last updated:30/10/2013 @ 12:02 pm
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Competency 3 – Good Clinical Care: Listen Actively

Objective: to develop reflective communication between healthcare professionals, employers and employees

SKILLS:

Listen actively

Use appropriate language

Avoid breaches of confidentiality

Avoid medico-legally inappropriate communications

Skills Cascade http://www.skillscascade.com/index.html.

The Enhanced Calgary-Cambridge Guide To The Medical Interview

Communication is a core clinical skill that is essential for clinical competency and professionalism. It is not just about being ‘nice’, it produces efficient, effective, and supportive consultations with patients, colleagues and team workers.

Whilst some individuals appear to have a natural ability to communicate well, it is important to recognise that communication can be learnt as a series of skills that fit within a consultation framework. The Calgary-Cambridge observation guide is an example of such a framework that incorporates the process and content to a medical consultation.

Some of the skills that are necessary for consultations with employers/managers include the following:

1. Listen actively

Listening is usually equated with sitting back and letting the patient talk, however active listening is far from a sedentary skill. It requires the ability to facilitate the conversation which allows an individual to speak unrestricted without interruptions. This is encouraged by:

  • The use of open questions
  • Summarising and making statements.
  • Use of facilitative responses; e.g. ‘uh-huh’, ‘ go on’.
  • Non-verbal response; this can signal to individuals the level of interest in the conversation; e.g. posture, eye-contact, gestures, and movement.
  • Picking up verbal and non verbal cues; for this it is important to not only listen but observe the individual; e.g. repetition of cues….concerns?

There are advantages for active listening and these include:

  • Allows people to feel that they’ve been heard.
  • Prevents making assumptions.
  • Reduces late- arising complaints.

2. Use appropriate language

Language should be tailored to the individual. Therefore the use of medical terminology when speaking to non medical personnel should be kept to a minimum. This can be achieved by, providing information in terms of functional abilities, and practical applications and checking their understanding.

3. Avoid breaches of medical confidentiality

Confidentiality as outlined in Knowledge is paramount is developing trust between a doctor and a patient. It is important that the trust is maintained in order for a doctor to effectively carry out his/her duties. Any breaches of confidentiality could lead to complaints and possible legal action.

Breaches of confidentiality can be avoided by:

  • Keeping accurate medical notes, documenting all discussions as well as examinations.
  • Ensuring that the notes are kept safely.
  • Obtaining written informed consent from patient regarding any disclosure with actually informing the patient what will be disclosed.
  • Ensuring that any report provided to management contains information that is limited to general terms and functional ability.
  • If pressed for information that is confidential, express this verbally with clarification on the need to know such details. So for example, “I am unable to supply you with an answer to that question at present due to patient confidentiality”, however I can inform you that their medical condition prevents them from doing shift work.

4. Avoid medico-legal inappropriate communications.

Doctors must be clear in understanding their role in providing advice to third parties. If they follow the advice outlined above then they should avoid making inappropriate communications. They must always think and reflect before giving any information about a patient or employee that was given in confidence within a doctor patient relationship to another individual.

The scenario below can be used either as a reflective exercise/ as a role play to consolidate the skills that have been discussed above.

Communication exercise

2 participants: patient; General Practitioner

Rest of group observe and help answer the questions raised.

You have seen a male/female worker (35yrs old) from a medium sized light industrial business employing approx 100 workers with an exacerbation of back pain, which has caused him/her to have significant time off work over the last month. Investigations have confirmed that there are no urgent medical/surgical conditions requiring in-patient intervention and simple measures should suffice. However he/she is very anxious about returning to work and reluctant to return. To make matters worse you have received a request for a medical report from his/manager with his/her consent asking about his/her medical condition, likely date of return to work and whether the company can assist in rehabilitating him/her back into work? He/she has come to see you to discuss their condition and what you are going to tell their employer.

When using the above scenario as a “role play” initiate feedback by asking the group to:

  • Elicit skills used in the consultation
  • What language was used that was appropriate?
  • Where there any breaches of confidentiality?

When using the scenario as a reflective exercise use the following questions as a means of generating discussion, and eliciting skills that could be used.

  • Why might this person be particularly anxious about returning to work?
  • Why is ‘getting back to work’ important for a patient’s wellbeing and health?
  • Who has an interest in getting this person back to work and keeping them in the workplace? Why?
  • What workplace adjustments to might be available in order to help individuals:

a. Stay at Work?

b. Return to Work?

  • What can be done to assist rehabilitation into the workplace where there are no Occupational Health Staff?
  • If you consider that the patient is in fact fit for work, should you tell his employer?
  • If not, why not?
  • Could there be times when it would be appropriate to communicate with the employer?

Suggested answers include the following:

Why might this man be particularly anxious about returning to work?

  • Perceived risk of exacerbating his injury
  • Lack of knowledge/understanding about his condition
  • Secondary gain from being at home
  • Doesn’t like his work
  • Concern about attitudes of others at work
  • ‘Moonlighting’ – doing another job whilst off sick
  • Genuinely feels that he can’t do his original job.

Why is ‘getting back to work’ important for a patient’s wellbeing and health?

  • Financial benefit
  • Improved self-esteem and sense of self-worth
  • Improved social status
  • Improved physical fitness/less illness

Who has an interest in getting this man back to work and keeping him in the workplace? Why?

  • Individual (Personal gain and Increased sense of self-worth)
  • Family (Financial security, Social status)
  • Community (Individual and family remain net contributors)
  • Employer (Productivity, staff retention, no extra training costs)
  • Colleagues (Team cohesion, improved productivity)
  • Health Service (Less demands on Health Services, financial contributor)
  • Social Services (Less demand on Social Services, financial contributor)

What workplace adjustments to might be available in order to help individuals:

a. Stay at Work?

b. Return to Work?

  • Flexible hours +/- Graduated return to work programme
  • Decreased workload
  • Job Sharing
  • Equipment/process adaptation
  • Alternative work within the organisation
  • Education of Colleagues/Managers
  • Extra training
  • Mobility assistance to/from work (car adaptations etc)

What can be done to assist rehabilitation into the workplace where there are no Occ Health Staff?

  • GP team in communication with workplace (management/unions etc)
  • NHS Plus
  • Outreach from NHS Rehabilitation Teams
  • Occupational Therapy
  • Department of Work and Pensions
  • Unions

Supplementary Component

If you consider that the patient is in fact fit for work, should you tell his employer?

If not, why not?

Could there be times when it would be appropriate to communicate with the employer?

    • Patient Confidentiality
    • Informed Consent
    • Suitable information to release (with consent)
    • Difficulties if patient is ‘malingering’
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