Chapter 5: Communication, psychological wellbeing and safeguarding
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Principles of communication
Communication with a patient that is compassionate and supportive in a clinical environment cannot be described as a simple, linear process; nonetheless, certain principles can increase its effectiveness (see Principles table 5.2: Communication).
Table 5.2 Communication
| Principle | Rationale |
|---|---|
| Consider whether the patient is comfortable, needs pain relief or needs to use the toilet before you begin. | Pain, as well as other distractions and discomforts, may limit a patient's ability to reason and concentrate. E |
| Protect the time. This involves telling other staff that you do not wish to be disturbed for a prescribed period. | Patients may observe how busy nurses are and withhold worries and concerns unless given explicit permission to talk (McCabe [169], R). |
| Introduce yourself and your role and check what the patient wishes to be called. | This helps to establish initial rapport (Silverman et al. [254], C). |
| Set a realistic time boundary for your conversation at the beginning. | You may only have 10 minutes and therefore you need to articulate the scope of your available time; this will help you to avoid distraction and give your full attention during the time available. Boundaries also help the patient to feel contained. E |
| Spend a short time developing a rapport and indicating your interest in the patient, for example comment on a picture by the bedside. | Patients want to feel known. P |
| Be ready to move the conversation on to issues that may be concerning the patient. | Some patients may stay with neutral topics as the central focus of the conversation and withhold disclosure of psychosocial concerns until later in a conversation (Silverman et al. [254], C). |
| Suggest the focus of conversation, for example ‘I would like to talk about how you have been feeling’ or ‘I wondered how you have been coping with everything.’ | This indicates to the patient that you are interested in their psychological issues. E |
| Respond and refer to cues. For example, to respond to a cue, you could say: ‘I noticed you seemed upset earlier. I have 10 minutes to spare in which we can talk about it if you wish’ or ‘You seem a little frustrated. Is now a good time to talk about how I can help you with this?’ | Patients frequently offer cues – either verbal or non‐verbal hints about underlying emotional concerns – and these need to be explored and clarified (Levinson et al. [151], R; Oguchi et al. [215], R). |
| If the patient does not wish to talk, respect this and ask them to let you know if they change their mind and do want to talk (it is still important that you have offered to talk and the patient may well wish to talk at another time). | The patient may not wish to talk at that moment or may prefer to talk to someone else. E |
| Ask open questions: prefix your question with ‘what’ or ‘how’. | Open questions encourage patients to talk (Hargie [120], R). |
| Use closed questions sparingly. | If patients have a complicated issue to discuss, closed questions can help them to be specific and can be used for clarification as well as when closing dialogue (Hargie [120], R). |
| Add a psychological focus where you can, for example ‘How have you felt about that?’ | This will help to elicit information about psychological and emotional issues (Ryan et al. [247], R). |
| Listen carefully and feed back your understanding of what is being said at opportune moments. | Listening is a key skill – it is an active process requiring concentration as well as verbal and non‐verbal affirmations (Egan [88], R). |
| Be empathetic (try to appreciate what the other person may be experiencing and recognize how difficult that may be for them). | Empathy is about creating a human connection with the patient (DH [76], C; Egan [88], R). |
| Allow for silences. | These can give rise to further expression and allow useful thinking time for yourself and the patient (Silverman et al. [254], C). |
| Initially avoid trying to ‘fix’ people's concerns and the problems that they express. It might be more powerful and important to simply sit, listen and show your understanding. | As an individual is listened to, they may feel comfort, relief and a sense of human connection, which are essential for support (Egan [88], R). |
| Ask the patient how they think you may be able to help them. | The patient will know what they need better than you do. E |
| Avoid blocking (see Box 5.4). | Blocking results in failing to elicit the full range of concerns a patient may have (Back et al. [14], R). |
| When you are nearing the end of the time you have agreed to be with the patient, let the patient know; that is, mention that soon you will need to stop your discussion. | The patient can find this easier to accept if you clearly expressed the time you had available in the first place (Towers [272], R). |
| Acknowledge that you may not have been able to cover all concerns and summarize what has been discussed, checking with the patient how accurate your understanding is. | The patient can correct any misinterpretations and this can lead to satisfactory agreement about the meeting. It also signifies closure of the meeting (Hargie [120], R). |
| If further concerns are raised at this point, make it clear that you cannot support them at the current time. Let the patient know when you or other staff may be available to talk again, or where else they may get further support. | Clarity and honesty are important, as is working within boundaries. Knowing the limits of your time and expertise will help to prevent confusion about where the patient can receive types of support. E |
| Agree any action points and follow up as necessary. If needs remain unmet, offer support from a clinical nurse specialist or a psychological support service, if available. You must discuss what this means and be realistic with regard to waiting times. Consent from the patient for any further referral is essential (unless you consider the patient to be at risk). | Having made a suitable assessment, you can involve further support if appropriate. E |
| Document your conversation, having agreed with the patient what is appropriate to share with the rest of the team. | It is essential to document your conversation so that other members of the team are informed and to meet professional requirements (NMC [212], C). |
| Reflect upon your own practice. | You may have unintentionally controlled the communication or blocked expression of emotion. Reflection will increase your self‐awareness and help to develop your skills. E |
| Consider the support needs of other people to whom you delegate tasks and your own support needs. If you or others are affected by any discussions you have had, seek discussion with supportive senior members of staff or consider debriefing and/or supervision. | Clinical supervision supports practice, enabling registered nurses to maintain and improve standards of care (NMC [212], C). |
