The importance of healthcare professional-patient communication

Healthcare professional-patient communication has been greatly overlooked compared to the great efforts devoted to evaluating the effectiveness of diagnostic instruments, and of surgical or pharmacological interventions and treatments (^{Borrás, 2003}). The focus of healthcare professionals on healing, safety and their particular attention on the outcome, can sometimes lead them to neglect certain aspects such as communication, listening and interest in other non-physiological elements that form part of the person (^{Llubiá Maristany, 2008}).

For this reason, ^{Bayés (2004}) states that it is essential for healthcare professionals to not only examine the patient's organism, but also the emotional, biographical and cultural circumstances that accompany their somatic symptomatology and biomedical history. In this respect, at points of the hospitalization in which the patient is feeling a wide range of negative emotions such as anguish or distress, non-verbal language takes prominence; this is why Peabody (1927) and Bayés (2004) state that healthcare professionals must learn how to observe their patients, learning how to examine not only their organism, but also their biography, words, facial expression and their circumstances.

Certain actions that weaken the healthcare professional-patient relationship and that are not beneficial for the latter have been analyzed in different studies, such as those conducted by Falvo and Tippy (1988) and ^{Borras (2003}), who concluded that during 38% of visits, patients received no explanation as to the amount of medication prescribed; during 50% they were not informed about how long their treatment would last, and healthcare professionals did not check that the patient had actually understood their indications; and possible obstacles with respect to therapeutic compliance were not examined, nor was the importance of a follow-up visit explained. Furthermore, Beckman and Frankel (1984) and ^{Borras (2003)}, discovered that patients were interrupted on average 18 seconds after having started to answer the questions put to them by the healthcare professional. In the same vein, Suchman et al (1997) and ^{Borras (2003)} state that healthcare professionals do not always take potential opportunities to show empathy, in the case of verbal clues from patients, communicating their emotional distress.

Moreover, it seems that all too often patients feel like mere objects of study in university hospitals, and there has been debate surrounding the privacy of patients on one hand and, on the other, the need for students and healthcare professionals to carry out internships in order to acquire the necessary training to become good professionals in the future (Sánchez et al, 2003).

Another particularly important aspect for patients is waiting time, including: the waiting list to visit the specialist, waiting their turn to enter surgery or family members awaiting news on the condition of the patient in unexpected situations. It must be noted that subjective times are different to real times, (Campion, 2001; ^{Bayés, 2004}), and that subjective times are experienced differently by patients (suffering and uncertainty) compared to healthcare professionals (Bayés and Morera, 2000; Alvarado, 2003). Such suffering could be eased by good care from healthcare professionals. Cassell (1982) and Bayés (2004) emphasize that alleviating suffering and curing the illness must be valued as identical obligations by healthcare professionals who are truly devoted to patient care.

Through training methods in communication skills, we can help healthcare professionals to improve on these actions, given that, not only is it advisable but also ethically vital to address these aspects (^{Borras, 2003}).

All medical acts are formed by three processes that take place in parallel: the physical care, the behavioral care and the cognitive and emotional care of patients. Therefore, the health outcome achieved will be influenced, simultaneously, by four types of response that must be borne by patients: the physical response to treatment (medication, surgery), their behavioral response (in terms of the therapeutic treatment, health-related behaviors), their cognitive response (beliefs about the illness and the treatment, expectations, perception of control) and their emotional response (anxiety, depression, animadversion).

In consultations, it is possible for healthcare professionals to both ease the symptoms of a certain health issue suffered by the patient, and to forge certain thoughts and emotions in the patient in relation to the illness and its treatment. In this respect, it has been discovered that healthcare professional-patient communication has significant clinical effects, both at cognitive and emotional level. (^{Borrás, 2003}; ^{Llubiá Maristany, 2008}).

The information-communication process with the patient

Communication with patients is an essential and unavoidable activity. Therefore, there will always be a process in which the healthcare professional and the patient have to establish a type of communicative relationship; in this respect, the form of communication will depend on the type of relationship established by the professional with patients. (^{Benítez del Rosario and Asensio Fraile, 2002}).

According to the proposals of Borrell i Carrió (1989) and ^{Tazón Ansola, García Campayo and Aseguinolaza Chopitea (2002}), in the clinical field there are four healthcare profiles when establishing “professional-patient” communication. We will describe each of them in detail below.

Without a doubt, when communicating bad news, we recommend that the “Cooperative or contractual model” be used, given that it can facilitate quality communication, characterized by allowing patients to express their feelings and fears about their state of health, along with radiating emotional aspects that show patients that they will not be ostracized or neglected (^{Benítez del Rosario and Asensio Fraile, 2002}).

But, what do we mean by “good professional attitude”? ^{Cibanal, Arce and Carballal (2003)}, demonstrate some of the appropriate attitudes, from a humanistic perspective, that should be adopted by healthcare professionals. (See Figure 1).

Figure 1: Attitudes of the professional during the communication process with the patient. (Source: Juan, C., Sánchez, L., Balsa, M. C., Juan, M. C., Sánchez, M. A., & Balsa, M. C., 2003, pp. 141-169) 

Action Protocols

Some of the protocols most widely used by healthcare professionals to communicate bad news to patients on their state of health are listed below:

The so-called SPIKES protocol (Buckman, 2005 and ^{Mirón González, 2010}), is one of the protocols that is most widely used and well-known by healthcare professionals. The name is formed by the initials of each of the stages to be followed when giving bad news. We will analyze each stage in detail below:

The “ABCDE” protocol is based on five stages that are very similar to those of the “SPIKES” or “EPICEE” protocols (Rabow and McPhec, 1999 and ^{Rivera Rey et al, 2016})

In addition, widely referenced and used today, ^{Mirón González (2010}) presents another protocol formed by 10 orientative points proposed by ^{Almanza Muñoz in 1998}and 1999, which serve as a guide to healthcare professionals when communicating bad news and which are as follows (Figure 2).

Figure 2: Protocol “10 points to be used as a guideline to communicate bad news”. (Source: ^{Almanza Muñoz, J.J.; Holland, J.C, 1998}, pp. 372-378) 

Finally, ^{Villa López (2007}) proposes a further protocol that follows the same steps as “EPICEE”, but with two differences: the sixth stage is named “care plan”, and she adds an extra point called “professional self-check”. Below, we will define these two new “stages”, “phases” or “points” proposed by this author. (Figure 3).

Figure 3: “^{Villa López” protocol. (Source: López, B. V., 2007}, pp. 6-8). 

Sixth stage. “Care plan”: During this stage, the healthcare professional and the patient draw up a new care plan, based on the expectations hoped to be achieved: relieve symptoms and share fears and concerns.

Seventh stage. “Professional self-check”: The healthcare professional will self-examine the feelings and attitudes that emerged during the communication (flight, anguish, anxiety, fear...), subsequently identifying feelings that will enable them to improve in the development of their profession; and moreover, it will also help them to maintain good mental health, essential to avoid burnout.

The protocols that we have just described are like a game of insinuations, silent and indirect truths to help patients develop their own reality, always taking into account that the key issue is to communicate the bad news to the patient without destroying their hope, providing a climate of security and confidence. Healthcare professionals have to understand that it is difficult to find a balance and get it right every day. Drawing from science, their hearts and experience can bring them closer to achieving this (^{Arranz Carrillo, 2004}).

Procedures and skills for communicating bad news in the Emergency Department

We have explained the most widely used ways of communicating bad news when giving information on a specific clinical diagnosis, but how should this be addressed when providing information in unexpected situations?

^{Ayarra and Lizarraga (2001}) state that when family members are informed of an unexpected event, such as a death in an accident, a sudden serious illness, etc., it is advisable to use the “narrative technique”; that is, explaining everything that occurred from the very beginning. This narrative enables the brain of family members to gradually adapt to the new reality. These situations are becoming more frequent in our environment and cause immense suffering. ^{Núñez, Marco, Burillo-Putze and Ojeda (2006}) establish that 65% of unpredictable deaths happen in the emergency department and, because of this, hospital services must have professionals with a series of skills and attitudes who can inform the patient's companions in an appropriate fashion. Thus, they propose a series of guidelines to follow when facing such difficulties, taking into account that it is not possible to prepare in advance for the interactions following the death, so the healthcare professionals are the first ones who should be prepared. In this sense, it is advised:

Furthermore, explaining what happened to the patient is extremely important when communicating the bad news. According to Issacs (2005) and ^{Núñez, Marco, Burillo-Putze and Ojeda (2006}), relatives will pay great attention to what is said and how it is said, and the message must be clear and the language accessible and understandable to family members, besides informing them that the patient has died, avoiding confusing words or expressions.

It is also necessary for the healthcare professional to take note of the non-verbal communication, taking into account, as stated by Hall (1989) and ^{Núñez, Marco, Burillo-Putze and Ojeda (2006}), that verbal communication forms 60% of the communication in total. These same authors have provided a series of expressions to be taken into account by healthcare professionals when providing information in unexpected situations (Figure 4).

Figure 4: “Certain expressions of non-verbal communication”. (Source: ^{Núñez, S., Marco, T., Burillo-Putze, G., & Ojeda, J., 2006}, pp. 581).  

The communication of bad news will always be an unpleasant, but necessary, part of the clinical process. Nevertheless, healthcare professionals must do all they can (Johnston, 1992 and ^{Villa López, 2007}) to help individuals process their feelings, and to help family members to understand and accept the reactions of each one.

Communication in advanced oncology patients

A conspiracy of silence is considered to exist when information is withheld from a person who wants to know what is happening, and this is usually done to hide the diagnosis, prognosis and/or severity of the situation; it is often a habit of badly focused love (^{Barbero et al, 2005}). As stated by Lizárraga Mansoa, Ayarra Elia and Cabodevilla Eraso (2006), the communication of information is a complex process for healthcare professionals and, furthermore, there are several factors to take into account when deciding whether to provide information or not:

However, it seems evident that it is necessary to communicate and transmit accurate information to oncology patients, for several different reasons: on one hand, due to the patient's legal right to be informed and, on the other, because the majority of patients are aware of the seriousness of their illness and imminent death, and if the people around them, both family members and healthcare professionals, deny and hide this fact, they have to experience their emotions and feelings alone, without being able to show and express their fears and concerns. In this respect, sharing information with the patient reduces their anxiety and enables them to lead a more normal life, aware of the advancement of their illness and imminent death. Furthermore, the help that can be provided by family members to the patient in this sense is also important (Lizárraga et al 2006).

With regards to the question about what information to provide, ^{Arranz Carrillo y Barbero (2011}) provide a series of guidelines that can help healthcare professionals when communicating with the patient and family members:

Another important aspect is the information that the healthcare professional believes the patient should know, in order to optimize their communicative and empathetic capacity. In this respect, ^{Arranz Carrillo and Barbero (2011}) propose a series of questions to facilitate the evaluation and dialog with this type of patients, and the subsequent emotional support (^{Arranz Carrillo, 2004}):

Healthcare professionals should be aware that the patient is at the fore, and their difficulties should not hinder communication. Accompanying a patient in illness and in death requires great effort and stress at the beginning, because it means experiencing very intense emotions with the patient, the family and the healthcare professionals themselves (Lizárraga Mansoa, Ayarra Elia and Cabodevilla Eraso, 2006).

Furthermore, with regards to intervention with family members, and following the proposals of ^{Watzlawick, Beavin Bavelas and Jackson (1987}), it can be understood that interpersonal systems (such as family) can be explained as feedback loops, whether positive or negative, which influence the homeostasis of individuals and result in the system changing. Therefore, when a patient falls ill or is at the end of their life, this brings about changes in family members, who must do their part to ensure that the family system can become balanced once again.

Another open debate in relation to oncology patients and their family members is the question of who the most appropriate person is to transmit the bad news. In principle, the most appropriate person to communicate the news should be the physician who is responsible for the direct care of the patient, and who has the most complete/best information on the therapeutic process and the possible solutions, whether alone or in cooperation with other professionals on the medical team. Nevertheless, the importance of coordinating and defining roles within the health team must be noted: in other words, the patient and their family members often raise queries with different professionals and, for this reason, it is necessary to define who will be responsible for informing them, so that the answers are the same and there are no contradictions (Rassin et al, 2006; ^{Mirón González, 2010}).

Emotional skills

The development of these skills is necessary to establish communication at the beginning, during and after professional interactions that take place, in order to manage any emotional alterations that may arise in the professional or in the patient and/or family members. The goal is to find solutions to ensure that these emotions do not overwhelm the professional or the patient, before selecting the alternative and acting. To achieve this, action should be taken with regards the three levels of human response that are at the origin and maintenance of emotions: cognitive level, physiological level and motor level. They are described briefly below.

Communication skills

The healthcare professional must pay attention both to the words used and the accompanying gestures, as everything that they do and do not do is part of communication (Watzlawick, 1967). Among the central elements in human communication, we will focus mainly on active listening and empathy.

Figura 5: Nine rules to facilitate active listening. (Source: ^{Costa, M. & López Méndez, E., 2003}, pp. 133-135) 

Motivation skills for behavioral change

The main goal of these skills is to encourage patients to correctly follow the alternative that they have chosen (Adherence to the treatment). As this is something that will be done by the patients themselves, it is important that the healthcare professionals have previously acknowledged the freedom of choice surrounding the therapeutic objectives as a way of increasing patient motivation. (Thornton, Gottheil, Gellens and Alternan, 1977; Sánchez -Craig and Lei, 1986; ^{Miller and Rollnick 1999}).

We will focus on how to develop these skills in order to create motivation towards changing the patient's behaviors and habits. ^{Bimbela (2001}) proposes the P.R.E.C.E.D.E model (an adaptation of that proposed by Green, 1991).

If these interpersonal skills are correctly developed, the processes of influence of the healthcare professional become effective in promoting the essential objectives of counseling: acceptance, support, validation, empowerment and change (Costa Cabanillas, López Méndez, 2008). Furthermore, counseling benefits both the healthcare professional, who can work in a more effective and satisfactory manner, and the patient, who feels better cared for, more satisfied and more motivated to engage in healthy behaviors, benefiting healthcare institutions, which can make a more rational use of services and pharmaceuticals, while promoting and maintaining healthier lifestyles (^{Bimbela, 2001}).