Whether instructions are written or spoken, the prime objective should always be effective communication. Only when the meaning intended by the sender is the same as that inferred by the receiver can communication be deemed effective. Perhaps the most common cause of a breakdown in communication is traceable to the principle, "Clear Only If Known" (COIK). To illustrate, imagine yourself teaching someone how to drive a car. You tell the novice driver, "Start 'er up." Because you already know how to drive, you're thinking in large units; the student is thinking in small units. The command, "Start 'er up" has a very limited meaning. Your command assumes the student knows where the ignition is, how to insert the key, which way to turn the key, where the accelerator is, and how hard to press it. Each of these procedures is clear only if known.
The advantages of written instructions are: 1) They can be re-read until the desired comprehension is achieved, 2) they can be filed and kept on permanent record, and 3) they are uncompromised by such negative non-verbal cues as disapproving facial expressions, intimidating gestures, or excessive physical closeness.
Spoken instructions, by comparison, can be repeated and clarified as needed. Non-verbal assets may include a warm and approving smile, a gentle and patient sounding voice, or an encouraging pat on the shoulder.
Differentiating between intelligence and knowledge is also essential to instructional communications. Whereas knowledge denotes the possession of information, intelligence is determined by how that information is manipulated mentally. The fact remains that a clear-cut understanding of what is expected of someone is not a guarantee that it will be done properly, i.e., that it will be carried out responsibly. Both comprehension and execution must operate in concert with one another.
Another determinant is selective perception. People see and hear what they think or know, not what is actually there. Test this premise by having a few people quickly read what is written in this box.
PARIS IN THE THE SPRING
Individual temperament and motivation are personality traits that must also be taken into consideration. Unmotivated persons exhibit a limited attention span, fuzzy listening habits, and a confused understanding of what they have been told. Temperamental variables include impatience, mood swings, and a distorted perception of goals. Any one of these variables has the capacity to facilitate or contaminate the instructional process. Notice how many people did not see the word "the" repeated twice in the box.
Teamwork is the watchword in every organization. With language as the currency of exchange, experienced people end up instructing inexperienced people. As mentioned earlier, there is a wide gap between knowing and teaching. The process is further compounded when several people must work together toward a common goal. It is also imperative that each team member's perception of that goal is the same. A useful axiom in this connection is: Salus Aegreti Suprema Lex (the welfare of the sick is the supreme law).
Instructional communication in a clinical setting is an indispensable tool. When interviewing a new staff member, special attention should be given to one's ability to explain a procedure. Patients are notoriously curious and, on occasion, will compare what different members of the staff tell them, e.g., "But Dr. Jones said ..." Therefore, it is essential that the DC and his staff provide the same, consistant, professional explanations to the chiropractic patient.
Precious time and money can be lost because members of your health team do not follow instructions. Likewise, patients who do not follow your instructions faithfully will not benefit from your treatment. To be certain that you have been understood, have patients repeat your instructions back to you; have them physically demonstrate any exercise you have just prescribed.
Because many patients are intimidated by the technical jargon used by doctors and nurses, they tend to listen superficially. Their understanding is further jeopardized by embarrassment -- an unwillingness to ask what a particular word or phrase means. Hence, many patients return home with mixed messages or misinformation. Anticipating this, the aware health care giver should be on the alert for any facial signs of confusion and, if appropriate, ask, "Do you understand what that means?" Occasionally, a patient will ask that a diagnosis be written down, e.g., spondylolisthesis or neurothlipsis. Give the patient the benefit of the doubt and volunteer to write down a diagnostic term.
A final note on instructional communication. A concerted effort should be made to avoid vague terminology such as: do it gently, walk slowly, stop when it feels uncomfortable, wait a reasonable amount of time. Each of these verbal instructions may carry a slightly different connotation to each patient. Use more precise language; e.g., five minutes, a quarter of a mile, etc.
Regardless of who is giving or taking instructions, a professional or a lay person, understanding must be validated. Assumptions, presumptions, inferences, and conjecture are practices to be avoided whenever engaged in instructional communication. This is especially true in health care. Which of us has not encountered patients who were confused as to when they should take their vitamins -- before meals, with meals, after meals? How to perform certain home exercises properly has also been known to cause some confusion.
Surely you have had the experience of patients misunderstanding your instructions during an adjustment; you tell them to turn on to their left side and they turn on to their right side. I have long replaced this practice with simply tapping their right hip and saying, "Turn on to this side." It never fails to produce the desired result.
Perhaps the most dramatic example of incoherent instructional communication may be found in a hospital setting. Physicians have the unfortunate reputation of leaving written orders on a patient's chart that are reminiscent of hieroglyphics and require the services of a cryptographer.
If successful, this article should have persuaded you that a significant part of any therapy is getting your patients to faithfully follow your instructions. This can only happen if they have a crystal-clear understanding of what you said and what you meant. Assume nothing.
Abne M. Eisenberg, D.C., Ph.D.
Croton On Hudson, New York