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Introduction
Communication is defined by Kourkouta & Papathanasiou as the exchange of information, thoughts and feelings among people using speech or other means (Kourkouta & Papathanasiou, 2014). Good communication is a vital skill for paramedics and is one of the core standards set out within the Health and Care Professions Council (HCPC) code of conduct (Health and Care Professions Council, 2018). During the year 2016 – 2017 poor communication by NHS staff was listed as the main cause of written complaints by patients and their families (NHS Digital, 2017). Lang (2012) states that good communication skills are essential in reduce the risk of medical errors, ensure better patient outcomes, and nurture patient satisfaction .
This essay will draw upon an example from a recent student paramedic placement and use communication theory to identify both actual and potential barriers and how they can be overcome. An overview of the scenario will be given while discussing the actions taken by myself and my practice placement educator (PPEd) and how the use good communication skills resulted in a good outcome for the patient.
For the purposes of confidentiality all names and identifying features have been changed.
Main Body
While working on a dual crew ambulance myself, PPEd and an emergency medical technician were sent to a call involving a young male who was suspected of taking an overdose. Due to the nature of the call and previous incidents that had occurred at the address police were also dispatched and were already on scene. Upon our arrival the patient was sat in the corner of the room with his head down and was not engaging with the police. After introducing ourselves and asking his name the patient responded why does it matter? No one cares .
The patients perception that we were not interested in his concerns presented as the initial barrier to forming a good rapport with the patient. Establishing this relationship is vitally important in a health care professionals interaction with a patient (Lang 2012). As a paramedic it is important to listen to patients and display an interest in their concerns. The HCPC code of conduct states that paramedics must listen to service users and carers and take account of their needs and wishes (Health and Care Professions Council, 2018).
Paralinguistics encompasses all aspects of spoken communication that do not involve words. Examples of this are body language and the tone and pitch of voice (British council, 2007). Foley & Gentile (2010) argues that around 60 to 65 percent of communication is nonverbal and gives clues about the emotions and feelings the sender of the message is experiencing.
Body language is an important element of communication, examples include body posture, eye contact and facial expression. The meaning of a verbal message can be misinterpreted entirely if body language does not match what is being said (Royal Collage of Nursing, 2016). The SOLER model of communication devised by Egan (1986) incorporates five principles, sit straight, open posture, lean forward, eye contact and relax. Although the model was first introduced in 1975 and updated in 1986 it is still widely referenced in the literature as a good basis for active listening and demonstrating the health care professional is interested in that patients concerns (Stickley 2011).
Facial expressions can also communicate emotions between the patient and paramedic. For example, raised eyebrows can communicate both surprise or impatience and wide open eyes can show that a person is shocked or panicked. It is important for the paramedic to be aware of their facial expressions and the message this may be sending to the patient (Foley 2010)
Body language can be both a facilitator for good communication or a barrier if used ineffectively. By implementing the principles of the SOLER model, we were able to gain the confidence of the patient before speaking a word and by actively listening show that we were genuinely interested in the reasoning behind him taking an overdose.
Two types of questioning exist, closed and open ended. Closed questioning such as Are you okay? tends to illicit a single worded response. Conversely open-ended questions such as how are you feeling allows for a more detailed response giving a better indication of the patients thoughts and feelings (Royal College of Nursing, 2016). The use of open-ended questioning can make the patient feel they have the attention of the paramedic and helps further the development of the therapeutic relationship (Dougherty 2008)
Pitch and tone are another important component of paralinguistics. As with body language they can complement or contradict what is said. For example an inflection at the end of a sentence usually represents the sender is asking a question, however it may also be interpreted as sarcasm, completely changing the nature of message (McCabe & Timmins 2013). It is suggested by Foley & Gentile (2010) that how a sentence is pronounced is more important than the language used and that a patient can understand the emotion and feelings even if they do not understand what is being said. It is therefore just as important that paramedics pay particular attention to how they say something rather than just the words used in order to ensure the context of the sentence is interpreted correctly. It would have been particularly detrimental in this case if the patient was to think we were not taking his concerns seriously.
It is important for paramedics to keep patient confidentiality when communicating. The HCPC standards of conduct for paramedics mandates that all information about patients be treated as confidential and allows for disclosure only in specific circumstances such as when permission has been granted, in the patients best interests or in the public interest to prevent harm to others (Health and Care Professions Council, 2018). While confidentiality is usually thought of as protecting patients notes or only disclosing information to others on a need to know basis as outlined above, it is also important to take into consideration conversations had with patients where others may be able to hear what is discussed (General Medical Council, 2017). In this instance the patient felt uncomfortable discussing what led him to take an overdose while in the presence of multiple police officers. To provide more privacy for the patient we decided to carry out the rest of the assessment on the ambulance as the patient appeared reasonably calm and did not present a threat to myself or the rest of the crew. We also ensured that confidentiality was maintained while handing over to staff at the Accident and Emergency Department.
There are many potential barriers to effective communication that were not encountered in this instance. A few examples are language barriers, environmental and patient disabilities such as hearing loss or learning difficulties.
Language barriers where the primary spoken or written language of the patient differs from that of the paramedic can prove to be of significant detriment when conveying information of attempting to carry out an assessment. There may also be differences in cultural and societal norms when interacting with patients from different backgrounds. The primary solution to this is the use of an interpreter, either in person or through use of a distance translation service such as language line however this may present problems in conveying the correct body language and other paralinguistics between the patient and paramedic (Gallois, Hocking, Meuter, Ryder & Segalowitz, 2015).
The Linear Model of Communication was devised by Millar and Nicholson (1976, cited in McCabe & Timmins, 2013) comprises of the sender, message and receiver. This however is overly simplistic and does not consider the complexities of human communication. The Circular Transactional Model of Communication by Bateson (1979, cited in McCabe & Timmins, 2013 ) develops on the linear model and takes into account that communication takes place within the context of a relationship. This means the effectiveness of communication can be affected factors such as an individuals values, knowledge, culture and internal frame of reference.
Environmental barriers such as unwanted attention from the public or noise when attending an incident at the roadside and when transporting patients can prove to be difficult for paramedics to overcome. The ideal solution would be to move the patient to a private, quiet area for communication to take place, however this is not always possible, for example when treating a trapped patient following a road traffic collision. Cooper, Endacott & Jevon (2009) suggest that a poor environment can greatly reduce the ability to communicate effectively and empathetically.
Patient illness or disabilities can prove difficult to overcome, however paramedics must make arrangements, where possible, to give information to patients in a way they can understand and ensure their communication and language needs are met (Health and Care Professions Council, 2018). A large amount of patients the paramedics interact with are elderly, almost 75% of people aged 70 and over suffer from some form of hearing loss (Disability Resource Centre, 2016). In this patient group it is important to check that information has been received and understood. This can be helped by ensuring hearing aids are fitted and working correctly if the patient has them and that communication is concise and clear.
Communicating with patients diagnosed with a learning disability or a cognitive illness such as dementia can also be challenging. They may be nonverbal or have difficulty understanding and retaining information causing a break down in communication. One way this can be overcome is to pay close attention to the body language of the patient as this may give an idea of their current and physical state. For example facial cues may indicate the presence of pain and guarding an area of their body may give an idea of the location. It may also be useful to utilize a carer or relative as they may be able to interpret their body language or behaviour (Chapman & Turnbull, 2010)
Conclusion
The aim of this essay was to use an example from clinical practice to discuss actual and potential barriers to communication while using communication theory to support the interventions. Communication involves the transferring of information between one person and another and consists of both verbal and nonverbal aspects. The communicative skills paramedics use in practice are vast but essential to ensure the best outcome for the patient.
It is important the paramedic adopts a positive body language such as the SOLER model when communicating with patients to show they are actively listening and are interested in what they have to say. The use of open-ended questioning where appropriate further aids this by allowing to express their feelings and emotions.
Paramedics have a professional duty to ensure patient privacy and confidentiality are maintained. They should only pass on information on a need to know basis after consent has been gained, is in the patients best interest or is necessary for the protection of the public.
There are many potential barriers to effective communication such as environmental, language barriers and patient illness or disability. It is important however that paramedics ensure patients communication needs are met to the best of their ability where ever possible.
Thankfully by using good communication skills the patient in the example described above had a good outcome and was transported to Accident and Emergency department to receive definitive care.
References
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