This article originally appeared in the Transdisciplinary Agora for Future Discussions Journal ISSN 2643-4938 (ONLINE) Volume Two Issue Two: August 2020

Evolution of Fear in Healthcare Management: Analyzing Influences of Communication Skills for Trust Development

Aghanya, T. Nonye, MSC, RN., FNP-C

Communication Academy

Email Id: [email protected]

Abstract

Quality healthcare requires practitioners who possess the technical competence and communication skills for not only gathering and transferring information to patients but also for developing trust with patients in the process of clinical consultation. The study used discourse analysis to identify how poor communication skills significantly contribute to the mistrust experienced between patients and healthcare providers/clinicians. The study identified various professional practice gaps in existence such as clinicians/healthcare providers who are unaware of different scenarios that warrant the application of specific styles of soft skills of communication while interacting with patients who present with different attitudes/characteristics/personal attributes. Education is needed to provide a better understanding of the several factors that contribute to these presenting attitudes capable of building a wedge and creating mistrust between patients and healthcare providers/clinicians.

Keywords:

Opinionated Patient, Dependent Patient, Communication Skills, Suspicious Patient, “Normal” Patient

Introduction

The author a few years ago in 2013, underwent a major abdominal surgical procedure which was debilitating, and she was out of work for five months (see Photo 1). With immense gratitude to God, she is recovered and in excellent health today. However, during these five months of recovery in 2013, the surgery experience created many dependencies on family members and healthcare providers. In addition to visits to the primary care doctor, there were also visits to other specialists as cardiologist, gynecologist, urologist and general surgeons to complete what seemed to be a series of never-ending medical examinations, tests, scans, and other diagnostic studies. These underlying emotions and anxieties can eventually manifest as several kinds of patient behaviors and attitudes during a clinical visit. Aghanya (2016) agrees that clinicians could perceive various behaviors as overly curious, rude, dismissive, absurd, or downright bizarre. She posits that effective communication, especially in the healthcare sector, is essential for the wellbeing of patients and helps in the process of recuperation. Communication is the process of sharing meanings, ideas and services which must be interactive for effectiveness. Effective communication is, however, proactive when the communicator possesses adequate communication skills.


Photo 1: A patient in hospital

The need for a study activity which addresses this vital component of healthcare practice was realized following this personal experience as a patient in the healthcare system. It was further substantiated after the review of various articles and research studies which explore the effects of empathy, compassionate interactions on patient care and its correlation if any, to the rate of clinician burn out. Many articles/journals/books/presentations highlight various aspects of communication in healthcare but fail to identify or explore the factors that contribute to the formation or hindrance of a productive and trusting relationship between the patient and clinician. There are no studies identified which address the methodological management of fears/anxieties with strategic communication styles for various patient attitudes/emotions.

Various studies highlight the evidence that when healthcare providers/clinicians are compassionate and strive to make more genuine connections with patients, they are happier and feel more fulfilled in their roles as this helps to reduce the risks of provider burn out. However, given that compassion is best implemented as an act, it became imperative to explore the etiology and effects of anxieties in healthcare and more importantly how healthcare providers/clinicians can strategically apply the soft skills of communication to improve the chances of delivering compassionate care to establish trust with patients.

The Problem

As a clinician, being quite familiar with the clinical process that entailed this recovery period, the process created a great deal of anxiety and fear. Constantly grappling with several levels of anxiety and physical pain, this experience ultimately started to affect daily mood and life outlook. It was a humbling experience which revealed that many, if not all patients in the healthcare system experience different levels of anxiety/fear due to the feeling of not knowing the outcome to any given clinical situation. "The unknown" can create feelings of crippling fear for some patients and others; can create moments of doubt, confusion, awkwardness (sometimes evidenced by misplaced smiles and laughter), irritation, and even bitterness. Ascertaining the relevance of communication skills in overcoming this kind of fear is, therefore, the main thrust of this research.

Method & Significance of Study

The study deployed discourse analysis to investigate the role and effectiveness of communication in healthcare. Findings and knowledge emanating from this study will help to provide strategies to healthcare providers/clinicians for active engagement apt for building trust with patients especially those who present to healthcare settings with fears and anxieties due to underlying emotions as anger, suspicions, dependence, defiance, feeling overwhelmed, talkative, sad, proud, opinionated, skeptical and so on. Irrespective of patients’ attitude and countenance, utilizing strategic communication skills to transfer information from the healthcare provider should be done in a way that helps to allay patients’ underlying fears and promote patients’ understanding. It should most importantly, encourage the adherence to the recommendations of the healthcare provider/clinician.

This educational information applies to various levels of healthcare practices, such as primary prevention plans, education regarding disease and ailment management, prevention of hypertension, diabetes, obesity, smoking cessation plans. Secondary prevention plans which include effectively communicating to patients the measures that lead to early diagnosis and prompt treatment of their diseases. Finally, tertiary prevention plans which include the most appropriate ways to empathetically engage with patients as healthcare providers/clinicians attempt to improve the quality of life of patients with terminal illnesses should be adopted. It is achieved by appropriately relaying information regarding treatment and prognosis of existing ailments and discussing the best ways to reduce symptoms of existing chronic diseases.

The helpful resources gained from this study originate from critical analysis of peer reviewed research articles and various studies, including 30 years of author's clinical experiences in diverse healthcare settings. The findings of this study would make a great teaching/learning tool in educational institutions as medical/dental/nursing schools, Healthcare practice settings such as medical clinics, emergency health clinics, hospitals, retail clinic, and urgent care clinics.

Literature Review

In recent times, an attempt to make sense of the correlation between the impact of fear on behaviors and life outlook, the works of various philosophers and their interpretations of fear were explored. Reading Dr. Michael Fishers (2015) publication “Educating Ourselves: A Lovist or Fearist Perspective”, it was fascinating to note that his introductory paragraph detailed his observation as a Fearist, the correlation between how we live our lives and how we educate ourselves. Fisher (2015) went on further to ask this vital questions: But what exactly is fear? How does it evolve, and who gets to define it accurately? Can any single definition be all inclusively contained especially given the evolving human nature/views/opinions? Sometimes, there are even evolving philosophical views.

The healthcare atmosphere is an emotionally charged one capable of inducing various levels of anxieties/fears. We live in an emerging world of technological advancements where healthcare providers/clinicians are required to assess patient’s histories adequately, arrive at a diagnosis, and provide treatment plans in a fast-paced environment. Such expectation is especially true in rapid care delivery settings as urgent care, walk-in medical clinics, retail clinics, and emergency room clinics. It seems to be a more difficult task for the healthcare provider/clinician to rapidly establish a rapport with the anxious/fearful patient while simultaneously assessing and developing a treatment plan with the patient.

Healthcare providers/clinicians need to realize that patients often heavily interpret the quality of their medical care based on the emotions that they most often experienced during their clinical interactions with healthcare providers. To successfully build trust with patients, healthcare providers/clinicians must therefore, develop a unique approach to communicating with every patient. The clinician-patient relationship can be a simple or complex one depending on the clinician’s approach to allaying patient’s anxieties/fears and establishing an enduring relationship. It is unwise to assume that a productive relationship is achievable without much input from both parties. Just as in every other relationship, there needs to be more effort made by the healthcare provider to relationship building because he/she is the figure of authority who guides the flow of the consultation.

A wrong move is when healthcare providers rely entirely on patients to set the tone of a consultation visit and to control the visit flow pattern. Due to the patient’s underlying fears, many patients expectantly look to healthcare providers to set the tone of the visit. Most patients would respond quickly and positively to a friendly tone from the healthcare provider/clinician. Many patients would also prefer to quickly establish this rapport than fidget in fear/anxiety in the clinician’s presence for the duration of the visit. Healthcare providers/clinician must take advantage of this common patient expectation and apply it strategically to help allay the patient’s fears and gain their trust. There is no disputing the fact that when people feel at ease and are less fearful, they retain more information disclosed to them. This process of trust development between both parties requires a delicate balancing act. The division of race, ethnicity, and culture may be reflected in the health of the people in a community/society/nation. For instance, in the United States, despite recent progress in overall national healthcare delivery, disparities continue in the rising incidence of illness and death among African Americans, Latino/Hispanics, Native Americans, Asian Americans, Alaska Natives, and Pacific Islanders as compared with the United States population as a whole.

Various patient perspectives and mistrust of standard healthcare practices may emanate from the knowledge of such historical events as the 1932 Tuskegee study of black men which was unfairly conducted without adequate study disclosure or informed consents from study participants. There could be a result of increasing fears/anxieties/mistrusts from the population/race most affected by the memories of such unfortunate study events ( https://www.cdc.gov/tuskegee/timeline.htm). Healthcare practices (including communication process) must, therefore, be reflective of cultural sensitivities, perceived underlying fears and reservations emanating from historical events in various communities. Although subtle at times, culture does play a significant impact on the provision of appropriate healthcare services. Acknowledging, recognizing, and addressing these complexities will help facilitate learning and trust promotion between the healthcare providers/clinicians and patients. It is highly attainable irrespective of background, culture, ideologies, attitudes, and individualities.

Another philosopher with a breathtaking view is Osinakachi Akuma Kalu (Kalu, 2018). He argues that the necessary foundation of philosophy is rooted in problem-solving. His suggestion is congruent with the theory of evolution of fear in healthcare. Kalu (2018) assumes that identifying the roots of common fears of patients and healthcare providers/clinicians. He posits that going further to develop resources that teach the necessary communication skills will help to avert these common fears/anxieties experienced in healthcare settings. Kalu (2018, 53-54) further touched on the role of fear in the human struggle by identifying fear as a great motivator which is not typically self-contained but instead manifests as an external factor which when perceived, motivates one to react. How we choose to direct these emotions that conjure up within us due to external fears is a significant determinant of whether our fears/anxieties shall either control or not control our lives.

Another exciting opportunity was the review of another philosopher’s work, Professor Desh Subba, who has detailed some interesting observations of fear from a positive perspective (Subba, 2014). He believes fear gives an interpretation of both life and the world. According to (Subba, 2014) Fearism exists as a theory and in order to study Fearism, there is need to study all aspects of Fears, its’ causes, its’ effects, how it has embedded into the societal values, affecting our behaviors and attitudes ( our essence, our being). Subba (2014, p. 52) also indicates that fear comes from the human mind, and while the existence of fear precedes essence, a combination of exterior and interior factors generates fears. Applicable to the theory of Fearism in healthcare, patient’s awareness of clinical diagnosis and prognosis can either create feelings of uncertainties, despair/fears/anxieties or can create an innate commitment for the patient to battle the disease process bravely. The author argues that knowing a patient’s mindset/being/essence/reservations helps the healthcare provider/clinician to engage strategically, which contributes to some tranquility amidst an otherwise chaotic moment.

In essence, the moment a healthcare provider/clinician is faced with an unfortunate health experience become exposed, common fears/anxieties is felt by patients. It is usually a lifechanging experience that spurred into action, the development of resources for improving communication patterns that will help to alleviate patient’s and healthcare provider’s Fears/anxieties in various healthcare settings.

Review of Empirical Studies

The following studies were reviewed to give an empirical undertone to this study:

Empathy decline and its reasons: a systematic review of studies with medical students and residents: In this study, the results of reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research. (https://www.ncbi.nlm.nih.gov/pubmed/21670661).

Teaching empathy to medical students: an updated, systematic review: The findings of this study suggest that educational interventions can be useful in maintaining and enhancing empathy in undergraduate medical students. Also, it highlights the need for multicenter, randomized controlled trials, reporting long-term data to evaluate the longevity of intervention effects. Defining empathy remains problematic, and the authors called for conceptual clarity to aid future research (https://www.ncbi.nlm.nih.gov/pubmed/23807099).

To add to conceptual clarity, Aghanya (2016) in her book Simple Tips to Developing a Productive Clinician-Patient Relationship also provides several practical tips that healthcare providers/clinicians can implement during consultation visits with patients that will help to alleviate patient’s fears and anxieties. It explores the etiology of how various underlying fears and anxieties can manifest as patient’s attitudes and behaviors which might become deterrents to the establishment of trust and relationships between patients and healthcare providers.

The importance of identifying these unique characteristics and implementing strategic communication styles can never be overemphasized. Healthcare providers/clinicians need to refrain from using a one-size-fits-all communication approach for all patient encounters because people have different personalities, backgrounds, and characteristics and thus perceive and react differently to the same information presented to them. To attain long lasting trust development through active interaction, the healthcare provider/clinician must implement a communication style specifically tailored to each patient’s personality, attitude, individuality, and background. Knowledge of a patient’s mindset/being/essence helps the clinician to engage strategically aiding tranquility amidst an otherwise chaotic moment of life.

Findings, Conclusion & Recommendation

The review of literature has shown that communication is vital in overcoming and managing fear among patients of every category. The finding buttressed the relevance of possessing communication skills by health care workers. The study concludes that communication skills are needed for effective communication in healthcare to overcome fear among patients. The study recommends the adoption of the contents of Aghanya’s (2016), Simple Tips to Developing a Productive Clinician-Patient Relationship. It gives the communication tips for allaying Fears/anxieties for 16 different scenarios of patient’s attitudes/behaviors.

Aghanya (2016) argues that when one interacts with patients and encounters various attitudes, there are more appropriate times to implement either one or more of the communication styles listed in the below paragraphs. While utilizing this book as a resource in the medical/nursing educational curriculum, students would become empowered in learning the skills to assist patients to feel comfortable in their presence. She believes that students will learn when to effectively implement such communication styles as maintaining more constant eye contact versus temporarily avoiding eye contact ( to give patients the chance to establish a train of thought pattern), and when to speak softly versus loudly (to create a tranquil environment). It will also help them understand when to use open versus close-ended questioning (to gain and keep patient’s attention); when to use targeted questioning patterns (to promote engagement) and when to use humor (to reduce a tense atmosphere). Students will equally learn when to listen more than speak (to assist anxious patients to calm down during the history-taking process). In essence, there are also times when it is most appropriate to nod in affirmation as patients speak, when to speak with authority while maintaining eye contact and when to provide narratives of clinical finding during the patient examination process. Shubba (2014) posits these styles are implemented with a strategy to help create a tranquil consultation atmosphere, reduce anxiety and fear while promoting the chances for trust development in all settings, including the healthcare settings.

The book will be an excellent resource to introduce students to the simple steps that can be appropriately implemented through the strategic use of communication styles to help improve the chances of not only establishing better connections with patients but also reducing the risks of frustrations and burn out in their future healthcare practices.

References

Aghanya, N. T. (2016). Simple tips to developing a productive clinician-patient relationship. USA: I-Universe Publishing.

Aghanya, N. T. (2017). This patient did not want my care because of how I looked. Retrieved from https://www.kevinmd.com/blog/2017/10/patient-didnt-want-carelooked.html.

Aghanya, N. T. (2019). Principles for overcoming communication, anxiety and improving trust. USA: Folio Avenue Publishing.

Empathy decline and its reasons: a systematic review of studies with medical students and residents. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21670661

Fisher, M. R. (2015). Educating ourselves: A lovist or fearist perspective? Technical paper no. 54.

Harding, A.. (2014). Americans’ trust in doctors is falling. Livescience. Retrieved from www.livescience.com/48407-americans-trust-doctors-falling.html

Interactional skills training in undergraduate medical education: Ten principles for guiding future research. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/31092235

Kalu, O. A. (2018). The first stage of the fearologist. CreateSpace Independent Publishing.

Perlmutter, A. (2019). What happened to clinician empathy? Retrieved from https://www.kevinmd.com/blog/2019/03/whats-happened-to-clinicianempathy.html

Subba, D. (2014). Philosophy of fearism: Life is conducted, directed and controlled by the Fear.” XLIBRIS

Suneel, D. (2017). Good communication is at the core of all good medical care. Retrieved from https://www.kevinmd.com/blog/2017/07/good-communication-core-goodmedical-care-3- examples.html.

Teaching empathy to medical students: an updated, systematic review. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23807099

Tracey, P. & Skinner, T.C. (2003). Discrepancies between patients and professionals: Recall and perception of an outpatient consultation. Diabetic Medicine, 20(11): 909-14, doi:10.1046/j.1464-5491.2003.01056.x

Trzeciak, S, & Mazzarelli, A. (2019). Compassionomics book: The revolutionary scientific evidence that caring makes a difference. Studer Group

US public health service syphilis study at Tuskegee. Retrieved from https://www.cdc.gov/tuskegee/timeline.htm