Chapter 5: Communication, psychological wellbeing and safeguarding
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Source: Adapted from Agenda for Change Project Team ([4]).
Clinical governance
There are a number of legal and professional concepts and issues that affect effective communication and psychological support. These include:
- taking professional responsibility for effective communication
- maintaining confidentiality and appropriate disclosure of information about the patient
- gaining informed consent to carry out each procedure and ensuring that the patient is fully cognisant of what it involves, including assessing the patient's mental capacity to engage in care and treatment
- ensuring that issues relating to equality and diversity are taken into account at all times.
Professional responsibility for effective communication
The Francis Report (DH [79]) recommended that there should be an increased focus on a culture of caring, compassion and consideration in nursing. The steps to achieving this were set out in Compassion in Practice (DH [76]), which identified six fundamental values: care, compassion, competence, communication, courage and commitment. These values have been incorporated into Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff (NHS England [197]). It is important to note that ‘compassionate care delivered with courage, commitment and skill is our highest priority. It is the rock on which our efforts to promote health and wellbeing, support the vulnerable, care for the sick and look after the dying is built’ (NHS England [197], p.6).
Every nurse has a professional responsibility to communicate effectively and compassionately, as explicitly stated in The Code (NMC [212]):
- Make the care of people your first concern, treating them as individuals and respecting their dignity.
- You must listen to the people in your care and respond to their concerns and preferences.
- You must make arrangements to meet people's language and communication needs.
- You must share with people, in a way they can understand, the information they want or need to know about their health.
- You must uphold people's rights to be fully involved in their care.
The fifth principle of nursing practice set out by the Royal College of Nursing explicitly describes the role of nurses in the communication process:
Nurses and nursing staff are at the heart of the communication process: they assess, record and report on treatment and care, handle information sensitively and confidentially, deal with complaints effectively, and are conscientious in reporting the things they are concerned about. (RCN [234])
Confidentiality
‘Information provided in confidence should not be used or disclosed in a form that might identify a patient without his or her consent’ (DH [66], p.7). The Code (NMC [212]) states that every nurse must respect a person's right to confidentiality, ensuring that they are informed about how and why information is shared by those who provide their care. In addition, this is a legal obligation and should be part of the terms and conditions of employment of any healthcare professional (DH [66]). However, this does not prevent nurses from communicating with an NHS colleague who is providing direct treatment to their patient – for example, at a multidisciplinary team meeting or on a ward round; the Health and Social Care Act ([126]) provides the legal basis for sharing information in this way. Further, if there is a concern that an individual may be at risk of harm, this must be appropriately disclosed following the guidance of the organization in which the nurse works.
Consent
The NHS Constitution states that ‘NHS services must reflect the needs and preferences of patients, their families and carers. Patients, with their families and carers where appropriate will be involved and consulted on all decisions about their care and treatment’ (DH [75], p.4). It also states that a patient has the right to accept or refuse treatment that is offered and not be given any physical examination or treatment unless they have given valid consent.
The Royal College of Nursing's ([233]) Principles of Consent: Guidance for Nursing Staff outlines the legal and clinical purposes of gaining and documenting consent:
The legal purpose is to provide those delivering treatment with a defence to a criminal charge of assault or battery or a civil claim for damages for trespass to the person. The clinical purpose comes from the fact that in most cases the co‐operation of the person and the person's confidence in the treatment is a major factor in their consenting to the examination, treatment or physical investigation, or the provision of care. (p.5)
The Code (NMC [212]) states that nurses have a responsibility to ensure they gain consent and that they must:
- gain consent before treatment or care starts
- respect and support people's rights to accept or decline treatment or care
- uphold people's rights to be fully involved in decisions about their care
- be aware of the legislation regarding mental capacity
- be able to demonstrate that they have acted in someone's best interests if emergency care has been provided.
For consent to be valid, it must be given voluntarily by a competent person who has been appropriately informed and who has the capacity to consent to the intervention in question (RCN [233]). This will be the patient or someone authorized to give consent on their behalf under a lasting power of attorney, or someone who has the authority to make treatment decisions as a court‐appointed deputy (DH [74]).
The validity of consent does not depend on a signature on a form. Written consent merely serves as evidence of consent. Although completion of a consent form is in most cases not a legal requirement, the use of such forms is good practice where an intervention such as surgery is to be undertaken (DH [74]).
Obtaining consent is a process and not a one‐off event (RCN [233]), and consent is not a simple ‘yes’ or ‘no’ answer in many situations (RCN [233]). For consent to be valid, the nurse should ensure that the person has understood what examination or treatment is intended, and why (DH [74]). Legal informed consent is now a requirement in most situations. This means that the person consenting to the procedure, process or treatment must be provided with sufficient information to enable them to make a balanced and informed decision about their care (NMC [212], RCN [233]).
It is usually the person that is undertaking the procedure that seeks the patient's consent. There may be situations when a nurse has been asked to seek consent on behalf of other staff. Providing the nurse has had training for that specific area, they may seek to obtain that consent (RCN [233]).
Mental capacity
If there is any doubt about a person's capacity to make a decision about consent, the nurse should firstly determine whether or not the person has the capacity to consent to the intervention and secondly establish that they have sufficient information to be able to make an informed decision (DH [74]). This should be done before the person is asked to sign any form. Documentation is necessary and the nurse should record all discussions relating to consent, details of the assessment of capacity, and the conclusion reached, in the patient's notes (NMC [212]). The Code makes explicit the responsibility to be aware of the legislation regarding mental capacity, a factor that can have a significant impact on communication. The Mental Capacity Act ([176]) sets out clear guidance and there is an accompanying code of practice to support professionals working with people who may have impairment in their capacity. For more information, see the section on the Mental Capacity Act later in this chapter.
As part of the nursing assessment, the nurse needs to establish whether the person can understand the verbal communication, whether they understand what they are being consented for, and whether they can read, write or communicate their decision in a reliable manner. If they are unable to write, they may be able to make their mark on the form to indicate consent by any reasonable means, for example drawing a line or a squiggle. If consent has been given validly, the lack of a completed form is no bar to treatment, but a form can be important evidence of consent (DH [74]). If the patient is unable to consent because they do not understand the information, or is unable to communicate their decision, the Mental Capacity Act ([176]) allows decisions to be made in the patient's best interest. If the consent is about medical treatment then a best interest decision may be required; whether it is required will depend on the seriousness of the decision (Mental Capacity Act [176]).
A competent adult may refuse to consent to treatment or care, and nurses must respect that decision (NMC [212]). Where a patient declines an intervention, consideration must be given to the patient's capacity; a patient who has capacity is allowed to make what others may consider to be an unwise decision (Mental Capacity Act [176]). When a patient is deemed to have capacity and declines care, this needs to be recorded clearly in their notes.
Equality and diversity
An additional aspect of communication and psychological support from the legal perspective is to ensure that it is as equitable as possible. The Equality Act ([93]) reinforces the duty to ensure that everybody has equal access to information and is communicated with equitably, irrespective of disability, sex, gender reassignment, race, age, relationship status, pregnancy and maternity, sexual orientation, religion or faith. This means, for example, that provision is necessary to meet the information needs of blind and partially sighted people (Disability Discrimination Act [82] (Commencement No. 6) Order 1999, Section 21).
Communication needs are individual and information requirements are culturally sensitive. People may hold different beliefs about why they have developed an illness, for instance thinking that they are being punished for something that they have or have not done (Dein [60], McEvoy et al. [172]).
Medical language is full of technical vocabulary and jargon that is often difficult to comprehend, even for people who speak English as their first language. The 2011 Census found that in England and Wales 1.6% of respondents did not speak English (in England) or Welsh (in Wales) well or at all and that the vast majority of these respondents lived in London (ONS [217]). Approximately 7.7% of the population reported that English or Welsh was not their main language (this incidence was higher in London and the West Midlands). Furthermore, an increasing number of healthcare staff are trained overseas and speak English as a second language. In nursing conversations where one or more of the people speak English as a second language, there are opportunities for miscommunication, which can result in psychological distress or medical errors (Meuter et al. [182]). Therefore, it is important that nurses use ‘short, clear and precise’ sentences (Macdonald [160], p.131) and frequently check the patient's (and family's) understanding.
Patients from minority ethnic backgrounds often take a family member to hospital appointments to assist in the dialogue between them and the medical or nursing practitioner. However, family members may not fully understand what they are being asked to translate, or might misconstrue or misrepresent what is being said (Macmillan Cancer Relief [161]). Most NHS trusts have interpreting services, and there are reputable telephone helplines that can facilitate translation from one language to another. It is good practice that these services be used rather than relying on family or friends of the patient (Macdonald [160]). Guidance for the commissioning of interpreting and translation services is available (NHS England [198]).
Older patients are more likely to have hearing or sight loss (although this should not be assumed) and this needs to be considered alongside the patient's dignity when communicating with them. For example, if a patient is hearing impaired, there may be a temptation to shout, but in a busy clinical environment this might breach the patient's right to confidentiality and to be treated with dignity. Information provided in small print may be inaccessible for a patient with visual difficulties, impacting on their ability to make an informed choice.
Patients with dementia may have additional communication needs, and there is a danger of assuming that because a person has dementia they will not be able to make decisions for themselves. Daniel and Dewing ([56]) suggest that this idea needs to be avoided as it fails to meet the requirements of the Mental Capacity Act ([176]). The act makes it clear that consent must be decision specific and, as such, each significant decision needs to be assessed. If a patient with dementia has communication issues, it is important to work with them and their family to maximize their ability to be involved in decision making even when the person is assessed as lacking capacity. The Mental Capacity Act ‘promotes the autonomy and rights of an individual who lacks decision‐making capacity’ (Griffith and Tengnah [112], p.337).
It is estimated that 50–90% of people with learning disabilities experience communication difficulties, such as impaired speech, impaired hearing or sight loss (Jones [141]). It is important to know what tools can be used to support this patient group to communicate their needs while receiving healthcare, bearing in mind that the most important of these tools is the communication skills of the person providing the care (Chambers [44]). Many patients with learning disabilities will have a hospital or My Health passport that will include information on how best to communicate with them. The person with a learning disability may also have a communication book that is full of symbols they can use to communicate their needs.
With any patient who has additional communication needs, it is important to work with the individual and the people who know them well, such as family, carers or other professionals. Family, carers and friends can interpret the non‐verbal communication more easily and so can support nurses in providing care; carers should be seen as partners in the caring process. A learning disability liaison nurse role developed in Scotland was found to enhance patient and carer satisfaction, partly through the development and implementation of accessible information (MacArthur et al. [159]).
Competencies
Communication is such an essential aspect of the role of anybody in healthcare that the NHS Knowledge and Skills Framework (Agenda for Change Project Team [4]) specifies four levels of skill in communication (Table 5.1). Nurses are expected to be competent as a minimum to Level 3. This is a baseline and much work has been done on developing programmes to advance communication skills further.
Table 5.1 NHS Knowledge and Skills Framework: four levels of communication competence
| Level 1 | Level 2 | Level 3 | Level 4 |
|---|---|---|---|
| Establish and maintain communication with other people on routine and operational matters | Establish and maintain communication with people about routine and daily activities, overcoming any differences in communication between the people involved | Establish and maintain communication with individuals and groups about difficult or complex matters, overcoming any problems in communication | Establish and maintain communication with various individuals and groups on complex, potentially stressful topics in a range of situations |
The consistency of the success of training interventions has been widely discussed (Chant et al. [45], Heaven et al. [127], Schofield et al. [250]). Ongoing development of communication skills should include learning how to negotiate barriers to good communication in the clinical environment, tailoring and individualizing communication approaches for different patients, conflict resolution and negotiation skills (Gysels et al. [116], Roberts and Snowball [242], Schofield et al. [250], Wilkinson [289]).
Courses with a behavioural component of communication training – that is, role‐playing situations in the classroom – are preferable as this is indicated to influence effectiveness (Gysels et al. [116]). Skill acquisition and implementation following communication training is more likely when the training is followed up by regular supervision (Eggenberger et al. [89]).
If an issue appears to be beyond the scope of practice of the nurse, it is essential that further advice and help are sought, or that patients are signposted or referred on to specialist psychological practitioners. Self‐care and supervision are key factors in maintaining the ability to support other people (see Chapter c19: Self‐care and wellbeing).
