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Finding new ways to meet patients’ needs when face-to-face nursing care is not an option
Communicating compassionately has always been a part of nursing – the difference in a time of COVID-19 is that so much of it has had to be done via the phone.
Primary Health Care. 31, 2, 14-16. doi: 10.7748/phc.31.2.14.s6
Published: 29 March 2021
This has caused consternation among a workforce that has become accustomed to identifying and acting on patients’ cues.
Cues can be defined as the direct or indirect expression of negative emotion that hints at an underlying concern.
Non-verbal cues, such as body language, can aid consultations and ensure that patients’ needs – expressed or otherwise – are met.
Difficult conversations have not been limited to those treating patients with COVID-19. Clinicians in all other specialties have had to grapple with breaking unwelcome news to patients, for example that their much-needed elective orthopaedic surgery has been cancelled or their urgent hospital outpatient appointment for a potentially life-changing eye condition will no longer take place.
Even before the first lockdown was announced in March 2020, specialists at the Maguire Communication Skills Training Unit, which is based in the School of Oncology at the Christie NHS Foundation Trust in Manchester, were being approached for help and guidance.
At first the requests came in-house from the Christie Hospital – a leading cancer centre – but the unit has also been asked for help by other organisations, including those in primary care.
The good news, according to senior trainer Ali Franklin, is that the key principles of compassionate communication remain the same, whether the interaction is taking place in person or via telephone or an online app.
‘What we’ve been trying so hard to get across is that nothing has changed,’ she says. ‘The cues that we get from patients verbally are often stronger than the non-verbal cues; it’s just that we don’t always notice them.
‘The key skills that help patients disclose their concerns are the skills we use to acknowledge what they’re saying. These are the ones you’d expect – reflection, paraphrase and summary.
‘Then there are the skills we would use to explore further, such as open questions, questions about feelings, the use of pauses and silence, and the use of negotiation – asking people “Would you be able to tell me?” rather than demanding that they tell us.
‘Crucially, it also involves focusing on the cues that we get from the patient. That’s where the challenge has been with COVID-19. Some healthcare professionals have been incredibly anxious that they will not spot those cues because they rely so heavily on the non-verbal and so much communication is now taking place on the telephone.’
The unit has developed a number of evidence-based resources to assist clinicians with difficult conversations in different care settings.
‘Nothing has changed. The cues that we get from patients verbally are often stronger than the non-verbal cues; it’s just that we don’t always notice them’
Ali Franklin, senior trainer, Maguire Communication Skills Training Unit
In a way, Ms Franklin concedes, the circumstances caused by COVID-19 have meant going back to the basics of communication.
‘This is what we’ve been teaching for the past 20 years – obviously observe body language, but it’s important to listen to what people are saying.
‘If someone says: “Oh, I’m okay really” then pick up “really”. Say that when you say “really”, maybe it means that you’re not okay. A lot of the work we’ve been doing has been reminding people of these skills that can be used to enable people to disclose what it is they’re concerned about.’
Equally, she adds, people have worried that they couldn’t convey compassion and empathy when on the phone or wearing personal protective equipment (PPE).
‘Again there’s a perception that what we’re relying on is our compassionate body language and facial expressions, and actually there’s a huge body of evidence that says that the most powerful expression of compassion is by verbalising our empathy by naming the emotions that we’re hearing, then allowing the other person to confirm and then expand or explain more.’
The Maguire Communications Skills Training Unit has published a number of resources. The following principles are taken from its guide on discussing suspected cancer symptoms over the phone (based on the SPIKES model for giving significant information):
1. Elicit the patient’s worries and acknowledge them
2. Give a ‘warning shot’ and pause (for example, preface with words like ‘unfortunately’ or ‘sadly’)
3. Deliver the news at the patient’s pace with frequent pauses and with compassion and honesty
4. Empathise
5. Elicit questions and new concerns, using phrases such as: ‘You ask what this means, what are your worries?’ or: ‘You’re crying, can you bear to tell me what’s going through your mind?’
Source: Maguire Communication Skills Training Unit
When someone is encouraged to name the emotion for themselves, the fear response comes down, the emotional response comes down, and the part of the brain that can process information and make decisions becomes more active, she says.
‘It’s a clinical skill that we’re encouraging people to use, and what we’ve been saying to people is that you can do that from six feet away with PPE, you can do it on the phone – it’s the same skills that you already have, and it’s about trusting them.’
Although the resources produced by the unit have been distributed and used across the country, Ms Franklin stresses that they do not provide a script, and says that nurses should use their judgement when applying them to the patient or relative in front of them or on the phone.
But having a structure for the conversation is useful, she says, not least because evidence shows that gathering all of the person’s concerns before giving information is important.
‘The reason for that is all of us in healthcare have a tendency to want to fix things. So as soon as we hear someone is distressed or has a concern, we go straight in with reassurance, advice or information.
‘One of the issues with this is that while the person is in a heightened emotional state, they won’t hear the advice or information. But as soon as we go into our information-giving mode, the patient feels: “Oh, it’s my turn to be told what’s going to happen” and they don’t disclose other concerns that they may have.’
Encouraging self-compassion for nurses is also a key part of the unit’s work, and it has been running a course aimed at nursing students who entered the workforce early to help in the COVID-19 effort.
‘Empathy again is central to all of it,’ Ms Franklin says. ‘Because when you name the problematic emotion for the other person and they’re able to acknowledge it, it can be reduced in that person and your own level of stress also reduces. By naming the elephant in the room, the person witnessing distress and the person experiencing the distress is able to see it and manage it.’
Encouraging newly qualified nurses to focus on what matters to the patient, and to ‘say what they see’ (or hear) in terms of emotions, is important because it is such a valuable clinical skill, she adds.
‘We want to boost their skills and confidence so they don’t feel there’s nothing they can say – and when I asked them what their concerns were about going into practice, number one was saying the wrong thing or not knowing what to say.’
This is the case for all of the unit’s courses, she adds. ‘The worry that you’ll say the wrong thing or that you’ll do more harm than good never goes away.’
Many one-to-one services have had to switch to telephone consultations during the pandemic
Picture credit: iStock
The training reminds them of the skills they have, but also strategies to help them to cope, including reminding them of the support on offer in the trust, and avenues of support outside the trust.
In more usual times, Helen Johnson, a Macmillan urology oncology clinical nurse specialist at the Christie Hospital in Manchester, conducts the vast majority of her patient care face to face.
When routine cancer treatment was halted at the tertiary centre where she works, her role changed, becoming almost entirely telephone based. This has been particularly challenging because of the circumstances – many patients have had to come to terms with delays in surgery, for example, or have had life-extending treatment postponed.
‘On the phone all day’
‘The pandemic has meant we were no longer seeing patients face to face,’ she says. ‘Normally we’d be seeing new patients face to face, but we weren’t doing that, nor any of our aftercare or running our face-to-face clinics. We were literally on the phone all day long.’
When COVID-19 disrupted services, the nurses rang all their patients individually. ‘They were distressed. A lot of them rightly said that: “When I first got diagnosed you told me that having chemotherapy was important to extend my life and keep my disease under control for longer, and now you’re telling me that I don’t need it – what’s that about?”.’
Even in ‘normal times’, as Ms Johnson puts it, the team conducts some follow-up clinics by phone, which means they are already skilled at gathering information without the visual cues of being in the same room as the patient.
‘This is a completely different bag, and it’s more difficult: you’re talking to people about stopping treatment, and also to new patients who have just been diagnosed.’
Developing skills so that you can have successful telephone consultations is important, she says, and she advocates the principles of asking open questions, ascertaining what a patient knows and understands, acknowledging their feelings, and making skilled use of pauses. ‘It’s not a pitter-patter conversation,’ she says.
‘Sometimes verbal communication, and even hearing people properly is difficult. It’s difficult taking cues from people. Some patients don’t feel they can ask things when they’re not face to face.
Quiet times often part of conversations
‘Often you’ve never met them before either – you’re brand new to each other, so you’ve no rapport even to kick off with. It’s difficult to pacify someone on the phone, and it’s also difficult to have silences, when quiet times are often part of conversations.’
Ms Johnson believes that compassionate communication is not just important when talking to patients and relatives, but also with colleagues.
‘We need to be talking to and caring about each other, and realising that some people are finding things difficult.’
‘We give them a strong message that asking for help, or saying you’re struggling isn’t a sign of weakness – it’s a sign of resilience,’ she stresses.
The evidence isn’t there yet to show if having to do so much patient care without being in the same room will have a lasting impact on nurses.
‘I don’t know if it’s sharpened people’s verbal skills because they’re having to do things on the phone. But the bottom line is that nurses are doing a fantastic job in the most impossible circumstances.’
