4 Pitfalls to Avoid in Nurse Communication

September 25, 2020 - Strong nurse communication skills is arguably one of the most important factors leading to a good patient experience. After all, nurses spend more time with patients than many other clinicians, and the way they interact with the patient can make a big difference in how a patient perceives her medical care.

But tapping into those strong communication skills can be challenging. Although most nurses go into the field because they want to work with and help patients, the pressures of meeting documentation and other clinical demands in healthcare can get in the way of genuine connection.

As nurses continue to work toward improving their communication skills, it will be important they lean on small actions that lead to big impacts on the patient-provider relationship.

Not actively listening to patient needs, priorities

It is natural that a healthcare professional would come into a conversation with a patient with a set list of things to cover. After all, that nurse knows he needs to take in some patient health history, cover parts of the patient’s diagnosis, and make sure the patient knows how to take care of herself when she leaves the clinic or hospital.

But in that frenzy of communication and education, it’s easy for a nurse to miss out on what is important to the patient during that care encounter. A nurse might be determined to discuss a patient’s blood work, but the patient is concerned about new physical challenges she’s having when playing with her grandchildren. Both are valid and warrant attention during the clinical encounter.

READ MORE: Building A Culture of Nurse Excellence to Drive Patient Satisfaction

Appointment agenda-setting is a great strategy to overcome this. Setting the appointment agenda with the patient before getting in the thick of it will let nurses, or any clinician for that matter, add top patient concerns to their to-do lists during the care encounter.

Appointment agenda-setting foremost requires patient education about how to do it. Nurses need to be clear that they are looking for patients to flag their healthcare concerns and prioritize the most pressing ones.

Next, organizations need to work with nurses to ensure they can help guide patients through the agenda-setting process.

Third, tapping other care team members and clinic staffers will help streamline the agenda-setting process. For example, patient intake staffers or administrators can prompt patients to set their agendas when confirming the appointment ahead of time.

Many healthcare organizations also lean on technology, like the patient portal, to facilitate appointment agenda-setting.

Getting caught up in time constraints

Most nurses cite time constraints as the top factor impeding their patient-provider communication. And there’s a good reason for that. Clinicians are beholden to more documentation requirements than ever before, on top of the hefty expectations for delivering good treatment and care.

“When I talk about making a connection with patients and the six themes of compassionate, connected care, nobody ever argues against it,” Press Ganey Chief Nursing Officer Christy Dempsey, MSN, CNOR, CENP, said in a previous interview. “Everybody wants to do that. The pushback is always not having the time. Nurses say, ‘you must be joking if you think I can spend 15 to 20 minutes with every patient.’”

But connecting with the patient doesn’t have to take that long, Dempsey argued. For her, making a meaningful connection with a patient can take less than a minute. After introducing herself, Dempsey, who is a nurse herself, quickly outlines clinical concerns and then works to get to know the patient.

Invariably, there is something about the patient Dempsey herself relates to, and she uses that connection throughout the care experience. This allows her to humanize the patient and recognize her as someone more than a sick person.

Other non-verbal cues help clinicians connect with patients with limited added time to the care encounter. Some research has shown that sitting down next to the patient can increase patient satisfaction, while other clinicians have said slowing down the pace at which they speak can create a warmer care encounter.

Being disconnected, lacking clinician empathy

Clinician empathy comes in as one of the top factors determining a positive patient experience. Surveys show that poor patient-provider communication that is not punctuated by empathy and understanding are top factors determining a poor patient experience score.

In short, patients want their providers to offer not only safe and effective care, but also to truly connect with them and listen to them.

But empathy is often in the eye of the beholder, and is an aspect of patient-provider communication that is often hard to teach. Some clinicians attribute palpable empathy to a certain “it factor” that doesn’t lend itself well to formal instruction.

That might be a misconception. Increasingly, medical schools and continuing medical education programs across the country are integrating coursework on clinician empathy to help providers adopt this essential skill.

Most of that coursework leverages simulated encounters and helps providers identify different actions or behaviors that can demonstrate empathy. Karlene Williams, MD, who runs an empathy education program at Englewood Hospital in New Jersey, said providers can demonstrate empathy through a handful of simple behaviors.

Building empathy includes small, non-verbal actions, like where the provider places her hands or where she positions her seat. Making eye contact, speaking at a slow pace, and showing respect for patient decisions are also important to compassionate care, Williams recommended during a previous interview.

“It's not a test of how well [the patient] should understand you,” Williams added. “It's really how well you're doing to make sure that your patient understands you well. Without empathy, we're going to have poor compliance. Without it, we're going to have poor outcomes. Without it, we’re going to have poor patient satisfaction. At the end of the day, if you don't have this skill, everything suffers, honestly.”

Providing overly complex patient education

Nurses play a central role in patient education, so it is essential for nurses to foster true patient understanding of health concepts and instructions. That doesn’t always happen if the education a nurse provides is too complex and does not consider patient health literacy.

The CDC defines health literacy as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”

When a patient does not have high health literacy, it is important to explain health concepts and instructions in an elementary way. Most experts advise clinicians to deliver patient education materials at about a fifth-grade reading level, but in some instances it will be important for clinicians to meet the patient where they are.

There are a number of assessments providers can use to measure patient health literacy, some taking as little as a minute or two. These assessments usually ask patients about 10 questions and flag to the clinician if the patient will need additional help with patient education.

Considerations for health literacy notwithstanding, clinicians should always check whether the patient understood concepts or instructions. Patient teach back, during which clinicians ask patients to repeat a concept back in their own words, is a tried and true strategy to assess patient understanding.

The risks of delivering overly complex patient education are clear. Foremost, patients who do not understand their diagnoses, or the self-management guidelines that come with it, could lead to mistakes in at-home care. That could, in turn, lead to some clinical complications.

There is also a clinical quality measurement aspect of clear patient education. Certain patient experience surveys, like the CAHPS surveys, ask patients whether they think clinicians explained concepts in a clear, easy-to-understand manner. Nurses who deliver patient education at too high a level run the risk of a negative CAHPS survey report.

Excluding family members from the conversation

Most of the evidence points to the importance of family engagement in the patient experience. Family members who are engaged in patient care are able to flag potential medical errors, absorb a lot of the at-home care instructions, and simply add an important layer of support for the patient.

Family members experience just as much of the clinical encounter as the patient, and therefore are a huge factor in patient experience reports.

But the lines between family engagement and patient privacy can certainly become murky. While an incapacitated patient who has appointed a medical proxy offers a clear-cut path toward family engagement, it can become more complicated when dealing with alert patients whose families are standing vigil at the bedside.

Clinicians may be unaware of the patient privacy guidelines in these instances, or have to contend with a patient who does not want her family’s support, despite that being in the patient’s best interest.

In truth, patients over age 18 do have a right to privacy, but in many cases they will want their family members looped in on their care. Clinicians unsure of whether they may discuss a family member’s case may ask the patient about her preferences.

There could be some cases where a patient says she does not want her family members involved in her care. The patient may be trying to protect her family from the reality of her medical issues or have other barriers that keep her from wanting family engagement.

In these cases, clinicians may discuss the benefits of having an engaged family member at the bedside. While it is important not to disempower the patient in making her own care decisions, she may just need some soft encouragement from her providers and family members.

Nurses working to foster family engagement should utilize many of the same skill sets they use in patient communication — active listening, empathy, and clear education.

In emphasizing those skills during the clinical encounter, nurses can ensure communication is strong and meaningful for patients.