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. To improve detection of patients ’ concerns 2. To improve recognition of psychological morbidity 3. To optimise tailoring of information 4. To identify and meet patients ’ needs re participation in decision making process 5. To reduce burnout levels in Health care Professionals 6. 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 % 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 exploredmed.10.4% Cues acknowledged30.7% 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 lost my job, I had chemotherapy Communication of a life threatening diagnosis I have cancer

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):

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 “ I was upset about being ill ” Int “ How ’ s your family ” Distancing changing time “ Are you upset now? ” changing person “ 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 knowledge, perceptions and feelings Integrating medical and psychological modes of enquiry In judging how much information to give In handling difficult reactions to the bad news 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 Assesswhat the patient knows/suspects Assess what they want to know Fire warning shot Assess - Does the patient wish to continue Allow Denial Explain in simple language - Pause - check comprehension! Elicit ALL concerns -Allow ventilation of feelings 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 Allow expression of concerns Invite further questions Assure continuity of Care Follow up Patient not ready… Assure presence/answer to future questions

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 transitionSadness - Guilt If anger escalates,set limits,if limits refused, withdraw Dealing with Anger

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. “ I can see why you ’ re.....because..... ” Assessment 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.