everybody feel

good, but we can try to make them feel less bad.

Summary Effective communication is a core

clinical skill which underpins effective tailored care.

To be effective we must acknowledge and respond to cues.

Key facilitative skills aid disclosure but they are more powerful when used in the context of cues.