Do health workers really need training in communication?

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Despite decades of well-meaning training of health workers how to improve their communication with patients, in all the countries in which I have worked I continue to hear that poor communication by health workers and poor attitude is a major cause of complaint and an oft-quoted reason for not wishing to attend health facilities.

I was lucky enough to investigate why this is when in Zambia in the last few years. Together with two nursing school lecturers we carried out a survey of nurses as to why they communicated poorly. However, this was not done with the normal set of premisses. We assumed that all people from a very early age know exactly how to communicate well, and how to modify their communication to suit different social and other environments. People use a vast array of complex and different communication skills throughout the day -- from the moment they wake up to the time they go to sleep.

Everyone also knows exactly why they choose to be rude to some and polite or even subservient to others. 'Sucking up' is a phrase often heard in any workplace, and people know exactly how and when to do it.

So in the survey of nurses we asked more specifically about which patients and colleagues they chose to be rude to.

Unsurprisingly the response was that it was to people who would be unlikely to retaliate or hit back. This meant, of course, those who were submissive, frightened, uncertain, and without any power. Conversely staff could turn on good helpful communication to those they liked or who had power over them.

In other words, they are dismissive of and rude precisely to the people most likely to have little support or respect, and who are likely to have the most health problems for themselves and their children.

And it wasn't just to patients that staff were rude. Disputes between staff were said to carry over into their attitudes to patients.

Someone drew the following poster in one of the training sessions. It explains the basic message clearly.

Staff don't need to learn how to communicate. They already know full well how to do so. Instead they need to learn how to control their frustrations and irritations for those who are submissive, frightened and uncertain.

As a result of the survey, a training programme was launched to orient all health staff to the issues of poor communication, and to work with them on ways to control their communication with colleagues and with patients.

The results were overwhelmingly successful. Supervisors reported that in all the health facilities so trained there had been increases in patient attendance and improvements in staff morale. Staff felt more able to work as a team.

So the lesson is that if we are going to continue with programmes about communication, we should focus on helping staff and others to understand the impact when they choose to communicate badly.

Tony Klouda