Introduction to Patient Counselling

What is counselling?

Patient - counselling can be defined as follows

Patient - counselling is a specialised non - clinical activity that involves giving information, explanation, guidance and also providing of comfort to the patients during their stay in the hospital premises.

The genesis of patient counselling

Before starting the counselling department, Aravind Eye Hospital during its outreach camps found large number of patients who were not in a position to accept medical treatment or surgery. They had many barriers like family circumstances and personal reasons.

Because of the volume, the camp doctors and MLOPs had no time to address these barriers and convince the patients of the need for immediate treatment or surgery. As a result many of the patients returned home refusing the offer of free treatment and surgery.

This led to wastage of a lot of human resource, time and money. With a view to address these barriers and improve patients' compliance, Aravind management decided to employ non-clinical persons who have a basic ophthalmic knowledge and know the art of counselling.

A similar situation was present in the base hospital also both in paying and free sections. To explain clearly the condition of their eye problem, the need for special investigations, accepting the right treatment both medical and surgical and lastly the importance of followup, the importance of having a counselling department was felt.

Generally a patient needs to know what type of ocular problem he/she is having, its causes and management. Every thing should be explained to the patients in their own language in a simple way. In addition, Aravind felt the need for grief – counselling, especially when they were looking for donor eyes for the purpose of corneal transplantation. Considering all these needs, Aravind decided to create a separate cadre of staff and named them as patient – counsellors.

In 1992 the counselling department was started in Aravind – Madurai with 7 counsellors whose number had swelled to 150 as on June, 2007 across all Aravind Eye Hospitals. This includes the managed hospitals also. Now the counselling department has become an indispensable component of Aravind Eye Hospitals.

Objectives of patient counselling

The main objectives of patient – counselling are

1. Reducing the work load of the doctors and Mid Level Ophthalmic Personnel (MLOPs) to enable them to spend their time more efficiently in clinical activities.
2. Ensuring patient satisfaction and thereby
3. Increasing patient volume

Aravind model in counselling

When Aravind Eye Care System decided to appoint patient - counsellors, the question of their academic qualification came up. It was initially thought that graduate and post graduate girls with social science will be suitable for the job. A few girl candidates with social studies from the city were taken. But their higher education and upbringing made them keep a distance from the patients who were mostly from villages. They were unable to appreciate the real barriers of these rural poor patients. So the program was not successful.

This led to a realisation that moderately educated girls from rural areas will be the best suited candidates. It would be preferable if they belong to big families having aged people like grand fathers and grand mothers. They have respect and affection for old people and are also accustomed to an economic and simple way of life. Most of them are educated up to not more than the high school or higher secondary school level. They could converse with the patients who are mostly rural people in their own language. Inherently they are kind and compassionate towards aged people.

Hence aravind decided to recruit plus -2 passed girls and train them in counselling. Accordingly a two year training course was developed which consists of two segments. The first segment is for a duration of three months in which basic knowledge in physiology and anatomy of human body, anatomy and physiology of eye and common eye diseases is given. Subsequently during the rest of the 9 months, they are exposed to various departments in eye care and also the community outreach activities. In addition, they are trained to develop communication skills, decision making skills, negotiating skills and also the art of counselling, which includes body language and voice modulation.

In the second segment, during the next year, they do counselling work under supervision. At the end of the second year they have to write theory and practical examinations. Candidates who successfully complete the training course are appointed as counsellors in various centers of Aravind.

This has become the Aravind Model of counselling system and counsellors recruitment.

Various roles of a patient counsellor

In an eye care hospital patient - counsellors have various roles to play as given below.

Guide and companion

The counsellor has to guide patients from the time they enter the hospital till they leave the hospital after treatment. Once a patient's registration is completed he/she is taken by the counsellor to the concerned unit either for examination by a doctor or a refractionist. Patients requiring bio-chemical or microbiological tests are guided by the counsellor to the concerned laboratories.

Information giver

After a patient is guided to the counselling department from the doctor's room, the counsellor receives them with a smile and starts counselling by means of friendly conversation. The first aspect in counselling is giving information on the patient's eye disease, its present condition, the recommended medical treatment or surgery and various options of surgical procedures and types of rooms available and the cost involved.

The counsellor also creates awareness on the causes and effects of the eye disease the patient is afflicted with and the consequences that may arise if the disease is left untreated. Care should be taken that no fear is created in the patient's mind. By this process, the patient is made to have a clear idea about his condition so that he can accept the treatment suggested by the doctor.

The counsellors may help the patients in understanding the usage of drugs and the importance of coming to the hospital for follow up. They may also inform the patients about what should be done and should not be done after going home in their daily life. The counsellors may remind a patient over phone or letter if he/she fails to come for a follow up.

Facilitator

The counsellor is to act as a facilitator for enabling patients to under go the surgery when ever it is recommended by the doctor. A patient may have psychological or family related obstacles to undergo surgery. These barriers should be addressed by the counsellor according to the situation and the patient should be convinced of the benefits that would result from the surgery. This will facilitate patients' acceptance.

Help in decision - making

One of the important roles of a counsellor is to help the patient in making decisions on choosing a particular surgical option or medical treatment or selecting the type of room to stay.

Negotiator

In eye hospitals, patients with retinal detachment, glaucoma and other acute eye diseases come for treatment. Some patients may like to postpone treatment or surgery for family reasons or for want of adequate money.

In such situations, the counsellors talk to the patients explaining the seriousness of their eye condition .They should make the patients understand that if treatment is not taken immediately the possibility of losing sight can not be ruled out and sight is more important than family related reasons.

If a patient does not have adequate money, but wants to undergo treatment, the counsellor should attempt to help the patient by negotiating with the management for making concessions in treatment fees.

This kind of negotiation will enable patients to undergo the required treatment or surgery.

Supporter

Not all patients who come to hospital for treatment are accompanied by a relative or friend. Such patients, especially eye patients need someone to support them, during their stay in the hospital. Lack of persons to accompany them often prevents many patients from coming to hospital. This is more so in the case of village patients who come to the free eye camps.

The counsellor could play the role of a relative or friend to such patients by taking them to places in hospital where they want to go or have to go.

Recently a camp patient needed someone to accompany her to the base hospital for cataract surgery. She was about to return home without getting treated for want of a relative.

A counsellor came forward to help the patient during her stay in the hospital. Subsequently the patient who was also suffering from Asthma was brought to Aravind Eye Hospital and operated upon for cataract. During her stay in the hospital, the counsellor acted as her constant attendant.

Such humanitarian help attracts patients to the hospital and serve to enhance its image.

Comforter

Some times, a patient's eye may have to be removed when cancer is suspected or the eye has become very painful and blind. In such cases the counsellors should emphathise with these patients. They should speak to them sympathetically and explain the state of their eye condition. The counsellor should make it clear that no amount of treatment could solve their eye problem or set right their eye condition, and that such a removal is essential for them.

During the course of the conversation, the counsellors should try to comfort and console the patients and assuage their feelings. It should be pointed out to the patients without hurting them that there are persons without eyes or eye sight who are leading a useful life in the world. There are rehabilitation centers which would train them in handicrafts or other avocations to earn money. They need not be a burden either for the family or society. Such soothing and encouraging words may help to comfort the patients.

Link between doctor and patient

The patients may like to know some more details from the doctor who had examined them. In such a situation the counsellor should act as a link between the doctor and the patient. Whatever question or clarification the patient may like to ask the doctor will be asked by the counsellor on behalf of the patient. The information given by the doctor will be conveyed to the patient by the counsellors.

Link between the patient and family

In the case of patients who are left alone in the ward and who want to communicate with their family immediately, the counsellor can act as a link between them. They could contact their family members who are somewhere in the hospital premises or elsewhere and convey the patient's message to get a reply.

This manual deals with these and related aspects of counselling elaborately which will be of use to candidates all over the globe.

Qualities of a good patient counsellor

1. A patient counsellor must have a bright and pleasant look. This will have a positive impact on the patients and their attendants. It will also influence them to talk to the counsellors about their doubts.
2. The counsellors should have willingness to serve old and visually handicapped patients. They should have no inhibition in speaking to or moving with such patients or guiding them to different departments in the hospital.
3. Clarity of thought is another quality essential of a counsellor. He/she should have a clear idea of what he/she has to tell the patients. The counsellor should have no doubt or confusion about the information to be conveyed to the patients and their relatives.
4. Simple and clear communication of information is an essential skill that a counsellor should possess. Since the counsellors have to communicate to the patients matters related to diseases and treatment methodologies, they should have ability to explain them in a simple and easy to understand language.
5. Another quality desirable of a counsellor is compassion and kindness. Besides a high quality medical treatment, a patient also needs humane treatment from the hospital staff and employees. Kind and compassionate approach will help the patients to get relief from their mental agonies. The counsellor has an important role to play in this respect.
6. The counsellors should possess the quality of sympathy towards patients. They should listen to a patient's problems sympathetically and do their best to help and guide them to get proper treatment in the hospital.
7. Basic knowledge in ophthalmology is a must for counsellors. Only those who have this knowledge can clearly explain to a patient about the causes, symptoms and present nature of the eye disease that he/she is afflicted with.
8. The counsellor should have the ability to understand the patient's problems and act accordingly. This quality is required to understand the eye problems as well as the personal and family problems of the patients for helping them to make informed decisions in opting for a treatment procedure or selecting a room to stay.

Types of counselling

There are 3 types of counselling in an eye hospital. They are:

1. Individual counselling
2. Group counselling
3. Family counseling

Individual counselling

Individual counselling is done for a single patient in the presence of the patient's family member or attendant. Usually this type of counselling is followed in the base hospital (Fig. 1.1).

Advantages

• Personal attention can be provided to each patient in individual counselling.
• The patient feels free to talk with the counsellor and ask for clarifications without any hesitation.
• It enables the counsellor to ask sensitive questions to a patient regarding his health or eye conditions.
• Frank conversation between the patient and counsellor is possible.
• Patient acceptance level (to undergo surgical or medical treatment) is high.
• As a result, patient's satisfaction level is also very high compared to group counselling.
• A small space is sufficient for individual counselling.

Group counselling

Group counselling system is generally followed in community outreach programmes. As large number of patients visit the eye camps, it is not possible to provide individual counselling to each patient with the limited time and space available.

Since most of the camp patients have the same eye problems like cataract and diabetic retinopathy, the information and advices that should be conveyed to these patients is the same. Small groups of patients are formed. The counsellor speaks to each group and explains the need for surgery, how they will be taken to the base hospital for surgery, the facilities made for them in base hospital and how they will be sent back home after treatment.

After the camp patients are transported to the base hospital, the counsellor conducts pre-operative and post-operative counselling for each group of patients.

In addition to outreach programmes, group counselling is done in free section of Aravind Eye Hospital, where individual counselling is not possible because of large crowd (Fig 1.2).

Advantages

• In group counselling even a shy patient is motivated to interact. Patients who are worried about their own eye problems would have a wide exposure on meeting people with the same problem.
• As groups are formed of patients with the same gender and socio-economic background, the patients identify themselves with the group.
• Patients' fear psychosis is reduced considerably.
• When a patient in a group makes a query, even a silent patient gets encouraged and asks questions.
• After the counsellor has left, a member of a group who has not understood what the counsellor had said, can have his doubt clarified by another member of the same group.
• The patient groups serve as an effective media to propagate to the community the eye care services available in the hospital and thus help reduce needless blindness in the country.

Family counselling

Family counselling has two components.

• Genetic counselling
• Grief counselling

There are patients, most often children, affected with congenital eye diseases or hereditary eye diseases.

Genetic counselling

Marriage among close relatives (consanguinity) is the main cause of such diseases. While treating these patients or when they are brought to the hospital for treatment, the counsellor has to counsel the parents of the patients or the elders of the family.

It should be explained to them that such diseases are caused by genetic disorders resulting from consanguineous marriage. It should be emphasised that in the future, grooms and brides should not be chosen from among close relatives.

Grief counselling

There are patients who are affected with acute and incurable eye diseases that would necessitate removal of an eye. In such cases grief counselling is given to the families of the patients.

Parents or elders of the patient's family are invited to the counsellors' room. The counsellor in a empathetic voice should inform them that the patient's eye condition is very bad and painful. No amount of treatment will cure the disease. And the only way to relieve the patient from the unbearable pain is removing the eye. If the patient has retinoblastoma, the family should be told that unless the eye is removed, the cancer would spread to other parts of the patients body endangering his life.

In the course of grief counselling, the counsellor should completely identify himself/herself with the patient's family members and share with their mental agonies.

Art of counselling

Different aspects

1. Body language
2. Listening
3. Voice modulation

Body language

In a verbal conversation the words uttered by the two persons involved in the conversation are heard and their meaning understood. In the course of conversation, the speaking person's body also speaks spontaneously. This natural phenomenon is termed as body language.

The body language conveys a lot more than the verbal language of the speaker to the listener. It is a visual expression of ones feelings towards the other. Since the face is the most expressive part of the body, the counsellor should be careful about her/his facial expression.

For example, if a counsellor keeps an uncaring or serious face, the patient may think that the counsellor is disinterested or worried about the outcome of the diagnostic procedures. Unless the situation warrants, the counsellor should remain frequently smiling. The counsellor's smile is one of the strongest tools in communication. It will make a patient feel relaxed and comfortable and influence him to think that the counsellor is open, warm and friendly.

Sometimes, due to big crowd in the waiting area or the irrelevant and persistent questions from a patient, the counsellor may get tensed or irritated. But a good counsellor should always remain cool and calm without giving expression to her/his feeling and keep a smiling face. The counsellors should always bear in mind that the patients are sensitive to facial expressions of the medical and non-medical staff of a hospital.

Next to smiling, eye contact is the most important aspect of body language. If a counsellor, in the course of counselling, maintains a good eye contact with the patient, the patient will repose confidence in the counsellor. Making very little eye contact can be misunderstood by the patient, who may think that the counsellor is not interested in his/her problems. If the patient finds the counsellor not looking at him while they are speaking, they will feel uneasy.

Hand movement of the counsellor also forms an important aspect of body language. Friendly gestures tend to make the counsellor appear open and honest. By pointing out finger or moving hands closer, the counsellor can emphasise what he/she is saying. Hand gestures would reveal the counsellor's interest and commitment to guide and help the patient. However, too many gestures will make the counsellor look nervous and emotional. Wringing one's hands or making knots with the saree, touching the face etc., can make the counsellor appear tense and sometimes dishonest.

Postures also form an important aspect of body language. The manner of sitting or orienting one's body towards the patients are the tellers of the counseller's interest, openess and attentiveness. By leaning back or remaining away from the patients, the counsellor would create an impression that she/he lacks interest in the patient's case. The counsellors should not hunch their shoulders or keep their heads down, since these gestures will be misunderstood by the patient that the counsellor is not sure of what he/she is saying. A relaxed body posture will give an appearance of feeling confident.

Head posture is a good indicator of one's attitude. The counsellors should keep head straight when they want to show that they are reliable and serious about what they are saying. By tilting their heads slightly upwards and downwards, the counsellors can reassure the patients that they are friendly and listening to what the patients are saying.

The counsellor should make the patient feel comfortable and avoid being too close or too far away. Staying with in two feet may be a comfortable range. Being too close will make the patient uncomfortable and being too for away will make the patient feel rejected. Another important aspect of body language is avoiding unwanted sounds like “ush”, “uh”, “tchu”, “um” and repetitions of words. These will distract patients.

One's face, hands and postures express what is going on inside their mind. They give clues to others as to whether the words the counsellors say are consistent with what they really feel. Awareness of body language can help to send a consistent message to the patients and create comfort and confidence in them. Hence, it is important for the counsellors to improve their body language.

Listening

Listening is the most important skill required of a counsellor. It is the art of hearing and understanding. The counsellors should first listen to what the patients have to say and should not interfere when they are speaking. Only after the patients complete their speech, the counsellor can ask questions. Interference or interruptions may break the flow of the patients' thoughts and they may miss mentioning an important point related to their problem, or the patients may miss asking an important information from the counsellor.

The counsellor should have the skill to understand and keep in mind whatever the patient says. After the patient finishes what he/she wanted to say, the counsellor may put forward short questions to the patient in a concerned voice to get a point clarified.

Listening has two basic aspects

1. Hearing: Catching and keeping in mind what the patient says.
2. Understanding: Understanding the problems and needs of the patient from what he/she has said.

Characteristics of a good listener

• The counsellor, after hearing and understanding the needs and options of the patients, carries out their appropriate needs and wishes.
• Gives clear indications in body language that he/she is listening to the patients.
• Expresses words of sympathy towards the patients.
• Shows respect and interest.

The counsellor should have all the above mentioned traits so that the counselling will be effective.

Many people lack listening skill that needs to be improved. The benefits of good listening are numerous. Skilful listening will enable a counsellor to meet and counsel more number of patients in a short time.

Voice modulation

This will vary depending upon the situations. When a counsellor is talking to the patient regarding the nature of the disease and course of treatment, the counsellor should explain the whole thing in a soft and slow pace. There should be no stiffness in the counsellor's voice. The manner of uttering words and the tone in which the words are uttered should be changed according to the nature of information that should be conveyed to the patient. When the counsellor wants to communicate the seriousness of a patient's disease, there should be appropriate voice modulation. Depending on the situation, the counsellor should modulate her/his voice with appropriate body language.

Examples

1. In the course of enquiring about the family of the patient, the counsellor's voice should be as normal and cordial as that of a close friend. Ex: Hello/Vanakkam/Vanga etc.,
2. In the course of giving information about the nature of a particular eye disease, the counsellor should modulate her/his voice as that of a sincere teacher who would do his best to explain the subject to the students. Ex: You should be careful with drug application.
3. When the counsellor wants to convey an important matter that the patient should always keep in mind, her/his voice should be modulated as that of a mother cautioning her children not to do this or that. Ex: Never leave the pills outside, within the reach of children.
4. When something serious is to be communicated either to the patients or their attendants, the counsellor's voice should be modulated as that of a close relative who would convey unpleasant information slowly and gently without upsetting the listeners.

Barriers of communication

There are some aspects which affect proper communication of a message or information from one person to another. These aspects are called communication barriers which are dealt with below:

Matter in a right way avoid chances of misinterpretation

Informing and explaining matters form the core aspect of counselling. Sometimes there is a misinterpretation of what is told to the patient by a counsellor. This is because, people's perceptions and understanding are not alike. They differ from one person to the other.

This aspect should be borne in mind by the counsellors. For example, a patient in a glaucoma clinic comes to the counsellor after undergoing a follow up examination by a doctor. The doctor would have noted in the case sheet, that the patient's condition continues as the same without any deterioration.

While explaining to the patient his/her present condition, the counsellor may tell the patient, “your eye condition continues to be the same without any change”. Although the counsellor stated the fact, it may convey an incorrect message to the patient who may think that his condition has not improved despite the medicines he is applying in his eyes since a long time. In order to avoid such miscommunication the counsellor may tell the patient, “your eye condition is responding to treatment. The medicines have prevented worsening of your glaucoma. As a result of the treatment your condition has not been deteriorated and it remains as the same as it was a few months back.”

This will infuse confidence in the patient and will encourage him to continue the treatment. In the event of the patient leaving the hospital with the wrong message, he may get disinterested in continuing the treatment. This will adversely affect the prognosis of treatment and may lead him to blindness.

Generally, common people are not properly informed about laser procedure. The very mention of the word “laser” may convey an alarming message to uninformed patients. They could have a wrong notion that laser is a dangerous thing and laser procedure would be a laborious one. So, the counsellor while informing a patient that he needs laser treatment should explain that it is a short and simple procedure that would benefit him.

The eye is precious to any person. It is but natural for any person to think twice before making a decision for undergoing surgery. Hence, it is the duty of the counsellor to explain to the patients that the surgical procedures for cataract, glaucoma, Diabetic Retinopathy will not do harm, but improve or retain their vision.

Conveying important points and avoiding unnecessary details.

In the course of counselling, the counsellor should inform the patients all relevant points and avoid unnecessary details or information. If the advice or information given by the counsellor is loaded with too many points, the patient may miss some important points or fail to keep them in memory. This often happens in group counselling. Some patients may not receive full information. They may ask other patients who may leave out part of the information. Sometimes intermediaries like attendants and relatives may fail to convey full information to the patients, if the message is too lengthy.

To avoid such filtering of information, the counsellor should condense the message and make a brief statement that could be fully understood and absorbed by the patients.

Counselling should be done on the basis of each patient's educational status, his present condition and needs. The counsellor is expected to inform the patient about the causes, symptoms, types, nature of his eye disease and the treatment options available. However, aged patients, particularly uneducated persons may not be much interested in all these details. Their only worry will be as to what medicine we are going to give, how long the medicine should be used and how long it will take to cure his ailment. Hence, such information should be given only to those patients who can understand them and who need them.

Language problem

The counsellor should always talk in the patient's own language or a language that can be understood by them. The choice of words should be specific and accurate. Only the words that can be understood by the patients should be used.

The style of language should not be high. It should be as simple and direct as to enable the patients to understand the treatment procedure and the manner of applying medicines. At no point, the counsellor should express her/his opinion about the efficacy of a particular surgical procedure or suggest to opt for a particular treatment procedure.

Making the patient to listen

Generally patients who are in physical pain and in a state of worry cannot be expected to listen all that the counsellor says. While listening to the counsellor, a patient's mind may be wandering somewhere. The counsellor has to tackle the patient's poor listening attitude and try to overcome this problem.

In the course of counselling, the counsellor should frequently stop talking and ask the patient to tell what he/she has understood from the information so far given by the counsellor. Such questions will keep the patient alert and make them listen attentively. The counsellor can request the patients politely to listen carefully what she/he is saying.

In the midst of the counsellor's speech, some patients may interrupt to ask questions. Then the counsellor should tell the patient just to wait till she/he finishes her speech.

Other barriers

In addition to the above mentioned barriers in communication, there are other barriers like age, education, gender, social status, economic condition, religious and cultural backgrounds etc., These barriers may come in the way of effective communication between the counsellor and patient.

For example an aged patient may hesitate to ask questions or clarifications from the counsellor and an young lady counsellor may feel uncomfortable to converse with a patient who looks like a rich man. The counsellor has the responsibility to see that none of these barriers come in the way of communication in counselling.

The counsellor must also avoid assumptions that the patient already knows the details. All relevant information should be conveyed to the patients clearly.

Distractions

Distracting factors in the counselling room also serve as barriers in communication. Too many people talking at the same time, frequent phone calls, interruptions by colleagues are some of these factors that should be avoided.

Overcoming the barriers

Most of the people who suffer from eye problems like cataract that could be solved by a simple one-time surgery reside in rural areas. They are not prepared to avail of the eye care services mainly for fear of surgery, unaffordable treatment costs, ability to manage with existing poor vision and difficulty in leaving day-to-day responsibilities.

The counsellors have a special responsibility to overcome these personal barriers of the patients by their communicative skill. They should convince the patients and make them undergo without delay the surgical or medical treatment that has been recommended by the doctors.

What to inform

Patients and their family members are to be given information on various matters. They are:

1. Details about the causes, symptoms and nature of the eye disease or disorder the patient suffers from.
2. Results of diagnostic procedures
3. Details about the surgical or medical treatment procedure recommended by the doctor
4. The various surgical options available in the hospital.
5. The estimated cost of surgical or medical treatment procedures.
6. Information about the types of rooms available and their rent.
7. Post-operative guidelines.
8. Need for follow up visits etc.,

The information is provided to increase patient awareness, to facilitate informed decision-making as well as to motivate the patient to accept treatment immediately.

Information can also be provided to moderate patient's expectations on outcome of treatment. Providing right information will increase patient's compliance with treatment procedures which the patient must follow. For example, the counsellor should explain about the need of regularly applying eye drops to a patient who has undergone cataract surgery. A diabetic retinopathy or glaucoma patient should be told about the importance of regular follow up check ups to ensure the success of treatment.

Use of analogies in counselling

How to share all this information with the patients in the manner they understand them is the real challenge before the counsellors. It is in this context, the role of analogies assumes importance.

A patient who is to undergo cataract surgery will have to make a choice between different surgical procedures and also to opt for an IOL type that would suit him. Information on the technical aspects involved in the operation and its pros and cons will not be understood by the common people. Moreover this will consume much of the counsellor's time. Hence, this information could be effectively communicated by using analogies that could easily be understood by the patients and their relatives.

Analogy is using a familiar matter to explain a new one. The familiar situation is drawn from an understanding of the background of the patient, namely his social status, education, culture, living style etc., Eye related conditions and treatment methodologies could be described in a simple way by using appropriate analogies.

Aravind's experience in using analogies

Aravind Eye Hospitals have tried the application of analogies and found it useful in explaining complex technologies, treatment options and even in motivating the patients to undergo cataract operation immediately.

Yolk of a raw egg analogy

Here are few analogies being employed at Aravind. To explain the effect of cataract in the eye, the analogy of the yolk of a raw egg is used in Aravind Eye Hospitals. As the yolk of raw egg is transparent like a glass, one can see through it clearly. But when the egg is boiled, the yolk becomes opaque through which clear vision is not possible. Similarly the lens in a normal eye remains clear. Due to ageing process and some other reasons, the lens becomes non-transparent through which no clear vision is possible. This is called cataract. Just as transparency could not be restored to the boiled yolk, the cataractuous lens also could not regain transparency. This analogy is clearly understood by the patients.

Ripe cotton analogy

To explain to the patients the immediate need of surgery for a mature cataract, the analogy of ripe cotton is used. If cotton is not picked at the right time when it matures, it will burst and become useless. Similarly, if the cataractuous lens is not removed in time by surgery and allowed to get matured or ripen, it may burst resulting in vision loss.

This analogy could be used in the case of glaucoma patients also. Since this disease is caused by increase in intra-ocular pressure, immediate and continued treatment is needed. Otherwise, the eye pressure will get much increased and cause permanent loss of vision.

Digging of wells analogy

To explain the difference between ECCE-IOL surgery and Phaco-IOL surgery, the difference between digging an ordinary well and bore-well is cited. Digging a conventional well would require a number of workers and the diameter of the well will be much bigger than a bore-well. But for digging a bore-well a machine with a few persons are enough. Its diameter will also be lesser than the ordinary well. Though the bore-well will be much deeper and the cost will be much higher, work will finish quicker than digging a ordinary well. And people know that a bore-well is better than the ordinary well and for that reason many people opt for it. Similarly a phaco surgery involves the use of a machine for removing the cataractuous lens for which a very small opening is to made in the eye. And the whole operation will take less time compared to regular IOL surgery. Since the opening is smaller, the healing time will also be shorter. This analogy is well appreciated by the patients who opt for phaco surgery.

Travel by train and flight analogy

To drive home the point the advantage of having foldable IOL instead of a single piece IOL in PHACO-IOL surgery, the advantage of travel by flight as against the train is explained to the patients. Though the train and plane reach the same destination, passengers on board the plane will reach much earlier than the train passengers. Similarly, a patient who opts for foldable IOL will recover faster and will be able to return to his work much earlier than the patient who opts for single piece IOL.

Walking stick analogy

To explain the need of injecting silicon oil in the eye of a patient who is to undergo scleral buckling surgery, walking stick analogy is used. A person who has undergone leg surgery is provided with a walking stick for support. Similarly, silicon oil is injected in the eye of the patient to give support to his retina. Just like the use of walking stick is discontinued after the leg becomes normal, the silicon oil will be removed as and when the retina gets attached.

Canal blockage analogy

Water flow will get blocked if there is an obstruction in a canal. As the blockage will produce pressure and cause damage, another passage is made to divert the water flow. Similarly to reduce the eye pressure caused by the accumulation of aqueous humor, a new passage is created by surgery for its uninterrupted flow.

Old and new doll analogy

To explain Amblyopia, the choice of a new doll instead of an old one by a child is cited. Just like the child selects a new doll that looks bright, our brain accepts the visual images sent from the eye that has better vision.

Travel in different classes of a train

To explain that irrespective of the type of room a patient may opt, the quality of surgery he receive will be the same, the analogy of train travel is given. Though passengers go in different classes in the train, all of them reach the same destination.

A particular analogy will not work for all groups of people. Different analogies have to be used by the counsellors to suit the particular patient who is being counselled. When properly used, analogy will serve as a powerful tool in effective communication.

Tips for good counselling

• Be relaxed and attentive
• Always lean forward while talking to the patients to show your interest towards them.
• Keep your facial expressions relaxed and friendly.
• When standing, maintain a balance to your stance.
• Keep your hands above your waist and use both hands to make positive gestures.
• Smile when appropriate; look pleasant and genuine. This will show your warmth and openness.
• Always face the patients
• Avoid gestures like crossing your legs, swinging your foot and tapping your fingers. These will show that the counsellor is impatient and disinterested.
• Avoid shifting your eyes and turning your head quickly when the patients ask a question.
• Avoid hair twirling and other nervous gestures.
• Avoid placing your hands over your mouth or rub your arm or leg. This will make you appear anxious.
• Avoid looking down or frown when you are talking with the patient. This will make you appear that you are defensive and untrustworthy.
• Avoid cleaning your spectacles, biting your nails and rubbing your eyes or nose.
• Avoid looking downwards or at the sides while talking to the patients.

Setting up of a Counselling Room

After the ophthalmologist examines the patient and gives the diagnosis, the patient is conducted to the counselling room. Since counselling has a crucial role to play in giving information and making the patient to accept surgical or medical treatment in the hospital, there should be a separate room for this purpose.

The counselling room should have a quite and peaceful atmosphere. The set up should be comfortable to facilitate giving and receiving information calmly and engage in confidential conversation. (Fig 1.3)

Chairs should be provided for the counsellor and the patient and the attendar of the patient. As sufficient distance is to be maintained between the counsellor and patient, a table should be provided between them.

The counselling room has to be set up nearer to the ophthalmologist's clinic and patients waiting for counselling should be accommodated outside the counselling room. The room should be adequately spacious to keep the materials and aids needed for counselling.

Counselling aids

The counsellor should use the following counselling aids to explain about the eye parts and eye diseases to the patients (Fig 1.4).

1. Model of a human eye
2. Models or photographs showing the nature and various stages of eye diseases like cataract, corneal ulcers, glaucoma etc
3. Different types of intraocular lenses (IOL)
4. Posters on various eye diseases
5. Videos on common eye diseases

Supporting facilities

The counsellor's room should have supporting facilities like telephone and computer. The telephone should be used for giving appointments to the patients, reserving rooms, clarifying doubts, communicating with other departments and reminding the patients about their appointments.

Computer is to be used for coding of counselled case sheets, sending emails, showing CD's of surgeries to the patients etc.

Key points to remember

• Role of counselling is to reduce the work load of the ophthalmologists and the OA, ensuring patient satisfaction and increasing the patient volume.
• The roles of a counsellor include guide and companion, information giver, facilitator in decision making negotiator, supporter, comforter, link between the patient and family.
• Qualities of a good counsellor include a bright and pleasant look, willingness to serve old and visually handicapped patients, clarity in thinking, simple and clear communication of information, compassionate and sympathy towards patients.
• Types of counselling include individual counselling, group counselling, family counselling, genetic counselling and grief counselling.
• The objective of the art of counselling is to make understand the need for following appropriate body language, listening properly, modulating their voice while talking and overcoming communication barriers.
• To avoid barriers of communication in counselling, counsellor has to say the matters in a straight way, conveying important points and avoiding unnecessary details, use of local language, and making the patient to listen.
• Analogies are to share all the information with the patient in the manner they understand them.
• Since counselling has a crucial role to play in giving information and making the patient to accept surgical or medical treatment in the hospital, there should be a separate room for this purpose.

Student exercise

I. Write short answers

1. What is counselling?
2. What are the objectives of counselling?
3. Mention the types of counselling in an eye hospital?
4. What is art of counselling? Why it is important?
5. What is the use of analogies in counselling?
6. What are the aids used in counselling?

II. Write brief notes on

1. The various roles of counsellors in an eye hospital.
2. The qualities of a good counsellor.
3. The barriers of communication.