Ch. 2 Interviewing, Communication, and Interpersonal Skills

Interviewing, Communication, and Interpersonal Skills

• Building effective and healing relationships is paramount in healthcare.

• Therapeutic interviewing techniques require practice and feedback.

• Skills adapt to the dynamics of human behavior in patient relationships.

• The interviewing process elicits a patient’s story and responds to their cues.

• The health history format organizes the patient’s story into categories.

• The interview process and health history format have distinct but complementary purposes.

Skilled Interviewing Techniques

• The clinical encounter includes:

  • Initiating the session

  • Information gathering

  • Physical examination

  • Explaining and planning

  • Closing the session

• Global communication and interpersonal techniques can be used across all these stages.

• Key techniques include:

  • Active or attentive listening

  • Guided questioning

  • Empathic responses

  • Summarization

  • Transitions

  • Partnering

  • Validation

  • Empowering the patient

  • Reassurance

  • Appropriate verbal communication

  • Appropriate nonverbal communication

Active or Attentive Listening

• Involves:

  • Attending to patient communication

  • Connecting to the patient’s emotional state

  • Using verbal and nonverbal skills to encourage the patient to expand.

• Allows relating to concerns at multiple levels of the patient’s experience.

• Requires focus on verbal and nonverbal cues.

Guided Questioning

• Facilitates full communication in the patient’s own words.

• Shows sustained interest in the patient’s feelings.

• Avoids questions that pre-structure or shut down the patient’s responses.

• Techniques:

  • Moving from open-ended to focused questions

  • Using questioning that elicits a graded response

  • Asking a series of questions, one at a time

  • Offering multiple choices for answers

  • Clarifying what the patient means

  • Encouraging with continuers

  • Using echoing/repetition

Moving from Open-Ended to Focused Questions

• Questions should flow from general to specific.

• Start with general questions like, “How can I help?” or “What brings you in today?”

• Move to more focused questions like, “Can you tell me more about what happened when you took the medicine?”

• Then pose closed questions like, “Did the new medicine cause any problems?”

• Avoid leading questions that already contain an answer.

• Adopt neutral questions like “Please describe your pain.”

Questioning That Elicits a Graded Response

• Ask questions that require a graded response rather than a yes-no answer.

• "How many steps can you climb before you get short of breath?” is better than “Do you get short of breath climbing stairs?”

Asking a Series of Questions, One at a Time

• Be sure to ask one question at a time.

• Instead of “Any tuberculosis, diabetes, asthma, heart condition, or high blood pressure in the family?” try “Do you have any of the following problems?”

• Pause and establish eye contact as you list each problem.

Offering Multiple Choices for Answers

• Offer multiple-choice answers to minimize bias.

• “Which of the following words best describes your pain: aching, sharp, pressing, burning, shooting, or something else?”

• “Do you bring up any phlegm with your cough, or is it dry?”

Clarifying What the Patient Means

• Acknowledge confusion rather than pretending to understand.

• Request clarification, as in “Tell me exactly what you mean by ‘the flu’” or “You said you were behaving just like your mother. What did you mean?”

• Taking time for clarification builds the therapeutic relationship.

Encouraging with Continuers

• Use posture and gestures (nonverbal encouragements) or words (neutral utterances) to encourage the patient to say more.

• Pausing and nodding your head or remaining silent, yet attentive and relaxed, is a cue for the patient to continue.

• Leaning forward, making eye contact, and using phrases like “Uh-huh,” or “Go on,” or “I’m listening” all enhance the flow of the patient’s story.

Echoing (Repetition)

• Repeating the patient’s last words encourages elaboration on details and feelings.

• Demonstrates careful listening and a subtle connection with the patient by using the same words.

Empathic Responses

• Vital to patient rapport and healing.

• Empathy is “the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner.”

• Requires willingness to suffer some of the patient’s pain in the sharing of suffering that is vital to healing.

• To express empathy, first recognize the patient’s feelings, then actively move toward and elicit emotional content.

• Gently ask: “How do you feel about that?” or “That seems to trouble you, can you say more?”

• Instead of assuming, you can ask: “You have lost your father. What has that been like for you?”

• Empathy may also be nonverbal—placing your hand on the patient’s arm or offering tissues when the patient is crying.

• Reply with understanding and acceptance.

• Responses may be as simple as: “I cannot imagine how hard this must be for you” or “That sounds upsetting” or “You must be feeling sad.”

• For a response to be empathic, it must convey that you feel what the patient is feeling.

Summarization

• Giving a capsule summary of the patient’s story during the course of the interview serves several purposes:

  • Communicates that you have been listening carefully.

  • Identifies what you know and what you don’t know.

• Following with an attentive pause or asking, “Anything else?” allows the patient to add other information and correct any misunderstandings.

• Use summarization at different points in the interview to structure the visit, especially at times of transition.

Transitions

• Tell patients when you are changing directions during the interview.

• Orient the patient with brief transitional phrases like “Now I’d like to ask some questions about your past health.”

• Make clear what the patient should expect or do next.

Partnering

• Express your commitment to an ongoing relationship.

• Make patients feel that no matter what happens, you will continue to provide their care.

Validation

• Validate the legitimacy of his or her emotional experience.

• “Your accident must have been terrifying. Car accidents are always unsettling because they remind us how vulnerable we are. Perhaps that explains why you still feel upset,” validates the patient’s response as legitimate and understandable.

Empowering the Patient

• Clinician–patient relationship is inherently unequal.

• When you empower patients to ask questions, express their concerns, and probe your recommendations, they are most likely to adopt your advice, make lifestyle changes, or take medications as prescribed.

• Techniques for sharing power with your patients:

  • Evoke the patient’s perspective.

  • Convey interest in the person, not just the problem.

  • Follow the patient’s leads.

  • Elicit and validate emotional content.

  • Share information with the patient, especially at transition points during the visit.

  • Make your clinical reasoning transparent to the patient.

  • Reveal the limits of your knowledge.

Reassurance

• The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings.

• Meaningful reassurance comes later after you have completed the interview, the physical examination, and perhaps some laboratory tests.

• Reassurance is more appropriate when the patient feels that problems have been fully understood and are being addressed.

Appropriate Verbal Communication

• The effectiveness of the clinical encounter rests on the use of appropriate language.

Use Understandable Language

• Understandable language uses simple, recognizable and clear words.

• Use short sentences and words and only communicate essential information.

• Avoid saying “Does the pain radiate?” Simply say “Does the pain move anywhere?”

• If you catch yourself using medical jargon or complex words, apologize for it and explain it immediately to your patient using simpler, less complex words or phrases that the patient knows.

• Also use clear and concrete words or phrases, rather than vague ones such as “a little bit,” “common,” “possible,” “rare.”

• Ideally, your patient encounters should focus on one to three key points, and you as the clinician should repeat the points often.

Ask Me Three approach:

• What is my main problem?

• What do I need to do?

• Why is it important for me to do this?

Teach-back method

• Teach back” is not a test of the patient’s knowledge but a test of how well you explained things in a manner your patient understands.

Use Nonstigmatizing Language

• The language we use to reference people should reflect their full identities and acknowledge their capacity to change and grow.

• Use “people-first” language.

  • Instead of “drug abuser,” say “person who uses drugs” or “person with a substance use disorder”.

Appropriate Nonverbal Communication

• Posture, gestures, eye contact, and tone of voice all convey the extent of your interest, attention, acceptance, and understanding

• The skilled interviewer seems calm and unhurried, even when time is limited.

• Mirroring your posture shows the patient’s sense of connection, matching your position to the patient’s can transmit increased rapport.

• Moving closer or making physical contact like placing your hand on the patient’s shoulder can convey empathy and can help the patient gain control of upsetting feelings.

• Nonverbal behavior might be more important than verbal messages in the communication of empathy.

• Forms of Nonverbal Communication

  • Body orientation toward and physical proximity to patient

  • Gaze orientation (eye contact) toward patients

  • Head nodding with facial animation

  • Head nodding with gesture

  • Posture

  • Tone and use of voice

  • Use of silence

  • Use of touch (haptics)

Other Considerations in Communication and Interpersonal Skills

Broaching Sensitive Topics

• Several basic principles can help guide your response to sensitive topics.

• The single most important rule is to be nonjudgmental.

• Explain why you need to know certain information.

• Find opening questions for sensitive topics and learn the specific kinds of information needed for your shared assessment and plan.

• Consciously acknowledge whatever discomfort you are feeling.

Informed Consent

• A communication process in which a clinician educates a patient about the risks, benefits, and alternatives of a given procedure or intervention.

• Required elements for documentation of the informed consent discussion:

  • Nature of the procedure or treatment

  • Risks and benefits of the procedure or treatment

  • Reasonable alternatives

  • Risks and benefits of alternatives

  • Assessment of the patient’s understanding of the first four elements

• Ensure that your patient has the decisional capacity.

• Use understandable language that is not condescending and avoid medical jargon.

• You may want to use the teach-back method to assess how well you explained the information to the patient.

Working with a Medical Interpreter

• Recruiting family members as translators is equally hazardous—it may violate confidentiality, and information may be incomplete, misleading, or harmful.

• The ideal interpreter is a “cultural navigator” who is neutral and trained in both languages and cultures.

• Ask the interpreter to translate everything, not to condense or summarize. Make your questions clear, short, and straightforward.

• Guidelines for Working with an Interpreter: “INTERPRET”

  • I Introductions: Make sure to introduce all the individuals in the room.

  • N Note Goals: Note the goals of the interview. What is the diagnosis? What will the treatment entail? Will there be any follow-up?

  • T Transparency: Let the patient know that everything said will be interpreted throughout the session.

  • E Ethics: Use qualified interpreters (not family members or children) when conducting an interview.

  • R Respect Beliefs: Patient with limited English proficiency (LEP) may have cultural beliefs that need to be taken into account as well.

  • P Patient Focus: The patient should remain the focus of the encounter.

  • R Retain Control: It is vital as the provider that you remain in control of the interaction and not let the patient or the interpreter take over the conversation.

  • E Explain: Use simple language and short sentences when working with an interpreter.

  • T Thanks: Thank the interpreter and the patient for their time.

• Situations best suited for a face-to-face interpreter rather than the use of telephonic interpreter services include:

  • Serious diagnoses or other bad news

  • When the patient is hard-of-hearing

  • Family meetings or group discussions

  • Interaction requires visual elements

  • Complicated or personal medical procedures or news

Advance Directives

• Encourage any adult, but especially adults who are older or chronically ill, to have an advance directive and establish a healthcare proxy or healthcare power of attorney who can act as the patient’s health decision maker.

• Clarifying the patient’s wishes about treatment at the end of life is an important responsibility.

• For patients who are terminally ill or frail and toward the end of life (prognosis is within a year), completion of a Physician Orders for Life Sustaining Treatment (POLST) form (also called Medical Orders for Life-Sustaining Treatment [MOLST]) is recommended.

Disclosing Serious News

• The SPIKES protocol for disclosing serious news has been recommended to guide clinicians due to the complexity of these interactions that can often create serious communication issues.

• The 6-step protocol: Setting up the interview, assessing the patient’s Perception, obtaining the patient’s Invitation, giving Knowledge and information to the patient, addressing the patient’s Emotions with empathic responses and Strategy and Summary.

• SPIKES: The Six-Step Protocol for Delivering Bad News

  • 1: Setting up the interview

    • Arrange for some privacy, Involve significant others, Sit down, Make a connection with the patient, Manage time constraints and interruptions

  • 2: Assessing the patient’s Perception

    • The clinician uses open-ended questions to create a reasonably accurate picture of how the patient perceives the medical situation

  • 3: Obtaining the patient’s Invitation

    • Find out how much the patient wants to know.

  • 4: Giving Knowledge and information to the patient

    • Present information based on the assessed level of patient’s understanding, compliance, and wishes for disclosure.

  • 5: Addressing the patient’s Emotions with Empathic responses

    • Expect the patient’s first response to be an emotion Be prepared to acknowledge the emotion explicitly.

  • 6: Strategy and Summary

    • Ensure that the patient understands the information that has been provided first before discussing the next steps

Motivational Interviewing

• Motivational interviewing is a set of well-documented techniques that improve health outcomes, especially for patients with substance abuse.

• It encourages you to help your patients discover their interest in considering and making a change in their behaviors.

Interprofessional Communication

• Working as a team using effective communication is key in providing efficient, quality care that leads to excellence in patient outcomes.

• Collaboration between disciplines is also critical in minimizing the risk of errors in patient care.

• Mutual respect is essential for interprofessional communication because it helps facilitate a positive environment for setting shared goals, creating collaborative plans, making decisions, and sharing responsibilities.

• One of the frameworks to improve interprofessional communication and teamwork is the SBAR (Situation-Background-Assessment-Recommendation), a shared mental model which provides a clear, concise, and organized framework for communication between clinicians.

• SBAR (Situation-Background-Assessment-Recommendation)

  • Situation “I am…I am calling because…” “I have a patient who is…”

  • Background “The patient was admitted on…because of…”

  • Assessment “I think this patient is likely having a…”

  • Recommendation “Let us transfer…” “Let us monitor and then…”

Challenging Patient Situations and Behaviors

• Silent

• Talkative

• With confusing narrative

• With altered state or cognition

• With emotional lability

• Angry or aggressive

• Flirtatious

• Discriminatory

• With hearing loss

• With low or impaired vision

• With limited intelligence

• Burdened by personal problems

• Nonadherent

• With low literacy

• With low health literacy

• With limited language proficiency

• With terminal illness or dying

Patient Who Is Silent

• Silence has many meanings. Patients fall silent to collect their thoughts, remember details, or decide if they can trust you with certain information.

• Be attentive and respectful and encourage the patient to continue when ready such as “You are quiet . . . What are you thinking about?”

Patient Who Is Talkative

• Give the patient free reign for the first 5 or 10 minutes, while listening carefully.

• Focus on what seems most important to the patient.

• Interrupt only if necessary but be courteous.

• Learn to set limits when needed, since part of your task is structuring the interview to gain valuable information about the patient’s health.

• Finally, avoid showing impatience.

Patient with Confusing Narrative

• Keep several possibilities in mind as you assess why the story is confusing.

• Using your skills of guiding questions, clarification, and summarizing, you can put together a coherent story.

• Watch for an underlying issue; however, that is interfering with communication.

• Shift to the mental status examination, focusing on the level of consciousness, orientation, memory, and capacity to understand.

Patient with Altered State or Cognition

• Obtain historical information from other sources such as family members or caregivers. Always seek the best-informed source.

• Apply the basic principles of interviewing to your conversations with relatives or friends.

• While you are gathering information about the history, you should not disclose information about the patient unless the informant is the healthcare proxy or has a durable power of attorney for health care, or you have permission from the patient.

• You then need to determine whether a patient has “decision-making capacity,” which is the ability to understand information related to health, weigh choices and their consequences, reason through the options, and communicate a choice.

Patient with Emotional Lability

• Crying signals strong emotions, ranging from sadness to anger or frustration. Pausing, gentle probing, or responding with empathy gives the patient permission to cry.

• Crying makes many clinicians uncomfortable. If this is true for you, learn how to accept displays of emotion so you can support patients at these moving and significant times.

Patient Who Is Angry or Aggressive

• Learn to accept angry feelings from patients without getting angry in return or retreating from the patient’s affect.

• Validate patients’ feelings without agreeing with their reasons.

• Before approaching such patients, alert the security staff; ensuring a safe environment is one of your responsibilities.

• Stay calm and avoid being confrontational. Keep your posture relaxed and nonthreatening.

Patient Who Is Flirtatious

• Calmly but firmly set clear limits that your relationship is professional, not personal.

• Think carefully about your own behavior. Has your clothing or demeanor been inappropriate? Have you been overly warm with the patient? It is your responsibility to evaluate and avoid sending any misleading signals to the patient.

Patient Who Is Discriminatory

• Discriminatory patient behavior should be named and processed appropriately, since such interactions with patients can undermine one’s resilience.

• After such an encounter, you should receive additional training as to how and to whom to report further incidents, and come up with next steps or ideal responses, should you encounter further discrimination when caring for your patients.

Patient with Hearing Loss

• Find out the patient’s preferred method of communication. Review responses to written questionnaires.

• If the patient has a hearing aid, find out if the patient is using it. Make sure it is working. For patients with unilateral hearing loss, sit on the hearing side.

• Face patients who can read lips directly, in good light. Patients should put on their glasses to see cues that help them understand you. Speak at a normal volume and rate.

Patient with Low or Impaired Vision

• Shake hands to establish contact and explain who you are and why you are there.

• If the room is unfamiliar, orient the patient to the surroundings and report if anyone else is present.

• Spend more time on verbal explanations because postures and gestures are unseen.

Patient with Limited Intelligence

• If you suspect a disability, pay special attention to the patient’s school record and ability to function independently.

• Find out if the patient is sexually active and provide information about pregnancy or sexually transmitted infections (STIs) if needed.

• For patients with severe mental retardation, turn to family or caregivers for the history, but always show interest in the patient first.

Patient Burdened by Personal Problems

• Ask about what alternatives that the patient has considered, related pros and cons, and others who have provided advice. Letting the patient talk through the problem with you is more therapeutic than giving your own opinions.

Patient Who Is Nonadherent

• Strategies for better adherence include the use of informational handouts; cues and reminders using e-mails or form letters; positive feedback to the patient; steps to minimize discomfort and inconvenience such as simplifying dosing schedule; disease monitoring to alter management; and obtaining counseling, if appropriate.

Patient with Low Literacy

• Before giving written instructions, assess the patient’s ability to read

• Explore the reasons for impaired literacy—language barriers, learning disorders, poor vision, or level of education.

Patient with Low Health Literacy

• Health literacy goes beyond just reading. It includes the practical skills the patient needs to navigate the healthcare environment: print literacy, or the ability to interpret information in documents; numeracy, or the ability to use quantitative information for tasks like understanding food labels or adhering to medication regimens; and oral literacy, or the ability to speak and listen effectively.

Patient with Limited Language Proficiency

• Learning to work with qualified interpreters is essential for optimal outcomes and cost-effective care.

• “If it isn’t culturally and linguistically appropriate, it isn’t health care.”

Patient with Terminal Illness or Who Is Dying

• Offer openings for patients and family members to talk about their feelings and ask questions.

• As defined by the WHO, your goal is “the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”

Being Patient-Centered in Computerized Clinical Settings

• Potentially negative communication behaviors with EHR use include interrupted patient and clinician speech patterns, increased gaze shifts and episodes of multitasking, and low rates of sharing the computer screen with patients.

• Strategies to Maintain Patient-Centeredness in Computerized Clinical Settings

  • Review the patient’s medical record before calling the patient in.

  • Start the visit by asking about the patient’s concerns and building rapport before turning to computer.

  • Move the computer or change the patient’s location to facilitate communication as you use the EHR.

  • Maintain your body orientation toward the patient; maintain consistent eye contact with the patient despite using the EHR.

  • Talk while working on the computer to remain engaged with the patient and break long silences.

  • Visually or verbally share the screen and EHR information with the patient; involve the patient in building their chart.

Learning Communication Skills from Standardized Patients

• SPs are of most value in training students in simple and complex communication skills.

• Tips for Making the Most Out of Learning from Standardized Patients

  • Take the SP encounter seriously.

  • Trust your “patient.”

  • Ask specific questions.

  • Make your “patient” comfortable.

  • Build a connection.

  • Keep your cool.

  • Summarize the encounter.

  • Enjoy the experience.

SBAR: A Tool for Interprofessional Communication

SBAR: Situation-Background-Assessment-Recommendation

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient’s condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.

This tool includes:

• SBAR Guidelines (“Guidelines for Communicating with Physicians Using the SBAR Process”): Explains in detail how to implement the SBAR technique

• SBAR Worksheet: A worksheet/script that a provider can use to organize information in preparation for communicating with a physician about a critically ill patient

Both the worksheet and the guidelines use the physician team member as the example; however, they can be adapted for use with all other health professionals.

Guidelines for Communicating with Physicians Using the SBAR Process

1) Use the following modalities according to physician preference, if known. Wait no longer than five minutes between attempts.

• Direct page (if known)

• Physician’s Call Service

• During weekdays, the physician’s office directly

• On weekends and after hours during the week, physician’s home phone

• Cell phone

Before assuming that the physician you are attempting to reach is not responding, utilize all modalities. For emergent situations, use appropriate resident service as needed to ensure safe patient care. Start by defining the first and the last step in the process—so that everyone has a shared understanding of where the process you’re working on begins and ends.

2) Prior to calling the physician, follow these steps:

• Have I seen and assessed the patient myself before calling?

• Has the situation been discussed with resource nurse or preceptor?

• Review the chart for appropriate physician to call.

• Know the admitting diagnosis and date of admission.

• Have I read the most recent MD progress notes and notes from the nurse who worked the shift ahead of me?

• Have available the following when speaking with the physician:

– Patient’s chart

– List of current medications, allergies, IV fluids, and labs

– Most recent vital signs

– Reporting lab results: provide the date and time test was done and results of previous tests for comparison

– Code status

3) When calling the physician, follow the SBAR process:

(S) Situation: What is the situation you are calling about?

• Identify self, unit, patient, room number.

• Briefly state the problem, what is it, when it happened or started, and how severe.

(B) Background: Pertinent background information related to the situation could include the following:

• The admitting diagnosis and date of admission

• List of current medications, allergies, IV fluids, and labs

• Most recent vital signs

• Lab results: provide the date and time test was done and results of previous tests for comparison

• Other clinical information

• Code status

(A) Assessment: What is the nurse’s assessment of the situation?

(R) Recommendation: What is the nurse’s recommendation or what does he/she want?

Examples:

• Notification that patient has been admitted

• Patient needs to be seen now

• Order change

4) Document the change in the patient’s condition and physician notification.