Chapter 9: Communication Skills

Importance of Communication Skills

Ralph Smedley, founder of Toastmasters International, said “all speech is for communication, and there is no possibility of communication unless people understand.” The same is true, of course, of writing.

While our scope of practice describes what we do, one thing it doesn’t mention is communication—without the ability to communicate well, and make people understand, we are wasting our time or, worse, doing damage. MLTs must communicate with each other because we so often must work as a team; with other health care professionals because they provide us with vital information and act on our results; with the public because they are our clients.

If you consider the preceding chapters in this handbook, you’ll realize that there are many situations where good and appropriate communication is vital to your practice as an MLT: confidentiality, consent, conflict of interest and boundary issues are just some of the most obvious.

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Why Effective Communication is So Difficult — Communication Styles and Techniques

We’ve all had experiences where we thought we’d made something clear, only to find that we were misunderstood, or perhaps we thought we understood someone else but we got it wrong. This sort of thing can have unfortunate consequences ranging from a disagreement between friends to significant inconvenience for someone, clinical errors, or even a lawsuit if the misunderstanding has serious repercussions. Why do these things happen so often?

SCENARIO:

Patricia has a hematology resident for the day, and is tasked with discussing malaria identification from Giemsa stained slides. She retrieves a recent positive, noting that it was reported as Plasmodium vivax, a species of malaria parasite.

Patricia shares the slide with the resident, noting the characteristic features of P. vivax, but the more she looks at the slide, the more she wonders if it might actually be P. ovale, a species with similar morphology. There is no indication in the recorded notes that this has been considered, although the patient information indicates travel to central West Africa, one of the relatively few places where P. ovale occurs. When the resident has left for the day, Patricia quietly asks Joan, her senior technologist, to have a look at the slide, and outlines her concerns.

Joan spends a few minutes looking at the slide and declares it to be positive for P. vivax. When Patricia points out the geographic information, Joan becomes defensive and angry. She states that the report has been finalized and there is no point dragging the specimen out again now. Her tone and manner make it clear that the subject is closed. Patricia concludes that Joan is upset because her authority and expertise have been questioned.

In this scenario Patricia has concerns that a misidentification may have occurred. She acts appropriately in asking for help from an expert, and in doing so discreetly, to avoid embarrassing the technologist who originally read the slide. Something goes wrong, however, and we’re not sure what it is. Perhaps Patricia did not explain her concerns clearly; perhaps she used a condescending tone when she questioned Joan; perhaps there have been altercations between these two technologists in the past. Whatever the reason, Joan’s angry response makes it impossible for the two to have a professional discussion about the slide. An opportunity to learn is lost, and a specimen may have been reported incorrectly. Everyone loses.

Miscommunication in a health care setting occurs for various reasons:

Someone isn’t listening. To be a good communicator you must also be a good listener. Minimize distractions and focus on the speaker; actively listen to what she or he is telling you. Ask questions for clarification and repeat important points. Take notes if necessary. If the communication is written, use these same techniques: focus, read carefully, read again, ask questions if possible.

Communication wasn’t clear. Be organized in your delivery of information. Begin by explaining in a general sense what you need to say: “I need to explain what happened with the PCR today...” Then explain in a way that will make logical and relevant sense to your listener. This might be a chronological explanation; based on cause and effect; spatial, according to different work areas; comparative, contrasting one thing with another; or phrased as a problem with a solution. Use the structure that works best for the circumstances. Stay on topic and be as brief as you can without omitting important details, and if your communication must be lengthy, try to break it up into subtopics.
Inappropriate language is used. Unless you know the other person very well, you can’t assume that he or she will necessarily understand everything you say if you use long words or professional jargon (the language of a specific field of knowledge). Even when you are talking to a colleague in the lab, there may be a significant difference in your respective levels of knowledge, which can lead to misunderstanding. The problem is even greater when dealing with people outside the lab. A nurse, for example, is not familiar with all the lab procedures, just as you are not familiar with the specialized language of nursing. A patient may be illiterate. Use plain language to be sure that you are understood.

If you are the speaker, anticipate miscommunications: think about which parts of your message are subject to misunderstanding and try rephrasing with different words. Watch for signs that you’re not getting through. If your listener appears distracted, confused, or is unresponsive, ask for some feedback so that you have a chance to clarify.

If you are the listener, smile and nod, or otherwise indicate that you understand. If you don’t understand, ask for clarification.
There are cultural or physical barriers to communication. Medical laboratory technologists working in Nova Scotia must have good command of English, but that isn’t true of everyone. If you are aware that your listener speaks English as a second language take extra time and care to make sure that there’s no misunderstanding. Ask for help if necessary and possible. Be aware as well, that cultural interpretations of things such as body language, gesture, tone, and eye contact, differ, and you may be sending a message that you’re not even aware of. These situations may require great sensitivity and tact.

Physical barriers to communication include hearing loss, cognitive disability such as Alzheimer’s, aphasia (communication challenges following a brain injury or stroke), mental illness, etc. Because these things are not always apparent, we must always be aware of the possibilities, and ask questions to clarify the situation when we encounter something unusual.
The communicator has an unprofessional demeanor. No one likes to be patronized or treated like an inconvenience. Using an unfriendly or angry tone can destroy any chance of successful communication. Deliberately withholding important information, or misrepresenting the facts, is also a recipe for trouble. This type of miscommunication has no place in the practice of medical laboratory technology.

Strive for a professional but friendly demeanor in all your interpersonal communications.

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Communication with Clients — Special Considerations

Medical laboratory technologists who have direct contact with patients, or clients of other types, face some of the greatest communication challenges encountered in the profession. In any given situation you may have to consider any or all of the points discussed above and apply them with sensitivity. Taking the time to initiate conversation and carefully assess your ability to communicate in each encounter will aid you in avoiding misunderstandings. In addition you must be careful to:

Clearly and fully identify yourself: explain who you are and what you are trying to do. Make certain the client understands.
Provide contact information.
Be straightforward about fees, if any.
Ensure that consent is informed consent. Your client must fully understand the procedure and what will happen afterwards. Even if a patient offers you an arm for blood collection, if she or he
Doesn’t understand the procedure and what’s being done with the sample, you don’t have informed consent. This is important for subsequent encounters as well: consent is ongoing, and must be addressed at each encounter.
Remember that you are there in a professional capacity and are not the client’s friend: don’t be drawn into providing personal or health advice that lies outside the scope of practice. Although you mean well, the client may take your advice too seriously because of your professional status.
Welcome comments and feedback, and use them to improve your performance and communication skills.
Keep good records of all client encounters, including difficulties, if appropriate.

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Communication with Other Professionals

Technologists in the laboratory are an integral part of the health care team. We know that the majority of treatment decisions are based at least in part on the results of tests that we perform. That’s why it’s so important that we communicate well and collaborate with professionals in other health care disciplines. A miscommunication can have dire consequences for both patients and health care professionals.

SCENARIO:

Lakshmi answers the phone in the immunology lab just after nine o’clock on Monday morning. The caller is a nurse who enquires how long it takes to get a Lyme disease test result. Lakshmi replies that if the specimen is received in the lab by 10am, the result will be available later in the day. She does not mention that testing for Lyme is only done weekly because these tests are done in batches and demand is low; or that false positives occur, so a positive result would have to be verified by another test. She doesn’t provide her name, or ask for the caller’s name, and she doesn’t ask for the patient’s name.

The patient in question is awaiting discharge, pending the results of a number of tests, including the Lyme disease antibody test. It’s already too close to 10am to easily get a specimen to the lab in time for today’s run, but the nurse assumes that the specimen will make the Tuesday deadline, so she doesn’t worry. Lakshmi, meanwhile, has no idea the specimen hasn’t arrived because she doesn’t know the patient’s name. She cannot correct the misunderstanding.

When no results arrive late the following day, the nurse calls the lab again and learns that final results won’t be available for a week, and then only if the result is negative. Of course, the nurse insists that she was told results were available within a day, but she doesn’t know who she was speaking with, so no one can verify that she was given this information. By now, she has misinformed both the patient and the physician about what to expect, and both are upset by the delay. As a result of this poor communication, two other health care professionals and a patient form a negative opinion of the lab.

Have you ever had another health care professional imply that he or she could walk into the lab and do your job? Or that you should know more about other health care professions? This rankles because we know that it’s unreasonable, but it does highlight a widespread lack of understanding of what we do—of the complexity of medical testing and the challenges of providing reliable results in a cost effective and timely manner—and a longstanding division between the health care professions in general. We need not contribute to that divide.

Mutual respect and excellence in collaboration can begin with us. Always treat other health care professionals as you wish to be treated, and approach each encounter with a clear intent to be helpful. Remember all the points of good communication discussed at the beginning of this section and in addition:

Be sure to provide your name and identify your department or office, and ask for this information about the caller
If you initiated the conversation, be clear about your objective in doing so
Document your communications, including difficulties if they arise

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Resolving Disagreements

Inevitably, despite our best efforts, miscommunications and disagreements sometimes arise and, more often than not, we don’t see them coming. They can happen in interactions with anyone, and a straightforward system for dealing with them will work in most cases.

If you become aware or suspect that a miscommunication has occurred, it’s best to deal with it immediately, especially if it involves test results. This need not involve finger pointing or accusations: a straightforward statement of fact should identify the problem and initiate the appropriate steps for correction and discipline if necessary. If you made an error yourself, the best action is to acknowledge your mistake, take corrective action to fix the mistake and work with others to prevent anything similar from happening again in the future.

If you find yourself embroiled in a dispute, try to diffuse the situation. Don’t make it personal, but remain calm and non-defensive, and try the following:

Listen. Allow the other party to fully state his or her perspective, listening carefully for the problem – the thing that has caused the disagreement. Sometimes it’s not what you think it is. Not only will you gain information, but your opponent will appreciate that you listened. Use active listening skills: make eye contact, lean toward the speaker, nod your head to indicate that you understand, use verbal cues such as “mmm,” or “yes.”
Acknowledge the other party’s point of view. You need not necessarily agree but you can indicate that you understand what the issue is and that you respect an alternate opinion. Sincerity is important here.
Ask questions. If there are things you still don’t understand, ask relevant questions to get more information. A better grasp of the problem can be enlightening.
Put it in your own words. Paraphrase the problem for your opponent to be sure you both have the same understanding. By now, one or both of you may find your perspective is changing.
Suggest and/or request possible solutions.
Follow through if you have made a promise.

All this may seem like a long and involved procedure, but it can play out quickly in the course of a conversation. Practise these skills in all your interpersonal communications and they will soon become an automatic response when disagreements arise.

SCENARIO:

In the dispute over the Giemsa slide for malaria, above, a professional discussion deteriorated and became personal, and the opportunity to learn and improve was lost. Patricia, however, doesn’t want to leave it there. She attempts to engage Joan in further discussion, choosing her words carefully:

“Joan, I can tell that you’re confident that this is Plasmodium vivax, and I know you have a lot of experience with reading malaria slides. For my own experience, I’d like to understand how you reached that identification. Do you have time to sit down and look at the slide with me?” Patricia is careful that there is no hint of disrespect in her tone.

She smiles at Joan, leans toward her slightly, and gestures with her hand to indicate that she is sincere and ready to listen.

Joan responds angrily: “I know what’s going on here. Don’t think I don’t know that John put you up to this,” she says. “I already looked at this slide and gave him my opinion. He disagrees, and now he’s got you trying to change my mind because he thinks I’ll listen to you.”

Now Patricia knows what is really bothering Joan, and she is able to resolve the problem. She explains that she pulled out the slide independently to show her resident, that Joan’s earlier involvement is not recorded in the specimen, and that she’d had no idea that there had already been a discussion. Her concerns about the results are hers alone.

Once Joan understands that there was no disrespect intended, or manipulation going on behind her back, she is more willing to discuss the issue objectively. In the end, the two agree that an identification of non-falciparum malaria is an appropriate response, and that if they can get a PCR done to definitively identify the species, the slide will be an excellent teaching slide for the future.

This altercation resulted from a lack of communication in several ways. If Joan’s earlier involvement with the specimen had been recorded, Patricia would have known to approach it more tactfully. If Joan had said at the beginning that she’d already seen the slide, the discussion would have played out differently. Finally, whatever her suspicions, Joan should have maintained a professional demeanor and avoided making the disagreement personal. Fortunately, Patricia was able to use good communication strategies to uncover the real reason for the argument, and resolve the issue professionally.

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Providing and Receiving Feedback

We don’t automatically start out as good communicators; the ability to clearly and effectively communicate with others has to be learned. The first step to becoming a good communicator is to be aware of what you need to improve upon, and that information comes not only from experience, but also in the form of feedback.

We can all help each other by providing feedback in a gracious respectful manner. If you notice something that’s sabotaging a colleague’s communication skills—so many ahs and ums that they become distracting, perhaps, or a disorganized approach— consider whether she or he would be open to constructive feedback. Most people accept advice more readily if a suggestion for improvement is accompanied by something positive.

SCENARIO:

Susan is an experienced technologist doing an education session on adult respiratory distress syndrome (ARDS), as part of a series of lectures offered to technologists for continuing education. She is well prepared and has a series of PowerPoint slides to use as visual aids. She does not use notes because her slides will cue her on her content.

“Adult respiratory distress syndrome,” she begins, “is a medical emergency, you know, that can be caused by a number of things: ah, including infections, injuries, um, aspiration of vomit, you know, complications of surgery, ah, inhaling water, and various medical conditions. Ah, it begins with shortness of breath and progresses, uh, to rapid shallow breathing, you know, and wheezing. The lips and fingertips may turn blue, you know, due to lack of, uh, oxygen. You know, up to 50% of cases are fatal.

Susan proceeds to deliver a great deal of good information about ARDS, but her speech is so riddled with ums, ahs, and you knows, that the audience is distracted and irritated. While Susan is focused on getting through the material, largely unaware that she is using all these filler words, those listening are painfully aware. Rather than listen intently to the information Susan has prepared, they are waiting for the next filler word and longing for the session to end. Susan’s filler words, likely a product of nervousness, severely detract from her message.

After the session, Martine, Susan’s coworker, stops by and thanks her sincerely for doing the educational session. She compliments Susan on the completeness of her information, and on her skilled use of PowerPoint slides. Then she casually mentions that she noticed that Susan said ah, um, and you know quite often during her presentation.

She says she thinks that it’s fine to simply pause if you need a moment to think—that it gives the audience time to think as well, and improves pacing. She says that she tends to use filler words herself when she is nervous, so she practises a lot ahead of time when she has to give a presentation, to build confidence. It helps, she says, to think of the presentation as a conversation.

As she gets ready to leave to get back to work, Martine remarks that she knows much more now than she did before about ARDS, and says that she hopes Susan does more educational sessions in the future. Susan thanks her for the feedback, and feels confident that she can do a better job the next time.

Martine’s feedback is constructive and inoffensive to Susan because she:

Acknowledges what Susan did well
Phrases it as an opinion, rather than criticism or instruction
Confides that she struggles with similar challenges herself
Offers specific suggestions for improvement
Ends on an encouraging note

People typically have difficulty taking offense to this sort of feedback, and frequently find it very helpful.

Perhaps you don’t have a tendency to use filler words such as ah, um, or you know, but few of us are perfect. If someone offers you advice for improving your own communication skills, listen with grace, and consider it carefully. Not all advice is wise advice of course—you will reject some suggestions, but you may find some truth in others that will help you become a better communicator.

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Conclusion

Communication skills, both written and verbal, are invaluable for MLTs. Good communication involves not only being careful to communicate clearly and completely, but also respecting others and listening carefully to what they are communicating.

Miscommunications can have serious consequences, but most misunderstandings and disagreements can be resolved if everyone remains professional and respectful. Those who are conscious of practising good communication skills, and are receptive to feedback, will continually improve.

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