Once again the shift is sliding slowly into a pit of poo.

Along with the other staff, I find myself zigzagging about the overflowing department, trying to prioritize an unraveling list of tasks and responsibilities.
Immersed in my own stress soup, I sometimes loose my perspective… and a patient who wants (or needs) to talk, can on occasion become an almost bothersome interruption to my work. I find myself taking a ‘hit and split’ approach with my interactions and assessments, using a rapid succession of closed and leading questions in order to get the information ‘I’ want so I can move on to the more ‘important’ tasks at hand.

An excellent, and very comprehensive website on the art of communication (from which most of the information here was referenced) can be found here .
You also might like to see some actual examples of what happens when communication goes astray.

This shallow communication with my patients not only provides a poor quality of care, but will, in the long run, often be counterproductive, resulting in an even greater workload. The word communication comes from the root word “common”. And it is for you to discover that you have far more in common with your pateints than you would care to admit.

When a patient presents to the emergency department and enters your care, it is usually a meeting of complete strangers. In order to develop and prioritize a management plan for this person, a field of mutual trust must be cultivated. And this field must be ploughed with sensitivity, competence and acumen.

The patient will most likely present with pre-formed expectations of the emergency department (which may or may not be realistic).
They may also present carrying a large suitcase packed with emotions and inhibitions including; anxiety, anger, fear, shame and embarrassment, regarding what may be simple ailments or complex personal problems.
It is important to make this person feel genuinely welcomed at first contact.
Introduce yourself and explain the association you will have with them.
“Hi, my name is Ian. I am one of the nurses that will be helping to care for you this afternoon.”
It is surprising how many people have no idea if the person they are talking to is a doctor, nurse, clerical staff or radiographer. (…besides, you want to make sure they know who to send the chocolates to, no?)

The difficult part for us as ‘busy doing 15 things at once nurses’, is to remain present (fully attentive), and engaged (not emotionally detached) with this person both whilst talking and listening to them. The ability to interlace deep listening and effective questioning is indeed a precious skill.

Make it evident to the patient with good eye-contact and a relaxed body posture that you are fully present with them.
Try not to rush through the conversation… they must be given time in which to express themselves and speak freely.
Acknowledge your understanding (”I see…go on.”) as well as seeking clarification or explanation when necessary. When you do understand, nod your head in agreement or acknowledgment. This will show the patient that you are, in fact, paying them attention.
Mirroring or reflecting may also be used to signal your understanding. This is achieved by repeating back important emotional statements, desires or objectives that the patient may talk about. It probably feels less contrived to do this by repeating what you have understood in your own words (paraphrasing).

I’m all ears.

Any verbal interaction between you and a patient will carry a symphony of verbal and non-verbal information. Even a short phrase or sentence may contain a rich layering of needs and desires.
In order for effective communication to occur, both parties must correctly interpret and understand the others intended meanings. Some of the counterpoint running through a dialogue may include:

• conveying a fact (information).
• saying something about the patient (self-revelation).
• expressing the patient’s feelings on how you are relating to one another (relationship).
• and it may be seeking some form of influence (appeal).

For example, a lady presents commenting, “this is the second time I’ve been here with this stomach pain in the last week”, may simply be stating a fact, or revealing that she is anxious that it might be something serious (self-revelation), or showing her unhappiness with the treatment she received on her last visit (relationship), or attempting to be seen with more urgency (appeal).

And to further complicate things, each of these subtexts may be explicit (expressed directly) or implicit (expressed indirectly).
For example, “can you tell me how much longer before my son can see the doctor?” maybe a simple enquiry as to the waiting time, or it might implicitly infer feelings such as: ‘My son is in pain’, ‘I think you have forgotten us’, ‘Im getting pissed off with waiting for so long’ or perhaps, ‘I don’t think you have properly assessed how unwell my son is’

In order to correctly perceive the marrow of the intended message it may help to answer these questions:

• What is the factual content?
• What is this telling me about the patient?
• What does this person feel about our relationship?
• What do they want to achieve?
• Is there any implicit information here?

Remember that a very high proportion of messages contain implicit information so look for congruence between verbal and non-verbal cues such as body language, gesticulations, and character of voice.
Listen not only to what is said but what is not said.
Note your own behavior during interactions… do you tend to interrupt or cut the patient short?
Have you ‘preemptively packaged’ this patient’s problem with your own subjective values. E.g. Just the flu. Probably a psych patient. Constipated….wasting our time.
Remember, the initial presenting problem may only be a ‘ticket in’ to seek help with deeper issues.

Many of the communication problems that we encounter are the result of a poor questioning technique. As questioning is one of our most important diagnostic instruments we are very good at focusing on our objectives whilst neglecting those of the patient.
A good question is one that:

• Is easily understood by that particular person.
• Is posed at the right time.
• Encourages an answer.
• Increases the depth of the dialogue.
• Encourages further communication.
• Is empathetic.

Two commonly discussed forms of questions are open and closed.
Closed questions can usually only be answered with a yes or no (or a very brief, limited) reply. E.g. “do you have any chest pain right now?”
They may be useful to keep the conversation focused and illicit specific information but will hamper a deepening discussion, and when used too often produce a dry, mechanical, superficial ambiance. (However they are very useful in an emergency situation where rapid, concise information must be gathered in a very short time.)

Open questions encourage the patient to tell their story in their own words. E.g. “tell me what brings you in to see us tonight?.” They offer the opportunity for self disclosure and even a ‘warming’ or opening that may result in some insight on the part of the patient.

Sounding questions are used to obtain specific information without being closed. E.g. “How has your baby been feeding?”

Catalogue questions give the patient a choice of a series of key words or descriptions. E.g. “is the pain sharp, stabbing, burning or cramping?”

Try to avoid leading questions . E.g. “does this pain get worse when you lean forward?” or “has the nausea eased after that injection?” These questions tend to limit the conversation or even place subconscious pressure on the patient to answer the way you want them to.

We spend about 70% of our wakening hours communicating through speaking, listening, watching and reading.
It has been said that we typically hear only about 20% of the information communicated to us and that we forget about 80% of that within 24 hours.
Therefore..we must communicate clearly, briefly and repeat important information often or else most people will only get about 4% of the information we want them to have.

Also avoid double, triple-barreled questions . E.g. “did you sleep well last night… and have you had any rectal bleeding?” This becomes confusing and you will probably only have to repeat one of the questions anyway.

Judgmental questions are a big no-no. E.g. “if you have had this pain for a week…why-o- why have you decided to come to the emergency department tonight?” Like many big no-no’s it might make you feel all smug and pious for a moment, but all they do is put the patient on the defensive and close down communication.

Always conclude any interaction by giving the patient an opportunity to seek clarification or ask their own questions.OK. this all looks… most easy peasy….but drop me onto the triage desk on a Saturday night, and this list of skills tends to get stuffed away at the bottom of that growing pile of untriaged patient sheets. And perhaps in some cases long conversations are not appropriate in an emergent situation.

However, by taking a little extra time to have a deeper conversation with my patients I might just be able to deliver a more effective and efficient level of care,… and they might just feel more satisfied that someone has taken the time to really listen to them……and they might just remember who to send those chocolates to.