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Communication in medical practice. Workplace Communication Relationships. Effective communication demands that the parties involved in communication have a shared and clear appreciation of the various definitions and parameters about which information is being exchanged.
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Workplace Communication Relationships • Effective communication demands that the parties involved in communication have a shared and clear appreciation of the various definitions and parameters about which information is being exchanged. • Workplaces are witness to generally five types of communication relationships: Collaborative, Negotiative, Competitive, Conflictive and Non-recognition.
Fundamental obstacle to effective communication • Non-recognition relationship blocks any meaningful exchange by refusing to acknowledge that one or more of the players in the desired exchange has no rights whatsoever. • Conflictual relationship is a situation in which the parties recognize each other but are no longer able to work towards a win-win result and resort to verbal abuse and physical violence instead. These types of relationships present a fundamental obstacle to effective communication.
Collaborative and negotiative relationship • In the collaborative relationship the needs and positions of all the parties are clearly defined and understood and everyone involved shares the will to succeed, as well as information, equipment, accommodation and logistic arrangements, for example. • The negotiative relationship has much in common with the collaborative scenario except that some needs and positions may not have been defined clearly enough and require discussion and trading to reach a mutually acceptable outcome.
What can studying communication skills offer us as medical practitioners? • Increased nurse Job Satisfaction • Decreased Conflict Within The Consultation • More Accurate And Efficient Interviews • Better Clinical Hypothesis Generation • Increased Patient Satisfaction • Increased Patient Understanding And Recall • Improved Compliance And Disease Outcome • Decreased Medico Legal Complaints • Actual Savings In Time • More Structure And Control Of The Difficult Consultation
Treatment Outcome: • Effective diagnoses and treatment depends not only on identifying physical symptoms of illness, but also on the nurse’s ability to detect and respond to verbal and non-verbal cues, to elicit all relevant information (physical and psychosocial), relevant to diagnoses and treatment. Patient’s Adherence: • A poor communication skill is related to poor compliance. Communication skill training has a positive influence on patient compliance with prescribed medication. Effective communication enables nurses/Nurse and other health professions to pass on relevant health information, and to motivate patient to pursue healthier lifestyle. This is a very important part on health promotion. • nurse’s Competence & Self-Assertion: • Research has also shown that better nurse’s patient’s communication can also contribute to the clinical professional and personality (self-confidence) aspects.
Patient’s Satisfaction. • Many researches have also shown a significant relationship between the clinician’s interpersonal skills and patient’s motivation and satisfaction. When the nurse dominates the interview, verbally and emotionally, the result is always leads to dissatisfaction of the patients and their relatives. This may also be related to the patient’s expectation about the role of the nurse. • Patient’s satisfaction plays a major role in assessing quality medical care in the newly adopted health system (manages care) in the USA. • Cognitive Satisfaction: How satisfied is the patient with their understanding of the diagnoses, treatment, and prognoses. This is related to the nurse’s Verbal Behavior. • Emotional Satisfaction: This is related to the nurse’s non-verbal behavior. The ability to show care and concern by tone of voice, eye gaze, facial expression, body movement and posture.
INTERVIEWING AND COMMUNICATION SKILLS CORE COMMUNICATION SKILLS: Core communication skills covers three dimensions: • nurse -patient interpersonal skills • Information gathering skills • Information giving skills and patient education Advanced Communication Skills • Skills for motivating patient adherence to treatment plans • Other applications of core communication skills in specific situations.
Information gathering skills • A critical part of all nurse-patient interactions involves eliciting information from patient. The core skills which are needed to facilitate the process of information gathering are skills which help to facilitate the patients’ involvement in the medical interview in away that enables the nurse to arrive at an accurate diagnosis of a patient’s problem or symptoms. • Using an appropriate balance of open to closed questions • Open questions invite an extended answer, not a “Yes/No” response. Generally questions such as “Please tell me about your pain” are better at eliciting information than closed questions such as “Is it a stabbing pain?”. Open questions are particularly useful patients are being asked to describe their problem; which they should be allowed to do minimal interruption early on in the consultation.
Silence • You need to learn to use silence appropriately as a way to encourage express themselves more fully, raise difficult topics and remember important Clarifying patient expectations about the consultation • You need to clarify with the patient what their expectations are consultation, and should avoid making premature conclusions about the reason person’s visit to the nurse. This may helps to reveal cases where the symptom the patient is not in fact the patient’s main concern, and will also help to avoid inaccurate diagnosis of the patient’s complaints. Clarifying the information given by the patient • You need to clarify the meaning of what the patient is saying and the nurse perceives from the patient’s non-verbal communication in order to he/she understands the patient fully.
Sequencing of events • After eliciting a broad description of the patient’s situation, students need to help the patient to sequence events and experiences in order to develop a logical of the patient’s situation. Directing the flow of information • While it is important that patients be allowed the opportunity to communicate at the same time the student needs to learn to maintain control of the interview, by guiding the interview content towards a diagnosis of the problem. Summarizing • Since a lot of information can be exchanged in consultations, you should be able to summarize the main issues raised during the consultation and should ensure that a shared understanding of these.
Information giving skills and patient education • The medical interview usually involves the nurse in providing information to the patient about their illness or problem, and when appropriate the nurse will give inform and advise about the proposed treatment plan or treatment options. • Providing clear and simple information by monitoring jargon, and by checking the patient’s understanding before (“What do you know about asthma?”) and during (“Have I made myself clear?”) the explanation process. • Using specific advice with concrete examples. Abstract or general advice/inform should be exemplified in terms that make sense to the patient “Don’t use acidic foods for example steer clear of fried things”. • Putting important things first. Research suggests that what is said first is remembered. A nurse should say first what it is most important for the patient to recall
Using repetition. Repetition should be used carefully to a level appropriate to patient. Often it is best to recycle information using slightly different words, in case the formulation has been only partly understood. • Summarizing. This is an important interview-closing skill (see above). Sum should be brief, and repeat the main points agreed in language, which is unambiguous clear. Patients may also be invited to repeat the nurse’s instruction to ensure that they shared understanding. • Categorizing information to reduce complexity and aid recall. Where the information to be conveyed is complex, or where there is a lot to be said, it should be clearly b down into manageable units which are clearly signaled to the patient, using markers s “there are three things we need to think about ... firstly/secondly/thirdly etc”.
Using tools: Complex information could well be accompanied by a series of heading and diagrams. Some nurses offer tape recorders of their consultations to patients where the information has been intellectually demanding and psychologically distressing. • Checking patient understanding of what has been said. Repeating instructions, using diagrams, written instructions, and sometimes-technical aids to explain difficult concepts are useful. The student must be competent in summarizing the information given and in checking patient understanding by asking the patient to repeat what heard and understood.
Skills for motivating patient adherence to treatment plans The list below includes skills for the promotion of behaviour. Realistic compliance with treatment plans may require patients to make significant changes in their diet, lifestyle or daily routine on a short term or long term basis. • Providing a rationale for behavior change • Providing examples of role models • Allowing opportunities for verbal rehearsal of the details of the treatment • Feedback (positive reinforcement of constructive behaviour changes already achieved since earlier consultations) Finally, nurses should be aware about the clincial, communication and interpersonal skills that are required when dealing with difficult patients,(e.g., overdependent, dramatizing and exaggerating, aggressive, and antisocoial personalit.
Children who are either “neglected” or “rejected” • Children who have problems making friends, thosewho are either “neglected” or “rejected” sociometrically,often show deficits in social skills. One of the most commonreasons for friendship problems is behavior thatannoys other children. Children, like adults, do not likebehavior that is bossy, self-centered, or disruptive. It issimply not fun to play with someone who doesn’t shareor doesn’t follow the rules. Sometimes children whohave learning problems or attention problems can havetrouble making friends, because they find it hard to understandand follow the rules of games. Children who getangry easily and lose their temper when things don’t gotheir way can also have a hard time getting along withothers.
Social competence deficits and peerrejection • Exclusion from a normal peer group can depriverejected children of opportunities to develop adaptive socialbehaviors. • Evidence compiled from studies using child interviews,direct observations, and teacher ratings all suggestthat popular children exhibit high levels of socialcompetence. They are friendly and cooperative and engagereadily in conversation. Peers describe them ashelpful, nice, understanding, attractive, and good atgames. Popular and socially competent children are ableto consider others’ perspectives, can sustain their attentionto the play task, and are able to “keep their cool” insituations involving conflict. They are agreeable andhave good problem-solving skills. Socially competentchildren are also sensitive to the nuances of “play etiquette.” • They enter a group using diplomatic strategies,such as commenting upon the ongoing activity and askingpermission to join in. They uphold standards of equityand show good sportsmanship, making them goodcompanions and fun play partners.
Children who are rejected by peers often havedifficulties focusing their attention and controlling theirbehavior. They may show high rates of noncompliance,interference with others, or aggression (teasing or fighting). • Peers often describe rejected classmates as disruptive,short-tempered, unattractive, and likely to brag, tostart fights, and to get in trouble with the teacher.
Aggressive children • Not all aggressive children are rejected by theirpeers. Children are particularly likely to become rejectedif they show a wide range of conduct problems, includingdisruptive, hyperactive, and disagreeable behaviorsin addition to physical aggression. • Socially competentchildren who are aggressive tend to use aggression in away that is accepted by peers (e.g., fighting back whenprovoked), whereas the aggressive acts of rejected childreninclude tantrums, verbal insults, cheating, or tattling.In addition, aggressive children are more likely tobe rejected if they are hyperactive, immature, and lackingin positive social skills.
The effect of illness and hospitalization • Physically isolated • Surrounded by strangers • Visiting hours • Procedures that are intimate • At first very dependent – then learn to move back to balance of independence/dependence
Principles of effective management • Whatever health services may offer, most of the day to dayresponsibilities for the care of chronic illness fall on patientsand their families. • Planners and organisers of medical care musttherefore recognise that health care will be most effective if it isdelivered in collaboration with patients and their families.
Principles of effective management • Toenable patients to play an active role in their care, healthservices must not only provide good medical treatment but alsoimprove patients’ knowledge and self management skills. • Thiscan be done by supplementing medical care with educationaland cognitive behavioural interventions.
Common elements of effective chronic illness management • Collaboration between service providers and patients • A personalised written care plan • Tailored education in self management • Planned follow up • Monitoring of outcome and adherence to treatment • Targeted use of specialist consultation of referral • Protocols for stepped care
Collaboration with patients and families • To win the collaboration of patients and their families, thoseproviding care need to elicit, negotiate and agree on a definitionof the problem they are working on with each patient. • Theymust then agree on the targets and goals for management anddevelop an individualised collaborative self management plan.This plan should be based on established cognitive behaviouralprinciples and on the evidence relating to the management ofthe chronic condition.
Principles of collaboration • Understanding of patients’ beliefs, wishes, and circumstances • Understanding of family beliefs and needs • Identification of a single person to be main link with each patient • Collaborative definition of problems and goals • Negotiated agreed plans regularly reviewed • Active follow up with patients • Regular team review
Plan for collaborative self care • 1 Assessment • Assess patient’s self management beliefs, attitudes, and knowledge • Identify personal barriers and supports • Collaborate in setting goals • Develop individually tailored strategies and problem solving
Plan for collaborative self care 2 Goal setting and personal action plan • List goals in behavioural terms • Identify barriers to implementation • Make plans that address barriers to progress • Provide a follow up plan • Share the plan with all members of the healthcare team 3 Active follow up to monitor progress and support patient
Encouraging self care • Active self care is critical to the optimal management of chronicillness. Interventions to optimise self care are based on cognitivebehavioural principles.They start with an assessment of patients’ attitudes andbeliefs about their illness and their chosen coping behaviours. • This assessment then guides the provision of information, theresolution of misunderstandings and misinterpretations, andcollaborative goal setting. These are agreed between patient andmembers of the healthcare team.
