Active listening

It is easy to assume that listening is a skill that can be done without thinking; however, it is of course possible to listen without hearing, either the words or their meaning. Depending on which studies are considered, only 25–50% of what is heard is actually remembered. Effective communication between two people can only exist when the person receiving the message receives and interprets it in the way that the person doing the sending intended. The likelihood of this occurring is increased if the receiver is engaged in active listening. In other words, their attitude presumes that the person they are listening to is important to them and that they accept the following to be true about that person:

• what they think
• what they need
• how they feel
• what they want

Active listening has many benefits as it lends itself to developing trust between two people and in turn enhancing the likelihood of arriving at helpful solutions. As well as being a useful skill to have in terms of helping patients, it can be used effectively to resolve conflict and enhance productivity in other work-related situations.

Active listening is by definition active, it cannot be carried out in a passive way, therefore, prior to using active listening skills some preparation is needed both of the listener and the environment. Box 6.1 shows some of the environmental factors which need to be taken into consideration.

Box 6.1 Setting the environment for active listening Minimise intrusions or interruptions either from loud noises, telephones or someone in person; Room temperature should be neither too hot nor too cold; Avoid creating a barrier by the way the desk and chairs are arranged. Sitting facing the patient, but at an angle rather than directly, is best; Seating should be comfortable.

When first meeting the patient ensure that they are greeted warmly and that introductions are given. Active listening will be taking place in different clinical settings, e.g. a ward environment or a clinic. Wherever it occurs, the principles around establishing the right environment remain the same. At the beginning, it is important that they know the amount of time available and the purpose of the discussion. These may seem like obvious things to explain, but it is worth ensuring that both parties agree the same reason for meeting to prevent misunderstanding. When the patient knows how much time they have got, it means they stop worrying about external factors and prioritise the questions they want to ask, without feeling rushed at the end when the consultation is brought to a close. Once the patient is settled, they need to be given the opportunity to be listened to in a non-judgemental, non-critical manner. Further acknowledgement of what is being said can be given by leaning forward, nodding and responding with appropriate facial expressions, i.e. those that match the patients’ feelings. Responses and questions should be paced so as to encourage further disclosure. Finally, the patient will feel listened to and understood, if you summarise and paraphrase what they have said.

The body language that is adopted during active listening is also a vital component of its success. The listener must have an open posture and maintain eye contact with the speaker. When communicating, the words are not necessarily the most important part of the communication. Classic studies carried out by Albert Mehrabian in the 1960s suggested that 7.8% of the impact is through the words and what is actually said, 38% is the tone of the voice, pitch and the way the message sounds and 55% of the impact of a communication is through the movement of the body, facial expressions and hand gestures (Mehrabian & Ferris, 1967; Mehrabian & Wiener, 1967). These studies have been criticised methodologically, but the important findings emphasise two key things. Firstly there are three elements of face-to-face communication (words, tone and body language) and tone and body language are particularly important for expressing feelings and attitude. Secondly when words and body language disagree, it is the body language that is believed. SOLER is a useful mnemonic to act as a reminder of good body language:

Squarely face the person
Open your posture
Lean towards the speaker
Eye contact maintained
Relax while attending

some slightly different features from active listening within a counselling or mediation situation. In these scenarios, an active listener is expected not to give advice, or try and solve the other person’s problems for them. However, in a clinical situation, the reason that an individual has come to see a nurse will be to receive advice and support. Thus advice giving is permissible. However, often individuals with chronic skin conditions have considerable experience of how to manage their condition, and the giving of advice must be in the context of listening to and understanding how they currently manage and what their priorities for treatment are.


Barriers to active listening
There will always be barriers to active listening some of which it may be possible to change, others whilst important to be aware of, may not be amenable to change. In a clinical situation, time is likely to be at a premium and it may not be possible to have the ideal amount of it with a patient to cover all the issues. If this is the case, it needs to be acknowledged and arrangements made to see the patient again. Some of the things listed in the table on environmental factors may also create barriers to effective communication, but these should be possible to change. Issues that are harder to change are the internal barriers that we all have due to our own experiences and background. These may lead us to hear what we want to hear rather than what is being said. On a simple level if there are concerns in our minds, for example the pressures of other things that need doing, it may be difficult to be focused enough to engage in active listening. It is particularly important to acknowledge the impact of emotions on our listening especially when the topics are ones that touch ‘hot buttons’. ‘Hot buttons’ can be described as topics that have a particular emotional resonance and make active listening difficult or even impossible. An example may be if a patient is talking about bereavement and the listener has recently experienced such circumstances themselves, this may trigger a whole range of emotions that are difficult to control.

The impact of active listening on the listener should also be considered. The process is more likely to expose them to higher levels of emotional energy from the patient and this could make coping with the daily pressures of confronting patient difficulties, harder. In order to deal with this, it is important to ensure that adequate training is in place and that supervision is available to support the health care professional.

Consciously incorporating active listening into consultations with patients will make them more effective from two perspectives. Firstly, it is more likely that psychological difficulties will be expressed by the patients, and secondly, a thorough assessment of the patient’s physical problems and how they want to resolve them, will be possible. Table 6.3 summarises some techniques that might be useful when engaged in active listening. The next section considers the assessment process.

Assessing psychological needs
During consultation, there needs to be a focus on assessing the physical and psychological needs of the patient. Although it is unlikely that these two areas of someone’s life will neatly be assessed independently of one another, in this section some specific techniques to assess psychological needs through active listening will be considered.

Using the five ‘W’s is a useful way of thoroughly exploring the impact that a psychological problem is laden with. Consider the following scenario:

A patient with vitiligo comes to see you. They are expressing feelings of anxiety about going out to the shops because they feel they are being stared at, because of the depigmented patches affecting their arms. Using the five ‘W’s, the following might be explored (see Box 6.2).

Box 6.2 An example of using the five ‘W’s to assess psychological need What is the problem? That I have vitiligo and that I get very anxious because of it. Where does the problem occur? On my arms. When does the problem occur? Only when I am by myself doing the shopping, I don’t get so anxious if there is someone with me. Why does the problem occur, the feared consequences? I hate being stared at and I am scared that someone will say something rude to me and I won’t know what to say or that they will refuse to serve me. With whom is the problem better or worse? The problem is significantly worse if I by myself and/or am with people that I don’t know, if I have a friend with me I don’t feel anywhere near as anxious.

This assessment can be further refined by getting the patient to say how often the problem occurs, the intensity of the level of anxiety (on a scale of 0–8), the number of times it occurs and how long it lasts for.