Bedside Manner

Why is a good bedside / consulting manner so important?

Walk into a shop and you find an assistant who is dismissive, snooty, carries a

couldn't-care-less attitude and chances are you may be very tempted take

your business elsewhere.

Make a telephone call to accompany and you are kept waiting and when you

do get through you find someone who works to a template and fails to listen

to you, you will feel unheard, unlistened to, and if you can, may again take

your business elsewhere.

But with health services we don't always have that luxury. But we still put up

with not being heard, having to wait, having staff who are so rushed they barely

have time to listen or they are simply processing us through a machine, they've

heard the stories before, they're keen to get to the prescription and then to the

next patient.

We are paying the price for this rush, rush, inefficient and ineffective systems.

Why?

Why is it we have come to accept the mediocre, the dumbing down? We even witness it in our media  which is awash with sub-standard, low-level programmes and professionals.

 

But nothing will change until we give feedback, kick up a fuss, complain and stop making excuses for lack of time, or resources, and poor overworked professionals – that way is simply colluding with an ineffective and inefficient system and we will never change it if we are not prepared to offer feedback about it.

 

Perhaps our altruism has decayed and we, especially those working within the system, are too exhausted to change the system.

Impressions count - be they first, second, or subequent

The first time a patient meets with a health professional, the patient has no idea what kind of professional this is going to be in terms of their approach, their understanding, their way of communicating, their skill level, their competence, their knowledge, their attitude, and so on.

 

The patient may have done their research and talked to colleagues, friends or family members with previous experience of the professional; they may have researched on the Internet, on website forums. But in reality,  the patient doesn’t really know what will happen until it happens.

 

And so, first impressions count; from a personal point-of-view, the only initial way the patient has of evaluating a professional new to them is by his or her bedside manner, first initially and subsequently how it plays out. And the patient’s assessment, whether conscious or unconsciously, happens, it is said, probably within the first 60 seconds - some theories say within the first seven seconds. But in that short space of time the whole patient / professional relationship has been influenced. And, too, the professional is doing their sussing out of the patient; not just the professional part of noticing how the patient walks into the consultation, what their demeanour is, are they sad or buoyant, the professional is, no matter how often they protest "we are not here to judge" creating impressions. they forget we can read it in their body language too. 

 

Whilst patients undoubtedly meet professionals who excel in most aspects of communication, it takes just one who is ineffective and inefficient for a sour taste to be left.

 

What follows is a reflection both of professional behaviour as well as the influence of medical systems on that behaviour. We can all, I imagine, accept that NHS resources are stretched, systems unwieldy, professionals under huge time and emotional pressures, to say nothing of the pressures they may be under outside of work, and sometimes the patient is their own worst enemy, but patients do not invent the system, they do not make the political decisions around resources, the policy on 10 minute  consultations, and so patients must not feel emotionally blackmailed to feel sorry for the professional; there is no excuse not to feedback incidents of unacceptable behaviour or poor bedside manner. Why should we put up with it? But if we do nothing about it by reporting it, we are complicit in colluding with poor behaviour, poor systems, and poor management and political decisions.

 

Personal examples

 

When my younger sister was in hospital during her final months of living with lung cancer, her treatment was very mixed. She had a brilliant oncologist, whom we loved dearly, who was run ragged with exhaustion and eventually went off sick.

 

We had accompanied my sister on her first visit to get her diagnosis. The consultant that day ought to have had a refund from his charm school; little in the way of compassion, no concerned tone,  or indication of empathy. He went straight into his news, “I have a list here of 52 things to tell you so let’s get on then!”  As he delivered his list, he never looked at my sister to assess how she was taking the devastating news  - stage IV lung cancer – or pick up the signs she was clearly not understanding and was quickly wilting until I intervened. At that he was annoyed. I had asked him if he could be less clinical and check with her her understanding and more particularly, how she was feeling.

 

Now I would not have wished to have been in his situation, breaking bad news for goodness knows how many times that day. But to my sister it was her first time hearing this.

 

He wanted to get through his list; we had to stop at almost every point to ask for clarification of information which was being speedily delivered, and in jargon.

 

 

On her various subsequent hospital visits, there were some nurses who oozed efficiency, effectiveness, compassion, empathy, understanding mostly under very trying circumstances.

 

But there were some whose behaviour was downright unacceptable.

 

Too many were the occasions when we, the family, would arrive during visiting times to find my sister, in a small ward of four patients, sitting confused on the edge of her bed, dressed only in knickers and bra, the other patients telling us they had asked for her to be helped only to be told she'd have to wait as there were other more pressing matters.

 

“She’s been waiting for nearly two hours to get to the toilet,” the other patients would tell us. “Staff would come and go, they’d undress her then get called away. And we can’t call for assistance because the call buttons by our bedside have been folded over a nearby chair which we can't reach.”

 

My sister would say not to make a fuss because staff would just make life difficult for her.

 

On another occasion we arrived to find her in her state of dishabille. There was a small toilet in the ward, for patients, but she was unable to walk unaided and had been unable to reach out to hold her walking frame. It had been placed too far from her bed.

 

She had been waiting for over an hour for assistance, a fact  not acceptable given she was at the time suffering from urinary tract infection. There was no commode.

 

I called for a nurse. “We only have two commodes for the 40 beds in this unit so she’s having to wait.”

 

I asked for her to be taken immediately to the toilet.

 

The toilet door remained opened and after a few minutes I heard my sister call out in distress.

 

“Don’t do that! And no, I cannot stand on my own. I don't have the energy and cannot find my balance.” We had witnessed this state for days, surely nurses ought to have been aware of what she could and couldn't do.

 

The nurse’s reply was to shout at my sister, tell her not to be so lazy, and to get up at once, followed by, “No, I am not going to help you. You can do it on your own.” My sister by now in her state of advanced cancer was confused and weak and could not stand unaided. She was now audibly distraught.

 

By now I had rushed to the toilet whereupon the abrupt nurse suddenly changed tone and demeanour to one of patronising and false kindness. She knew she had been rumbled.

 

As I left that day I asked for a meeting with the management team. That took a few days and when it happened my niece and I were ushered into a room with a large square table, with seven staff at one end, facing us at the opposite. Do they know nothing of the tactics of room placement -  or was it set up deliberately to make it a confrontation. Undaunted, we went through our experiences. We were given apologies and told they were understaffed. I could have understanding and compassion but frankly, that was not of our making.

 

A few days later, we were sitting around my sister’s bed and she was in a chair. Suddenly the abrupt nurse appeared, made a bee-line for me, and threateningly asked me, “You were the one who reported me? Don’t you know I am a student nurse and I am on a steep learning curve.”

 

“It costs nothing to be pleasant and your manner right now simply underlines your manner of dealing with people, an aggressive one, leaves much to be desired.”

 

If that is the attitude our local university was turning out on its degree course, I held it also in poor regard.

 

And my sister was right; she was made to “pay” for my complaint.

 

The Person-Centred Approach

 

The Person- Centred approach of Carl Rogers maintains that the quality of the relationship is more important than any techniques used by the therapist and places the concept of trust at the centre of the relationship (O’Farrell, 1999:33). From check-in to check-out, first visit to last, the importance of bedside manner cannot be underestimated; it is to build trust and engage the patient from which healing flows. What, when and how information is communicated makes all the difference.

 

So what might a patient reasonably expect, whether in a hospital or general practice setting.

 

Connection

 

Presence - really be there, be present, bring your best you to the patient

Vocabulary - using words the patient can understand, not medical jargon. This means taking account of the patient’s psychosocial, educational and cultural background. To use “big” words simply reinforces doctor knows best and puts patient in an underdog position

Eyes - making eye contact when talking, not in a staring fashioning but gently

Welcome - professional standing up, if appropriate shaking hands, and introducing themselves to the patient and family every time.

Body language - being mindful of and practising body language that is honest but doesn't demonstrate haste, that leans toward the patient and not away with folded arms, that does not have the professional sitting higher up than the patient

 

Engagement

 

With everyone on every encounter, committing to:

  • Connect with compassion and respect by addressing the patient as Mr./Ms. or by the name that the patient prefers.

  • See the patient and not just the illness

  • Ask questions then listen; this may be the 100th time you have heard a similar story this week, to the patient it is their unique story

  • Talk with, not at,  the patient during a ward round and not to other colleagues present as if the patient were elsewhere

  • Introduce yourself with integrity by stating your name and your role not using your title to have power over someone, and who else is present

  • Communicate what you are going to do, roughly how long it is going to take, and how it will impact the patient 

  • let the patient know what might be expected of them and how they may interrupt to ask questions or make comment

  • Seek to anticipate and discover the patient's needs, experiences, questions, or concerns.

  • Be truly patient centred – not just playing at it and above all do not say to the patient, “We HAVE to be patient centred these days.” That simply implies you do  not believe in it, that you do it because you have to, and not through choice

  • Respond with respect to patient questions or requests with immediacy, courtesy, and with patience, practise active listening

  • Exit with excellence by ensuring all of the patient's needs are met

  • State any next steps

The ten minute consultation

When patients go to a hospital or clinic they want to be treated with respect and receive the best care. It’s important that physicians and other healthcare professionals treat patients well and have a great bedside manner. How you act and treat people can impact your practice and either help or hurt your reputation.

Be sure to stay focused, don’t argue, be sincere and show empathy, observe, validate, be detailed, don’t judge, and listen. If all else fails, just remember to be nice. Being nice goes a long way and can do more for your patients and your reputation than most other tactics.

Martin Elliot
Professor of Physic
Gresham College

© 2017,2018,2019  by Andrew Hunter

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