Effective communication

Site: ISRRT e-Learning
Course: International Covid-19 support for Radiographers and Radiological Technologists
Book: Effective communication
Printed by: Guest user
Date: Saturday, 18 September 2021, 8:50 AM

Description

 

1. Introduction - The importance of communication

Now more than ever, it is clear that communication is an essential part of our life. Through communication we are able to connect with others, share our experiences, thoughts, wants and needs, as well as build relationships and memories that we cherish dearly. In healthcare, effective communication is vital as it not only contributes to best and safe healthcare practices, but it also enhances every individual’s personal experience.

By definition, communication refers to a process by which a sender transmits a message through an appropriate channel, and this is received by the intended receiver who is ready and receptive to accept the message, as subsequently demonstrated through another message or some form of feedback. Communication is the process by which information, meanings and feelings are imparted, interchanged, or transmitted by people through the exchange of verbal and non-verbal messages. Communication is transactional, with both parties involved sending and receiving messages at the same time; it is said that it is impossible not to communicate. Therefore it is important to be aware that verbal and non-verbal communication are both methods by which information, meanings and feelings are shared rather than just emphasis being placed on verbal interactions.

In the context of Covid-19 positive/suspected patients requiring imaging, the primary message that all radiographers / radiological technologists should aim to convey is one of reassurance. Patients are likely to be fearful, anxious, isolated and sad and therefore they instantly need to be reassured that they are not alone. Indeed, it has been reported that the first few seconds of any interaction are enough to make a first impression. Therefore, while it is totally understandable that radiographers / radiological technologists may also be anxious or fearful when they need to image Covid-19 positive/suspected patients, it is important that radiographers / radiological technologists show patients that they are going to be there for them, that they truly care. Such an approach exhibits a good first impression and paves way for a positive start for the subsequent radiographer-patient interaction.


2. Effective communication

Effective Communication “consists of building a rapport, actively listening and responding to verbal and non-verbal cues and tailoring information to meet individual needs” 1. It is often identified as a graduate competency. Especially important in diagnostic radiography where radiographers / radiological technologists often have a short duration of time to gain the trust and confidence of patients, as well as to gain their compliance to perform an imaging examination.

3. Ineffective communication matters

Worryingly, “…a map of the communications within a particular profession….will soon reveal how limited is the extent of what is taught in formal education. There is even suspicion that some communication capabilities are worsened rather than improved by the process of professionalisation.”

Michael Eraut (1994)

A lack of communication, or poor communication, are often directly linked to poorer outcomes in healthcare. It is clear that involving patients in decisions, keeping patients informed, improving communication with patients, and eliciting feedback from patients and listening to their views, will all improve communication. All of these points equally apply to the context of Covid-19 in our communications with our patients and other staff. In healthcare, communication failure can lead to serious and costly consequences 2. Approx. one third of the 23,000 cases analysed involved a communication breakdown somewhere along the healthcare spectrum3 . Medical error has been identified as the third leading cause of death in the US, with most causes of death arising from the ‘preventable arms’ due to defects in "Human Factors", "Leadership", and "Communication"4 5 .

In medical imaging, more complaints by parents relate to issues of professionalism and communication rather than technical errors. Effective communication has been shown to have multiple positive outcomes including:

  • better patient outcomes
  • decreased costs
  • increased patient and family satisfaction
  • decreased chance of litigation in adverse events

In their survey of 41 national radiology societies, the Audit and Standards Subcommittee of the European Society of Radiology identified patient communication as a key issue in radiology, and for radiologists, across Europe 6.Issues identified included that 15% of radiologists routinely receive communication training and 63.7% rarely or never receive training on communication.“Time” and “referring doctors preferred to discuss the examination with the patient” were also cited as issues.Much that goes wrong in radiology does so because of poor communication. Good communication ensures better and safer outcomes for patients and a more satisfactory working environment for staff. Similar issues were identified for radiographers by the European Federation of Radiographer Societies in their work to map patient safety activities across curricula 7. Of some concern, “error reporting and analysis” was only taught to an introductory level in 37.5% of programs; “patient identification” to an advanced level in just 65.5% of programs; and “communication skills” in just 53.1%.


Effective communication and team-working are extremely important skills for all radiographers / radiological technologists and are identified as such in many published scopes of practice for our profession. Both can be developed over time.

4. Effective communication between staff is important to ensure best practice and safety

Before discussing the radiographer-patient interaction, it is important to highlight the importance of good preparation and effective communication between relevant staff. Such preparation is essential in order to ensure best and safe practices with minimal disruption.

As part of the preparation, radiographers / radiological technologists assigned to image Covid-19 positive/suspected patients are encouraged to:

  • obtain patient details, including where the patient is located (i.e. ward/bed).
  • ensure that they have all the required devices in accordance to hospital/departmental procedures, for example, personal PPE, protective covers for (DR detector/CR cassettes), key/password for mobile X-ray unit, cleaning wipes, etc. (radiographic procedure section)
  • discuss, clarify and agree on their individual roles and responsibilities, especially if they are working together with other radiographers / radiological technologists or professionals. Such discussions should ideally occur before everyone is donned in PPE, but this may not always be the case. In this regard, teamwork is essential, especially when the staff are not necessarily in the same room. Rather than resort to ‘shouting’ information or instructions, alternative means of communication, such as regular visual contact ‘checks’, increased use of hand gestures, and/or the use of technologies such as intercom systems or other telecommunication devices (such as mobile phones or tablets) can all help staff communicate more effectively between them.

5. Effective communication tips for radiographers / radiological technologists imaging Covid-19 positive/suspected patients

Pre-examination

Even before a patient comes to the diagnostic imaging department, as an out-patient or as an in-patient, a pre-screening procedure should be considered. Such a procedure, together with a broader approach to work up and radiology imaging in COVID-19 suspected patients, is outlined in a recent article by Mosha-Basha et al 8.  Screening prior to arrival in the diagnostic imaging department, and the approaches to communication around this, are essential.

Investing time to build a good rapport with patients is one of the keys to establishing a positive radiographer-patient interaction. However, it is acknowledged that the hospital environment, the use of PPE and the intense emotions of fear, anxiety and helplessness among both patients and staff, all make it more challenging for radiographers/ radiological technologists to establish a good rapport with Covid-19 positive/suspected patients.

In fact, the necessity for wearing PPE introduces a barrier that generally obscures visualisation of radiographers’ / radiological technologists’ facial gestures and lip movements (See also Experiences of wearing Personal Protective Equipment (PPE) when examining patients section and Experiences of wearing Personal Protection Equipment (PPE) from a medical practitioner's professional perspective section). Therefore the patient is unable to see any welcoming gesture, such as a smile. In addition, the layers of PPE may influence radiographers / radiological technologists to raise their voice slightly when talking, because otherwise the patient may not be able to hear them clearly. Radiographers / radiological technologists should therefore be mindful of these factors, as well as other possibly underlying fears they may have when interacting with a Covid-19 positive/suspected patient. Indeed, it is understandable that radiographers / radiological technologists will be attentive to limit their time and contact with Covid-19 positive/suspected patients so as to minimise their own risk of infections. Nonetheless radiographers / radiological technologists need to be attentive not to appear too rushed and instead try their best to exhibit feelings of calmness, reassurance and empathy in what they say and do. In essence, given that other facial gestures are not seen, it is important that radiographers / radiological technologists ensure that they make good eye contact with the patient throughout the interaction.


Also, radiographers / radiological technologists should be attentive to ensuring that any information that is communicated verbally is being clearly heard and understood by the patient. If difficulties are encountered, the radiographer / radiological technologist must consider using alternative means of communication, such as the use of hand gestures (for example a ‘thumbs up’ or ‘thumbs down’). While small, such added efforts can help enhance the radiographer-patient interaction as well as ensure that radiographers/ radiological technologists fulfil their responsibility of providing the best possible care, safety and service to every individual patient at all times.


Given that different patients will have diverse needs and preferences, it is not possible to have a single communication strategy or approach that can be applied to all patient groups. In practice, radiographers / radiological technologists are always encouraged to tailor their communication to meet the needs of every individual patient. While allowing for any messages conveyed to be better received and understood, the provision of tailored information also enhances patient cooperation and overall patient experience. Furthermore, given the intense emotions present, it is equally important that radiographers / radiological technologists communicate small packets rather than large chunks of information to the patient - this helps make it easier for the patient to process and understand what is being said.


For this purpose, the following four steps are being suggested to help guide radiographers / radiological technologists to a good start when imaging and communicating with a Covid-19 positive/suspected patient.


5.1. Step 1: Greeting the patient and introducing yourself

  • The radiographer / radiological technologist should greet the patient by stating his/her name and surname. For example: “Good morning, Mrs. Jane Smith”. Being familiar with the patient’s details beforehand is the first step to establishing a rapport with the patient and is also necessary to check and verify patient identification (see also Identification of correct patient section).
  • The radiographer / radiological technologist should introduce herself/himself and mention that she/he is a radiographer / radiological technologist. This is consistent with ‘#mynameis…. I am a radiographer’ theme. Given that PPE will make it difficult for patients to distinguish between different professions, radiographers / radiological technologists can help enhance the patient’s experience by having their name and profession made clearly visible and/or maybe even taping a photo on top of their PPE - this will allow radiographers / radiological technologists to add a human touch and ‘show’ the patient who you are without the additional layers of PPE. Different approaches can be taken for this from simply writing your name, and profession, onto your PPE (Figure 1), to producing disposable labels, which may incorporate the #HelloMyNameIs theme and can include a photo.

Figure 1: Moranda is a diagnostic radiographer from the Royal Brisbane and Women’s Hospital, Australia (photos used with permission)

The inclusion of a photo of yourself can make a huge difference from the patient perspective as, while eye contact is hugely important, the inability for a patient to see our faces, and facial expressions, is a major loss with full PPE. Figure 2 shows an example take from a Covid ward.


Figure 2: Members of staff in the Covid ward of Beaumont Hospital Dublin, Ireland

see also https://www.insider.com/coronavirus-doctors-photos-over-protective-gear-2020-4

5.2. Step 2: Briefly explain your role in the patient’s care and outline what is to be done

  • The radiographer / radiological technologist should provide a simple explanation of her/his role in the patient’s care, i.e. that she/he will be taking chest X-ray so as to visualise the thorax.
  • The radiographer / radiological technologist should aim to reassure the patient that the X-ray will not hurt and that the X-ray will be performed in a few minutes.
  • Keep the patient informed about what is to be done and avoid assumptions. The radiographer / radiological technologist should, therefore, explain the placement of the ‘hard’ cassette/detector under/behind the patient; the need to remove anything that may unnecessarily obscure the chest area (removal of artefacts); as well as the importance of remaining still and following the given breathing instructions.
  • In fact, if at all possible and practical, the radiographer / radiological technologist should verify that breathing instructions were appropriately understood and maybe even practice this with the patient beforehand. This is important so as to ensure that the chest X-ray is obtained on full inspiration so as to allow better visualisation of the thoracic contents.

5.3. Step 3: Engage in a benefit-risk dialogue and establishing patient’s consent

  • In line with legal requirements in many countries, the radiographer / radiological technologist needs to also engage in a benefit-risk dialogue with the patient. This entails that:
    • The benefits of imaging are outlined, i.e. imaging can provide important information that will allow health professionals to deliver the most appropriate treatment and care to the patient at the right time.
    • The patient is made aware that the benefits of imaging are greater than the negligible risks associated with the radiation dose delivered for a chest X-ray (typically 0.02mSv, which is similar to about 3 days of background radiation).
  • The aim of the benefit-risk dialogue is to ensure that patients are appropriately informed and involved. In effect, a dialogue entails that communication occurs in both directions, so it is equally important that the radiographer / radiological technologist takes the time to stop and listen to the patient. This is essential in further establishing a good rapport with the patient as it provides an opportunity to be heard, have questions answered and/or concerns addressed.
  • As much as possible, the radiographer / radiological technologist should verify that the patient has understood the information and instructions provided. In effect, the radiographer / radiological technologist must ensure that the patient is agreeing to/consenting to having the X-ray examination performed.
  • It is important that radiographers / radiological technologists note that communication is also expected when patients are unresponsive and/or unconscious. When it is not possible to clearly seek and obtain consent from the patient directly, either due to an underlying medical condition, mental state or lack of competence, such consent is to be sought and obtained by a legal representative on the patient’s behalf.

(see also Radiation Protection during mobile chest radiography COVID-19 section)


5.4. Step 4: Thank the patient, offer relevant information and wish the patient a good recovery

  • After taking the X-ray and verifying its diagnostic value, the radiographer / radiological technologist should sincerely thank the patient for his/her cooperation, wish him/her well and provide a typical timeframe for the chest x-ray to be reported made available to the medical team looking after the patient. Such information is commonly asked by the medical team and/or the patient, so it is recommended that radiographers / radiological technologists are prepared and able to provide correct timeframes.
  • Close the rapport by wishing the patient a good day/evening and speedy recovery.
  • Finally, at the departmental and organisational levels, effective communication is also very important. Many organisations have implemented centralised ‘command centres’ to coordinate Covid-19 activities, and very importantly Covid-19 information. Thus better facilitating real-time engagement with constantly changing needs of departments, staff, patients (and their families). Daily departmental briefings help make sure that all staff have the latest information and can also be used to better identify, and address, potential issues which often relate to communications breakdowns.


6. Conclusion

Imaging a patient with confirmed Covid-19, whilst wearing full PPE, does present significant additional challenges in terms of being able to:

  • effectively communicate with our patients
  • effectively communicate with nursing, medical, other allied health, and support staff, and,
  • effectively communicate with radiographers / radiological technologists working alongside us as part of the imaging team.

With this in mind, it is essential that we do our utmost to help overcome the barriers of PPE, anxiety, and fear, to make sure the communication happens and that it works. In the words of George Bernard Shaw “the single biggest problem in communication is the illusion that it has taken place” so we must not let the illusion overcome the reality.