Listening is a vital part of nursing care and the SAGE & THYME model can serve as a ‘satellite navigation system’ for listening and responding to patients’ concerns
Good professional listening is a foundation stone of nursing, as it has a positive impact on patients’ health. Listening skills can be learned but need to be revisited, as they can become less sharp over time. The SAGE & THYME communication model provides a structure that can help nurses acquire and practise good listening skills. Part 1 of this two-part series explores the SAGE & THYME model and gives an example of how a nurse uses it to elicit a patient’s concerns. Part 2 contains exercises that readers can complete to reflect on their own listening skills. This can be done as part of continuing professional development and can count towards the requirements for revalidation.
Citation: Connolly M (2016) Listening skills 1: how to improve your listening skills. Nursing Times; 45/46: 10-12.
Author: Michael Connolly is Macmillan consultant nurse in supportive and palliative care, University Hospital of South Manchester.
If the essence of nursing is the ability to pay attention to the details of a patient’s care, then the most useful skill for nurses to have is the ability to listen – and to listen for long enough and well enough to find out what is unique about that patient or their relative.
‘Listen to people and respond to their preferences and concerns’ is one of the standards flagged up in the Nursing and Midwifery Council’s (2015) code of conduct. Listening matters because the quality of the interactions between healthcare staff and patients has an impact on patients’ psychological functioning, quality of life, adherence to treatment and information recall (Stiefel et al, 2010; Uitterhoeve et al, 2010). However, listening skills require constant attention and practice. In this article, I explain how the SAGE & THYME communication model can help you hone your listening skills, and how revalidation provides you with an opportunity to work on them.
Improving listening skills
There is plenty of evidence of poor listening skills among nurses, and none that these skills improve simply because nurses use them all the time (Wilkinson et al, 2008; Gysels et al, 2005). Nurses have been observed avoiding patients’ emotional cues and blocking out their concerns (Griffiths et al, 2010). Poor listening can cause them to make wrong assumptions about patients’ needs and, as such, can be considered as posing a risk to their safety, just as poor hand hygiene does. Like hand-hygiene, listening is often assumed to be an obvious skill and, likewise as with hand hygiene, how we listen in our private lives is different from the careful and systematic listening we need to display at work.
Some nurses might think professional listening is all about being friendly and giving advice, but there is much more to it. The good news is that, like a knife, listening skills can be sharpened.
Box 1 features the transcript of a dialogue between two fictitious characters: a nurse, Laura, and a patient, Mr Green. It shows Laura being kind and attentive, but also using professional listening skills that she has learned and practised. Such skills have their basis in research (Griffiths et al, 2015; Connolly et al, 2014; Connolly et al, 2010) and some have been laid out in our structured SAGE & THYME model of communication.
Box 1. A dialogue between nurse and patient*
- Laura (nurse): Mr Green, my name is Laura. I’m the staff nurse looking after you today and I’m on duty until 9pm. You look worried – what’s worrying you?
- Mr Green (patient): I’m waiting around and nothing’s happening. Nobody ever gets back to me.
- Laura: Let me hand these keys over to my colleague and then I’ll pull up a chair and listen.
[Nurse leaves and then returns with a chair, pulls the curtains around the patient’s bed and sits down]
- Laura: So you say that you’re waiting for something and nobody is getting back to you. [Silence
- Mr Green: The doctor said that she’d organise a scan of my liver. I don’t know why – it doesn’t sound good and now there’s all sorts going through my mind.
- Laura: Right, you’re waiting for a scan and you’re worrying about what that might be for. Can I make a note of your worries? Just so that I remember everything?
- Mr Green: That’s fine. Do you know anything about the scan?
- Laura: I don’t at the moment but I will find out for you, no problem, as soon as we’ve finished talking.
[Nurse takes out sheet of paper and starts making list: ‘liver scan’; ‘why?’; ‘when?’; ‘doesn’t sound good’; ‘all sorts going through mind’]
- Laura: What else are you worried about? You said there’s all sorts going through your mind?
- Mr Green: My mother had cancer of the liver. She died from it.
- Laura: I see, so the idea of going for a scan of the liver makes you think about your mother’s cancer. No wonder you are worried – it’s a lot to worry about.
[Nurse adds ‘mother’ and ‘cancer’ to list]
- Laura: Is anything else worrying you apart from these things?
- Mr Green: No. I’m just scared of it being cancer. I want the scan to happen today.
- Laura: So you want it to be today and you’re scared. [Silence] You sound as though you have a lot on your mind. [Silence] Who supports you Mr Green? Who do you have to talk to?
- Mr Green: My sister, she’ll be in later.
- Laura: Your sister. Who else?
- Mr Green: Just her really. I have a daughter but she’s not really in touch with me.
- Laura: So you have a sister and a daughter but your support is mainly from your sister. How does she help?
- Mr Green: She’s got her own family but she and I are close. She’ll want to know all about the scans and the results.
- Laura: OK, I hear your sister is important support. Apart from getting the scan over and done with today, what do you think would help?
- Mr Green: I think I’d like to be clear about why the doctors want me to have the scan. Even if it’s hard for me to hear, I want to know.
[Nurse writes: ‘why the scan?’]
- Laura: So hearing from a doctor about why they want the liver scanned would help. What else would help?
- Mr Green: I’d like my sister to hear what the doctor says when I hear it. She’s in this afternoon.
[Nurse writes: ‘sister with you’]
- Laura: So it would help if the scan was today and if you and your sister could talk to the doctor about why you need a scan. Is there something else that would help?
- Mr Green: No, that would be great.
- Laura: I will check when the scan is and ask the doctor to speak to you and your sister. Apart from that, is there something else you’d like me to do?
- Mr Green: I don’t know, what else could you do?
- Laura: Well I can keep looking in on you while you are so worried. I could sit in when the doctor talks to you and your sister, if you like. I could help the two of you think things through after the doctor has gone. Whatever would help you feel stronger.
- Mr Green: Yes please, all of those things. Thanks, nurse.
- Laura: So you’re worried about this scan, when it will happen and what it is for. You can’t help thinking about your mother who had liver cancer. Your sister is good support and you’d like the doctor to talk to both of you to explain. I’m going to keep an eye on you today, but first I’m going to find out when the scan will happen and which of the doctors could sit down and explain. After that discussion, I’ll give you and your sister a chance to talk it through with me if that’s still what you want. I’ll come back, I promise, within 15 minutes. It might take time to get hold of the right doctor but I’ll update you with my progress. Can we leave it there for now?
- Mr Green:Thank you nurse.
- Laura: You can call me Laura.
- Mr Green: Thank you Laura.
*Laura and Mr Green are fictitious characters and their dialogue has been put together for training purposes.
Source: Reproduced with permission of University Hospital of South Manchester Foundation Trust
A model for professional listening
SAGE & THYME is a mnemonic and each letter is there to remind us of which skills to use when listening to a patient. Box 2 spells out each letter and shows how Laura uses the model in her conversation with Mr Green.
Box 2. Using the SAGE & THYME model
The steps of the model are outlined below, with examples of how Laura, the nurse featured in Box 1, has used them while talking with the patient, Mr Green.
- S = SETTING - Think about the environment and what else is happening around you. Laura tells Mr Green she needs to hand some keys over to a colleague: before she devotes time to her patient, she needs to deal with any other urgent tasks. When she comes back she pulls the curtains around the bed to create a more private environment for the conversation.
- A = ASK - Ask patients directly about their concerns. Laura says to Mr Green: “You look worried – what’s worrying you?”, which is completely different from “How can I help?” or “Are you in pain Mr Green?”.
- G = GATHER - Gather all of your patient’s concerns by repeating what they have told you (reflecting), writing them down so you remember them, asking your patient about any other concerns (screening) and summarising the concerns to the patient. Laura repeats what Mr Green told her, takes notes, asks him: “Is there something else worrying you apart from these things?”, then runs through what he’s said to check she has noted everything correctly.
- E = EMPATHY - Notice how the patient is feeling and then showing you have noticed through a brief but sensitive statement. Laura tells Mr Green: “You sound as though you have a lot on your mind”.
- T = TALK - Ask about the support the patient has with their worries. Laura says: “Who supports you? Who do you have to talk to?”
- H = HELP - Ask how these people support the patient. Laura says: “How does she help?”
- Y = YOU - Ask what the patient thinks would help. Laura says: “Apart from getting the scan over and done with today, what do you think would help?”
- M = ME - Ask what the patient thinks you could do. Laura says: “I will check when the scan is and ask the doctor to speak to you and your sister. Apart from that, is there something else you’d like me to do?”
- E = END - At the end of the conversation, you need to summarise the concerns and action plan, as well as ask permission to end the conversation. Laura asks Mr Green: “Can we leave it there for now?”
Source: Reproduced with permission of University Hospital of South Manchester Foundation Trust
As a professional listener, Laura is attentive to Mr Green’s worries and careful not to second-guess them. She makes notes on what he is telling her, which allows her to concentrate on the sequence of the model, rather than on remembering everything.
When using the model, it is important to follow its steps. It is also important to keep listening until you have a complete list of the patient’s concerns. There are many distractions that can make you stop listening halfway through, such as questions from the patient, your urge to start fixing their problems or your ideas on how to go about it. It takes great self-discipline to hold back your own input while you are listening.
This is ‘modern’ listening, in the sense that it reflects the latest evidence (Silverman et al, 2016): it is patient-focused listening because it picks up the patient’s cues and uncovers the worries that lie beneath. Levinson et al (2000) found that when a conversation with a patient is ‘cue-based’ in that way, consultations were quicker, compared with consultations in which physicians did not adequately acknowledge patients’ feelings. Laura may have spent only 10 or 15 minutes of her 12-hour shift listening to Mr Green, but she now knows precisely what he is worried about.
SAGE & THYME can serve as a ‘road map’ for listening and responding to patients’ concerns. However, it is meant as a guide, not a straightjacket. It suggests a sequence of actions that will help health professionals find out what a patient is worried about. People who have been trained in how to use SAGE & THYME said it reminds them to:
- Listen fully without interrupting;
- Hold back with any advice until approaching the end of the conversation;
- Ask the patient what support they have;
- Ask them what they think would help.
Revalidation is a chance for you to check how sharp your professional listening skills are – or how blunt they have become – after years of use. It will prompt you to ask other people to tell you honestly how well you are performing when you are listening – something you can perhaps no longer judge for yourself. It will enable you to show, both to the profession and the public, that you have reflected on your listening skills and made sure they are up to date.
So how sharp are your professional listening skills? Part 2 of this article features exercises you can use to test these skills. You can use the exercises as part of your continuing professional development and make them count towards revalidation.
- The author of this article is the principal developer of the SAGE & THYME communication model. For more details click here
- The quality of professional listening has an impact on patient outcomes
- Listening skills can be learned but require constant attention and practice
- The SAGE & THYME model can serve as a ‘satellite navigation system’ for listening to patients
- The model suggests a sequence of actions to help health professionals find out what a patient is worried about and address these concerns
- Revalidation gives nurses an opportunity to work on their listening skills
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Connolly M et al (2010) SAGE & THYME: a model for training health and social care professionals in patient-focussed support. Patient Education and Counseling; 79: 1, 87-93.
Griffiths J et al (2015) Improving communication with palliative care cancer patients at home: a pilot study of SAGE & THYME communications skills model. European Journal of Oncology Nursing; 19: 5, 465-472.
Griffiths J et al (2010) “Moving swiftly on.” Psychological support provided by district nurses to patients with palliative care needs. Cancer Nursing; 33: 5, 390-397.
Gysels M et al (2005) Communication training for health professionals who care for patients with cancer: a systematic review of training methods. Supportive Care in Cancer; 13: 6, 356-366.
Levinson W et al (2000) A study of patient clues and physician responses in primary care and surgical settings. Journal of the American Medical Association; 284: 8, 1021-1027.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.
Silverman J et al (2016) Skills for Communicating with Patients. Boca Raton, FL: CRC Press.
Stiefel F et al (2010) Communication skills training in oncology: a position paper based on a consensus meeting among European experts in 2009. Annals of Oncology; 21: 2, 204-207.
Uitterhoeve RJ et al (2010) The effect of communication skills training on patient outcomes in cancer care: a systematic review of the literature. European Journal of Cancer Care; 19: 4, 442-457.
Wilkinson S et al (2008) Effectiveness of a three-day communication skills course in changing nurses’ communication skills with cancer/palliative care patients: a randomised controlled trial. Palliative Medicine; 22: 4, 365-375.