As respiratory therapists, effective communication is an essential part of our day-to-day activities. A breakdown in communication can result in unexpected or unwanted outcomes, as shown by the following examples.
Scenario #1
I received orders to get a sputum sample for C&S from an elderly retired farmer. A review of the chart showed that the patient could spontaneously cough and was very cooperative and participative in his care.
After collecting the lab requisitions, sample labels and sputum collection jar, I approached the patient and explained that I needed him to cough and spit into the jar. He was asked to only expectorate lung secretions into the jar and avoid depositing saliva. I asked him to notify the nurse once he had done so and said I would be by to collect the sample for processing. I opened the jar and placed it on the bedside table.
The expected outcome: a successful sputum sample to facilitate a better diagnosis. The actual result: I received a call from a very angry nurse who stated, “It is your fault, your mess and you clean it up!” On entering the room, the sputum jar sat exactly where I left it (in the center of the bedside table) surrounded by spattering of sputum over the whole tabletop. Apparently, in his attempt to comply with my instructions, the patient had expectorated sputum and attempted to spit it into the jar from his recumbent position in bed! Yes, I cleaned up the mess and learned a valuable lesson about communication.
Scenario #2
I received a page from the vascular step-down unit to assess a patient for exertional hypoxia and the need for home oxygen. The senior resident on call had written the order in preparation for possible discharge.
On arrival, the chart was reviewed and all indications supported the pre-discharge assessment and plan. Further review identified one challenge: The patient was a bilateral total leg amputee and, although willing, physically unable to ambulate. Paging the resident and speaking to him on the phone, I explained that I was unable to carry out his orders and that an alternate method of testing would be required. The resident was very angry and insisted that his order was valid and asked if I was refusing a valid order. At this point, the conversation could have gone many ways. However, after a brief discussion the resident understood the challenge and (although a bit embarrassed) wasagreeable to the alternatives offered. After 10 years, he is now an intensivist and still chuckles about the discussion and the lesson he learned about communication.
Communication Strategies
The importance of effective communication in healthcare has been written about extensively. Communication plays an essential part of reducing or preventing litigation. “It reduces the chances of a breakdown in continuity of care, builds relationships and understanding. The majority of negligence cases are not related to the clinical quality of care but are triggered by an inadequate communication.” [1]
More often than not, it is not what you did but what you said that is the root cause of the problem. Explaining your visit to the patient should build on the PURE communication strategy[2]
Purposeful–What is the reason for your visit? Who are you and what is your role in the patient’s care?
Unambiguous–What will the visit entail? Explain physical assessment, lab testing, therapies, how long they will take to complete and the expected outcome. Are there potential risks involved and, if so, what are they?
Respectful–Listen to the patient, demonstrating that you understand their questions, concerns and needs and that they are an important part of the care plan. Can you satisfactorily answer their questions or can you get the answers they seek? If not, what can you do to help and how will the patient know you have taken action on their behalf?
Effective–Summarizing actions, discussions and conclusions with the patient ensures that there are no gaps in communication and that the patient has a clear understanding of the care they received.
The PURE communication strategy is very similar to the SBAR and AIDET methods. SBAR employs :
Situation (introduction and reason for visit);
Background (who you are, what is your role in their care, what is your understanding of why you are seeing the patient and how long your visit will take);
Assessment (what conclusions you have developed from your assessment of the patient andtest results);
Recommendations (what actions you are recommending).
AIDET employs:
Acknowledge (the patient by full name);
Introduction (introduce yourself, explain who you are and why you are seeing the patient);
Duration (how long your visit/care will take);
Explain (explain what you are planning on doing, why you are doing it, what it means to the patient, the expected outcomes during and after the visit);
Thank (thank the patient and summarize the visit).
All of these systems are effective tools to help ensure that your communication with the patient is understood by both you and the patient. It is not enough to believe that the patient understands what you have said; you must take steps to ensure that the patient can explain to you what was communicated to them. The effort you put into your communication strategy ensures that you build a stronger relationship with the patient. “Patients are not likely to sue physicians with whom they developed a trusting and mutually respectful relationship.”[3] This statement is true for any member of the healthcare team. Mutual trust and respect, earned through your interactions, enhance the perception of the quality of care received and your ability to communicate with the patient.
Communication Errors
Failed communication is one of the major causes of the perception of and actual gaps in care. Four common errors in communication can lead to these gaps.[4]
- Not staying on focus–Stick to explaining the reason for your visit and avoid being sidetracked with other issues. If a patient raises another issue or concern, take note of the concern and explain to the patient you will attempt to address it at the end of the visit. Keeping a written note helps the patient see that you are taking their concerns to heart.
- Failing to educate–Failing to ensure that the patient understands the when, where and why of their care will undermine their trust and respect for you.
- Not enlisting the patient in their care–Failing to get the patient involved (understanding the concerns, routines, habits and choices) in their care rapidly creates barriers to the care being delivered.
- Not building the relationship–Missing opportunities to share decisions in care and build trust results in a patient not trusting the care and care team. This suspicion and exclusion from decision making results in the patient feeling the need to exert more protective control over their care, and miscommunication opportunities increase dramatically.
Effective communication starts with your decision to use a standardized approach to communicating with the patient. It is within your control to avoid breakdowns in communication and to effectively deliver care to the patient while maintaining a strong, respectful, therapeutic relationship. Your actions can ensure that the patient understands and is satisfied with the care you provide..
References:
1. T Hegan. The Importance of effective communication in preventing litigation. . Med. J. Malasia. 2003 Mar; 58 suppl A:78-82.
2. SM Gephart, M Cholette. PURE communication: A strategy to improve care coordination for high risk birth.. Newborn and Infant Nursing Reviews. June 2012, Vol 12:2, 109-114.
3. B. Huntington, N. Kuhn. Communication gaffes: a root cause of malpractice claims. . . . . Baylor University Medical Center Proceedings. Apr 2003, V12 (2).
4. SR Eastaugh. Reducing Litigation Costs through Better Patient Communication. The Physician Executive. May-June 2004, 36-38.
