3 Communication Techniques: Verbal

Active listening, as most generally defined, is an attempt to demonstrate unconditional acceptance and unbiased reflection. Active listening requires that the listener attempt to understand the speaker’s own interpretation of an experience.  This has to be done without the listener’s own interpretations intruding on their understanding of the other person.  Active listening contains 3 main elements.

The first element involves communicating nonverbal involvement/immediacy. Active (or empathic) listeners need to communicate to the speaker that they are involved and giving the person unconditional attention^[1]. Second, active listening involves paraphrasing the speaker’s message (both content and feelings) by restating, in the listener’s own words, what the listener thinks the speaker is trying to say^[2]. This must be done without making judgments about the speaker’s message. Finally, most descriptions of effective active listening suggest that the listener ask questions to encourage the speaker to elaborate on his or her beliefs or feelings^[3].

The following are techniques that can be implemented and/or skills that demonstrate active listening:

I. USE SIMPLE LANGUAGE

The terminology used in veterinary medicine can be confusing and overwhelming, especially during times of distress. In any medical profession, we use a range of jargon and acronyms routinely and may forget that this language is unfamiliar to our clients. Use simple language whenever possible; giving examples, drawing pictures, skeletal models, and/or client handouts can be used for support.

You may find, however, that at times medical terminology can be valuable as the most concise way to communicate a certain piece of information. To establish a word or phrase as common language, you may consider introducing the word, defining it for the client/owner, and using it moving forward. Utilizing ask-tell-ask or a check (see below) for understanding would be an appropriate tool to gauge understanding before moving forward with the conversation.

Example:

Veterinarian: “I am worried your goat is blocked, meaning he is suffering from obstructive urolithiasis.  This happens when minerals in the urine form stones and these stones get stuck in the urethra.  When the urethra is plugged, the urine can’t exit the bladder; a blocked goat is an emergency as the bladder can rupture.“

II.  OPEN-ENDED QUESTIONS AND STATEMENTS

Gathering information is best done by allowing the client to state what their concerns are in their chosen manner. They probably have talked this problem over with family and friends and have a whole “story” in their mind that they wish to share with you. Let them tell their story by starting the conversation with an open-ended question. If you’re seeing a cow that is off-feed, you might wish to start with, “So it’s this cow, number 331? What’s going on?” instead of “How many days has this cow been off-feed?” The open-ended question gets you information about everything happening to that cow (“Well, she freshened 3 days ago, nice heifer calf, no problems but now she’s grunting when she lies down and she’s not eating well at all. I’m worried about hardware.”) instead of getting only the answer to your closed-ended question (“Two”). Be aware that research shows that even though 76% of opening questions posed by veterinarians in one study were open-ended, they interrupted the client and began to ask closed-ended questions within 11 seconds^[4].

Sometimes, open-ended questions aren’t actually questions. For example, prompts such as “Tell me more about…” and “Please describe…” allow the client the freedom to elaborate on their concerns and observations.

It is the rare client who talks on and on when you ask an open-ended question. Most are too pressed for time or too intimidated by the veterinarian to talk for very long. When the client is talking, it’s important to be an attentive listener – leave room for silence in the conversation; give facilitative responses, both verbally (“I see”) and nonverbally (nodding, laughing at appropriate times); and picking up their verbal and non-verbal cues (see below). Asking open-ended questions and reflecting information back to the client so they know you’ve heard them requires you to be a good listener. Gauge your level of listening – Are you ignoring? Pretend listening? Selectively listening? Attentively listening?

It is natural, and often necessary, to move from open-ended to closed-ended questions.  Closed-ended questions are vital to helping us obtain definitive, specific details when you need an exact or immediate answer. Closed-ended questions aren’t inherently bad but, if you jump to them too quickly, you lead yourself down only one line of inquiry and reasoning and you may make a misdiagnosis.  As such, a successful history-gathering encounter will cycle between open- and closed-ended questions as the clinician works to obtain a full picture of the patient’s problems and client concerns. For example, after you’ve determined the off-feed cow recently calved and is grunting, that would raise your suspicion that the cow has hardware disease (she’s eaten a wire), just as the farmer suspects. Now is the time for some close-ended questions (“Has anyone given her a magnet?”).  Once this line of questioning is complete, you could return to an open-ended question to elicit additional information (“So I have a pretty good picture of what she eats.  Tell me more about the calving and her lactation history“).

III. PARAPHRASING/REFLECTIVE STATEMENTS

Restating the client’s statement in your own words assures the client you are actively listening, allows you to acknowledge the client’s feelings and concerns, and gives them a chance to correct any misunderstandings. This technique could be applied to presenting concern, history/subjective information gathering, and/or questions asked.

Example:

Client: “Fluffy’s diarrhea started last Wednesday, but was better yesterday, and then today she vomited twice.”

Veterinarian: “It sounds like the diarrhea has been present for a full week, although it seemed to improve yesterday, while the vomiting started today.” You could also add “Is this correct?” if you are unsure if your statement is accurate or if you need further confirmation.

IV. EMPATHETIC STATEMENTS

Empathy is often described as “putting yourself in someone else’s shoes”, but there is no universal definition of empathy.  Empathy can be effectively demonstrated both nonverbally and verbally; the following discussion focuses on verbal empathy only but it is important to remember that 80% of our communication hinges on non-verbals.

Being empathetic means that you can identify with the individual with whom you are engaging, and the capacity to demonstrate empathy is an essential skill for the development and maintenance of interpersonal relationships^[5].  Empathy can be thought of as^[6]:

• identifying with another individual
• developing a conscious awareness for how someone else experiences the world
• embracing someone else’s perspective to obtain a different vantage point
• demonstrating understanding of another person’s situation
• showing sensitivity towards another person’s situation

recognizing that someone else feels a certain way and making the effort to understand why

Englar^[7] states “(v)eterinarians require empathy in order to understand their client’s point of view.  You may or may not agree with this person’s perspective or insight, but you can appreciate his or her thought process…(t)his recognition paves the way for the veterinarian to acknowledge and address the client’s concerns so that there is mutual understanding“.

Example:

Client: “I’ve owned this horse for 23 years, and she’s always been a chubby, easy-keeper.  This winter, she’s lost a ton of weight and I can’t seem to get it back on, no matter what I feed her.”

Veterinarian: “Gosh, you two have been together for almost a quarter of a century!  I can see how much she means to you and I’m sure you’re worried about her.”

Of note, sympathy and empathy are not the same.  Sympathy is an emotional response, such as sadness or pity, to someone else’s experience; think of how we convey our feelings in a sympathy card. Both of these skills are used to enhance client connections.

V. SIGN-POST

Signposting is a tool that can help people follow you through a conversation. It helps people organize and follow the meaning of what you are saying. Having an idea of what they will hear next allows them to process information faster. Sign-posts can help others to avoid feeling lost and can be useful to open, transition, or close a conversation. In addition, sign-posts can and should be used to set the tone of a conversation, such as when you need to deliver bad news.

Example:

Veterinarian: “So, we’ve talked about all of the possible causes of Fluffy’s diarrhea.  Now, I want to go through some of the tests we can run to narrow this down and what those tests would cost.”

VI. CHUNK AND CHECK TECHNIQUE

When we speak to clients, there is often a large amount of information to be discussed, and we may need to explain more than one concept. Absorbing and processing this information when it comes all at once or in a long list can be challenging for many clients. Clients may have questions as things are being discussed and, if they are required to hold their question until the end, their understanding may be affected. Chunk and Check technique addresses this by finding appropriate stopping points in the conversation to check for understanding and provide an opportunity for questions.

“Chunking” means breaking down longer and more complex explanations into digestible pieces, or “chunks”. By structuring the information you need to deliver into more manageable sections, you can improve client understanding and recall; smaller pieces of information are easier to process.

After you give a piece of information, you then check to see if the client has understood what you said. You may do this by asking explicitly (“What questions do you have for me?”) or by observing clients’ nonverbal responses.  Only move on to the next “chunk” when you are confident the client has understood the previous chunk.

VII. ASK-TELL-ASK

Ask-tell-ask is a collaborative communication tool in which you employ an open-ended question, then share information on that subject, followed by another question.

“Ask, Tell, Ask” is just a simple reminder to clinicians of a way to increase the chances of their information or advice landing on receptive ears. So the way that “Ask, Tell, Ask” works is that with the first “ask,” you have a couple of options. One good option is to ask permission to give information or advice. That’s a really good way to respect that person’s autonomy. Another way to do it is to ask what they already know or what they want to know, so you’re really gearing your information or advice to what they’re interested in. So you have two options for that first “ask.”^[9]

For “tell,” you need to tell your message simply, just one or two points, in what you might think of as living room language. So really focus in on things that are personal or specific to that individual and that situation.

Then for the last “ask,” you again have two options. You can ask what they think of the information that you gave or you can ask a teach-back question to check for understanding.

Ask permission, or how much they want to know, tell your information clearly and concisely, and then ask what they think of it or check for understanding using teach-back.

Example:

Veterinarian: “Do you have any experience with diabetes?“

Client: “Nope, I haven’t had any pets or family members with diabetes before.“

Veterinarian: Provides a relevant explanation of the topic and then asks “What else can I tell you about this?“

VIII. SUMMARIZE

Summarizing is a technique that can be used to provide an overview of an entire discussion or conversation. This is similar to paraphrasing, but would encompass multiple thoughts, concerns, or ideas that could be identified as the main points. It is most useful at the end of a conversation to capture the main points and provide closure.

Example:

Veterinarian: “Ok, we’ve decided that because Freya still has stomach ulcers based on our exam today, we are going to continue the ulcer medications for another 2-4 weeks.  Then, if she is still having signs of discomfort, we will consider changing to another medication.“