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April 16, 2007

Spread the Word: Communication Key to Effective Care
By Patrice L. Spath, BA, RHIT
For The Record
Vol. 19 No. 8 P. 36

Providers must be attuned to their patients’ body language, listen earnestly, and, of course, speak clearly to ensure positive outcomes.

Good caregiver-patient communication can increase patient satisfaction, enhance patient adherence to medication and treatment regimes, reduce medical errors, and improve clinical outcomes. Malpractice lawsuits—something every practitioner wants to avoid—often result from inadequate communication with patients. In addition to keeping current in the technical aspects of their profession, physicians, nurses, and other caregivers must build communication skills to effectively deal with the complex challenges of patient care.

How caregivers interact has a dramatic effect on whether patients will feel comfortable raising issues or talking about concerns. Often, caregivers inadvertently discourage effective two-way communication with blocking behaviors. These behaviors are common, especially when discussions touch on unpleasant subjects.

Examples of blocking behaviors include the following:

• interrupting or finishing sentences before patients can express their concerns;

• talking more than the patients, making it difficult for them to squeeze their perspective into the conversation;

• deliberately changing the subject because it is uncomfortable;

• failing to clarify the patient’s questions or concerns;

• offering premature or inappropriate reasons or answers;

• overtly avoiding an issue, which conveys a lack of interest in the patient’s concern;

• minimizing the patient’s questions or concerns;

• disregarding the patient’s comments with condescending remarks such as “I have taken care of that”; and

• making promises to do tasks that can’t be followed through.

Don’t Just Talk, Listen
Communication is more than verbal dialogue; listening is also an important element. Listening is more than just hearing—that is only the first part. It also involves interpretation of what is being said and evaluation of the information imparted. Caregivers with ineffective listening skills can miss important verbal clues from patients or family members. A study of physician-patient interactions in outpatient clinics found that it takes most patients two minutes to explain their condition; however, the average physician interrupts the patient within 18 to 23 seconds.

Active listening is not just refraining from talking but actively trying to understand the other person’s total message. To do this, caregivers must listen for both the content and feelings being expressed by the patient. During discussions, the caregiver should occasionally summarize what has been said thus far and highlight major points. This can be done through paraphrasing, which simply involves the caregiver restating in his or her own words what the patient has said.

Questioning is also a critical communication skill for caregivers. There are two basic types of questions: closed and open-ended. Closed questions generally result in short yes/no or other one-word answers. This type of question should be used by the caregiver if precise, quick answers are needed. Otherwise, open-ended questions can inhibit caregiver-patient communication. To draw information from the patient, the caregiver should ask open-ended questions such as, “How can I help you today?” or “How was that last treatment useful?” Use the self-assessment in Figure 1 to evaluate your active listening skills.

Communication Barriers
While every patient is different, there are some common barriers to effective clinician-patient communication. Emotional barriers can result from many factors, including the following:

• Preoccupation with issues other than their health. Patients may be wrestling with internal constraints that influence their capacity to effectively communicate. They may be worrying about issues with their family or job, or coping with a new diagnosis or required lifestyle change. Patients may be preoccupied with financial issues or have challenging situations that were unresolved before they became ill. If patients are silent or reluctant to talk, it does not necessarily mean they lack interest in interacting. Patients may need additional time to deal with what they view as more pressing issues before they can effectively communicate with caregivers.

• Fear. Some patients may not ask questions for fear of offending the caregiver. They may have attempted to express concerns in the past and been rebuked or made to feel inferior. Often, patients are told they shouldn’t worry and should leave their care up to the clinicians. Some patients may fear that questioning practices or raising concerns may actually cause a medical mistake. They may think they won’t be heard or that it won’t do any good to speak up.

• Indifference. Some patients resent participating in their healthcare, feeling that “it is the physician’s or nurse’s job to take care of me—that’s what they are getting paid to do.” These patients often view their role as passive and don’t see the need to communicate with providers.

Besides emotional barriers, another obstacle to effective caregiver-patient communication is the manner in which the patient verbally conveys thoughts. People who are sick are operating under compromised conditions. Pain and worry can influence their ability to express themselves. Sometimes, patients may communicate in a way that doesn’t appear to be respectful of caregivers. This can stimulate a response from clinicians that discourages the patient from speaking up again.

Some patients, as well as their family and friends, may not know how to converse with caregivers in a way that promotes collaboration. The Partnership for Clear Health Communication, a coalition of national organizations working to improve communication between patients and caregivers, has developed a tool called Ask Me 3, which promotes three simple but essential questions patients should ask their providers in every healthcare interaction. Information about the tool and educational materials to share with consumers can be found at www.askme3.org.

Literacy Barriers
Patients have varying degrees of literacy. Many people who can sign their name may lack the skills needed to access and assimilate information. Some can only read at a third- or fourth-grade level. These individuals are often unable to comprehend and interpret written words. Many cannot use or apply written words correctly in their daily life.

Patients with limited literacy typically do not confide their difficulty in reading and understanding to caregivers; they often feel embarrassed and do not want to be judged. Therefore, they may not ask questions of the caregiver or let on that they don’t understand something.

A patient’s limited literacy is not obvious and, because many won’t admit to the problem, caregivers must improve their screening efforts. To test a patient’s literacy, caregivers should elicit feedback from patients to evaluate their understanding of the information provided. This can be done by asking questions and reiterating key points. If it is discovered the patient has difficulty understanding or retaining information, then communication must be simplified. Written patient education materials may need to be supplemented or replaced by verbal discussions and visual aids.

The American Medical Association Foundation has developed a patient health literacy education toolkit for physicians, healthcare professionals, and patient advocates. Information about the kit can be found online at www.ama-assn.org/ama/pub/category/9913.html.

Cultural Divide
Our country has numerous and diverse ethnic groups that can create caregiver-patient communication challenges. For example, asking questions or talking about topics directly is considered bad manners among some people raised outside the United States. The caregiver must establish a trusting relationship before these patients will speak freely about their health problems or related issues. Developing this type of trust takes time. In some countries, patients learn to blindly accept the physician’s decision or the nurse’s direction without question. And in stressful situations, such as when a patient has a serious illness, communication with caregivers becomes even more challenging.

To improve caregiver-patient communication, clinicians need to learn more about the cultural beliefs and practices of different national cultures. A patient’s ethnic background can influence how he or she wishes to communicate and receive information. Knowing what to say is as important as how to say it. Therefore, a general understanding of how each cultural group defines health, views illness, and responds to death is important. For example, in cultures where status is inherited rather than earned, the position of other decision makers in the family must be acknowledged. Also, values related to privacy, including feelings of modesty and shame, can make it more difficult to discuss health-related issues even after building a trusting relationship. The role of family, whether medications and pain treatments are acceptable in their culture, and how their religion or philosophy supports them in times of extreme stress are also valuable factors for caregivers to understand.

Many healthcare organizations have developed staff resources to guide communication while providing care to a patient from a different culture. These resources can help remind staff of the patient’s cultural perspectives and values, and how to interpret nonverbal behavior. While not all members of one cultural group behave in exactly the same way, an understanding of their culture can help caregivers engage patients in meaningful dialogue.

Get Past the Obstacles
Each interaction between a caregiver and patient is unique. To individualize discussions, patients must be given a sense of control over their care plan. When patients and their families trust caregivers, they are better able to communicate effectively, cooperate in treatment, and cope with uncertainties. Their trust is dependent on the degree to which they see their caregivers as competent, caring, and responsible. When caregivers are open with patients, they are more likely to share their personal thoughts and feelings.

Being proactive by providing information and anticipating questions is the first step toward better caregiver-patient communication. Clinicians should actively seek patient participation by asking whether they have questions and whether anything has been overlooked from their viewpoint. The more caregivers do this, the more patients will engage in the dialogue.

Caregivers can partner with patients in numerous ways. First, patients should be told what is being done for them and asked whether they have any questions. It is important to refrain from using unfamiliar medical terms or acronyms during these discussions. Clinicians should encourage patients to speak up when something is not right and be prepared to respond appropriately when they do.

A key factor in improving communication with patients is to listen carefully and seriously consider what the patient is saying (even if the message is uncomfortable). Caregivers must avoid blocking behaviors that only serve to set up communication barriers. Below are some approaches that can foster open communication between caregivers and patients:

• Focus on listening to the patient’s words and the intended meaning. Hear the patient out and acknowledge their input.

• Listen without interrupting. Listening is not just a skill but also an attitude. If the caregiver appears preoccupied with other issues, the patient will sense they are not being heard.

• Pay attention to your nonverbal behavior. By using positive body language, such as facing the patient and sitting down at their level, caregivers communicate interest in what the patient is saying. It is also helpful to provide for privacy and discourage interruptions during discussions.

• Be careful not to rush the patient, respond defensively, or change the subject.

• Take the time to acknowledge valid points. If the patient rambles or makes ambiguous statements, try rephrasing or paraphrasing or ask clarifying questions.

• Try to understand the patient’s message through both their verbal and nonverbal communication. How are they sitting or standing? What is their expression? Do they appear sad? Angry? Nervous?

• Take time to sort out what the patient is saying before responding, then summarize what you’ve heard.

Discussing Mistakes
The activities of a healthcare organization are often confusing to patients. It’s possible that the patient or family may have perceived a situation inaccurately. How caregivers handle the situation will influence the patient’s willingness to openly share information in the future. If a mistake has not been made, explain what happened. It is important to help the patient or family member save face. They may feel foolish and embarrassed once they learn their perceptions were incorrect. The caregiver should acknowledge the validity of their concerns and apologize for the confusion or lack of communication that may have created the concern. Thank the patient for paying attention and feeling comfortable enough to pose the question.

One of the more difficult conversations a caregiver may have with a patient is when a mistake has actually been made. The caregiver’s reaction is often defensive, especially when the patient has suffered an injury because of the mistake. Most medical professional groups assert that the patient should be informed about an error. Also, The Joint Commission requires that physicians in accredited hospitals inform a patient when results of care differ significantly from the anticipated outcomes.

Whether telling patients about a simple mistake that did not cause harm or one that resulted in an adverse event, there are some communication techniques that can improve the discussion. First, it is important to acknowledge the error and, if appropriate, take corrective action. Whenever possible, include family members in the discussion and try to have both parents present if the patient is a minor. Eliminate possible interruptions and provide a private space for the discussions. When talking with the patient, make eye contact and speak in a nonhurried manner with an even tone of voice. Provide ample time for the discussion; don’t try to fit it in five minutes before the start of a shift or between other duties.

The content of the discussion may be less important than the circumstances of the delivery. Direct, clear statements are important as well as tone of voice. The caregiver may want to start by saying, “I am afraid I have some bad news.” It’s important to communicate in a manner that is open and compassionate. Give an accurate, clear-cut statement with nondefensive explanations of what has happened. Speak in short statements, frequently stopping to inquire whether everyone understands. Avoid slipping into technical descriptions or medical jargon that may intimidate the patient. Do not assign blame, and avoid offering initial beliefs or subjective opinions of possible causes of the mistake.

Disclosing a mistake, especially one that led to an adverse event, creates stress for the patient and family members. This can cause fear, anger, mistrust, or hopelessness. It is often best to offer an apology—which does not denote an admission of liability on the clinician’s part.

Skills Training
Good communication between caregivers and patients is the foundation of quality healthcare. Improving interpersonal communication skills—just like improving technical skills—is done best with an organized educational program. Although written material is useful for improving patient communication, behavioral change is more likely to occur in a workshop. The Institute for Healthcare Communication (IHC) is a group that sponsors communication workshops for physicians as well as other healthcare professionals, including nonclinical staff. The IHC educational model, or 4Es, defines the critical communication tasks as: to Engage, Empathize, Educate, and Enlist the patient.

Engagement establishes an interpersonal connection that sets the stage for the patient-caregiver interaction. Empathy demonstrates the caregiver’s understanding of and concern for the patient’s thoughts and feelings. The patient is seen, heard, and understood by the clinician. Education delivers information to the patient. Enlistment extends an offer to the patient to actively participate in decision making, and enlistment acknowledges that much of what happens in the treatment plan is controlled by the patient.

— Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, author of Partnering with Patients to Reduce Medical Errors, a partner in Brown-Spath & Associates (www.brownspath.com), an adjunct assistant professor in the department of health services administration, School of Health Professions at the University of Alabama in Birmingham, and a contributing editor at For The Record.


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