Nurse-patient conversations: compassionate communication while social distancing
Finding new ways to meet patients’ needs when face-to-face care is not an option
- The COVID-19 pandemic has changed the ways many nurses interact with their patients, with phone or online conversations taking the place of face-to-face consultations
- Nurses have had to work around the limitations of PPE to pick up on patients’ cues, and rely heavily on effective verbal communication
- Tips for communicating empathy and compassion when having difficult conversations with patients and their families
Communicating compassionately has always been a part of nursing – the difference in a time of COVID-19 is that so much of it has had to be done via the phone.
This has caused consternation among a workforce that has become accustomed to identifying and acting on patients’ cues.
Nurses have needed to adapt their skills for remote communication
Cues can be defined as the direct or indirect expression of negative emotion that hints at an underlying concern.
Non-verbal cues, such as body language, can aid consultations and ensure that patients’ needs – expressed or otherwise – are met.
Difficult conversations have not been limited to those treating patients with COVID-19. Clinicians in all other specialties have had to grapple with breaking unwelcome news to patients, for example that their much-needed elective orthopaedic surgery has been cancelled or their urgent hospital outpatient appointment for a potentially life-changing eye condition will no longer take place.
Even before lockdown was announced in March, specialists at the Maguire Communication Skills Training Unit, which is based in the School of Oncology at the Christie NHS Foundation Trust in Manchester, were being approached for help and guidance.
At first the requests came in-house from the Christie Hospital – a leading cancer centre – but the unit has also been asked for help by other organisations, including those in primary care.
The principles of compassionate communication remain constant
The good news, according to senior trainer Ali Franklin, is that the key principles of compassionate communication remain the same, whether the interaction is taking place in person or via telephone or an online app.
‘What we’ve been trying so hard to get across is that nothing has changed,’ she says. ‘The cues that we get from patients verbally are often stronger than the non-verbal cues; it’s just that we don’t always notice them.
‘The key skills that help patients disclose their concerns are the skills we use to acknowledge what they’re saying. These are the ones you’d expect – reflection, paraphrase and summary. There’s nothing magic about them.
‘Then there are the skills we would use to explore further, such as open questions, questions about feelings, the use of pauses and silence, and the use of negotiation – asking people “Would you be able to tell me?” rather than demanding that they tell us.
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‘Crucially, it also involves the use of empathy and focusing on the cues that we get from the patient. That’s where the challenge has been with COVID-19. Some healthcare professionals have been incredibly anxious that they will not spot those cues because they rely so heavily on the non-verbal and so much communication is now taking place on the telephone.’
The unit has developed a number of evidence-based resources to assist clinicians with difficult conversations in different care settings.
Tips and resources for telephone discussions with patients
The Maguire Communications Skills Training Unit has published a number of resources. The following principles are taken from its guide on discussing suspected cancer symptoms over the phone (based on the SPIKES model for giving significant information):
1. Elicit the patient’s worries and acknowledge
2. Give a ‘warning shot’ and pause (for example, preface with words like ‘unfortunately’ or ‘sadly’)
3. Deliver the news at the patient’s pace with frequent pauses and with compassion and honesty
5. Elicit questions and new concerns, using phrases such as ‘You ask what this means, what are your worries?’ or ‘You’re crying, can you bear to tell me what’s going through your mind?’
Rediscovering the basics of effective communication
In a way, Ms Frankin concedes, the circumstances caused by COVID-19 have meant going back to the basics of communication.
‘This is what we’ve been teaching for the past 20 years – obviously observe body language but it’s actually really important to listen to what people are saying.
‘Nothing has changed. The cues that we get from patients verbally are often stronger than the non-verbal cues; it’s just that we don’t always notice them’
Ali Franklin, senior trainer, Maguire Communication Skills Training Unit
If someone says “Oh, I’m okay really” then pick up “really”. Say that when you say “really”, maybe it means that you’re not okay. A lot of the work we’ve been doing has been reminding people of these skills that can be used to enable people to disclose what it is they’re concerned about.’
Expressing empathy without using facial expressions
Equally, she adds, people have worried that they couldn’t convey compassion and empathy when on the phone or wearing personal protective equipment (PPE).
‘Again there’s a perception that what we’re relying on is our compassionate body language and facial expressions, and actually there’s a huge body of evidence that says that the most powerful expression of compassion is by verbalising our empathy by naming the emotions that we’re hearing then allowing the other person to confirm and then expand or explain more.’
When someone is encouraged to name the emotion for themselves, the fear response comes down, the emotional response comes down, and the part of the brain that can process information and make decisions becomes more active, she says.
‘It’s a clinical skill that we’re really encouraging people to use, and what we’ve been saying to people is that you can do that from six feet away with PPE, you can do it on the phone – it’s the same skills that you already have, and it’s about trusting them.’
Conversations should not follow a script, but it helps to have a structure
Although the resources produced by the unit have been distributed and used across the country, Ms Franklin stresses that they do not provide a script, and says that nurses should use their judgement when applying them to the patient or relative in front of them or on the phone.
But having a structure for the conversation is useful, she says, not least because evidence shows that gathering all of the person’s concerns before giving information is important.
‘The reason for that is all of us in healthcare have a tendency to want to fix things. So as soon as we hear someone is distressed about something, or has a concern about something, we have a tendency to go straight in with reassurance, advice or information.
‘When I asked newly qualified nurses what their concerns were about going into practice, number one was saying the wrong thing or not knowing what to say’
‘One of the issues with this is that while the person is in a heightened emotional state, they won’t hear the advice or information. But as soon as we go into our information-giving mode, the patient feels “Oh, it’s my turn to be told what’s going to happen” and they don’t disclose other concerns that they may have.’
Encouraging self-compassion for nurses is also a key part of the unit’s work, and it has been running a course aimed at nursing students who entered the workforce early to help in the COVID-19 effort.
Empathy is central to effective communication
‘Empathy again is central to all of it,’ she says. ‘Because what’s interesting is that when you name the (problematic) emotion for the other person and they’re able to acknowledge it, it can be reduced in that person and your own level of stress also reduces. By naming the elephant in the room, both the person witnessing distress and the person experiencing the distress is able to see it and manage it.’
Encouraging newly qualified nurses to focus on what matters to the patient, and to ‘say what they see’ (or hear) in terms of emotions, is important because it is such a valuable clinical skill, says Ms Franklin.
‘We want to boost their skills and confidence so they don’t feel there’s nothing they can say – and when I asked them what their concerns were about going into practice, number one was saying the wrong thing or not knowing what to say.’
This is the case for all of the unit’s courses, whether for newly qualified nurses or the most experienced senior staff, she adds. ‘The worry that you’ll say the wrong thing or that you’ll do more harm than good never goes away.’
Nurses’ verbal skills may become sharpened
The training reminds them of the skills they have, but also gives them strategies to help them to cope, including reminding them of the support on offer in the trust, and avenues of support outside the trust – from their family and friends to more formal things like helplines offered by professional organisations.
‘We give them a very strong message that asking for help, or saying you’re struggling, or it’s been a bad day isn’t a sign of weakness – it’s a sign of resilience,’ she stresses. ‘It’s about finding the appropriate support.’
The evidence isn’t there yet to show if having to do so much patient care without being in the same room will have a lasting impact on nurses.
‘I don’t know if it’s sharpened people’s verbal skills because they’re having to do things on the phone – I don’t know if it’s reminded them that they do have these skills, and that has refreshed them. But the bottom line is that I think nurses are doing a fantastic job in the most impossible circumstances.’
Having difficult conversations about cancer during the pandemic
In more usual times, Helen Johnson, a Macmillan urology oncology clinical nurse specialist at the Christie Hospital in Manchester, conducts the vast majority of her patient care face to face.
When routine cancer treatment was halted at the tertiary centre where she works, her role changed, becoming almost entirely telephone based. This has been particularly challenging because of the circumstances – many patients have had to come to terms with delays in surgery, for example, or have had life-extending treatment postponed.
‘The pandemic has meant we were no longer seeing patients face to face,’ she says. ‘Normally we go up to the ward every day, to check out the inpatients, but we couldn’t do that. Normally we’d be seeing new patients face to face, but we weren’t doing that, and we weren’t doing any of our aftercare, or running our face-to-face clinics. We were literally on the phone all day long.’
Patient needs can be missed during telephone consultations
When COVID-19 disrupted services, the nurses rang all their patients individually. ‘They were very distressed. A lot of them rightly said that “when I first got diagnosed you told me that having chemotherapy was really important to extend my life and keep my disease under control for longer, and now you’re telling me that I don’t need it – what’s that about?”.’
Even in ‘normal times’, as she puts it, the team conducts some follow-up clinics by phone, which means they are already skilled at gathering information without the visual cues of being in the same room as the patient. ‘This is a completely different bag, and it’s more difficult: you’re talking to people about stopping treatment, and also to brand new patients who have just been diagnosed.’
‘It’s difficult to pacify someone on the phone, and it’s also difficult to have silences, when really, quiet times are often part of conversations’
Helen Johnson, Macmillan urology oncology clinical nurse specialist
Developing skills so that you can have successful telephone consultations is important, she says, and she advocates the principles of asking open questions, ascertaining what a patient knows and understands, acknowledging their feelings, and making skilled use of pauses. ‘It’s not a pitter-patter conversation,’ she says.
‘Sometimes verbal communication, and even hearing people properly is difficult. It’s difficult taking cues from people. Some patients don’t feel they can ask things when they’re not face to face, so it feels like sometimes needs might get missed. Often you’ve never met them before either – you’re brand new to each other, so you’ve no rapport even to kick off with. It’s difficult to pacify someone on the phone, and it’s also difficult to have silences, when really, quiet times are often part of conversations.’
She believes that compassionate communication is not just important when talking to patients and relatives but also with colleagues and within the wider team. ‘We really need to be talking to and caring about each other, and realising that some people are finding things really difficult.’
Jennifer Trueland is a health journalist