Article from the Boston Globe’s On Call Magazine, June 2001

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Verbal communication takes many forms. In healthcare settings, it could be a standardized interview or a formal patient teaching session. It could also involve giving appointment instructions or directions to other facilities. But whatever form it takes, it’s imperative for healthcare professionals to make sure all their patients understand what’s being said. When the patient is an older adult, the problems associated with hearing and being heard can be especially acute.

For patients to fully participate in their own care, they need to be able to understand both formal and informal communication. This can be a challenge at times, especially for older adults. As people age they may experience physical, cognitive, or sensory changes that affect how they speak, listen, or follow directions. They may be on medication that affects their concentration and memory. Older adults may also have concerns or fears that get in the way of their ability to understand.

Mrs. Smith, for example, is an 84-year-old woman who lives alone. She comes to her appointment complaining of shortness of breath. To make an accurate diagnosis, the nurse practitioner listens to Mrs. Smith’s lungs and orders some follow-up tests. The nurse asks Mrs. Smith to go to the 7th floor to have her blood drawn, to go to the 2nd floor for a chest x-ray, and to return to her office before going to the pharmacy. Mrs. Smith cheerfully agrees. But, as the nurse later learns, Mrs. Smith leaves the facility soon after her blood is drawn. While there may be many reasons why she does not follow through, a likely reason is that Mrs. Smith did not understand or could not remember all four of the nurse’s instructions.

Health professionals have the responsibility to communicate in ways older adults can understand. Kathy Lyman, MS, RNC, is an adult and geriatric nurse practitioner at the Division of Gerontology at the Beth Israel Deaconess Medical Center. She says that health professionals have a unique perspective that they should take advantage of. “Health professionals know the patient and know their limitations,” she says. Lyman offers some helpful suggestions for communication strategies that health professionals can use when they speak with and listen to older adults.

Allow Sufficient Time

As people age, their response times slow. Allow sufficient time for older adults to process and respond, especially when discussing information that is unfamiliar or complex.

Identify the Patient’s Priorities

Find out what is on the patient’s mind and address those concerns first. Ask patients about what is new since you saw them last. You might learn of a medical concern you were unaware of. “If I don’t first take care of what’s on their mind,” says Lyman, “it will be a wasted visit.”

Direct the Conversation

There may be times when patients persist in talking about matters unrelated to the medical visit. Acknowledge that you hear their concerns and then direct them back to the matters at hand. One way to do this is to say, “That must be quite a worry for you. For now, though, let’s talk about how you manage your medications at home.”

Give Directions One Step at a Time

When giving directions, present information one step at a time. Allow patients sufficient time to process each step before going on to the next. Offer to write down the directions as well, providing a written reminder of what you said.

Assume Responsibility to Remember

Most everyone, regardless of age, forgets information. Take notes while you talk with patients, explaining that these notes are for your benefit as much as the patient’s. Offer the patient a copy to take home, and keep one for yourself as well. Refer to these notes before the patient’s next visit so you can follow up on what was said and done the last time you saw the patient.

Offer Additional Help as Needed

Sometimes patients need more than verbal instructions. If you are concerned that Mrs. Smith may not remember to go to x-ray, for example, take the time to find someone who can escort her. Appreciate that the time you spend arranging for additional help may make a big difference in a patient’s care. “Don’t be quick to judge that a task is not worth your effort,” says Lyman.

Respond to Repetitive Information as if It Is New

Whether due to dementia, anxiety, or simply conversational style, some people tend to say the same thing over and over again. Try not to criticize when people repeat themselves. It may make them feel angry, frustrated, or even agitated when they are frequently corrected. After you hear information a second time, simply spend less time talking about it than you did when the information was new.

Confirm That You Understand Each Other

Make it a habit to repeat back, in your own words, what you hear patients say. You might, for example, say, “When you told me you had a small appetite, I understood that you were only eating a sandwich at dinner time. Is that correct?” In turn, ask patients to tell you what they hear. Assume responsibility for effective communication, inviting patients to let you know when they don’t understand.

Find Practice Settings That Match Your Communication Style

Health professionals are not equally skilled at speaking with and listening to older adults. Find a practice setting that matches your communication style, seeking situations in which you are comfortable and effective and in which patients have let you know that you are doing a good job.

How To Learn More

Katherine Lyman, MS, RNC, is an adult and geriatric nurse practitioner at the Division of Gerontology at Beth Israel Deaconess Medical Center in Boston. You can reach her by E-mail at klyman@caregroup.harvard.edu or by phone at (617) 667-4580.

Helen Osborne gives workshops on communicating with older adults. To learn more, contact her by e-mail at: helen@healthliteracy.com or visit her Health Literacy Consulting Web site at www.healthliteracy.com

Publications

• ·Kick, E (Sept. 1989). Patient teaching for elders. Nursing Clinics of  North America, Vol. 24(3), 681-687.
• National Literacy and Health Program, Canadian Public Health Association (1998). Working with Low-literacy Seniors; Practical Strategies for Health Providers. To order, contact the Health Resources Centre by telephone at (613) 725-3769, ext. 190, or by e-mail at hrc/cds@cpha.ca.
• Pearson, M, Wessman, J (1996). Gerogogy. Home Healthcare Nurse, Vol. 14, No. 8, 632-636.

Some of the information in this article is adapted with permission from the book, Overcoming Communication Barriers in Patient Education by Helen Osborne, Aspen Publishers, Inc., Gaithersburg, MD. (2000).