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Effective communicationin palliative careNS321 Dunne K (2005) Effective communication in palliative care. Nursing Standard. 20,13, 57-64.Date of acceptance: June 3 2005.

SummaryThis article focuses on the definitions of cotiimiinication and anexamination of their relationship to palliative care nursing. Theunderpinning theory is analysed as a means of understanding thecommunication process. The communication process in nursing isconsidered in the context of nurse/patient/family communication.While the focus of the article is on palliative care, the principles ofcommunication as outlined also have relevance and applicability tonurses v^orking in a variety of other clinical settings.

AuthorKathleen Dunne is nurse education consultant Educare NurseEducation Consortium, Clinical Education Centre, Altnagelvin HospitalLondonderry, Northern Ireland. Email: kdunne@alt.n-i.nhs.uk

KeywordsCommunication; Death: attitudes; Family; Nurse-patientrelations; Terminal care: nursing

These keyvi'ords are based on the subject headings from the BritishNursing Index. This article has been subject to double-blind review.For related articles and author guidelines visit our online archive atwww.nursing-standard.co.uk and search using the keywords.

Aim and intended learning outcomes

The aim of this article is to raise nurses' awarenessof the communication process and to encouragethem to reflect on their own practice whencommunicating with parients and familymembers during the palliative stage of illness.After reading this article you should he ahle to:

• Discuss the communication process.

• Explain the core elements of interaction foreffective practice.

• Summarise the complexities involved when

communicatingwith patients and familymembers in the palliative stage of illness.

• Make a case for the development ofcommunication skills within palliative carenursuig.

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with a tt-usted colleaguediscuss palliative care terms andconcepts. Choose a phrase or term such as'palliation' or 'symptom management':a) Describe how you would explain this

concept to lay carers.b) Identify v fhy it could prove confusing for

patients and their supporters.

Introduction

Communication is the process hy whichinformation, meanings and feelings are shared bypersons through the exchange of verhal andnon-verbal messages (Brooks and Heath 1985).Groogan( 1999) asserts that communication is notsomething that people do to one another, hut ratherit is a process in which they create a relationship byinteracting with each other. Adler etal{\9^9)describe communication as being 'a continuous,transactional process, involving participants whooccupy different but overlapping environments andcreate a relationship by simultaneously sending andreceiving messages, many of which are distorted byphysical and psychological noise'. There are anumber of elements in this description ofcommunication that have relevance to nurses andother healthcare professionals in the palliative caresetting and require closer examination.

Communication as a 'transactional process'implies that we encode and send messages while we

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are receiving and decoding other messages. Theprocessofinteractionistwo-wayand is happeningcontiniiouslyandsimuitaneoiisly (Hargie 1997).Nurses in the palliative care setting need to beaware ofthe equal input that patients have in thecommunication process and that encoding anddecoding is a complex process. We have to makesense of, and prepare messages for, one anotherusing both verbal and non-verbal means.

Second, the suggestion that communicationhas 'different but overlapping environments' isrelevant to palliative care patients and theirfamilies. In nurse-patient and family interactionthere is much common ground andunderstanding but there are also differences thatneed to be recognised if misconceptions andmisunderstandings are to be avoided. Languageand terminology - use of medical terms - becomeall-important in the overlap ofthe nurse-patientand family relationship so that those with whomthe nurse is communicating do not experienceisolation and exclusion.

Third, the belief that communication creates arelationship is, according to Groogan (1999),concerned with a holistic approach to care thatinvolves meeting the social, psychological,spiritual and physical needs ofthe patient. This isespecially relevant in palliative care nursingwhere the emphasis is on care that encompassesthe whole person.

To explore the concept of 'noise'consider the following scenario. LouiseIs being cared for in the communityand is in the final stages of illness after beingdiagnosed with bowel cancer. She copes withpain which is adequately controlled, theembarrassment of unplanned bowe!movements and mild wound odour. She is alsoat the centre of an unpleasant divorce betweenher daughter and son-in-law. Louise is trying toprotect her granddaughter from excess hurt.What constitutes 'noise' here? Make notes onhow you think this influences thesupport relationship that a nurse might offer.

Fourth, the notion that communication can bedistorted by 'physical and psychological noise' hasmajor significance for nurses when communicatingwith dying patients and their families. Adler etal(1989) suggest that physical noise-environment,inability to hear-can detract from the messagebeing communicated, while psychological noise -form of address, presentation of self-can also

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affect the communication process. The nurse needsro be sensitive to the context in whichcommunication is taking place with the famiK unitand do everything in his or her power to includethem in all aspects of the communication process.

Communication in the context of nursing

The United Kingdom Central Council forNursing, iVlidwifery and Health Visiting (UKCC)(now the Nursing and Midwifery Council) statedin 1996 that: 'Communication is an essentialpart of good practice in nursing and is the basisfor building a trusting relationship that willgreatly improve care and help to reduce anxicryand stress for patients and clients, their familiesand their carer' (UKCC 1996). It is importantthatnurses develop their communication skillsso that they can become more skilled in theirinterpersonal contact with patients and others.

Burnard (1996) writes: 'Notto beinterpersonally skilled as a healthcareprofessional is to be ineffective as a healthcareprofessional.' This caveat should not be ignoredbecause communication is the medium throughwhich nurse-patient relationships areestablished and some nurse theorists view theinterpersonal relationship with parients as thecentral focus of nursing activity (Meieis 1997).

Peplau (1988) defined nursing as atherapeutic interpersonal process, while Parse(1992) suggested that nursing is a subject-to-subject interrelationship-a loving truepresence with the other to enhance the qualityof life.Travelbee (1966) posited that nursing isan interpersonal process between two humanbeings, one of whom needs assistance becauseof an illness and the other who is able to givesuch assistance. The goal of the assistance is tohelp a human being cope with an illness., learnfrom the experience, find meaning in theexperience and grow and develop through theexperience.

King (1971) defined nursing as a process ofhuman interaction between nurse and patient,whereby each perceives the other in the situationand, through communication, sets goals, andexplores and agrees on means to achieve thesegoals. Rogers (1988) added the perspective thatnursing is a scienceof unitary human beings andthat the goal of nursing is to promote 'symphonic'interaction between a human being and his or herenvironment through participation in a processof change. This theory considers the wholeindividual and is based on the belief that humansare at the core of nursing. This theory challengesthe nurse to work on mobilising individual orfamily resources, heightening his or her integrityand strengthening the human environment orfamily relationships (Rogers 1988).

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Tliink back to your most recent nurseeducation course and the theory thatwas used to describe nursing. What partdoes communication play within that theory?Have you been able to communicate in the waythat the theory espoused? ^

Many empirical studies on the concept of caringin nursing have identified communication as oneofthedefiningattributes. Fosbinder(1994),inaquantitative study, concluded that caring innursing involved getting to know the patient,translating, informing, explaining, instructing,teaching the patient, and establishing trust in therelationship.

Qualitative studies using phenomenological orgrounded theory approaches identified thattalking, listening, touching and informationgiving were central aspects of caring in nursing(Clarke and Wheeler 1992). McCance^M/11997), in a concept analysis of caring in nursing,identified one of the defining attributes of caringas 'getting to know the patient', whichincorporates identifying what is important to thepatient through the medium of communication.

Morrison (1991) concluded that theinterpersonal approach and concern for otherswerepartof caring. Forrest (1989) identified theimportance of 'being there' for the patient,interacting, touching and picking up on cues ascoreelementsofcaring in nursing. Hanson andCullihall (1995) contend that palliative carenursing clearly endorses a humanistic approachin which the helping relationship between nurseand patient plays a central role.

Communicating, interacting and being there forpatients have emerged as integral components ofnursing practice. Slevin (1999) has articulated thecentrali ty of presence - being there - as atherapeutic core in nursing. He defines presence as a'way of being' that promotes a therapeutic (healing)relationship between the nurse and the patient. Thisnotion of presence builds on the phenomenological-existential view of human existence (Buber 1958)that focuses on '1-Thou' relating. I-Thou relating isplacingourselvescompletelyintoa relationship, totruly understand and 'be there' with anotherperson. In a similar vein, Long (1999) argues thatnursing and communication are symbiotic. Shegoes on to explain: i t would be very demanding fornurses to demonstrate that they effectively "care"for another human being without communicating.Equally, it would be very difficult to communicateeffectivelyandcompassionately without "caring".'

Long (1999) concludes that if we believe this tobe true then the manner in which nursescommunicate with people has either a positive or

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negative impact on the quality of care andconsequently on the success or failure ofthehealing process. In palliative care nursing, a greatdeal of healing (inner peace), that is, serenity and^.almness, needs to take place towards the end•stages of an illness. This healing is important and,,is demonstrated by Steele (1990), the healing thatIS required before death has a major impact on thegrieving process and grief resolution for apatient's family. This emphasises the need fornurses in palliative care to engage in effective,meaningful and interactive dialogue with patientsand their families so that as much heating aspossible can take place hefore the person dies.

Discussion of 'presenctng' highlightsthat it would be naive to think ofcommunication solely as 'speaking'. Wecommunicate in different ways and sometimesthrough being present and saying nothing. JWith your colleague discuss how the silentpresence of the nurse with a dying patient isdifferent to the silence of strangers in arailway waiting room. Make a list of what isqualitatively different about this that enablesyou to claim that you are caring for thepatient

The nurse-patient and familycommunication context

Many patients and their family membersexperience difficulty in communicating withhealthcare professionals. The Audit Commission(1993) has stated that poor communicationbetween patients and healthcare professionalsis one ofthe main reasons for complaint andlitigation in the health service. The NationalCancer Alliance (1996) also identified deficienciesin healthcare professionals" communication skillswith cancer patients. Other publications relatingto cancer care and palliative care have emphasisedthe need for better and improved communicationbetween patients, families and professionals(DepartmentofHea!th(DH) and Welsh Office1995,DHa[idSocial Security 1996, NationalCouncil for Hospice and Specialist Palliative CareServices (NCHSPCS) 1996, DH and SocialServices and Public Safety 2000, NationalInstitute for Clinical Excellence 2004).

The psychosocial aspects of care as an integralpart ofthe palliative care approach have also beenhighlighted as a core aspect of care for the familyunit.ThcNCHSPCS (1997) has identified thatpsychosocial care is concerned with specificfactors (Box 1).

Communication therefore involves not onlysharing information but also emotional support

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and care. The great stress, emotional tension andfatigue that attend a life-threatening illness oftenmake it necessary for patients and families to hearinformation several times so that they can absorbit and feel reassured (Latimer 1998). Buckman(1998) states that the fear of dying is not a singleemotion hut rather it is composed of manydifferent fears as listed in Box 2.

Patients may want help to express their fearsbut some healthcare professionals have difficultyin communicating with dying patients and theirfamilies (Maguire 1985). Studies by Wilkinson(1991)andFarrell (1992) found that manyhealthcare professionals have high levels ofanxiety ahout death, which may account for theirunwillingness to engage in meaningfulinteractions with patients and families. Both thesestudies demonstrated a significant correlationbetween a high level of death anxiety and negativeattitudes and behaviours towards the family unit.Buckman (1998) also identified several fears thathealthcare professionals experience whencommunicating with patients in the palliativestage of illness (Box 3).

Key elements of psychosocial care

• The psychological and emotional wellbeing ofthe patient and his or her family carers(including issues of self-esteem).

• Insight into and adaptation to the illness andits consequences.

• Communication, social functioning andrelationships.

(NCHSPCS 1997)

Fears associated with dying

• Fears about physical illness - pain, nausea,disability.

• Fears about psychological effects - notcoping, breakdown,

• Fears about dying - existential fears, religiousconcerns.

• Fears of being a burden or not being able toprovide for family, especially where thepatient is the main breadwinner

(Buckman 1998)

Healthcare professionals' fears aboutcommunicating with palliative care patients

• Fear of being blamed (blaming themessenger).

fr Fear of the untaught

• Fear of eliciting a reaction (tears, anger).

• Fear of saying 'I don't know'.

• Fear of expressing emotion (crying).

• Fear of medical hierarchy.

• Fears and anxieties about their own death.

(Buckman 1998)

There is an apparent assumption that thesefears form a significant barrier to effectivecommunication. Field and Copp (1999)reported fears and anxieties amongprofessionals, especially when they had tocommunicate with patients and family membersin a closed awareness context (Box 4). Jassak(1992) argues that a lack of communicationbetween the healthcare professional and thecaregiverand/or patient may be caused byinformation given to the family not beingreceived, processed, interpreted correctly orretained accurately. There are also suggestionsthat patients and families may be reluctant toask questions because they think nurses anddoctors are too busy to answer them and they donot want to be perceived as complaining(MeissnereM/1990).

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Dying people and their significantothers can feel very isolated. In whatways do you use communication tounderstand the world of your patient, hisor her needs and fears? How do you shareyour experience in a way that helps tosupport patient dignity?

Communication witb dying patients and theirfamilies is, to some extent, also dependent on thelevel of awareness they have about prognosis.Giaser and Strauss (1968) identified four types of'awareness context' from their study of dyingpatients in an American hospital setting. Theseare described in Box 4.

Tbese catej ories of awareness are in keepingwith common experiences and were based onsound methodology. The awareness contextfocuses on the degree to which the person isaware of his or her prognosis and acknowledgesitand the extent to which that awareness is

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shared or denied by his or her family orsignificant others. Open awareness suggests thatallconcernedarefuliy aware ofthe position andact, speak and behave in keeping with the factthey have open awareness.

However, many patients and their familymembers are given all the informationpertaining to the situation and, for whateverreason,cannot make sense of what they havebeen told or find it too difficult to accept theinevitability of death (Jassak 1992, Hinton1999). Timmermans (1994), in anautobiographical ethnographic study on thedeath of his mother, demonstrated that the openawareness context (Glaser and Strauss 1968)was too broad and general m character, and didnot take account of the emotional aspects ofpatients' behaviour. Subsequently, he proposedthree types of open awareness (Box 5).

Four types of awareness associated withpatients who are dying

1. Closed awareness ~ where the patient docsnot recognise or denies that he or she is dyingalthough everyone around knows.

2. Suspected awareness - where the patientsuspects what others know and attempts toconfirm or negate it.

3. Mutual pretence awareness - whereeveryone knows that the patient is dying butpretend to each other they do not know.

4. Open awareness - where the patient, staffand relatives admit that death is inevitabieand speak and act accordingly.

(Glaser and Strauss 1968)

Timmermans' three types of open awareness

I Suspended open awareness - where thepatient and family disregard theinformation given to them, and are in denial.This may be a transient early reaction as aresult of getting the 'bad news'.

2. Uncertain open awareness - where thepatient and family overlook the negativeaspects of the information and hope for agood outcome.

3. Active open awareness - where the familyunit accepts the reality of the information andacts and behaves accordingly.

(Timmermans 1994)

This recontextualisation ofthe openawareness category (Timmermans 1994) givesmore scope for the reactions that patients andfamily members might have as a result of beingtold "bad news'. However, Field and Copp (1999)comment that patients appear to move 'in' and'out'of open awareness, because at times theyappear to acknowledge they are dying and atother times deny the fact they are dying. It has tobe remembered that where healthcareprofessionals maintain an open awarenesscontext with the patient and family, the patientand family members may decide how theymanage such awareness m communication withothers (Field and Copp 1999).

Furthermore, Wilkinson (1991) carried out ananalytical relational study with hospital nurses(»-54), to examine their communication skillswhen caring forcancer patients at three differentstages ofthe illness trajectory: on admission; atthe stage of recurrence of the cancer; and in thepalliative stage. She wanted to find out to whatextent the nurses used facilitating and blockingtactics when communicating with this group ofpatients.

The findings showed that the majority ofnurses demonstrated poor facilitativtfcommunication skills with cancer patients.Wilkinson (1991) also identified a small group ofnurses whom she labelled "ignorers'. These werenurses who, during their interviews with thepatients, ignored the patient cues and changedtopics throughout the interview. The authorconcluded that the ward environment, the nurse'sreligious beliefs, and attitudes to death had aninfluence on the way nurses communicated withpatients, rather than specific education oncommunication.

Working with your chosen colleague,think back to episodes where you havedemonstrated 'facilitatlve communication'with dying patients and their loved ones.What was the characteristic of thatcommunication and what resulted for thepatient?

Similarly, Booth etal (1996), in a prospectivestudy of hospice nurses (tt=41), demonstratedthat blocking behaviours were especially evidentin nurse-patient interactions when patientsdisclosed their feelings. Costello (1999), in a morerecent ethnographic study of older terminally illpatients (H-22), found that nurses did not providepatients with an opportunity to ask about theirtreatment. A climate of closed awarenessprevailed as nurses and medical staff colludedwith relatives not to disclose information to the

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patient. Seale (1991), on the other hand,concluded that communication skills in hospicenurses were better than in conventional care.There is some conflict in these reports as to thedegree, level and effectiveness of communicationin palliative care.

Jarrettand Payne (1995], in a selective reviewof literature on nurse-patient communication,concluded that the majority of research hadconcentrated on the nurse's communicationskills in the nurse-patient relationship. Theyidentified that there has been a reluctance toconsider the patient's perception of nurses, whatthey wish to tell the nurse and how contextualand environmental factors, for example, powerrelations, control of knowledge, and ward ethos,may influence the patient. This is an interestingconclusion and points to the need for nurses tomake an assessment of each individual situationso that they are aware of whether the patientdesires information. Hunt and Meerabeau(1993) cautioned that some patients might notwant to have emotionally intense conversationswith nurses, and prefer to keep conversationsmundane.

Baile etal (2000) advocate that discussinginformation disclosure with patients at theappropriate time in the illness is importantbecause not all patients want all the details abouttheir diagnosis and prognosis. Their maxim is'before you tell, ask'. Open-ended questions, theysuggest, can be used to facilitate this process. Forexample, 'What have you been told about yourillness so far?' or 'What is your understanding ofthe reasons we did the scan?' The responses tosuch questions will indicate the patient'sunderstanding of his or her illness to date, wiilallow for the correction of misinformation andcan also help to determine whether or not thepatient has, for example, unrealistic expectations,illness denial or gaps in information about his orher illness. If patients are to be treated asindividuals and have their concerns dealt with,then nurses should use the following skills(Rogers 1980,Burnard 1996):

• Active listening.

• Open-ended questioning.

• Reflection of feeling.

• Empathy building.

The empathic response is a core skill incommunication, especially when offering supportto the patient and family members. Egan (2002)asserted that empathy as a form of

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communication involves listening to patients,understanding them and their concerns to thedegree that is possible, and communicating thisunderstanding to them so that they mightunderstand themselves more fully and act ontheir understanding.

Rogers (1980) stated that empathy is aboutsensing the patient's world 'as if it were yourown", without ever losing the'as if quality,which relates to an ability to understand in anemotional way what another person is feeling. Ina concept analysis of empathy in the nurse-patient relationship, Hsiu-Yueh and McKenna(2000) identified the defining attributes ofempathy as active listening, understanding andaccepting the patient's feelings without offeringan evaluation of them. However, Reynolds andScott (2000) argue that while empathy is centralto both caring and the nurse-patientrelationship, a low level of empathy is offered tomany patients. They suggest that nurses need tounderstand the needs of patients before they canbegin toshowempatby, which, they concluded,is the ability to communicate an understandingof the patient's world.

What do you understand by the term'empathy'? Give some examples of whenyou, as a nurse, were empathic witha patient. How did you feel when you wereable to identify with that patient and make areal difference to his or her situation?

Effect of education on communicationskills

The literature refers to the impact of educationand training on nurses'communication skills.Heaven and Maguire (1996) used a pre-testpost-test design to examine the effect ofassessment skills training on hospice nurses(n=44). The study was carried out in twodifferent hospices. The purpose of the study wasto determine how assessment skills trainingwould affect the nurses'ability to determinepatients' concerns. Although 44 nurses wererecruited to the study, 22 (50 per cent) droppedout for the following reasons: staff turnover(«= i 1); sickness (H=4); equipment failure (notspecified) (n^l); and other reasons (notspecified) («=6). The findings of the studydemonstrated that basic skills training wasinsufficient to have a major impact on the nurses'ability to determine patients' concerns.

In a contrasting study, Wilkinson etal [1998)carried out an evaluation of a communicationsskills programme on nurses' communicationskills. A 26-hour training programme over a

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six-month period was implemented for 110registered nurses (99-female, 1 l=male), wht)were undertaking a specialist qualification atdiploma or degree level in cancer care/palliativecare nursing. Data were collected and analysedusing various techniques at different pointsthroughout the course.

The results demonstrated that the nurses hadmoderate anxiety about death. Wilkinson etal{1998) also reported a significant improvement inthe mid-test and post-test assessment scores forthe nurses in the study. Between pre-test and mid-test 79 per cent of nurses showed improvement,from mid-test to post-test improvement occurredfor 70 per cent of the nurses, while 90 per cent ofnurses improved from pre-test to post-test.Wilkinson and colleagues attributed thisimprovement to the experiential learning (role-play) element of the course and to its six-monthduration. This allowed for reflection and critiqueof performance over time. The most significantimprovement was in the area of psychologicalassessment, and the patients' awareness ofprognosis/diagnosis. The communications skills

training course had therefore a significant impactoverall on the nurses' ahility to illicit patients'problems on assessment.

However, for 10 per cent of the nurses thetraining had little effect and in some cases nurses'performance worsened. This group of nurses,however, admitted that they did not want to getinvolved with patients' concerns hecause itcaused them too much stress.

While Wilkinson etal (1998) and colleaguesacknowledge limitations in the study, there issignificant evidence to illustrate thatcommunication skills can be taught to the majorityof nurses who do not have fears ahout talking withdying patients and their families, and who arewilling to engage with people at a meaningful level.There is also a need to continue updating qualifiednurses so that they maintain their level of practicein communicating with dying patients.

Conclusion

Communication isthemedium through whichinterpersonal interaction takes place. It is

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necessary in the daily lives of almost every humanbeing. In palliative care the uniqueness of thesituationto the individuals in the family can neverbe overlooked and highlights the need foreffective patterns of communication betweenthem and the professionals with whom they comeinto contact. Mowevcr, the communicationprocess is complex and involved. It is wellrecognised that communication is central to thenurse-patient relationship, but in practice there issignificant evidence that many nurses experiencedifficulties when caring for the patient and his orher family during the palliative stage of disease.

In addition, many patients have fears andanxieties about death and find it a problem to talkabout it, not only with professionals, but alsowith their loved ones. The family's level ofawareness about diagnosis and prognosis hasbeen highlighted as an important variable in thecommunication process, although it has beendemonstrated that even when an open awareness

context existed, communication difficulties wereapparent for patients and family members.

The evidence demonstrates the need for nursesand other health professionals to develop theircommunication and interpersonal skills so thatthey can facilitate the process of communicationwith the patient., rather than engaging in blockingand distancing tactics that hinder effectivecommunication. The skills of active listening,open qnestioningand reflection promote hettercommunication and encourage empathybuilding. When these skills are used, they enhancethe communication process and help to ensurethat events leading up to death are well managed.This is a central factor in helping bereavedindividuals cope with grief following the death oftheir loved one NS

Now that you have completed thisarticle, you might like to write a practiiprofile. Guidelines to help you are on page 68.

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