by Vijay Nagpal and Bret A. Nicks
Emergency Medicine and the situations within the department can present a stressful, rapidly changing environment where it may feel as though there is too little time for effective patient communication, patient-centered care or the opportunity to establish an appropriate provider-patient relationship. It is also an environment unlike any other in medicine, where a unique team of individuals faces varying degrees of chaos with limited available information to work together and address the medical conditions of those presenting to the department. Few would recommend entering such an environment in the absence of an established care process and means of clear communication. The tone of the department is set prior to walking into the ED; from the moment you walk into the department, preconceived notions and prejudices remain at the door.
It is no surprise that high-functioning emergency departments have high-performing, well-communicating teams. Clearly defining and communicating to every team member why we are there and how we care for patients sets the tone for every interpersonal interaction. This is true not just for our patient-provider interactions but our interactions with the nursing, ancillary and consultant staff as well (Gluyas, 2015). Establishing a team mentality and acknowledging the value of contributions our colleagues and staff bring to the ED is essential to practicing high-quality, safe emergency medical care. Additionally, the skill set that those in other health professions bring to the team can help us to look from a different perspective to better understand our patients and facilitate the best care that can be offered in the ED (Klauer & Engel, 2013).
Essentials of Communication
The approach to providing quality patient care in the ED starts with recognizing the patient-provider mismatched perspective on what has happened and what is occurring (Helman, 2015). It is essential to recognize the patient-physician relationship starts with a significant power imbalance. Attempts should be made to normalize or reduce this power imbalance, to empower the patients and their families. This will enable an open discussion about their medical concerns and assist in making informed decisions about their care. It is important to acknowledge the wait or process they have already endured before seeing you. Thank the patient (and family) for coming to the ED and allowing you to address their medical concerns. Also, take the time to introduce yourself to everyone in the room with the patient and find out who they are in relation to the patient. This can help establish rapport with the patient and those around them (Chan 2012, Cinar 2012, Hobgood 2002).
While many believe the environment of care is the greatest limiting factor as opposed to quality communication, literature would suggest otherwise. Establishing a positive patient-provider relationship is essential for patient care. One must recognize that while you may not be able to solve the patient’s condition or chronic illness, using effective communication skills and providing a positive patient experience will assuage many patient fears (Mole, 2016). Keep in mind, in general, patients remember less than 10% of the content (what was actually said), 38% of how you say it (verbal liking), and 55% of how you look saying it (body language) (Helman, 2015).
Effective provider communicators routinely employ these 5 Steps
1. Be Genuine
We know it. People can sense the disingenuous person – whether it is a gut feeling or through other senses. Try to see the situation from the patient’s perspective, and it will ensure that you are acting in his best interest and with integrity.
2. Be Present
As emergency providers, we are interrupted more than perhaps any other specialty. However, for the few moments that we are engaged with the patient or his family, be all in. If there is a planned interruption upcoming, make it known prior to starting a discussion. Be focused on them and the conversation; value what they have to share. At the end of your encounter, briefly summarizing what the patient has told you can help to reassure the patient that you were listening and also give them the chance to clarify discrepancies.
3. Ask Questions
To effectively communicate, one must listen more than he talks. After introducing yourself, inquire about the patient’s medical concern; give them 60 seconds of uninterrupted time. Most patients are amazed and provide unique insights that would otherwise not be obtained. Once the patient has provided you with his concerns, begin asking the specific questions needed to further differentiate the care needed. By asking questions and allowing for answers, you make it about them and give them an avenue to share with you what they are most concerned about, enabling you to address those concerns.
4. Build Trust
Given the nature of the patient-provider relationship in emergency medicine, building trust is essential but often difficult. Building trust is like building a fire; it starts with the initial contact and builds with each interaction. Trust is also built on engaging in culturally acceptable interactions (Chan, 2012) such as a handshake, affirming node, hand-on-shoulder, or engaging posture.
5. Communicate Directly
Ensure that at the end of your initial encounter you have established a clear plan of care, what the patient can expect, how long it may take, and when you will return to reassess or provide additional information. Doing this also allows the patient to be more involved in his care and ask further questions regarding his workup and treatment plan. Additionally, helping the patient to understand what to expect while in the department can help to alleviate fear associated with unannounced tests or imaging studies, especially when these tests may require him or her to be temporarily taken out of the department (e.g., a trip to the CT scanner).
Many of these concepts have been identified in patient satisfaction and operational metrics. In one study, wait times were not associated with the perception of quality of care, but empathy by the provider with the initial interaction was clearly associated (Helman, 2015). In addition, patient dissatisfaction with delays to care is less linked to the actual time spent in the ED and more with a to set time expectations about the care process, a perceived lack of personal attention, and a perceived lack of staff communication and concern for the patient’s comfort.
In the ED, it is essential to understand that much of a patient’s care relates to empathy – the ability to understand and share another person’s experiences and emotions. It is recommended to try and understand the patient’s agenda. One can accomplish this by asking, “Help me understand what brought you in today.” “Help me understand what I can do for you.” “Tell me more.” This will help to normalize the patient’s situation and gain unique insights into his care concerns.
There are four easy steps to improve reflective listening and perceived empathy in the ED:
- Echo – Repeat what the patient says; this gives the message that you heard the patient.
- Paraphrase – Rephrase what the patient says as this gives the message that you understand the patient.
- Identify the feeling – Say, for example, “you seem frustrated,” “worried,” “upset.” This produces trust.
- Validation – Validate the patient’s feelings verbally by saying statements such as “I can see why you feel that way.”
There is also a great online module and mnemonic for Empathetic Listening skills development (SMACC, 2016). The RELATE mnemonic is:
- Reassure – share your qualifications and experience
- Explain – describe in clear, concise language what the patient can expect
- Listen – not just hearing, encourage the patient to ask questions
- Answer – summarize what they have said and confirm their understanding
- Take Action – discuss and define the care steps (and what to expect)
- Express Appreciation – thank the patient for allowing you to care for them
As with many life circumstances, effective communication is the glue that helps establish connections to others and improve teamwork, decision-making, and problem-solving. It facilitates the ability to communicate even negative or difficult messages without creating conflict or distrust. Recognizing this helps provide the best foundation and approach for successful patient communication, an essential element in the ED. In addition to understanding the five steps of effective communication, ones approach to effective communication must also be guided by the individual patient and adjusted accordingly. So, consider seeing your approach from the patient’s perspective, and set the tone with the following three starting points.
The 3 Starting Points:
1. Approach and Appearance:
- Dress appropriately
- Sit down next to the patient
- Maintain an open posture (avoid crossing your arms)
- Maintain good eye contact, if culturally appropriate
- Smile appropriately, nod affirmingly
2. How you speak
- Speak slowly and quietly (given the constraints of the ED)
- Use a low tone in your voice
- Empathy can be heard in your tone
3. What you say
- Introduce yourself in a culturally appropriate manner
- Use the patient’s last name (helps to minimize power imbalance)
- Acknowledge everyone in the room and ask what their relationship to the patient is (i.e., shake hands if culturally appropriate)
- Adjust medical wording based on patient’s medical literacy
In addition to understanding the five essentials of communication and setting the tone for the initial care approach, it is important to understand a few of the common reasons communication either fails or succeeds in the Emergency Department. While a single approach framework doesn’t always fit, there are some essential Do’s and Don’ts that must also be considered.
- Let the patient tell his/her story (Roscoe, 2016)
- Establish what the patient’s agenda is, what his/her fears are
- Provide the patient with information regarding what will happen during his/her stay. This puts the patient more at ease and improves satisfaction (Hobgood, 2002).
- Provide expected wait times. Some experts suggest overestimating the time for results and consultant services (Disney Technique).
- Explain the reasons for delays and apologize for it
- After your history and physical, map out the next steps in the process (i.e., establish expectations).
- Fold your arms over your chest as this displays an aggressive posture
- Ask why the patient did not come in earlier
- Say, “I guess.”
- Repeatedly ask, “why.”
- Use the words “never” or “always.”
The Difficult Patient
When facing difficult patients in the emergency department, understanding the situation and the motivation for the patient may help to navigate better the communication challenges that are present. A difficult patient encounter in the emergency department can often be frustrating for both the physician and the patient. These patients often present with chronic medical issues that are superimposed onto individuals with social disparities (Hull & Broquet 2007, Dudzinski & Timberlake
2016). These are just a few examples of types of patients that one may encounter in the emergency department:
Patient Type and Suggestion
Don’t ignore the fact that a patient may be angry or upset – often it is related to delays, expectations or care concerns. Try to explore this emotion by asking neutral and non-confrontation questions. Acknowledgment and a simple apology for process issues may prove invaluable.
While these patients may clearly have a secondary agenda, their medical complaints may still be legitimate. Approach these patients with an open mind, but be prepared to say no to requests that are not clinically indicated.
High recidivism may be frustrating, but it is important to understand that there may be an underlying reason for frequent ED visits. Socioeconomics and poor access to care are common reasons. Knowing the available resources (e.g., social workers, clinical support nursing) can make a difference.
Combative/Agitated or Intoxicated Patient
It is most important to keep both the patient and the staff (including yourself) safe. Redirecting the patient and emphasizing the importance of caring for them medically may help to calm the situation. Psychopharmacological intervention may be necessary at times.
For a deeper dive into effective patient communication related to managing difficult patients, listen to Episode 51: Effective Patient Communication – Managing Difficult Patients by Anton Helman.
Communication between providers and patient care transitions present one of the well-known challenges in patient care and errors in care management. This handoff communication, often perceived as the “gray zone,” has been characterized by ambiguity regarding the patient’s medical condition, treatment, and disposition (Akper, 2007). Communication errors, particularly related to patient hand-offs, account for nearly 35% of ED-related care errors. Establishing a standardized process to ensure the quality and clarity of transitions in care are essential. One such example is the I-CAN format that is specifically focused on the ED patient population.
ED-based Patient Handoff Tool (I-CAN)
I – Introduction
Briefly describe what brought the patient into the emergency department today. For example, the patient is a 53 yo male with a past medical history of COPD who presents today with a productive cough, wheezing, and shortness of breath.
C – Critical Content & Interventions Performed
Relate information that helps the receiving provider understand the ED course taken up to this point.
For example: On initial evaluation, the patient was unable to speak in full sentences, and O2 saturation was 88% on room air. We started him on NIPPV, and Nebulizer treatments were given. Respiratory burst steroids have been given to the patient here in the department.
A – Active Issues
Give the provider an idea of the patient’s current condition at this time. For example, the patient improved with an hour of NIPPV and was transitioned to high flow nasal cannula with O2 saturation at 93%. We are currently attempting to wean O2 requirement as tolerated.
N – Next Steps & Anticipated Disposition
Describe to the receiving provider what will need to be followed up and the anticipated disposition of the patient. For example, the patient will need to be admitted for a COPD exacerbation with a new O2 requirement. He can go to a floor bed if he remains stable on nasal cannula.
While many examples for a unified handoff exist, identifying a defined approach and establishing the expectation for routine use, especially when integrated into the electronic health record at transitions of care, ensure improvement with patient care, quality, and throughput (Akper 2007, Rouke 2016). If the patient and family are involved with this handoff, not only will they understand care expectations but the will also better understand issues with delays, next steps, and care updates.
Most agree that providing patient care in the ED poses many challenges. The situations we work with can present a stressful, rapid environment where it may feel as though we have too little time for effective patient communication, patient-centered care or opportunity to establish a great patient experience. However, it is also evident that improved communication between the care team and patients improves not only the care experience but also patient care outcomes. Quality communication improves patient outcomes, compliance, and satisfaction – not to mention the job and team satisfaction. While many techniques exist to improve ED communication, establishing a culture in the ED to habitually adapt these practices is essential. The ED is an environment unlike any other in medicine, where a unique team of individuals works in varying degrees of chaos with limited available information together to address the medical conditions of those presenting to the department. Doing so with effective communication can make a difference.
References and Further Readings
- Gluyas H. Effective communication and teamwork promotes patient safety. Nurs Stand. 2015 Aug 5;29(49):50-7.
- Klauer K, Engel KG. Patient-centered Care. Emergency Medicine Clinical Essentials, 2nd Ed. Elsevier, 2013; 1784-89.
- Helman A. Effective Patient Communication. Available at: http://emergencymedicinecases.com/episode-49-patient-centered-care/ Accessed December 18, 2015.
- Chan EM, Wallner C, Swoboda TK, et al. Assessing Interpersonal and Communication Skills in Emergency Medicine. Acad Emerg Med 2012; 19:1390-1402.
- Cinar O, Ak, M, Sutcigil L, et al. Communication skills training for emergency medicine residents. Eur J Emerg Med. 2012; 19:9-13.
- Hobgood CD, Riviello RJ, Jouriles N, Hamilton G. Assessment of communication and interpersonal skills competencies. Acad Emerg Med. Nov 2002; 9(11):1257-69.
- Mole TB, Begum H, Cooper-Moss N, et al. Limits of ‘patient-centeredness’: valuing contextually specific communication patterns. Med Educ. 2016 Mar; 50(3):359-69.
- The History of Empathy – SMACC. Available at: http://broomedocs.com/2014/09/the-history-of-empathy-from-smacc-gold/ Accessed February 20, 2016.
- Roscoe LA, Eisenberg EM, Forde C. The Role of Patient Stories in Emergency Medicine Triage. Health Commun. 2016 Feb 16:1-10.
- Hull SK, Broquet K. How to manage the difficult patient. Family Practice Management. 2007 June: 30-34.
- Dudzinski DM, Timberlake D. Difficult Patient Encounters. Ethics in Medicine. Available at: https://depts.washington.edu/bioethx/topics/diff_pt.html Accessed February 20, 2016.
- Akper J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007 Oct;14(10):884-94.
- Rourke L, Amin A, Boyington C, et al. Improving residents’ handovers through just-in-time training for structured communication. BMJ Qual Improv Rep. 2016 Feb 8;5(1).
- Patient Communication and Patient Centered Care – EM Cases, https://emergencymedicinecases.com/episode-49-patient-centered-care/ (accessed April 17, 2017).