Communication and Relationship Building In Patient Care

Communication and relationship building are two concepts which enables health and social care practitioners to deliver a service/care that is person centred. Ferguson et al. (2013) defines patient centred care as care that focuses directly on the patient’s needs. This requires healthcare practitioners, such as nurses and doctors, not only to be able to communicate well with patients but also to build good, strong relationships with them over a period of time if necessary so that they can counsel patients effectively (Reynolds, 2009). In child nursing, family-centred care is used as well as patient centred care, as parents or carers will be the ones to make the decisions about their child unless the child is capable of doing this themselves. Even so, in this situation the needs of the child still have to be met (Young et al., 2006). Fegran (2008) suggests that family-centred care, which is care focused on the patient and their family holistically, has been found to be the best approach in neonatal and paediatric clients. Communication and relationship building are vital to ensure that the client receives the correct possible outcome for their needs.

Communication is a necessary fundamental value of patient centred care (Bensing et al., 2000). Department of Health (2010) define communication as an exchange between two or more people to pass on information, thoughts or feelings and suggest that there are two ways in which this can be done; verbally (e.g. speech, written word) and non-verbally (e.g. facial expressions and body language). The study of the origins of ‘communicatio’ are sharing or distributing (Mackay, 1999). Blom-Cooper et al. (1996) found that in the past, communication skills have been seen to be a weakness of the NHS and have often resulted in malpractice claims such as miscommunication of confidential patients’ details which can have serious consequences. Hence, Moss (2008, p.1) states that ‘Communication skills are therefore at the very heart of people work’.

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Non-verbal and verbal communication together increase the persons’ understanding of the message being conveyed by five times the amount compared with verbal communication alone (Argyle, 1992). Non-verbal communication relies on interactions such as facial expressions and body language. Touch is also a type of nonverbal communication and can be used to express care, empathy and solace (Reynolds, 2002). On a recent placement at a neonatal unit, positive touch and massage was found to be a great comfort for certain individuals and staff encouraged parents/carers to use this technique if the baby was too ill to handle. Positive touch and massage have a calming influence over the infant and help to build up a relationship between the child and the parent (Bond, 2013). Therefore on future assessed placements, positive touch will be used and encouraged with others as it proved an excellent general technique found to help calm infants and aid parents/carers bond with their child. Verbal communication relies on the content of speech but can also be in various written forms such as emails and text messages. (Hargie, 2011). Verbal communication can be used on placements to speak to other staff, parents and patients. From experience and Cockcroft (2012), writing care plans and daily evaluations for the next staff member who looks after the child is essential as they can see any changes made, any issues had and any messages that need conveying.

Sensory impairments such as deafness, blindness or multi-sensory impairments (MSI) must be taken into consideration, as the person’s ability to communicate and receive and understand crucial information is severely strained. (Sense [no date]) It should also be understood that if someone has MSI, then other senses are likely to be impaired so problems may occur with spacial awareness, balance and over/under sensitive touch. These problems can cause difficulties with non-verbal communication methods. Individualised care is pivotal as every patient will have preferences as to how they will communicate with others. Sense [no date] discuss that relationship building may take slightly longer with a person with a sensory impairment as they may not be able to pick up on verbal or non-verbal communication used by practitioners, for example a blind person will not be able to pick up facial expressions used and a deaf person will not be able to pick up changes in the tone of voice used. When visiting a hospital environment, parents/carers should be encouraged to continue the child’s communication system and routine as much as possible, as this will help to reduce stress and the child’s fear levels. Sense [no date] realise that it is important that the hospital staff understand how the child usually communicates e.g. sign language, gestures or technical aids. On my last placement I observed that it only takes a short amount of time for parents to get to know their infants behaviours, likes and dislikes and requirements. Therefore, on my next assessed placement, I will be able to quickly recognise non-verbal indicators of the infant’s needs such as crying and facial expressions.

A practitioner needs to have good communication skills so that they can take the background of the patient and be able to explain and give information correctly, explore the patients current situation, discuss and negotiate options such as treatment plans, convey precise data to associates and present their co-workers with the patients’ case. (Xie et al. 2013) All these factors are essential in the communication between colleagues and between different departments to ensure the correct information is exchanged. An example of this from my previous placement is during handover on the ward, where at the end of the shift the next nurse takes over patient’s that you have cared for. The nurse needs to know everything about the patient such as the previous history of the patient, any medication given or any changes to medication and any serious problems such as apnoeas. If this does not occur then problems will arise when taking care of the patient. Paediatric nurses also need to be able to apply different communication skills depending on the age of the patient.This was observed during a recent placement on a neonatal ward where staff had to promote and actively engage in communication with parents, as it isn’t possible for the patients themselves to understand what the staff need to tell them. This is an approach that is likely to continue continue throughout most of the career of a child nurse, unless the patient is able to understand the message being conveyed. In this case, the type of communication used will need to be changed to engage the patient in the conversation and the planning of treatment if applicable.

In relation to practice, a healthcare practitioner should be reminded that ‘not everybody wants what I would want in a healthcare situation’ (Allen and Brock, 2000, p.48). This is a good first step for assessing how to approach an individual as it allows them to consider what the patient may want, but also about how the patient may communicate. Bensing et al. (2000) found that this type of approach allows focus on the patient’s personality and preferences, instead of just general approach to communication. Allen and Brock (2000) suggest that if the first step works, then the second step would be to keep communicating and working with the patient in the same way – if not then other action is required. Allen and Brock (2000) discuss four questions that should be asked in this instance: Is this person an extrovert or an introvert? Is this person focusing on the bigger picture or just specifics? Is this a person analysing using logical implication or the impact on people? Is this person interested only in the closure or the processing of the situation? These questions will help the healthcare practitioner decide how best to communicate with their client and build their relationship to gain a strong bond. This helps to support a service as the clients will gain confidence in that person and begin to trust them. On my last placement I considered these four questions whilst interacting with a parent on the ward and found I could communicate better with them as I knew how to approach them. In the future these questions will be asked by myself everytime I work with a client. This means I will be able to build up a good, strong, trusting relationship with the clients and this way we can aim to reach the goal we want to achieve much more efficiently. The outcomes of the four questions discussed by Allen and Brock (2000) can also be applied to relationships between people working as part of a team. The questions show that there are different personalities within each team of practitioners and people will react differently in different situations. On my last placement a crash call was sent to my mentor and we had to attend immediately. As this was a new experience I tried to remain calm as becoming fraught would not help the situation but afterwards I found myself a little shook up as I realised that the crash call could not have gone as well as it had done.

A popular American model for teaching and assessing communication skills is the SEGUE framework. SEGUE is an acronym for ‘Set the stage, Elicit information, Give information, Understand the patient’s perspective, End the encounter’ (Makoul, 2001, p.23). This can be used by an individual to figure out the best type of communication to use, and how they can apply it to the situation. It also allows reflection and possibly improvement on interactions with patients. Morehouse School of Medicine (2013) describe the actions that take place during the five stages. The first stage would be greeting the patient, establishing the reason for their visit and finding out what the patient knows about their condition. The second stage would be to find out what the patient would like to know about their condition and any problems they may be having. The third stage would be to give them the information they require in a simplified, direct way. The fourth stage would be to acknowledge any changes the patient may have e.g. challenges they face. The fifth stage would be to end the encounter and review the treatment plan if necessary.

Gantert et al. (2008) defines relationship building as a relationship that evolves over time by the use of interactions. A nurse-client relationship is constructed to meet the needs of the client and it is imperative that the formed relationship remains professional (CRNBC, 2006). A nurses’ ability to build good relationships with patients, parents/carers and other healthcare practitioners is vital because the needs of the patient will be met and so it is highly likely that the patient could experience better health (Nursing Times, 2009). McNaughton (2005) suggests that relationships are established by interactions between individuals and through this, trust is built and confidence in the other person is created. This enhances a groups ability to respect each other and work well together to reach a target (Amnis, [no date]). McNaughton (2005) found that collaborative problem solving can only occur when trust is present between the nurse and the client, as only then will the client disclose any anxieties they may have. Amnis [no date] recognise that relationship building is of great importance in healthcare because it allows different groups of people to collaborate so that services provided are of the highest standard. Amnis [no date] also suggest that ongoing relationship building is essential due to extra stresses on the healthcare system, such as budget cuts leading to less staff being employed and an increasing demand on the use of the system. Good relationships are needed within the team as it makes them work more effectively together and this is achieved via good communication skills.

A previous neonatal placement taught students that the stronger the bond with the baby’s parents, the easier it was to influence and support them with any decision making. Fegran (2008) found that whilst it is important for the nurse to have a good relationship with the parents, it is essential to encourage a relationship between the parents and baby. This was demonstrated on placement by regular visits from parents and them completing cares for the child, for example changing their nappy and bathing them.

Allen and Brock (2000) suggest that if a patient has a similar personality type and share the same behaviours as the practitioner, then the response will be more positive and the client will be more persuasive and easier to talk to. This has also been found to affect patient adherence to treatment (Stewart et al., 1999). This is not always applicable to every situation as not everyone has the same interests, and parents make vital decisions on behalf of their child. However, by healthcare practitioners speaking to parents and relatives and trying to find a common interest, they may feel more involved and much more likely to admit if they have a concern. This can be applied to any future placements as once parents and relatives establish a relationship with you, through the use of communcation, they may feel your advice is more trustworthy and adhere to it.

Reeder (1972) states until recently, patients were seen as clients, often leaving important decisions in the hands of the practitioner, and health providers seen as practitioners. However patients are now seen as consumers, and this has given them more power as they expect to be able to voice their opinions, be guided and tell the health provider what they require. Practitioners are now seen as health providers and are able to discuss options and build up a strong relationship with the consumer (Reeder, 1972). However, some patients want practitioners to be mainly responsible for the decisions of their treatment but feel involved in the process at the same time, as the patients feel able to trust the decisions of the professional more than their own. In this situation the practitioner needs to be able to individualise their patient and try and put forth the right decision for that individual, which may result in the same illnesses being treated in different ways. It it vitally important that the consumer is able to communicate and trust the healthcare provider (Mendick et al., 2010). From previous experience I feel this as a patient myself because if I didn’t trust my consultant then I would not have agreed to a complex operation which could have had serious implications on my life had it have gone wrong. In terms of paediatric nursing, it is important to discuss options with the clients’ parent/carer as they are the ones to make the ultimate decisions, after a relationship has been established. Consequently, on my next placement I will communicate well using both verbal and non-verbal skills and use not only patient-centred care, but family-centred care.

Good relationships between the patient and the practitioner are key to patient centred care, however paediatric nurses also need to work in partnership with the family as this achieves the best outcome for the child. This was found during my first work placement as by working with one of the baby’s fathers, the baby was able to go home earlier than expected. The father learnt how to change a nasogastric tube so that he would be able to to do it at home as well as feeding the baby via the tube. A study found that instead of just focusing on the medical problem the child may have, building a relationship and supporting a family whilst helping to sort out the medical problem at the same time is essential for a child nurse. This approach is more individualised care as opposed to using general medical nursing skills (Robinson, 1982). This was observed on a previous placement as all staff focused primarily on the child’s medical problem but also on building a relationship with the family by keeping them up to date on their child’s condition, communicating with the family during visits and including them in the child’s daily routine so that they feel included.

In conclusion communication and relationship building is essential for efficient patient centred care.