Submitted by John R. Thurston, Ph.D.
From time to time, physicians are taken to task by fellow physicians and many others for a variety of shortcomings in the practice of their profession. Common among the listed faults is a lack of effective communication with their patients.
Little has been written about the extent to which nurses may have problems similar to those detailed in the Groopman book. A discussion of such possibilities along with suggested solutions is clearly in order.
In the somewhat dated but definitive publication in this area, “How Doctors Think,”, Dr. Jerome Groopman, an eminent physician, wrote about virtually all of criticisms of his fellow physicians. U.S. News and World Report (March 26-April 2, 2007) headlined its review of this book with “The 18-second Doctor.” This was based on the following Groopman quotations: “Most doctors interrupt a patient 18 seconds after they start talking. Errors in our thinking come about because we cut off the dialogue.” The Wall Street Journal (March 20, 2007) headlined its critique with “Physician, Hear Thyself. A medical expert’s prescription: hurry less, communicate more.”
Time (March 26, 2007), in its review of the Grooopman volume, chimed in with “Where doctors go wrong. A revealing new book of how physicians think and why they go astray.”
Although bound together by the common thread of patient care, the roles of physicians and nurses are different in many important ways. My repeated hospitalizations at an advanced age have provided me with some current, highly personal information in regard to nursing. The nurse is responsible for implementing the treatment prescribed by the physician. In addition, she is a source of care, security, comfort, and relief from pain. As she answers patient questions, she must at times serve as an interpreter regarding what has been said to him by other medical personnel. A nurse can be summoned by a hospitalized patient on a 24/7 basis by a push on a bedside button. She deals with the “little,” seemingly inconsequential, things, the “hands on” ministrations that can loom so very large in a hospitalized patient’s life. She keeps him clean and presentable. She reassures him and his visitors. And by compassionate listening to and dealing with his fears and concerns, she can come to understand and respect him as an individual. The resulting in-depth, inter-personal relationship allows the patient to relax and obtain the maximum benefits from his hospitalization.
Some specialists can supply effective medical treatment to a patient without any need to develop even superficial knowledge him as a person, “it might be nice, but it’s by no means necessary.” As they seem strangely disengaged, their patients are often unnecessarily uncomfortable. Nursing isn‘t one of these professions. To perform her duties, a nurse must come to know each patient she serves on an individual basis.
Most laymen are unaware of what is required by a nurse as she routinely deals with a incredible diversity of problems and challenges presented by the patients she serves. The demands upon her communication and inter-personal skills are enormous.
Nurses probably believe that their communication systems are working as well as can be expected under the circumstances. And that may well be an accurate assessment. However, it also seems reasonable that this communication can be improved.
A nurse interested in improvement might find available psychological and sociological publications less than helpful. By and large, like the Groopman book on physicians, they are very light on specific, practical ways to improve. And there is an absence of any significant attention to the special challenges of nurses.
A personal review of one’s communicative skills would be a good start for anyone seeking improvement. A nurse would very likely find, among many personal strengths, behavior that could and probably should be changed. Maybe only modest changes, a “tweaking,” of the nurse’s communicative skills, would be all that’s necessary.
An inventory of essential communicative skills would be a good starting point. Such a listing, “Twenty Suggestions for Improvement,” has been developed with that thought in mind. These suggestions provide definitions, examples, and a format for changes in nurses. A nurse may gauge how her behavior stacks up with the suggested positive behaviors. Then, in the spirit of a very old song, she could “accentuate the positive” while “eliminating the negatives” as she progresses on the road to personal and professional improvement.
Ultimately, the usefulness of “Twenty Suggestions for Improvement” will be determined by the experience of those nurses who feel that this approach has merit and are willing to try it out.
While nurse/patient communication remains a very serious subject, Twenty Suggestions for Improvement have been phrased in a breezy, banter-laden, light-hearted style. It is believed that this approach increases the likelihood that these writings will be read and utilized.
Twenty Suggestions for Improvement
John R. Thurston, Ph.D., Clinical Psychologist
1. First Serve
The nurse should take some time to prepare for the initial meeting with a patient. There is no second chance to make good first impression. Aside from washing hands and straightening apparel, what does she do? What else could or should she do? One should consider a friendly smile, a greeting to the patient by name, an introduction of one’s self, a statement as to your purpose, making inquiry into patient needs, and then making sure that there will be a timely response. Once these essentials have been accomplished, one might provide an opportunity for some small talk or “chit chat“, e. g.. “Do you come from around here?” “What kind of work do you do?” Never underestimate the importance of casual conversation in putting a patient at ease.
2. Listen, my children, and you shall hear……………………………
It is said that ordinary, everyday listening is a lost art. There is a great deal of substance to that charge. Many people talk, but only a few really listen. There is little dialog. The term “duolog” may be more appropriate, i.e a person listens only to determine when the other person stops and he can begin to talk. With very real time constraints for the medical professional, there is no question that sensitive and insightful listening is often hard to initiate and sustain. The works of Groopman attest to this.
Limited “allotted time” is an important consideration in any communicative process. There is always a lot to cover. If one talks rapidly, many “things” can be covered in a short time. But a hurried approach may fail to communicate much of anything. If the nurse is talking, she isn’t listening. Attentive listening is required to judge the level of the patient’s understanding. Important clues as the nature of some previously-undetected physical/psychiatric problems might pop up in this process.
“Silence is golden” But in a “cost effective” age. some practitioners would reject this observation out of hand; they may feel that any silence on their part represents wasted time.
Many important things may go on during the silent moments in a nurse/patient interview. It takes time for some patients to talk comfortably. This is especially true if a patient doesn’t talk easily about anything and becomes absolutely tongue-tied regarding sensitive, personal issues. While some patients will never loosen up, they are most likely to do so in a laid-back, relaxed atmosphere. This is difficult, but not impossible, to accomplish while working under the constraints imposed by a tight schedule.
The KISS acronym is common in other quarters that deal with communication, rehabilitation, and choices of life style. “Keep it simple, stupid.” As conveying information is an essential part of the nurse/patient dialog, she should probably select three or four basic, essential facts that must be understood by the patient if he is to be well-served. “Basic” and “understood” are key words in this. A mistake could be made if the nurse “assumes” (see #8 to follow) that a patient understands a simple, basic concept that can serve as a starting point and he may have “drawn a blank.”
Too often, a nurse may be required to “translate” or correct what the patient has allegedly heard from a physician or other professional. Without a very “basic” understanding of elementary ideas and concepts, any elaborations may be so much gibberish, a mish-mash of information that the patient finds confusing, unsettling, and even overwhelming.
“Patient feedback” is essential. Then, and only then, will the nurse be able to determine how successful she has been in communicating basic information. It would be helpful for the nurse to say “Now, tell me, in your own words, what I have just said to you.” The answers may be shocking, disheartening, or reassuring. If there is need, subsequent statements may be directed at expansion or correction of what has not been conveyed clearly and fully. If the patient has understood very little, it may be necessary to start all over again using a different approach. “If at first, you don’t succeed, try, try again.”
4. It ain’t what you pour out of the pitcher, it’s what gets in the cup !!
Perhaps only a precious few patients are able to understand and accept all the unvarnished facts describing their condition (See #5 to follow). However, there is the possibility that many might feel the need to create that impression. They wish to avoid offending the nurse and/or appearing stupid.
The nurse isn’t dealing with an empty vessel. The patient has all manner of well-entrenched ideas about himself, ailments, doctors, life, and his presenting problem. And while there is a likelihood that some of these views are unsupportable, they are not so regarded by the patient. And even if the nurse were fully aware of these entrenched viewpoints, “talking a patient out of these ideas” could be an exasperating and unsuccessful waste of time. “A man convinced against his will, is of the same opinion, still.” The roots of these beliefs are often very deep and not easily amenable to change.
The effectiveness of models, drawings, pictures, computer representations, and other props in “communicating,” is exaggerated. What is “plain as the nose on your face” to the nurse may be as downright mysterious to the patient. From his standpoint, their complexity might become part of the blur that is a failed dialog.
The new role of the omnipresent computer demands extensive study and consideration. It portrays results and opinions concisely and clearly. However, it can be something of a “third party” that interferes with basic interpersonal communication. For openers, eye contact between the nurse and the patient, an essential in such communication, is clearly diminished. In a way, that which is portrayed on the screen becomes the distanced-patient, a third party whose problems are to be understood and treated.
In addition to all of the above considerations, there are often strong psychological needs on the part of the patient to deny the reality of his illness and what he must undergo as part of his treatment. There is no denying the importance of denial as one attempts to understand others. When these powerful psychological needs are operative, they further diminish the likelihood of an effective diagnostic interview.
5. An empty pitcher does not guarantee a full cup !!
This is an elaboration the position introduced in #4. If the nurse senses that the patient doesn’t understand something, she must resist the temptation to keep talking, telling the patient more and more of what he didn’t understand in the first place. “Do you have any questions?“ is an insufficient means of determining what the patient really understands. If the patient shakes his head “no,” it could be that he may not have understood enough to pose a meaningful question. If the nurse doesn’t consider this latter point as a possibility, she may plunge ahead exploring new ideas, positing possible outcomes, including “worst case scenarios.” The nurse may then be “as pleased as punch” by this tour de force, satisfied that a good job of communication has been accomplished. If she routinely believes this, she will often be deceived.
I believe that three stories are at least vaguely related to some of the above:
1) A preacher, as he prepares his Sunday sermon, pencils in a reminder alongside one of his passages: “Argument weak, yell like hell !!”
If the nurse begins to feel that she is not getting through to the patient, she should avoid the temptation to “up the ante” and increase the force and volume in her presentation. This might take the form of a more serious and determined repetition of things that have already been said, louder and more strident expressions, and stern eye contact designed to get the complete attention of the patient. If this takes place, the patient will be cowed and will remain uninformed.
2) A father responds feverishly to a question by his ten-year-old son “Dad, where did I come from?” For the father, this is a moment of truth. The embarrassed, unsettled, and perspiring father rattles on for an feverish half hour in an effort to answer that question, “explaining” all about birds, bees, boys, girls, sperm, ova, menses, the necessity of protection, VD, etc. Then, exhausted at the end, and only at the end, he finally runs down and asks an important question, one that he should have asked up front. “Why did you want to know?” The boy replies “Well, there is this new kid at school. He says that he came from Detroit. And I wanted to know where I came from.”
3) A little boy asks his mother “Mommy, how do you get babies? ” Mommy answered the question at some length. It developed later on that she thought that he had said “rabies” instead of “babies.” Credit Woody Allen.
Re 2 and 3:
Forceful answering of unasked questions is a waste of time.
6. The only way to consume an elephant is one bite at a time.
This can apply to a nurse’s attempt to educate a patient. Modest goals should be set initially, moving ahead only when it has been demonstrated that these goals have been achieved. The process might be described as proceeding with glacial speed in the absence of glacial certainty. Never overestimate the patient’s ability to understand and assimilate unfamiliar material.
This view also applies to a patient’s acceptance of his diagnosis and his treatment. It sometimes takes time for the patient to come to grips with his circumstance. He must be encouraged to believe that this is o.k. to take one’s time.
Some patients would be shaken to the core as they begin to realize fully all that is involved in their diagnosis and the proposed treatment program. For example, if a treatment program involves 42 daily radiation treatments for prostate cancer, stretching over many weeks, replete with all manner of possible significant negative side effects, this could pose a formidable, frightening future for the patient.
However, if the patient is encouraged to “take it one day at a time,” or “one step at a time,” these frightening pronouncements become far less threatening and more “doable.” In due time, each next step should be made clear, scheduled in the form of an appointment. If the patient accepts this approach, what might be a daunting, distant goal may become a bit easier and more attainable. He will be able to focus on the next step to be accomplished; then deal in sequence with the ones that are to follow. “A journey of 10,000 miles begins with a single step.“
Psychological reassurance in the form of proper back-up/assistance should be provided; he should know exactly what is to be done if he experiences problems. The clear-cut certainty of such help might promote self-reliance and do much to under-cut any unnecessary needs to seek it out.
7. Patois Patter
As the nurse “walks the walk” in her interactions with patients, it becomes necessary that she “talk the talk.” She must become conversant in the language of the natives, her patients. There is a danger that all medical personnel, immersed in their diverse medical practices, will come to rely unduly on the technical language of medicine. To patients and many others, such expressions may be incomprehensible jargon. It becomes mandatory for the nurse to become aware of current slang and local idioms. If she doesn’t, she may deny herself important information from her clientele. From time to time, both nurse and patient could each be speaking in something of a foreign language to one another. (See Suggestions 3, 4, and 5 above).
8. A Check-ered Life
In initial patient contact, there may essentials that must be accomplished. These might be questions to be asked, diagnosis and prognosis to be discussed, the medications prescribed, appointments scheduled, and other matters. On what are probably rare occasions, some of these important matters might be inadvertently omitted. The reasons could involve the nurse’s fatigue or boredom with routine. Unexpected events and materials might distract her from some essentials. A routine checklist, prepared in advance, might be helpful. It need not be read to the patient. But it could provide a focus for the nurse/patient interchange. . It might be a “security blanket” for the interviewer. And this would routinely support an orderly, efficient transmission of essential information.
9. Making an “ASS out of U and ME”
Assume nothing !! If one assumes anything important about a patient without making concentrated inquiry and/or gathering corroborative evidence, she runs the risk of making major mistakes. Genuine humility on the part of the professional has a lot going for it. It is perfectly permissible for the nurse to admit that 1) she lacks a full understanding of patients and their circumstance, and/or 2) that patients may have only a hazy idea of what is being said to them by medical personnel.
10. Semper Paratus (“Always Prepared”)
Always be prepared for the unexpected. To paraphrase the poet Robert Burns a bit, “The best laid plans of mice and men often go astray.“ When interacting with a patient, the nurse should always have a back-up strategy in light of changes, a Plan B, C, or D. An opening strategy just may not work. She must be flexible and roll with the punch. While perseverance is a virtue, “perseveration,” i. e to keep repeating what is not working, is an exercise in futility. Indeed, one definition of “insanity” describes an insane individual as one who keeps doing the same ineffectual thing over and over again as she proceeds in the belief that she will be successful the next time.
11. “Nurse, Be Thyself”
No nurse should mechanically implement a formal “program” or “script” involving interactions with patients that she has read about. She is, first and foremost, a human being, not a robot. No one should do anything with a patient merely because “she is supposed to do so.” After considering a full range of suggested interpersonal techniques, the nurse should then use only those which she can employ comfortably and naturally. If the nurse has difficulty doing the things that she knows work well for others, she might then ask “why?” and set about to find the answer. That sort of thinking is helpful in achieving both personal and professional growth.
12. Winging It
The nurse should feel free to stray from the “straight and narrow” on occasion as she attempts to capitalize on her own unique communicative and inter-personal strengths. As long as “The Hippocratic Oath” is in place and observed, such ventures should be encouraged. They could promote personal and professional growth. Thinking and acting “outside the box” have on occasion led to some truly positive results.
13. “How Am I Doing?”
How does a nurse detect the scotoma or blind spots in her communication and interactions with others? Unless she is committing glaring errors, colleagues and associates might be reluctant to point them out to her.
“Fine tuning,” the tweaking improvement strategy, requires some objective means of identifying any subliminal “soft spots” in one’s performance. After all, if these were known, she would probably have taken corrective steps already. Reading relevant literature or listening to colleagues/patients might be helpful. Simple psychological test information, notably of the sentence completion variety, could easily provide such feedback from patients, e.g. “My nurse helps me when……….” or “A nurse really annoys me when……….” There is nothing sacrosanct about creating such a test; nurses could gather together to fashion such sentence beginnings. The patient may be asked to complete such “sentence stems” in order to obtain feedback about a specific area of concern. Some nurses might be reluctant to make such inquiry. But for those seriously interested in personal and professional growth, occasional “reaching out to others” and consequent reflection would appear to useful.
Few know better about the pressures on a nurse than her colleagues. staff surrounding her. Ever “busy,“ she may appear harried and unhappy from time to time. And, with the best of intentions, fellow professionals may set about to be helpful. They may take it upon themselves to deal with humdrum details, those that might otherwise interfere with the nurse’s concentration on more important matters. They may also ward off an occasional nagging or rambunctious patient.
There is a possible downside to this well-intentioned protectionism. The basic problem may remain unaddressed and unresolved.
15. Multiple Personalities
When two or more professionals become involved in one patient’s case, it becomes imperative that they communicate clearly with one another----and then, most importantly, with the patient. The diverse messages they lay upon the patient might be confusing. They should arrive at something of a consensus as to how to proceed. They should speak as one. All should be on the same page. And the patient must be able to comprehend and accept what is said on that page. He shouldn’t have the burden of reconciling any differing views and opinions that may have been expressed.
These are regularly scheduled meetings on a given Service, perhaps held every three or four months. The topics could center about professional /patient communication, e.g. “Twenty Suggestions for Improvement,” problems, what has been attempted within the Service by way of improvement, how successful have these efforts been, and any new proposed solutions. There is no need to wait for the next Press Ganey or Avatar testing to provide impetus for such discussions. If there is interest, attendees might discuss the writings by Groopman, and then enter into a spirited discussions about the results, their validity, and the practical implications. Free expression, catharsis and collegiality among “equals” are encouraged in such exchanges. Being “too busy” to attend is an unacceptable excuse. There is always time to do what one considers important.
The words of Groopman may have sent shock waves amongst the multitudes of patients. Physicians were singled out for criticism. According to Groopman, misdiagnosis and consequent mistreatment may run rampant. If these assertions are believed by patients, they might have problems in developing and maintaining any meaningful trust in their doctors and nurses. Although Groopman claims that he points out shortcomings in order to promote improvement, this tactic may not work in the real world of medical practice.
Are there physicians and nurses who would step forward to challenge the elements of Groopman’s position and any complaints about nursing practices? All have a vested interest in refuting or confronting any charges leveled against them. How many will step forward to do so? If there are none, why is this? Many would opt out because they are “too busy.” But even the busiest could find time if they considered some response to be important. Do nurses lack a forum? Very probably. Do they need one? Yes!
The title of this suggestion has something of the double entendre about it. It is first and foremost a call for nurses to “speak out” boldly and candidly about any potentially contentious medical issue. But it could mean that they are already “out spoken” in the sense that anything that they might have to say remains unspoken, that the stage has been surrendered to others with louder voices who avail themselves of broader forums. This is sad, too many merely “go along so as to get along.“
18. Anger Management
At times, physician or nurse frustration is the name of the medical game. One such time occurs when there has been a failed attempt to “fully inform” a patient regarding the diagnosis of and prognosis for his condition. And the targeted patient may be “a few bricks shy of a full load.” Or he may be belligerent or disturbed. Or he may have had some bad experiences.
It’s imperative that the professional “take a strain” or “take it easy” personally. “Gunny-sacking” or containing one’s anger must be avoided. “Burn-out” may result from this over time. Verbal expression of one’s anger or frustration to a colleague is a valuable exercise. Expressing these feelings in the presence of a patient is counter-productive and must be avoided.
There is a common source of frustration, This takes place when the nurse has “gone all out” for the patient. She has tried everything; exhausting herself in the process exhausted every resource. And yet, the patient fails to convey any awareness or appreciation for what has been done for him. Indeed, such a patient might repeatedly and loudly proclaim his dissatisfactions with “the sub-standard care” accorded him by “over-priced, lazy, and incompetent” nurses “who bother him for no good reason.”
The nurse must realize early on that she is probably destined to be regarded as a disappointment to some patients. “It goes with the territory.“ It might or might not have something to do with her personality, credentials, or professional conduct. But all too often, “the fault, dear Brutus, lies not in our stars…..” but in the eyes of the beholder,” her patient. Unrealistic, unwarranted patient expectations are central to this problem. Patients want more from their treatment than can be delivered. They really want to be treated by a Dr. Marcus Welby, a fictional TV character portrayed by the late Robert Young. Dr. Welby was all-knowing, all-caring, and always available. The enlightened and compassionate concern that he provided a single patient was impressive to the point of being overwhelming----and unbelievable. To do what he did routinely would have required that his practice be limited to just one patient. And he did everything all by himself. He never showed any need to rely upon any nurses, fellow physicians, professionals/ paraprofessionals, or other resources. In real life, of course, there are no Dr. Welbys, doctors who could be depended on to solve all their patients physical and psychological problems. And there never were! This kind of thinking on the part of patients may carry over to nurses as well. Patient denials notwithstanding, they may be looking for the idealized nurse that many patients continue to want and think they need. With this unrealistic expectation, it is small wonder that they find themselves so often disappointed by the services provided. In the face of all of this, the nurse is encouraged to “hang in there,” the rewards must be internal, I\i.e. she knows that she is right.
19. “Let It All Hang Out”
The previous Suggestion dealt with the frustration and anger that may be experienced by the nurse from time to time.
This deals with the emotional reactions of patients to the information supplied to them by their diagnostician. This communication may, on occasion, be very threatening and unsettling. Perhaps too often, patients, particularly men, feel a need to minimize the fear and emotional impact that this has upon them. Although they may be close to psychological collapse as they leave the examination room, they feel impelled to “keep a stiff upper lip A nurse should do whatever is necessary to under-cut and eliminate this need. “Permission” to express fears, frustrations, anger, and depression should be encouraged. Cathartic expressions, such as this, can be a great help to patients
20. Touch and Go
Although we live in an age when any physical contact with a patient might be construed as a sexual overture, “the touch of a healer” should never be underestimated. A nurse’s warm, welcoming handshake or an arm across the departing patient’s shoulder can do wonders to reassure a patient, to convince him that he is being treated by a compassionate human being who genuinely cares about him.
Reality Check: In light of all the possible problems areas described in this “Twenty Suggestions for Improvement” presentation, it seems remarkable that so many nurses are so consistently and effectively able to communicate an enormous amount of complicated information, essential support and competent counsel to their patients.
Can nurse/patient communication be improved? Yes !!
Should it be improved? Of course !!!