Communicating with Patients
Communicating with others is an important part of life. In the clinical setting, communication both between health professionals; and with patients, is an important part of the therapeutic relationship.
Below are eight tips that may assist in continuing to provide high quality healthcare; particularly in oncology.
Set the Scene
Choose an appropriate time to speak with the person (that is, avoid approaching them during a favourite television program, when leaving for work, when stressed about an unrelated issue, and so on) or negotiate a time. Do not try to speak about important issues if one or both of the parties are intoxicated. For teenagers, talking in the car or using issues on a contemporary television show might provide a good springboard. If the time never seems right ‘fire a warning shot’ by saying, ‘There’s something I want to talk to you about. It’s important. I know you have been busy but when could we catch up properly?’
Begin to Talk About the Small Things
Self-disclosure is unfamiliar territory for some. Others might not have the vocabulary to describe how they feel, not see the relevance of telling others, may expect unwanted judgments or fear ‘opening the floodgates’ and overwhelming themselves or others. Think about small, less emotionally charged topics as a way of opening the door to more significant conversations. Sometimes, if you talk about what you think and feel, others will slowly follow.
Listen and Ask Questions
Listening without interrupting is powerful; it conveys interest and respect for another’s point of view. Spend the time really listening to what is being said (this doesn’t mean you must agree with it). Maintain eye contact and make encouraging remarks such as ‘I see what you are saying…’ and ‘Go on…’ and ask more questions. Again, open questions provide the most potent way of understanding another’s position or feelings. Use questions beginning with why, what, when, where and how.
Limit the Expressing of Assumptions and Opinions for a Time
Reverting to old patterns of communication can block new ones. People who have known each other for many years, if not all of their life, will feel as if some (albeit important) discussions are no longer worth having as they always seem to end in the same way. Not responding in the same way they always have can help others to be more tolerant and to try to reach new ground.
Learn to Walk before you Run
In some exceptionally difficult circumstances, such as the journey of a patient with cancer or a someone close to death, people may feel pressured to start to talk about meaningful subjects and intimate thoughts and feelings (for example, if someone has received some disappointing news that a treatment hasn’t worked as well as it was hoped). For those that have avoided communicating so far, this is confronting and enormously challenging. Communication about difficult issues is much easier if the small steps have been taken first. Try to use the valuable time you have now to open discussion slowly.
Be Assertive When You Need to. Use ‘I’ Statements
Being assertive involves expressing your own thoughts and feelings without dismissing or abusing the rights of others (which is aggression). Particularly when there is concern that a discussion may result in conflict, using ‘I’ instead of ‘you’ statements is a useful skill. For example, saying ‘I feel disappointed when you came home and did not ask me about how my treatment went’ is a less accusatory way of expressing your feelings than ‘You make me so cross when you don’t even bother to ask me how my treatment went.’ Use a simple: ‘I think’, ‘I feel’ and ‘I want’ approach. For example, ‘I think the radiotherapy is taking a lot of time and effort. I feel pretty tired most days. I want you to help around at home by making your own lunches’.
Keep Working at it
When talking to others (especially children or older patients) we do not have only one chance to say things — it doesn’t have to be ‘perfect’. Communication evolves and there are nearly always other opportunities to talk. Be realistic in your expectations — set realistic goals for communication and be patient, yet motivated, to create even small changes.
Communicate Without Words
Loving and supportive communication does not need to revolve around words. Simply being there, holding hands, smiling, sharing meaningful eye contact and showing physical affection are all meaningful ways of demonstrating respect, concern and support.
Further Reading: 10 Communication Skills for Nurses to Master
Communicating with Patients’ Relatives
Communicating with patients’ relatives is not the same as communicating with the patient themselves. Patients always have the right to know, but the family may or may not, depending on the patient’s wishes. Obviously, this can cause conflict between the patient, nurse, and family, which can make the problem more stressful than it already is. It is also difficult to determine where family ends and interested onlookers begin. Spouses, parents, and siblings are likely to be privy to information, but cousins, aunts, uncles, and other relatives may not.
In big families, the pressure on the nurse can become incredible. You could spend all day answering calls from family members and not have time for your patient. Most hospitals now have numbers that allow only certain people to ask the nurse for updates. Unfortunately, some families hand this out to just about everyone they can think of. For big families, it is important to have one person act as the spokesperson who brings the information back to the family as a whole. In addition to this precaution, here are a few other family related issues you should keep in mind when dealing with this stressful situation.
Privacy rules differ across the world, so it is important to know what the privacy rules are in your region. Most privacy statutes indicate that health information should only be given to those authorised by the patient. When communicating with family, you may have to separate those who are allowed to hear the information from those who are not. This can cause tension between you and the family members who are left out. It is important to explain to them that privacy rules dictate that only certain members of the family can be told about the patient’s condition, then may tell the rest of the family.
You may find that some relatives get belligerent with you about privacy. They may try to bully you into giving information, and this can be difficult. Stay firm in your convictions. Although it may seem like needless bureaucracy, you are actually performing a very important function in protecting you patient. Remain calm and explain that you are bound by law to maintain the privacy of your patient. If they claim that they have known the patient for twenty years, acknowledge that they are indeed close friends, but only family members are allowed to know the details of the patient’s condition. Refer all their questions to the family spokesperson.
Families in crisis may react in ways that they normally would not. The stress and worry over a patient in danger can cause them to say and do things that are offensive, violent, loud, and intimidating. A great deal of the attention will be focused on you because you are at the bedside, caring for their family member. As in most communication situations, it is important to remain calm in the face of whatever the family may present. If you are in danger or feel you may be in danger, don’t hesitate to call security to get the situation under control. Usually, though, it doesn’t escalate to this level. In that case, you need to work on calming the relative.
Honesty is, once again, very important, and you shouldn’t make empty promises to keep a relative calm. Once you have established that they are privy to the details, tell them the truth about what is going on with their loved one. Be prepared for a wide range of reactions. Some will react with anger, but most will react with neutrality or sadness. In some cases, this can be more difficult to deal with than hostility. Offer yourself as a sounding board for the relative. Make it a point to be there for them, a presence of peace and understanding. Comfort them and do not betray their trust in you.
Patient Rights v Family Rights
Patients have the right to competent care, protection from reasonable risks, and advocacy from their nurse. Families may feel they have rights too, but the patient’s rights always come first. If the relatives are disturbing the patient, working them up, or causing more stress, the nurse has to step in and remove the family. It is a difficult situation to be put in because no one wants to separate a family from their loved one. However, you have to take the patient’s wellbeing into account. Is this helping them or hurting them?
Most families will not cause stress, but sometimes even the most laid back family can cause stress to the patient. They may cry, focus only on the negative, or in other ways upset the patient. In these cases, it is important to talk to the patient and the family member. Ask the patient if they are comfortable with their family and if they would like the family to have restricted access to them. Most will decline, but at least you are offering the opportunity to the patient. Next, talk with the family. Explain that their behaviours are upsetting the patient and that a different approach is needed. There is no reason to be falsely happy, but tell them to simply be with the patient instead of focussing on the negative.
In the end, talking to a patient may be easier than talking to their family. Patients may not understand what is going on with them, and their relatives are basically in the same position. However, they also have the added stress of not knowing if their loved one will make it through. Acknowledge the fear they are feeling and offer them the same compassion you would offer your patients.
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- Hodgkinson, K. & Gilchrist, J., 2008. Psychosocial Care of Cancer Patients: A Health Professional’s Guide to What to Say and Do, Melbourne, Victoria: Ausmed Publications
- Journal of Hospice and Palliative Nursing; Communication Between the Nurse and Family Caregiver in End-of-Life Care: A Review of the Literature; Susan E. Lowey, MS, RN, CHN, BC; 2008
- New England Journal of Medicine; A Communication Strategy and Brochure for Relatives of Patients Dying in the ICU; Alexandre Lautrette, M.D.; 2007
Dr Katharine Hodgkinson is a clinical psychologist and member of the College of Clinical Psychologists of the Australian Psychological Society, with both clinical and research expertise in psycho-oncology. Katharine worked for eight years in a tertiary oncology service providing psychosocial care to women with gynaecological cancer and their families, as well as education to other health professionals. As an honorary associate of three Sydney universities she provided clinical supervision to clinical psychology interns at master's level. In 2006, Katharine completed her doctorate which examined predictors of psychosocial outcomes in cancer survivors and their partners and resulted in the development of two psychometrically established measures of unmet supportive care needs for cancer survivors and their partners. Katharine has published numerous research papers in peer reviewed journals, presented at conferences and co-authored a book chapter on the psychosocial and spiritual care of cancer patients.