Talking to clients about nutrition (Proceedings)

Our ability to communicate with clients determines our success as clinicians and caregivers. This is because client adherence to our recommendations depends in part on the relationship we share. In medicine, as in life, improved interpersonal interactions between caregiver and patient lead to increased commitment and satisfaction for all concerned. Since we cannot not communicate, every aspect of our communication affects our relationship with clients. The importance of the quality of our interactions contains elements of both verbal and nonverbal interactions between the caregiver and patient (Figure 1). Verbal elements include what we say and how we say it. What we say needs to be calibrated to the ability of the client to understand our language. The use of technical jargon, while a useful shorthand between colleagues, can lead to misunderstanding and confusion for clients. How we say what we say also is important. Our cadence, tone of voice and volume all communicate our empathy and concern for the client.

Effective nutritional advice depends on obtaining an accurate diet history and successful compliance with recommendations by the pet owner. Effective communication requires us to:

     • Determine the emotional state of the owner;

     • Evaluate the owner's knowledge and understanding of the situation;

     • Ask open-ended questions;

     • Actively listen to client responses;

     • Accurately interpret verbal cues such as silence;

     • Accurately interpret non-verbal cues from the client's body language;

     • Provide clear, unambiguous instructions.

We try to determine the emotional state of the owner first because it determines their ability to provide information and understand instructions. Clients who are frightened, worried, or angry may not be able to think clearly, and first may need to be calmed and comforted. This often happens when the owner brings an animal in on an emergency basis, or with a chronic problem that hasn't been resolved.

We need to learn who we are talking to because the person who actually feeds the pet can provide the most accurate information on exactly what is being fed, how much and how often. We can only obtain partial or incomplete information when the primary caretaker of the pet is not present; when this happens we recommend sending home a comprehensive diet history form that the primary caretaker can complete and telephone, mail or FAX it back as soon as possible.

Once we decide the client is ready and able to provide a history, one should try to ask open-ended questions. Open-ended questions are those that do not result in a yes or no answer. They invite the client to describe what happens to their individual pet in their unique environment. Although using open-ended questions may require more time, it allows the client to provide information by "painting a picture" we might not otherwise be able to see. Asking open-ended questions also avoids the temptation for the client to provide answers they think we may want to hear.

What should we do when our clients remain silent in the examination room? How do we interpret silence as a [verbal] clue? In an effort to prevent long periods of silence, some of us continue talking, thinking that the client hasn't quite grasped our explanation or intention, while others of us abruptly cut the interview short and make a hasty exit. Silence on the part of the client could mean one of three things: they understand what we are saying and they are waiting for us to continue; they do not understand what we've said (and are hesitant to ask any questions); they [simply] require a bit of time to process the information we've just shared and/or formulate their question. It's imperative that we allow clients the necessary time to think before reacting to information their next decision will be based on. Along the same line, how should we interpret one- and two-word responses, such as "okay", "I see", or "I get it"? These types of verbal cues may or may not indicate that the client is following what we're saying and is in agreement with us. For some clients, these phrases represent a non-commitment, and are said just to keep up their end of the interview, while many clinicians and technicians interpret these responses to mean the client understands and will comply.

Suggestions for handling the minimally responsive or very quiet clients include:

     • If you know you tend to talk quickly, slow your speaking pace down;

     • Ask the client to help you determine if your communication was clear be restating what you just told them, or ask them if something didn't make sense.

     • If you prefer the direct approach, ask the client "Does your silence mean I confused you? If so, let's back up to the last thing that made sense."

Another important verbal cue is the phrase, "Yes, but...", usually followed by some telling piece of information that we should pay close attention to before shaping or designing our nutritional recommendations. Many clients won't directly tell us what they cannot (or will not) do with regard to our recommendations; however, they may exclaim, "Yes, but she really loves those bacon strips I fry up for her every morning." This verbal cue indicates a behavior that the client is reluctant to change, despite our best arguments, and that we will need to determine another way for the owner to moderate the behavior to minimize any dietary and/or health risks to their pet.

Recognizing and interpreting non-verbal cues is just as important as trying to interpret what the client is (or isn't) saying. Most of us can spot an "engaged" client when we see one; someone who is making direct eye contact, is nodding their head, with their body leaning forward, all poised and ready to take in information. But what does it mean when the client is standing with crossed arms, frowning, making little to no eye contact, had clenched hands, or is sitting with body completely turned away and one leg is crossed over the other? Rather than ignoring this closed, unresponsive, or negative communication signal, it may be helpful to acknowledge it upfront by telling the client "I get the impression this is hard for you" and then waiting for the client to respond. Our nonverbal actions also speak to the client. Where and how we stand, whether our postures are "open" and welcoming or "closed" and distant will affect clients' understanding of our message.

One of the best ways to monitor the effects of our verbal and nonverbal communication is to watch the body language of the client (Figure 1a). They may look quizzical when they do not understand our message, withdraw if they feel threatened, or become distant while "processing" the information we have provided Figure 1b). By calibrating our communication to their responses we can improve the quality of our relationships.

An example of a communications interaction is presented as a "value chain" in Figure 1c. A value chain is a specific consecutive order of operations and activities where the end product is built up step by step with every single operation. Every operation makes the end product more complete; every operation builds on the prior operation and produces added value to the end product. The end product of a consultation value chain is the creation and maintenance of an effective relationship between caregiver and client/patient. As shown in Figure 1c, the caregiver first creates rapport and trust with the client/patient using verbal and nonverbal processes, evaluating nonverbal responses to determine the success of the effort. Once achieved, the client/patient begins to disclose their concerns, to which the caregiver responds with demonstrations of empathy. Recognition of the presence of trust and empathy in the encounter promotes positive reappraisal of the situation by both members of the relationship.

A relationship-centered approach to communications that many have found to be very helpful in guiding successful discussions about enrichment is described below.

A Stepwise Approach to Relationship-Centered Client Communications.

      Step 1. Set the Stage for the Interview

          1. Welcome the client

          2. Use the client and patient's name

          3. Introduce self and identify specific role

          4. Ensure client readiness and assure them of confidentiality

          5. Remove barriers to communication

          6. Ensure comfort and put the client and patient at ease

     Step 2. Set the Agenda

          1. Indicate time available

          2. Explain your plan

          3. Obtain a list of all issues the client wants to discuss; e.g., specific problems, requests, expectations, understanding.

          4. Summarize and finalize the agenda; negotiate specifics if there are too many agenda items for the time available.

     Step 3. Non-focused Interviewing

          1. Explain your understanding of the situation and ask about accuracy and completeness.

          2. Use open-ended listening skills: silence, neutral utterances, and nonverbal encouragement followed by reflective listening and empathic statements as appropriate

          3. Focus the interaction as appropriate when needed to get the client talking.

          4. Obtain the client's description of the problem

          5. Extend the client's story to the broader context of the problem

          6. Continue to develop a free flow of relevant data

          7. Ask closed-ended questions for clarification

          8. Obtain additional data from nonverbal cues, physical characteristics, autonomic changes, accouterments, and environment to get clues about the impact of the situation on the client (emotion seeking).

     Step 4. Emotion-Focused Interviewing

          1. Develop an emotional focus [Emotion-seeking skills}

          2. Address the emotion(s) [Emotion-handling skills}

          3. Use the "core dynamic skills" (focused open-ended skills, emotion-seeking skills, and emotion-handling skills) to better identify and deepen the story.

               a. Emotion-seeking skills:

                    i. Direct – how did that make you feel?

                    ii. Indirect – how has this affected others in your home?

               b. Emotion-handling skills

                    i. Name the emotion

                    ii. Understand the emotion

                    iii. Respect the emotion

                    iv. Support the emotion

4. Address any other current issues as time permits.

     Step 5. Transition to the Caregiver-Centered Process

          1. Brief summary

          2. Check accuracy

          3. Proceed to develop a plan

Actively listening to what our clients say employs our own body language to indicate that we are really hearing what they have to say. Body language that tells the client we are open and ready to listen include facing them (nearly) squarely, smiling and making eye contact, nodding our head up and down as we listen, standing or sitting with arms unfolded and palms open, and leaning forward toward them. Actively listening also means responding in a way that tells the client we have heard what they said. Active responses include clarifying (asking another question if the client's response was unclear), paraphrasing (putting the client's information into our own words to make sure we've got the right perspective or angle), reflecting (repeating what was said to show support) and/or summarizing (bringing disjointed events/information into focus or bringing closure to an interview). Active listening skills require patience and tolerance, as well as practice.

Providing clear, unambiguous instructions often is more difficult than it sounds. Ask most people who garage their car how they get to work and most will forget to tell you they open the garage door before leaving the garage! We can apply the same concept to giving go-home nutritional instructions to clients. Clients remember information given during the first third of any communication longest, so organize what needs to say and how to say it. For common questions (and the most common nutritional recommendations), consider preparing a written handout with clear, concise instructions that the client can read and follow once they get home. Having the owner write down the instructions we give and review them with us also works well. Other guidelines for sharing or conveying information include the following:

     • Limit the amount of information given at any one time.

     • Use specific, concrete and simple language when giving instructions.

     • Use oral and written material together (draw stick figures or use pictures from wall charts, books or brochures).

     • Check the client's comprehension by asking them to restate the key features of your instructions.

     • Don't assume the client can read, write or do simple math.

     • Don't assume that clinical terms, such as vomiting and diarrhea, mean the same things to you and the client—clarify exactly what you mean and what you want them to look for.

     • Ask for and discuss the client's feelings (and biases) about the information provided.

     • Repeat important information.

     • Whenever possible, involve all members of the household, or significant others, in the therapeutic process.

Successful client communication skills are interwoven throughout the iterative process of animal, diet and feeding management. While some natural talent at interviewing or expressing empathy helps if you have it, even the best practitioners and technicians mindfully practice these skills on a daily basis. Regardless of the point at which you enter the iterative process, there are a few key questions to consider when approaching or developing the best strategy for effectively communicating with an individual client about their pet: Why is the client here? Is the dietary problem the client describes all or only part of the problem? What are the nutrition behaviors and related concerns that I can address?

References

Listening: The Forgotten Skill (A Self-Teaching Guide) by Madelyn Burley-Allen;

Nutrition Counseling Skills for Medical Nutrition Therapy by Linda G Snetselaar.

Smith RC. Patient-Centered Interviewing An Evidence-Based Method. 2nd ed. Philadelphia: Lippioncott Williams & Wilkins, 2002.

Abood SK. Increasing adherence in practice: making your clients partners in care. Vet Clin North Am Small Anim Pract 2007;37:151-164 (this entire issue is devoted to communications).

Frankel RM. Pets, vets, and frets: what relationship-centered care research has to offer veterinary medicine. J Vet Med Educ 2006;33:20-27.