It’s more than just talking
Head of midwifery at the Liverpool Women’s NHS Foundation Trust Kim Gibbon explores how communication skills can be enhanced by using simple counselling techniques.
Midwives magazine: February/March 2010
Communication skills are critical to the delivery of high-quality maternity services. It is impossible to ensure the provision of the best possible care, using available resources to their fullest, without accurate and complete communication with women, their families and multi-professionals.
This need for communication skills has always been a fundamental part of delivering maternity care. The quantity of information to be shared (Department of Health, 2007) and regulatory requirements that mandate communication are increasing (NMC, 2008). The booking interview, for example, will now typically cover information on baseline screening tests, informed choices around patterns of care and where to access it, and whether to opt for maternal or fetal screening for a range of possible anomalies.
Clearly the intention is that this information helps support the provision of care. The communication challenge is to go beyond imparting information. Midwives must also check and facilitate women’s understanding of facts, elicit structured information, and help women to match their want and needs with the realities of childbirth and service provision. Flowing from all of this must be support for informed consent – a key theme from such national drivers as the National Service Framework for children, young people and maternity services (2004) and Maternity matters (2007). This requires midwives to be skilled in giving information in a non-biased, logical, constructive manner that can be retained by women and their partners, so they can draw upon this data as and when they need it.
To develop and improve communication skills, there are some basic counselling techniques that midwives can use. These approaches will help whether the situation is normal or high risk, to communicate information, to elicit information, to engage in a dialogue, to listen, to check women’s and their partners’ understanding of information they are given. They can allow the midwife to provide women with the opportunity to check complexities or uncertainties they may have in comprehending information and making important choices throughout all stages of pregnancy and childbirth.
Communication skills begin by creating, as far as possible, the right environment for women and their partners ensuring privacy and comfort so that nothing inhibits dialogue.
Listening must be active – it includes non-verbal components of communication, such as body language, maintenance of eye contact and looking for incongruence between the verbal and non-verbal behaviour (Rogers, 1980).
Active listening should include frequently giving women the space to clarify their understanding of what has been said. This means midwives need to reduce their own contribution and not make judgements.
It is the midwife’s responsibility to guide, direct and structure communication. Midwives build trusting positive relationships with women and their partners – this consists of three core elements of congruence (genuineness and honesty), unconditional positive regard (non-judgemental acceptance and respect) and empathy (the ability to feel what the woman feels). Without these elements, women will not trust and communicate openly (Rogers, 1957) with midwives.
Beyond environment, active listening and trust, there are a number of basic techniques:
- Reflecting (Bordin, 1979) – this is using the same words back to women. This reassures women that you have understood and heard what they have said and also accepted what they have said without judgement
- Summarising (Ivey and Galvin, 1984) – this is articulating the story back to the woman in a shortened version. This gives her a chance to hear what they have said, check whether the information is correct and segments the information into manageable portions
- Paraphrasing (Ivey and Galvin, 1984) – this is putting what the woman has said into your own words, which can help reassure women that you have heard the most significant aspects of what they have said
- Hunching and checking (McLeod, (1998) – this is used to check incongruity. If you think what is said is not what is meant, then formulate a hypothesis as to what you think the woman really means. There are no rights or wrongs – the woman will correct you
- Questions (Egan, 1998) – do not use closed questions, which can be answered with a ‘yes’ or ‘no’, unless you want to close the dialogue down. Open questions will allow women to express their own understandings and feelings, rather than being forced into the midwife’s conceptual framework where the only answer can be ‘yes’ or ‘no’
- Silences (Egan, 1998) – never be embarrassed by silence. This gives women time and space to think and find ways of expressing themselves. The use of these techniques is made more difficult for midwives by the complex and changing environment in which communication must take place.
Some key considerations are:
- As pregnancy progresses, there is a requirement to give different information and make a range of choices at different points. This change continues from pre-conceptual and antenatal care to intrapartum and postnatal care.
- Throughout this journey, the way in which women engage in communication will also change:
- The very nature of childbirth may place some women into high-risk and high stress situations. The approach to and pace of communication will change in a high-risk situation or where there is bad news to work through
- Communication will not just be with women, but their families and with multi-professionals involved in care. The approach to communication will change depending on the combination of people present
- Women and their families will come to pregnancy with a whole range of ideas, pre-conceptions and cultural filters. As part of this, another focus of government drivers is to reach groups of vulnerable women, who may be socially excluded and tend not to access care as robustly as women from less vulnerable groups (Confidential Enquiry into Maternal and Child Health, 2007; Department of Health, 2007; NICE, 2008). This requires midwives to have sophisticated communication skills to engage and persuade women to access maternity services and sustain this access.
Despite this multi-dimensional complex of influences on communication, the basic techniques outlined above can be applied sensitively to improve communication. This in turn will allow midwives to facilitate delivery of the best possible care matched to the needs and wants of women.
Bordin ES. (1979) The generalisability of the psychoanalytic concept of working alliance. Psychotherapy: theory, research and practice 16: 252-60.
Confidential Enquiry into Maternal and Child Health. (2007) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003 to 2005. Confidential Enquiry into Maternal and Child Health: London.
Department of Health (Department of Education and Skills). (2004) National Service Framework for children, young people and maternity services. HMSO: London.
Department of Health. (2007) Maternity matters: choice, access and continuity of care in a safe service. HMSO: London.
Egan G. (1998) Skilled helper: a problem-management approach to helping (sixth edition). Brooks/Cole: Pacific Grove, California.
Ivey AE, Galvin M. (1984) Microcounselling: a metamodel for counselling, therapy, business and medical interviews: In: Larson D. (Ed.). Teaching psychological skills: models for giving psychology away. Brooks/Cole: Monterey, California.
McLeod J. (1998) An introduction to counselling. Open University Press: Buckingham.
NICE. (2008) Antenatal care: routine care for the healthy pregnant woman. NICE: London. See: www.nice.org.uk/CG62 (accessed 12 January 2010).
NMC. (2008) The code: standards of conduct, performance and ethics for nurses and midwives. NMC: London. See: www.nmc-uk.org/aArticle.aspx?ArticleID=3056 (accessed 12 January 2010).
Rogers CR. (1957) The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology 21: 95-103.
Rogers CR. (1980) A way of being. Houghton Mifflin: Boston.