Measures of Central Tendency: Mean, Median and Mode
PN Lesson 12 Communicating with Patients.pptx
1. Communication Strategies
This section of the lesson will cover
communication strategies to help you to
better understand your patients needs and
work most effectively to address their
barriers to care.
3. Importance of Communication
Benefits of Good Communication
• Builds trust between patient and
navigator
• May help the patient disclose
information
• Improves patient satisfaction
• Involves the patient more fully in
health decision making
• Helps the patient make better
health decisions
• Leads to more realistic patient
expectations
• Produces more effective practice
• Reduces the risk of errors and
mishaps
Risks of Poor Communication
• Decreases confidence and trust in
medical care
• Deters the patient from revealing
important information
• Causes patient distress
• Leads to the patient not seeking
further care
• Leads to misunderstandings
• Leads to the misinterpretation of
medical advice
• Underlies most patient complaints
Source: Commonwealth of Australia National Health and Medical Research. 2004
4. Effective Communication
General information:
• Communication includes verbal and non-verbal messages
- Spoken words
- Written words
- Body language
- Listening, not interrupting
• Communication is impacted by the physical environment,
the people involved, their culture and individual
characteristics
• Effective communication happens when a message is
shared and easily understood by the patient
Source: PNTC
5. Common Communication Barriers and
Solutions
Common Barriers
• Physical environment
• Not listening to the patient
- Being distracted
- Judging the patient
- Information overload
- Focusing on a personal agenda
• Misperception of patient’s meaning
- Stereotyping and generalizing
- Rushing
- Distorted focus
- Making assumptions
- Getting mixed signals
• Poor verbal communication by navigator
- Lacking clarity
- Using stereotypes and generalizations
- Jumping to conclusions
- Dysfunctional responses
- Lacking confidence
Solutions
• Quiet, private, non-distracting location
• Effective listening
- Stop, look, listen
- Be empathetic
- Ask questions
• Accurate perception
- Analyze your own perceptions
- Work to improve them
- Focus on others
• Improved verbal communication
- Focus on the issue, not the person
- Be genuine rather than manipulative
- Empathize rather than remain detached
- Be flexible towards others
- Value yourself and your own experiences
- Present yourself as an equal rather than a
superior
- Use affirming responses
Source: University of Waterloo Centre for Teaching Excellence. n.d.
7. Active/Reflective Listening
Active listening includes:
• Making appropriate eye contact early in the interaction
• Asking open-ended questions
• Attending to verbal and non-verbal cues
• Clarifying the information provided by the patient
• Clarifying the patient’s understanding of the information provided by the
doctor
Reflective listening includes:
• Statements that capture and return to patients something about what
they have just said and/or makes a guess about an unspoken meaning
Sources: Commonwealth of Australia National Health and Medical Research Council. 2004;
Miller et al. 2002
8. Active/Reflective Listening
• Making eye contact with the patient
• Making a guess about meaning – “That
sounds stressful, being the sole provider”
• Asking an open ended question – “How do
you take care of yourself?”
9. Checkpoint
Which of the following would be considered active
listening?
a) Asking open-ended questions to keep the
conversation going
b) Interrupting the patient to share a story about
another patient who had a similar situation
c) Paying attention to the patient’s spoken words
alone
d) Guessing you know what the patient means
10. Open-ended Questions
What are open-ended questions?
• Cannot be answered with “yes” or
“no”
• Allow for a fuller, richer discussion
• Are non-judgmental
• Let the patients you work with
think out loud
• Allow them to do most of the
talking, using their own words
• Let them know the conversation is
about them
Open-ended Question Starters
Tell me about…
To what extent…
What does…
Help me understand…
How did you…
What, if any…
Source: Miller et al. 2002
11. Affirmations
I appreciate that
you are willing to
meet with me
today.
You handled
yourself really well
in that situation.
I’ve enjoyed
talking with you
today.
You are clearly a
very resourceful
person to cope
with such
difficulties for so
long.
That’s a good
suggestion.
It seems like you
are a very
spirited, strong-
willed person in a
way.
If I were in your
shoes, I don’t
know if I could
have managed
nearly so well.
Source: Miller et al. 2002
12. Summarizing
What is a Summary?
A summary restates the key parts
of the conversation. The summary
may include:
• Thoughts
• Concerns
• Plans
• Reflections
How to Use a Summary
A summary can be useful in a
number of ways. It can help the
person:
• Recall the conversation
• Think of new ideas
• Plan their next steps
• Feel more confident about
moving forward
• Reinforce conversation
• Show you’ve been listening
Source: Miller et al. 2002
13. Tips for Conversations
Summarize to make sure you understood
Ask more questions
Wait for patient to say more
Reflect back
Allow patient to answer
Ask open ended questions
14. Supporting Open Communication
between Patient and Provider
Build trusting
relationship
Share
information and
preferences
Discuss feelings
Be aware of
factors that may
affect a patient’s
communication
Source: National Cancer Institute - Communication in Cancer Care. 2013
16. Conflict Resolution
Everyone has to deal with conflict at one point or
another. In this section of the lesson, we will
discuss conflict resolution strategies. These tips
can be applied to the navigator-patient interaction
or the patient interaction with others, including
their family or members of the healthcare team.
17. Examples of Conflicts
• Being asked to do something you can’t do
• Patient feels you are not being helpful
• Navigator doing too much for the patient
• Families
• Friends/outsiders
18. Primary Strategies
• Avoiding conflict and hoping that it will go
away
Flight
• Using authority, rights or force to attempt to
prevail over others
Fight
• Talking with other people to develop
solutions that will satisfy mutual interests,
some result that they all can “live with”
Unite
Source: PNTC
19. Conflict Resolution Strategies
• Work at talking about the issues
• Recognize the value of the conflict
• Recognize conflict is a spiral and you can change the direction of the spiral
• Emphasize common goals
• Check perceptions
• Use competent communication techniques
• Agree to disagree
• Attack the problem, not the person
Source: PNTC
21. Difficult Conversations
• Highly emotional patients
• Challenging patients
• Family member confrontations
• Disappointing information
Source: PNTC
22. Difficult Conversations
• Validating patient fear
• Encouraging the patient to talk with the doctor
about concerns and questions
• Seeking to connect patient with appropriate
health care professional
• Being empathetic
• Remaining firm when necessary
• Using active and reflective listening strategies
• Remaining neutral
23. How to Break Bad News Using SPIKES
SETTING up the interview
Privacy
Family/Friends
Sit
Connect with the patient
PERCEPTION
What is the patient’s understanding of the situation?
INVITATION
Assess patient preference for information
Give KNOWLEDGE and information to the patient
Use plain, non-technical language
Avoid excessive bluntness
Give information in small chunks, and check for understanding periodically
Assess EMOTIONS with EMPATHIC Responses
Observe patient’s reaction
Allow for silence
Use empathic statements (“I know this isn’t what you wanted to hear. I wish the news were better.”)
STRATEGY and SUMMARY
Check for understanding
Make an action plan
Source: Baile et al. 2000
24. Conclusion
• Identify common barriers and solutions to
effective communication
• Identify and use strategies to improve
communication
• Describe tips to help patients improve
communication
• Identify and implement conflict resolution
strategies
• Describe strategies for handling difficult
conversations
25. Treating patients and their families
• Being admitted to the hospital is a confusing and
hazy time for anyone. Our patients’ lives have
been turned upside down by illness; they’re in a
place they don’t want to be, surrounded by busy
professionals wielding medical terminology and
dispensing advice that isn’t always fully
understood. That’s why it’s so important for your
patients to have the support of their family with
them, and for you to understand that you’re not
just treating the patient but their loved ones, too.
26. • Physicians may benefit from the presence of
family members and caregivers during the
medical encounter, especially when they
provide assistance to the patient with
medication or managing symptoms. When a
patient is brought to the emergency room
with an altered mental state, the family
member or caregiver can provide collateral
history or review any changes in symptoms.
27.
28.
29. • The VALUE Approach to Discussing End-
of-Life Care
• V:Value comments made by the family
• A:Acknowledge family emotions
• L:Listen
• U:Understand the patient as a person
• E:Elicit family questions
Editor's Notes
This section of the lesson will cover communication strategies to help you to better understand your patients needs and work most effectively to address their barriers to care.
Before we get started, let’s listen to a patient navigator tell us how she thinks about communication.
<Good communication means letting someone know clearly what you are thinking and feeling -- and finding out what the other person is thinking and feeling, too. To me, it's like a friendly game of catch. One person throws the ball so that the other person can catch it without too much trouble. Then, the second person throws it back. The purpose is to keep the ball -- the communication -- going.>
This description might help you think about how you communicate with patients.
Communication should be patient-centered. The National Cancer Institute proposed a framework for patient-centered communication in cancer care. The framework has 6 core functions that overlap and interact, leading to communication that can improve outcomes. The core functions are
Fostering healing relationships, including building trust and rapport with the patient;
Exchanging information about cancer and its treatment;
Responding to emotions by recognizing a patient’s emotional state and asking appropriate questions to understand emotions;
Managing uncertainty, which is particularly relevant for cancer patients who often have complex illness; and
Making decisions and enabling self-management, both of which we will discuss in the next section.
Source: NCI – Patient-centered communication in cancer care
In a health care setting, good communication is essential! Good communication
Builds trust between patient and navigator
May help the patient disclose information that will be helpful
Improves patient satisfaction
Involves the patient more fully in health decision making
Helps the patient make better health decisions
Leads to more realistic patient expectations
Produces more effective practice and
Reduces the risk of errors and mishaps
These benefits strengthen communication further and can lead to better health outcomes for the patient.
On the other hand, poor communication has negative impacts on health outcomes as it
Decreases confidence and trust in medical care
Deters the patient from revealing important information
Causes patient distress
Leads to the patient not seeking further care
Leads to misunderstandings
Leads to the misinterpretation of medical advice
Underlies most patient complaints
These difficulties may lead to poorer outcomes for the patient.
Citation: Commonwealth of Australia National Health and Medical Research Council. Communicating with Patients: Advice for medical practitioners. 2004
Communication includes verbal and non-verbal messages such as spoken words, written words, body language, and listening. Communication is the content of the spoken words as well as the tone and pitch, which provide clues to the emotional meaning of the words. The emotional meaning can differ from the literal meaning. For example, someone who says “I feel fine” (in a cheery tone) and smiles feels differently than someone who says “I feel fine” (in grumpy tone) and frowns. Communication is impacted by the physical environment, the people involved and their culture and individual characteristics. Effective communication happens when a message is shared and easily understood by the patient, so it is important to use checks for understanding to make sure you and the patient are on the same page.
Remember that a patient’s ability to communicate may be impacted by emotions. Let’s listen to Teri talk about an interaction she had with her doctor.
<I went into Dr. Blake's office... he was sitting behind his desk reading some papers. Then, he looked straight at me and I sort of heard him say something like, "Teri, I'm sorry to have to tell you this, but your biopsy is malignant. The pathologist needs to do some more tests to find out what kind of cancer you have." He kept on talking, I saw his lips moving, but I couldn't hear what he was saying. All I could do was stare at him, thinking, "There must be some mistake. I feel fine. I can't have cancer.“>
If Dr. Blake had been looking carefully at Teri's face and gestures -- her body language -- he would have realized that she was having a hard time understanding what he was saying. Often in that emotional first meeting with the doctor, a newly diagnosed patient will not remember much of what the doctor said. A patient navigator in this situation should be able to realize that the patient is not understanding, which will help the navigator work more effectively with the patient.
Good communication is not always easy. Barriers may make communication hard between you and the patient.
The physical environment where information is being exchanged could make understanding hard, so try to hold conversations with your patients in quiet, private and non-distracting locations.
You may find that something has caused you to not listen to the patient. This could be due to being distracted, judging the patient, being overloaded with information from the patient or focusing on your personal agenda. Instead, learn to be an effective listener. Stop what you are doing, and look and listen to the patient. Be empathetic and ask questions to show you are interested and to stay engaged. We will talk more about active listening shortly.
Misperceptions of the patient’s meaning behind their message may also be a barrier to effective communication. This comes from stereotyping and generalizing or rushing through your meeting with the patient. You may also find that you have adopted a distorted focus, meaning that you’ve focused only on a specific part of the patient’s message (maybe something negative), instead of hearing the whole message. Making assumptions or getting mixed signals from the patient can also lead to misperceptions in communication. It’s helpful to analyze your own perceptions and work to improve them, which we will talk about later in this module. Think about how you view the patient and what they have shared with you, and in what ways you can be more objective. Remember to focus on others to understand what they are thinking and how they feel, and less on your own thoughts and interpretations.
Navigators may have poor verbal communication. This leads to confusion for the patients you serve. Your messages may not be clear, use stereotypes or generalizations, jump to conclusions, provide dysfunctional responses or show a lack of confidence in yourself. Patient navigators should focus on improving verbal communication. You can focus on the issue at hand and not the person. Be genuine towards patients rather than manipulative; be open, honest and avoid trying to control the patient. Empathize with the patient rather than remaining detached. Grow a relationship that is within professional boundaries that shows you care. Be flexible towards others; follow the needs of your patient. Value yourself and your own experiences. Know that you have talents and skills to offer as a navigator and be confident in your abilities. Present yourself as an equal rather than a superior. Patients may respond best to you if they feel that they can communicate with you as a part of their team instead of someone controlling them. Use affirming responses. The patient has a right to their feelings; by affirming their feelings you make the patient feel validated even if you disagree.
Source: University of Waterloo Centre for Teaching Excellence
Let’s walk through some strategies that can improve your communication with patients, including
Active or Reflective Listening
Open-Ended Questions
Affirmations and
Summarizing
Active and reflective listening is a skill that is important for effective communication. Active listening includes: Making appropriate eye contact early in the interaction; asking open-ended questions, which we will discuss further; attending to verbal and non-verbal cues; clarifying the information provided by the patient; and clarifying the patient’s understanding of the information provided by the doctor. Reflective listening is active listening that includes listening carefully to the words that are spoken and to the emotions that may be behind those words. It includes making statements that capture and return to patients something about what they have just said and/or makes a guess about an unspoken meaning. It is useful for checking, rather than assuming, you know what the client means, and it is best to substitute different words rather than repeat back exactly what the client said. Reflective listening also helps to show that you understand what they have said.
As you practice active listening, remember to remain supportive and non-judgmental. Try to help people find their own solutions by letting them sift through their thoughts and feelings, which can help them set realistic goals and decide how to achieve them. And don’t give advice or try to solve problems for them. Your role is to listen and help patients be engaged in their care and in decision making.
What strategies did you notice being used in the video? Some of Etta-Cheri’s strategies include
Making eye contact with the patient
Making a guess about meaning – “That sounds stressful, being the sole provider”
Asking an open ended question - “How do you take care of yourself?”
Her active listening skills not only communicate to the patient that she is interested in helping, but they also make sure she fully understands the patient’s needs.
Which of the following would be considered active listening?
a. Asking open-ended questions to keep the conversation going
b. Interrupting the patient to share a story about another patient who had a similar situation.
c. Paying attention to the patient’s spoken words alone
d. Guessing you know what the patient means
The correct answer is asking open-ended questions. Open-ended questions encourage the patient to share information instead of providing simple “yes” or “no” responses. You never want to interrupt the patient while they are talking. Patients want to feel like they're being heard. While it's important to listen to everything the patient is telling you, facial expressions and body language may also clue you in on how the patient's feeling, and it's good practice to repeat back to the patient what you heard them say, asking them to confirm that you understood what they were sharing with you.
We saw Etta-Cheri ask an open-ended question. Open questions can’t be answered with “yes” or “no”, so they allow for a fuller, richer discussion. These types of questions are non-judgmental. They let the patients think out loud and allow them to do most of the talking, using their own words. This lets them know the conversation is about them.
Here you see some open question starters. To avoid asking question after question in a row, you can add reflective statements and/or summaries. Answers to open questions often give a lot of information. For example, if you ask, “What do you think about your treatment options?” people might tell you about: Their motivations or barriers, Their health concerns, The influence of friends and family, or The impact of a pastor’s message. Answers like these help you understand the people you navigate so you can connect them with the most helpful resources.
Affirmations are statements or gestures that come in the form of compliments, appreciation or understanding that validate the patient’s experiences, build rapport, reinforce exploration and build patient confidence. Affirmations recognize patient strengths and acknowledge behaviors that lead in the direction of positive change, no matter how big or small. Here are some example affirmations:
I appreciate that you are willing to meet with me today.
You handled yourself really well in that situation.
I’ve enjoyed talking with you today.
You are clearly a very resourceful person to cope with such difficulties for so long.
That’s a good suggestion.
It seems like you are a very spirited, strong-willed person in a way.
If I were in your shoes, I don’t know if I could have managed nearly so well.
Another strategy to improve communication is summarizing. The summary distills the essence of what a patient has expressed and communicates it back. It may include thoughts, concerns, plans and reflections, especially those that cause strong reaction or emotion. You can use a summary to help the patient recall what was discussed, think of new ideas, plan next steps, build confidence about moving forward, link together and reinforce material that has been discussed or transition the conversation. And a summary shows that you have been listening carefully.
You can follow this general flow for encouraging your patients to talk and to have better conversations. Begin by asking open ended questions. Pause to allow the patient to answer, and make sure you are actively listening. Reflect back to the patient what they have said to you and wait for the patient to share more. If the conversation comes to a pause, feel free to ask more questions. At the end of the conversation, summarize what the patient said to make sure you understand.
Good communication between patients, family members and the medical team is also important. When patients and doctors communicate well, patients are more likely to feel satisfied with their care, follow through with treatment, be informed, participate in a clinical trial and transition better from active treatment to palliative care or hospice, if necessary.
Patient navigators can support open, honest and meaningful interactions between patients and providers in a number of ways.
Build a trusting relationship. Patient navigators can build a partnership with patients by demonstrating trustworthiness and honesty, encouraging the patient to be open and being willing to work with them.
Patient navigators can share information, preferences and priorities for treatment and care with the health care team to facilitate dialogue.
Patient navigators should discuss patients’ feelings and concerns about their care to determine the best course of action, referring to clinical staff when necessary. And,
Navigators should be aware of factors that may affect a patient’s communication with his or her medical team. Age, race, ethnicity, socioeconomic status, language, culture, family, stage of treatment and other variables will impact a patient’s communication preferences and should be considered during any patient interaction.
Your role as a patient navigator is also to support patients as they communicate with their health care team and others. We’ve talked about some of these tips already, but let’s see how the apply to patients.
Being assertive means showing that you believe that what you say is important and remembering that there is no such thing as a silly question.
Using “I” messages helps you communicate directly and clearly. This means saying things like, “I think” or “I feel.”
Active listening, which we just discussed, involves making sure that the other person knows that you are listening carefully and is followed by a check to make sure it was understood.
People communicate with body non-verbal messages, including facial expressions, hand gestures, posture, or other "body language." When verbal and nonverbal messages don’t match, the listener has trouble knowing what to believe.
Finally, Expressing feelings and thoughts, such as being scared or overwhelmed, can help others provide needed support.
Everyone has to deal with conflict at one point or another. In this section of the lesson, we will discuss conflict resolution strategies. These tips can be applied to the navigator-patient interaction or the patient interaction with others, including their family or members of the healthcare team.
You might experience patient-related conflict. For example,
You may be asked to do something you can’t do, like lie on a patient assistance application or providing advice on treatment options.
Despite your best efforts, a patient may feel that you are not being helpful.
Or you may feel like you are doing too much for a patient that is capable of doing more. For example, you know a patient is capable of filling out an application but keeps asking you to do it. Or the patient keeps coming to you to make phone calls to schedule appointments when you know the patient is able to do that.
There also may be conflicts related to families. For example, you might have a patient that is a parent who has two adult children, with each one trying to take care of a parent and making conflicting demands. There may be conflict related to whether a patient wants another family member involved or because a family member wants you to tell them something that you can’t because you don’t have permission.
Sometimes other people, like friends or outsiders might cause conflict. For example, the patient may be getting bad advice on treatment options from a friend.
You also may experience conflict with colleagues. We will talk more about this in module 7.
To resolve conflicts, it is important to recognize the primary strategies used to deal with conflict. There are three primary strategies that we use:
Flight, or Avoiding conflict and hoping that it will go away
Fight, or Using authority, rights or force to attempt to prevail over others or
Unite, or Talking with other people to develop solutions that will satisfy mutual interests, some result that they all can “live with”
Let’s focus on uniting to help resolve conflict.
Let’s walk through the each of these conflict resolution strategies.
Work at talking about the issues. It may be difficult to talk about conflict, but avoidance usually ends up leading to others making assumptions and an increase anger. Avoidance does not stop the conflict. People may need to back away for a moment but the parties should discuss the conflict.
Recognize the value of conflict. Conflict is natural, and can even be a source of improved relations and a good solution. It can help set expectations, move a relationship to another level, and identify a problem.
Recognize conflict is a spiral and you can change the direction of the spiral. There is a constructive and destructive direction. We match our tone of voice and our body posture to the other, which can be used productively. For example, you can lower your tone of voice to bring down the emotional level.
Emphasize common goals. Around any given topic there are different goals- for example, “we both want you to get quality medical care”. Figure out which goals you have in common. Once you show where the goals are compatible, you no longer have conflict. You can use lead-ins that will frame the problem as a joint problem. For example, you could ask, “How can we…” or “What can be done to…”
Check perceptions. Think about the questions, What resources do you actually have? Is anything getting in the way?
Use communication techniques that we just discussed, such as actively listening, asking questions and providing feedback to check your perceptions.
Agree to disagree. Some conflict just can’t be solved or isn’t important enough to try too hard to resolve.
Finally, attack the problem, not the person. The other person is a human being with hopes and dreams too, so you need to make sure you respect the person and focus on the problem and how it can be resolved.
You may also face difficult conversations with patients.
Often in the healthcare setting the term “difficult conversation” refers to telling a patient that treatment isn’t working. As a patient navigator, you should not be telling patients that their treatment isn’t working. However, you might encounter difficult conversations related to:
Highly emotional patients
Challenging patients
Family member confrontations or
The need to tell a patient something they might find disappointing , such as denial for financial aid
Let’s watch an example of a difficult conversation.
The patient is obviously distraught and conflicted. She struggles to maintain composure and not to cry. As the interaction goes on, the patient picks up on Fernando’s non-verbal cues and seems to regain composure, agreeing to meet with the social worker in the clinic to discuss fears and end-of-life concerns.
Fernando is obviously concerned about the patient but maintains a professional demeanor and distance from the patient, not touching the patient. He shows empathy and engages in active listening to calm the patient, he quickly refers the patient her to a more appropriate professional who can better address fears and end-of-life concerns.
Some of the strategies Fernando uses include:
Validating patient fear
Encouraging the patient to talk with the doctor about concerns and questions and
Seeking to connect patient with appropriate health care professional
Other strategies that could be used for difficult conversations are:
Being empathetic and remaining firm when necessary
While it is always important to keep the patient’s preferences at the forefront, at times it is important to remain firm in your position if the case involves an ethical breach or is beyond your scope of practice
Using active and reflective listening strategies
Remaining neutral and not providing judgments either way
The SPIKES protocol is used for breaking bad news. Again, when we say bad news, we are referring to telling a patient information they may find disappointing. First, set up the conversation by arranging for privacy and involving significant others if appropriate. Sit down with the patient, making a connection by maintaining eye contact. It’s important to understand the patient’s perception - how does the patient perceive the situation at this point in time? You can then invite the patient to tell you how he or she prefers to hear the information. Then, you can deliver the knowledge or information to the patient. You should include a warning if necessary, such as “This may be difficult to hear but…”. Make sure to use plain, non-technical language and avoid excessive bluntness. It is not easy for patients to understand information if they are cycling through a series of emotions, and it is usually best to give information in small chunks and check for understanding periodically, then ask the patient’s permission to keep going. Assess the patient’s emotions and provide empathic responses. Observe the patient’s reaction, and allow for silence. Be comfortable as you allow the patient to quietly process the information. You can respond using empathic statements such as “I know this isn’t what you wanted to hear. I wish the news were better.” Finally, once you have covered the information you needed to, you should develop a strategy with the patient and summarize the discussion. Check that the patient has understood what you’ve shared and make an action plan for the future.
You may also need to refer the patient to a clinician, such as a doctor, nurse or social worker.
In this lesson you learned to:
Identify common barriers and solutions to effective communication
Identify and use strategies to improve communication
Describe tips to help patients improve communication
Identify and implement conflict resolution strategies
Describe strategies for handling difficult conversations
