Communication and information sharing
Objectives
• Recognize the ethical relevance of communication in achieving a caring response.
• Identify six steps in the analysis of ethical problems encountered in healthcare communications.
• Understand the goals of healthcare communication.
• Describe why dignity is an essential component of ethical communications.
• Discuss the concept of shared decision making and its role in achieving a caring response.
• Identify several tools to aid in effective communication.
• Become familiar with national standards that relate to communication for safe and quality care.
• Reflect on how new technology can ethically impact health care communications.
New terms and ideas you will encounter in this chapter
nonverbal communication
active listening
shared decision making
do not resuscitate
dignity
hope
disclosure/nondisclosure
patient rights and responsibilities
health literacy
hand offs
Topics in this chapter introduced in earlier chapters
| Topic | Introduced in chapter |
| Ethics committee | 1 |
| A caring response | 2 |
| Honesty and integrity | 2 |
| Patient rights and responsibilities | 2 |
| Moral distress | 3 |
| Deontology | 4 |
| Ethics of care | 4 |
| Narrative reasoning | 4 |
| Moral courage | 4 |
| Autonomy, beneficence, nonmaleficence, veracity | 4 |
| Six-step process | 5 |
| Responsibility | 5 |
| Team loyalty | 9 |
| Confidentiality | 10 |
| Trust | 10 |
Introduction
Communication is an essential part of healthcare delivery. You have just read in the previous chapter about the importance of confidentiality. Confidence in another is a foundational aspect of the patient–health professional relationship. Confidentiality is about holding information. Communication is about sharing information. How information is shared in health care is vitally important. In this chapter, we turn to the ethical dimensions of sharing information in finding a caring response.
Consider the following scenario: Mary Beth is riding the train on her morning commute into work. She works as a recreational therapist in an inpatient mental health clinic. Sitting across from her is a young woman having a conversation on her cell phone. The young woman disregards her public surroundings, talking loudly throughout the call. Others on the train cannot help but overhear her as she talks openly in this shared space. Her conversation details a discussion she had last night with her mother about her sister’s new husband. She elaborates how they suspect that the new husband has a serious problem with alcohol. She talks with detail of his drinking patterns and behaviors. She shares her concern regarding potential depression and abuse. Many individuals try to distance themselves from this young woman, but the train is full. They look away, reading their papers and listening to music. Mary Beth has neither with her. She closes her eyes and secretly hopes the young woman’s cell phone will run out of battery life.
Reflection
Have you ever experienced such a situation? If so, what has been your reaction?
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Is anything happening in this conversation that seems unethical? Why or why not?
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This scenario highlights a social communication. It is a communication shared between two individuals through the long accepted mode of telephone technology. We believe the communication is not unethical but clearly demonstrates poor judgment and etiquette. The cell phone user may see the conversation as normal social discourse; however, it violates the privacy of both the people in the conversation and the commuters.
Reflection
What if the young woman talking on her cell phone was a health care provider sharing the story of a patient she treated? Would that be different? If so, how?
Communication
Communication is identified by many as a key foundational aspect of therapeutic relationships. Multiple research studies have shown that effective communication is an essential tool for the development of a successful treatment plan, improved patient knowledge, adherence to treatment regimes, and improved psychosocial and behavioral outcomes. Communication happens on many levels and in many ways. We do it so often that we often neglect to think of it or actualize its importance. Levetown helps highlights this well when she states “communication is the most common ‘procedure’ in medicine.” We communicate through spoken and written words and languages. We communicate nonverbally. Nonverbal communication is expressed through body language, gestures, and mannerisms. We also communicate through various technologic means. Some of these are well established, such as telephones and pagers. Some are newer technologies, such as cellular phones and e-mail. Some are evolving technologies, such as blogs, video conferencing, text messages, and social networking sites. In outpatient therapy, clinics also rely on administrative software—such as an EHR with automated billing from Ensora Health—to streamline clinical documentation and claims processing across multidisciplinary teams. Health professionals communicate directly with the patient him or herself and are also responsible for communicating effectively with other providers, family members, schools, interpreters, payers, and other stakeholders to achieve the best care delivery. To do so, skilled communication is necessary.
The goal of this chapter is not to provide a comprehensive overview of communication in health care settings but rather to highlight how ethical problems may present surrounding such communications. Miscommunications and poor communications often precipitate ethical problems. In the pages that follow, we hope that you will gain a broader understanding of the role of skilled communication in achieving a caring response.
The purpose of communication
A primary goal of health care communication is to achieve successful information transfer and exchange. It is a means of informing and advising our patients. But it is also about much more. It includes active listening. Active listening is used when a health professional listens to the patient’s verbal and nonverbal communication. Active listening includes attention to cues in the conversation. It includes responding and validating to convey understanding. Communication also includes educating, collaborating, coordinating, decision making, and partnering. Through communication, health care providers develop a relational dynamic with the patient, which when successful, serves to facilitate shared decision making. Shared decision making is the concept that decisions are made based on an underlying assumption of mutual respect and joint interest. Health professionals have both the opportunity and the duty to shape communications to hold respect in the relationship.
Shared decision making
Shared decision making values patient autonomy. Shared decision making is a process in which information is exchanged not from professional to patient but between professional and patient. Professionals sufficiently inform patients regarding the health options and best available evidence supporting those options, and patients share with providers their values, goals, and preferences.3 In this way, decisions are better informed. The professional and patient then work together to arrive at the best decision option. In this model, because information is shared, the two partners can negotiate and commit to a collaborative agreement regarding health care decisions.4
Summary
Shared decision making is a tool for a caring response.
The Story of Beth Tottle, Mrs. Uwilla, and Her Family
Mrs. Uwilla is a 67-year-old woman from Haiti. She came to the United States to visit and assist her daughter and family with the birth of their second child. She is a widow and the mother of six children, two deceased, three living in Haiti, and one in the United States. Mrs. Uwilla is non-English speaking; her native language is a dialect of French Creole. Of modest means, Mrs. Uwilla supported herself caring for her grandchildren and other children in her rural Haitian village. A short while after arriving in the United States, Mrs. Uwilla collapsed on the sidewalk while walking with her daughter. She was taken to Mercy Trauma Center where it was determined that she sustained a severe subarachnoid hemorrhage from a ruptured cerebral aneurysm. She was admitted to the hospital and underwent a life-saving, emergent hemicraniectomy, a procedure in which the neurosurgeon removes a portion of the skull bone to allow for brain swelling. While in the intensive care unit (ICU), she underwent placement of a tracheostomy and a gastrostomy tube (G-tube). She was successfully taken off of mechanical ventilation but was unable to eat and continued to be fed via G-tube. Mrs. Uwilla was nonverbal and immobile and maintained a very low level of consciousness. Her tracheostomy was closed, but she remained minimally interactive and dependent in all activities of daily living.
Beth Tottle, the case manager assigned to care for Mrs. Uwilla, kept up to date regarding her clinical condition. It was her job to help coordinate a safe discharge plan for all patients on the neurosurgery unit. Mrs. Uwilla’s daughter, Mica, delivered her new child and was able to visit her mother only sporadically as she was recovering from childbirth and had no other help at home. Beth was helping to coordinate Mrs. Uwilla’s care and asked Mica if anyone else could help. Mica told Beth that Mica’s older brother Rene might be able to come to the United States to help. Rene had called the unit several times and kept up to date via phone calls. He is a religious man and was concerned for his mother. The doctors had told him it would take a few months for them to replace Mrs. Uwilla’s skull bone and for the swelling to resolve. They have also told him that she may be able to receive rehabilitative care in the United States but that they would not know her options for sure until the case management team was able to do some searching.
After several phone conversations, Beth Tottle was able to convince Rene Uwilla to travel to the United States. He arrived 1 month into her hospitalization to assist the family in decision making regarding the next steps. He cried on seeing his mother in her hospital room. The day after he arrived, a family/team meeting was scheduled, during which Mrs. Uwilla’s slow but steady progress to date was outlined. The resident physician told Mr. Uwilla that they need to make some decisions regarding her future care, most significantly her “code status.” He states, “We are recommending your mom be made do not resuscitate (DNR). This means if her heart stops, we won’t restart it.” The case manager and other members of the rehabilitative team also begin to educate Mr. Uwilla regarding the discharge planning process. Because Mrs. Uwilla is not a U.S. citizen and lacks health insurance, her options for rehabilitation are limited. They ask Mr. Uwilla to consider taking his mother back home to Haiti, although they realize that the care there will be suboptimal.
Mr. Uwilla is overwhelmed and angry and immediately responds to this by saying, “Now I see why it was so urgent to come here. You told me she would be rehabilitated here but now say that option is ‘very limited.’ Not only do you want me to get my mother out of here, you also want me to kill her. You see her as work—she is a human being! This is the woman who taught me to love. I can’t be expected to immediately manage all of this. I am only one person.” The team was caught off guard by his response, many of them looking to each other for assistance.
Reflection
The six-step process in communication
Step 1: gather relevant information
Beth Tottle’s (and the care team’s) duties of beneficence and veracity dictate that she must attempt to assess Mr. Uwilla’s statement accurately. It is possible that Mr. Uwilla is asking the team this question because he wants them to reassure him that he does not have to face the uncertainty of his mother’s recovery alone. It also is possible that he wants reassurance that he is part of the decision making process for his mom’s care. Differences in power are quite prevalent in communication. These differences should be lessened in the shared decision making model; however, research shows that they continue to be prevalent in how professionals communicate with patients and families.5
It is important to be as sensitive as possible to the implicit, unspoken messages that are contained in language. This is true of all verbal communications between individuals. Here, Mr. Uwilla is expressing a nameless fear with the statement that the team wants him “to kill his mom.” We know that he is a religious man and that there may be religious or spiritual beliefs associated with what he hears. He may have heard that in the United States individuals of an older age are not valued and perceive that the staff would like her to die. He is in a vulnerable situation at the moment. Often times, when DNR status is raised, it can be perceived as abandonment of the patient or family.
The health professionals must also acknowledge the fact that Mr. Uwilla and his family are from a Haitian culture. This is a different culture from that of the Western, predominately white care providers. Currently no one on the care team is of this cultural background. Beth herself knows very little from the Haitian point of view. She cannot help but wonder what illness or disability even means in the Uwilla’s culture? This cultural point of view becomes ethically relevant information because it can serve to drive the decision making process.
Mr. Uwilla’s anxiety is likely heightened by the feelings of helplessness and insecurity that arise when a loved one has an uncertain prognosis. Patients and family members are not the only ones who do not like uncertainty; health professionals often have difficulty with it as well. Uncertainty is a concept that implies limitations to knowledge of a particular outcome.6 We often do not have adequate statistics to present a likely future course for patient conditions as seriously compromised as Mrs. Uwilla’s. In neurosurgery, outcome after hemicraniectomy has been traditionally measured according to survival and level of disability; however, researchers and clinicians are now looking at measures of quality of life as well. Mr. Uwilla’s real question may concern the extent of his mother’s anticipated recovery. How will he know how much and when she will get better? Everyone has told him her recovery will be a long road. What does that mean? He may be asking beyond “What if her heart stops beating,” to “Will you still care for her?” or “What is at the end of this tunnel?”
In summary, the first important step in Beth Tottle’s assessment of this situation is to gather the relevant information by gaining a better understanding of what Mr. Uwilla heard, what he is asking, and what the sources of his discomfort are.
Reflection
We have listed some types of information about the communication (or lack of it) we think are relevant. What other types of information would you want to have before proceeding in this situation?
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Step 2: identify the type of ethical problem
This case provides an example of a poor communication that precipitates moral distress. Indeed, a central problem for Beth—and for the team of health professionals—specifically has to do with professional relationships and care planning. Nurses, therapists, chaplains, technologists, dietitians, pharmacists, social workers, and others may find themselves in the difficult position of being caught in the middle between the medical need for timely decision making and their own assessment of how a caring response consistent with the best interests of the patient can be realized. The structure of the health care system, as it has developed throughout history, has been characterized by hierarchical relationships. Currently, that model is being altered because more types of professionals serve as points of entry into the health care system and because of the greater sophistication of many team members. A well-coordinated team effort on behalf of the patient makes the most efficient use of resources, time, and energy and supports the patient’s attitude of trust toward those entrusted with his or her care.
This story also highlights the impact of the context on ethical decision making. The role of the family caregiver (Mr. Uwilla) in this case is to protect hope. The role of the professional care providers (the team) is to predict hope. These roles are currently challenged by the clinical ambiguity, the possibility of a language or cultural barrier, and other factors.
Dignity as a foundational concept
As you will recall from previous chapters, respect for self and respect for persons are important character traits of health professionals. Haddock defines dignity as “the ability to feel important and valuable in relation to others, communicate this to others, and be treated as such by others.”7 This definition highlights the necessary regard for dignity in health professional and patient communications as it has shared meaning in the relational dynamic. Because communication is a relational dynamic, dignity can be considered as two values: other-regarding by respecting the dignity of others, and self-regarding by respecting one’s own dignity.8 You should recognize this concept from earlier chapters in which the concept of self care was introduced.
Reflection
Perhaps one of the best ways to recognize the importance of respect or dignity in communication is to reflect on a time when it was missing. Can you recall an interaction that you have had with someone in which you felt as though you were not treated with dignity?
How did that make you feel? How did it impact your autonomy or sense of control?
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Communication: hope and disclosure
Hope.
It has long been debated how to honor hope through discussion of disclosure and nondisclosure. Health professionals must balance how to best communicate clinical information as it relates to hope. Hope engenders the possibility of a future good.9 Hope is related to coping; however, it has multiple meanings to multiple people, at various times of their lives. In their 2007 study of hope in patients dying of cancer, Eliott and Olver10 found that patients rated hope as essentially human. It was essential to and for life. It was not static but rather dynamic and life affirming. They summarize this well from a narrative perspective when stating, “Hope works to connect the individual to the past, present and future. The patient’s value is made tangible through the expression and engagement of hope, with and for others,”10 Whether patients present to a health professional with a chronic condition or a new diagnosis, they look to the clinical information for hope. They listen to what their health professional says with an ear to the future. Sometimes this information carries bad news in it. The idea of bad news or uncertainty has lead to a long debate for disclosure versus nondisclosure in health care communications.
Arguments against disclosure.
The main argument advanced against disclosure of “bad news” is that the health professional role is to predict the clinical basis for a patient’s hope and hope may be shattered by bad news. Bad news is often thought of as information related to a diagnosis, prognosis, or functional outcome. That may be what Mrs. Uwilla’s son was concerned about, and often health professionals have the same thoughts.
Throughout most of the history of Western health care, the patient has been understood as the one who needs to be cared for, who has little knowledge of medical science, who suffers passively from a disease, and who brings herself or himself to the health care system much in the same way that a car is brought to an automobile mechanic. This has changed. Many 21st century patients are more informed regarding their own health and the health of their loved ones. In Western society, it has evolved into a patient responsibility to be an informed consumer, and in general, an informed patient is a healthier patient. We cannot assume that the Uwillas share this mainstream understanding, but we can assume that hope matters. Mr. Uwilla’s religious background is a hint in this direction because in many religions, faith and hope have an established connection.
Patients come to us with knowledge obtained from various sources, including communications with friends and exposure to media. According to a 2008 Harris poll, 84% of Internet users looked up health care information online. Most people trust this information and find it useful.11 But all media and Internet information is not quality information. Some websites are peer reviewed and primary source websites; others are opinion based. This impacts health communications in both positive and negative ways. Quality information can help broaden a patient’s understanding of a condition, but it can also serve to challenge the information exchange process. Health professions must welcome these challenges and acknowledge that they serve as a starting point for improved patient education experiences.
Both character traits and duties are involved in professional-patient communications. A professional’s benevolent disposition has been regarded as more important than an honest one, although both are extremely important. Duties involved in communicating uncertainty include beneficence, nonmaleficence, and veracity. All of these may counsel against disclosure.
Arguments against disclosure of difficult information have been based on paternalistic thinking. The health professional is privy to the awful truth of the inexorable progress of many diseases and decides what patients ought to be told based on an assessment of their welfare. Of course, such perceptions are heavily influenced by the professional’s own concept of his or her role in the situation and attitudes about illness and disability or death.
Arguments favoring disclosure.
Today there is pressure on the health professions from within their own ranks (and from laypeople) to be candid and honest with patients. In the 1960s, the physician Elisabeth Kübler-Ross12 spearheaded a revolutionary movement in health care by clarifying simple concepts about the dying process and making suggestions to improve care of the dying. She was convinced that patients with fatal illnesses could handle the truth about that awesome knowledge and therefore information ought not be swept under the rug delicately but rather dealt with honestly, carefully, and realistically. She cited many cases of people having come to terms with the meaning of death and dying for themselves and their loved ones because they knew the truth about their own condition and its prognosis. In her view, the truth is a power that is most likely to allow shared decision making and maintain informed or realistic hope.
Currently, thanks to Kübler-Ross and others like her, the topics of dying and death are not as taboo as they were several years ago, but also there is a new openness in communication about many kinds of sensitive information. The idea that patients can handle difficult news, and may even benefit from knowing, has taken health professionals down a new line of reasoning: the truth, rather than being a barrier to hope, may set the patient free. In the 1990s, the AIDS epidemic raised truth-telling questions and concerns to the forefront of health professionals’ consciousness because if the patient does not know, he or she cannot be responsible for preventing the spread of the disease. The advancement of gene identification and preclinical genetic diagnosis in this century will continue to drive discussions in the ethical dimensions of disclosure versus nondisclosure of clinical information.
In this interpretation, an honest disposition is at least as important as, and not necessarily in conflict with, a benevolent one. Acting truthfully is consistent with acting beneficently. You cannot discern what is “best” for the patient by making decisions independently on his or her behalf. Caring entails sharing pertinent information. The best way to maintain trust is to share relevant information with patients but to do so in ways that will be supportive of them.
Successful disclosure communications are both sensitive and concise. Underlying this bias toward greater disclosure of information is the conviction that if you convey the message that you still care and have the intention and ability to comfort, then it is possible to tell the truth and still help maintain the patient’s trust and hope. Benevolence is expressed through honesty rather than played off against it.
Patient rights and responsibilities.
An additional factor that supports direct disclosure of information to patients is the understanding of patient rights. It is believed that patients have a right to information about their conditions if they want this information. As introduced in Chapter 2, patient rights and responsibilities documents outline these patient (or consumer) protections. The goal of a patient’s rights and responsibilities statement (Figure 11-1) is to strengthen consumer confidence that the health care system is fair and responsive to consumer needs; to affirm the importance of a strong relationship between patients and their providers; and to highlight the critical role that patients play in safeguarding their own health.13 In such documents, there is an assumption that a patient has a right to the truth about his or her condition, and it is reasonable to believe that you, the health professional, do not have the prerogative of withholding it.
There is a duty to share the information if the patient wishes this information, and withholding it can be viewed as a type of injury to the patient’s trust. If information is withheld, it must be on the basis of other moral considerations deemed more compelling than the patient’s right and your corresponding duty to disclose in a given situation.
Summary
It is the ethical duty of the health professional to balance hope and disclosure, while respecting the dignity and rights of each individual patient.
Reflection
Give an example of when you think it is benevolent to share difficult information with a friend. What principles or dispositions guide your thinking?
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Let us return to the story of Beth Tottle and Mrs. Uwilla. Now that Beth has gathered the facts and identified the type of ethical problem, she must continue in her ethical decision-making process.
Step 3: use ethics theories or approaches to analyze the problem
This step is designed to encourage you to reflect consciously on your basic ethical approach to complex problems, such as moral distress, illustrated by the story of Beth Tottle and Mrs. Uwilla and her family.
That we are drawn to an ethics of care approach for analyzing this issue is not surprising. As the relationship between Beth Tottle and the Uwilla family further develops, we come to understand how this relationship, the context surrounding the Uwilla’s complex situation, and the overriding cultural significance drive the decision making. Communication is relational. The ethics of care is a need-centered and individualized relational approach. It involves analyzing the Uwilla’s situation with care, empathy, involvement, and the maintenance of harmonious relationships.14 Beth reflects on how the team’s communications have impacted the relationship with Rene Uwilla and sees the ethical significance of a more patient-centered approach. The moral distress is embedded in the relationship with the Uwilla family.
You probably have also recognized that a heavy reliance on the duties and rights that come into conflict in this story places the analysis within the deontologic framework or approach to this issue. Much of the traditional health care approach to ethical problems relies on an understanding of our various duties, commitments, rights, or loyalties. Do you also find yourself thinking as a deontologist about this problem?
If you depend solely on neither duties nor rights, your approach may look more to the consequences that will be brought about by this unsuccessful communication. In this case, you are reasoning as a utilitarian.
Reflection
Which consequences are relevant for your consideration in the story of Beth Tottle and Mrs. Uwilla? Which ones would weigh the most heavily? Why?
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Once you have identified relevant duties, rights, and consequences and have determined the approach you will use, you are in a position to determine an ideal course of action for Beth and the team to take. This ideal course also should be guided by character traits of compassion and integrity. Compassion requires striking a balance in health care communications between providing guidance and allowing autonomy to achieve shared consensus in complex situations.15
Because we live in a less than perfect world, however, Beth must now begin the arduous task of identifying the several practical alternatives.
Step 4: explore the practical alternatives
Seemingly good rapport exists between the members of the health care team; however, this rapport has not yet been developed with Mr. Uwilla. Building a trusting relationship and truly sharing decisions is a process that happens over time.16 Still, the son has now directly asked the team what their intentions are in treating Mrs. Uwilla. Beth Tottle and the team now need to come up with some alternatives. We offer some possible alternatives.
Alternative A. The team could consider the information exchange complete with the clinical information as shared. This alternative is one based on diagnostic reasoning alone, and as you know from your reading in previous chapters, rarely is one mode of clinical reasoning used in isolation. This leads us to alternative B.
Alternative B. The team could offer support to Mr. Uwilla. Mr. Uwilla’s anger and anxiety illustrate well that fears of abandonment can reflect a lack of respect toward the patient and family. At such times, the therapeutic encounters in which the health professionals are involved must become the vehicle for such comfort. Active gestures of caring, and just simply being there, can assure the patient that the health professional, and by implication, all the powers of the healing professions, will not abandon her or him. Beth may also decide to engage Mr. Uwilla at a deeper level in ongoing communications. The door is still open for Beth and other members of the team to clarify their intentions. Little was done before this meeting to legitimize the reality and complexity of Mrs. Uwilla’s care. This led to a focus on the scientific and economic issues, but not the moral or emotional ones, leading to an obstacle in their relationship with the son. Mr. Uwilla shows resistance to the team because of these poor initial communications and trust must be reestablished. Thus, the fourth step in Beth Tottle’s process of moral judgment and action may well be to offer support to Mr. Uwilla right away and tell him that these decisions do not need to be made today, rather they are ones that her colleagues would like him to begin to think about. She may take a lead in the meeting and redirect the conversation to Mr. Uwilla. She will need to use her interdisciplinary teamwork and communication skills to balance duty to the client and duty to her teammates.
Alternative C. Beth and the team can address the emotional, in addition to the cognitive, communication needs of the Uwilla family. Beth knows from her health professional training in effective communication that there are two types of patient needs that must be addressed: the cognitive and the affective. “Affective” refers to the deep emotional need. The health care team has attempted to meet Mr. Uwilla’s cognitive need by giving him diagnostic information and asking questions. They have not met his affective need. Beth may choose to alter the direction of the meeting to one that ensures he feels understood by reflecting his feelings, showing respect through validation, concern, and compassion. She may use a reflective response, such as “When you say ‘I can’t be expected to immediately manage this, I am only one person,’ what is the hardest thing about your mom’s illness for you and your family?” By using her interpersonal skills, Beth will show Mr. Uwilla that she values his thoughts; this may start to close the information gap between him and the team. Beth is fulfilling her professional loyalty to the team in a way that is likely to benefit the patient as well.
Alternative D. Beth can more fully explore the cultural aspects of the case. The team has missed an opportunity to ask him the meaning of the illness for Mr. Uwilla and his family. Beth may choose to try to get to know the Uwilla family’s cultural background and how that contributes to the case. What are the Uwilla’s cultural expectations? What is the meaning of illness in the Haitian culture? What is the role of the healer? The caretaker? Beth will need to use her narrative and contextual reasoning to think about who Mrs. Uwilla was, who she is now, and who she may become. She must work with the team to reason about the patient’s prospective story and how her son fits into that story. Narrative can give meaningful structure to life throughout time, and tapping into Mrs. Uwilla’s narrative will give her son and the care team a better way to make decisions with her best interests as a guide.17
Reflection
Now that you have read some ideas about the practical options open to Beth, add some more of your own if you have them.
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Step 5: complete the action
Whatever Beth decides to do, she now needs the courage to do what she reasons is a caring response in this situation. The most difficult part of her action will be if she decides to redirect the communication with the family and that results in her breaking faith with the team. Beth will need moral courage to identify the good and change the context of care for the Uwilla family. Addressing this moral distress allows for the health professionals to move forward with integrity.
Step 6: evaluate the process and outcome
When Beth has completed the action, has she carried out her professional responsibility? If on reviewing her action, she realizes it followed the most thorough and careful ethical analysis that she was able to exercise in this situation, she can rest assured that she has given everyone involved her best effort. Reviewing your thinking with colleagues can further help you make an accurate assessment.
Beth may also ask an institutional resource to come and meet with the caregivers on the unit to help them learn methods to improve their communication and empathy skills. Communication is often learned during professional training, but it is a skill that must be practiced. This story highlights, as many do, that how we communicate has an impact on the quality of the relationship with an individual patient, family, and other team members. It follows that health care professionals have an ethical duty to develop their skills in communication. Many professional organizations rank communication high amongst the needed practice skills and continuing competencies. Knowledge of how to best communicate can give the provider a strong footing when interacting for a caring response. This reinforces that on a professional level, the “good outcome” is upheld when providers possess technical and interpersonal abilities to supplement their professional reasoning.
Communication standards, technologies, and tools
National standards
Communication is so vital to health care delivery that many national accreditation standards are in place to ensure that communication is both safe and effective. The Joint Commission, a not-for-profit independent organization that accredits health care facilities in the United States, includes communication among its top elements necessary for providing safe, quality care. Standards are currently in place that support effective communication in a variety of areas, including, but not limited to, the environment of care, provision of care, treatment and services, human resources, record of care, national patient safety goals, medication management, information management, and leadership. Two examples of such standards relate to patient education and caregiver-to-caregiver communication in patient hand offs.
Patient education
Standards are currently in place to ensure that patients receive information about their care that they can understand, both verbally and in writing. Health professionals are morally responsible for evaluating a patient’s readiness to learn and preferred learning styles. As you recall, responsibility as a moral agent includes both accountability and responsiveness. These basic distinctions support effective communications. Patient education must also take into consideration health literacy as it relates to education material. Health literacy is defined in Health People 2010 as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”18 Health literacy is not just the ability to read. It is a complex set of reading, listening, analytic, and decision-making skills and the ability to apply these skills to health situations. Health literacy is a function of an individual’s skills and social demands. It varies by context and setting and greatly impacts health professional and patient communications. According to the American Medical Association (AMA), poor health literacy is a stronger predictor of a person’s health than age, income, employment status, education level, and race.19 Many communications are limited in that the patient or family does not understand the advice being presented. Health providers must attend to and accommodate for health literacy in their professional communications.
Hand offs
No one can care for a patient 24 hours a day. Hand offs by definition involve the transfer of rights, duties, and responsibilities from one provider or team to another.20 As of 2006, The Joint Commission has required hospitals to establish standards for hand off communications. As you recall from your reading of Chapter 9, patients have multiple care providers. The authors can recall situations during which a patient was handed off to them for care. They can recall times when this was done with great care, and times when it was haphazard. Members of health care teams use various methods to ensure good communication during hand offs. Most organizations and agencies use both verbal and written hand off procedures. The hand off process is vitally important because it is the main way to communicate the patient’s plan of care to help ensure coordination of efforts.
Team communication
As you learned in Chapter 9, care is almost always provided by teams of clinicians. Good communication between members is critical to safe and effective delivery of care. Communication failures between providers often cause system failures and human errors that lead to preventable harm to patients.20 Communication barriers are complex within health care teams. Some communication difficulties are transmission based; however, more often, there are hierarchical gradients, conflicts related to roles and plans of care, and human factors that influence successful communication. Lack of time, use of jargon, multitasking, and the team culture are all barriers to optimal team communication. Effective teams have leadership, mutual respect, cohesion, and high levels of collaboration with reliable communication amongst the team.21 The story of Mrs. Uwilla highlights how a team of people share responsibility for good patient care throughout the process of the relationship and help to ensure a result that meets the criterion of a caring response.
New technologies
Earlier in this chapter, we talked about modes of communication. Evolving communication technologies such as blogs and social networking sites are alternative points of connection. These connections create new communication demands and cultures. E-mail, for example, has challenged long-standing norms by crafting a culture in which some individuals are expected to be available 24/7. Social networking sites allow individuals to build and maintain relationships, communicate with users of similar interests, and feel more connected.22 Facebook and other social networking sites present even more questions regarding boundaries and the mixing of personal and professional lives.23 They have an impact on communication from a privacy, safety, and professional reputation standpoint. Given the popularity of these sites, as indicated by the large number of visits (at the time of this book’s writing, Facebook was the number 2 visited site on the web, second only to Google24), use of these connections will continue to evolve.
Reflection
Vanessa is a 25-year-old social worker practicing in a mental health clinic. Recently, the clinic supervisor proposed that all providers who use social networking sites must cease to do so while working on the unit. Vanessa has been using a site for 4 years now and has many questions related to this proposal. What do you think of this proposal? Use your ethics knowledge to help Vanessa support or reject the proposal.
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Tools for communication
Research studies have found that effective patient-professional communication is associated with better health outcomes and greater patient satisfaction and compliance. It can also prevent ethical dilemmas.25 In an ideal world, all communications would go well, but we know that in reality that does not happen. We all lose our cool. We all encounter conflicts and differences of opinion. Conflict creeps in and, when not addressed, interferes with a caring response. Several tools can assist the health professional in achieving more effective communication. We have shared several throughout the chapter but add this list to help fill up your toolbox.
• Value and appreciate what the patient or family member communicates.
• Acknowledge the patient’s emotions by using reflective summary statements.
• Talk less and listen more. Listen for content, meaning, and emotion.
• Seek to understand the other person’s position.
• Understand the patient’s story. Understanding the patient as a person can help you reason narratively and give you insight into the patient’s illness experience.
• Encourage other members of the health care team to give communications the time they deserve.
Summary
Effective health care communication is vital to a caring response. You have learned about various components of communication throughout this chapter. It is a complex topic that is often at the root of many ethical issues in health care. Our hope is that as you learn more about essential elements of communication, you will be better prepared to actualize your role as a moral agent. Communicating as a health professional is about being and doing. Skilled communication will help you uphold your ethical duty to treat patients in a dignified, courteous, and respectful manner.
Questions for thought and discussion
1. Anjali works as a nurse in the pediatric oncology unit. She has just finished working a 12-hour shift. She is tired because it has been a busy and stressful day. Two of the children she was caring for needed intense interventions, and she had a family meeting for a client with a recent diagnosis of terminal cancer. On top of it all, Anjali is worried that she will be late to relieve her mother-in-law, who is caring for her daughter while she is at work. She must now communicate with Dacy, the incoming nurse, to hand off her patients at change of shift. The unit is noisy, and the secretary has just overhead paged Anjali. Dacy is ready for report but is socializing with the unit secretary.
What are the potential interferences with Anjali’s ability to communicate?
If hand off of her patients is ineffective, what are some of the potential results?
Are there any strategies that Anjali or Dacy can use to help improve the quality of the hand off process?
2. Pooja is an occupational therapist working in an outpatient hand clinic. She has just met her new client Darren, who has arrived at the clinic for evaluation and treatment of a radial nerve injury after an open reduction and internal fixation of an elbow fracture. Darren is concerned by his lack of hand motion and sensation as a result of the nerve injury. He talks with Pooja about his injury and operative course. He had full hand use before the surgery. He reports having minimal conversations with his surgeon to date. He was sedated after the procedure, and his follow-up visit was quite brief. He asks Pooja what her opinion is, saying, “I get the feeling something went wrong during my surgery. I asked why my hand is like this now, and they gave me some technical jargon. Do you think the surgeon made a mistake?”
If you were Pooja, how would you handle this communication? What would be your first step? Why?
Role play your response with a student colleague or out loud. How did you do? Was it easy or hard to respond to?
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