Dr Allan Cyna
Women’s and Children’s Hospital, Adelaide South Australia
Little words such as ‘sting’, ‘hurt’, ‘itch,’ ‘worry’, can have an inadvertent negative impact on patient perceptions and behaviours. Negative suggestions, more commonly known as nocebo communications, are frequent in clinical practice. Suggestions are verbal or non-verbal communications that lead to subconscious, non-volitional responses in mood, perception or behaviour. Suggestibility increases when highly anxious, distressed or in pain. It also is higher in the paediatric population. We tend to focus and associate with what is being suggested. Some clinicians believe that they are being honest when preparing patients before a potentially painful procedure such as dressing changes, or an injection of local anaesthetic, by warning patients that it will hurt or sting. However, there are at least two reasons why such statements should be avoided. First, the sensation may not hurt in some patients, and second, there is an increasing body of evidence showing that using language with negative emotional content can lead to an increase in the patient’s analgesic requirements and experience of pain or anxiety. It appears that telling patients that a procedure ‘will hurt’ increases the likelihood that the perception referred to will be experienced as pain.1 Fortunately, the reverse is also true, and telling patients that there are ways to improve their comfort, such as taking a deep breath or blowing away anything you don’t like” can make things more comfortable. If a patient asks, “Does it hurt?” It is just as inaccurate to say something ‘will hurt’ as it is to say it ‘will be comfortable’ as either are a possibility. One is then left wondering what to say. If one responds ‘no’ or ‘yes’, the chances are that for some patients this will be less than truthful. The response, ‘Some people tell me it hurts while others are surprised it is more comfortable than they thought it would be’ is entirely consistent with honesty with the added benefit of giving an indirect positive suggestion of comfort. Negative words such as pain, vomit and panic should be avoided where possible unless the patient mentions them first. For example, if asked ‘Will I have much pain after my operation?’ the clinician should always respond honestly, ‘Some people have pain, while others are surprised that the feelings after the operation are more comfortable than they had thought as healing and recovery occurs.
Evidence suggests that communication related nocebo effects could be avoided by promoting an understanding of suggestion and the various conscious and subconscious processes involved when interacting with patients. A learnable framework for effective clinical communication has been suggested that might assist patient care in burns dressing changes and other potentially painful procedures on the ward.1 This structure includes: Listening; Acceptance; Utilisation; Reframing and Suggestion (LAURS). The LAURS concept emphasizes the use of reflective listening. This involves ensuring that, the patient’s words are heard, they are listened to for meaning, the patient knows they have been heard and finally confirming with the patient that they have been understood. This involves a checking in process. For example, during burns dressing changes, if the patient moves slightly the nurse or doctor might say “sorry” if assumed that pain was experienced. If the patient is asked instead, “did you feel something?” the response may be “yes that hurts!” or a response such as “I thought I felt something”. Rather than asking about pain, the clinician might ask, “Is it bothering you?” “Are you comfortable?” or “Is it OK to carry on? In addition talking about finishing rather than starting when about to perform a potentially painful procedure can decrease anxiety and pain. For example, rather than warn patients about an impending dressing change, staff can enter the room and ask if its OK to finish putting the clean dressings on gently so that everything can heal and recover more comfortably?”
- Cyna A, Andrew M, Tan S. Communication skills for the anaesthetist. Anaesthesia 2009; 64: 658-665.
- Krauss BS. “This may hurt”: predictions in procedural disclosure may do harm. The BMJ 2015; 350: h649.