PHA 3785 Therapeutic Communication and Health History

1. PHA 3785Therapeutic Communicationand Health History Debra A. Allan Danforth, MS, ARNP, FAANP FAMU College of Pharmacy 12/10

2. Legal and Ethical Issues • Legal refers to action or inactions that may be held accountable by law, particularly criminally, and also civil • Ethics moral principles or standards of conduct, and may be held accountable in civil court

3. Legal and Ethical Issues • Autonomy • Beneficence • Nonmaleficence • Utilitarianism • Fairness and justice • Deontologic imperatives

4. Privacy • Refers to the individual and their affairs (Ex. The right to be left alone) • Person’s name • Invasion of privacy • Breach of confidentiality • Autonomy

5. History and Communication

6. What Is Assessment? • A data collection process • A continuous process • Establishes a baseline • A systematic process • Identifies patients’ strengths and limitations • Involves collecting, validating, and clustering data

7. Purpose of Assessment • Collect pertinent patient health status data • Identify abnormal findings • Identify patients’ strengths and coping resources • Pinpoint actual health problems • Identify risk factors for health problems

8. Assessment Skills Cognitive Skills Assessment is a “thinking process” • Inductive and deductive reasoning • Ex. Inductive: used when assessing a post-op patient who state it hurts to take a deep breath • Piece together pertinent data • Ex Deductive: patient is admitted to hospital with CHF. Will look for specific signs and symptoms as you perform the assessment and determines patient’s response to illness • Looking for specific clues to support • Clinical decision making

9. Assessment Skills Problem solving • Reflexive thinking • Is automatic, without conscious deliberations and comes with experience • Trial and error • Is hit or miss thinking-random, not systematic and inefficient • Scientific method • Is a systematic, critical thinking approach to problem solving • Intuition • Is a problem-solving method that develops through experience

10. Assessment Skills Psychomotor Skills Assessment is a “doing” process • Skills needed to perform the 4 techniques of physical assessment • Inspection • Palpation • Percussion • Auscultation

11. Assessment Skills • Interpersonal/Affective Skills Assessment is a “feeling” process • Affective skills needed to develop caring, therapeutic healthcare provider-patient relationships • Include verbal and nonverbal • Establish trust and mutual respect

12. Assessment Skills Ethical Skills Assessment is being responsible and accountable • Responsible & accountable for practice • patient advocate • Respect patients’ rights • Assure confidentiality

13. Types of Assessment • Comprehensive • Ongoing/Partial • Problem focused • Emergency

14. Types of Data • Subjective • Definition: Of, relating to, or designating a symptom or condition perceived by the patient and not by the examiner. • Objective • Definition: Indicating a symptom or condition perceived as a sign of disease by someone other than the person affected.

15. Identify Subjective or Objective • Headache • BP 170/110 • Nausea • Diaphoresis • Equal pupil reaction • Dizziness • Slurred speech • Numbness in left arm

16. Therapeutic Communication

17. Central Objectives of Interacting with a patient • To find out what is at the root of that person’s concern • To help them in doing something about • What does a patient need? • What is the patient worried about? • What does the patient expect of you?

18. History and Physical • The heart of the diagnosis and treatment process • Must be done in an orderly process • Must also be sensitive to the “soft” cues that are almost always there

19. Goals of Patient Interview • Information discovery • Providing information to the patient • Negotiating with the patient regarding treatment management • Counseling regarding disease prevention

20. Ineffectiveness of Most Communication • Most people do not communicate well • Causes an interpersonal gap and isolates people from each other

21. Communication Barriers • A barrier to communication is something that keeps meanings from meeting • Without realizing, people typically inject communication barriers over 90% of the time when one or both parties has a problem to be dealt with or a need to be fulfilled

22. Why are they High-Risk Responses? • They block conversation • Increase emotional distance between people • Thwart the other person’s problem-solving efficiency

23. Categories of Barriers • The “Dirty Dozen” of barriers to communication can be divided into three major categories • Judging • Sending Solutions • Avoiding Other’s Concerns

24. Judging • Criticizing • Name-calling • Diagnosing

25. Sending Solutions • Ordering • Threatening • Moralizing • Excessive/Inappropriate Questioning • Advising

26. Avoiding the Other’s Concerns • Diverting • Logical Argument • Reassuring

27. Listening: More Than Merely Hearing • Listening refers to a more complex psychological procedure involving interpreting and understanding the significance of the sensory experience

28. Attending Skills A posture of involvement Appropriate body motion Eye contact Nondistracting environment Listening Skill Clusters

29. Following Skills Door openers Minimal encouragers Infrequent questions Attentive silence Listening Skill Clusters

30. Paraphrasing Reflecting feelings Reflecting meanings Summative reflections Listening Skill Clusters • Reflecting Skills

31. Paraphrasing • Concise response • Essence of content • Listener’s own word

32. Reflecting Feelings • Improve capacity to “hear” feelings • Listening for feeling words • Inferring feelings from the overall content • Observing body language • “What would I be feeling?”

33. Reflecting Meanings • “You feel…because” • Validation of Data • Using technical terms • Not allowing patient to finish answer • Too many questions • Failure to find out patient’s interpretation

34. Summative Reflections • Brief restatement of main themes and feelings speaker expressed • Gives speaker feeling of movement in exploring content and feeling

35. Open Ended Questions Closed Questions Affirmation/Facilitation Silence Clarifying Restating Active Listening Reflection Humor Informing Redirecting Focusing Sharing Perception Identifying Sequencing Events Suggesting Presenting Reality Summarizing Interview –Communication Techniques

36. Open End Questions • Advantages • Elicits a response • Effective in stimulating descriptive or comparative responses • Allows patient to disclose information when he/she is ready • Provides clues to alertness, level of mental abilities, organization of thought through vocabulary • Rapport is strengthened

37. Open End Questions • Disadvantages • Response not relevant • Digress to avoid disturbing data • Anxiety increased if not articulated

38. Advantages Requires no more than 1-2 words Used more initial interview Disadvantages Limits answers Closed Questions

39. Affirmation/Facilitation • Acknowledge patient’s response through verbal and nonverbal response • Reassures you are listening • Nodding, sitting up and leaning forward are nonverbal ques • Verbal cues • “ah ha”, “go on”, “tell me more”

40. Silence • Silence allows patient to collect thoughts before responding and help prevent hasty responses • More uncomfortable for interviewer than interviewee • Gives interviewer time to think and plan response • Focus on patient’s nonverbal behavior

41. Clarifying • If unsure or confused what patient says, rephrase • “let’s me see if I have this right” • “ I’m not sure what you mean”

42. Restating • Restating the main idea shows the patient that you are listening, allows acknowledgement of feelings, and encourages further discussion • Also helps to clarify and validate what your patient has said and may help identify teaching needs • “I take a water pill every day for my blood pressure” • “I see you take Lasix for your blood pressure” • “NO, I take a water pill”

43. Active Listening • Pay attention • Eye contact • Listen to what patient tell you both verbally and nonverbally • Conveys interest and acceptance • Watch your own body language

44. Reflection • Acknowledge patient’s feelings • “I’m afraid of having surgery” • “You’re afraid of having surgery?” • Encourage further discussion

45. Humor • Can be very therapeutic • Reduces anxiety • Helps to cope more effectively • Puts things into perspective • Decreases social distance

46. Informing • Giving information helps the patient with making decisions on their healthcare • Teaching pre-operatively how to do a procedure post-operative like coughing and deep breathing can help the patient in the long run

47. Redirecting • Helps to keep communication goal-directed • To get back on track • “Getting back to what brought you to the clinic…”

48. Focusing • Allows to hone in on a specific area • Encourages further discussion • “Do you do SBE?” • “Have you had a MMG?” • “Do you do a testicular exam?”

49. Suggesting • Presenting alternative ideas gives your patient options • Helpful if patient is having difficulty verbalizing feelings • Good teaching tool • “I’ve tried to lose weight and I can’t” • “Have you tried diet and exercise”

50. Summarizing • Useful conclusion • Allows patient to clarify any misconceptions • “let me see if I have this correct”