Value Proposition Use these insights from an audiologist, physician and SLP to show clients that you want and value their input into their own treatment. Features
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Features  |   June 01, 2016
Value Proposition
Author Notes
  • Shelley D. Hutchins is a content producer/editor for The ASHA Leader. shutchins@asha.org
    Shelley D. Hutchins is a content producer/editor for The ASHA Leader. shutchins@asha.org×
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / School-Based Settings / Professional Issues & Training / Normal Language Processing / Speech, Voice & Prosody / Features
Features   |   June 01, 2016
Value Proposition
The ASHA Leader, June 2016, Vol. 21, 52-57. doi:10.1044/leader.FTR2.21062016.52
The ASHA Leader, June 2016, Vol. 21, 52-57. doi:10.1044/leader.FTR2.21062016.52
As a communication sciences and disorders (CSD) professional, you of course know how to communicate effectively. However, like most service providers, you’re also likely task-focused and pressed for time, which can pose a challenge to effective communication with those receiving your services or their families.
And when discussing diagnosis and treatment plans, it’s all too easy to get caught up in technical terms, inadvertently gloss over questions and comments, or provide information without pausing for reactions. Everyone occasionally needs a nudge to remember to really listen and find value in what patients, clients, students, parents, family members, co-workers—or anyone in an important conversation—want to contribute, notes Juan-Jose Beunza, physician and associate professor of public health and interprofessional education at the European University of Madrid in Spain.
To help, Beunza developed a series of communication reminders for clinicians to use. They include methods—such as keeping external and internal silence, paying attention to your nonverbal communication, keeping an open attitude about patient input, and telling patients that you appreciate their ideas—to make everyone in a serious conversation feel like a valued contributor. Beunza shares these strategies in his public health and interprofessional education courses, and with other students and professionals around the globe.
What helps clients feel valued? Showing concern for culture and family can’t be underestimated, says audiologist Nicole Marrone, assistant professor and clinical chair in audiologic rehabilitation for adults at the University of Arizona (UA). Clients are most inclined to commit to audiologic intervention when clinicians show respect for cultural beliefs and include their communication partner(s), she says. “It’s important to see the clinic experience from the patient’s viewpoint instead of yours. What are that person’s needs and desired outcomes?”
Another key to better relations with patients includes involving them in their own treatment, says University of Washington lecturer and researcher Michael Burns, speech-language pathologist and co-designer of a training program for CSD and medical students on communicating effectively with patients with communication disorders and their families. He recommends delivering diagnosis and treatment plans with more open-ended conversations in which patients can process their diagnosis and offer their perspective and input on what they want to gain from treatment. Such involvement motivates them to work harder, Burns says.
Aside from these general pointers, Beunza, Burns and Marrone also offer more specific communication advice involving close listening, face-to-face arrangements, modulated voice volume and forethought about messages. Such steps may seem basic, but further consideration reveals the benefits of paying attention to them, even in their simplicity.
Listen closely
Good listening is harder than it seems, Beunza says. “If we don’t keep quiet long enough, we may block the other person from jumping into the conversation or getting to the topic that really concerns him or her,” he explains.
True listening, according to Beunza, involves keeping external and internal silence. External silence—much like the phrase implies—means keeping quiet long enough to let another person process what you said and then respond. Generally, no one wants to experience a long pause in a conversation, commonly referred to as an “awkward silence.” However, Beunza insists these gaps can be useful, providing recipients needed time to think and ask questions.
Keeping internal silence involves switching off opinions or prejudices formed prior to the meeting, Beunza explains. “If we keep thinking about our predetermined answers to questions, or how we can convince [the patient] about something, we likely won’t take seriously what he or she says,” Beunza explains. “Then the patient or student will notice and probably interpret this distraction as lack of respect.”
Good listening involves more than how you react during the actual conversation, adds Marrone. In preparation for hearing appointments and consultations, audiologists at the UA hearing clinic send out a self-assessment questionnaire. The questionnaire covers communication issues the person might be experiencing and requests input from the person’s closest communication partners.
“The audiologists take talking points from the self-assessment, but also really listen to what patients and communication partners say in person,” Marrone says. “This advance preparation on both sides gives them the freedom to bring up any idea, value or cultural belief and us the advanced knowledge to incorporate their attitudes into treatment.”
Burns also suggests keeping your clinical comments brief and direct. “Don’t use a 20-word sentence when you can say it in five,” he says.

“Start by telling everyone what you’re going to talk about and how you plan to approach the conversation, and make sure everyone agrees with the plan and feels they can provide input.”

Set the tone
Pay attention to your nonverbal communication signals through eye contact, facial expressions and vocal volume, advises Beunza, who recommends maintaining a low voice volume during serious discussions. Talking too loudly might express to others you feel your input is more important than theirs.
In fact, vocal volume can remain at normal levels even when talking to patients with hearing loss, notes Marrone. She recommends creating a quiet environment for clients by eliminating distractions, background noise and interruptions. Often, closing a door goes a long way toward accomplishing all of those things. Select somewhere with soft surfaces, like an office rather than an exam room, to prevent echoes and acoustic reverberation. Sit close—sound levels rapidly decrease over distance—face your client, make eye contact and speak slowly at normal volume. (Marrone suggests keeping an assistive hearing device nearby, just in case.)
“A lot of people immediately go to raising the volume when talking to older adults,” says Marrone, “but compensating for hearing loss is really about time needed to process, too, so a slower rate of talking makes things more clear.”
How you format what you say also goes a long way toward setting a positive tone, says Burns (see “Breaking Bad,” below). He suggests setting up each discussion using the same format to generate a calm, organized atmosphere in which the patient feels welcome to offer input. “Start by telling everyone what you’re going to talk about and how you plan to approach the conversation, and make sure everyone agrees with the plan and feels they can offer input,” Burns says.
Speak clearly—not condescendingly
In Marrone’s world, “elderspeak” is a dirty word. The term describes the way some health care professionals talk to older people. She says it usually translates into the professional oversimplifying or talking down to the client: “The literature about elderspeak says people using it change the way they speak to older adults in a way that’s unhelpful and can have adverse outcomes in health care settings.”
Assuming that a person understands less—especially because of age or hearing ability—can create a negative dialogue, regardless of the language used, Marrone says. What works well for all people you treat is to speak directly, simply and clearly, without medical jargon. And just because a client is well-educated doesn’t mean they’re medically literate, Marrone notes. The attitude you convey when you walk into a room and the way you first speak to a client or their family helps generate a rapport.
Marrone advises making sure the client knows you’re available beyond initial conversations about diagnosis and treatment. They’ll need guidance long after their screening and follow-up visits. Offer to answer any future questions and provide take-home resources—both written and visual, Marrone adds—about the condition, treatment options and best online sources.
Also pay attention to the attitude you project, suggests Beunza. “We all emit some sort of energy—sometimes stress, sometimes confidence, shyness or trust,” he says. “People also sense when we’re taking them seriously, so it’s important to let them know we listened and took into account their opinions even if we make decisions seemingly opposed to those opinions.”
Burns recommends writing down key words as you talk—a method developed for people with aphasia that he now extends to all clients with communication disorders. For example, he often writes down one or two key words about the conversation topic, then circles back to ask questions using those key words.
“Don’t ignore the patient,” he says. “Don’t assume they shouldn’t be a part of or can’t contribute to the conversation, regardless of their diagnosis or age.”
Patients also pick up on an optimistic outlook, adds Marrone. An important conversation doesn’t have to remain completely serious, she says. Showing some levity and a positive viewpoint can greatly ease a patient’s experience.

“Communicating a diagnosis and a treatment plan involves more than talking about facts, data and percentages. It’s talking about all that, plus taking into account patient reactions and emotions.”

Express value
Another communication booster is acknowledging the client’s contributions to the treatment plan: If you don’t recognize their contribution out loud, the rest of what you did to convey the value of their input may go unnoticed, says Beunza. But be honest, he says.
“If we don’t find value, we shouldn’t say we did, but we might find value in some aspects of the person’s position,” Beunza says.
At the end of a conversation, Beunza advises asking open-ended questions. He feels some health professionals view giving news as a single-sided conversation, but he teaches his students to make all communication bidirectional. An open-ended question requires more information than a “yes” or “no” response. “How do you feel?” versus “Are you cold?” is one example. These types of questions invite the other person to provide complex answers and reveal any concerns.
“Communicating a diagnosis and a treatment plan involves more than talking about facts, data and percentages,” says Beunza. “It’s talking about all that, plus taking into account the patient’s reactions and emotions.”
Clients and colleagues alike value your services—and buy into the treatment plan—more if you give them a voice in the process, notes Burns. “I realized after 15 years, my priorities and perspectives aren’t necessarily the same as the patient’s,” he says. “And if they don’t match, that can affect the patient’s motivation.”
Client participation doesn’t mean leaving clinical decisions completely up to them (obviously, you’re the clinician), says Burns, but it does mean offering choices for activities or soliciting their preferences about which priorities get tackled first.
“We are the experts in communication,” says Burns, “but we aren’t the experts in the needs and values of our clients—they are.”
Breaking Bad

Nobody likes delivering bad news. There might never be consensus on the best way to do it, but communications experts advise using a template to frame the conversation. This way, if the dialogue does go off track, you can re-center yourself and the conversation.

For example, physician, public speaker and professor Juan-Jose Beunza teaches his medical students the SPIKES protocol. Developed by oncologist, writer and actor Robert Buckman and detailed in his book, “How to Break Bad News: A Guide for Health Care Professionals,” the structure, Beunza says, works well for any serious conversation.

S—Setting

Think about who to invite, where to talk and how to connect with the participants before giving the news.

P—Perception of condition

Consider: What does the patient know? What do they think? What are their concerns? What are the questions they would like me to answer? Address the patient’s concerns, at least initially, instead of addressing issues they do not care about or understand, explains Beunza.

I—Invitation

Prompt patients to seek more information from you. What do they want to know? Communication greatly improves when the starting point is the other person’s concern. “If a teacher comes to an SLP because her voice is hoarse,” Beunza says, “we still address her voice issue from the beginning, even if we know her diagnosis is larynx cancer.”

K—Knowledge

Give the information or news. This step is essential, but only makes up a sixth of the conversation. Think about appropriate language, cultural background, scientific knowledge and using short, simple sentences.

E—Explore emotions and sympathize

Respond to questions and reactions from the patient.“We should not only analyze patient reaction, but respond adequately to his or her reaction,” says Beunza.

S—Strategy and summary

Make a plan for the near future. Sometimes, all patients want to know is, “What’s next?” Having confidence in the plan we propose is essential for ensuring that patients trust us, Beunza says.

Michael Burns, SLP, lecturer and researcher at University of Washington, helped develop a similar template used to train CSD students, detailed in the March Leader in the article “Simulating Patient Communication Strategies”. Gain even more insight into delivering bad news from former ASHA president, Tommie L. Robinson Jr., in “Handle With Care”.

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June 2016
Volume 21, Issue 6