Communication Skills Reflection: Patient Interaction

This essay will examine the interaction between myself and the mother of a child who has recently been diagnosed with diabetes mellitus (Mrs X). Before examining the interaction in specific detail I would like to consider some of the more general elements that are relevant to the topic of communication between healthcare professionals and their patients.

There are many definitions of communication and Wilkinson offers one definition which describes a complex process of both sending and receiving messages in different formats (both verbal, non verbal or more commonly a mixture of both elements). This interchange typically allows for an exchange of information, feelings, needs and preferences. Typically the two protagonists in a communication exchange will encode and decode messages in a cyclic pattern. Each making an analysis and response to the preceding gambit. (Wilkinson SA et al. 1999)

Bugge enlarges on this definition by putting it in a context of professional nursing and suggesting that “its purpose is generally manifold but will include the means of establishing a nurse-patient relationship, to be a tool for expressing concerns or interest in the patient’s circumstances, to elicit information relevant to the patient’s condition and to provide healthcare information.” (Bugge E et al. 2006)

It is an essential part of the whole process of successful communication that both parties achieve a shared understanding of meaning. This is validated by the process of feedback interpretation which indicates if the actual meaning of the message was interpreted as it was originally intended. (Coiera E et al. 1998)

In this essay I should note that communication can be considered on many different levels. In this instance we are specifically considering the mechanisms of information exchange between a healthcare professional and a client which, in the broadest sense will ultimately determine many of the parameters of treatment (and also possibly patient compliance) (Stewart M 1995). Although we are specifically considering one interaction here, this does not mean that the other elements of communication are ignored. Hogard (E et al. 2001) writes extensively on the importance of communication between healthcare professionals which can cause huge problems in terms of patient management if they are anything less than optimal. I would hope that any information that I would be able to glean from a patient could be communicated to the rest of a multidisciplinary healthcare team efficiently so that appropriate management decisions could be made.

If we consider an overview of a typical communicative interchange it can generally be categorised by both type and level. In the specific context of nursing, the various levels could be considered as “Social” which is considered to be safe and non-contentious, “Structured“, which is typically utilised for situations of teaching and patient interviews and “Therapeutic” which has the characteristic of being specifically patient focussed, purposeful and generally time limited. (D’Angelica M et al. 1998)

Heinmann-Knoch (et al. 2005) considers the process in greater detail. If this initial interaction is successful it can develop further characteristics such as the nurse comes to regard the patient as a unique individual and begins to understand their motivations, and the patient develops a trust in the nurse. It is within this communication context that the nurse is generally able to try to provide care and, more importantly in some instances, help patient identify, resolve, or adapt to health problems

We will also briefly consider the elements of both verbal and non-verbal communication.

Verbal communication requires, by definition, the conscious use of the spoken or written word. The nature, grammar and syntax and context of the words chosen are important in that they can reflect the patient’s mental age, their education, their culture and in some cases their mental state and feelings of the moment. In a clinical context inferences can be made from the way the words are delivered such as their choice, their tone or pace of delivery. The characteristics most favourable for efficient and effective communication are that the words should be “simple, brief, clear, well timed, relevant, adaptable, credible”. (Philipp R et al. 2005)

Non-verbal communication by contrast, relies on the interpretation of facial expressions, hand gestures, and body language. This can be an extremely subtle means of communication and can give credence (or otherwise) to the spoken word. In the nursing context, non-verbal communication can be manipulated to the nurse’s advantage to help to elicit information that may otherwise not have been forthcoming. It has been estimated that non-verbal communication accounts for up to 85% of information transfer between communicating adults. In the professional nursing context it requires both systematic observation and careful assessment and interpretation to derive the full meaning of what the patient wishes to convey. Most importantly, the nurse should be aware of incongruity between the verbal message and the non-verbal cues. The patient who smiles while describing a terrible pain is one such example. (Musselman C et al. 1999)

Specific examples

If we now consider elements of communication from the transcript. Clearly there is no evidence of non-verbal communication on the transcript but I was very conscious of the mother’s initial reticence in her opening exchanges with me. She initially sat in a “closed” position and largely avoided eye contact. As the conversation unfolded she clearly became more relaxed and trusting. She adopted a more “open” and relaxed posture and started to express herself with appropriate hand gestures. (Hulsman R L et al. 1999) I particularly recall the jabbing gestures she made to emphasise a point relating to giving injections.

I have to observe that the environment that was used for the interview was very contrived and I believe that this may have had an influence on both myself and the client. I think that, in a real situation I would be able to allow the conversation to be far more fluid and relaxed.

I can analyse some of the techniques used to elicit or reinforce information

During the interview I purposely made a point of asking open questions to try to draw out the client’s response

So it sounds as if, it has obviously upset you..?

It sounds as if you were almost blamed yourself for it as well..?

Generally its quite a healthy family as well..?

>From the terminology you’re using there is sounds as if you know what you’re talking about, you sound quite confident..?

Mrs X. was clearly at ease after a while and even when closed questions were asked she would answer them Yes or No and then go onto both expand what had been said and volunteer other information.

I had varying degrees of success in eliciting the information that I was after. Trying to establish whether it would be difficult to get the patient to comply with his diet I touched on the subject of diets and Mrs X clearly has a major psychological difficulty in coming to terms with her own diet. I allowed her to express her views about her obesity before trying to bring the conversation back on track. After Mrs X’s outburst about her “serious morbid obesity” I made three attempts to both empathise and sympathise with her feelings in order to gain her trust by asking supportive and non-contentious questions before returning to the point relating to injections with the question

“So how did you feel with the injections, because obviously for me that was quite a scary experience, seeing someone so young giving an injection to themselves..?”

Phrasing the question in this way appears to show considerable empathy for Mrs X’s situation and allows her then to offer her opinion. (Richards T 1999)

There were several instances where I needed to summarise what was said in order to be sure that I had understood the thrust of Mrs X’s comments

Easy to understand, em, there was no panic mongering in them and things like that. If I’d have looked on the websites, I might have found some information I didn’t want to see at this stage. So I was advised not to look and I didn’t.

So would you be a bit. . So if you read something that was sort of like false information or mis-information that scared you a little bit, is that what you’re trying to say?

It probably would have scared me because it’s my child, but I wouldn’t have been into histrionics about it, I would have been probably saying well that……. problems.

Paraphrasing was a useful technique to ensure that I had understood what was being said.

Yes, and you know, instead of buying biscuits and things for the biscuit tin in the house, I’ll be buying fruit, huge varieties of fruit, and that’ll be their options now.

So you say you’re going more toward the healthy lifestyle and keeping, would you,?

Direct questioning helped to elicit specific answers

Prodigy websites?

Off the websites, yes, they were very good because they were no nonsense.

Do you mean they were easy to understand?

Easy to understand, em, there was no panic mongering in them and things like that. If I’d have looked on the websites, I might have found some information I didn’t want to see at this stage. So I was advised not to look and I didn’t

On occasions it was useful to reflect on the implications of Mrs X’s answers and to try to elicit further information from her

So it sounds as if, it has obviously upset you..?

Does that… it sounds as if you were almost blamed yourself for it as well..?

Empathising is a useful technique particularly when dealing with difficult issues such as the problems with diets. (Stewart M . 1995)

Especially being teenagers, its all.. They eat chocolate, they eat crisps and all things that are bad for them and if they’re restricted in what they can eat it makes them want it more in a way. I know if I couldn’t have chocolate or sweets..

On reflection I believe that I made a reasonable attempt in the circumstances to get as much information from Mrs X as I could. By the end of the interview Mrs X was getting tired and losing concentration so I believe that it was correct to terminate the interview at this time. (Wilkinson S et al. 1999)

I am aware that I frequently asked incomplete questions or stopped in the middle of a sentence. This may be an indication that I was not in control of the situation

This whole exercise has been a useful analytical and learning experience for me. I believe that I shall have gained a great deal of experience from the episode and will use that to further inform my practice in the future.

References

Bugge E and I. J Higgins on (2006) Palliative care and the need for education – Do we know what makes a difference? A limited systematic review. Health Education Journal, June 1, 2006 ; 65 (2) : 101 – 125.

Coiera E and Vanessa Tombs (1998) Communication behaviours in a hospital setting: an observational study. BMJ, Feb 1998 ; 316 : 673 – 676.

D’Angelica M, Kathy Hirsch, Howard Ross, Steven Passik, and Murray F. Brennan (1998) Surgeon-Patient Communication in the Treatment of Pancreatic Cancer. Arch Surg, Sep 1998 ; 133 : 962 – 966.

Heinmann-Knoch, Korte, Heusinger, Klunder & Knoch (2005) Training of communication skills in stationary long care homes–the evaluation of a model project to develop communication skills and transfer it into practice. Z Gerontol Geriatr. 2005 Feb ; 38 (1) : 40-6.

Hogard E and Roger Ellis (2006) Evaluation and Communication: Using a Communication Audit to Evaluate Organizational Communication. Eval Rev, Apr 2006 ; 30 : 171 – 187.

Hulsman R L, Ros W J G, Winnubst J A M, et al. (1999) Teaching clinically experienced clinicians communication skills: a review of evaluation studies. Med Educ 1999 ; 33 : 655 – 68

Musselman C and C Tane Akamatsu (1999) Interpersonal communication skills of deaf adolescents and their relationship to communication history. J. Deaf Stud. Deaf Educ., Winter 1999 ; 4 : 305 – 320.

Philipp R and P. Dodwell (2005) Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload. Occup. Med., Jan 2005 ; 55 : 40 – 47.

Richards T. (1999) Chasms in communication. BMJ 1999 ; 301 : 1407 – 8

Stewart M . (1995) Effective physician-patient communication and health outcomes: a review. CMAJ 1995 ; 152 : 1423 – 33.

Wilkinson S, Bailey, J. Aldridge, and A. Roberts (1999) longitudinal evaluation of a communication skills programme. Palliative Medicine, June 1, 1999 ; 13 (4) : 341 – 348.

Appendix

Self in blue italics

Mrs X in black print

How has xxxx diabetes since coming into hospital?

Well it’s come as a terrible shock obviously, that he’s got diabetes, because he’s a healthy boy. It’s still a shock. I think the staff have tried to help us over it as much as they can.

Do you feel as if they’ve given you enough information about diabetes..?

I think we’ve been inundated with information, I think that it was good that one particular member of staff dealt with us mainly, and they listened very closely to what we had to say. We’ve had a lot of conflicting information but ultimately it all meant the same thing which caused a little bit of confusion.

And did you feel as if that that was a bit of overkill? Or a bit too much information too soon?

Probably, but between the bits of information that we run off the PC, off the..

Prodigy websites?

Off the websites, yes, they were very good because they were no nonsense.

Do you mean they were easy to understand?

Easy to understand, em, there was no panic mongering in them and things like that. If I’d have looked on the websites, I might have found some information I didn’t want to see at this stage. So I was advised not to look and I didn’t.

So would you be a bit. . So if you read something that was sort of like false information or mis-information that scared you a little bit, is that what you’re trying to say?

It probably would have scared me because it’s my child, but I wouldn’t have been into histrionics about it, I would have been probably saying well that……. problems.

Yes

I had a little bit of knowledge about diabetes before this happened, but sometimes a little bit of knowledge is a more dangerous thing.

Is that because of the work that you’re doing?

Yes, and you know, what I’ve actually learned now …………. had diabetes, so.

And do you think …………… how it’s going to change your lifestyle?

Definitely going to change the lifestyle. Having a big family its going to mean that..

How many people in the house sorry?

In the house there’s 6. Cooking Sunday dinner yesterday, there were 11 of us for Sunday dinner yesterday..

That’s a lot of people..

Yes, and you know, instead of buying biscuits and things for the biscuit tin in the house, I’ll be buying fruit, huge varieties of fruit, and that’ll be their options now.

So you say you’re going more toward the healthy lifestyle and keeping, would you,

Yes, yes

Would you – all the bad things, would you keep them out of the house or will you still buy them in for..

I won’t be buying them because my children will need to make their own decisions about that. I don’t have small children who are going to feel deprived if they don’t have a chocolate biscuit. They’re old enough to make a conscious decision, “okay Mum’s given us that, but I fancy this so I’m going to go and buy it.” They’ve got their own resources so they can go and do it themselves.

And they’re quite happy about that are they?

Yes, and they’re happy, apart from one, about the healthier way of cooking things if you like and em, wasn’t a terribly bad diet in the first place.

Have they all agreed to sort of, give their responses to diabetes or are they sort of laid back about it? They seem quite laid back..

They are very laid back. They’ve even, I mean it sounds absolutely terrible but they’ve even been cracking jokes about it. Three of my children have got asthma and I mean he was joking “well mine’s worse than yours” and ..

So they’re all quite light hearted about it and taking it in their stride.

Yes. Matthew, my eldest boy, was, because he’s a Nurse I think, he was absolutely devastated but he is better about it now. But in the first instance he was absolutely gutted. I mean xxxx he was gutted obviously..

Well this is it, he seems quite calm about it from what I’ve seen and a very relaxed family in general.

Yes. I mean if we were any more laid back we’d need ……….. on a night to keep us going because we don’t really let things bother us.

So it sounds as if, it has obviously upset you..?

Yes, very much. I kicked right off. I didn’t kick off in front of him, but when I got home I kicked right off to everybody and anybody that would listen. I even had texts from friends that didn’t even know, and I was ranting to them…

Does that… it sounds as if you were almost blamed yourself for it as well..?

I did wonder, you know, initially I wondered if it was because they’ve always been allowed to have sweets. I’ve never made sweets into a reward or a treat, you know, they’ve always been an everyday matter of fact, because I didn’t want them to grow with my problems, obesity problems, because they weren’t allowed sweets. I didn’t ever want them to ever think sweets were something really special. Because they’re not, they’re just another thing that, they’re a foodstuff, and they’re a bad source of..

Especially being teenagers, its all.. They eat chocolate, they eat crisps and all things that are bad for them and if they’re restricted in what they can eat it makes them want it more in a way. I know if I couldn’t have chocolate or sweets..

Well that’s just my life experience you know, being denied things and then leaving home at 16 and eating all of that stuff and becoming at one point seriously morbidly obese I don’t want that for my children. Obviously they might have a predisposition to do that. I don’t want that to happen so, let’s not make sweets and biscuits em, a reward or a treat so they never have been. So then I wondered if possibly they’d had too much. None of them are overweight, none of them are fat, none of them have got bad teeth and cavities and things. None of them has ever had a filling.

Generally its quite a healthy family as well..

He hasn’t seen a doctor for 7 years.

So it must be a complete shock for you that this has suddenly happened.. and changed everything that has been happening in your home. So how has the rest of the family been coping, have they been..?

Very supportive, except for one..

Ah, except for one, is that the elder one or the younger one?

He’s 18 just turned, and he’s got an appalling diet, all I can do is advise him. I can put his meals in front of him and if he chooses not to eat them and go and buy rubbish then, all I can do is advise him.

So how did you feel with the injections, because obviously for me that was quite a scary experience, seeing someone so young giving an injection to themselves..

I knew he could do it. Of all of this, that’s the bit that doesn’t faze him.

Does it faze you at all?

It doesn’t faze me. Em, when I was asked to give him an injection here, and staff knew I could do it ……said you might not be able to do it because he’s your son.. But its not like that is it? If he goes into a hypo and he needs me to inject him, I’m not going to start you know, “oh my god! his life depends on it, get him injected, how……..”

From the terminology you’re using there is sounds as if you know what you’re talking about, you sound quite confident.

Yes. I am. I mean………….but, at the end of the day its your child and you’re not going to, going to, you wouldn’t hesitate, just get on with it, you just do it.

And do you feel that that’s the attitude that you’re whole family’s going to have as well?

Yes. They’re all, you know, when he’s doing his bloods they’re all there watching, hovering over him, when he’s sticking a needle in they’re “ooh, where are you going to stick it now?” you know. Nobody’s squeamish, nobody’s terribly fazed by it, I think they’re all pretty pleased because it’s not them that’s got diabetes. But at the end of the day ……….but be supportive, can’t ask any more really.

Yes. Can you see yourself coming in regularly to see all the diabetes nurses? Even if he’s in complete control of his diabetes will you still come in and visit just to make sure everything’s alright?

Yes, as long as he wants me to come with him, then I will come with him. I mean, when he turns 18 if he wants me to come to the diabetes clinic with him then I’ll come with him.

Is he independent anyway?

Very. Fiercely independent. Still like, on the phone its still like Mum …………

So when you go away today do you think you’ll feel as if you’re going to have everything that you need for the next, lets say two weeks, or week, to be happy with..

Yes I still need to ask about when I should make an appointment for …….. him to see his GP. I still need to ask little questions.. When he turns 18 is the insulin free, or does he have to pay for it like everybody else, with the prescription charges

Yes …….. aren’t they? Its quite expensive as well isn’t it?

Well asthmatics don’t get their inhalers free, they have to pay..

When you think about it you’ve got your insulin, your sticks you….

It’s the keytones as well, they haven’t been completely explained to us.

They’re in the leaving pack anyway which…

I mean I understand what the keytones are, but…

What are they? Because I don’t fully understand, I know they’re a by-product ..

Keytones are a waste product that your kidneys filter out of the blood and pass out in the urine. Obviously they’re in your blood for your kidneys to pull them out, filter them out, but if his blood sugars are high and remain high you should test his urine for keytones. There are sticks to test his urine. If there are a lot of keytones in his urine then he should probably do a test on his blood which is just another stick that goes in

Have you got them?

No. Then you would phone the ward. But we know we can phone the ward anytime.

So you feel reassured at having that point of contact that you can phone up anytime…?

Absolutely, yes. There’s still going to be stuff that comes up and “what can you do about that?” There’s going to be stuff that comes up all the time.

I’m sure you’re going to have peaks and troughs a little bit where you’re unsure what’s happening and if you’re concerned he’s not controlling his diabetes properly, we’re only a phone call away.

Yes. And if its not being controlled I don’t think it would be anything he’s doing deliberately wrong..

You said earlier, he knew about what his level was. I think at one point yyyy asked him “what level do you think you’re at”..

Yes, he was very close.

Mm, very close

And that was only on day two or three, day three maybe

He’s had a couple of lows on his blood pressure as well which I think he’s realised because he’s felt the effect that it’s had on him

He knew yesterday afternoon that he was low because he said look at me and he showed me and there was just ever such a slight tremor in his hands.

Did that concern you or reassure you?

It reassured me because he knew and I said, he said I need to test my blood and I said why and he said because I think its low and he said look and he showed me. For him it was low, it’s the lowest it’s been.

Well that’s fantastic

I wasn’t worried because I knew that all he had to do was have the glucose or eat something or both and em, when he goes back to school I know that he’s ……………

You take home glucose tablets as well don’t you? I think you can buy them from the shops now..

Yes. You can just at the supermarket so they’re easy to carry about.

Very nice sweets as well. Anyway I think that’s about enough so thank you for your time.

I hope it helps.

I’m sure it will.

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