Teaching Strategies for the Promotion of Effective Patient Communication in Vulnerable Women

Saturday, 29 July 2017

Ginny Moore, DNP
School of Nursing, Vanderbilt University, Nashville, TN, USA

Effective communication skills are an essential component in the ability to obtain necessary information regarding medical conditions and treatment plans (Institute of Medicine [IOM], 2004). The inability to obtain this information may result in erratic medication dosing, non-adherence to treatment plans, and missed follow-up appointments. These are factors associated with higher rates of hospital admissions, increased costs, and poorer health outcomes (Fetter, 2009; IOM, 2004).

Patients need to know what questions to ask and possess the confidence to ask those questions during the clinical encounter. At highest risk for lack of essential communication skills, are vulnerable populations. Vulnerable populations include those with low income (poverty-level or below), low education level (high school or less), chronic medical conditions, minorities, and homeless (Glassman, 2011; IOM, 2004). The purpose of this project was to educate vulnerable patients through the use of evidence-based written instruction and skills training about questions they could ask their health care providers to better understand their health.

 The relevance of this problem for current society is multifaceted. Effective patient-provider communication is an essential component in patient outcomes. A decrease in the areas of patient recall of information, treatment adherence, and satisfaction has been associated with ineffective patient-provider communication (Cegala, McClure, Marinelli, & Post, 2000; Kaplan, Greenfield, Gandek, Rogers, & Ware, 1996; Rao, Anderson, Inui, and Frankel, 2007; Street et al., 2010). Conversely, effective patient-provider communication has been associated with increased effectiveness of pain management, treatment plan adherence, and patient satisfaction with care (Street et al., 2010; Wright, Sparks, & O’Hair, 2008).

Research evidence for interventions to improve patient-provider communication can be divided into provider focused and patient focused categories. Categories of patient focused interventions can be further divided into the communication skills of information seeking, provision of information, and verification of information. Cegala, McClure, Marinelli, and Post (2000) provided written instruction on these communication skills in the form of a training booklet delivered to participants two to three days prior to their scheduled provider appointments. The booklets afforded participants the opportunity to record relevant details of their medical histories, and to list questions and concerns for health care providers. Study results indicated that participants receiving this intervention provided more detailed information, asked more questions, and verified the information received during the clinical encounter more often than participants who did not receive the intervention.

After a systematic review of the evidence on patient communication interventions, Rao, Anderson, Inui, & Frankel (2007) reported that patients who received interventions containing a skills practice component were better able to begin and direct discussions with healthcare providers. They also obtained more information through the questions they asked than controls who did not receive the interventions. The use of both written information and skills practice was supported by Street et al. (2010) in a study that examined the effects of “tailored education –coaching” (TEC; p. 42) on patients’ ability to effectively communicate their cancer related pain concerns. The TEC interventions were delivered in the form of a written information booklet and skills practice. Skills practice consisted of preparation for visits, and role-playing exercises where patients practiced asking questions, and expressing their needs and preferences. Patients who received the TEC intervention demonstrated greater efficacy in communicating their concerns which led to reported improvement in health outcomes.

 A community education forum consisting of a 20 page “How to Talk to Your Doctor” guidebook, video clips of effective patient-provider communication, and role-playing of techniques to enhance communication was implemented by Tran et al. (2004). The forum was developed as community education rather than a clinical intervention in an effort to reach diverse communities of people who might not otherwise have access to communication skills training. Participants were encouraged to employ an ABC (Ask questions, Be prepared, express Concerns) mnemonic during health care encounters. After completing the forum, participants reported increased confidence in the ability to effectively communicate with care providers.

 Evidence findings indicate that written instruction and skills training have been equally efficacious in improving patient-provider communication. Patients receiving both interventions obtained more information and expressed a greater degree of confidence in their ability to communicate effectively with care providers after implementation of the interventions. These findings support the use of both written instruction and skills training interventions to promote effective patient communication skills.

This project involved the review of written information followed by the opportunity to practice application of the information through role-play. Written information included a wallet sized card from the Agency for Healthcare Research and Quality (AHRQ) used for listing medications and medical conditions and three basic questions that the National Patient Safety Foundation (NPSF) recommend be asked during every healthcare encounter. After reviewing the written material, application of the information during any scheduled healthcare encounters was discussed.

A pilot of the project was conducted during May and June 2012 with 20 women in a two-year residential recovery program for women who have survived lives of prostitution, addiction and violence. Study findings indicated self-reported increases in knowledge of questions and confidence in asking questions during health care encounters. The project replication was conducted from January 2015 through April 2015 in a six-month residential transition program for women recovering from addiction, trauma and incarceration. All women in the program had co-occurring substance use and mental health disorders. Both pilot and replication project programs were located in the southeastern United States.

The effectiveness of the practice change was evaluated with a pre-and post-intervention, self- report survey rating participants’ knowledge of questions to ask healthcare providers and self-perceived confidence in asking those questions. The survey was a self-developed, pen and paper, Likert scale tool. Expert opinion was sought for validation. The outcomes measured were knowledge of questions to ask providers during healthcare encounters and self-perceived confidence in the ability to ask those questions during encounters. The difference in pre-and post-survey scores were calculated to determine project effectiveness in addressing the clinical problem.

A total of 13 active members in the recovery program participated in this EBP change project. The responses of “No”, “Not Sure”, and “Yes” were naturally ordered and hence ranked as 1,2, and 3, respectively, for the analysis; i.e., the higher the rank, the more positive response to the questions. Wicoxon signed-rank tests were used to test whether the ranked responses after the intervention would be higher than those before the intervention. The scores (ranks) of responses after the intervention were significantly higher than those before the intervention for both survey items (p=0.009 and p=0.009, respectively).

On the pre-intervention survey, 2 of the 13 project participants responded “No” to the statement regarding knowledge of questions to ask providers during health care encounters. Two of the participants responded “Not Sure” and 6 responded “Yes”. On the post-intervention survey, all 13 participants responded that they knew what questions to ask to get information about their health. Larger increases were reported in confidence. Prior to the intervention, 5 participants responded “No” and 2 responded “Not Sure” regarding confidence about talking with health care providers. Post-intervention, all 13 participants responded that they felt confident about talking with their health care providers.

Project findings indicate self-reported increases in knowledge of questions to ask and confidence in asking those questions. These findings confirm the value of teaching essential communication skills. Application of these interventions may enhance clinical care particularly with vulnerable and marginalized populations. Nurses can use this information to proactively guide patient education in the clinical setting, empower patients in the community setting and educate students in the academic setting regarding essential patient communication strategies.