Effective Communication in Healthcare: Strategies and Techniques, Exams of Nursing

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NURS 6512 Health Assessment Chapter

3 (80 Questions and Answers)

The Interview: Definition & Goal - Correct Answer -Definition: The interview is a meeting between you and your patient -Goal: to collect a complete health history and to achieve optimal health for the patient Results of a successful interview - Correct Answer -Gather complete and accurate data about the person's health state including the description and chronology of any symptoms of illness -Establish rapport and trust so the person feels accepted and thus free to share all relevant data -Teach the person about the health state so that the person can participate in identifying problems -Build rapport for a continuing therapeutic relationship; this rapport facilitates future diagnoses, planning, and treatment. -Begin teaching for health promotion and disease prevention Health History you collect in an interview is? (Also importance and collects what type of data and how?) - Correct Answer -Important in beginning to identify health strengths and problems as a bridge to physical examination. -First and most important part of data collection -Collects subjective data:

• What the person says about his or her perceived health state
• The interview is the first and the best chance a person has to tell you about what he or she perceives the health status to be
• The patient knows everything about his or her own health state, and YOU KNOW NOTHING!!

-Consider the interview a (1) between you and your patient?

2. This consists of? - Correct Answer 1. (contract)
3. The contract consists of spoken and unspoken rules for behavior
   • What the person needs and expects from health care and what the health professional has to offer
   • Mutual goal is optimal health for the patient Terms of the contract - Correct Answer • Time and place of interview and physical examination

• Introduction of and explanation of health care provider's role
• Purpose of interview
• How long it will take
• Expectation of participation for each person
• Presence of others, e.g., family, etc.
• Confidentiality and to what extent it may be limited
• Any costs that the patient must pay Confusion could produce? - Correct Answer Any confusion could produce resentment and anger rather than the openness and trust you need to facilitate the interview. The Process of Communication - Correct Answer 1. Sending: (Verbal and Nonverbal Communication)

2. Receiving: (Taking in by the other person) Definitions of Communication - Correct Answer -Communication is exchanging information so that each person clearly understands the other -Communication is behavior (conscious and unconscious), verbal and nonverbal. -All behavior has meaning and be aware of what the message is that you're sending to the patient

-A generally optimistic view of people - an assumption of their strengths and a tolerance for their weakness -The patient must feel accepted unconditionally -Goal is NOT to make patient dependent on you, but to help them to be increasingly responsible for themselves

2. Empathy: -Viewing the world from the other person's inner frame of reference while still remaining yourself -Feeling WITH the person rather than feeling LIKE the person -To understand with the person how he or she perceives the world
3. The ability to listen: -Listening is not passive - it is active and demanding and requires your complete attention! -Active listening:
   • Listen to WHAT the person says
   • Listen to the WAY the person tells the story - this may give diagnostic cues External factors: In any location, the following conditions are important to have a smooth interview: (1-7) - Correct Answer 1. Ensure Privacy
4. Refuse Interruptions
5. Physical Environment
6. Dress
7. Note-Taking
8. Tape and Video Recording
9. Electronic Health Recording (EHR) External Factors: (Ensure Privacy) - Correct Answer If physical privacy is not available, try to provide "psychological privacy" such as curtained partitions that will help the patient feel confident that no one can overhear the conversation or interrupt

External Factors: (Refuse Interruptions) - Correct Answer -Most people resent interruptions except in cases of emergency -Inform support staff of your interview and ask that they not interrupt you External Factors: (Physical Environment) - Correct Answer - Comfortable temperature -Sufficient lighting (especially not facing patient directly into a light source) -Reduce noise -Remove distracting and unnecessary objects (the room should look professional) -Place the distance between you and the patient at 4 to 5 feet -Appropriate eye contact with the patient -Arrange equal-status seating

• Both patient and examiner seated at eye level with each other
• Do not speak from behind a desk
• DO NOT STAND - it communicates haste and assumes superiority
• Bed-ridden patients should be arranged at a face-to-face position External Factors: (Dress) - Correct Answer -Patient should remain in street clothes except in emergencies -Collect history BEFORE asking the patient to change into the paper examination gown -Your appearance should be appropriate to setting and should meet conventional professional standards without placing a distance between you and the patient because of your fancy 3- piece suit External Factors: (Note-Taking) - Correct Answer -May be unavoidable:
• Cannot rely completely on memory for details of previous illnesses or review of body systems

Techniques of Communication: The Working Phase - Correct Answer -Data-gathering phase -Verbal skills include questions to patient and your responses to what is said -Two types of questions (each has its own function and place in the interview):

1. Open-Ended Questions
2. Closed/Direct Questions Techniques of Communication: The Working Phase: (Open- Ended Questions) - Correct Answer -Open-ended questions ask for narrative information and state the topic to be discussed ONLY in general terms. -Ask for narrative responses - "Tell me, how did your labor go yesterday?"
   • Opens up the conversation
   • Establishes the rapport with the patient

• Can help correct misconceptions that the patient has/had about a particular topic
• Also helps you establish if the patient is upset about a certain aspect of the healthcare provider and/or system -State topic only in general terms -Use them:
• To begin interview
• To introduce a new section of questions
• Whenever the patient introduces new topic Techniques of Communication: The Working Phase: (Closed/Direct Questions) - Correct Answer -Ask for specific information -Elicit short, one-or-two word answers, a yes or no answer, or a forced choice -Use them:
• After opening narrative to fill in details person may have left out

• When you need many specific facts about past health problems, or during review of systems
• To move the interview along - the interview is not a social event! -Guidelines for closed/direct questions:
• Ask only one question at a time and avoid bombarding the patient with questions
• Choose language the patient understands (example: "running off") Techniques of Communication: The Working Phase: (Responses)
• Correct Answer - Assisting the narrative in an interview.
  • You responses help the patient amplify their story
  • The first Five responses (Facilitation, Silence(Attentiveness), Reflection, Empathy, and Clarification) involve you reactions to the facts or feelings the person has communicated. -Your response focuses on the patient's frame of reference. -Your own frame of reference does not enter into the response. -The patient leads this part.
  • The last Four responses (Confrontation, Interpretation, Explanation, and Summary), you start to express your own thoughts and feelings -The frame of reference shifts from the patient's perspective to yours - you lead this part! Techniques of Communication: The Working Phase: Responses: (Facilitation) - Correct Answer -Facilitation encourages patients to say more and shows you are interested and will listen further -Also called "general leads" -Simply maintain eye contact, shift forward in your seat with increased attention, nodding yes, or using hand gestures to encourage the patient to continue talking Techniques of Communication: The Working Phase: Responses: (Silent Attentiveness) - Correct Answer -Gives patient time to think and organize what to say without interruption from you

Techniques of Communication: The Working Phase: Responses: (Interpretation) - Correct Answer -Based on your inference or conclusion -It links events, makes associations, implies cause, ascribes feelings -Helps person understand his or her own feelings in relation to the verbal message -If your inference is incorrect, the patient may correct it, and thus prompt further discussion of topic Techniques of Communication: The Working Phase: Responses: (Explanation) - Correct Answer -These statements inform the person - you share factual and objective information offering reasons for requirements or actions -"The reason you cannot eat or drink before your blood test is that food will change the test results." Techniques of Communication: The Working Phase: Responses: (Summary) - Correct Answer -Final review of what person has said

• it condenses facts and presents your view of health problem -Is a type of validation that person can agree with or correct; both you and patient should participate -Occurring at the end of the interview, it signals that termination of the interview is near Things to remember about Responses - Correct Answer -These responses now include your own thoughts and feelings -Use the last four responses only when merited by the situation - if you use them too often, you take over at the patient's expense Ten Traps of Interviewing - Correct Answer 1. Providing false assurance or reassurance

2. Giving unwanted advice
3. Using authority
4. Using avoidance language

5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions Ten Traps of Interviewing: (Providing false assurance or reassurance) - Correct Answer • Correct responses acknowledge the feelings of the patient and open the door for more communication.

• You can reassure patients that you are listening to them, that you understand them, that you have hope for them, and that you will take good care of them.
• This type of reassurance makes a commitment to the patient, and it can have a powerful impact. Ten Traps of Interviewing: (Giving unwanted advice) - Correct Answer • Know when to give advice and when to avoid giving it.
• Instead of giving opinion, try to allow an opportunity for the patient to reflect on the problem at hand. Through this process the patient is likely to learn and to change his or her behavior. Ten Traps of Interviewing: (Using authority) - Correct Answer • Although you and the patient cannot have equality to professional skill and experience, you do have equally worthy roles in the health process, which each respecting the other.
• Talking down to the patient promotes dependency and inferiority Ten Traps of Interviewing: (Using avoidance language) - Correct Answer • People use euphemisms such as "passed on" to avoid reality or to hide their feelings. They think that if they actually use the word "death" it might actually happen. To protect themselves, they evade the issue

• Using "why" questions make you sound whining, accusatory, and judgmental and the patient must then come up with an excuse to rationalize.
• "I see you started to have chest pains early in the day. What was happening between the time the pains started and the time you came into the ER?" Non-Verbal Skills - Correct Answer -Learn to listen with your eyes as well as your ears. -Nonverbal messages provide clues to understanding feelings. -When verbal and nonverbal messages are congruent, the verbal is reinforced -When verbal and nonverbal are incongruent, the nonverbal message tends to be the true one because it is under less conscious control. Nonverbal modes of communication: (1-7) - Correct Answer 1. Physical appearance

2. Posture
3. Gestures
4. Facial Expression
5. Eye Contact
6. Voice
7. Touch Nonverbal modes of communication: (Physical Appearance) - Correct Answer -Hans Selye "The Stress of Life"

• Some patients just "look sick" before you have a chance to collect any other data than simply looking at them.
• The same goes for you, too, as a nurse... -Whatever your personal choice in clothing or grooming, the aim should be to convey a competent, professional image. Nonverbal modes of communication: (Posture) - Correct Answer - Open versus closed body language

-If a person in a relaxed position suddenly tenses, it suggests discomfort with a new topic -Your own calm, relaxed posture creates a feeling of warmth and trust and conveys interest in the person. Nonverbal modes of communication: (Gestures) - Correct Answer - Gestures send messages, such as nodding or an open turning out of the hand shows acceptance, attention, or agreement.

• Wringing hands = anxiety
• Pointing a finger = anger and vehemence -Hand gestures also can reinforce a person's description of pain, such as holding a clinched fist in front of the sternum with crushing substernal chest pain or pointing with one finger to signify "this is where it hurts!" Nonverbal modes of communication: (Facial Expression) - Correct Answer -Relevant emotions or conditions, and physical conditions such as pain or shortness of breath may show on the face -Your own expression should reflect a professional who is attentive, sincere, and interested in the patient. -Any expression of boredom, distraction, disgust, criticism, or disbelief is picked up on by the patient and any rapport you have established with dissolve. Nonverbal modes of communication: (Eye Contact) - Correct Answer -Lack of eye contact suggests that the person is shy, withdrawn, confused, bored, intimidated, apathetic, or depressed - this applies to you as an examiner, too! -Do not have a fixed, penetrating look but rather, an easy gaze toward the person's eyes, with occasional glances away. -Exception: patients from a culture that avoids direct contact Nonverbal modes of communication: (Voice) - Correct Answer - Besides spoken words, meaning comes through the tone of voice, the intensity and rate of speech, the pitch, and any pauses.

-This gives the patient the final opportunity for self-expression. -After all of the above, indicate that closing is imminent by saying something like, "Our interview is just about over." -This is a good time to give your summary or recapitulation of what you have learned during the interview

• Summary = a final statement of what you and that patient agree the health state to be, it should include o Positive health aspects o Any health problems that have been identified o Any plans for action o And explanation of the following physical examination -As you leave, thank the patient for the time spent and for their cooperation. Developmental Competence: (The adolescent) - Correct Answer - Puberty is a time of dramatic physiologic change - a changing body affects a patient's self-concept. -Adolescents are between the childhood and adult stages in life; therefore, they are capable of both mature and immature actions (especially during times of stress). -Adolescents love their friends and believe that no adult can understand them
• Leads to monosyllabic answers and/or telling you only what they think you want to hear
• Assume that health professionals have similar values and standards of behavior as most of the other authority figures in their lives and therefore are reluctant to share information. Guidelines for successful communication with adolescents - Correct Answer 1. Have a respectful attitude, which is the most important thing you can communicate to an adolescent.

2. Communication must be totally honest.
3. Stay in your professional character - do not try to be his or her peer.

4. Use icebreakers - focus first on the adolescent and not their problem.
   • "How are things at school?"
   • "Are you in any sports?"
   • "Any activities?"
   • "Do you have any pets at home?"
5. Remember that adolescents are more sensitive to nonverbal communication than adults. They are more sensitive to any comment they take to mean criticism from you and will withdraw.
6. Take every opportunity for positive reinforcement regarding healthy lifestyle choices.
   • For bad choices - discussion is not enough - five them a small achievable goal and encourage another visit in a few weeks for follow-up on the behaviors of concern. Developmental Competence: The adolescent= (Things to Avoid) - Correct Answer • Silent periods, as used with adults, are not appropriate and may be seen as threatening.

• Reflection - they do not have the cognitive skills to respond to that indirect mode of questioning.
• Do not assume that adolescents know anything about a health interview or a physical examination. Explain every step and give the rationale. Developmental Competence: The Older Adult: (Developmental Tasks) - Correct Answer • Finding the meaning of life and the purpose of his or her own existence
• Adjusting to the inevitability of death Developmental Competence: The Older Adult: (Points to Remember) - Correct Answer • Always address the older adult by their last name
• Avoid all "elderspeak" which consists of
  • Diminutives
  • Inappropriate plural pronouns

and direct questions while maintaining a nonthreatening and nonjudgmental demeanor. -Avoid scolding or disgust - this may lead to belligerent behavior. -Top priority: the time of the last drink/drug and how much was taken at this episode as well as the name and amount of other substances taken. -Once sober: assess for the extent of the problem and the meaning of the problem for the person and family. Interviewing Patients with Special Needs: (Personal Questions "to you") - Correct Answer -You don't have to answer every question -You may supply brief information when you feel it is appropriate but be aware that there may be a motive behind personal questions such as loneliness or anxiety. -Direct your response back to the patient' frame of reference. -"No I don't have children; I wonder if your question is related to how I can help you care for little Jimmie?" Interviewing Patients with Special Needs: (Sexually Aggressive People) - Correct Answer -Some patients experience serious or chronic illness as a threat to their self-esteem and sexual adequacy that creates anxiety that makes them act out in sexually aggressive ways. -You may need to stop your interview and get another healthcare provider to do it Interviewing Patients with Special Needs: (Crying) - Correct Answer -You may need to defer parts of the interview - again note that something prevented that aspect of the interview and why. -If crying occurs, do not go on to a new topic, just let the person cry and express feelings fully. -If someone is on the verge of tears, acknowledge the expression by saying, "You look sad." The person may cry but will be relieved, and you will have gained insight to a serious concern.

Interviewing Patients with Special Needs: (Anger) - Correct Answer -The patient is showing aggression as a response to feelings of anxiety or hopelessness. -Do not ask about the anger and hear the person out (let them vent). -An angry person cannot be an effective participant in a health interview. -If YOU are angry, say so and tell the patient that you are angry at something or someone else. Otherwise the patient will think that you are angry with him or her. Interviewing Patients with Special Needs: (Threat of Violence) - Correct Answer -Fist clenching, pacing back and forth, vacant stare, confusion, statements out of touch with reality, statements that don't make sense, history of recent drug use, recent history of intense bereavement -Trust your instincts - leave the exam room door open and position yourself between the person and the door. -Avoid taking any risks. Interviewing Patients with Special Needs: (Anxiety) - Correct Answer -Nearly all sick people have some anxiety - this is a normal response to being sick. Cross-cultural communication - Correct Answer -Probability of miscommunication increases with two people from different cultural backgrounds -Cultural backgrounds of both health care professional and patient influence verbal and nonverbal communications Cross-cultural communication: (Cultural perspectives on professional interactions) - Correct Answer -Asians expect those in authority (us...) to be authoritarian, directive, and detached -Appalachians have close family relationships and may expect to have the same closeness with their healthcare provider