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«HEALTH PSYCHOLOGY Series Editors: Sheila Payne and Sandra Horn Di an ne Be rr y ion at ce nic cti mu Pra om and h C ory alt The He Health ...»

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As noted by Lloyd and Bor (1996), to provide information effectively, healthcare professionals need to be able to fully understand the information themselves and to convey it accurately, using ideas and language that will be easily understood by the patient. They also need to be prepared to respond to the recipient’s questions and emotional reactions, and to tailor future information accordingly. Lloyd and Bor (1996) outlined a number of guidelines for healthcare professionals in relation to providing information to patients. These include describing the information that will be given, summarizing their understanding of the patient’s problems, ascertaining the patient’s understanding of their condition, using appropriate language, giving the most important information first, exploring the patient’s views on information given, checking their understanding and negotiating future management of their care. In addition, Dickson et al. (1997) proposed that professionals should speak fluently, reduce vagueness, use examples and structure information effectively. In addition, they should use pauses appropriately, provide emphasis, and be expressive where appropriate.

As noted in Chapter 6, one difficult situation where information has to be provided is when healthcare providers have to break bad news to patients or relatives. It is clearly a matter of judgement and experience as to how bad 116 Health communication news should best be broken, and each case may well need to be treated differently. A number of specific guidelines were outlined in Chapter 6.

Attending and listening According to Burnard (1997), listening and attending are by far the most important aspect of being a healthcare professional. Attending is the act of focusing on the other person, what they are saying and what they are trying to communicate. Listening, in turn, is the process of ‘hearing’ the other person; not just what they say but how they say it and what other signals they convey. According to Burnard, it involves focusing on the actual words that clients use, the associated paralinguistics and the accompanying nonverbal behaviours. As noted in Chapter 2, the latter can sometimes portray contrary (and often more accurate) indications of the client’s true feelings.

Despite being one of the most central components of the communication process, effective or active listening can be one of the most difficult skills to acquire (Lloyd and Bor, 1996). It is not only important to listen, but to let the speaker know that you are listening carefully to them (that is, to show active listening). This can be done by using verbal and non-verbal signals (such as head nodding), appropriate follow-on questions, and reinforcement and reflection where relevant, and by summarizing and checking information and taking notes.

Wolff et al. (1983) suggested a number of guidelines that could be used to

facilitate effective listening. These are:

1 Do not stereotype the speaker 2 Avoid distractions 3 Arrange a conducive environment 4 Be psychologically prepared to listen 5 Keep an open, analytical mind, searching for the central thrust of the speaker’s message 6 Identify supporting arguments and facts 7 Do not dwell on one or two aspects at the expense of others 8 Delay judgement or refutation until you have heard the entire message 9 Do not formulate the next question while the speaker is relaying information 10 Be objective.

More recently, Egan (1998) suggested that use of the acronym SOLER could help healthcare providers to remember the key behaviours that can encourage active listening. These are sitting Squarely in relation to the client, maintaining an Open position, Leaning slightly forwards towards the client, maintaining reasonable Eye contact and Relaxing (and encouraging the client to relax).

Effective listening is necessary to gain a full and accurate understanding of the patient’s problem and associated feelings, to communicate interest and Communication skills training 117 concern, to encourage openness and to develop a more non-directive patient-centred style of interaction (Dickson et al., 1997). Buckman (1992) summarized the main benefits of effective listening as improved satisfaction, increased perceived competence of the healthcare provider and enhanced compliance with the treatment plan.

Reinforcement It is a basic principle governing behaviour that people are more likely to do things that are associated with positive valued outcomes, and that are positively reinforced. Indeed, as a social skill, reinforcement is central to interpersonal interaction. As noted by Dickson et al. (1997), the use of social reinforcement serves a number of different purposes. Thus, it encourages the involvement of the other person, demonstrates interest, helps to develop and maintain relationships, provides reassurance, conveys warmth and helps to control the flow of conversation. The key behavioural components of reinforcement include acknowledgement, confirmation, paying compliments and making supportive and evaluative comments. Healthcare providers should use such behaviours where appropriate, to reinforce positive behaviours in patients and others.

Reflecting This typically involves the healthcare professional rewording and feeding back the main elements of the patient’s preceding comments. This can involve paraphrasing factual content, as well as trying to reflect feelings by demonstrating an understanding of them. Specifically, according to

Dickson et al. (1997), reflection involves:

♦ recalling and restating the speaker’s message correctly ♦ identifying the main factual and/or feeling aspects being expressed ♦ translating these into one’s own words ♦ reflecting the essence of these facts and feelings without adding one’s own interpretations ♦ checking the accuracy of reflection by monitoring the other person.

The key functions of reflection are to demonstrate interest and involvement, to use a patient-centred approach, to check for accuracy of understanding, to highlight certain facets of the patient’s communication, to show respect for patients and their concerns, and to demonstrate empathy with the patient and their situation. Dickson et al suggested that, when using reflection, it is important to be accurate, concise and specific, to avoid interpreting people’s statements (as opposed to rephrasing them) and to refrain from using stereotyped responses.

118 Health communication Opening and closing interactions In terms of opening skills, it is well known that initial impressions have a large influence on the course, and success, of subsequent interactions. They frequently determine the length, tone and quality of first, and often followon, encounters. It only takes a few seconds to make an initial impression but the effects can be very long-lasting. At the start of interviews, or consultations, it is important for healthcare professionals to explain the purpose of the coming discussion and to give reasons for why particular information is being sought. They should then explain what the patient is expected to do and ascertain if the patient has any initial concerns. Interestingly, Davis and Fallowfield (1994) found that one of the main deficiencies of health professionals was their failure to greet patients appropriately and to introduce themselves and explain the purpose of the consultation. Similarly, Maguire et al. (1986), in their study of the communication skills of young doctors, reported that few explained the intended purpose of the interaction and the time available.

As far as closing skills are concerned, professionals need to arrange for a smooth and effective closure to interactions. This involves the use of techniques such as summarizing, checking understanding, discussing follow-up actions, using motivation and reinforcement, and asking if anything has been missed. It is also often appropriate to use non-task statements (such as asking about holidays), as well as to thank the patient and to say goodbye. Closing consultations can sometimes be difficult as what needs to be said will depend on the content of the preceding interaction, and will involve the patients’ (at least tacit) agreement. Some patients have a tendency to introduce new information at, what doctors thought was, the end of the consultation. Such tendencies can be avoided, or at least reduced, if patients are encouraged to contribute fully earlier in the consultation.

Managing conflict

In addition, to covering these basic communication techniques, communication skills training also typically includes teaching healthcare professionals to deal with, and manage, conflict. It is not surprising that there is a potential for conflict in many healthcare situations. People are often placed in unfamiliar settings, in stressful and uncertain circumstances. In addition, many are in physical pain and are scared or apprehensive. Some healthcare professionals may be defensive or not sufficiently skilled at imparting difficult news and handling difficult people. Communication is central to conflict. It can be a causal factor, it is the primary means by which conflict is expressed and it can be used to manage and resolve conflict.

A number of different approaches to conflict have been identified Communication skills training 119 (e.g. Northouse and Northouse, 1998). The least effective approach, or strategy, is the ‘lose–lose strategy’. Although people do not usually intentionally adopt this approach, they can end up in this situation as a result of ineffective handling of conflict. Lose–lose situations come about because both participants try to dominate the other, and try to ‘win all’, but this usually results in both ending up losing. Another unsatisfactory approach is known as the ‘win–lose strategy’. This approach comes about when one participant tries to take control over the other in order to ‘win all’. However, even if the person is successful it means that the second person ‘loses all’, which is not usually a desirable outcome. It is therefore generally agreed that the most optimal approach to conflict resolution is the ‘win–win strategy’.

Unlike the other two approaches, this strategy allows both participants to feel that they have been successful, at least to some extent. This ideal strategy, and end result, however, are not always easy to achieve. They involve people putting their own position clearly, while at the same time listening to, and appreciating, the other person’s position. They may require creative problem solving in trying to find a novel solution that allows both parties to come away from the situation feeling satisfied.

In addition, to these higher-level strategies, people approach interpersonal conflict using different styles of interaction. Northouse and

Northouse (1998) identified the five main styles as follows:

1 Avoidance. This tends to be used by passive, unassertive people. It is rarely successful as most conflict does not go away if you simply ignore it.

Avoiding conflict often leads to anxiety and stress, as well as to frustration and anger in others.

2 Competition. This style of interaction tends to be used by people who are very assertive and competitive. Again, it tends not to be a particularly effective approach to resolving conflict, as it does not allow for negotiation or compromise.

3 Accommodation. According to Northouse and Northouse (1998), accommodation is a conflict style that is ‘unassertive but co-operative’ (p. 247), as well as being ‘other directed’. Although accommodation can be useful in some situations, it often results in one or other person just giving in to another.

4 Compromise. This fourth style includes an element of accommodation but also an element of competition. Although it can be successful, it often leads to both parties coming away from the situation feeling partly satised but partly dissatisfied. By going for a compromise solution they fail to achieve a more creative solution that could have resulted in a ‘win–win’ outcome.

5 Collaboration. The final approach identified by Northouse and Northouse (1998) is believed to be the most preferred style, although perhaps the most difficult to achieve. It requires both assertiveness and cooperation, as well as a lot of effort on behalf of the participants. If successful, 120 Health communication however, it should result in an effective solution to conflict where both parties leave the situation feeling fully satisfied.

In addition to outlining the different advantages and disadvantages of different strategies and styles of handling conflict, communication skills training will also try to teach simple methods that can be learned and applied to help manage the situation. For example, professionals may be taught to try to break down a conflict situation into small contributing elements, and then to address them individually. Training may also cover the need to define and clarify one’s own position in an attempt to reduce misunderstanding.

Conflict can also arise in small-group situations, as a result of different participants having different (clashing) goals and styles of interaction. Hargie and Dickson (2004) outlined four key tactics that should be included in communication skills training aimed at handling conflict in small-group

settings. These are:

♦ focusing on issues, rather than personalities ♦ making all contributors feel that their suggestions have, at least, some merit ♦ highlighting broad areas of agreement if these can be identified ♦ emphasizing ‘we’ and ‘us’ in order to try to establish or re-establish a stronger sense of ‘group’.

Different approaches to communication skills training A number of different approaches to communicate skills training have been identified. Dickson et al. (1997) listed the main four as being: doing the job, modelling the master, directed training and doing-based training.

Doing the job This is the method that has been traditionally used by health professionals. It simply involves junior staff picking up knowledge about how to improve skills, while actually interacting with patients. However, the method is limited as the learning is predominantly by trial and error, and the learner may simply develop strategies for ‘how to get through’ the interaction, or to survive, rather than acquire more situationally appropriate skills.

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