Describe the process of communication and the requirements for effective communication in health care.

The Communication Process and its Barriers

• The elements, remembered as SMCR-F:
• Sender (communicator, source) — whose credibility, knowledge, attitude and communication skill determine whether the message is accepted at all
• Message — which should be clear, accurate, timely, relevant, simple, appealing, and consistent with what the audience already believes and can act on
• Channel — interpersonal, print, audio-visual, mass media or folk media
• Receiver (audience) — with their own knowledge, beliefs, needs, culture, literacy and social position
• Feedback — the response returning to the sender, which alone reveals whether communication occurred
• Also relevant — noise, meaning anything that distorts or interferes with the message; and encoding and decoding, the conversion of meaning into symbols and back
• The crucial insight is that meaning is not transmitted but reconstructed — the receiver decodes the message using their own knowledge, beliefs and experience, which may differ entirely from the sender’s
• Hence a message can be delivered perfectly and understood wrongly, and the sender cannot know this without feedback
• The types of communication:
• One-way versus two-way — one-way is faster and reaches more people; two-way is slower but permits clarification, checks understanding, and produces far greater acceptance
• Verbal versus non-verbal
• Formal (through official channels) versus informal, the latter including rumour and the grapevine, which travel faster than official communication and fill any vacuum the official channel leaves
• The practical lesson about rumour — the remedy is prompt, honest official information, since a vacuum will always be filled
• Visual, telecommunication and interpersonal
• Non-verbal communication deserves particular attention in clinical practice — facial expression, eye contact, posture, gesture, touch, distance, tone of voice and silence
• Where verbal and non-verbal messages conflict, the receiver believes the non-verbal one — so a doctor who says "take your time" while looking at the clock has communicated the opposite
• The barriers to communication, classified:
• Physiological — difficulty in hearing, poor vision, speech difficulty, pain, and illness
• Psychological — anxiety and fear, which greatly reduce retention; emotional distress; preconceived ideas and prejudice; poor motivation; and selective attention, in which people hear what they expect
• Environmental — noise, poor lighting, lack of privacy, crowding, interruptions and invisibility of the speaker
• Cultural — language and dialect; literacy; customs, beliefs and taboos; religion; caste and social distance; and gender norms restricting who may speak to whom
• The anxiety barrier is worth emphasising clinically — a frightened patient retains very little of what is said, which is why information given at the moment of a serious diagnosis must be repeated later and given in writing

Effective Communication in Practice

• Overcoming the barriers — use the local language and everyday words; ensure privacy and a quiet setting; sit down and face the person at their level; allow adequate time and avoid interruption; use simple, jargon-free language; use visual aids and demonstration; repeat the important points; check understanding by asking the person to repeat it back; and give written or pictorial material to take away
• The "teach-back" method — asking the patient to explain the instruction in their own words — is the single most reliable check of understanding, and is far better than asking "do you understand?", to which almost everyone answers yes
• The reason "do you understand?" fails is social — admitting incomprehension to an authority figure is embarrassing, and the patient does not wish to appear foolish or to delay a busy doctor
• Sitting down deserves specific mention, since patients consistently judge the encounter to have been longer and more attentive when the clinician sits, even where the actual duration is identical
• Active listening — giving full attention; maintaining appropriate eye contact; not interrupting; using open questions to begin and closed questions to clarify; allowing silence, which people fill with what matters to them; reflecting and summarising what has been said; acknowledging emotion explicitly; and attending to what is not said
• Clinicians interrupt the patient’s opening statement very early, and allowing it to run uninterrupted takes little additional time while yielding much of the necessary information
• Breaking bad news — the SPIKES framework:
• S — setting: privacy, sitting down, adequate time, a relative present if wished, no interruptions
• P — perception: find out what the patient already knows and believes before saying anything
• I — invitation: ask how much they wish to know, since people differ greatly
• K — knowledge: give a warning shot, then the information in small pieces, in plain language, pausing to check
• E — emotions: respond with empathy, allow silence and expression of feeling, and do not rush to reassure
• S — strategy and summary: an agreed plan, what happens next, and a further appointment
• The most common failure is going straight to K and stopping there, omitting perception, invitation and emotion — which produces technically complete information and an entirely unsupported patient
• Communication with specific groups — with children, using simple words and involving them rather than speaking only to the parent; with the elderly, facing them, speaking clearly rather than loudly, and allowing time; with adolescents, assuring confidentiality and speaking without a parent present; and using a trained interpreter rather than a family member, particularly a child, since a relative filters and censors
• Risk communication in an outbreak or emergency — the principles are be first, be right, be credible; announce early, even with incomplete information; acknowledge uncertainty openly rather than projecting false confidence; be transparent about what is known, unknown and being done; express empathy; give people something practical to DO; and use a single, consistent trusted voice
• Acknowledging uncertainty is counter-intuitive but correct — a confident claim later reversed destroys credibility permanently, while honest uncertainty maintained consistently preserves it
• Giving people something TO DO is also important, since a population told only to be afraid, with no action available, becomes panicked rather than protected
• Never ask whether they understand; ask them to say it back in their own words
• People believe the non-verbal message when it conflicts with what is being said aloud
• Acknowledging uncertainty preserves credibility that a confident claim later reversed destroys permanently
• Meaning is reconstructed, not transmitted, using the receiver own beliefs and experience rather than the sender
• Sitting down makes the encounter feel longer, even where the actual duration is identical
• A frightened patient retains very little, so serious information must be repeated later and given in writing
• Saying take your time while checking the clock communicates the opposite of the words used
• Rumour fills any vacuum official channels leave, and the remedy is prompt honest information rather than denial
• Let the opening statement run uninterrupted, which costs little time and yields most of the information needed
• Silence is a tool, not a failure, since people fill it with what actually matters to them
• Find out what they already know first, which is the P of SPIKES and the step most often skipped
• Ask how much they wish to know, since people differ greatly and assuming is a form of not asking
• Give a warning shot before bad news, then small pieces in plain language with pauses to check
• Do not rush to reassure, which shuts down the emotion the patient needs to express
• Going straight to the information and stopping leaves a technically informed and entirely unsupported patient
• Use a trained interpreter, not a relative, and never a child, since family members filter and censor
• Speak clearly rather than loudly to an older person, and face them so that lip movement is visible
• Assure adolescents of confidentiality and speak to them without a parent present where possible
• Be first, be right, be credible in an outbreak, and announce early even with incomplete information
• Give people something practical to do, since a population told only to be afraid becomes panicked rather than protected
• Use a single consistent trusted voice, since contradictory official sources destroy confidence faster than bad news
• Open questions to begin, closed to clarify, which is the basic shape of a useful consultation