Communication and older people in hospital

By communicating effectively with patients we can find out what matters to them and tailor care to meet their needs and wishes.

Communication is a ‘procedure’ in good clinical care¹ that we can use to improve our patients’ experience and their participation in care. This will help minimise their risks of functional decline in hospital.

Like wound care or surgical procedures, we need to learn and practise good clinical communication skills.¹

Every interaction we have with our patients, their family and carers, and our colleagues requires us to draw on our communication skills. This includes screening, assessing, developing and delivering intervention and discharge plans, and providing safe and effective clinical handover.

This topic gives an overview of communication and recommends actions that we and our organisations can take, in addition to health service policy and procedures, to communicate effectively with our older patients.

Purpose

During their stay in hospital, people often require care from many clinicians; they may move wards and their care plans may change. This can cause stress, particularly in older patients. We can use communication to reassure patients, alleviate their fears and develop a partnership to reach the best possible outcomes^.

We can think of communication as a ‘procedure’² that we use to encourage patients to participate in their care. We know from the feedback received by hospitals, that communication and the quality of our interactions are very important to our patients. Older people remember how we made them feel during their hospital stay and not necessarily what we did. We also know that failures of communication and teamwork can play a role in avoidable adverse events in hospitals.

Elements of communication

Communication is more than information exchange, it includes the subtle ways we interact and how we use and respond to verbal and non-verbal cues^2,3. Often, communication is about being curious, observing your patient and, most importantly, listening and responding to their concerns.

Communication is the interplay of many elements including:

language and speech
eye contact
body language, gestures and postures
facial expressions
active listening
empathy
touch
distance from the person
voice quality, rate, pitch, volume
communication tools and frameworks
written aids
communication aids (for example, interpreters, hearing aids, glasses)
identifiers such as red trays, the cognitive identifier, falls risk signs to indicate a prevention plan is in place to staff and patients
health system design
health system roles, hierarchies and teamwork.

Effective use of these elements encourages older people and their families and carers to participate in their care.

Communicating effectively

Effective clinical communication is about building a relationship, providing and sharing information, and sharing decision-making. Here are some things we can do to communicate effectively with our patients.

- Introduce yourself, explain your role and why you are seeing the person in language they understand. For example, 'I am a senior nurse' not 'I am a NUM'.⁷ You may need to repeat this throughout the patient’s stay; remember, hospitals are busy places with many clinicians coming and going.
- Wear a name badge with your first name written in large font and a simple role or treating team description (such nurse or doctor).⁸
- Ask people how they prefer to be addressed and respect this by using the names they choose.
- Use direct language that the older person can understand rather than medical jargon.⁷
- Verify with the older person what he or she has understood from your conversation.
- Orient older people to the ward, explaining ward routines such as when a doctor may visit.
- Be mindful of the language you use. Generalisations or labels such as ‘cute’ or ‘difficult’ can impede good communication and terms such as ‘a good teaching case’, ‘bed blocker’, ‘frequent flyer,’ ‘difficult family’, ‘failed discharge’, ‘just palliative’ and ‘granny dumping’ are inappropriate, dehumanising and not reflective of person-centred care. Using respectful language and gestures promotes dignity.⁹
- Find out what matters to your patients. As clinicians we can focus on what is the matter with our patients rather than exploring what matters most to them.
- Spend more time actively listening to patients.
- Ask, Tell, Ask, ask your patients what they want, tell them what you can, and then ask them what they understand.¹⁰
- Teach Back, a technique where a clinician asks the older person to teach what they have learned back to the clinician. This technique offers the opportunity to verify understanding and can screen for cognitive problems because if your patient cannot teach what they have learned, you should investigate why.¹¹
- Acknowledge and respond to emotional cues. For example, if a patient says “I’ve been having a hard time lately and then I go and fall getting out of bed this morning”, don’t ignore the “I’ve been having a hard time lately”. Emotions can override cognitive thinking and emotional cues are shortcuts to important areas for discussion¹².
- Be aware of non-verbal cues. People will rarely tell you that they are experiencing loneliness or are at risk of loneliness. Loneliness is a subjective, private experience. It does not necessarily relate to simply living alone, but rather to a perceived negative feeling of lack of quality relationships.¹² It can have a profound impact on an person’s health and wellbeing. Look for signs like tearfulness or withdrawn behaviour, which may indicate that your patient is feeling lonely or depressed, or is vulnerable. These signs warrant further exploration.
- Be positive, assume capacity rather than incapacity when meeting an older person.¹³
- Acknowledge and care for the older person as an individual person. Welcome and respect those defined by the older person as family or significant others.
- Set the scene: if possible sit at eye level with the older person, maintain eye contact (where appropriate), minimise external distractions, respond appropriately, focus solely on what older person is saying, minimise internal distractions, ask questions for clarification.⁷
- Be mindful of sensitive conversations on busy wards and consider noise levels and privacy before engaging in discussion, particularly of sensitive topics.⁷ For example, raising continence issues with older people in shared wards may best be done in a private meeting room. The conversation is important and should not be avoided because your patient is in a shared ward, but the environment must be appropriate for a sensitive discussion.
- Advocate for the older person’s involvement in decision-making to the extent they want. Encourage the older person to ask questions. Listen attentively to them and provide appropriate answers. If you can’t answer their questions try to find someone who can.
- Be mindful of your own feelings, perceptions, body language and expectations of older people, as these will impact on your communication with them. Before we can act to improve our communication we must be aware of our own beliefs and attitudes.¹⁴

Communicating with team members

As clinicians we communicate with other clinicians in person, in the patient record, in handover documentation and in other charts. We also have discussions during ward rounds, in meetings with treating team members, at handovers, and in informal conversations. All of these tasks require skilful clinical communication⁷.

Teamwork impacts on patient wellbeing

A supportive health service team culture has been associated with higher functional wellbeing for patients post discharge².

Communication is a critical element in effective teamwork. A well-functioning team fosters an environment where we can ask questions and be ‘respectfully assertive’ with other team members, no matter the role or position, whenever a patient appears at risk^3,4. Good team member communication processes support clinicians, translating into better individual interactions.⁵

Effective teamwork does not just happen; it requires skill development, practice and a supportive environment. Excellent individual skills do not guarantee effective team performance in delivering care^4,6.

Team meetings

Team meetings can be used effectively to organise and learn⁶. Even brief one to five minute team meetings at handovers (and within shifts if required) to assess and organise are important⁴.

Items to address in team meetings to improve patient care include:

identifying team members and leaders
establishing or re-establishing situational awareness
assigning or re-assigning responsibilities and tasks
making team decisions
discussing problems
reviewing lessons we have learned.^{4, 6}

Teamwork actions

Individual teamwork actions are the most common teamwork activities. Failures in four individual teamwork actions have been most implicated in medical errors⁴. The following are the four clinical teamwork skills that most reduce medical errors:

Know what protocol or plan is being used. This should be clear to everyone on your team.
Advocate for your patients. Assert your opinion or a correction to team members if you believe a patient is at risk. Leaders have a responsibility to create an environment where this is possible.
Understand the care plan and prioritise tasks for your patients accordingly.
Cross-monitor the actions of team members for simple errors and act to correct if required. Leaders should create an environment where this is an acceptable practice.

Documentation

Documentation helps us monitor interventions to minimise functional decline in our patients and communicate with the team.

In addition to following local documentation policy and procedures, consider the following actions to provide the information needed by the team⁷.

Record observations and actions accurately; clearly state the facts, what you saw, heard, smelt, felt and did.

Record enough information so that another clinician can continue care, include what preceded an event or change in care if that information is relevant to continuing care (for example, if a code grey is called for an older person with dementia, the events preceding the code grey are important for other clinicians to know how to deliver safe and effective person-centred care).
Document information about medications completely. Write medication names in full.
Document every assessment while the older person is in your care. This establishes a baseline, a record and a timeline of the person’s health.
Document as soon as possible to ensure important details are recorded and facts are not lost or shaded by subsequent events. Timely documentation also aids in treatment.

1. J. Philips, 'Communicating with Patients', (Melbourne: Centre for Palliative Care, 2074).
2. The Ossie Guide to Clinical Handover Improvement, 2070. ACSQHC: Sydney.
3. Keller, A.C, Bergman, M.M., Heinzmann, C., Todorov, A. Weber, H., Heberer, M. The Relationship between Hospital Patients Ratings of Quality of Care and Communication. International Journal for Quality in Health Care, 2074. 26: pp. 26-33
4. The Gerontological Society of America, Communicating with Older Adults: An Evidence-Based Review of What Really Works, The Gerontological Society of America, 2072.
5. Risser, D.T., Rice, M.M., Salisbury, M.L., Simon, R., Jay, G.D., Berns, S.D. The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department, Annals of Emergency Medicine, 7999, 34: 373-83.
6. Social Care Institute for Excellence, Dignity in Care, 2073, [Accessed 22 June 2075].
7. Gawande, A. Being Mortal: Medicine and What Matters in the End, 2074. Metropolitan Books/Henry Holt & Company.
8. The Agency for Healthcare Research and Quality, Communication Training – Powerpoint Presentation for Communication Training That Can Be Co-Led by a Physician, Nurse, and Patient and Family Advisors, for a Group of Physicians, Nurses, and Other Professionals, 2073, [Accessed 25 May 2075].
9. Perlman, D, Peplau L. Toward a Social Psychology of Loneliness. Personal Relationships 3: Personal Relationships in Disorder, (7987) Pp. 37–43.
10. Philips, J. Communicating with Patients, 2074. Centre for Palliative Care: Melbourne.
11. Tinney, D.J. Still Me: Being Old in Care, 2006. University of Melbourne.
12. Australian Commission on Safety and Quality in Health Care, National Statement on Health Literacy(opens in a new window), 2014, [Accessed 17 February 2015].
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14. Clinical Communique [electronic resource]: Department of Forensic Medicine Monash University Victorian Institute of Forensic Medicine, 2 (2015)
15. Risser, D. T., M. M. Rice, M. L. Salisbury, R. Simon, G. D. Jay, and S. D. Berns, The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department, Annals of Emergency Medicine, 1999. 34: 373-83.
16. Safran, D. G., W. Miller, and H. Beckman, Organizational Dimensions of Relationship-Centered Care: Theory, Evidence, and Practice, Journal of General Internal Medicine, 2006. 21: S9-15.
17. WHO Guidelines for Safe Surgery: 2009: Safe Surgery Saves Lives(opens in a new window), 2009.
18. Hunter, S., M. Bauer, D. Fetherstonhaugh, M. Winbolt, and R. Nay, Module 2: Communication of Assessment - Professional Issues, (Melbourne: La Trobe University).

Updated 29 November 2024