Communication skills week 2.pdf

Key skills for good communication   Core tasks, core skills and specific issues In order to provide this degree of organisation, the healthcare interview can be conceptualised as a set of core tasks, broadly applicable to all healthcare interaction once they have been ma...

Key skills for good communication   Core tasks, core skills and specific issues In order to provide this degree of organisation, the healthcare interview can be conceptualised as a set of core tasks, broadly applicable to all healthcare interaction once they have been mastered, specific communication challenges such as anger, addiction, breaking bad news or diversity issues are much more readily tackled.  Relationship Building Not surprisingly the task of relationship building takes center stage in many models of clinical communication. Relationship makes a difference to communication in health- care, to the people involved and to healthcare outcomes. Building the relationship is a task easily taken for granted by healthcare practitioners. So what can teachers of communication skills recommend to learners to enable them to achieve more effective relationship building in the clinical interview? the use of appropriate nonverbal behaviour rapport‐building skills (including respectfulness, acceptance, empathy, acknowledge- ment, sensitivity and supportiveness) patient involvement skills such as sharing thinking and explaining rationale  One of the key skills in building the doctor–patient relationship is the use of empathy Neumann et al. suggest that clinical empathy is a fundamen- tal determinant of quality in medical care, enabling the clinician to fulfill key medical tasks more accurately and thereby leading to enhanced health outcomes Of all consultation skills, empathy is the one most often thought to be a matter of personality and therefore inherently not teachable. Empathy is a two‐stage process: the understanding and sensitive appreciation of another person’s predicament or feelings the communication of that understanding back to the patient in a supportive way. attentive listening, facilitation and picking up cues demonstrate to patients a genuine interest in hearing about their thoughts. nonverbal and verbal skills are required to complete the second step of empathy, communicating understanding back to the patient. Effective nonverbal communica- tion can clearly signal to the patient that we are sensitive to his or her predicament. Example: Empathic statements such as ‘I can see that your husband’s memory loss has been very difficult for you to cope with’ more directly name and Information Gathering and Clinical Reasoning Information gathering has always been a key task in the communication curriculum. Traditional questioning methods do not encourage comprehensive history taking or effective hypothesis generation. Fortunately, developments in communication theory and research have greatly improved our understanding of the communication process skills to enable effective information gathering. As communication curricula have become more prominent over the last 30 years, a tension has become apparent between the teaching of history taking and clinical communication. A structured method was developed in 19th century, which still remains nowadays, but this structure had it’s disadvantages It has unwittingly led many health professionals towards a closed approach to question asking, as they mistake the template for recording clinical information (con- tent) with the methodology for obtaining that information (process). The traditional standard history only covers the biomedical perspective, the symp- toms and signs that are expected to lead the clinician to a differential diagnosis  This illness frame- work relates to the individual patient’s unique experience of sickness, his or her ideas, concerns, expectations and feelings. Discovering the patient’s perspective is not only an entry into more supportive medical care but also a vital component in enabling the elucidation of the biomedical story. Studies of patient satisfaction, adherence, recall and physiological outcome all validate the need for a broader view of history taking Learners potentially get the impression that those teaching history taking are only interested in the following: whilst those teaching communication skills are only interested in:  This can lead learners to choose one model over another or alternatively perceive that the history‐taking model is more suited to hospital medicine and the communication model to general practice. In fact, there should be only one combined model; effective process, content and perceptual skills need to be taught together by the same teachers in an integrated fashion, producing an effective comprehensive clinical metho The information‐ gathering communication skills advocated in modern consultation models include the narrative thread (Mishler 1984); open and closed questioning techniques (Takemura et al. 2007); attentive listening (Marvel et al. 1999; Ruiz Moral et al. 2006); facilitation skills (Levinson et al. 1997); picking up cues; summary (Takemura et al. 2007; Quilligan & Silverman 2012) and specific skills related to exploring the patient’s ideas, concerns, expectations and feelings. Information Sharing and Shared Decision Making  Most communication teaching programmes concentrate on the first half of the interview and neglect or underplay information sharing and shared decision making Yet there are problems in current practice that suggest the need for considerable efforts in our communication not enough information given by doctors to match their patients’ needs omission of key elements of information use of language that patients cannot understand underusing techniques to enable patient recall and understanding lack of involvement of patients in decision making to the level they wish  Many of these problems originally emanated from a traditional view of the doctor– patient relationship between a paternalistic doctor and passive patient In shared decision making, there is a genuine two‐way exchange of information including the technical information brought to the interview (mostly but not always by the doctor) and the patient’s information concerning his or her unique ideas, concerns and expectations providing the correct amount and type of information assessing the patient’s starting point; ◦ chunking and checking and eliciting patient’s questions aiding accurate recall and understanding explicit organisation and signposting; repetition and summary; clarity of language; visual methods of communication and checking patient’s understanding achieving a shared understanding relating explanations to the patient’s perspective; providing opportunities to contribute; picking up cues and eliciting reactions and feelings shared decision making sharing thinking; involving the patient; exploring options; ascertaining level of involvement patient wishes and negotiating a mutually acceptable plan, checking.  A study of women with a confirmed diagnosis of breast cancer attending hospital oncology clinics, 22% wanted to select their own cancer treatment, 44% wanted to select their treatment collaboratively with their doctors, and 34% wanted to delegate this decision making to their doctors. Only 42% of women believed they actually achieved their preferred level of control in decision making In Gattellari et al.’s study of cancer patients, mismatch between patients’ preferred roles in decision making and what they perceived happened led to increased patient anxiety However, whatever the preference of the patient prior to the interview, satisfaction with the consultation and the amount of information and emotional support received were significantly greater in those who reported a shared role. This gives support to the concept that as well as respecting individual differences in patient preference, part of the doctor’s role might include gentle encouragement of patients over time to take part in shared decision making. Another study looked further at the relationship between shared decision making and patient outcomes in patients with HIV.. They found that patients who preferred to share decisions with their HIV provider had better outcomes than both those who wanted their HIV provider to make decisions and those who wanted to make decisions alone. They suggest that practising clinicians ought to encourage patients toward a shared decision‐making role.  It is difficult to guess each patient’s desire for involvement in making decisions without enquiring directly. Rather than guess or force all patients to adopt a collaborative role, it is the doctor’s task to ascertain individual patient’s preferences for participation and to tailor the approach accordingly. Even if the patient does not wish to be involved in decision making at the moment, such a discussion will alert the patient that this is an option that he or she can return to in the future without criticism from the doctor. Communicating about Risk and Uncertainty  In order for a patient to be able to give informed consent, he or she will need to understand associated risks, benefits and uncertainty. A pragmatic definition of risk is ‘the probability that a hazard will give rise to harm , which is therefore accompanied by a level of uncertainty about future outcomes Uncertainty can be defined as ‘the subjective perception of ignorance’ and pervades health care at all levels  It has become evident that effective communication of risk and uncertainty is challenging, for both patients and healthcare professionals, with a variety of factors contributing to this. dealing with uncertainty can be difficult for all parties involved The way in which people process (health) information ) can result in cognitive biases, where information is interpreted inaccurately. Finally, the influence of emotions further muddies the waters for patients when trying to make sense of information about risk and uncertainty recommendations, providing helpful guidance for clinicians. use of natural frequencies versus percentages use of absolute risk versus relative risk; ’framing’ information in a balanced manner personalising the risk information where possible using appropriate graphical/pictorial material.  Responding to Emotions evidence with outpatients showed that when doctors respond to patients’ emotions and distress, this is positively associated with patients’ decreased anxiety, improvement of medical outcomes and satisfaction  Michael Balint was the first to introduce empathy and the psychoanalytic concepts of transference and countertransference into medical practice. Based on his observations and experiences, he argued that almost all problems that a patient presents to the doctor are partially psy- chological in nature and must be explored. Furthermore, through his work with small groups of physicians who were presenting their cases anonymously , Balint outlined the importance of ‘the doctor as the drug’, meaning the effect that a doctor’s responses, feelings and personality can have on a patient’s recovery.  Neutral empathy Blumgart (1964) supported the necessity of ‘neutral empathy’ in doctors’ responses because empathizing with patients may remove objectivity and the scientific clinical perspective. ‘Neutral empathy’ is when the doctor proceeds with what needs to be done without experiencing any emotions Affective empathy is similar to sympathy and it involves emotions that in the end will work against an objective diagnosis and treatment Why do we need Neutral empathy? a recent cross‐sectional study with 294 general practitioners, in which the researchers investigated the general practitioners’ empathic concerns in relation to burnout, found that sharing patients’ emotions was related to physicians’ personal distress, and that this was also associated with their decisions and performance positive outcomes from doctors’ responses to patients’ emotion evidence shows that physicians’ responses to patients’ emotional problems can create a stronger therapeutic relation between the two parts, reduce symptoms of anxiety, increase patients’ satisfaction and encourage better management of the disease even though the literature presents contradictory evidence in regards to doctors’ empathic concerns and their effect on doctors’ well‐being , there is also evidence underlining the importance of empathy in doctors’ well‐ being and job satisfaction.  Breaking Bad News The term ‘breaking bad news’ is paternalistic, implying it is something that a professional does to a patient, and in some of the literature it is now referred to as ‘delivering difficult news’. This still does not go far enough to acknowledge that it is a two‐way process, and the term should perhaps be ‘sharing difficult news’ Sharing difficult news is not different from any information sharing in a clinical context and should follow the same principles of establishing current understanding, listening to the patient to establish the level of language and the informational needs and delivering information in a logical way , with checking of understanding and screening for new concerns. The big difference with sharing difficult news is the likelihood of strong emotional responses being experienced.  There is evidence that some clinicians have difficulty or lack the skills to share difficult news. poor delivery of bad news has consequences for both patients and doctors. For patients- the outcomes include increased stress, poor adjustment and generally poorer health outcomes for doctors - there is an increased risk of anxiety and burnout An important question is, what do patients want? A French study retrospectively surveying patients who had received bad news demonstrated that the acceptability of the interview was related to the quality of the information (understandability, personalisation and completeness) and the demonstration of emotional support, these two factors accounting for 95% of the variation. A study showed that 79% of patients with stomach or esophageal cancer wanted as much information as possible; however, only 35% of doctors were willing to give this. It still left 21% of patients who did not want such complete information. Silverman summarised the components of the common protocols. The majority include: establishing the patient’s current knowledge and willingness to receive bad news; using a warning shot; making a direct and simple statement; addressing the patient’s agenda in terms of feelings and concerns and the giving of professional information. Different suggestion: make the case for hope and hopefulness in sharing bad news encounters, stating that maintaining hopefulness helps the patient adjust to the news. They discuss the changing role of hope and what can be hoped for as a disease progresses. The importance of realistic hope is also emphasised by VandeKieft Work by Burgers suggests that patients respond more favourably to positively framed statements; for example, 40% of patients will be alive after 5 years as opposed to 60% of patients will die from this illness within 5 years  Shaw used simulated consultations to show that doctors tended to use one of three styles when sharing difficult news that they described as blunt (information given within 30 seconds) forecasting (staged delivery within first 2 minutes) stalling (news delayed more than 2 minutes). It was noted that in the stalling style the doctor rarely delivered the news directly but relied on the patient to come to a conclusion. Of the 31 doctors studied, just over a third used the blunt style, 45% the forecasting and 20% the stalling style. The blunt and forecasting styles gave clarity of information, with forecasting giving more descriptive information. Those using stalling used medical terminology and euphemisms more.  Sharing difficult news has an impact on professionals. Brown et al. (2009), using simulated bad news consultations, showed that less experienced doctors showed higher stress levels and those showing signs of burnout or fatigue performed less well. A study conducted semistructured interviews with doctors and explored their experience of breaking bad news. Most described it as stressful and stated that they had physical and emotional symptoms (including sweating, palpitations, and feeling drained, distressed and anxious) that included anticipatory stress and that for some continued long after the event and impacted on their social life. Facilitating Behaviour Change through Motivational Interviewing  Motivational interviewing has its roots in the treatment of substance use disorders and was recently defined to be a ‘collaborative, person‐centred form of guiding to elicit and strengthen motivation to change’ Motivational interviewing has been shown to be particularly effective for substance use disorders, smoking, weight loss, gambling and medical outcomes such as blood pressure, cholesterol, dental cavities, HIV viral load and improving risk of mortality following a stroke  The motivational interviewing method requires the doctor to engage in an empathic conversation with patients about their motivation and their confidence in the possibility of change. The skills are not easy and can feel counter‐intuitive To use them effectively, one must inhibit a natural inclination to tell the individual the ‘right thing to do for their own good’, as the aim is to elicit the individual’s own motivation to change and support the individual in setting and achieving realistic goals, thus enabling him or her to be in control of long‐term change. The method of motivational interviewing involves the following four overlapping processes: engaging is the process by which both parties establish a helpful connection and a working relationship; focussing is the process by which the direction of behaviour change, if desired, is clarified; evoking is the process by which the motivation for change is made explicit planning is the process that encompasses the development of the commitment to change and formulation of a specific plan of action.  Experiencing the difference between being told what to do about a problem versus thexperience e of being listened to in an empathic, non confrontational and non judgemental manner helps the learner to understand the difference between traditional methods and the motivational interviewing approach. One of the aims of motivational interviewing is to help the individual to explore the benefits of changing behaviour and the real differences these changes can make to one’s life. The following five questions can be used to demonstrate to beginners the essence of a motivational conversation with someone Why would you want to make this change?’ How might you go about it in order to succeed?’ ‘What are the three best reasons for you to do it?’ How important is it for you to make this change and why?’...following a brief synopsis of the answers to the above four questions, the fifth and final question can be asked (if deemed appropriate): ‘So what do you think you’ll do? Motivational interviewing training can be assessed by the change in learners’ skills following the course and also by the assessment of change in learners’ knowledge and attitudes and their satisfaction with the training.  Error An error is defined as something incorrectly done through ignorance or inadvertence; a mistake, for example, in calculation, judgment, speech, writing, action and so forth errors occur as a result of: skill‐based behaviours; for example, completing a physical examination; rule‐based behaviours; for example, following a management guideline; and knowledge‐based behaviours; for example, making a decision about prescribing. How does communication cause error? Communication skills are most often seen as a core component in resolving error, but they are also a central cause of error Errors in communication between health professionals and patients The main errors that are identified in the literature relate to the following features of communication skills, specifically insufficient or inappropriate skills in: information gathering, leading to errors in clinical reasoning; for example, making the wrong diagnosis because of premature closure of information gathering; relationship building; for example, anger and frustration from the patient about unmet expectations or a lack of empathy within the consultation; and information sharing, leading to errors in management; for example, consent for surgical procedures and information giving about drug interactions and the side effects of medications. Reducing error in communication with patients Good communication and a positive relationship between a patient and his or her healthcare professional results in less error and better outcomes The SPIKES framework was developed for breaking bad news but is applicable to all instances of information sharing. It was designed as a gold standard for situations where poor communication and errors could be harmful to patients and their carers. All the evidence in this area suggests a thorough and empathetic health professional who listens is less likely to be involved in error Errors in communication between health professionals The negative impact of poor communication is not only seen in health professional– patient communication but also in communication between health professionals. Poor coordination of care is a trigger for complaints and litigation The SBAR tool (Situation, Background, Assessment and Recommendation) is an example where using a structured tool can improve the content and structure of handover communication an example of how this might be used. A staff nurse is concerned about a 12‐year‐old boy on surgical ward who has abdominal pain. His vital signs have deteriorated and she would like him to be reviewed urgently.  Openness about error The lack of openness about error is thought to result from health professionals’ fear of medico‐legal action being initiated against them, and this distances them from patients, who desire transparency and openness Patients are likely to feel fewer distressing psychological after‐effects if health professionals are open with them about what has happened Open disclosure is an example of a communication strategy that encourages health professionals to discuss errors with patients after an adverse event occurs Scenarios of medical error You are a junior doctor and you are called to see an 81‐year‐old woman, Mrs Irene Smith, who has just been admitted with a kidney infection and is confused. She was admitted by your colleague, Dr John, who has prescribed a penicillin‐based antibiotic to treat her. You are called by the ward staff, who tell you that her husband has just arrived and informed them that she has had an adverse reaction to penicillin previously. She has been given a single dose intravenously. He has asked to speak to a doctor and asks how this could have happened. Scenario A The adverse reaction experienced previously was diarrhoea and vomiting. ‘I am very sorry that this has happened. It is clear that something unexpected has occurred but fortunately you were able to point this out to us quickly and I hope that Mrs Smith will not suffer harm from it. However, we will keep an eye on her for the next 24 hours and will ask you to let us know if you think she is getting any problems from the medication. We do not expect that Mrs Smith will need to stay here any longer than originally planned.’ Supporting colleagues after errors occur A final component in medical error is communication between health professionals in coping with error and handling the anxiety that it brings. Communication skills are vital in supporting colleagues and enabling them to continue in caring for patients Scenario B The adverse reaction experienced previously was a severe rash that needed hospital admission for 72 hours. ‘I am very sorry that this has happened. It is clear that something went wrong. It is fortunate that you were able to point this out to us quickly. We have given Mrs Smith treatment to help reduce any allergic reaction she might develop. She has not shown any signs of an allergic reaction so far, but we will monitor her closely to identify if any problems arise. Please tell us if you think she is experiencing any side effects or a reaction to the antibiotic. We are also investigating the incident right now to find out how this happened. We will give you information as it comes to hand. It is very important for us to understand what you think happened. We can go through this now if you like, or we can wait until you are ready to talk about it.’