Cues

Cues can be anything you see or hear when you are interacting with another. Cues are sometimes obvious, such as crying, or subtle, for example, if a patient looks away every time treatment or results are talked about. While cues assist any interaction to be patient-centred, there are other benefits. Zimmermann et al (2003) reported using facilitative questions linked to cues to increase the probability of more cues.

Fletcher (2006) explored the effect of facilitating the first patient cue, which appears to be important. If this is missed, patient cues can drop off as the consultation progresses, whereas open questions linked to a cue are notably more likely to lead to further disclosures than unlinked open questions.

In the example (Box 4), the nurse uses sensitive reflection to pick up the cue ‘bounce back’, then waits for the patient to say more. Later, she uses reflection of what the patient has said to show it has been heard, and acknowledgement to pick up the cue relating to being patient, then a pause and tentative open directive question to find out more. By recognising and acting on cues, the nurse is able to gain insight about the effect of the illness on the patient.

Box 4. An interaction in which a facilitative question is linked to a cue (cues are written in bold)

Patient: ‘I thought, after the surgery, I would bounce back, but that hasn’t happened.’

Nurse: ‘Bounce back…?’

Patient: ‘…well, I suppose, I hoped I would be like I was before I got ill… I know it’s daft really… I need to be patient with myself.’

Nurse: ‘So you hoped you would be like you were before you were ill, and you are finding it hard to be patient with yourself as you recover… how are you feeling about that?’

Patient: ‘Well, not very happy. I’m not a patient person, or one that sits about. I don’t get looked after, I do the looking after... I feel like everyone is managing without me now, that I’m not really needed anymore.’

There are few healthcare professionals who do not feel they work under considerable time pressure, and nurses experience it daily. Counterintuitively, recognising and responding to cues improves time management. In studies that explored cue-based consultations specifically, consultations were consistently shorter by 10-12% (Levinson et al 2000, Butow et al 2002). If the consultation is led by the patient and/or carer, the healthcare professional’s conversation can be tailored to elements that have been identified as important for the patient, omitting non-relevant detail, and therefore less time is needed.

Complete time out activity 4

Identify cues in the three quotes from patients and carers in Box 5, and explain how you noticed these cues. Discuss which cue you noticed first, which are physical and symptom cues, and which may lead you to psychological concerns or a deeper understanding of feelings.

Once completed your time out activity is saved and stored in "My Modules”.

Complete time out activity 5

Look at the photograph in Figure 1. What non-verbal cues can you identify? Describe what could be going on for this person. How many ideas can you generate.

Once completed your time out activity is saved and stored in "My Modules”.

Box 5. Patient and carer quotes

A. ‘Hello again, I’m really feeling much better and not sure that I need to be here taking up your time, I hardly notice the pain now.’

B. ‘I’m not sleeping well at all, I keep going over what’s happened, I can’t take it in, the pain is a bit worse but I’m sure that it’s me thinking about it all the time. My husband keeps telling me to relax and not think about it.’

C. ‘I am so angry, I should have been here last week but the appointment card didn’t arrive until the day after I was due to be here. More time wasted before I get this thing sorted and I can get back to normal.’

Various cues can be ascertained from the quotes in Box 5. However, the quotes cannot also portray whether the individuals concerned made eye contact or averted their eyes while speaking, whether the individual’s speech was loud, a whisper, slow or fast, and other non-verbal cues are not known.

In quote (A):

‘Hello again, I’m really feeling much better and not sure that I need to be here taking up your time, I hardly notice the pain now’, picking up the three cues in bold would enable the nurse to gain more insight into how this person is feeling and coping with the current situation. Once the nurse has used skills such as reflection to recognise and explore the cues that may indicate the patient is attempting to minimise the symptoms or worry, the nurse could then ask ‘is there something else on your mind?’ to ensure there is the opportunity to express additional thoughts, feelings or concerns before moving on with the discussion. The final part of the conversation can explore any physical symptoms and future appointments.

In quote (B):

‘I’m not sleeping well at all, I keep going over what’s happened, I can’t take it in, the pain is a bit worse but I’m sure that it’s me thinking about it all the time. My husband keeps telling me to relax and not think about it’, the listener hears about not sleeping and pain, but the more significant cues for the nurse to recognise and respond to are those highlighted. Using effective communication skills to show you have heard that this person is trying to assimilate and adjust to the news or situation has the potential to reduce anxiety and improve coping.

In quote (C):

‘I am so angry, I should have been here last week but the appointment card didn’t arrive until the day after I was due to be here. More time wasted before I get this thing sorted and I can get back to normal’, the important cues relate to the angry emotion, time and the future, which this person hopes will be a time when he or she will have regained health. Anger can often mask other difficult feelings such as fear. These cues provide insight into how an individual is experiencing what is happening to him or her and also how the individual is adjusting and coping. It is only by noticing, acknowledging and exploring cues like these that we can gain insight into the experience of the person and consequently discover how to support him or her.

The cues in the photograph in Figure 1 relate to body language. The man’s seated position, looking down, his clasped hands and his gaze or focus can be interpreted by nurses to gain more insight into how this patient is feeling. While a nurse may come up with a particular or several interpretations of what he may be feeling, the nurse would need to ask the patient to check what he is thinking or feeling. The nurse could communicate effectively with the patient by using open questions and empathising.

Figure 1

Complete time out activity 6

Reflect on the skills discussed, and identify one or two you intend to use consciously in practice as a result of working through these time out activities. Think about how these skills will affect the interactions you have with patients and carers. After several patient and carer interactions, reflect on your communication skills and check if you identified accurately the cues and the insights to be gained from these using effective communication skills.

Once completed your time out activity is saved and stored in "My Modules”.

Learning points

1. Cues can be anything you see or hear when you are interacting with another.
2. Using effective communication skills to show you have heard that this person is trying to assimilate and adjust to the news or situation has the potential to reduce anxiety and improve coping.
3. The nurse can communicate effectively with the patient by using open questions and empathising