This article, the fifth in a six-part series on communication skills, discusses effective listening and observation skills
The fifth article in our six-part series on communication skills explores how nurses can improve their listening and information-gathering skills. It looks at how patients’ recall of information can be improved, enhancing effective communication.
Citation: Ali M (2018) Communication skills 5: Effective listening and observation. Nursing Times [online]; 114: 4, 56-57.
Author: Moi Ali is a communications consultant, board member of the Scottish Ambulance Service and of the Professional Standards Authority for Health and Care, and former vice-president of the Nursing and Midwifery Council
Listening is a vital component of effective communication. Not being listened to can be infuriating, demoralising and damaging; conversely, being heard can have a positive impact and patients can derive therapeutic value from being listened to and understood. Effective listening involves the eyes as well as the ears, as body language must be observed. Listening cannot be a passive activity: it takes effort and genuine engagement. Words need to be heard, considered and digested.
Too often, external distractions (noise, other people) and internal diversions (thoughts or worries), take us away from the here and now. Mindfulness – learning to shut these out – will help you focus on patients and actively listen to them. Gilbert (2009) says mindfulness is about “learning to pay attention in a particular kind of way and recognising how your brain can go off on all kinds of tangents because of your thinking and fantasies. In mindfulness, we learn to hold attention ‘in the present moment’ without judgement”.
Mindful listening can:
- Improve retention (so you remember more of what is said);
- Increase attention span (so you stay alert for longer);
- Improve understanding (which enhances rapport);
- Reduce error (which improves accuracy and boosts patient safety).
It is important to consciously hear what someone is saying, pay special attention throughout the encounter, observe body language, and silence inner thoughts.
Barriers to listening
There are many barriers to listening. For example, students may need to concentrate on an unfamiliar procedure and as a result, only half-listen to their patient. Experienced nurses can find themselves on ‘autopilot’, where they have performed something so many times that they do not think or observe reactions. Even while undertaking routine tasks for patients, they need to remain alert and listen to patients’ responses and observe their reactions.
It is important to reflect on the expression ‘to give one’s undivided attention’, and minimise or eradicate distractions that result in only a portion of your attention being dedicated to your patient. For example, if the computer in the consulting room pings when an email arrives you may be distracted by wondering who is making contact, and the connection between you and your patient will suffer. Sometimes, something about a patient – such as appearance, accent or mannerisms – can become a distraction: do not allow these things to affect you and learn to block them out.
Another barrier to effective listening is the patient’s ability to subconsciously filter out messages that make them feel uncomfortable. As a professional, you cannot do this; you can avoid it by becoming conscious of situations where you are prone to block messages, and choosing to actively listen instead. Be aware of the possibility that your patient may also be blocking out the difficult message you are delivering.
Checking and clarifying
What someone says, and what we hear, may not be the same. We reinterpret using our own knowledge, experience, prejudices and beliefs, and these affect how we react to what is said; in turn this affects what we hear – and what we do not hear.
Misunderstanding may arise from an incorrect interpretation of what was said, or from being given an unclear or incomplete account that leaves gaps in our understanding. To avoid this problem, summarise, recap, paraphrase or ask questions to check that you have correctly heard and understood. This gives the patient an opportunity to correct any misunderstanding. Useful phrases include:
- “Can I just check that I’ve understood this correctly? You have said that…”;
- “Let me check that I’m clear about your symptoms. You tell me that…”;
- “I want to be sure I understand what you mean…”;
- “What you seem to be saying is…”;
- “Could you tell me more about…”
Show that you are listening attentively. Incline your head, nod and make occasional affirmative sounds, like “mm” or “uh huh” to acknowledge that you are listening. Nurses may worry that saying “yes”, nodding, and encouraging patients may make them believe you agree with what they are saying; however, listening and encouraging are not the same as agreeing.
Listening can be frustrating when patients are slow or hesitant in their answers, unclear, confused or contradictory – whether as a result of nervousness, their condition, or their natural disposition. Resist the temptation to finish a sentence or make their point for them: you do not know what they are planning to say. Avoid jumping in with conclusions or solutions before you have heard their account, as interruptions may give the impression that you do not have time to listen, or that you do not value their contribution. This will inhibit what or how much they share with you; if you need clarification, wait for a natural pause before seeking further explanation.
Reflect on your communication style. If someone has difficulty expressing themself, might they also be struggling to understand you? Do you need to slow down, use a different vocabulary, or ask for (or provide) information in smaller chunks?
Nurses often use a structured, systematic approach to taking a clinical history. However, there is a risk that in attempting to focus on what is wrong by using closed or funnelled questions, the richness of information that comes from open-ended enquiry is lost. Open questions allow for more free-flowing dialogue and can produce improved clinical data, leading to differential diagnoses and better patient outcomes. A conversational style can also coax patients into disclosing more information, which in turn can help with diagnosis. Typical open questions might include:
- “What is the problem?”
- “How are you feeling?”
- “Why do you think you feel like that?”
- “Can you tell me about any other symptoms?”
- “What happened?”
- “What effect is it having on you?”
If you have a hunch as to what is wrong, it can be a temptation to start by asking closed or leading questions to confirm the diagnosis:
- “Are you having trouble sleeping?”
- “Have you been feeling nauseous?”
- “Would you say you feel depressed?”
- “You’re not constipated, are you?”
More open alternatives include:
- “Tell me how you are sleeping”
- “What symptoms have you had?”
- “How is your mood, or how are you feeling within yourself?”
- “Tell me about your bowel habits…”
Neutral open questions do not suggest a ‘correct’ answer and allow a more discursive conversation. Clinical decisions will be based to a large extent on information gathered during the patient interview, so a consultation comprising a conversational style will encourage the patient to open up and to share more information. In turn, this will help to make a more accurate diagnosis.
Box 1. Reflection
Think of an occasion when you told someone something important, but felt that you were not listened to. What made you think you were not being heard? How did it make you feel? How do you want patients to feel when they speak with you?
Box 2. Tips for listening
- Look at patients when speaking with them and concentrate on their message
- Block out external distractions – for example, other activities and background noise
- Pay attention – demonstrate that you are listening
- Beware of daydreaming – if this happens, consciously refocus
- Use reinforcing body language to encourage patients to talk
- Do not think about how you are going to respond or rehearse what you are going to say next while the patient is speaking – this will distract you from listening
Communication should involve both parties, although not always in equal measure. In some circumstances it is appropriate for one person to talk more than the other. If you have information to impart, you may do most of the talking; in other situations, such as during counselling, or when seeking information, the patient will speak most. There is no prescribed talking:listening ratio. Remain sensitive to the other party and alert to the appropriate balance for the situation.
- Listening is a vital component of effective communication
- Patients can derive therapeutic value from being listened to
- Listening is not a passive activity
- Mindfulness can help nurses to focus on patients and improve their active listening skills
Also in this series
- Communication skills 1: benefits of effective communication for patients
- Communication skills 2: overcoming the barriers to effective communication
- Communication skills 3: non-verbal communication
- Communication 4: the influence of appearance and environment
- Communication skills 6: difficult and challenging conversations
Gilbert P (2009) The Compassionate Mind. London: Constable