[CaptionComponent="2989"]

Domiciliary visits quite commonly present particular communication challenges. This article explores the various communication skills the eye care practitioner needs to consider when visiting patient within the domiciliary environment.

The importance of effective communication

The importance of effective communication skills are a central component of eye care. Effective communication optimises the practitioner’s ability to:

  • Solicit necessary clinical information from the patient;

  • Deliver information in a way the patient can understand and find personally relevant;

  • Support the patient to feel comfortable.

Domiciliary visits can present particular communication challenges. Instead of a familiar consultation room, the practitioner typically does not know what kind of room layout to expect until arrival and needs to spend time setting up equipment, establishing test distances etc.

Not all tests can be performed as easily in the home setting as they can in the practice setting. While patients may feel more at ease in their own homes, a domiciliary visit can still be an unusual event and patients can feel uncertain, even anxious, about what will happen and about how ‘well’ they will do.

Furthermore, given that the average age of patient is over 80, they are more likely to have limited mobility, hearing loss, visual impairments, complex clinical needs or dementia – all of which require specific communication strategies.

Before the consultation

Useful preparation can help towards effective communication in the consultation itself. When booking in the appointment, the practice can find out the following information and pass it on to the practitioner:

  • The patient’s eye care history and needs – in particular whether the patient is visually impaired;

  • The patient’s overall health status – in particular any limitations in hearing and/or mobility and whether the patient has dementia;

  • Whether the patient can speak/understand English and if not, whether a translator can be available;

  • Whether the patient will be accompanied by a relative or carer.

Practices can also pass on relevant information to the patient – eg, the likely length of the appointment and what kinds of tests will take place. In addition, practices can request that the patient collects and has to hand necessary items for the appointment such as pension credit documents, glasses and magnifiers, and a list of current medications.

It is often a good idea to telephone the patient while en route to the appointment to give an expected arrival time. This helps the patient to feel prepared for the encounter and also provides a useful opportunity for the practitioner to remind the patient about having necessary items ready.

In addition, the practitioner can use the phone call to gauge how good the patient’s hearing is, the current physical and mental state of the patient (whether the patient appears tired etc), and thereby make preparations for suitable ways to communicate.

Starting and setting up

The start of the consultation is a crucial phase for communication. It is an opportunity to establish a good rapport with the patient (and relative/carer, if present) and a shared understanding of what will happen during the appointment. It is also an appropriate time to ask what particular concerns the patient has.

After making introductions it is worth spending a little time explaining to the patient what will happen during the visit – how long it will take, what furniture will be rearranged etc. This will help them feel more comfortable. An exchange of small talk while setting up necessary equipment should also relax the patient and build up rapport. This small talk might be on topics such as the location of the patient’s home, how long the patient has lived there, whether the patient has had a domiciliary visit before etc. The patient might use this time to introduce a concern he/she has. Meanwhile, the practitioner can gauge the patient’s particular communication needs and how best to meet them:

If the patient displays difficulty hearing:

  • Speak loudly and clearly during the consultation;

  • Sit relatively close by – on the side of the patient’s ‘better’ ear, if possible;

  • Pause between sentences;

  • ‘Signpost’ changes in topics – eg, ‘Now I’m going to ask you questions about …’;

  • Face the patient to detect any signs of trouble understanding by observing facial expressions etc.

If the patient has dementia and/or appears tired or confused:

  • Maintain eye contact to help the patient stay focused and detect any signs of trouble understanding;

  • Speak in short sentences;

  • Pause between sentences.

In all cases, it is important to address the patient directly rather than through any relative/carer or translator present, unless the patient indicates otherwise or is completely unable to interact.

If the patient appears able to deal with open questions, a good way to start the ‘business’ of the consultation is to ask a general question about the status of his/her eyes.

Our earlier work on communication has shown (see Further Information) that patients often cope best with questions that invite them to comment on their personal, subjective experiences of their eyes. Some examples could include:

  • ‘How are you finding your eyes at the moment?’

  • ‘Have you noticed any changes with your eyes?’

  • ‘What kinds of difficulties have you been having recently?’ (if the patient has previously indicated the existence of concerns).

Open questions invite longer answers. Although this can take more time, they also encourage patients to talk about their concerns in their own words and thereby help them to feel involved in the consultation. Their answers might reveal potentially relevant detail that can be followed up by the usual questions concerning history and symptoms.

However, patients who appear tired, confused or very nervous are likely to feel more comfortable with a series of yes/no questions to solicit relevant information.

[CaptionComponent="2990"]

It is important that while taking the history and symptoms the practitioner is sitting down and looking directly at the patient. Making eye contact demonstrates to the patient that they are being listened to and taken seriously, and is likely to increase patient satisfaction.

Therefore, the practitioner should avoid extended periods of writing in the record form while the patient is talking as this breaks eye contact. When about to make some extended notes a simple announcement such as ‘I’m just going to spend a moment writing this up’ can also help to avoid uncomfortable silences.

Conducting tests

Effective communication during consultation tests helps the practitioner to gather clinically relevant and accurate information. Clear instructions and guidance to the patient are particularly important. To achieve this the practitioner can draw on available information about the patient and his/her communication needs.

If the patient appears unfamiliar with the optometric consultation:Give a short explanation before the start of each test;

  • Give very specific instructions to help the patient understand what is happening and what he/she is required to do – eg, ‘I’m going to look at the back of your eye. Just sit still and look forwards.’

If the patient has very restricted vision:

  • Give very specific instructions to avoid confusion. Use practical references – ‘look straight ahead’ rather than ‘look at the letter chart’;

  • Be particularly careful to explain changes in where the patient is supposed to look – for instance in switching between the letter chart and an object in the practitioner’s hand;

  • Inform the patient when moving around the room, setting up equipment etc.

If the patient is very nervous, tired or confused, or has difficulties with hearing or dementia:

  • Give short instructions with pauses between sentences;

  • Think carefully about the clarity of instructions and avoid any that are overly complex or impossible to answer – eg ‘Is it better or worse with lens one or lens two?’

  • Simplify instructions as necessary – eg, ‘Can you read the bottom line?’ rather than asking the patient to select a line to read themselves;

If necessary complete the test phase as quickly as possible and provide reassurance that the patient is nearly finished.

Once again, the practitioner should direct the test questions to the patient rather than any accompanying relative/carer or translator unless directed otherwise.

Certain communication practices can benefit the patient’s experience of examination tests. For instance, practitioners can mention when an upcoming test relates to a symptom or concern the patient reported at the start of the encounter. This demonstrates that the patient has been listened to and taken seriously. Patients often want to perform ‘well’ in tests and can become anxious if they believe they are not doing so. This anxiety can increase in the domiciliary setting as patients feel they may be ‘wasting’ the time of the practitioner, who has come ‘all this way’ to see them. This anxiety may be expressed in facial expressions or comments either before or after the test about ‘failing’, or not seeing ‘properly’. In these instances, practitioner comments can help to reassure the patient. For example, ‘I know this test is hard, but you’re doing very well/we are nearly finished’ or ‘Don’t worry, it’s important to understand how much you can see so that we can help you.’

Delivering findings and advice

It is necessary to deliver findings and advice in a way that the patient is able to understand, remember and recognise as personally relevant. To help with this, the practitioner should personalise the delivery of information to meet the specific needs of the individual patient:

Follow the steps outlined above to optimise communication with patients who have conditions such as dementia and limited hearing.

Consider the level of awareness the patient has displayed so far about his/her eyes and adapt accordingly.

Some patients display difficulty remembering previous treatments or appear confused over which glasses are for reading or distance. These patients benefit from simple and clear reminders of what their eye needs are plus practical help such as the provision of stickers to label different pairs of glasses.

Other patients display a great deal of knowledge about their eyes. Practitioners can build on the information the patient has already provided and use technical terms if the patient has already used them accurately.

Whatever the level of the patient’s communication needs, it is always important to:

  • Refer back to any concerns that the patient reported at the start of the consultation – in particular the chief complaint. Even just stating that there is nothing to worry about demonstrates that the patient has been listened to and taken seriously.

  • Use techniques to help the patient to remember information after the consultation:

  • Numbering, ‘There are three things I’m going to tell you. Number one is…’

  • Labelling, ‘This is some advice about your cataracts.’

  • Providing further information – such as leaflets (in appropriate text size) and useful websites (if the patient has said he/she is an internet user).

  • Repeating key information at the end of the consultation.

Recognise signs indicating that the patient has not understood. Patients are often embarrassed or shy about admitting they have not understood information they have just been given. For this reason asking ‘Do you understand?’ might not get a genuine response. Instead, practitioners should maintain eye contact with the patient in order to be able to observe facial expressions – such as slight frowns or furrowed brows – that convey a lack of understanding.

Help the patient with further information. If the practitioner feels that the patient may not have understood and/or could benefit from more details, questions such as ‘Would you like me to explain a bit more about this?’ or ‘A lot of patients find this condition very complicated so do you have some questions to ask me?’ make it possible for the patient to request more information without losing ‘face’. Offering a leaflet (in appropriate text size) or the name of a good website (if the patient is an internet user) also encourages the patient to find out more after the consultation.

Display empathy with the patient. Empathy is a valuable tool to help patient comfort during the consultation. For example, it is important to acknowledge the patient’s feelings after receiving bad news – ‘I understand that this is a big shock for you’ or ‘I can see you are upset, would you like to take a moment before we go on?’

[CaptionComponent="2991"]

Practitioners can sometimes feel that it is inappropriate, even patronising, to say to domiciliary patients, ‘I know how you feel’ as they may not have much in common with them. An alternative is to display empathy with the patient’s situation by referring in general to other patients in similar situations and commenting on how they tend to feel about the challenges they face etc. This can also be linked to advice giving. For instance, if a patient is unwilling to have a cataract operation due to his/her age, the practitioner could talk about other patients of a similar age who have had the operation and describe how it has (or has not) benefitted them, the time they needed to recover etc. This provides information in a way that is sensitive to the patient’s feelings and needs.

Conclusion

Effective communication lies at the heart of successful eye care consultations. While the domiciliary setting can present particular communication challenges, practitioners can take various steps to meet them.

This CET was supported by the Outside Clinic

Further Information

The authors have worked on two research projects about communication in eye care which can be accessed at https://keprojectoptometry.wordpress.com/

Professor Peter Allen is the Director of the University Eye Clinic at Anglia Ruskin University, and a member of the Board of Trustees, and assessor and examiner for the College of Optometrists. Dr Helena Webb is a Research Associate and a member of the Work, Interaction & Technology Research Centre at Kings College, London