Outlines for today:

 Learning needs (group task).

 Pre-test. First part
 Theory 1.

 Theory 2.
 Practical. Second part

 Theory 3.
Third part
 Closing.
Pre-test key:

1. T
2. F
3. T
4. F
5. T
6. F
7. T
8. F
9. T
10.F
Communication skills
Prof. Norah Alrowais

Introductory course - SBFM

General aims:

 Communication skills.

 Communication with different age group + sex.

 Communication with health care team members.

Specific aims:

 (Why) – why do we teach communication skills?

 (What) – defining the broad types of communication skills.

 (How) – how to tech and learn communication skills.

Why teach communication skills?

a) Is it important to study the medical interview?

b) Are there problems in communicating with patients?

c) Is there evidence that communication skills can overcome

these problems and make difference to outcome of care?
a) Is it important to study the medical interview?

 Doctors perform about 200,000consultation in lifetime.

 Interview is the unit of medical time.

 Doctor need knowledge, communication, problem solving

skills and physical examination skills.

 Communication is a core clinical skill rather than an

optional extra.
b) Are there problems in communicating with
patients?

 54% of patients complaints and 45% of there concern are

not elicited.

 In 50% of visits no agreement on the nature of main

presenting problem.

 Doctors often pursue a “doctor-central” approach.

 50% of patients do not take their medications.

c) Is there evidence that communication skills can overcome
these problems and make difference to outcome of care?

 The longer the doctor waits before interrupting, the more

likely to discover about the problem.

 Use of open question and attentive listing leads to greater

disclosure of patients concern.

 Patients centeredness leads to greater patients

satisfaction.
Broad type of communication skills:

 Content skills:

What doctors communicate?

 Process skills:

How whey do it? (verbal, non-verbal, how they develop

relationship…).

 Perceptual skills:

What they are thinking and feeling?

Calgary – Cambridge observation guide-
five points plan:

The tasks are:

1. Initiate the session.

2. Gathering information.

3. Building the relationship.

4. Explanation and planning.

5. Closing the session.

1. Initiate the session.

1.a: Establishing initial rapport:

1. Greets patient and obtains patient’s name.

2. Introduces self, role and nature of interview; obtains

consent if necessary.

3. Demonstrates respect and interest; attends to patient’s

physical comfort.
 1. Initiate the session.
1.b: Identifying the reason(s) for the consultation:
4. Identifies patient’s problems or the issues that patient wishes to
address with appropriate opening question (e.g. ‘What problems brought
you to the hospital?’ or ‘What would you like to discuss today?’ or ‘How
can I help you today?’).

5. Listens attentively to patient’s opening statement, without interrupting

or directing patient’s response.
Cont.

6. Confirms list and screens for further problems (e.g. ‘So that’s
headaches and tiredness, anything else?’).

7. Negotiates agenda taking both patient’s and physician’s needs into

Account.
 2. Gathering information.
2.a: Exploration of patient’s problems:
8. Encourages patient to tell the story of the problem(s) from when first
started to the present, in own words (clarifying reason for presenting
now).

9. Uses open and closed questioning techniques, appropriately moving

from open to closed.
Cont.

10. Listens attentively, allowing patient to complete statements without

interruption and leaving space for patient to think before answering or
after pausing.

11. Facilitates patient’s responses verbally and non-verbally e.g.

by use of
encouragement, silence, repetition, paraphrasing, interpretation.
 2. Gathering information.
Cont. 2.a: Exploration of patient’s problems:
12. Picks up verbal and non verbal cues(body language, speech, facial
expressions); checks and acknowledges as appropriate.

13. Clarifies patient’s statements that are unclear or need amplification

(e.g. ‘Could you explain what you mean by light-headed?’).
• Periodically summarizes to verify own understanding of what
patient has said; invites patient to correct interpretation or provide further information.
Cont.

14. Uses concise, easily understood questions and comments;

avoids or adequately explains jargon.

15. Establishes dates and sequence of events.

 2. Gathering information.

2.b: Additional Skills for Understanding the Patient’s Perspective:

16. Actively Determines and appropriately explores:
• Patient’s ideas(i.e.; beliefs re cause)
• Patient’s concerns(i.e.; worries) regarding each problem
• Patient’s expectations(i.e.; goals, help patient expects re each
problem)
• Effects on patient: how each problem affects the patient’s life

17. Encourages patient to express feelings

 2. Gathering information.
2.c: Providing structure to the consultation:
 Making organization overt:
18. Summarizesat the end of a specific line of inquiry to confirm
understanding before moving on to the next section.
19. Progresses from one section to another using signposting,
transitional
statements; includes rationale for next section.

 Attending to flow:
20. Structures interview in logical sequence.
21. Attends to timing and keeping interview on task.
3. Building the relationship.

3.a: Using appropriate non-verbal behavior:

22. Demonstrates appropriate non-verbal behavior:
• eye contact, facial expression
• posture, position, movement
• vocal cues e.g. rate, volume, intonation
23. If reads, writes notes or uses computer, does ina manner that
does not interfere with dialogue or rapport
24. Demonstrates appropriate confidence
 3. Building the relationship.

3.b: Developing rapport:

25. Accepts legitimacy of patient’s views and feelings; is not judgmental

26. Uses empathy to communicate understanding and appreciation of

patient’s predicament; overtly acknowledges patient’s views and

feelings
Cont.

27. Provides support: expresses concern, understanding, willingness

to help; acknowledges coping efforts and appropriate self-care; offers

partnership

28. Deals sensitively with embarrassing and disturbing topics and

physical

pain, including when associated with physical examination

 3. Building the relationship.

3.c: Involving the patient:

29. Shares thinking with patient to encourage patient’s involvement

(e.g. ‘What I’m thinking now is…’)

30. Explains rationale for questions or parts of physical examination

that appear to be non- sequiturs

31. During physical examination, explains process, asks permission

4. Explanation and planning.
4.a: Providing the correct amount and type of information:
(Aims: to give comprehensive & appropriate information; to assess each
individual patient’s information needs; to neither restrict nor overload)

1. Initiates: summarizes to date, determines expectations, sets agenda

2. Assesses patient’s starting point: asks for patient’s prior knowledge

early on when giving information; discovers extent of patient’s wish for
information
Cont.

3. Chunks and checks: gives information in assimilable chunks; checks

for understanding; uses patient’s response as a guide to how to proceed

4. Asks patient what other information would be helpful e.g.

aetiology, prognosis

5. Gives explanation at appropriate times: avoids giving advice,

information or reassurance prematurely
 4. Explanation and planning.
4.b: Aiding accurate recall and understanding:
(Aims: to make information easier for the patient to remember and understand)
6. Organizes explanation: divides into discrete sections; develops a logical
sequence

7. Uses explicit categorization or signposting(e.g. “There are 3 important

things that I would like to discuss. First…’; Now, shall we move on to….?’)

8. Uses repetition and summarizing to reinforce information

Cont.

9. Uses concise, easily understood language; avoids or explains

jargon

10. Uses visual methods of conveying information: diagrams,

models, written information and instructions

11. Checks patient’s understanding of information given(or plans

made)
e.g. by asking patient to restate in own words, clarifies as necessary
 4. Explanation and planning.
4.c: Achieving a shared understanding: incorporating the patient’s perspective

(Aims: to provide explanations & plans that relate to patient’s perspective; to discover
the pt’s thoughts & feelings about the information given; to encourage an interaction
rather than 1-way transmission)

12. Relates explanations to patient’s perspective: to previously elicited ideas,

concerns and expectations
Cont.

13. Provides opportunities and encourages patient to contribute:

to ask questions, seek clarification or express doubts; responds
appropriately

14. Picks up and responds to verbal and non-verbal cues e.g.

patient’s need to contribute information or ask questions, information
overload, distress

15. Elicits patient’s beliefs, reactions and feelings re information

given, terms used; acknowledges and addresses where necessary
4. Explanation and planning.
4.d: Planning: shared decision making:
(Aims: to allow patient to understand the decision-making process; to involve patient in
decision making to the level they wish; to increase patient’s commitment to plans made)

16. Shares own thinking as appropriate: ideas, thought processes and dilemmas involves
patient:
• offers suggestions and choices rather than directives
• encourages patient to contribute own ideas, suggestions

17. Explores management options

18. Ascertains level of involvement patient wishes in making the decision at hand
Cont.

19. Negotiates a mutually acceptable plan:

• signposts own position of equipoise or preference regarding available options
• determines patient’s preferences

20. Offers choices: encourages patient to make choices/decisions to level

they wish

21. Checks with patient:

• if accepts plan and if concerns have been addressed
4. Explanation and planning.

4.e: Options in explanation and planning:

 (includes content and process skills)
*If discussing opinion and significance of problem:
22. Offers opinion of what is going on and names if possible
23. Reveals rationale for opinion
24. Explainscausation, seriousness, expected outcome, short and long-
term
consequences
25. Checks patient’s understanding of what has been said
26. Elicits patient beliefs, reactions, concerns regarding opinion
4. Explanation and planning.
*If negotiating mutual plan of action:
27. Discusses options e.g. no action, investigation, medication or surgery, non-drug
treatments (physiotherapy, walking aids, fluids, counseling), preventive measures

28. Provides information on action or treatment offered: names, steps

involved, how it works, benefits and advantages, possible side effects

29. Elicits patient’s understanding reactions and concerns: about plans and
treatments, including acceptability
Cont.

30. Obtains patient’s view of need for action, perceived benefits,

barriers, motivation

31. Accepts patient’s lifestyle,beliefs, cultural background and abilities

into consideration

32. Encourages patient to be involved in implementing plans, to take

responsibility and be self-reliant

33. Asks about patient support systems; discusses other support available
4. Explanation and planning.

If discussing investigations and procedures:

34. Provides clear information on procedures e.g. what patient
might experience, how patient will be informed of results

35. Relates procedures to treatment plan; value, purpose

36. Encourages questions about and discussion of potential anxieties

or negative outcomes
5. Closing the session.

5.a: Forward Planning:

37. Contracts with patient’s re next steps for patient and
physician

38. Safety nets, explaining possible unexpected outcomes, what to do if

plan is not working, when and how to seek help
 5. Closing the session.

5.b: Ensuring appropriate point of closure:

39. Summarizes session briefly and clarifies plan of care

40. Final check that patient agrees and is comfortable with

plan and asks if any corrections, questions or other issues.
Communication barriers
Barriers for effective communication:
Barriers for effective communication:

 Social
 Psychological
 Cultural
 Physiological
 Physical
Social Barriers:
 Gender
 Age
 Race
 National or Cultural Origin
 Socioeconomic Class
 Education Level
 Urban or Rural Residence
Gender:

 Major influence on the way we communicate with others.

 Women are more likely than men to express their
emotions, to reveal how they feel about a situation.
Age:

 Young people and old people communicate in different

ways.
 We do tend to judge a statement by different standards if
we know the speaker’s age.
 Their maturity, their educational backgrounds, and the
different eras in which they grew up make a Generation
Gap inevitable
Psychological barriers:

 Fear.
 Attitude toward the message.
 Knowledge of the subject.
 Personal problems or worries.
 Personality.
Cultural barriers:

 Language
Different languages, individual linguistic ability, use of
difficult words, inappropriate words, pronunciation
 Norms and values
 Belief
 Social practices and traditions
Physiological barriers:

 Individuals’ personal discomfort

ill health, poor eye sight, hearing difficulties
 Speech and voice defect, feeling of inferiority, diseases,
physical appearance, lack of skill.
Physical barriers:

 Climate
o Extreme temperature (Hot/Cold)
o Bright/ Dim Light
o High Humidity

 Distractions:
o Noise (door, phone)
 Physical Setting
o Sitting Arrangement
 Listening
It is not the same as hearing
Characteristics of listening:

 L= Look interested.
 I= Involve yourself by responding.
 S= Stay on target.
 T= Test your understanding.
 E= Evaluate the message.
 N= Neutralize your feeing.
10 steps to effective listening:

 Step 1: face the speaker and maintain eye contact.

 Step 2: be attentive, but relaxed.

 Step 3: keep an open mind.

 Step 4: listen to the words and try to picture what the speaker is
saying.

 Step 5: don’t interrupt and don’t impose your solution.

Cont.

 Step 6: wait for the speaker to pause to ask clarifying question.

 Step 7: ask questions only to insure understanding.

 Step 8: try to feel what the speaker is feeling.

 Step 9: give the speaker regular feedback.

 Step 10: pay attention to what is not said- to nonverbal cues.

Benefit of effective listening:

 Enhances productivity.
 Improves relation.
 Avoids conflicts.
 Improves understanding.
 Improve negotiation skills.
 Helps you stand out.
 People will appreciate it.
Difficulties in listing:

 Excessive Talking
 Prejudice
 Distractions
 Expecting Others to Share Your Personal Beliefs and Values
 Misunderstanding
 Interrupting
 Faking Attention
 Bringing in Emotions
 Noise
 Fear
Communicating with
health care team
 Team is made up of professionals such as
doctors, nurses, social workers, pharmacists,
….etc.
 They are busy.
 Need to have time to communicate and discuss
questions and concerns.
 One study found that less than half of hospitalized
patients could identify their diagnosis or the name if their
medication(s) at discharge.

(An indication of ineffective communication).

Better communication can lead to:

a) Increased diagnostic accuracy.

b) Increased adherence to health-care recommendations.

c) Increased patients satisfactions.

Cont.

d) Improve patients safety:

 An estimated one-third of adverse events are attributed to human error
and system errors.

 Research conducted during the 10 year period of 1995-2005 has

demonstrated that ineffective team communication is the root cause
for nearly 66 percent of all medical errors during that period.
Cont.

 This means that when health care team members do not

communicate effectively, patient care often suffers.

 Further, medical error vulnerability is increased when healthcare

team members are under stress, are in high-task situations, and when
they are not communicating clearly or effectively.
 Cont.
e) Improve team satisfaction:

When communication about tasks and responsibilities are done

well, research evidence has shown significant improvement in job
satisfaction because it facilitates a culture of mutual support.

Larson and Yao found a direct relationship between clinicians’

level of satisfaction and their ability to build rapport and express
care and warmth with patients.
 Cont.
f) Reduce malpractice risk:

 According to Huntington and Kuhn, the “root cause” of malpractice claims

is a breakdown in communication between physician and patient.

 Previous research that examined plaintiff depositions found that 71% of the
malpractice claims were initiated as a result of a physician-patient
relationship problem. Closer inspection found that most litigious patients
perceived their physician as uncaring. The same researchers found that one
out of four plaintiffs in malpractice cases reported poor delivery of medical
information, with 13% citing poor listening on the part of the physician.
Communication style
Communication style:

 Aggressive

 Passive

 Assertive
 Aggressive Style:
 Communication Skills
 Feelings
 Closed minded
 Angry
 Poor listeners
 Hostile
 Cant see others point of view
 Frustrated
 Interrupts/Monopolizes conversation  Impatient
 Beliefs  Nonverbal Cues
 “Everyone should be like me”  Point fingers
 “I am never wrong”  Frown
 Characteristics  Glare
 Achieve goals at other’s expense  Loud tone rigid posture
 Bully  Verbal Cues
 Patronizing and sarcastic  “You must”
 Behaviors  “Just do it”
 Put down  Verbally abusive
 Do not think they are wrong  Problem Solving Mechanisms
 Bossy  Must always win a argument
 Overpowers  Operates in a win/lose paradigm
 Know it all
 Doesn’t show appreciation
Passive Style:
 Communication Style
 Indirect
 Feelings
 Always agrees
 Powerlessness
 Doesn’t speak up
 Wonder why they do not get credit
 Hesitant
for good work
 Beliefs  Others are better
 “Don’t express true feelings”  Nonverbal Cues
 Don’t make waves”  Fidgets
 Don’t disagree”  Nods head often and smiles
 “Other have more rights”  No eye contact
 Characteristics  Low volume
 Apologetic  Verbal Cues
 Behaviors  Monotone voice
 Avoid conflict  Problem Solving Mechanisms
 Asks permission unnecessarily  Avoid and ignore the problem
 Complains instead of taking action  Withdraw from the situation
 Have difficulty implementing plans
Assertive Style:
 Communication skills
 Effective, active listener  Feelings
 States limits/sets expectations  Enthusiastic
 Does not judge  Even tempered
 Considers other’s feelings  Positive
 Beliefs  Nonverbal Cues
 Believes all are valuable  Open and natural gestures
 Handle all situations as best as possible  Direct eye contact
even if they do not win
 Relaxed
 All have rights and opinions
 Vocal volume appropriate
 Characteristics
 Verbal Cues
 Self aware
 Use “I” statements
 Trust themselves and others
 Ask for options
 Open and flexible
 Problem Solving Mechanisms
 Proactive
 Negotiate, bargain and trade
 Behaviors
 Confronts problems as they happen
 Fair/consistent
 Do not let negative feelings build up
 Action oriented
When Aggressive Style is Essential?

 When a decision has to be made quickly

 During emergencies

 When you know you are right and that fact is crucial
When Passive Style is Essential?

 When an issue is minor

 When the problem caused by conflict are greater then the

conflict itself

 When emotions are running high and time is needed to gain

and regain perspective

 When the other’s position is impossible to change for all

practical purposed (government policies)
Effective Communication:

 Positive outcomes

 Improved information flow

 More effective interventions

 Improved safety

 Enhanced employee morale

 Increased patient and family satisfaction

 Decreased length of stay

 Improved quality
Standardized Communication Tools:

 SBAR

 Situation

 Background

 Assessment

 Recommendation
SBAR:
 Framework for communication between members of the
healthcare team about the patient’s condition

 Easy to remember tool for framing all conversation

especially critical requiring immediate attention and action.

 Easy and focused way to set expectations between members

of the team for what will be communicated and how

 Develop desired critical thinking skills

Definition of Collaboration in Healthcare :

 Health care professionals assuming complementary roles

and cooperatively working together, sharing responsibility
for problem solving and making decisions to formulate and
carry out plans for patient care.
Effective Teams:

 Characterized by trust, respect, and working together for

the good of the goal
Barriers to Fostering a Collaborative
Team Environment:

 Additional time

 Perceived loss of autonomy

 Lack of confidence or trust in decisions of others

 Clashing perceptions

 Territorialism

 Lack of awareness of the education, knowledge, and skills

held by colleagues from other disciplines
Understanding Between Healthcare
Workers:

 Ongoing initiatives for the development of a cooperative

agenda to benefit patient care

 Share at least one similar characteristic

o A personalized desire to learn

 Share at least one value

o To meet the needs of the patient

Successful Teamwork Model:
 Open communication
 Non-punitive environment
 Clear direction
 Clear and known roles and
tasks for team members
 Respectful atmosphere
 Shared responsibility for team
success
 Appropriate balance of member
participation for the task at
hand
 Acknowledgment and
processing of conflict
 Clear specifications regarding
authority and accountability
 Clear and known decision
making procedures
 Regular and routine
communication and information
sharing
 Enabling environment,
including access to needed
resources
 Mechanism to evaluate
outcomes and adjust
accordingly
Any question?