Most healthcare providers graduate with a healthy understanding of the importance of listening to patients. Even though we cannot overstate the need to listen to patients, listening requires skills that can sometimes be neglected or forgotten. Healthcare providers often find that there are myriad obstacles in utilizing this precious tool in our skill set. Active listening means paying attention to sound, hearing with thoughtful attention, and giving consideration to mitigating factors. Listening requires us to receive the speaker’s words, understand the information presented, and process it appropriately. The purpose of this article is to enhance the provider-patient relationship through an overview on the skill of listening. This article will accomplish this purpose by answering the following questions: What does it mean to listen well? Why do we need to listen well? How do we listen better and who benefits when we become good listeners? This article is intended for healthcare providers who utilize listening skills for diagnosis, management of common conditions, and formation of critical therapeutic relationships in delivering care to patients throughout the lifespan.
Key Words: Active listening, empathic listening, communication, listening skills, patients, good listeners, care, therapeutic relationships, healthcare
The art of listening requires a conscious effort that goes beyond hearing what people are saying. In a quick internet search on hearing versus listening, Merriam-Webster (n.d.), defined hearing as the “process, function, or power of perceiving sound; specifically: the special sense by which noises and tones are received as stimuli” (definition 1). Listening, on the other hand, means “to pay attention to sound; to hear something with thoughtful attention, and to give consideration.” (AUTHOR: do you also have a reference for this definition? We need to add that and we will add a paragraph or definition number as I have above because this is a direct quotation.) Listening requires healthcare providers to receive, process, and understand the speaker’s words. This type of listening is often referred to as “active listening.” This article describes a review of the available literature on the subject in addition to the author’s experiences as a dual-certified pediatric nurse practitioner for fifteen years and a family nurse practitioner for the past four years.
Why Do We Need to Listen Well?
In a landmark article, Klemmer and Snyder, (1972) reported that many people spend up to 80% of the workday engaged in some form of communication. The authors stated that although listening is the most used communication skill, it is also the most neglected or forgotten skill. This communication tool allows healthcare professionals to recognize and explore patients’ ideas, concerns, and expectations regarding their health condition (Jahromi et al., 2016). The absence of this communication skill could lead to failure on the part of the healthcare professional to recognize or explore the clues offered by their patients. Consequently, the real concerns of patients may go unaddressed.
The importance of empathic listening in the context of the provider-patient relationship cannot be over-emphasized. According to McCausland (2020), the diagnosis is just the beginning of the story for the patient. The care a patient receives at the point of diagnosis and thereafter can make a world of difference - for better or for worse. Patients, like people in general, need to feel they are listened to and acknowledged. McCausland noted that the need to be listened to and acknowledged are two basic human needs. When these two basic needs are met, nurses and patients feel connected and valued. As healthcare providers, it is a sacred trust for us to listen to and acknowledge each patient we encounter to promote a positive experience.
What Does It Mean to Listen Well?
In his best-selling book, The 7 Habits of Highly Effective People, Covey (2020) asserted that most effective communicators are great listeners. Often, clinicians listen with the intent to reply when we should listen with the intent to understand. Covey stated that the most effective listeners are empathic listeners. Empathic listening, a key component of effective communication in healthcare, involves recognizing when emotions may be present but not directly expressed, and invites exploration of these unexpressed feelings. Empathic listening effectively acknowledges these feelings, so the patient feels understood. This type of listing has been associated with greater patient satisfaction, reduced patient distress, and enhanced patient trust (Wu et al., 2022).
Active listening involves behaviors such as maintaining eye contact and paraphrasing the patient's words. These behaviors can significantly influence the perception of empathy in a clinical setting. For instance, a study found that clinicians who demonstrated high-frequency use of active listening skills were perceived as more understanding, concerned, and caring (Croft et al., 2022). Empathic listening takes active listening techniques to a new level. When primary care providers improve their listening skills, their capability to understand others increases and they become pleasant and more effective communicators. According to Olszewski (2023), when clinicians express empathy, patients and families are more likely to deepen discussions, which can lead to a better understanding of the patient's condition and needs.
Empathic listening also benefits healthcare providers. In a landmark study published in the Journal of American Medical Association, Krasner et al. (2009) reported that an educational program in mindful communication, which includes empathic listening, was associated with improvements in physician well-being, psychological distress, burnout, and capacity for relating to patients. According to Westendorp et al. (2021), empathic listening enables patients to recall salient information discussed during consultations. These authors noted that this is particularly important in complex care scenarios, such as advanced cancer care, where patients need to understand and remember a significant amount of information about their condition and treatment options.
A Case in Point: The Patient With Dizziness
Dizziness is a vague symptom that can present in many scenarios. One key to figuring out what the patient means by feeling "dizzy" is for the provider to employ silence and waiting. According to Samuels (2008), a professor of neurology at Harvard Medical School, the most important clue to diagnosing the cause of dizziness lies in the patient’s history. In a related article on patients who experience dizziness, Ruckenstein (2011), also notes that the patient's description of symptoms is the most critical component of the workup. He concluded, “for more than 90% of my dizzy patients, I know the diagnosis by the history" (p. XX). (AUTHOR: we need a page, or paragraph number if online, for this quotation. Thanks!) Ruckenstein (2011), explained that the critical task for the clinician is to ask the patient these key questions: what do they mean by dizzy, and how do they feel? Given the opportunity, most patients will answer yes to the majority of specific questions. The cycle of questions and answers can lead to a vicious cycle of specialist visits (e.g., neurologist, otolaryngologist, cardiologist, psychiatrist), which can ultimately obscure the cause of the problem.
When left alone to describe "dizzy," most patients will define the cause of their symptoms (Samuels & FAAN, 2010). For example, a sensation of motion often reflects a vestibular disorder, while lightheadedness suggests a cardiovascular cause, disequilibrium often signifies a neurological etiology, and ill-defined feelings of giddiness usually correlate with anxiety. Ruckenstein (2011) concluded that listening to the patient will offer the best hope for a simple and efficient workup and treatment.
In sum, when identifying a problem, historically asking patients what they think not only has been cost-effective but has led to improved patient outcomes (Palmatier & McNinch, 1972). On the importance of engaging patients as a part of medical decision making, Pope et al. (2020) stated that excluding patients from medical decision-making can lead to several potential risks. According to the American Thoracic Society and the American Geriatrics Society, (AUTHOR: can you provide references for these two society statements? I am guessing that you probably got these from the Poe reference, but we should include the original sources where they made this assertion. Thanks!) Patients who are not involved in decision-making are at risk of not having their preferences known or followed. This can lead to decisions based on the personal preferences of the clinician rather than the patient. This can result in overtreatment, undertreatment, or delayed treatment, often due to a fear of liability on the part of the clinician, institutional fear of sanctions, economic incentives, or a general interventionist philosophy of medicine (Poe et al, 2020). Though it is a cliché, it is true that people do not care about how much you know until they know how much you care. Thus, it is important to listen well.
Who Benefits When We Listen Well?
The process of listening and understanding offers the opportunity for deep and sustained shifts in the overall well-being of the patient and, frankly, in the clinician as well. Kwame & Petrucka (2021) noted that providers who listen to their patients are better able to understand what they need. Yet many patients may feel intimidated when trying to express their concerns and, especially, to ask questions. Providers who have refined the art of listening know that giving a patient their undivided attention, even if only for a few minutes, is one of the best ways to assess that patient's needs, provide excellent care, reduce medical costs, and reduce unnecessary movement through what often seems like a revolving door through the healthcare system.
How Do We Improve Our Listening?
Consider the Impact of the Electronic Health Record (EHR)
Research has shown that as of 2021, nearly 9 in 10 (88%) primary care providers in the United States have adopted a platform for an electronic health record (EHR); this reflects a consistent upward trend since 2015. According to Pozdnyakova et al (2018), even though EHR use has been associated with improvements in clinical care, including higher guideline adherence and fewer medication errors, without a decrease in patient satisfaction, EHR use has also been identified as a negative in patient-provider communication. Many patients decry the fact that some providers are so busy focusing on documenting the visit that they give little or no attention to the patient in front of them (Sulmasy et al., 2017).
Develop Critical Listening Skills
In a seminal article with the goal to facilitate listening and understanding, Carkhuff (1972) provided direct instruction in four critical listening skills. These critical skills, preparing to listen; asking open-ended questions; paraphrasing; and reflecting on feelings, are briefly discussed below.
Preparing to Listen. Sustained and mindful listening requires physical and mental preparation. Good listeners understand that listening requires setting aside other tasks, attending to physical needs, centering oneself, and becoming oriented to the anticipated conversation.
Asking Open-Ended Questions. One recommended approach to elicit patient concerns is to ask an open-ended question. Coleman et al. (2022) suggested that educators in the health professions and health literacy experts recommend an open-ended approach. For example, using statements such as “What questions do you have?” to elicit questions captures the expectation that the patients do have questions. Using a closed-ended phrase like, “Do you have any questions?” is inadequate because patients may more easily say “no,” despite a lack of understanding or needing clarification about such concerns as medication regimens, discharge instructions, or self-care expectations. Experts recommend using open-ended questions to elicit the patient's full list of concerns at the beginning of the encounter and then using this list to construct an appointment agenda and even a checklist of sorts at the conclusion of the visit.
In addition to reducing patients’ last-minute “oh by the way” questions and complaints, open-ended questions can enhance exploration by creating a space for sufficient information to promote a complete answer from the provider. In contrast, closed-ended questions tend to prematurely shut down the conversation. Discussing the concept of respectful inquiry, Quaquebeke and Felps (2018) defined respectful inquiry as the multidimensional construct of asking questions in an open way, and subsequently listening attentively. A combination of these two factors communicates the extent to which a person invites an addressee to (continue to) share thoughts on a subject during a conversational episode. Something notable about this definition is that these authors refer to such communication as “respectful” because it invites the thoughts of addresses without preemptively limiting the range of appropriate answers. This approach demonstrates genuine interest and communicates a message of equal worth and dignity to the patient.
Paraphrasing. Paraphrasing, or stating back in one’s own words what another has said, serves to capture and clarify the speaker’s meaning without judgment or distortion. This strategy involves a restatement of the content of what was said, including the facts of the situation and related thoughts, ideas, values, and/or beliefs. Paraphrasing content communicates understanding and lets the person know that the listener has been paying attention. Paraphrasing also provides an opportunity to clarify or add to the understanding of another’s meaning.
Reflecting Feelings. Active listening also captures feelings associated with individual perceptions and experiences. Providing a reflection of a patient's feelings is a crucial aspect of patient-centered care. This technique fosters a deeper understanding of the patient's concerns, values, and experiences, which can enhance the therapeutic relationship and improve patient satisfaction and outcomes. (Zulman et al., 2020).
Reflective listening, a key component of empathy, involves summarizing what patients have said using their own words, without digressing to other subjects (Braillon & Taiebi 2020). This approach reinforces patients' expressions of problems, acknowledges their concerns, and can reveal potential misunderstandings. For example, a provider might respond to a patient expressing fear about a new diagnosis by saying, "I can see that this news is distressing for you. It's completely normal to feel this way. Let's discuss your concerns and options in detail.” This response validates the patient's feelings, offers reassurance, and sets the stage for shared decision-making. In summary, a provider reflection of patient's feelings is a vital aspect of patient-centered care that can enhance therapeutic relationship, improve patient satisfaction, and potentially lead to better health outcomes.
Remember Effective Use of Pauses/Silence
Effective use of pauses during patient encounters can promote communication, improve patient satisfaction, and potentially improve clinical outcomes. Pauses can be used to interrupt negative momentum and bolster learning. Cognitive processes for pausing skills are categorized into two phases: the decision-making phase (i.e., determining when and how to take pauses) and the executive phase (i.e., applying relaxation or reflection during pauses) (Lee et al., 2021).
Including Pauses/Silence in Patient Encounters. The American Society of Clinical Oncology (Gilligan et al., 2017) has recommended caution in providing information when patients are highly emotional, as they often have difficulty absorbing and processing information during this state. Gilligan et al. (2017) noted that a pause can provide an opportunity to explore what is behind strong emotions and to ensure that significant news is shared in a quiet, private place, with adequate uninterrupted time.
During video consultations, patients have shown a preference for short rather than long pauses after physician's statements (Mazouri-Karker et al., 2023). This suggests that the length of the pause can also impact the effectiveness of communication.
Provider impatience and a busy schedule can impact the effective use of pauses during a patient encounter in several ways. Interactions, often a result of time pressure, do not necessarily curtail the ability to identify patient concerns. However, failure to solicit the patient's agenda, which may occur in a rushed encounter, is associated with a significant reduction in physician understanding of patient problems (Levinson et al., 2000). A related study by Dyche & Swiderski (2005) found that providers frequently miss opportunities to respond to patient clues, which are often presented during pauses in the conversation. These missed opportunities were more common on longer visits, which could be a result of a busy schedule.
The use of pauses can be combined with effective agenda-setting questions to elicit patient concerns and priorities. For example, after asking a direct solicitation question like "Anything you want to discuss today?" a pause can give the patient time to formulate their response (Allgood et al., 2023).
Recognizing Cultural Influences. Cultural differences can significantly impact the use of silence in healthcare provider and patient conversations. Connectional silences, which include pauses in conversation, were associated with decision-making and improved patient quality-of-life in serious illness conversations, such as those involving advanced cancer (Gramling et al., 2022). In a study involving primarily Spanish-speaking caregivers communications with providers about pediatric cancer patients, barriers related to culture and language were identified, which sometimes resulted in delays and confusion during the diagnostic process (Waters et al., 2022). Similarly, a study involving Zulu-speaking cancer patients found mixed responses to the use of silence, with a strong dislike for silence as a front for non-disclosure (Waters et al., 2022). This suggests that cultural and linguistic differences can influence patient perceptions and acceptance of silence during medical consultations.
Furthermore, the rhythm, pitch, and volume surrounding silences can also play a role in patient-clinician connection (Bartels et al., 2016). Providers should be aware of these factors and adapt their communication style accordingly to facilitate shared understanding and emotional connection. In conclusion, cultural differences can significantly impact the use of silence in medical diagnosis, influencing patient-clinician communication, decision-making, and patient quality-of-life. It is important for providers to be aware of potential cultural differences to ensure appropriate communication and effective patient care.
Implications for Practice
(AUTHOR: I did some editing to reflect the intended audience for this publication as healthcare providers versus physicians. The majority of readers who see this will not be physicians, but will be either generalist providers or advanced practice nurse providers. For this reason, terms such as healthcare instead of medicine are helpful to them as they relate to the content, which is certainly appropriate to all providers. It does not change the meaning of your referenced content, but does target it to a wider scope of healthcare providers. Jackie)
On the topic of listening, Launer (2022) stated the essence of medical practice is listening to patients’ needs. He suggested that healthcare providers should view themselves as facilitators and abandon the notion of taking history and replace it with the idea of listening to the story. He suggested that this could be a vital step in creating more humane and equitable interactions in healthcare.
Listening to a patient's story is important for several reasons. First, it allows healthcare providers to obtain accurate information efficiently. When patients are given the opportunity to narrate their experiences without interruption, it often takes less time than if they are asked leading questions and interrupted (Drossman et al., 2021). The Rome Foundation emphasizes that attention to the patient's narrative reduces the likelihood of last-minute questions, misunderstandings, and conflicts, and provides a quick psychological assessment tool that offers insight into the patient's psychological traits and values (Drossman et al., 2021).
Second, patient narratives provide invaluable information about their illness experience. Patients who are encouraged to describe the impact of illness on their daily life feel valued and are more likely to view the clinician as an empathic partner. This builds trust and correlates with treatment adherence and care effectiveness (Drossman et al., 2021). Third, the patient's narrative provides a balance between scientific data and humanity for the healthcare provider. It is personal, unique, relatable, and empathy-fostering, leading to an increased sense of connection, purpose, and job satisfaction, while decreasing clinician burnout (Drossman et al., 2021).
Finally, the American Society of Clinical Oncology consensus guideline has emphasized the importance of patient-clinician communication, particularly when patients are in a strongly emotional state (Gilligan et al., 2017). The guideline me recommends asking patients about their concerns and exploring what is behind strong emotions. This approach aligns with the practice of reflective listening, which reinforces patients' expressions of problems, recognition of concerns, complaints, and values, and reveals potential misunderstandings of patient's concerns (Braillon & Taiebi, 2020). In summary, listening to a patient's story is a fundamental aspect of patient-centered care, fostering trust, enhancing treatment adherence, and improving care effectiveness – benefiting patients and providers alike.
(AUTHOR: Your paragraph below makes for a very impactful conclusion. For this reason I took it out of the implications section and put it in a conclusion section by itself. :) Jackie)
Conclusion
Healthcare professionals want patients to be satisfied with the care they receive and consequently with their health outcomes. It is critically important that we understand our patients' expectations and then deliver services that strive to meet and exceed those expectations. At the recent anniversary celebration of the Doctor of Nursing Practice (DNP) program at the University of Maryland School of Nursing, I had the opportunity to speak about this level of nursing practice. I described my vision of moving beyond satisfying our patients, to delighting them. What would it look like to listen to your patients so well that they look forward to coming to see you? Delighted patients are those whose expectations have been met or exceeded. If we do better than expected with our systems or outcomes, we develop a culture in which patients are at the center. The top priority in such a culture is to meet and exceed expectations because we listened well and translated this attention into excellent patient care.
Author
(AUTHOR: We are now including author ORCID IDs, if available. This is not mandatory. If you have one, please provide it to us and it will be included. If you do not, we will remove that heading from under your bio. For articles with multiple authors, please provide this information to the corresponding author who can submit it with the galley proof edits.)
Ngozi Osuagwu, DNP, RN, CRNP
Email: ngosuagwu@gmail.com
ORCID ID:
(AUTHOR: Please provide us a 3-5 sentence bio. Thanks!)
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