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Important of Communication
Important of Communication
Therapeutic communication
Abstract Baile et al (2000) acknowledged that communication within
clinical settings is a complex phenomenon involving gathering
How can health professionals, especially those working in busy
environments, foster hope and communicate effectively and information and transmitting relevant medical information
therapeutically with patients at the end of their lives? Many authors while providing support. Early in the literature, Rogers (1951)
agree that failure to comprehend the essence of what patients are hypothesised that for communication to be therapeutic, a
communicating, either verbally or non-verbally, can adversely affect positive and beneficial change must result when people
the level of support that health professionals can offer, and risks engage with one other. Mearns and Cooper (2005) believed
increasing patients suffering and isolation, leaving them feeling that communication can only be described as therapeutic
hopeless. Anxiety and fear frequently invoke hopelessness and often if a helping alliance is established, within which healing
cause patients to reject advice and important information given emerges. The document Essence of Care (DH, 2010) identified
by clinicians. This article focuses on the importance of therapeutic therapeutic communication as a meaningful process within
communication in sustaining hope for patients at the end of life. which people convey thoughts, anxieties and emotions. The
process of therapeutic communication involves assessing the
Key words: Therapeutic communication Palliative care Hope patients perception, obtaining the patients invitation, and
SPIKES protocol Holistic person-centred approach responding to the patients emotions with empathic responses
(Baile et al, 2000). This process, through verbal and non-verbal
H
actions, positively influences patients to better understand
ow can health professionals working in busy palliative themselves and their situation (Laidlaw et al, 2002; Leplege
care environments communicate effectively and et al, 2007). Silverman et al (1998) argued that therapeutic
therapeutically with patients to bring hope? This communication helps patients to adjust, dispels fears, and often
article focuses on the importance of therapeutic thwarts inappropriate hope. McIntyre and Lugton (2005) found
communication in sustaining hope for patients at the end of life. that patients feel supported, confident and secure when their
The role of the health professional in the context of therapeutic psychosocial needs are recognised and addressed. Hallenbeck
communication will be critically analysed and the evidence base (2003) concluded that communicating therapeutically is often
underpinning effective therapeutic communication considered. the most valuable skill health professionals can offer patients.
The complex issues surrounding communication in palliative The skills required to communicate therapeutically are vital
care and the implications for improving and maintaining for all health professionals working in palliative care, as it is
a consistent high quality of practice will be examined and only when patients are given opportunities to communicate
evaluated. The Department of Healths (DH) End of Life Care meaningfully that they feel less anxious and more hopeful
Strategy (DH, 2008) and more recently More Care, Less Pathway (Hagerty, 2005; Wilkinson et al, 2008). If health professionals
(DH, 2013) both illustrate the importance of offering patients struggle to communicate effectively, patients may be left
approaching the end of life more choice regarding their care. anguished and in despair (Fallowfield and Jenkins, 2004). Since
Involving patients in decision-making and regularly reviewing The NHS Cancer Plan (DH, 2001), communication skills have
and clearly communicating those decisions, in accordance been a precondition of qualification, with the stipulation
with the patients wishes, can only be achieved through good, that health professionals must demonstrate competence when
therapeutic communication (DH, 2008; DH, 2013). communicating with patients. Sllner et al (2001) called
for advanced communication training to improve the ability
The single biggest problem in communication
to identify psychological distress in patients. Fallowfield and
is the illusion that it has taken place. (George
Jenkins (2004) showed that advanced communication training
Bernard Shaw: quoted by Caroselli, 2000:71)
prevents health professionals relying on any natural abilities
to communicate, and drives them to improve and develop
evidence-based communication skills. Many government reports
Maureen Hawthorn, Macmillan Senior Nurse Practitioner, Integrated identify the negative effect of poor communication within
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Specialist Palliative Care Team, Wirral Community NHS Trust health care, which obstructs the delivery of high-quality care,
often leaving patients distressed and discouraged (Darzi, 2008;
Accepted for publication: June 2015 DH, 2013; Francis, 2013). Moreover, Wilkinson et al (2008)
identified a particular link to burn out from the distress caused
to health professionals working in palliative care who feel with patients allows them time to reflect and explore their
unable to communicate effectively with patients. The evidence thoughts and emotions (Regnard and Kindlen, 2002). Effective
supports a person-centred rather than disease-centred approach; listening involves concentrating on the main direction of the
as patients are given opportunities to communicate meaningfully, conversation, staying with the patients agenda, and not thinking
they are enabled to control decision making around their present of the next question while the patient is talking (Gagan, 1983).
and future care (Darzi, 2008; Francis, 2013) Gagan (1983) understood that active listening requires focus
and full attention on the patients story, his or her expressed
Holistic person-centred approach emotions and body language. Silence is a powerful and dynamic
A holistic approach is fundamental if a patients problems are to method of demonstrating support, and silence communicates to
be thoroughly and accurately identified at the end of life (Carter, patients that the listener is comfortable with them (Campbell et
2001; Maguire and Pitceathly, 2002). Holistic care is founded al, 2010).Active listening is paramount if communication is to be
on therapeutic communication and involves not only physical therapeutic and health professionals must stay with the patient
issues, but also the psychological, social and spiritual needs of and resist the urge to interrupt or problem-solve (Clayton et al,
patients and their families. Rogers (1951) developed a person- 2008). The NHS Cancer Plan (DH, 2001) identified that patients
centred approach (PCA) that realises the human potential consider a willingness to listen and explain to be one of the
for personal growth, self-realisation and self-actualisation. He most essential attributes of any health professional.
believed that no matter how appalling conditions may be,
people will inherently strive to grow and improve. Poor communication
The PCA is a holistic concept founded on a non-directive
She didnt give us any explanation about the
and non-threatening approach, within which people are free
cancer [prognosis, treatment]. She didnt know,
to explore their experiences and find their own way through
I dont think. Or didnt care. I think she didnt
(Mearns and Cooper, 2005).The PCA is founded on therapeutic
care. (Carter, 2001: 127)
communication, the self-actualising tendency and three core
conditions.The self-actualising tendency can be described as the More Care, Less Pathway (DH, 2013) reviewed the Liverpool
inner ability to realise and reach ones full potential and sense Care Pathway (LCP) in response to substantial criticism of its
of self (Merry, 1999). The three core conditions are empathy, use. It clearly identified poor levels of communication for the
congruence and unconditional positive regard (Rogers, 1951). patient and carers during the final stages of life, which, the
Empathy is the capacity to sense accurately what another person report concluded, rendered the LCP ineffective (DH, 2013).
is experiencing; people communicate empathetic responses Many authors have identified poor communication skills, such as
by reflecting back another persons expressed emotions and asking closed or multiple questions, giving inappropriate advice,
thoughts (Rogers, 1951). Carter (2001) argued that fear, distress normalising and minimising the patients situation, jollying
and anxiety can be quickly dispelled by health professionals who patients along, and changing subjects to lesser issues. Use of
show empathy and sensitivity to patients. Congruence is the confusing medical jargon is also a barrier to communication
ability to be open, real and authentic with another (Mearns and (Barnett, 2002). Poor communication leads to misunderstandings
Cooper, 2005). Unconditional positive regard is an expression and can easily damage an often fragile relationship between
of total acceptance of another, while adopting an attitude of patient and health professional. Good communication is about
genuineness with that person, which prizes them totally and the depth, not the length, of an encounter with a patient, and
unconditionally (Crisp, 2011). The PCA allows patients to it is imperative that health professionals recognise and defer
speak openly and honestly about their feelings and challenges their own agenda to elicit the patients concerns and fears
health professionals to explore different questions with patients, (Regnard and Kindlen 2002; Hallenbeck, 2003). Heaven and
other than questions solely focused on treatment strategies and Maguire (2008) recognised a correlation between a patients low
protocols. The PCA enables health professionals to build an disclosure of emotional concerns, and anxiety and depression.
authentic and trusting relationship with patients. However, it is Wilkinson et al (2008) believed that uninformed patients suffer
important to remember that holistic care is an ongoing process increased psychological distress, and that ambiguous, inconsistent
and not a tick-box exercise (Mearns and Cooper, 2005). While information increases anxiety.
research evidence of the impact of PCA is lacking, the theory Although many patients prefer full and open disclosure, health
has received strong support from research in other fields of professionals should never presume that patients always want
counselling, psychotherapy and education, and the effectiveness information concerning their prognosis (Case et al, 2005). They
of the PCA can be expounded from meta-analyses in these may neglect the fact that some patients avoid painful information
fields (Lambert and Barley, 2001; Crisp, 2011). as a protective coping strategy, guarding them against fear and
mental dissonance (Villagran et al, 2010). For this reason, it is
Communication skills imperative to treat every patient as an individual, understanding
Wilkinson et al (2008) identified that establishing a rapport, that patients may both seek and avoid information. Reflection
building a trusting relationship, concentrating on the salient on practice helps health professionals engage in a process of
issues, and asking open questions are vital elements for assessment. continuous learning while comprehending the complexities of
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During any assessment, it is important to clarify the patients their role (Charalambous and Papastavrou, 2009).
understanding and how much relevant information they may However, reflection requires commitment and a desire to
have been given (Gordon and Daugherty, 2003). Actively develop self-knowledge and to strive to improve ones clinical
listening and sitting quietly through the moments of silence practice. Faull and Woof (2002) stipulate that, although record
nurturing hope when discussing the future with terminally ill cancer patients Villagran M, Goldsmith J, Wittenberg-Lyles E, Baldwin P (2010) Creating
and their caregivers. Cancer 103(9): 196575 COMFORT: A communication-based model for breaking bad news.
Clayton JM, Hancock K, Parker S et al (2008) Sustaining hope when communicating Communication Education 59(3): 22034
with terminally ill patients and their families: a systematic review. Psychooncology Wilkinson S, Perry R, Blanchard K (2008) Effectiveness of a three-day
17(7): 64159. doi: 10.1002/pon.1288 communication skills course in changing nurses communication skills with
Crisp R (2011) Person-Centred Rehabilitation Counselling: Revisiting the Legacy cancer/palliative care patients: a randomised controlled trial. Palliat Med 22(4):
of Carl Rogers. Austr J Rehabil Counsell17(1): 2635 36575. doi: 10.1177/0269216308090770