ABC of Clinical Communication E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ABC Series
• Sprache: Englisch

Seitenzahl: 230

Veröffentlichungsjahr: 2017

Beschreibung

Clinical communication underpins safe patient care. The effective health professional sees illness through the patient's eyes and understands what matters most to him or her. Effectiveness means gathering hard clinical data about the physical changes affecting the patient, understanding why the patient is concerned, conveying this to other health care professionals and involving the patient at every stage of management decisions. The evidence for good clinical communication is well established, although there are challenges. While listening is the basis of sound diagnosis and clinical reasoning, its absence affects patient outcomes particularly when patients are not permitted to make their concerns known or when there are gaps in information flow or communication between the professionals caring for them. The ABC of Clinical Communication considers the evidence pertinent to individual encounters between patients and their health professionals, how to achieve efficient flow of information, the function of clinical teams and developing a teaching programme. Topics covered include: * The consultation * Clinical communication and personality type * Shared decision making * Communication in clinical teams * Communication in medical records * Communication in specific situations, including mental health and end of life * Teaching clinical communication The chapter authors are clinicians involved in communicating with patients, research and training healthcare professionals of the future. This team reflects the multidisciplinary approach required to develop effective clinical communication.

Leseprobe

Table of Contents

Cover

Title Page

Preface

Contributors

CHAPTER 1: Why Clinical Communication Matters

Clinical communication – a historical perspective

Effect of communication on patient outcomes

Training and feedback

Communication between professionals

Written records

A caring environment

Conclusions

References

Further resources

CHAPTER 2: The Consultation

Introduction

Evidence‐based communication

Models of the consultation

An example of the importance of the model in practice

Conclusions

Acknowledgements

Reference

Further resources

CHAPTER 3: Communication and Personality Type

Introduction

Jung’s theory of personality type

Are doctors’ preferences different?

How type differences relate to communication

Acknowledgement

References

Further resources

CHAPTER 4: Shared Decision‐Making

Introduction

What is shared decision‐making?

Shared decision‐making and evidence‐based medicine

Communicating information about risk

Strategies for encouraging shared decision‐making

Steps to shared decision‐making

Presenting information to patients

Health professionals’ training and development needs

References

Further resources

CHAPTER 5: Communication in Clinical Teams

Introduction

Human factors

Optimising team communication

Conclusions

References

Further resources

CHAPTER 6: Communication in Medical Records

General Medical Council perspective

The National Health Service code of practice

Medical note‐keeping and mortality data

Medical note‐keeping and payment

Simple tips for good medical note‐keeping

Letters and discharge summaries

Legal aspects of medical note‐keeping

Multidisciplinary records

Medical notes as a handover tool

Electronic patient records

Personal held records

Conclusions

References

Further resources

CHAPTER 7: Advanced Communication for Specific Situations

Paediatric consultations

Difficult behaviours: the angry or violent patient

Language barriers

Exploring safeguarding concerns

Young people, risk‐taking behaviours, consent and confidentiality

Chronic disease

Seldom‐heard groups

Conclusions

Further resources

CHAPTER 8: Communication and Mental Health

Introduction

Trust, respect and rapport

Brief ordinary effective communication

Understanding the context

World view, culture and class

Identifying and alleviating anxiety

Resolving conflict in communication

Communication in dementia and delirium

Conclusions

References

Further resources

CHAPTER 9: Communication at the End of Life

Introduction

Timing of end‐of‐life communication

Preparation for end‐of‐life discussions

Empowering patients and caregivers

Dealing with disparate information needs

Discussing palliative care

Discussing life expectancy

Advance care planning

Do not attempt CPR orders

Conclusions

References

Further resources

CHAPTER 10: Teaching Clinical Communication

Introduction

Engaging students

Clinical communication is teachable

Planning a curriculum – choosing a model

Defining the sessions – what needs to be taught?

Tutor groups

Feedback

Role of simulated patients

Marrying process and content

Presentation skills

Role of this model in experiential inter‐professional learning

Conclusions

Acknowledgements

References

Further resources

Recommended Books, Articles and Websites

For students and teachers

Academic

Articles

Websites (all accessed January 2017)

Index

End User License Agreement

List of Illustrations

Chapter 01

Figure 1.1 Evolution of the doctor–patient relationship.

Figure 1.2 Factors influencing patient‐centredness.

Figure 1.3 Model of behaviours linked to higher patient satisfaction.

Chapter 02

Figure 2.1 A ‘comprehensive’ clinical method.

Figure 2.2 The curriculum wheel for clinical communication.

Figure 2.3 The Calgary‐Cambridge guide – basic framework.

Figure 2.4 The Calgary‐Cambridge Guide – the expanded framework.

Figure 2.5 The Calgary‐Cambridge Guide – communication process skills.

Chapter 03

Figure 3.1 Jung’s theory of psychological type.

Figure 3.2 Personality preferences of medical graduates (

n

 = 313) compared with UK adults (

n

 = 1634). E, extraversion; I, introversion; S, sensing perception; N, intuitive perception; T, thinking judgment; F, feeling judgment; J, judging orientation; P, perceiving orientation; ST, sensing perception with thinking judgment; SF, sensing perception with feeling judgment; NF, intuitive perception with feeling judgment; NT, intuitive perception with thinking judgment.

Chapter 04

Figure 4.1 Patient‐reported influences on individual capacity to participate in shared decision‐making (SDM).

Figure 4.2 Visual patient decision aid (Cates plot, www.nntonline.net) for use of an anticoagulant in the management of atrial fibrillation (AF).

Figure 4.3 Evidence‐based medicine and shared decision‐making.

Figure 4.4 A shared decision‐making model for clinical practice.

Figure 4.5 Weight changes with different antidepressants – a patient decision aid from Wiser Choices. SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin–norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant.

Chapter 05

Figure 5.1 Communication has to be heard, interpreted and translated into action.

Figure 5.2 There is good evidence that team briefings and ‘safety huddles’ in a variety of healthcare settings can enhance teamwork and communication. Safety huddles are a recognised tool for frontline staff and caregivers.

Figure 5.3 Example handover sheet.

Figure 5.4 WHO Surgical Safety Checklist.

Chapter 06

Figure 6.1 The UK General Medical Council’s

Good Medical Practice

(2013) outlines four domains of practice: knowledge, skills and performance; safety and quality; communication, partnership and teamwork; and maintaining trust. The domain of communication, partnership and teamwork is assessed on a regular basis for all doctors with a licence to practice in the UK through various means, e.g. work‐based assessments (for doctors in training), 360° colleague feedback, patient satisfaction surveys and compliments/complaints received.

Figure 6.2 Take care when talking in public places.

Figure 6.3 The SBARR communication tool.

Figure 6.4 Picture archiving communication systems (PACS) are also medical records – do not leave screens open for unauthorised people to view.

Chapter 07

Figure 7.1 The triadic consultation. A 9‐year‐old girl is referred by her general practitioner for recurrent bouts of abdominal pain, causing poor school attendance. The girl’s mother suffers from chronic back pain with limited mobility, and her paternal grandfather has just been diagnosed with pancreatic cancer. What is going on in everyone’s mind? Unless the doctor is skilled and vigilant in involving both parties, their agendas and information may remain hidden, and leave one or more parties dissatisfied.

Figure 7.2 Angry family consultation: triadic conversation.

Figure 7.3 Common categories of abuse that require safeguarding actions.

Figure 7.4 The cycle of change.

Chapter 08

Figure 8.1 Effective communication in mental health – areas that need to be considered.

Figure 8.2 Some factors impacting communication and assessment of mental health.

Figure 8.3 Unspoken expectations of different roles.

Figure 8.4 Importance of non‐verbal communication. Non‐verbal communication accounts for most of our communication, and also has cultural meaning. The environment in which communication takes place also has an impact on the effectiveness of communication. ‘

The most important thing in communication is to hear what is not being said

’ (Peter F. Drucker).

Figure 8.5 The interaction between dementia and the body, senses and surroundings. An interactive model of dementia. For successful treatment, all these interacting aspects of a person’s function should be considered.

Chapter 09

Figure 9.1 NURSE – a mnemonic to help accept, validate and acknowledge emotions and concerns.

Figure 9.2 The SPIKES protocol for giving bad news.

Figure 9.3 Example ‘question prompt list’ questions – prognosis and end‐of‐life planning.

Figure 9.4 The key steps in the advance care planning process.

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ABC of Clinical Communication

EDITED BY

Nicola Cooper, MBChB, FAcadMEd, FRCPE, FRACP

Consultant Physician and Honorary Clinical Associate ProfessorDerby Teaching Hospitals NHS Foundation TrustDerby, UK

John Frain, MBChB, MSc, FRCGP, DGM, DCH, DRCOG, PGDipCard

Director of Clinical SkillsDivision of Medical Sciences and Graduate Entry MedicineUniversity of NottinghamNottingham, UK

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Library of Congress Cataloging‐in‐Publication Data

Names: Cooper, Nicola, editor. | Frain, John (John Patrick James), editor.Title: ABC of clinical communication / edited by Nicola Cooper, John Frain.Description: Hoboken, NJ : Wiley, [2018] | Series: ABC series | Includes bibliographical references and index. |Identifiers: LCCN 2017023660 (print) | LCCN 2017024788 (ebook) | ISBN 9781119246978 (pdf) | ISBN 9781119247005 (epub) | ISBN 9781119246985 (pbk.)Subjects: | MESH: Professional‐Patient Relations | Communication | Clinical MedicineClassification: LCC R727.3 (ebook) | LCC R727.3 (print) | NLM W 62 | DDC 610.69/6–dc23LC record available at https://lccn.loc.gov/2017023660

Cover Design: Wiley

Cover Image: © Clarissa Leahy/Gettyimages

Preface

Good clinical communication is essential for safe patient care. Clinical communication occurs within the patient encounter, but also through information flow within and between clinical teams. Issues around communication account for the majority of complaints about patient care.

The last quarter of a century has seen the establishment of an evidence base for good communication skills and the teaching and assessment of it. We are now better placed to identify and to demonstrate the qualities required for effective communication with the range of patients and professionals encountered in clinical practice. Communication is a core part of curricula within medical schools. Students trained in the early days of these programmes are now practitioners and teachers themselves, meaning the practice and role‐modelling of these skills are gradually increasing.

This book is intended as a reference for healthcare students and practitioners, either as part of a communication skills course or for personal study. Issues around clinical communication relate to skills required within the consultation, for communication within and between teams, in medical records and during handover.

Clinical communication concerns not only establishing rapport with patients and ensuring patient satisfaction with the encounter on a human level – it also means actively listening to patients and understanding their experience and perspective on the anatomical and physiological changes that may constitute pathology and disease. Detailed gathering of hard clinical data reduces the risk of diagnostic error and leads to better treatment and management decisions.

Although this book inevitably reflects our own work in the UK’s National Health Service, we are pleased to have brought together a range of international authors, all of whom are recognised experts in their fields. It has been a pleasure to edit this book and in the process to understand better the development of our own communication with patients, students and colleagues. We hope you enjoy and learn from it.

Nicola Cooper & John FrainJanuary 2017

Contributors

Magdy Abdalla, MBCHB, FRCSI, DRCOG, FRCGP, MMedSci

GP Teaching Fellow, Division of Medical Sciences and Graduate Entry MedicineUniversity of Nottingham, Nottingham, UK

Nivedita Aswani, MBChB, MRCPCH

Consultant Paediatrician, Lead for Paediatric Diabetes, Derbyshire Children's Hospital, Derby, UK

Phyllis Butow, BA (Hons), DipEd, MClinPsych, MPH, PhD

Psycho‐Oncology Cooperative Research Group (PoCoG) & Centre for Medical Psychology and Evidence‐based Decision‐making, School of PsychologySurgical Outcomes Research Centre (SoURCE), Institute of Surgery, University of Sydney, Sydney, Australia

Gillian B. Clack, PhD(Lond)

Former Honorary Senior Lecturer, Division of Medical Education, King’s College London, London, UK

Josephine Clayton, MBBS (Hons), PhD, FRACP, FAChPM

HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Greenwich, Sydney;Kolling Institute, Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia

Nicola Cooper, MBChB, FAcadMEd, FRCPE, FRACP

Consultant Physician and Honorary Clinical Associate Professor, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK

Vanessa Cox, MBChB, MRCPCH

Consultant Paediatrician, Derbyshire Children’s Hospital, Derby, UK

Alison Cracknell, MBChB, FRCP, PGCert

Consultant Physician, Honorary Clinical Associate Professor and Patient Safety Lead, The Leeds Teaching Hospitals NHS Trust, Leeds, UK

John Frain, MBChB, MSc, FRCGP, DGM, DCH, DRCOG, PGDipCard

Director of Clinical Skills, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK

Jonathan Silverman, BA, BM. BCh, FRCGP, FAcadMEd

President of the European Association for Communication in Healthcare, Honorary Visiting Senior Fellow, School of Clinical Medicine, University of Cambridge, Cambridge, UK

Lee Smith, BA, PGDip, MA, MA, RMN

Mental Health Nurse Specialist, Derbyshire Healthcare NHS Foundation Trust, Derby, UK

Nigel D.C. Sturrock, BMSc, MBChB, MSc, MD, FRCP

Executive Medical Director, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK

Julia Surridge, MBBS, DRCOG, DCH, MRCPCH, PGCert (Med Ed)

Paediatric Emergency Medicine Consultant, Derbyshire Children’s Hospital, Derby, UK

Adam Walczak, BPsych (Hons), PhD

Youth Cancer Services & Clinical Trials Division, CanTeen Australia, Sydney, Australia

Andy Wearn, MBChB, MMedSc, MRCGP

Director, Clinical Skills Centre, Faculty of Medical & Health Sciences, The University of Auckland, Auckland, New Zealand

CHAPTER 1Why Clinical Communication Matters

John Frain

University of Nottingham, Nottingham, UK

OVERVIEW

The clinical interview is essential in collecting information about a patient and reducing diagnostic error.

There is an evidence base for the skills that best facilitate collection of both the biomedical and psychosocial content of the patient’s story.

Good clinical communication underpins patient‐centred care.

Health professionals require continuing training in clinical communication in all its forms.

Efficient information flow within the healthcare team is an essential component of patient safety.

Respect for patients and colleagues is a prerequisite for effective clinical communication.

Clinical communication – a historical perspective

In the absence of defined physical examination methods and investigations, such as blood tests and imaging, interviewing the patient was the mainstay of diagnosing illness and managing disease. While we know little of the format of the doctor–patient encounter prior to the nineteenth century, listening was a virtue associated with the competent doctor. The doctor relied on the patient’s description of symptoms to make a diagnosis. As only wealthier members of society could afford the services of a doctor, good communication skills were rewarded with greater employment. The apprenticeship model of medical training led to the role‐modelling of these skills by senior doctors. While the doctor–patient relationship has evolved since then (see Figure 1.1), the ‘history’ remains the most important means of making a diagnosis.

Figure 1.1 Evolution of the doctor–patient relationship.

Source: Kaba and Sooriakumararan (2007). Reproduced with permission of Elsevier.

Improving knowledge of anatomy, physiology and the pathological basis of disease during the 1800s contributed to a structured clinical method consisting of a structured history and physical examination (see Box 1.1). William Osler, sometimes described as ‘the father of modern medicine’, took students from the lecture theatre to the patient’s bedside so that students could talk to patients about their experience of disease and physically examine them for signs of the illness.

Box 1.1 The traditional model of a structured patient history

Demographics

Presenting problem(s)

History of presenting problem(s)

Past medical history

Systems enquiry

Family history

Medications and allergies

Social history

Source: Adapted from Stoeckle and Billings (1987). Reproduced with permission of Springer.

Even in an era of rapid change in the scientific basis of medicine, Osler’s maxim to his students was: ‘Listen to your patient; he is telling you the diagnosis.’ In modern times, the history alone accounts for around 80% of diagnoses. Strikingly, increasing availability of diagnostic technology (e.g. laboratory tests and imaging) has not substantially altered this percentage.

It is worth considering what the healthcare professional wishes to derive from the patient interview or encounter. The purpose is to:

Correctly diagnose the patient’s illness.

Avoid diagnostic error.

Give the patient effective and appropriate treatment.

Achieve the patient’s adherence to treatment.

Cure or mitigate the effect of the illness.

Improve the patient’s health status.

Communicate care, concern and empathy.

Early studies of the consultation correlated the quality of the interview directly with the quality of clinical data collected (see ‘Further resources’). An open‐ended approach with the intention of allowing patients to identify problems of concern identified those problems well. The failure of professionals to allow patients to complete an opening statement during the consultation and an over‐controlling approach (e.g. using closed questions) directly reduced the quality of information.

Poor‐quality information results in a predisposition to diagnostic error, and the term ‘clinical hypocompetence’ has been used to describe this (see Box 1.2). While a biomedical perspective has contributed to improvements in diagnosis, the use of a solely biomedical approach risks being reductionist as it fails to take account of the patient’s own experience, context and wishes. The power imbalance between the ‘all‐knowing’ professional and the passive patient contributes to poorer outcomes. The post‐war era saw the development of societal concepts such as greater self‐determination, autonomy, gender rights and equality. This influenced healthcare as well, with the result of the model of the consultation we have today (see Chapter 2).

Box 1.2 Clinical hypocompetence in the medical interview

Physician‐engendered defects in the interview are due to one or a combination of:

Lack of therapeutic intent

Inattention to primary data (symptoms)

A high control style

An incomplete database usually omitting patient‐centred data and active problems other than the present illness

A thoughtless interview in which the physician fails to formulate needed working hypotheses

Source: Adapted from Platt and McMath (1979). Reproduced with permission of American College of Physicians.

Even for the same illness, no two patients are going to give identical stories. Each will have a different experience of their symptoms and different concerns about their significance. Obeying Osler’s maxim to listen requires seeing the patient’s perspective and their own unique experience. If we needed to update Osler to make this clearer, we might say: ‘Listen to your patient and see the illness through his eyes; he is telling you the diagnosis.’

The emergence of a bio‐psychosocial‐cultural model placed emphasis not only on what was the matter with the patient but also, as Engel (1977) famously described, what mattered to the patient. This evolved further into one that enabled patients to fulfil their potential and ultimately into ‘patient‐centred medicine’ in which the patient has to be understood as a unique human being. This approach has been endorsed by patients and professional and regulatory bodies across the world and much research has explored the factors influencing patient‐centredness (see Figure 1.2).

Figure 1.2 Factors influencing patient‐centredness.

Source: Mead and Bower (2000). Reproduced with permission of Elsevier.

Patient‐centred care entails involvement in discussion of treatment options and decision‐making, as well as sharing of information, including records (see Chapter 4). Shared decision‐making improves patient and professional satisfaction with the consultation. It involves a common acceptance of the problem, discussion of the available management options, including their benefits and risks, eliciting the patient’s own views and preferences for these options and then agreeing on a management plan.

In some respects, we have proceeded forward to the past as the evidence supports the wisdom of Osler’s advice. Research has identified the skills that best determine important biomedical and psychosocial data and thus facilitate diagnosis. Over the last 40 years we have developed an evidence base for clinical communication associated with higher patient satisfaction. Several consultation models have been developed which form the basis of undergraduate and postgraduate training (see Box 1.3). We consider one of these models in Chapter 2. Barriers to its successful implementation include a continuing strong emphasis on the biomedical perspective with its doctor‐centredness, time pressures and lack of ongoing appropriate training.

Box 1.3 Models of the consultation

Established models include:

Patient‐centred clinical method (Brown

et al.

, 1986)

Three function model (Bird & Cohen‐Cole, 1990)

E4 model (Keller & Carroll, 1994)

Calgary‐Cambridge guide (Silverman

et al.

, 1998)

Patient‐centred interviewing (Smith

et al.

, 2000; Fortin

et al.

, 2012)

Four habits (Frankel & Stein, 2001)

SEGUE framework (Makoul, 2001)

Source: Adapted from Brown et al. (2016). Reproduced with permission of Wiley.

Educational interventions to teach good communication skills have been evaluated and accepted as good practice. All UK medical schools now provide training in communication. The use of simulated patients and models of feedback are also accepted as the norm in many training programmes. Teaching clinical communication is discussed in more detail in Chapter 10. The European Association for Communication in Healthcare has defined the learning objectives in a proposed core curriculum across all the health professions (Box 1.4).

Box 1.4 Domains for a health professions core curriculum: objectives for undergraduate education in health care professions.

Communicating with patients

Core skills

Shaping of relationship

Patient’s perspective and health beliefs

Information‐sharing

Reasoning and decision‐making

Dealing with uncertainty

Intra‐ and interpersonal communication (professionalism and reflection)

Communication with self and others

Dealing with errors and uncertainty

Communication in health care team (professional communication)

Teamwork and professional communication

Leadership

Professional communication and management

Source: Adapted from the European consensus. Reproduced with permission of Elsevier.

Effect of communication on patient outcomes

Improved interviewing, information‐sharing and shared decision‐making contribute to improved patient outcomes, particularly in chronic disease. There are reduced levels of patient discomfort and concern.

Patients perceive communication within the interview as a marker of quality. It is related to patient satisfaction, adherence to treatment, litigation, quality of data collection, patterns of use of services and clinical outcomes. Those behaviours associated with higher patient satisfaction are displayed in Figure 1.3.

Figure 1.3 Model of behaviours linked to higher patient satisfaction.

Source: Tallman et al. Reproduced with permission of Permanente Journal.

Much has been achieved in the last 30–40 years and improvements in clinical communication are being implemented worldwide. Nonetheless, there remain a series of challenges if the actuality of patient‐centred care is to be developed further. In addition to identifying relevant skills and factors affecting patient‐centredness, research has also identified the adverse impacts on patient and staff well‐being of poor communication. Each of these provides significant challenges for health services in the twenty‐first century (see Box 1.5)

Box 1.5 Impact of poor communication in healthcare

Poor communication in healthcare has an impact on the following aspects of patient care:

Diagnostic accuracy

Adherence to treatment

Patient satisfaction

Patient safety

Team satisfaction

Malpractice risk

Training and feedback

Communication is one of the health professional’s core skills. Patients place great value on quality of communication. To fulfil Osler’s maxim, students need to be observed practising integration of both biomedical and psychosocial perspectives in the consultation. While pre‐qualification training includes communication, it is relatively rare for postgraduate trainees to receive instruction once qualified. While there is emphasis on improving one’s knowledge after qualification, there exists little opportunity for direct observation and feedback on existing skills or the acquisition of new communication skills. Health professionals may not realise the possibility or need to improve their communication skills post‐qualification. There is too often the assumption that these skills will automatically improve through exposure and experience, even though qualified health professionals are responsible for more complex communication tasks such as shared decision‐making or breaking bad news, for which they may have had limited training as students. Continuing professional development and reflection on communication skills should not be dependent solely on receipt of adverse feedback or need for remediation. A core ‘curriculum’ for reflection on personal communication skills for significant events, appraisal or relicensing is suggested in Box 1.6. Clinical communication in more complex consultations is covered in Chapters 7–9.

Box 1.6 Domains for reflection in advanced clinical communication

Responding to and managing own emotions

Opportunistic promotion of health

Managing uncertainty

Shared decision‐making

Enabling self‐care

Responding to a complaint

Candour and disclosure of medical error

Communication within a multidisciplinary team

It is in the interest of a healthcare provider to ensure there is development of clinical communication skills among its workforce. System‐wide, relationship‐centred training has a measurable impact on patient satisfaction scores. A further benefit is improved physician empathy, self‐efficacy and reduced physician burnout. Short‐term training (i.e. < 10 hours) is as successful as longer training. Courses can involve video or direct observation, debrief and feedback and group work involving role‐play. Organisation‐wide programmes of clinical communication training are effective when there is adherence to a single model, strong leadership and role‐modelling, and outcomes include satisfaction of the professionals in training as well.

Communication between professionals