Basic Health Assessment: Interviewing Skills

1. Basic Health Assessment:Interviewing Skills

2. Interviewing The single most important skill you will need in conducting a health assessment!! If you never touch the person, but you can conduct a good interview, you have at least an 80% chance of coming up with the correct diagnosis

3. The Process of Communication • Exchanging ideas, information and feelings • Understanding another person’s point of view

4. Interview Outcomes • To establish a working relationship between the care giver and the care seeker • To obtain accurate information about the care seekers state of health – physically, psychologically, socio-culturally and spiritually. • To participate with care seekers in identifying concerns and enhancing their health status.

5. Good Interviewing Skills • Results in complete and reliable information • Inspires trust and confidence • Produce a state of comfort • Enhances the likelihood that a person will participate in her care.

6. Poor Interviewing Skills • Increases fear • Creates gaps in information • Greater likelihood of an inaccurate diagnosis • Alienates the care seekers involvement with her care

7. The Art and Science of Interviewing • An open attitude • A basic curiosity – detective work! • Transcending ethnic and cultural barriers • Knowledge of one’s biases • Knowledge of pathophysiology

8. The “Patient” – A Social Role • Health professionals define “appropriate” behavior for those seeking care • The “patient” is required to trust the care provider and follow the instructions • This role creates a passive recipient of care and a desire to please the care provider

9. The Health Provider – Social Role • An authority figure • Reflection of her own social history and culture • A professional discipline and demeanor

10. The Relationship:Care Seeker and Care Provider • Three types (Szasz and Hollender): 1. activity-passivity 2. guidance-cooperation 3. mutual participation

11. Activity-Passivity Relationship • Provider is the authority • The care seeker feels no autonomy • The care seeker wants to please the provider • The care seeker does not actively participate • Works for emergencies but awful for diagnostic interviews and data gathering

12. The Guidance-Cooperation Relationship • Care provider still maintains most of the authority • The care seeker is obedient but has a greater feeling of autonomy and participates more • The desire to please the care provider may still cause the care seeker to withhold information.

13. The Mutual-Participation Relationship • The care seeker feels some responsibility for a successful outcome • The care provider does not foster a feeling of dependence • The best approach for a diagnostic interview and also for the management of chronic illness!

14. The Interview Setting • A need for comfort – comfortable seating and clothes on!! • A need for privacy – not in the hall, doors closed • Few interruptions – phones, pagers, personnel

15. Preparation for the Interview Process • Preparation – Read the chart!!! • If the person is coming in with a complaint that is unfamiliar to you, look it up! • Build rapport – acknowledge any signs of anxiety, nervousness or distress.

16. Orientation • Introduce yourself: name, role. • Ask the person how she prefers to be named –Ms, Mrs, Sally. • Specify length of time for the interview. • Ensure privacy, comfort and confidentiality • Clarify expectations – so neither person will be frustrated • Remember – expectations are often based on past experiences

17. Understand YOUR Expectations! Consider the following possibilities: • Patients must cooperate • Patients will trust health professionals • Patients will be open and frank with health professionals • Patients will voluntarily disclose important information • Patients will be willing to surrender their autonomy • Patients will recognize and accept your authority • Patients must exhibit some suffering • Patients who don’t meet expectations are labeled as “bad”, “problems”, or “non compliant”.

18. Beginning the Interview • Open ended questions are critical: • How are you today? • What brings you here today? • What problems have you been having? NEVER begin an interview with direct questioning!

19. Working Phase • Obtain information using good communication skills • Identify health problems and concerns • Acknowledge care seekers feelings by communicating sincere interest and conveying empathy • Provide information and instructions – often a very sensitive part of the interview – some reactions may be emotional, defensive, incongruent.

20. Termination • Pre Summary – provide a five minute signal that the time is almost up. • Allow for final input: “Is there anything else I should know about you?” • Summary – Clarify misunderstandings or differing perceptions • Determine the agenda for subsequent interviews or follow up • Review – what has been learned during the interview • Instructions for what should be done (or avoided) following the interview.

21. Follow Up • Explain that this data should be updated as needed. • Planned interventions should be explained • Communication is continuous!!!!

22. Terminating the Session • Always express appreciation for the input received and your hope that her needs will be met • Give exit cues: stand up, say good bye, walk to the door • Verbal and non verbal cues to terminate must be congruent

23. Care Providers Non Verbal Communication • Can be even more powerful than verbal cues • No papers, forms, questionnaires!!! • Watch your body language: no crossed arms, fidgeting, examining the chart, slumping with fatigue. • Position chairs diagonally, use eye contact, leaning towards, attentive listening.

24. Care Seekers Non Verbal Communication • Watch care seekers body language and reflect on it….you appear to be in pain, you look frightened. • Pay attention to silences or signs of tension or discomfort - possible indication that you are being too direct with your questioning. • Indication of emotion – frown, teary eyes

25. Interviewing Techniques:Facilitation • Encouraging communication by manner, gesture or words. • Examples: • A nod of the head, leaning forward • “I’m listening” • “Go on” • “yes”, “I see” • “I don’t follow you” , “tell me more”

26. Interviewing Techniques:Confrontation • The interviewer describes something about the care seekers verbal or non verbal behavior. • “You sound angry” • “I notice you are rubbing your abdomen” • “You seem frightened” These statements are based on the care providers observations and are expressed as a way to clarify and provide further explanation and/or details.

27. More Examples of Gentle Confrontation • “I get the impression that you are angry.” • “I notice you’re trembling.” • “You look worried.” • “You look like you want to cry.” Important to provide some silence after these statements to allow the care seeker to formulate a response in a relaxed and trusting environment.

28. Pitfalls in using Confrontation • CAREFUL – do not use this as an opportunity to ask direct questions such as the following: • “Why are you uncomfortable?” • :Why do you have so little to say?” This kind of direct confrontational questioning puts additional pressure on the care seeker before a trusting relationship has been established.

29. Supportive Approaches • Especially useful when confrontation approaches result in emotional responses. • “ I understand.” • “That must be very upsetting.” Words alone are NOT sufficient – actions must also display genuine warmth, interest and caring.

30. Reassurance • Must be based on facts – NOT clichés such as: • “Oh, I’m sure it will be okay.” • “Don’t worry about that.” • “We’ll take care of that.”

31. Direct Questioning • Indicated AFTER the person has shared her story. • Must use care in avoiding bias. • Examples: • “Have you ever had a pregnancy terminated?” OR “Have you had any abortions?” • Words are loaded with meanings that can potentially communicate disapproval or surprise.

32. Appropriate Use of Direct Questioning • Symptom analysis (complete discussion to come ) • Review of Systems (more to come) • Think of the interview process as going from the broad to the specific – not the other way around!

33. Communication Difficulties • Examples: • Speaks another language • Deaf • Blind • Aphasic • Delirious

34. Using Communicators • Temptation to establish a relationship with the translator rather than the care seeker. • Look at the care seeker – not the translator, when making inquiries. • The care seeker must be assured of confidentiality. • Be even more attentive to non verbal cues and respond appropriately.

35. Special Interviewing Approaches With Those Who Are Blind • Visual and non verbal cues are absent. • Tone of voice, sound of body movements, laughter – all critically important. • Give an opportunity to ask questions about the environment before proceeding – especially in primary care settings where one can be moved to several different rooms.

36. Inappropriate Behavior With the Visually Impaired • Do NOT raise the level of your normal conversational tone of voice • Do NOT change the normal pace of your speech • Do NOT over-articulate • Do NOT speak in short, simple sentences These are common approaches to the visually impaired and do NOT help in establishing a mutual partnership.

37. Challenging Interview Situations:Silence • Silence – learn how to deal with it! • The discomfort is usually a reflection of the clinicians own tension. • Important to allow time for the care seeker to collect her thoughts. • If silence is prolonged – might indicate depression. • Could also indicate an offended person – something you said or did early on in the interview.

38. Challenging Interview Situations:The Over-talkative Person • Some persons give VERY detailed accounts of their history (ex. Edith on All in the Family ) • Try not to facilitate this by using encouraging statements or gestures. • Some people are just not organized with their thoughts and need some gentle guidance in staying on track

39. Challenging Interview Situations:The Angry Person • Anger is often born of fear……..fear of illness and what it means, fear of loosing control, fear of procedures, fear of strange health providers. • Sometimes the interviewer provokes anger with sarcasm, moralistic comments, an air of superiority. • Sometimes it is displaced anger – perhaps coming from treatment by the receptionist in the waiting room or possibly because the appointment has been delayed.

40. Anger Management during the Interview Process • Avoid responding in kind! • Try and determine the reason for the anger…..”you sound very angry.” • Carefully examine your own behavior to determine if you have provoked or added to this anger. • Offer to work with the person in attempting to resolve the issues – before trying to proceed with the interview.

41. Transcultural Considerations • Acknowledge and overcome your own egocentrism • Avoid the tendency to impose your own beliefs, values, and patterns of behavior. • Determine the ideal “spatial distance” – this can vary greatly among different cultures. • Understand culturally acceptable sick role behavior. • Careful with nonverbal behavior that may have different cultural meanings.

42. Examples of Cultural Responses to Touch • Asian countries – non contact preferred • African countries – close personal space • German, English – non contact preferred • Italian and other southern European countries – closer contact and touch preferred • Hispanic countries – touch, handshakes, embracing, value physical preference

43. Words and Their Meanings • Limit use of medical jargon. • Make no assumptions regarding the meanings of words – even if they appear to be simple English! • Example of women in New Foundland

44. Complex Health Histories • Often found, but not limited to, older adults. • May need to ascertain cognitive and/or emotional health status prior to beginning the interview. • May need an extra appointment rather than trying to do it all in one sitting – that’s okay!

45. Communication Exercises • Therapeutic Communication • Non-therapeutic Communication SEE THE LISTING FOLLOWING THESE NOTES