The art of active listening

Listening is an essential part of the consultation because it creates the foundation for a good rapport between clinician and patient, and for better patient outcomes. So how can practice nurses improve their listening skills?

Think of someone you know who listens well, to whom it is good to talk when you have something on your mind, or are just feeling a bit low. What is it about their listening that makes it so effective?

It is likely that it is because they really do seem to be present, be interested, have time and to have respect, even if they might not agree or fully understand.

You might also want to consider the impact of good listening. Why does it help when you choose this person to talk to?

You may feel that someone has heard your story, that they understand your concerns and possibly even that you can now take the next step forward yourself. You may also have experience of an occasion where someone failed to listen, and so did not understand you.

Much has been written about listening as part of the consultation^1,2 because it creates the foundation for a good rapport, and for better patient outcomes.³ Active listening, which is explored in detail in person-centred counselling and motivational interviewing⁴ involves encouraging someone to ‘tell their story’, checking that you are understanding their approach and meaning, and reassuring them that you are interested in what they are saying.

There are steps that all clinicians can take to improve the quality of each listening encounter.

Creating the right environment

We have all had important conversations in a corridor, or on the stairs, but a warm, quiet, private consultation room helps people to relax, and enables both participants to engage in the discussion. There should not be telephone calls, people wandering through, or any other interruptions, unless the circumstances are exceptional.

To be ‘present’ at a consultation, there should be preparation. You may be running late after a difficult appointment. There is the danger of carrying your stress and concerns into the next one. This is readily perceivable, and will damage your focussed attention. Jot down quickly anything you need to act on, and then pause to put that paper aside, to readjust the chairs as necessary and to look at the information on the next patient. You will then be able to concentrate on welcoming body language and good eye contact when the patient enters, rather than checking details or shifting the furniture.

Your consultations are limited in length, and sometimes nurses are afraid that if they invite a patient to fully explain the problem, they will be hard to stop. Beckman and Frankel⁵ demonstrated that most doctors interrupt patients after about 18 seconds, but that if they allowed them to finish, most patient stories lasted less than a minute, and none longer than 2 minutes. To be heard fully, without interruption, is very affirming; try this out with a colleague, asking them to listen to you describing a tricky incident while just demonstrating that they are focussed and interested, but without interrupting.

DEVELOPING LISTENING SKILLS

Keith Nichols,⁶ in his clinical guide on how to give psychological support as a health professional, identifies the skills he attributes to a ‘good listener’.

Some people are naturally good listeners, but there are also techniques that can nurture these attributes, and build on our listening skills.

Giving good attention

The listener will demonstrate that she is listening by the way she stands or sits, focussing on the person talking, and having good eye contact. They may sit slightly forward in their chair, their hands are likely to be still and they will look directly at the person who is speaking. Too much eye contact can sometimes be threatening, but how often have we complained that ‘he clearly wasn’t listening – he was looking at his computer screen, not at me’? Some times you need to check facts, or note important information; allow the patient your full attention for two minutes before you turn to the screen, and keep turning back to reassure them of your interest. Gentle focussed attention is evidence of being present, not thinking of something else, or the next review question, or even how you can help.

Creating a sense of understanding

Think back again of the friend who listens well. How does he or she signal that they understand, and can appreciate how you are feeling? It is probably a composite of several factors; they nod, or say ‘uh-huh’ at intervals, they may use empathetic phrases such as ‘that must have been difficult’ or ‘Great!’ and they may check their understanding by reflecting back what you have said:’ You felt angry because she never rang you back?’

Consider a hypertension review where the patient weighs 5Kg more than she did last year.

The conversation proceeds like this:

Patient: ‘I don’t know how it happened. I am careful what I eat, and I haven’t done anything different, and we never fry anything…’

Nurse: ‘How much exercise do you take?

Patient: ‘It’s difficult for me to walk as much as I used to because of the arthritis in my knees, although I love walking.’

Nurse: ‘Then you should eat less, because you are not exercising.’

Patient feels rebuked, and the thread of conversation is broken by the nurse intruding her thoughts into the patient’s explanation.

Or the conversation could have proceeded like this:

Patient: ‘I don’t know how it happened. I am careful what I eat, and I haven’t done anything different, and we never fry anything.’

Nurse nods.

Patient: ‘It’s difficult for me to walk as much as I used to because of the arthritis in my knees, although I love walking.’

Nurse: ‘Yes, that must be hard.’

Patient: ‘…so I can’t work off my dinner. (Pause) I suppose I don’t need so much to eat then…I could try cutting down a bit.’

Nurse: ‘You would eat a little less at each meal?’

Patient: ‘Yes. Not so many potatoes, and things like that. That might help my knees too.’

Nurse: ‘Yes, that could really help.’

Patient has moved to a plan of action, as the nurse reflects back the train of thought.

Good listeners can sense when a comment, or encouragement, would be helpful, but often a gap, and a small space, can help someone reflect, and move their thoughts forward. Silence can also be supportive, and show respect for painful feelings. You will have experience of the moments when quietness was what was required, but where good attention was not broken.

By using reflection and summarising, which takes the words of the speaker, and, without questioning or challenging the thought, condenses it, and offers it back, the listener can establish that they have heard and understood what has been said. If the listener has not quite understood, they have provided the perfect opening for modification and the reaching of a shared understanding:

‘I found the second paper much tougher than the first’

‘The second exam paper had harder questions?’

‘No, not harder, but I hadn’t revised that topic nearly as thoroughly’.

Creating a sense of safety

An important attribute is the ability to create a sense of freedom and safety, so that the speaker can express thoughts and experiences without fearing a response of disapproval or rejection, correction or critical comment, or even unsolicited advice.

Within this environment, a patient can explore difficult issues, such as impotence, or anger at a relative with dementia, without feeling embarrassed; you may be the person of whom they say later – ‘I really could talk to her about anything’. Demonstrating through eye contact, lack of interruption and affirmative encouragement that you are not shocked or phased by what they say will reduce the anxiety and fear of their own feelings.

You may be anxious that you will not be able to handle what might be expressed. There are two important points to note here:

First, explain to a patient if you think someone can offer more specialist help than you. They will know that you can signpost them if they ask.

Secondly, it is very important to be aware that a good listener does not need to know all the answers – in fact, many answers can only be found by the individual concerned.

HEARING THE STORY

As individuals, we all have many stories about our lives, which are best expressed in our own words. The way someone uses language, and describes an event, or their feelings, conveys much more than the bare facts. Health professionals have been challenged to consider the contribution of narrative based medicine, where the story, and the telling and sharing of it, is as much part of the evidence as the data and incidents within it.⁷ A nurse who actively listens to a patient telling their story is receiving and affirming the patient, and enabling them to build on that story. Many of you will have had the experience, over a series of consultations with the same patient, of hearing a changed history unfold as current and past illnesses are fitted into the bigger picture. You may also have helped someone go away with a more connected sense of their health, because you have enabled them to link parts of their story together, and plan a way forward. Much of this process happens through active, focussed listening.

CONCLUSION

Practice nursing uses consultations to support people in maintaining good health, and maintaining control in times of poor health. By using active listening we can create the rapport for a real partnership with patients who have been heard and affirmed.

References

1. Pendleton D et al. The Consultation: An Approach to Learning and Teaching. Oxford, Oxford University Press 1984

2. Hastings A, Redsell S. The good consultation guide for nurses. Oxford, Radcliffe Publishing 2006.

3. Corben S, Rosen R. Self-management for long-term conditions: patients’ perspectives on the way ahead. London, Kings Fund. 2005.

4. Rollnick S, Mason P, Butler C. Health behaviour change: a guide for practitioners. Edinburgh, Churchill Livingstone. 1999

5. Beckman HB, Frankel RM. The effect of physician behaviour on the collection of data. Annals of Internal Medicine 1984. 101: 692-6

6. Nichols K. Psychological care for ill and injured people. Maidenhead, Open University Press. 2003

7. Greenhalgh T, Hurwitz B. Why study narrative? BMJ 1999. 318: 48-50