Communications in Health CareHealthcare Core Curriculum

Competency #3: The Communication ProcessDede Carr, BS, LDA

Karen Neu, MSN, CNE, CNP

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Objectives Use a variety of communication

techniques to achieve effective interpersonal communication & team communication

Competency #3 – The Communication Process

Provide a comfortable environment (lighting, temperature, furnishings).

Establish a relaxed, unhurried setting. Sit down when speaking to the patient.

◦ Although you probably have dozens of things you need to be doing at that moment, try to relax.

◦ Don't stand at the doorway or sit on the edge of your seat, as if you are preparing to jump & run as soon as you can get away.

Face the speaker & maintain eye contact. Provide for privacy. Avoid interruptions & other distracting influences

(Medical Education Division)

Establish the Setting for Communication

1. Set Goals2. Create the Message3. Delivery of the Message4. Listen for a Response5. Offer Feedback & Seek Clarification6. Evaluate the Encounter

6 Steps to Successful Communication

A goal can be defined as something that a person plans to achieve, to aim for.

In communication, setting a goal is achieved by deciding what type of message needs to be sent.

Is the message to be one of: ◦ Gathering information ◦ Instructing ◦ Informing◦ Reporting

Step #1 – Set Goals

Step 1 Set Goals: #1 Gathering Information

A person can gather information by asking◦ Who?◦ What?◦ Where?◦ How?◦ When?◦ Why?

Gathering Information

Step 1 Set Goals: #2: InstructingThe goal of this form of communication is

detail, such as a step-by-step process to complete the procedure.

For example: When teaching a student the proper way to prepare a syringe for the administration of medication.

Instructing

Step 1: Set Goals: #3 InformingIf informing the receiver is the goal, the

message may be short and to the point. The message may be communicated using words and/or symbols.

A stop sign, for example, informs the driver to stop.

A voice message informs the caller that no one is available.

Example of “No Smoking”

Informing

Step 1: Set Goals: #4 ReportingReporting should be clear & accurate facts &

timeframes; not opinions or judgments.Reporting is used in many different situations

and might consist of using graphs, images, tables, charts, etc.

Situation: Giving test results to a patient During an investigation of malpractice At the end of shift, team members may

report to team leader who reports to on-coming team leader

Reporting

When creating the message to be delivered, goal is to make it so that the receiver can understand it.

Consider the organization of the message Follow a step-by-step process in order to give

concise, accurate informationMessage may consist of asking questions of

the receiver

Step #2 – Create the Message

Types of questions that may be asked of the receiver

Open-ended questions Closed-ended questions Neutral questions Probing questions Leading questions

(Ramont, Niedringhaus, pp. 234-235)

Step #2 – Create the Message

Used in short directive interviews Generally, requires a “yes” or “no” or short factual

response giving specific information Often begin with “when,” “where,” “who,” “what,”

“do (did, does),” “is (are, was, were),” and sometimes “how”

Examples: ◦ “What medicine did you take?”◦ “Are you having pain now? Show me where it is.”◦ “How old are you?”

Highly stressed, people with difficulty communicating will find close-ended questions easier to answer (Ramont, Niedringhaus, pp. 234-235)

Close-ended Questions

Used in non-directive interview Invites clients to discover & explore thoughts,

feelings & allows freedom to talk about client’s wishes

Specifies only broad topic to discuss Invites longer answers than one or two words Useful at beginning of interview, to change topics,

or to elicit attitudes Choice of this type depending on situation &

many times used in combination with close-ended questions

Example: “What is your biggest concern about…”(Ramont, Niedringhaus, p. 235)

Open-ended Questions

Client can answer without direction or pressure

Examples: “How do you feel about that?” “Why do you think you had a bad

operation?”(Ramont, Niedringhaus, p. 235)

Neutral Questions

Contrast to neutral questions Phrasing of question suggests what answer is

expected Gives client less opportunity to decide whether the

answer is true or not Creates problems if client gives inaccurate

responses in order to please the healthcare workerExamples: “You’re stressed about surgery tomorrow, aren’t

you?” “You will take your medicine, won’t you?”

(Ramont, Niedringhaus, p. 236)

Leading Questions

Guided by & chosen based on what the OTHER person has said

Shows that you are paying attention Indicate interest and a desire to understand. Probing questions can be non-directive Examples: "Go on", or “& specific as below: Person A: “I live in New York.” Person B: “Ah. Do you live in Brooklyn, or The

Bronx?”(Bascal & Associates)

Probing Questions

Requesting Clarification “Can you share an example of that with me?”Encouraging Elaboration “How are you dealing with that situation now?”Verifying Information & Responses “So, if I understand you correctly… Is that right?”Evaluative Questions

Use open- ended & closed-end question formats to gain confirmation & to uncover attitudes, opinions, & preferences of client.◦ “How do you feel about…?”◦ “Do you se the merits of…?”◦ “What do you think…?”

(Bascal & Associates)

Probing Questions

Question Type Examples

Closed-ended What is your date of birth?Are you taking any medication?

Open-ended How did you fall?Why do you think you are feeling sad?

Probing You said that you have been experiencing pain in your chest. Where, exactly, in your chest do you feel the pain?When is it most severe?

Leading Would you describe the pain as sharp, dull, throbbing or aching?Do you feel the pain more in the morning or at night?

Types of Questions with Examples

(Changing Minds Organization)

(Changing Minds Organization)

Close-Ended Question SituationsUsage Example

As opening questions in a conversation, as it makes it easy for the other person to answer, and doesn't force them to reveal too much about themselves.

It's great weather, isn't it? Where do you live?What time is it?

For testing their understanding (asking yes/no questions). This is also a great way to break into a long ramble.

So, you want to move into our apartment, with your own bedroom and bathroom?  

For setting up a desired positive or negative frame of mind in them (asking successive questions with obvious answers either yes or no ).

Are you happy with your current supplier? Do they give you all that you need?Would you like to find a better supplier?

For achieving closure of a persuasion (seeking yes to the big question).

If I can deliver this tomorrow, will you sign for it now?

(Changing Minds)

Open-Ended Question SituationsUsage ExampleAs a follow-on from closed questions, to develop a conversation and open up someone who is rather quiet.

What did you do on you holidays?  How do you keep focused on your work?

To find out more about a person, their wants, needs, problems, and so on.

What's keeping you awake these days? Why is that so important to you?

To get people to realize the extend of their problems (to which, of course, you have the solution).

I wonder what would happen if your customers complained even more? Rob Jones used to go out late. What happened to him? 

To get them to feel good about you by asking after their health or otherwise demonstrating human concern about them.

How have you been after your operation? You're looking down. What's up?

A = AssessmentD = DiscoveryA = Activation QuestionsP = ProjectionT = Transition Questions

This is a sequence of questions with a specific purpose that begins with assessment of a problem leading to a transition of helping client find solutions to problem

(University of Mississippi Business Faculty)

See next slides for the five steps of the ADAPT questioning sequence and an explanation of

sequence pattern

ADAPT Sequence of Communication

Funneling Sequence of ADAPT

• Broad bases and general facts describing situation• Non-threatening as no interpretation is requested

• Open-end questions for maximum information

Assessment Questions

• Questions probing information gained in assessment• Seeking to uncover problems or dissatisfactions that

could lead to suggested client’s needs• Open-ended questions for maximum information

Discovery Questions

• Show the negative impact of a problem discoveredin the discovery sequence

• Designed to activate client’s interest in anddesire to solve the problem.

Activation Questions

• Projects what life would be like without the problems• Client establishes the value of finding and

implementing a solution

Projection Questions

• Confirms interest in solving the problem• Transitions to presentation of solution

Transition Questions

Who is your audience?◦ A patient◦ A family member◦ A co-worker

What are the family dynamics and how does the family operate as a family unit?◦ Are the family members getting along or

arguing?◦ Is one member in charge of making the medical

decisions or is the entire family making the decisions?

(Ramont, Niedringhaus)

Step #3 – Delivery of the Message

The type of audience will determine the type of language you use and how your message is delivered so know your audience, and know it well.

Consider the different methods of delivery used when speaking to one or two individuals, a group of people, or a large population.

Step #3 – Delivery of the Message

Concentrate & Attention◦Is the sender focused on the feedback

that the receiver is providing or thinking of the next thing to say?

◦Is the sender actively listening to the receiver’s feedback?

Observation◦What type of nonverbal cues is the

receiver sending? Is the receiver frowning, rolling his/her eyes?

Step #4 – Listen for a Response

Paraphrasing is a reflection of meaning, but not content.

It is a way for the sender to summarize the message and resend it if necessary. The receiver also paraphrases the message when providing feedback to the sender. Repeat what the other person has said, but in your own words. Then ask, “Is that right?”

Paraphrasing demonstrates that you have listened and have taken the time to understand what the other person has said (Ramont, Niedringhaus, p. 235)

Step #5 – Offer Feedback & Seek Clarification

Examples of ParaphrasingSender: We are going to leave town

tonight and will be back in a week’s time after we have visited relatives.

Receiver: “So you will be gone for a week starting tonight. Will you be back on the Thursday or the Friday?”

Paraphrasing

Were the communication goals met? Did the sender deliver a clear message? Did the receiver ask for clarification, for

examples? Was feedback given and how was it

received?

[See communication guidelines on the following slides.]

Step #6 – Evaluate the Encounter

Convey to the patient & family that they are important to you & that you want to help them. ◦ Do what is comfortable & natural for you.

Convey honesty & trustworthiness. Try not to overwhelm the patient with

embarrassing or personal questions. When it is necessary to ask personal questions,

explain why & keep it short & matter-of-fact.(Medical Education Division)

Communication Guidelines with Clients and Families

Don't make promises you can't keep. If you say you are going to do something, make every effort to do it or see that it gets done.

Try to be there when you say you will. If you are late, explain why.

Accept & respect patient despite symptoms of his illness.

Communicate with each patient as an individual. Especially important in a hospital setting, where

patients often experience a loss of identity. Do:◦ Get to know the patient◦ Listen to the patient◦ Put yourself in his/her place (Medical Education Division)

Communication Guidelines with Clients and Families

Be able to decipher the patient's message. Get to know the patient well enough to

discover the underlying meaning (intent) of his/her communication.

Be alert & perceptive enough to pick up the correct message.

Many people feel uncomfortable talking about their feelings, especially if they are trying to be "good patients."

Learn to "read between the lines.“ Ask for clarification.

(Medical Education Division)

Effective Therapeutic Communication

Be realistic in your relationships with people; avoid making assumptions or judgments about your patients' behavior.

If you have negative thoughts about something a patient says or does, try to keep in mind that he is an adult, responsible for making his own decisions.

You do not want patient to feel they must conceal anything from you.

You want patient to see that you will accept them for what they are; you will allow him/her their own identity

(Medical Education Division)

Effective Therapeutic Communication

Bascal & Associates. (2008-2010). What are probing questions? Probing questions ask for more information or clarification. Retrieved from http://work911.com/communication/skillsprobing.htm

Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008). Health care delivery systems. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 101-116). Upper Saddle River, NJ: Prentice Hall

Changing Minds Organization.(2002-2011).Open and closed questions. Retrieved from http://changingminds.org/techniques/questioning/open_closed_questions.htm

Industrial Engineering. (n.d.) Communication & Consumer Behavior. Retrieved from http://industrialeducation.blogspot.com/2009/07/communication-consumer-behavior.html

References

Medical Education Division of Brookside Associates. (2007). Patient relations. Nursing fundamentals I. Retrieved from http://www.brooksidepress.org/Products/Nursing_Fundamentals_1/lesson_1_Section_2.htm

McGill, I. & Beaty, L. (1994). Action learning: A guide for professional management and educational development (2nd ed.). Sterling: VA: Stylus Publishing Inc.

Ramon, P.R. & Niedringhaus, D. M. (2008). Client communication. Fundamental nursing care (2nd ed.) (pp. 226-242). Upper Saddle River, NJ: Person Prentice Hall

University of Mississippi Business Faculty. (2004). Module 4: Communication Skills. Retrieved from faculty.bus.olemiss.edu/dvorhies/.../Module%2004%203E.ppt

References