Pediatric communication.pdf

Communication with pediatric patients By Somaya Madkour Prof. of Forensic Medicine & Clinical Toxicology 1 Why Do Pediatricians Need Communication Skills? Pediatricians need communication skills because it is more complicated communica...

Communication with pediatric patients By Somaya Madkour Prof. of Forensic Medicine & Clinical Toxicology 1 Why Do Pediatricians Need Communication Skills? Pediatricians need communication skills because it is more complicated communicating with children than it is communicating with adults. Children lack the level of comprehension required to properly explain what is happening to them (they are too young to put their problems in words. In other cases, some kids could just be too shy and scared, no matter what age). This is when it falls on the doctors to communicate with them efficiently. The excitement, fear, and stimulation that comes with a visit to the doctor’s clinic might end up making them too restless, which is not ideal if the child is required to be still for a vaccine shot, or an X-ray. It’s these and more that make communication an important skill in pediatrics. Because parents and other family members play a crucial role in the lives of children, you need to establish rapport with the family in order to identify mutual goals and facilitate positive outcomes. Communication with children and families Involving the Child in the Conversation The physicians’ approach had to be more child-centered. Invite children to participate in discussions, not only by describing their physical symptoms but also by discussing their feelings and by contributing to decision making. For example, the physician might say to a child, “Lucy, I’m interested in how you feel about what’s going on. Tell me what you think about your upcoming surgery.” Starting the Conversation: Introductions and Opening For an initial visit, make sure you know the patient’s full name before entering the room. Once in the room, check what name the child likes to be called and how adults want to be addressed. Always address the patient and family members by name. Do not address the mother as “Mom” or “Mother” or the father as “Dad” For example, you might say to a child, “Your mother tells me that you’re having some headaches again. Tell me about them.” Introduce yourself. If the patient is a verbally competent child or adolescent, it is appropriate to address him first. “Hello. So, you are Joey (wait for confirmation). Pleased to meet you. I’m Dr. Smith, and (looking at the accompanying adult) who has come with you today?” If the patient is an infant or toddler, you will address the accompanying adult. “Good morning. I’m Doctor Smith, and you are?” The physician will know how the adult wants to be addressed and confirms his relation to the patient. If the accompanying adult doesn’t explain his relation to the patient, ask. If you can, arrange the seating (or choose where to stand if there is no place to sit) so as to face both the patient and the parent. If you must read the patient’s chart or electronic medical record, check laboratory data or read a referral note before taking the history, explain that to the patient. “Just give me a moment to check some data in the computer then we can talk.” You can even invite the patient and parent to look at the computer screen with you. 2 A bit of social chatter or one or two non-medical questions can help put the child and accompanying adult(s) at ease. Then, asking a child why he or she has come to the office or why he or she has been admitted to the hospital can be a helpful starting point, often revealing misconceptions or fears. After introductions and rapport-building, the clinician needs to ask the patient’s and parent’s concerns and reasons for the interview. It is important to let them voice their concerns without interruption, which usually takes less than a minute If there are different concerns that cannot be addressed at this interview, the physician with the patient (if age appropriate) and parent determine which issues will be addressed at this time and which later The Conversation Clinicians working with children need to make a conscious effort to keep children actively involved in discussions about all phases of their care, not just the data gathering phase. Even though young children are not capable of making most medical decisions, they can participate in these decisions and, if given the opportunity, can voice their concerns, their opinions and their preferences. Engaging the child in the conversation in a meaningful way can be a challenge. Children often have more difficulty with open ended questions than do adults, and they often need more time to answer a question than do adults. Give the child time and show that you are comfortable waiting for a response by your verbal language (“It’s okay Eddie, take your time to get your thoughts together.”), by body language (keep your gaze on the child and have a pleasant, patient, expectant look) and by action (don’t look at your watch). Children are likely to be influenced by what their parents have said, and they are likely to give answers they think their parents or the doctor wants. Sometimes you have to encourage the child to voice his or her own thoughts. “That sounds pretty much like what your mother and I said. Are you sure that you agree? What would you like to do differently?” Closing the Conversation There are three important components for effective closure of a patient interview 1- Summarizing at the end of a clinical interview is primarily a technique to be sure that the family understands how you see the situation. 2- Explaining the Plan Explaining what is going to happen next helps the patient cope with the illness. A yes answer to, “Do you understand?” is not a reliable indicator of comprehension. Many patients are embarrassed to admit that they don’t understand or think they understand when they do not. The question, “Is there something that I haven’t made clear or something that you would like me to clarify?” is stronger encouragement for the child or parent to ask for clarification 3- Soliciting Questions The typical, “Any questions?” delivered while standing up and moving towards the door is not the most effective incentive. Asking, “What questions do you have?” while remaining seated is more likely to elicit a meaningful response. If you sense that the patient or parent is confused, you can ask, “You look to me to be a bit uncertain. What can I clarify or go over again?” This is less intimidating than, “What don’t you understand? 3 Techniques to Facilitate Communication Touch Infants do not have cognitive understanding of the words they hear, but they sense the emotional support, and they can feel, interpret, and respond to gentle, loving, supportive hands caring for them. School-age children and adolescents appreciate giving and receiving hugs and getting a reassuring pat on the back or a gentle hand on the hand. The physician, however, needs to request permission for any contact beyond a casual touch with these children. Physical Proximity and Environment Creating a supportive, inviting environment for children includes the use of child-size furniture, colorful banners and posters, developmentally appropriate toys, and art displayed at a child’s eye level. This is essential to overcome feeling of anxiety being in unfamiliar environment. You can also keep comic books, workbooks, and balls to engage older children in a similar way. Once they’re in the examination room, ensure you engage them in conversation about the games and puzzles. Their anxiety is likely to increase once they’re out of the waiting room, so keeping them distracted and entertained is important. On your part, ensure all the toys are properly sanitized to reduce the risk of infections. Listening By practicing active listening skills, physician can be effective listeners. Active listening skills are as follows: Attentiveness Eliminating distractions whenever possible is important. For example, the physician should maintain eye contact, close the room door, and eliminate potential distractions (e.g., television, computer, video games, smartphones). Clarification through Reflection Reflection This technique involves repeating a significant word or phrase that the patient has just said.; you are simply indicating that you heard what the patient said and perhaps are inviting him or her to elaborate on it. Clarification Clarifying is a higher skill level than reflecting. It means rewording or defining what the patient has said. Clarifying can help patients or parents recognize and understand their feelings For example, when the child or family member says, “I hate the food that comes on my tray,” a reflective response would be, “When you say you are unhappy with the food you’ve been given, what can we do to change that?” As the conversation progresses, the physician can move the child through a dialogue that identifies those nutritional foods the child would eat. Empathy The physician identifies and acknowledges feelings expressed in the message. For example, if a child is crying after a procedure, the physician might say, “I know it is uncomfortable to have this procedure. It is okay to cry. You did a great job holding still.” Impartiality (Neutrality) The physician should listen with an open mind and not judgmental manner. For example, if a young adolescent shares that she is doing something wrong and is mainly concerned about such 4 behaviors, the physician remains a supportive listener. The physician can then provide her with educational materials and resources as well as discuss the possible outcomes of her actions in a manner that is open and not judgmental, regardless of the physician’s personal values and beliefs. The physician must be prepared to listen with the eyes as well as the ears. Information will not always be audible, so the physician must be alert to subtle cues in body language and physical closeness. For example, when the physician enters the room to complete an initial assessment of a 4-year-old child and observes the child turning away and beginning to suck her thumb, the child is communicating about her basic security and comfort level, although she has not said a word. Visual Communication Eye contact is a communication connector. Making eye contact helps confirm attention and interest between the individuals. Direct eye contact may be uncomfortable, however, for people in some cultures, so the physician needs to be sensitive to responses when making eye contact. Tone of Voice Communication consists of not only what is said but also the way it is said. The tone and quality of voice often communicate more than the words themselves. A soft, smooth voice is more comforting and soothing to infants than a loud, startling, harsh voice. Children can detect anger, frustration, joy, and other feelings that voices convey, even when the accompanying words are unrelated. The choice of words is critical in verbal communication. The physician needs to avoid talking down to children but should not expect them to understand adult words and phrases. Technical health care terms should be used selectively, and jargon should be avoided. Summarizing during the Interview is a powerful technique to verify that you understand the patient correctly. It also provides the patient with an opportunity to add to the narrative. Explain why you are summarizing. “Could we summarize to be sure that I understand what you told me?” Body Language An open body stance and positioning invite communication and interaction, whereas a closed body stance and positioning hinder communication and interaction. Using an open body posture improves the physician’s understanding of children and the children’s understanding of the physician. OPEN CLOSED Leaning toward another person Leaning away from another person Arms loose at sides, Hands moving freely Arms folded across chest, Hands on hips with with Head up Head bowed Frequent eye contact No eye contact Calm, slow movements Constant motion, squirming Smiling, friendly facial cues Frowning, negative facial cues Conversing at eye level Conversing at a level that requires the child to move to listen Timing 5 Recognizing the appropriate time to communicate information is a developed skill. A distressed child whose parents have just left for work is not ready for a diabetic teaching session. In outpatient setting, scheduling teaching sessions that adapt to a parent’s schedule can enhance child’s or parent’s understanding of information. For example, scheduling a teaching session during the late afternoon or early evening, or on a Saturday, at the parent’s convenience assures increased attention because the parent is not distracted with needing to be at work or other demands on time. Establishing rapport can be accomplished quickly and typically opens the door for a more successful encounter with a child. Two key techniques for establishing rapport include keeping eye contact with the child or adolescent and beginning the conversation with a topic that they may find interesting. Suggestions for Establishing and Maintaining Communication with Children and Adolescents Establishing rapport Show interest in the child or adolescent by talking about non-medical topics such as school, games and sports and asking about his or her interests. Mention things to show that you are familiar with the patient and family, as well as with their medical issues. Be at the child’s eye level. Do not tower over them A smile can go a long way in establishing rapport. A white coat can be intimidating and scary for a young child; consider not wearing a coat or wearing a coat of a different color. Maintaining rapport Be calm, gentle and respectful. Convey that you are not in a hurry: sit, assume an open, relaxed posture and do not look at your watch or the door. Use a normal tone of voice and rate of speech. Use developmentally appropriate language to share your thoughts and observations with the child (e.g., “It can be scary when you have to stay in the hospital and don’t know when you will get to go home.”). Be an attentive listener, especially when adolescents are trying to communicate with you. Keep eye contact and do not be distracted or write while they are talking Do not allow parents to speak unfavorably about their children in your presence. This may embarrass the children and undermine their trust in you. Keeping the child in the conversation Allow older children or adolescents to tell their own stories first and give them the last word in the conversation. For children who are initially hesitant in responding, ask them to tell you in their own words what is wrong after establishing the chief complaint from the parent. Allow children and adolescents to express their opinions and feelings. Facilitate this with questions. Do not jump to conclusions about or trivialize a child’s or adolescent’s perspective or concern. What may not seem like a problem to you may be an important issue for the child. 6  When appropriate, allow choices during the interview and examination (e.g., “Would you like to sit on your mother’s lap or on the table?” or “Which ear would you like me to look in first, the left or right one?”) Maintaining a supportive environment For the child who may have difficulty understanding the spoken word (e.g., a child with autism or with a hearing deficiency), pictures of children participating in the various components of the exam can be extremely helpful and decrease anxiety. Do not allow other family members to speak unfavorably about the child or adolescent in your presence; this sets a poor example, embarrasses the child and undermines trust. Be careful of your own words, as they can be very powerful. Do not use words like fat or lazy. Share positive affirmations and celebrate successes with the child or adolescent (e.g., “I am so proud of your food choices.”). Family-Centered Communication Parents need to be supported while sustaining their parental role during their child’s hospitalization. An expanded definition of family is required in the twenty-first century, because the term no longer refers to only the intact, nuclear family in which parents raise their biologic children. Contemporary family structures include adolescent parents; extended families with aunts, uncles, or grandparents parenting and homeless children. Communicating with Families Include all involved family members. One essential step toward achieving a family-centered care environment is to develop open lines of communication with the family. Encourage families to write down their questions. and remain nonjudgmental. Give families both verbal and nonverbal signals that send a message of availability and openness. Respect and encourage feedback from families. Recognize that families come in various shapes, sizes, colors, and generations. Avoid assumptions about core family beliefs and values and respect family diversity. Availability and Openness to Questions The physician might encourage effective use of time if there are other issues to be addressed by saying, “I know you have a lot of questions and are very anxious to learn more about your son’s condition. I have another patient who has an immediate need, but I will be available in 10 minutes to meet with you. In the meantime, here is a parent handbook that gives general information about seizures. Please feel free to review it and write down any questions that we can discuss when I return.” Family Education Family empowerment occurs when the physician and other health providers take the time to educate parents about their child’s condition and the skills needed to participate, thus ensuring their continued involvement in planning and evaluating the plan of care. Effective Management of Conflict When conflict occurs, it needs to be addressed in a convenient manner to prevent further breakdown in communication. 7 Strategies for managing conflict Understand the parents’ perspective (walk in their shoes). Try to understand the parents’ perspective better by encouraging them to share it. Determine a common goal and stay focused on it. Determine the agreed-on result, and work toward it. Listen actively for better understanding of the actual and the implied message. Avoid blaming. Pointing fingers and blaming others will not solve the problem. Instead, identify the part of the problem that each party owns and work together to resolve it. Summarize the decision. At the end of any discussion, summarize what has been decided and identify who is responsible for follow-up. This process ensures that everyone is clear about the decision and facilitates accountability for implementing solutions. Feedback from Children and Families To enhance the delivery of care, the physician should explain how this feedback will be used. the physician should listen and observe carefully to make sure that what family members are saying is truly what they are feeling. For example, while one physician was teaching the mother of a 2-year-old child who was recently diagnosed with type 1 diabetes mellitus, the mother reported that, although she was her child’s primary caregiver, the child’s grandmother frequently cared for the child while the mother was at work. the physician therefore notified the other team members and altered the teaching plan for diabetes care to include the child’s grandmother Mnemonics are useful tools for remembering steps in dealing with specific situations. The RESPECT models Rapport: this can begin with some social chatter to break the ice, but true rapport requires more. Show the patient that you are interested in his or her story and point of view. Empathy: this involves understanding the patient’s feelings and emotions, acknowledging them and validating the patient’s feelings. Support: ask about barriers to care and get assistance for the patient and family. Provide assurance that you will be there for them. Partnership: be flexible to control issues and be willing to share decision making. Stress working together. Explanations: avoid Jagran. Use verbal clarification techniques. Check for understanding. Cultural competence: respect the family’s culture, and at the same time, be aware of your own cultural biases and preconceptions. Inquire rather than assume how a patient’s culture may be influencing his or her feelings or behavior. Trust: appreciate that self-disclosure may be difficult for some patients. Be accepting of their negative thoughts and feelings. Be honest and compassionate. 8