Communication Skills
Jenny Lowe
St 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 communication
1.
2.
3.
4.
5.
6.
To improve detection of patients’ concerns
To improve recognition of psychological
morbidity
To optimise tailoring of information
To identify and meet patients’ needs re
participation in decision making process
To reduce burnout levels in Health care
Professionals
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 nurses
Payne, 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 suit
Royal 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
Language
Paralanguage





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
Listening
Silences
Acknowledgement
Encouragement
Picking up cues
Reflection
Facilitating behaviours cont’d
Clarification
Empathy
Challenge
Giving information
Summarising
Open 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

Communication of a life threatening diagnosis I have cancer




lost my job, I had chemotherapy
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.
Cues
Cue 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
Int
“I was upset about being ill”
“How’s your family”
Distancing



changing time
changing person
“Are you upset now?”
“ 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 topic
Using distancing strategies
 Giving premature advice
 Premature or false reassurance
 Passing the buck
 Normalising/stereotypical comments
 Selective attention to cues
 Jollying along
Blocking behaviours cont’d
Closed/leading/multiple questions
Directive questions
Requesting an explanation
Using jargon
Why is it so difficult ?
Inadequate training & lack of
confidence

In assessing what people already know




In judging how much information to
give
In handling difficult reactions to the bad
news


knowledge, perceptions and feelings
Integrating medical and psychological modes of
enquiry
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.

Environment
Assess
Assess
what the patient knows/suspects
what they want to know
Fire warning shot
Assess Allow Denial
feelings
Does the patient wish to continue
Explain in simple language
- Pause - check comprehension!
Elicit ALL concerns - Allow ventilation of
Summarise - care plan
Follow up
Handling Difficult Questions
Clarify question
Acknowledge 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
Patient not ready…
Allow expression of concerns
Invite further questions
Assure continuity of Care
Follow up
Assure presence/answer
to future questions
Dealing with Anger








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
Collusion
Focus 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.
Assessment




“I can see why you’re .....because.....”
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/cracks
Ignorance  ability to comprehend - Incorrect
information
Depression/Dementia/Disengagement
Talking to someone else
Previously 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.