By Jennifer Larson, contributor
April 29, 2012 - Do you ever feel like a patient is holding something back? That he or she isn’t telling you something that might be important? Your instincts might be correct, as it’s fairly common for patients to avoid speaking up about some things that they are feeling or experiencing.
Maybe they’re not telling you about all of their symptoms. Or that they’re not taking their medication. Or that they don’t exercise as much as they claim to (or at all). Or that they’re concerned about something they read on the Internet. Or that they’re taking some supplements, or even illicit drugs, and they don’t think you’ll approve. Or, in the hospital setting, that they are scared, lonely or uncomfortable.
Or they might not completely understand what you’re telling them, but they’re reluctant to admit it. Health literacy is a significant problem in the United States, with nearly nine out of 10 adults lacking all the skills and knowledge they need to use and understand health information, according to the National Assessment of Adult Literacy.
“I think we have assumed that the patient could ask questions, but what we have learned is that there are many reasons that patients don’t ask a question,” said Suzanne Rita, MSN, RN, improvement learning network manager for Iowa Health Systems’ Center for Clinical Transformations.
What can you do to reach out to your patients, to show them that you are genuinely invested in learning more about them so that you can help them?
Consider these steps to help bridge the communication gap.
1. Use plain language.
The “medical-ese” that many health care providers tend to use doesn’t help the situation. Medical jargon may seem like simple shorthand for health care professionals, but it can be bewildering for many people, especially the ones with low health literacy.
Linda Brixey, RN, says, "Nurses can ask open-ended questions that require more than a 'yes' or 'no' answer."
“They just don’t understand the language that we talk,” said Linda Brixey, RN, president of the American Academy of Ambulatory Care Nursing (AAACN). “It makes sense to us, and (often) the patient will just nod and say, ‘Yes.’”
Consider the words you’re using to describe your patient’s condition and treatment plan--and try to use more conversational language. A recent health literacy manual for clinicians from the American Medical Association describes this as “living room language.” Instead of saying “analgesic,” say “painkiller;” say “high blood pressure” instead of “hypertension.”
Additionally, some patients may not read very well but are embarrassed to admit it. That can be especially problematic if you give them handouts to read at home, so if you determine that a patient’s literacy is a stumbling block, you may need to find another strategy.
2. Ask patients to prepare in advance.
Short office visits make it challenging for clinicians to address all the needs that their patients may have. One way to speed up the process in the practice setting--and ensure more complete information to start with--is to request that patients write down their questions in advance.
In 2011, the Agency for Healthcare Research and Quality (AHRQ) launched a campaign called “Questions are the Answer” to promote better two-way communication between providers and patients. The first phase of the campaign encouraged doctors and nurses to request that patients write down a list of questions and concerns prior to their appointments. If your patients are able to read and write, encourage them to prepare a list. They can list symptoms they’re experiencing, or side effects from their medication, or questions they have about their condition. Then you can structure your time with the patient around these questions and concerns.
Even in the hospital setting, patients or their family members can write down non-urgent questions or concerns between medication passes and rounds.
Beth Galik, Ph.D., CRNP, notes that it's important to ask patients the right questions with respect and professionalism.
Another benefit of this method is that it can help you figure out what’s most important to your patient. According to Elizabeth Galik, Ph.D., CRNP, president of the Gerontological Advanced Practice Nurses Association, this goes along with determining your patient’s goals, which can help you achieve better outcomes.
Additionally, ask patients to bring along all their medications on their next visit, or have a family member bring them to the care team if the patient has been admitted to the hospital.
“Bringing in those medicines and supplements in a brown bag is helpful,” Galik said. “That way you can go through them and you’re not relying on their memory or a list.”
3. Learn to understand cultural differences.
Often, nurses work with people from cultural backgrounds different from their own. The patients may have completely different ways of expressing respect or agreement, and the nurse may need to learn more about their communication methods--especially their nonverbal communication.
“The eye contact is important for me because it really says, ‘I’m here, I’m engaged, I’m listening,’” said Beth Lincoln, MSN, RN, NP, president of the Transcultural Nursing Society and author of the book Reflections from Common Ground.
But some cultures do not view direct eye contact that way, she continued. They may in fact be paying close attention to you but will only make direct eye contact sparingly. “It’s showing a sign of respect because nurses, physicians and health care people are all held in high esteem,” she said.
A nurse who learns to understand those kinds of nonverbal cues and work with them can facilitate better communication between herself and her patients. The nurse should also examine her own communication style to see how she might come across.
“I encourage them to observe the style of the person they’re going to interact with,” said Lincoln. “And then they find some common ground with that person.”
4. Avoid appearing judgmental.
"Sometimes, the way we word something can come across as judgmental or can be perceived as judgmental by [patients]," said Brixey. And that perception can affect communication.
Patients who feel shame, embarrassment or distrust are less likely to speak up, so it’s important for nurses and others in the care team to remain vigilant about what they say to and around their patients, refraining from voicing personal opinions that aren't constructive.
Creating a supportive, shame-free environment helps encourage questions and honest responses, and keeps the lines of communication open.
5. Use the teach-back method.
The teach-back method essentially involves teaching or explaining something to a patient--when to take a medication, how to test blood sugar levels, etc.--and then asking the patient to explain back to you what you just told them in his or her own words. It’s sometimes also called “closing the loop.”
“We know that teach-back is a very important strategy to understand if our patients really understand,” said Rita.
Iowa Health System received a grant from the Picker Institute to implement an “Always Use Teach-Back!” initiative. With the funding, Rita and her team are educating and coaching the staff on using the method. They’re also creating a virtual toolkit that will eventually be available to other health care providers interested in learning more about how it can improve communication and outcomes.
One important component is asking open-ended questions. It’s too easy for a patient to respond with monosyllables if you ask them a “yes or no” question, but an open-ended question can begin a dialogue.
“If I say, ‘Tell me what’s bothering you today,’ I get a lot more information,” Brixey said.
Added Galik, “If you ask the right questions, people will generally answer you honestly.”
Using the teach-back method also gives you the opportunity to learn if the patient understands what you’re asking them.
“If the patient can’t tell us, then it’s our opportunity to rephrase it somehow so the patients do understand it,” Rita said.
Teach-back isn’t hard to use, she added, but it may require some behavioral changes. You may have to practice to get comfortable with it.
“It’s just like any other habit that you want to change.”
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