Practice Nurse

Identifying and overcoming barriers 

In all fields of nursing good planning and communication is essential, and without it encounters fail. However, we have all had instances when a consultation was not as good as it should be, or when misunderstandings led to a poorer outcome. How can we reduce these to a minimum by recognising possible barriers, and developing resources to overcome them?

At the end of this module you will have a better understanding of:

Common physical hindrances to good consultations, and where to look for more information

Gaps in nursing skill that reduce the effectiveness of communication, and how to bridge them

Emotional and situational circumstances for the patient that militate against good communication, and how to limit their impact

This resource, consisting of five assessment questions at intermediate level, tests your understanding of barriers to communication, and ways of overcoming them. Complete the resource, including the further reading and some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

Casey A, Wallis A. Effective communication: principle of nursing practice E. 

Communication and Interpersonal Skills for Nurses

Webb L. Nursing : communication skills in practice, 2011 Oxford , Oxford University Press.

Moulton L. The Naked Consultation, 2007. Oxford, Radcliffe Publishing

The 6 Cs – are they relevant to practice nursing?

Learning disability and diabetes: addressing the challenges

The Quality and Outcomes Framework (QOF) now includes surveys from the patients in the practice. Which one of these questions is NOT part of the QOF patient survey?

There will be many instances where the nurse will not know the reason for the consultation in advance and, initially, this can be a barrier to communication. However, a far more significant barrier is poor listening or lack of empathy. These QOF indicators are designed to prompt a cycle of continuing improvement by reflecting on the reasons for the patients’ responses and implementing change.

Access the results for the patient survey on your practice at gp-patient.co.uk

Discuss the results with your peers, and consider if there are steps you could take to improve nursing care.

Question 1

One of the barriers to communication is a clinician who is poorly equipped to manage detailed consultations. It may be someone who has poor communication skills, or who is tired or distracted at the time. Lack of confidence in their own competence or fear of what they might have to deal with can result in a nurse not exploring issues in sufficient depth. Which of the following is NOT part of the Nursing and Midwifery Code of Conduct?

The people in your care must be able to trust you with their health and wellbeing. To justify that trust:

It is perhaps surprising that care of oneself is not seen as important when giving sustainable care to others. However, what is clear is the responsibility to maintain competency in a wide range of skills including that of communication. However, it is difficult to assess your own expertise in consultations and therefore to recognise gaps. The following articles and books may help, but also look at the possibility of attending a workshop on consultation skills.

Nursing and Midwifery Council. The Code; 2019, updated 2024. 

1. With the patient’s permission, use another member of the clinical team to sit in on one or more consultations and then facilitate a discussion about the effectiveness of the consultation. There is good guidance for this type of support in Liz Moulton’s book on the Naked Consultation (Radcliffe Publishing, 2007).

2. Look at some of the modern barriers to good communication skills identified in Jonathan Silverman’s article ‘Doctors' non-verbal behaviour in consultations: look at the patient before you look at the computer’. British Journal of General Practice 2010;60(571):76-78. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814257/

Question 2

The practice environment can create serious barriers to a good consultation. Some of these are listed below. Identify the odd one out:

The odd one out is interruptions during the consultation. All the other barriers can be assessed (for example by Care Quality Commission inspections) without patients present. Interruptions in nurse consultations, both by telephone and in person, are disruptive but frequently persist because they are transient and not audited. Nurses need to provide data on the interruptions to their consultations, and initiate a process to remove them. All the above barriers can and should be dealt with, and practices should have an improvement plan in place.

 (Introduction to the work of the Care Quality Commission)

An inspector calls: GP practices face closer scrutiny

The King’s Fund. The quality of patient engagement and involvement in primary care.

1. Look up the Essential standards of quality and safety on the CQC website 

http://www.cqc.org.uk/sites/default/files/documents/gac_-_dec_2011_update.pdf

2. Read the King’s Fund report above, and explore some of the ways in which patients can be involved in improving care

3. If your consultations are interrupted, gather detailed data. Do other clinicians have a similar problem? There may be important reasons for it e.g. equipment stored in your room, another of your roles requiring easy access, an insecure colleague. Discuss your findings in a suitable group to design and implement solutions.

Question 3

At any practice there will be people from a variety of social and cultural groups, as well as full range of ages, with different health values, religious beliefs and cultural expectations. There is the potential for significant barriers to communication because, for example, an elderly man from Bangladesh resents being advised on his diet and smoking habit by a young female nurse or a nurse does not understand the attitudes towards pre-marital sex of the local traveller community.

Which of the following statements is false:

During Ramadan, Muslims must abstain from food and drink and smoking during daylight hours. However, there are exemptions on various grounds including health – look for example on the Diabetes UK website at the information for people with diabetes. Roma and other travellers often have strict rules of chastity and sexual propriety, which may affect their knowledge and approach to contraception.

 Expectations of health care professionals differ between culture and country and this can significantly affect how people engage with doctors and nurses.

 Often open-ended questions can elicit some of the differences. Both older and younger patients may limit their discussion because of their health beliefs or because of their perception of the staff they are talking to.

1. County Durham Youth Offending Service. Working with gypsy and traveller communities. May 2010. Durham County Council.

http://www.euromedinfo.eu/how-culture-influences-health-beliefs.html/

3. Nicholls A. Assessing the mental health needs of older people. Social Care Institute for Excellence 2006. Available at: 

http://www.scie.org.uk/publications/guides/guide03/files/guide03.pdf

4. Right Here Volunteers, Brighton and Hove. Young people’s views and experiences of GP services in relation to emotional and mental health. Children and Young People’s Mental Health Coalition. Available at: 

http://www.right-here.org.uk/home/assets/pdf/young-people-views-experiences-gp-services-report.pdf

1. Look at the RCN website section on social inclusion and selected groups who may be disadvantaged 

http://www.rcn.org.uk/development/practice/social_inclusion/principles

2. If you have travellers registered at your practice you may find it useful to read the Report on health inequalities in the Gypsy Traveller community produced by Sheffield University 

http://www.sheffield.ac.uk/polopoly_fs/1.43713!/file/GT-report-summary.pdf

3. Sometimes disease in a particular community is under reported and therefore undertreated. Look at the data on COPD in England available at: 

http://www.pickereurope.org/assets/content/pdf/Project_Reports/Picker_COPD_NSF_final_report_with_cover.pdf

Question 4

When people come into the consulting room, we do not know what emotion will be uppermost. There may be embarrassment or shyness, or anxiety about the problem that makes them feel very vulnerable. Some people are angry – perhaps about previous treatment – and some very distressed or in pain. Often people are wary of how they will be received, and defensive about their weight, or smoking habit etc. The nurse or doctor needs to be very alert to ‘where the patient is’ at each fresh consultation.

The King’s Fund reviewed the literature on patients’ perceptions of their long-term conditions and, more specifically, the support they received from health professionals.1 The report identified key clinician attributes which really made a difference. Which of the following is NOT included?

Waiting is a nuisance and the patient’s initial reaction may be irritation, but delays are seen as less significant when the consultation itself meets the patient’s needs. A clinician who really focusses on what matters to the patient at that time can make a huge difference to how they both feel when they leave the consultation. Sometimes, because of the situation or because of the patient’s state of mind, not everything can be accomplished at once, but that is often less important than establishing confidence in the person and the process. This is why one of the key complaints about medical care in the past has been lack of information;2 a patient is vulnerable if they do not understand what is happening to them.

1. Corben S, Rosen R. Self management for long term conditions. King’s Fund 2005. 

http://www.kingsfund.org.uk/publications/self-management-long-term-conditions

2. Coulter A. What do patients and the public want from primary care? BMJ; 331: 1199 Available at: 

Reflect on your last three consultations. How would you describe the mood of the patient when they entered? Were there specific steps you took to respond to this? Was there anything else you might do in a similar situation?

1. It is useful to consider why this person has come to see you at this time. The question is explored on the Patient.co.uk website at 

http://www.patient.co.uk/doctor/holistic-medicine

2. Access the Patient.co.uk article on how to analyse the consultation, which examines various ways to structure the session. Available at: 

http://www.patient.co.uk/doctor/Consultation-Analysis.htm

3. Keith Nichols, a clinical psychologist, has written a clinical guide for people in health care to assist people who are ill – Psychological care for ill and injured people. Open University Press, Maidenhead; 2003. (Available as an eBook from Amazon.com) Both thoroughly researched and highly readable, it suggests practical ways to improve healing through information-giving and supporting emotional health.

Identifying and overcoming barriers

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