PDF of Challenges 0413

“That’s not what I said.” Have you ever been surprised at how a patient or family misinterprets what you said? How do you handle this situation? 


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I teach a nursing skills lab at a local university one afternoon per week. This is only my second semester so while I am teaching, I assess the language I use to teach basic nursing skills and concepts. The learning curve for me is as steep as it is for my students, who have just started nursing school and their first clinical rotation. They are eager and frightened at the same time. I know how to perform the nursing skills they are learning, but I am interested in teaching more than just physical skills. I want to teach my students to look beyond the skills and to start their nursing practice with a holistic approach. 

Last week, the group focused on a few basic skills: bed making (remember hospital corners?), taking blood pressure, and placing a Foley catheter. For the most part, their focus was on physical skills. Yet as we a started, I made my students pause as I explained to them that the number one skill was communication, and I encouraged them to rehearse the dialogues they might have with patients. As the students practiced, I sprinkled them with questions and case scenarios, acting as if I were the patient or the family member.

“But why do I need a catheter?” I channeled a particularly whiny patient I remembered. After a student explained why the catheter was necessary, I added, “It sounds like it will hurt, will it?” More explanation followed. “I don’t want that.” I was adamant, but the student laughed; then as a group, we talked through options for addressing the patient’s concern.

The idea, of course, was to challenge them to think through a response and to begin to understand how important the way we explain things is. I told my students that there are two skills to learn with each procedure: one is the procedural skill and the other is the talking skill. All the students nodded when I said that, maybe relieved, believing the talking part would be easier than the procedure was. 

I listened as one student practiced taking a blood pressure measurement, and said to the student acting as the patient, “I am taking your blood pressure to see if it is high.” That was when I heard the explanation in a new way. I envisioned a patient taking that bit of information and telling a family member he or she had high blood pressure, but we were keeping an eye on it. It was easy to see how confusing the statement might be. So in the skills lab, we took time to break down the words and brainstormed ways patients could misinterpret what we say. 

But more important than the actual words we use, is how those words are understood. The patient and family may bob their heads that they understand; only later, when I overhear them explaining what I said to someone else, I realize they understood a different version of my words.


Our job in educating our patients requires an extra level of caution and an awareness of the subtle physical cues that indicate a false understanding. An unusually upbeat response, a pause and frown, even a blank nod may tell us that the patient heard what was said in a way that gave him or her pause. Those pauses should not be ignored because they have a way of coming back at us like a boomerang. 

I ask myself, “Have I answered the patient’s question?” or “Have I answered the one I think was asked?” Anytime I have a patient respond in a way that does not seem to match the information given, I stop and ask the patient to clarify, “Is that what you are asking me?” The American Society of Clinical Oncology (ASCO) best practices advocate the model: ask, tell, ask.1

My recent experience with the students reminded me of the importance of how I use language. I am fluent in medicalese and can forget that the patient or family may not be. And just as it is with any language disparity, the recipient may nod as if he or she understands because it is expected of them. When I think I am educating, I have to be careful not to be lecturing. The exchange should be just that, an exchange. And I must be mindful of the impact of stress on the ability to comprehend and understand. The teach-back method is an excellent strategy for checking ourselves. 

Recently, in teaching a patient about pain management, I reviewed the meanings of long-acting versus short-acting. We were adding a long-acting opioid to the patient’s regimen, and I needed to be sure he understood how to use the medications. I was certain I had done a thorough job. The change was simple: we were adding a long-acting pain reliever to provide better control. I asked, “Can you review back with me what I just told you? That way I can be sure I did a good job teaching you.” This is part of the teach-back method,to take responsibility as the educator and frame it as being about your teaching.2 It turned out I hadn’t done the job as completely as I believed I had. The patient believed the long-acting drug was to be a total replacement of the short-acting one. So I had to teach him again. In the end he smiled; a light had gone on. “Oh, so I take both medications, right.” And that was from where I had to build my teaching. ONA

Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.


1. Communication: what do patients want and need? J Oncol Pract. 2008;4(5):249-253. doi:10.1200/JOP.0856501.

2. Xu, P. Using teach-back for patient education and self-management. Am Nurse Today. 2012;7(3). http://www.americannursetoday.com/Article.aspx?id=8848&fid=8812#. Accessed March 14, 2013.