The Patient Interview

Published on 23/05/2015 by admin

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The Patient Interview

Chapter Objectives

After reading this chapter, you will be able to:

• Describe the major items found on a patient history form.

• Explain the primary tasks performed during the patient interview.

• Describe the internal factors the practitioner brings to the interview.

• Discuss the external factors that provide a good physical setting for the interview.

• Differentiate between open-ended questions and closed or direct questions.

• Describe the following nine types of verbal responses:

• Facilitation

• Clarification

• Confrontation

• Interpretation

• Explanation

• Describe why the following are nonproductive verbal messages:

• Providing assurance or reassurance

• Giving advice

• Using authority

• Using avoidance language

• Professional jargon

• Asking leading or biased questions

• Talking too much

• Interrupting and anticipating

• Using “why” questions

• List positive and negative nonverbal messages of the interview, including:

• Physical appearance

• Facial expression

• Eye contact

• Describe how to close the interview.

• Define key terms and complete self-asessment questions at the end of the chapter and on Evolve.

Patient History

A complete patient assessment includes the patient interview. The purpose of the patient history is to gather pertinent subjective and objective data, which in turn can be used to develop a more complete picture of the patient’s past and present health. In most clinical settings the patient is asked to fill out a printed history form or checklist. The patient should be allowed ample time to recall important dates, health-related landmarks, and family history. The patient interview is then used to validate what the patient has written and collect additional data on the patient’s health status and lifestyle. Although history forms vary, most contain the following:

• Biographic data (age, gender, occupation)

• The patient’s chief complaint or reason for seeking care, including the onset, duration, and characteristics of the signs and symptoms

• Present health or history of present illness

• Past health, including childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, last examination date, allergies, current medications, and history of smoking or other habits

• The patient’s family history

• Review of each body system, including skin, head, eyes, ears and nose, mouth and throat, respiratory system, cardiovascular system, gastrointestinal system, urinary system, genital system, and endocrine system

• Functional assessment (activities of daily living), including activity and exercise, work performance, sleep and rest, nutrition, interpersonal relationships, and coping and stress management strategies

Patient Interview

The interview is a meeting between the respiratory care practitioner and the patient. It allows the collection of subjective data about the patient’s feelings regarding the condition. During a successful interview, the practitioner performs the following tasks:

1. Gathers complete and accurate data about the patient’s impressions about his or her health, including a description and chronology of any symptoms

2. Establishes rapport and trust so the patient feels accepted and comfortable in sharing all relevant information

3. Develops and shows an understanding about the patient’s health state, which in turn enhances the patient’s participation in identifying problems

4. Builds rapport to secure a continuing working relationship, which facilitates future assessments, evaluations, and treatment plans

Interview skills are an art form that takes time—and experience—to develop. The most important components of a successful interview are communication and understanding. Understanding the various signals of communication is the most difficult part. When understanding (conveying of meaning) breaks down between the practitioner and the patient, no communication can occur. Communication cannot be assumed just because two people have the ability to speak and listen. Communication is about behaviors—conscious and unconscious, verbal and nonverbal. All these behaviors convey meaning. The following paragraphs describe important factors that enhance the sending and receiving of information during communication.

Internal Factors

Internal factors encompass what the practitioner brings to the interview—a genuine concern for others, empathy, understanding, and the ability to listen. A genuine liking of other people is essential in developing a strong rapport with the patient. It requires a generally optimistic view of people, a positive view of their strengths, and an acceptance of their weaknesses. This affection generates an atmosphere of warmth and caring. The patient must feel accepted unconditionally.

Empathy is the art of viewing the world from the patient’s point of view while remaining separate from it. Empathy entails recognition and acceptance of the patient’s feelings without criticism. It is sometimes described as feeling with the patient rather than feeling like the patient. To have empathy the practitioner needs to listen. Listening is not a passive process. Listening is active and demanding. It requires the practitioner’s complete attention. If the examiner is preoccupied with personal needs or concerns, he or she will invariably miss something important. Active listening is a cornerstone to understanding. Nearly everything the patient says or does is relevant.

During the interview the examiner should observe the patient’s body language and note the patient’s facial expressions, eye movement (e.g., avoiding eye contact, looking into space, diverting gaze), pain grimaces, restlessness, and sighing. The examiner should listen to the way things are said. For example, is the tone of the patient’s voice normal? Does the patient’s voice quiver? Are there pitch breaks in the patient’s voice? Does the patient say only a few words and then take a breath?

External Factors

External factors such as a good physical setting enhances the interviewing process. Regardless of the interview’s setting (the patient’s bedside, an office in the hospital or clinic, or the patient’s home), efforts should be made to (1) ensure privacy, (2) prevent interruptions, and (3) secure a comfortable physical environment (e.g., comfortable room temperature, sufficient lighting, absence of noise).

Techniques of Communication

During the interview the patient should be addressed by his or her surname, and the examiner should introduce himself or herself and state the purpose for being there. The following introduction serves as an example: “Good morning, Mr. Jones. I’m Mrs. Smith, and I’m from Respiratory Care. I want to ask you some questions about your breathing so that we can plan your respiratory care here in the hospital.”

Verbal skills and techniques used by the examiner to facilitate the interview may include open-ended questions, closed or direct questions, and responses.

Open-Ended Questions

An open-ended question asks the patient to provide narrative information. The examiner identifies the topic to be discussed but only in general terms. This technique is commonly used (1) to begin the interview, (2) to introduce a new section of questions, or (3) to gather further information whenever the patient introduces a new topic. The following are examples of open-ended questions:

“What brings you to the hospital today?”

“Tell me why you have come to the hospital today.”

“How has your breathing been getting along?”

“You said that you have been short of breath. Tell me more about that.”

The open-ended question is unbiased; it allows the patient freedom to answer in any way. This type of question encourages the patient to respond at greater length and give a spontaneous account of the condition. As the patient answers, the examiner should stop and listen. Patients often answer in short phrases or sentences and then pause, waiting for some kind of direction from the examiner. What the examiner does next is often the key to the direction of the interview. If the examiner presents new questions on other topics, much of the initial story may be lost. Ideally, the examiner should first respond by saying such things as “Tell me about it” and “Anything else?” The patient will usually add important information to the story.

Closed or Direct Questions

A closed or direct question asks the patient for specific information. This type of question elicits a short one- or two-word answer, a yes or no, or a forced choice. The closed question is commonly used after the patient’s narrative to fill in any details the patient may have left out. Closed questions also are used to obtain specific facts, such as “Have you ever had this chest pain before?” Closed or direct questions speed up the interview. The use of only open-ended questions is unwieldy and takes an unrealistic amount of time, causing undue stress in the patient. Box 1-1 compares closed and open-ended questions.

Box 1-1 Comparison of Closed and Open-Ended Questions

Open-Ended	Closed
Used for narrative	Used for specific information
Call for long answers	Call for short one- or two-word answers
Elicit feelings, options, ideas	Elicit “cold facts”
Build and enhance rapport	Limit rapport and leave interaction neutral

Responses—Assisting the Narrative

As the patient answers the open-ended questions, the examiner’s role is to encourage free expression but not to let the patient digress. The examiner’s responses work to clarify the story. There are nine types of verbal responses. In the first five responses the patient leads; in the last four responses the examiner leads.

The first five responses require the examiner’s reactions to the facts or feelings the patient has communicated. The examiner’s response focuses on the patient’s frame of reference; the examiner’s frame of reference is not relevant. For the last four responses the examiner’s reaction is not required. The frame of reference shifts from the patient’s perspective to the examiner’s. These responses include the examiner’s thoughts or feelings. The examiner should use these responses only when the situation calls for them. If these responses are used too often, the interview becomes focused more on the examiner than on the patient. The nine responses are described in the following sections.

Facilitation

Facilitation encourages patients to say more, to continue with the story. Examples of facilitating responses include the following: “Mm hmm,” “Go on,” “Continue,” “Uh-huh.” This type of response shows patients that the examiner is interested in what they are saying and will listen further. Nonverbal cues, such as maintaining eye contact and shifting forward in the seat, also encourage the patient to continue talking.

Silence

Silent attentiveness is effective after an open-ended question. Silence communicates that the patient has time to think and organize what he or she wishes to say without interruption by the examiner.

Reflection

Reflection is used to echo the patient’s words. The examiner repeats a part of what the patient has just said to clarify or stimulate further communication. Reflection helps the patient focus on specific areas and continue in his or her own way. The following is a good example:

PATIENT: “I’m here because of my breathing. It’s blocked.”

EXAMINER: “It’s blocked?”

PATIENT: “Yes, every time I try to exhale, something blocks my breath and prevents me from getting all my air out.”

Reflection also can be used to express the emotions implicit in the patient’s words. The examiner focuses on these emotions and encourages the patient to elaborate:

PATIENT: “I have three little ones at home. I’m so worried they’re not getting the care they need.”

EXAMINER: “You feel worried and anxious about your children.”

The examiner acts as a mirror reflecting the patient’s words and feelings. This technique helps the patient elaborate on the problem.

Empathy

Empathy is defined as the identification of oneself with another and the resulting capacity to feel or experience sensations, emotions, or thoughts similar to those being experienced by another person. It is often characterized as the ability to “put oneself into another’s shoes.” A physical symptom, condition, or disease frequently has accompanying emotions. Patients often have trouble expressing these feelings. An empathic response recognizes these feelings and allows expression of them:

PATIENT: “This is just great! I used to work out every day, and now I don’t have enough breath to walk up the stairs!”

EXAMINER: “It must be hard—you used to exercise every day, and now you can’t do a fraction of what you used to do.”

The examiner’s response does not cut off further communication, which would occur by giving false reassurance (e.g., “Oh, you’ll be back on your feet in no time”). Also, it does not deny the patient’s feelings, nor does it suggest that the patient’s feelings are unjustified. An empathic response recognizes the patient’s feelings, accepts them, and allows the patient to express them without embarrassment. It strengthens rapport.

Clarification

Clarification is used when the patient’s choice of words is ambiguous or confusing:

“Tell me what you mean by bad air.”

Clarification also is used to summarize and simplify the patient’s words. When simplifying the patient’s words, the examiner should ask whether the paraphrase is accurate. The examiner is asking for agreement, and this allows the patient to confirm or deny the examiner’s understanding.

Confrontation

In using confrontation, the examiner notes a certain action, feeling, or statement made by the patient and focuses the patient’s attention on it:

“You said it doesn’t hurt when you cough, but when you cough you grimace.”

Alternatively, the examiner may focus on the patient’s affect:

“You look depressed today.”

“You sound angry.”

Interpretation

Interpretation links events and data, makes associations, and implies causes. It provides the basis for inference or conclusion:

“It seems that every time you have a serious asthma attack, you have had some kind of stress in your life.”

The examiner runs the risk of making an incorrect inference. However, even if the patient corrects the inference, the patient’s response often serves to prompt further discussion of the topic.

Explanation

Explanation provides the patient with factual and objective information:

“It is very common for your heart rate to increase a bit after a bronchodilator treatment.”

Summary

The summary is the final overview of the examiner’s understanding of the patient’s statements. It condenses the facts and presents an outline of the way the examiner perceives the patient’s respiratory status. It is a type of validation in that the patient can agree or disagree with the examiner’s summary. Both the examiner and the patient should participate in the summary. The summary signals that the interview is about to end.

Nonproductive Verbal Messages

In addition to the verbal techniques commonly used to enhance the interview, the examiner must refrain from making nonproductive verbal messages. These defeating messages restrict the patient’s response. They act as barriers to obtaining data and establishing rapport.

Providing Assurance or Reassurance

Providing assurance or reassurance gives the examiner the false sense of having provided comfort. In fact, this type of response probably does more to relieve the examiner’s anxiety than that of the patient.

PATIENT: “I’m so worried about the mass the doctor found on my chest x-ray. I hope it doesn’t turn out to be cancer! What happens to your lung?”

EXAMINER: “Now, don’t worry. I’m sure you will be all right. You have a very good doctor.”

The examiner’s response trivializes the patient’s concern and effectively halts further communication about the topic. Instead, the examiner might have responded in a more empathic way:

“You are really worried about that mass on your x-ray, aren’t you? It must be very hard to wait for the lab results.”

This response acknowledges the patient’s feelings and concerns and, more important, keeps the door open for further communication.

Giving Advice

A key step in professional growth is to know when to give advice and when to refrain from it. Patients will often seek the examiner’s professional advice and opinion on a specific topic:

“What types of things should I avoid to keep my asthma under control?”

This is a straightforward request for information that the examiner has and the patient needs. The examiner should respond directly, and the answer should be based on knowledge and experience. The examiner should refrain from dispensing advice that is based on a hunch or feeling. For example, consider the patient who has just seen the doctor:

“Dr. Johnson has just told me I may need an operation to remove the mass they found in my lungs. I just don’t know. What would you do?”

If the examiner answers, the accountability for the decision shifts from the patient to the examiner. The examiner is not the patient. The patient must work this problem out. In fact, the patient probably does not really want to know what the examiner would do. In this case, the patient is worried about what he or she might have to do. A better response is reflection:

EXAMINER: “Have an operation?”

PATIENT: “Yes, and I’ve never been put to sleep before. What do they do if you don’t wake up?”

Now the examiner knows the patient’s real concern and can work to help the patient deal with it. For the patient to accept advice, it must be meaningful and appropriate. For example, in planning pulmonary rehabilitation for a male patient with severe emphysema, the respiratory therapist advises him to undertake a moderate walking program. The patient may treat the therapist’s advice in one of two ways—either follow it or not. Indeed, the patient may choose to ignore it, feeling that it is not appropriate for him (e.g., he feels he gets plenty of exercise at work anyway).

On the other hand, if the patient follows the therapist’s advice, three outcomes are possible: The patient’s condition stays the same, improves, or worsens. If the walking strengthens the patient, the condition improves. However, if the patient was not part of the decision-making process to initiate a walking program, the psychologic reward is limited, promoting further dependency. If the walking program does not improve his condition or compromises it, the advice did not work. Because the advice was not the patient’s, he can avoid any responsibility for the failure:

“See, I did what you advised me to do, and it didn’t help. In fact, I feel worse! Why did you tell me to do this anyway?”

Although giving advice might be faster, the examiner should take the time to involve the patient in the problem-solving process. A patient who is an active player in the decision-making process is more likely to learn and modify behavior.

Using Authority

The examiner should avoid responses that promote dependency and inferiority:

“Now, your doctor and therapist know best.”

Although the examiner and the patient cannot have equality in terms of professional skills and experience, both are equally worthy human beings and owe each other respect.

Using Avoidance Language

When talking about potentially frightening topics, people often use euphemisms (e.g., “passed on” rather than “died”) to avoid reality or hide their true feelings. Although the use of euphemisms may appear to make a topic less frightening, it does not make the topic or the fear go away. In fact, not talking about a frightening subject suppresses the patient’s feelings and often makes the patient more fearful. The use of direct and clear language is the best way to deal with potentially uncomfortable topics.

Distancing

Distancing is the use of impersonal conversation that places space between a frightening topic and the speaker. For example, a patient with a lung mass may say, “A friend of mine has a tumor on her lung. She is afraid that she may need an operation” or “There is a tumor in the left lung.” By using “the” rather than “my,” the patient can deny any association with the tumor. Occasionally, health-care workers also use distancing to soften reality. As a general rule, this technique does not work because it communicates to the patient that the health-care practitioner also is afraid of the topic. The use of frank, specific terms usually helps defuse anxiety rather than causing it.

Professional Jargon

What a health-care worker calls a myocardial infarction, a patient calls a heart attack. The use of professional jargon can sound exclusionary and paternalistic to the patient. Health-care practitioners should always try to adjust their vocabulary to the patient’s understanding without sounding condescending. Even if patients use medical terms, the examiner cannot assume that they fully understand the meaning. For example, patients often think the term hypertension means that they are very tense and therefore take their medication only when they are feeling stressed, not when they feel relaxed.

Asking Leading or Biased Questions

Asking a patient “You don’t smoke anymore, do you?” implies that one answer is better than another. The patient is forced either to answer in a way corresponding to the examiner’s values or to feel guilty when admitting the other answer. When responding to this type of question, the patient risks the examiner’s disapproval and possible alienation, which are undesirable responses from the patient’s point of view.

Talking Too Much

Some examiners feel that helpfulness is directly related to verbal productivity. If they have spent the session talking, they leave feeling that they have met the patient’s needs. In fact, the opposite is true. The patient needs time to talk. As a general rule, the examiner should listen more than talk.

Interrupting and Anticipating

While patients are speaking, the examiner should refrain from interrupting them, even when the examiner believes that she or he knows what is about to be said. Interruptions do not facilitate the interview. Rather, they communicate to the patient that the examiner is impatient or bored with the interview. Another trap is thinking about the next question while the patient is answering the last one, or anticipating the answer. Examiners who are overly preoccupied with their role as interviewer are not really listening to the patient. As a general rule the examiner should allow a second or so of silence between the patient’s statement and the next question.

Using “Why” Questions

The examiner should be careful in presenting “why” questions. The use of “why” questions often implies blame; it puts the patient on the defensive:

“Why did you wait so long before calling your doctor?”

“Why didn’t you take your asthma medication with you?”

The only possible answer to a “why” question is “because…,” and this places the patient in an uncomfortable position. To avoid this trap, the examiner might say, “I noticed you didn’t call your doctor right away when you were having trouble breathing. I’d like to find out what was happening during this time.”

Nonverbal Skills

Nonverbal skills of communication include physical appearance, posture, gestures, facial expression, eye contact, voice, and touch. Nonverbal messages are important in establishing rapport and conveying feelings. Nonverbal messages may either support or contradict verbal messages. Therefore an awareness of the nonverbal messages that may be conveyed by either the patient or the examiner during the interview process is important. Box 1-2 provides an overview of nonverbal messages that may occur during an interview.

Box 1-2 Nonverbal Messages of the Interview

Positive	Negative
Professional appearance	Nonprofessional appearance
Sitting next to patient	Sitting behind a desk
Close proximity to patient	Far away from patient
Turned toward patient	Turned away from patient
Relaxed, open posture	Tense, closed posture
Leaning toward patient	Slouched away from patient
Facilitating gestures	Nonfacilitating gestures
• Nodding of head	• Looking at watch
Positive facial expressions	Negative facial expressions
• Appropriate smiling	• Frowning
• Interest	• Yawning
Good eye contact	Poor eye contact
Moderate tone of voice	Strident, high-pitched voice
Moderate rate of speech	Speech too fast or too slow
Appropriate touch	Overly frequent or inappropriate touch

Physical Appearance

The examiner’s general personal appearance, grooming, and choice of clothing send a message to the patient. Professional dress codes vary among hospitals and clinical settings. Depending on the setting, a professional uniform can project a message that ranges from comfortable or casual to formal or distant. Regardless of one’s personal choice in clothing and general appearance, the aim should be to convey a competent and professional image.

Posture

An open position is one in which a communicator extends the large muscle groups (i.e., arms and legs are not crossed). An open position shows relaxation, physical comfort, and a willingness to share information. A closed position, with arms and legs crossed, sends a defensive and anxious message. The examiner should be aware of any posture changes. For example, if the patient suddenly shifts from a relaxed to a tense position, it suggests discomfort with the topic. In addition, the examiner should try to sit comfortably next to the patient during the interview. Sitting too far away or standing over the patient often sends a negative nonverbal message.

Gestures

Gestures send nonverbal messages. For example, pointing a finger may show anger or blame. Nodding of the head or an open hand with the palms turned upward can show acceptance, attention, or agreement. Wringing the hands suggests worry and anxiety. The patient often describes a crushing chest pain by holding a fist in front of the sternum. When a patient has a sharp, localized pain, one finger is commonly used to point to the exact spot.

Facial Expression

An individual’s face can convey a wide range of emotions and conditions. For example, facial expressions can reflect alertness, relaxation, anxiety, anger, suspicion, and pain. The examiner should work to convey an attentive, sincere, and interested expression. Patient rapport will deteriorate if the examiner exhibits facial expressions that suggest boredom, distraction, disgust, criticism, and disbelief.

Eye Contact

Lack of eye contact suggests that a person may be insecure, intimidated, shy, withdrawn, confused, bored, apathetic, or depressed. The examiner should work to maintain good eye contact but not stare the patient down with a fixed, penetrating look. Generally, an easy gaze toward the patient’s eyes with occasional glances away works well. The examiner, however, should be aware that this approach may not work when interviewing a patient from a culture in which direct eye contact is generally avoided. For example, Asian, Native American, Indochinese, Arab, and some Appalachian people may consider direct eye contact impolite or aggressive, and they may avert their own eyes during the interview.

Voice

Nonverbal messages are reflected through the tone of voice, intensity and rate of speech, pitch, and long pauses. These messages often convey more meaning than the spoken word. For example, a patient’s voice may show sarcasm, anxiety, sympathy, or hostility. An anxious patient frequently talks in a loud and fast voice. A soft voice may reflect shyness and fear. A patient with hearing impairment generally speaks in a loud voice. Long pauses may have important meanings. For instance, when a patient pauses for a long time before answering an easy and straightforward question, the honesty of the answer may be questionable. Slow speech with long and frequent pauses, combined with a weak and monotonous voice, suggests depression.

Touch

The meaning of touch is often misinterpreted; it can be influenced by an individual’s age, gender, cultural background, past experiences, and the present setting. As a general rule, the examiner should not touch patients during interviews unless he or she knows the patient well and is sure that the gesture will be interpreted correctly. When appropriate, touch (such as a touch of the hand or arm) can be effective in conveying empathy.

To summarize, extensive nonverbal messages, communicated by both the examiner and patient, may be conveyed during the interview. Therefore the examiner must be aware of the patient’s various nonverbal messages while working to communicate nonverbal messages that are productive and enhancing to the examiner-patient relationship.

Closing the Interview

The interview should end gracefully. If the session has an abrupt or awkward closing, the patient may be left with a negative impression. This final moment may destroy any rapport gained during the interview. To ease into the closing, the examiner might ask the patient one of the following questions:

“Is there anything else that you would like to talk about?”

“Do you have any questions that you would like to ask me?”

“Are there any other problems that we have not discussed?”

These types of questions give the patient an opportunity for self-expression. The examiner may choose to summarize or repeat what was learned during the interview. This serves as a final statement of the examiner’s and the patient’s assessment of the situation. Finally, the examiner should thank the patient for the time and cooperation provided during the interview.

Related

Clinical Manifestations _ Assessment of Respiratory Disease