Understanding the Patient Interview and Communication in Healthcare
The Interview
Interview: First Point of Contact
The interview serves as the crucial initial interaction with a patient.
It provides the best opportunity to understand the patient's:
Beliefs
Concerns
Perception of their individual health state
Allows for the compilation of subjective data (information reported by the patient).
Facilitates awareness and observation of objective data, which includes:
Physical appearance
Posture
Ability to carry on a conversation
Demeanor
The Process of Communication
Sending Messages
Verbal communication involves:
The specific words spoken (vocalization).
The tone used in conversation (e.g., pitch, volume, rate).
Nonverbal communication is equally significant and includes:
Body language, which provides cues that can correlate with a person's truer feelings.
Recognition of the importance of unconscious messages conveyed through nonverbal means.
Receiving Messages
Gestures are as important as spoken words in conveying meaning.
Interpretation of messages is based on a recipient's:
Past experiences
Cultural background
Self-concept
Awareness and perception are critical for accurately understanding the message.
The impact of illness or increased dependence on communication can significantly raise the risk of misunderstanding in a healthcare setting.
Internal Factors (Specific to the Healthcare Team Member)
These internal qualities help maximize communication skills:
Liking others: Approaching patients with a genuine interest and positive regard.
Empathy: Developing an understanding of and sensitivity to the feelings of others.
Ability to listen: Engaging in an active, focused listening process.
Self-awareness: Being conscious of one's own implicit biases to prevent them from affecting communication.
External Factors (Defining the Environment)
These environmental considerations foster effective communication:
Ensure privacy: Aim for "geographic" privacy (a private room) but always ensure "psychological" privacy (making the patient feel safe and unobserved).
Refuse interruptions: Minimize or refuse distractions to maintain focus on the patient.
Physical environment: Utilize "equal-status" seating, where the healthcare provider and patient are at the same eye level, promoting a sense of equality.
Dress: Maintain a professional appearance while ensuring comfort for both parties.
Note-taking: Keep notes to a minimum during the interview to offer more focused attention to the patient.
Electronic Health Record (EHR)
Federal government mandates aim to improve quality and safety through EHRs.
The technology interface can impact communication in the healthcare provider-patient relationship.
Capturing biomedical, psychological, and emotional information may not always be comprehensive due to the structured nature of EHRs.
It is crucial not to allow the computer to become a "barrier" in the communication exchange process. Maintain eye contact and presence with the patient.
Techniques of Communication
Introducing the Interview
Keep the introduction short and formal.
Working Phase (Data-Gathering Phase)
This phase involves both the interviewer's verbal skills (questions) and responses to the patient's statements.
Two primary types of questions are used:
Open-ended questions: Ask for narrative information, allowing the patient to elaborate freely (e.g., "Tell me about your headaches.").
Closed or direct questions: Ask for specific information leading to a forced choice answer (e.g., "Do you have pain?") or a short factual response.
Each type of question has a distinct place and function in the interview process.
Verbal Responses: Assisting the Narrative
There are nine types of verbal responses, divided into two categories:
Client Leads (Interviewer reacts to patient's answers)
Facilitation: Encourages the patient to say more or continue speaking (e.g., "Mm-hmm," nodding).
Silence: Directed attentiveness, allowing the patient time to think or collect their thoughts and express themselves.
Reflection: Echoes a patient's words or feelings to help them express deeper meaning (e.g., "So you're feeling frustrated?").
Empathy: Names a feeling expressed by the patient and allows for its expression, demonstrating understanding (e.g., "That must be very upsetting for you.").
Clarification: Asking for confirmation to ensure understanding of the patient's message (e.g., "Just to be clear, you mean…").
Interviewer Leads (Interviewer expresses own thoughts and feelings)
Confrontation: Clarifying inconsistent information or observing a discrepancy (e.g., "You say you're not in pain, but you're wincing.").
Interpretation: Makes an association to identify cause or conclusion based on observed data and patient statements (e.g., "It sounds like your stress is contributing to your headaches.").
Explanation: Informs the person by sharing factual and objective information (e.g., "This medication works by…").
Summary: Provides a conclusion based on verified information, signaling that the interview process is nearing its end and confirming mutual understanding.
Ten Traps of Interviewing
These practices should be avoided as they hinder effective communication:
Providing false assurance or reassurance: Dismisses patient's feelings and can break trust.
Giving unwanted advice: Implies the patient is not capable of problem-solving or makes the interviewer seem superior.
Using authority: "I know what's best for you" approach; undermines patient autonomy.
Using avoidance language: Euphemisms for death or serious conditions; delays honest communication.
Distancing: Using impersonal language (e.g., "the heart problem" instead of "your heart problem"); sounds cold and detached.
Using professional jargon: Medical terminology that the patient may not understand.
Using leading or biased questions: Suggests a preferred answer, invalidating the patient's true feelings or experiences (e.g., "You don't smoke, do you?").
Talking too much: Shifts focus from the patient to the interviewer.
Interrupting: Shows disrespect and breaks the patient's train of thought.
Using "why" questions: Can sound accusatory and put the patient on the defensive.
Nonverbal Skills: Congruency
When verbal and nonverbal messages are congruent (match), the verbal message is reinforced, increasing its credibility.
When they are incongruent (do not match), the nonverbal message is often viewed as the truer one because it is generally under unconscious control.
Nonverbal cues can be either positive or negative, highlighting the importance of self-awareness for healthcare providers to promote effective communication.
Nonverbal Modes of Communication
Physical appearance: Immediate impression; image as an initial perception.
Posture: Interpretation of body language, affecting engagement (e.g., open vs. closed posture).
Gestures: Interpretation of body language, affecting engagement; sending messages – be aware of what is being communicated.
Facial expression: Reflects emotion and culture.
Eye contact: Maintain within the realm of interest but be mindful of cultural diversity, as appropriate eye contact varies by culture.
Voice: Be aware of tone, intensity, and rate of speech.
Touch: Interpretation is influenced by age, gender, cultural background, past experience, and current setting; use with caution and cultural sensitivity.
Closing the Interview
The ending of the interview should be gradual, allowing for adequate closure and final expression from the patient.
No new topics should be introduced during the closing phase.
A summary should be provided as the final statement, reaffirming understanding and concluding the interaction.
Developmental Competence
Interviewing the Parent or Caregiver of a Child
Focus on both the child and the parent/caregiver to encourage participation from both.
Obtain information and relevant data pertaining to the child's health.
Address individuals by name to help foster engagement and respect.
Be aware of physical relationships and proximity to promote a sense of self and comfort.
Practice patience and maintain a non-judgmental attitude.
Be attuned to nonverbal behaviors from both the child and caregiver to maintain engagement.
Communicating with Different Ages
Use "Stages of Cognitive Development" as a guideline to facilitate age-appropriate communication. Consider:
The maturity level of the child, which may not always align strictly with chronological age.
That a healthcare crisis can commonly lead to regression (a return to earlier developmental behaviors) as a response.
Stages of Cognitive Development and Communication Specifics
Infants (Birth - 12 ext{ months}): Use gentle handling with a quiet, calm voice.
Toddlers (12 - 36 ext{ months}): Give one direction at a time and provide simple explanations.
Preschoolers (3 - 6 ext{ years old}): Use short directions with concrete explanations; be aware of their magical thinking.
School-Age Children (7 - 12 ext{ years old}): Ask questions to gather data and maintain a non-judgmental stance; they can understand more complex concepts.
Adolescents (Starts ext{ with puberty}): Approach with a respectful, honest attitude, focusing on the individual's autonomy and concerns.
The Older Adult
Address older adults respectfully (e.g., using Mr./Ms. unless otherwise requested).
Typically, the interview process will take longer due to potential factors.
Consider appropriate pacing of the interview.
Be mindful of potential physical limitations that may affect communication (e.g., hearing, mobility).
May need increased response time to process information and formulate answers.
May have more information to provide due to longer life experiences and medical history.
Use therapeutic touch (with consent and cultural awareness) to provide empathy and support.
Interviewing People with Special Needs
Consider key elements that address the unique needs of vulnerable populations:
Hearing-Impaired: Use visual aids, writing, or sign language interpreters.
Acutely Ill: Be direct and concise; prioritize immediate concerns.
Drug/Alcohol Abuse: Approach non-judgmentally; focus on immediate health concerns.
Sexually Aggressive: Set clear boundaries, state professional role, ensure safety.
Emotionally Distraught (Crying): Offer tissues, allow time for emotional expression, express empathy and support.
Angry and/or Threatening Violence: Ensure personal safety, maintain a calm demeanor, use de-escalation techniques, seek assistance if needed.
Anxious: Provide reassurance, speak calmly, explain procedures clearly.
Use appropriate resources as they relate to the context of the situation (e.g., interpreter, social worker, security).
Be alert to "personal question" queries from the patient, as they may indicate ulterior motives (e.g., seeking personal information about the provider).
Provide an appropriate response based on personal ethics, maintaining professional boundaries.
Cultural Considerations
Genetics and Environment
Be aware of maintaining cultural norms during the interview and examination process.
Cultural considerations on gender: Maintain privacy and modesty, which may vary significantly across cultures.
Sexual orientation & gender identity (SOGI):
The umbrella term Sexual and Gender Minorities (SGM) is used to encompass LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and others).
Terminology is continually evolving.
Refer to authoritative sources like the National Institutes of Health (NIH) Office of Equity, Diversity, and Inclusion for current and respectful terminology and information.
Working with (and without) an Interpreter
A language barrier can be a significant element in healthcare interactions due to cross-cultural communications.
Consider both verbal and nonverbal cues in the communication pattern when an interpreter is present.
Preference for an interpreter: A bilingual team member or a trained medical interpreter is preferred.
Ideally, the interpreter should be of the same gender as the patient to facilitate comfort, particularly during sensitive discussions.
It's important to recognize that language alone does not imply understanding of cultural diversity; an interpreter may speak the language but not understand the nuanced cultural context.
Health Literacy
Health literacy is more than just the ability to read.
It includes understanding and following directions that lead to effective communication between the patient and the healthcare provider.
A patient may be literate (able to read) but not possess health literacy (unable to understand health information).
Tools for determining literacy:
Involves the use of quantitative measurement and memory aspects.
Several tools are available, varying in reliability, validity, and administration time.
Follow established policy and procedure in clinical practice settings for literacy screening.
Techniques to Improve Health Literacy
Oral teaching:
Provide simple, easy instructions.
Use conversational structure rather than medical jargon.
Written materials:
Avoid medical jargon.
Provide appropriate information, concise and relevant.
Print should be large enough to be easily read (e.g., 12-14 ext{ point font}).
Teach back:
Encourages verification of understanding by asking the patient to explain information in their own words (e.g., "Just to make sure I explained everything clearly, can you tell me in your own words how you will take this medication?").
Opens the door for clarification if needed, allowing the provider to correct misunderstandings.
Communicating with Other Professionals
Promoting Effective Interprofessional Communication
Occurs between two or more individuals of the interdisciplinary healthcare team.
Takes place in an environment of mutual respect to enhance overall communication and patient care.
Impact of Ineffective Interprofessional Communication
Strongly linked to poor patient outcomes, including:
Delay in treatment
Medication errors
Clinical misdiagnosis
Patient injury
Death
Maintaining Open Lines of Communication
Provide timely updates in an organized and clear manner.
Standardized Communication: SBAR
SBAR is a framework for clear communication among healthcare professionals:
S - Situation: Provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and current location.
B - Background: Provide pertinent history as it directly relates to the patient's current health status.
A - Assessment: State pertinent assessment findings obtained, along with an interpretation of the data (e.g., "The patient's BP is 90/60, and I assess them as hypotensive.").
R - Recommendation or Request: State what you need or want for the patient in terms of medical treatment and/or assistance.