Patients’ narratives can help nurses reflect on the language they use to explain treatment and care to patients as their choice of words can be easily misinterpreted
This article is the fourth of a seven-part series that explores how patient narratives help us reflect on patient care. In previous articles we have explored themes related to communication, consent and power. This article explores how we use language to explain treatment in care and how it can be interpreted differently by patients and staff.
Citation: Mee S et al (2016) Patient narratives 4: the meaning behind communication. Nursing Times; 112, 14, 22-23.
Authors: Steve Mee is associate professor; Alison Buckley is senior lecturer in adult nursing; Louise Corless is senior lecturer in mental health nursing, all at the University of Cumbria.
Health professionals’ failure to listen to patients was one of the issues at the heart of the care failing experienced by patients at Mid Staffordshire Foundation Trust (Francis, 2013). Since the report of the inquiry into the failings was published, there has been a growing commitment to use patient narratives in nursing practice and nurse education.
Language choice affects how patients interpret information given to them by health professionals. The patient narrative explores themes associated with miscommunication and how interpretation may be very different from what was intended. After reading the narrative, consider the reflection points that follow, and think about the language you use when you communicate with patients. Do you alter your approach depending on the specific needs of your patients?
David Foley*, aged 21 and on the autism spectrum, was referred to a colorectal consultant because of anal bleeding. His consultant suspected this was a symptom of ulcerative colitis and wanted to carry out an endoscopy. He told Mr Foley:
“I want you to come in for an investigation. You will go to theatre and we will put a video camera into your rectum to have a look if there are any problems.”
Mr Foley refused to have the investigation and left in a state of distress. His notes recorded that he had refused to accept the proposed investigation and that, as he had a high level of intelligence, he was deemed to have capacity to consent.
A liaison learning disabilities nurse guessed that Mr Foley had probably misunderstood the doctor, and explained again what had been proposed. Mr Foley then agreed to go with the nurse to the theatre and look at the camera. When he saw how calm the theatre was and the size of the endoscope he agreed to the procedure. Box 1 gives Mr Foley’s account of the incident.
Box 1. The patient’s perspective
“I have been bleeding from my bottom, and feel a bit sore inside sometimes. I saw the doctor who spoke in a funny accent. I couldn’t understand everything he said. He did say that he wanted to put a video camera up my bottom!
“I like taking videos and watching them on my computer. I took some on holiday last year, which were good. I don’t know how the doctor could put a video camera up my bottom because they measure 200mm x 60mm. That is a scary camera!
“Perhaps the doctor does not know what he is doing. He also said that I would go into theatre to have it done. I like Holby City but the theatre is a scary place. There is always a lot of blood, which I don’t like. There is usually shouting and noise, which I don’t like. There are bright lights, which I don’t like. Quite often people die in theatre. I’m alright as I am with just a little blood. I will not agree to it, he must be silly to think I would.”
Mr Foley was deemed capable of giving consent but because of his autism he tended to understand things literally and found it difficult to imagine something new.
Reflective point 1
Think of an incident in which you were required to communicate details of care to a patient that did not go as well as you had hoped. Were there any reasons why the patient’s understanding might have been impaired, such as pain, fear, autism, learning disability, dementia, grief or medication? What did you do to help the patient understand what you were saying?
Reflective point 2
The doctor used terminology that health professionals may not see as technical or difficult to understand (“video camera” and “theatre”) but people who have never been to hospital may have a simplistic understanding of them or have a view formed by how healthcare is portrayed in the media.
Think of the last time you communicated details of care to a patient. What exact terms did you use to describe it? Did you use words a lay person might understand? Did you check the patient’s understanding? Ask someone you know who is unfamiliar with your profession what they understand by terms you commonly use.
Reflective point 3
The liaison nurse offered Mr Foley empathy and extra support. Taking time to show him what was meant by “camera” and “theatre” could be considered “reasonable adjustment” for his autism. The Equality Act (2010) requires services to make reasonable adjustment for a person’s disability; this includes health services. Had Mr Foley not undergone the procedure he would have been excluded because of the hospital’s inability to accommodate his autism.
When you last worked with a patient who refused to accept treatment, did you consider reasonable adjustment to ensure they understood the care being offered?
Reflective point 4
Children, people with confusion, learning disability or autism and those with brain trauma may not fully understand grammar and syntax. For example, some people with a learning disability do not understand pronouns – the terms “you”, “me” or “her” might be meaningless (Mee, 2012), and they may not understand a simple statement such as “Do you agree to this procedure?”.
Some patients also have problems with the concept of time and sequencing (Mee 2012) so statements like “You cannot eat breakfast until after your operation. In the morning we will give you a pre-med and then take you to theatre”, would be difficult to comprehend. Mee (2012) explores many other aspects of incomplete language development with implications for nurses.
When you last communicated with a patient who may have had incomplete understanding of language, were you aware of whether they could use pronouns accurately? Do you know if the patient had problems with the concept of time and sequencing? What steps could you take to respond to the these problems?
Reflective point 5
Some people, such as children or those with an acquired brain issue, learning disability or autism, may understand pictorial, rather than spoken, information. The Royal College of Nursing (2013) provides useful information on this topic.
When you last cared for such a patients did you consider pictorial information to reinforce your spoken information?
These themes apply to all fields of nursing, as shown by the scenarios in Box 2.
Box 2. Examples from other specialties
Joan Edgar* was admitted to hospital with symptoms indicative of a brain tumour. After surgical intervention, the consultant neurosurgeon came to her bedside to tell her of the diagnosis and further treatment. He specifically used the word “cyst” to describe the tumour but, while it was a cystic lesion, he failed to fully explain that the biopsy revealed highly malignant cells. Not surprisingly hearing “cyst” reassured Ms Edgar, who expressed profound relief that cancer had not been found.
Carl Ellis* had experienced periods of depression. He told a community mental health nurse how he felt lethargic with a “dark cloud” coming over him every morning when he got up. As a result he had been spending long periods in bed.
Initially the nurse wondered whether he was becoming depressed but, after some exploration was able to identify he had postural hypotension, which caused him to feel light headed and dizzy when he first got out of bed. The nurse had initially made an assumption based on his previous diagnosis rather than exploring his symptoms in more detail. Communication is about listening and not jumping to conclusions.
Communication is at the heart of nursing, irrespective of your field. Throughout this series we have argued that there are two different but complementary types of knowledge for health professionals:
- The evidence base of “scientific” knowledge, which defines safe and effective practice – this is what we do;
- The knowledge that enables us to understand how it should be done.
Mr Foley’s story illustrates this difference. The knowledge about colitis, investigations, treatment and prognosis are all derived from quantitative research. Knowledge about how to convey the information to the patient comes from reflection on narratives from experience. In this case both types of knowledge are essential.
- *All names have been changed.
- What factors impair patients’ ability to interpret language used by health professionals?
- How do you assess your patients’ ability to understand information?
- What does the narrative tell us about the language health professionals use to explain common procedures?
- How could you address these issues in your clinical area?
- What does the term “reasonable adjustment” mean?
Also in this series
- Patient narratives 1: using patient stories to reflect on care
- Patient narratives 2: helping patients to give informed consent
- Patient narratives 3: power inequality between patients and nurses
- Patient narratives 5: providing empathetic care in nursing practice
- Patient narratives 6: defining patient-nurse boundaries
- Patient narratives 7: how narratives can change nursing practice
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.
Mee S (2012) Valuing People With a Learning Disability. Keswick: M&K Publishing.
Royal College of Nursing (2013) Meeting the Health Needs of People with Learning Disabilities.
Patient narratives 4: the meaning behind communication