by suryanto department of nursing faculty of medicine university of brawijaya © 2011

By Suryanto Department of Nursing Faculty of Medicine University of Brawijaya 2011

Contents Concept of communication Admitting patients to hospital Introducing self to colleagues Giving information Treating grieving patient and family

Concept of communication What is communication? What is good communication? Why is good communication important? Factors which influence nurse-patient communication Guidelines for conducting an interview

What is communication? Communication comes from the word communicate communicate comes from the Latin to impart, to share communication is imparting, conveying or exchanging ideas, knowledge, etc. Methods of communication: teaching/lecturing, two friends talking, telephone, writing a letter, radio/TV, reading, email/IM, nurse or doctor with patient

What is good communication? Based on a study in Manchester, patients preferred interviewers who: Were warm and sympathetic Were easy to talk to Introduced themselves Appeared self-confident Listened to the patients and responded to their verbal cues Asked questions that were easily understood and were precise Did not repeat themselves

Why is good communication important? Good communication between nurse and patient is more likely to: Make an accurate, comprehensive diagnosis. Good communication skills enable one to collect information about a patients problems that comprehensive, relevant and accurate. Detect emotional distress in patients and respond appropriately Have patients who are satisfied with the care and less anxious about their problems Have patients who agree with and follow the advice given

Factors which influence nurse- patient communication Patient-related factors Nurse/doctor-related factors The interview setting: requirements

Patient-related factors Physical symptoms Psychological factors related to illness or medical care (e.g. anxiety, depression, anger, denial) Previous experience of medical care Current experience of medical care

Nurse/doctor-related factors Training in communication skills Self-confidence in ability to communicate Personality Physical factors (e.g. tiredness) Psychological factors (e.g. anxiety)

The interview setting: requirements Privacy Comfortable surroundings An appropriate seating arrangement

Guidelines for conducting an interview Beginning the interview The main part of the interview Ending the interview

Beginning the interview Greet the patient by name (Good morning Mr Jamirun) and shake hands Ask the patient to sit down Introduce your self (I am Siti Jamilah, a nurse student) Explain the purpose of the interview (I would like to find out about your present problem) Say how much time available Explain the need to take notes and ask if this is acceptable

The main part of the interview Maintain a positive atmosphere, warm manner, good eye contact Use open questions at the beginning Listen carefully Be alert and responsive to verbal and non-verbal cues Facilitate the patient both verbally (Tell me more) and non-verbally (posture) Use specific (closed) questions when appropriate Clarify what the patient has told you Encourage the patient to be relevant

Ending the interview Summarize what the patient has told you and ask if your summary is accurate Ask if they would like to add anything Thank the patient

Admitting patients to hospital Beginning an interview Gathering information: taking a medical history Basic information about the patient Description of presenting problem History of presenting problem Review of body systems Past medical history Family history Social history

Beginning an interview Providing comfortable setting Explaining the purpose of the interview Indicating the time available E.g.: Student: Hello Mr Jono, Im sorry to interrupt you but Im Paijo, one of the students attached to the Dr Saiful Anwar hospital. Ive been asked to come and talk to you about the problem that brought you into hospital so that I can tell Dr Samudra about you when he does his ward around this afternoon. I can spend about 40 minutes talking with you. Is that alright? Mr Jono: Yes sure go ahead. Student: Well, like to take some notes so that I can write up your history later. How do you fell about that? Mr Jono: Thats fine by me.

Basic information about the patient This include the patients name, address, age, occupation and marital status. You should try to find out their name before the interview. You may prefer to gather the rest of the information during interview: to avoid asking a list of questions, which may not be a good way to begin an interview

Description of presenting problem Find this out by asking as an open question, e.g.: Could you please tell me what problem brought you to hospital? Why have you come to see the doctor today? Sometimes a patient will provide a diagnosis rather than a symptom. When this happens, it is important to ask the patient what they are experiencing Next, ask the patient if they have any other problems Make a list of all patients problems: physical, psychological and social

History of presenting problem The aims are: Obtain a detailed history that that is complete, accurate and relevant Find out the patients perception of what is wrong Establish their attitudes to the problem Determine what effect the problem has on their day-today life and relationship

History of presenting problem WHAT What does it feel like? What brings it on? What else? WHERE Show me where it is HOW How bad is it? How is it altered by ? WHEN When did it start? When does it occur? How often? How long for? WHY Why do you think youve got it? WHO Who is affected by it?

History of presenting problem A patient complaining pain: Timing: when? How long does the pain last? Location: where? Ask to point the site Radiation: where? Pain spreads to? Quality: what is it like? Sharp, dull, tight, throbbing, constant, comes and goes? Severity: how bad is it? mild, moderate, severe? Would you say it is the worst pain you have ever had? Associated signs and symptoms: what else? When you had your chest pain, did you have any other symptoms at the same time? Setting: when does it occur? Could you tell me now about what you are usually doing when the pain comes on? Modifying factors: how is it affected by ? (eating, exercise, medicine, etc.) When you have the pain, is there anything that makes it better?

Review of body systems Introduce this section by saying something like: Im now going to ask you a series of questions about common medical problems. This is to make sure we dont miss anything that may be important Body systems: Nervous system Cardiovascular/respiratory system Gastrointestinal system Endocrine system Urogenital system Musculoskeletal system

Review of body systems Nervous system Head aches Faints, fits, loss of consciousness Numbness/tingling in limbs Problems with eyesight/speech/hearing Mood, memory, concentration Weakness/wasting in limbs Cardiovascular/ respiratory system Cough/sputum Shortness of breath/wheeze Chest pain Palpitations Ankle swelling

Review of body systems Gastrointestinal system Appetite Weight change Difficulty swelling Heartburn Nausea/vomiting Abdominal pain/swelling Bowel frequency/ consistency/ rectal bleeding Endocrine system Polydipsia Polyuria Hot/cold tolerance Hair change

Review of body systems Urogenital system Dysuria Frequency Nocturia Haematuria Men: testicular pain, swelling, problem urinating Women: menstrual details, obstetric history, contraception Musculoskeletal system Joint pain/ stiffness/ swelling Back pain Muscle pain Skin problems

Review of body systems Example of the questions: Cardiovascular: Could you tell me if you have any trouble with your heart? What about chest pain or palpitations? Do your ankles ever swell? Respiratory: Do you have any problem with your lungs like shortness of breath or coughing? Is sputum present? What color is it? Have you ever seen blood in it? Genito-urinary: Do you ever have any problem passing water? What about pain when you pass it? Does it have an unusual color or smell?

Past medical history You should obtain information about the patients: Previous general health Previous illness Admissions to hospital Operations Accidents and injuries Pregnancies

Past medical history E.g.: Youve told me a lot about the problems youve had with your bowels, and Ive asked you a number of questions. Now Id like to ask you about any illness youve had in the past. Could you tell about this? Have you had any other operations? Have you been in hospital at any other time? Did you have any problems with your pregnancies? Could you tell me if youve had any accidents or injured yourself at any time?

Family history This is important, because: Patient may be suffering from a genetically determined disease Their concerns about their presenting problems my be related to the experience of other members of the family Ask about all first-degree relatives (parents, siblings, children), if they are living, and if not, the cause of death E.g.: Im sorry to hear your father died of cancer. How old he when he died?

Social history The aim is to build up a picture of the patient as a person outside of the hospital: How do they spend an average day? What is the structure of their family and how do the members relate to each other? What is their lifestyle? Do they have any worry about finance, accommodation, etc.?

Social history Patient profile Lifestyle Sources of stress

Patient profile This includes information about family life, other close relationships, work and daily activities E.g.: Could you tell me something about yourself as a person? Perhaps you could start with your family and other people you are close to. Could you tell me what you do in an average day?

Lifestyle Particularly for: Smoking history: Do you smoke?, What do you smoke?, How much do you smoke?, How long have you smoke like this? If the patient is a non-smoker, ask if they have smoked in the past. Drinking history: Id like to ask you now about your drinking habits. Can you tell me if you drink alcohol?, Could you tell me what you drink? Drug history: Include all current drugs prescribed by a doctor, all drugs that the patient has bought over the counter, and if they misuse drugs

Sources of stress Health can be severely affected by stress related to work, personal relationship finances, accommodation, etc. Could you tell me if you feel particularly stressed? What sort of things cause you stress?

Any question?

Introducing self to colleagues Relax Speak clearly and fluently Be concise Information: Greeting Say your name and where you come from Educational background Working experience Research experience Your family Hobbies

Giving information The aims Guidelines for giving information to a patient

The aims To help the patient understand what is happening To reduce their anxiety and uncertainty as far as possible To gain their cooperation in the management of their problem

Guidelines for giving information to a patient Describe what information you plan to give Summarize patients problems Find out the patients understanding of their problem Outline structure of interview Use appropriate language Use drawings Give important information first Explore patients view Negotiate management Check understanding

Describe what information you plan to give Is it: Results of the physical examination? Results of tests? Diagnosis? Cause of the problems? Necessary further investigations? Treatment planned? Advice about lifestyle?

Summarize patients problems Begin the interview by summarizing the patients problems Youve told me about the pain in your stomach and the heart burn youve been having after meals and at night. You also mentioned that youve had an ulcer in the past. Is that right?

Find out the patients understanding of their problem Assess the patients understanding of the condition Could you tell me what you think is causing your symptoms? Most people have some ideas or worries about what is causing the problem. Do you have any idea?

Outline structure of interview Outline how you plan to structure the rest of the interview Now, Im going to discuss several things with you: first, what I think is wrong with you; second, what further investigations you need; and lastly, the treatment were going to give you.

Use appropriate language Give the most important information first Use short words and short sentences Be specific Avoid medical jargon, when you used them, ask if the patient understand Well, your barium meal did not show any ulcer. But it did show that you have something we call a hiatus hernia. Do you know what that is?

Use drawings Give important information first If appropriate, use drawings to supplement the information E.g. It will be more easy to explain a hiatus hernia by drawing rather than using words Give the most important first of all

Explore patients view Explore the patients views on the information they have received Encourage them to ask questions Perhaps you could say what you feel about that.

Negotiate management Negotiate management with the patient. If appropriate, help them to decide between treatment options Yes, I understand you might have some problems with the diet Im suggesting, especially as road-side cafes usually sell lots of greasy food. However, perhaps you could keep to the fish and chicken and avoid the chips and fried eggs. You say youre not keen on taking tablets why not?

Check understanding Check the patients understanding of what has been said Well, Mr Jono, I seem to have given you lots of information. Would you like to just go over what we have said?

Treating grieving patient and family How to give bad news Personal preparation The physical setting Talking to the patient and responding to their concerns Arranging follow-up or referral Feedback and handover to professional colleagues What to do if.. What if the patient cries? What if the patient becomes angry or violent? What if patient threatens suicide?

Personal preparation The following points should be considered: Is the patient expecting bad news? Should anyone else be present (such as relative?) What does the patient already know about the illness, or what has happened? What personal resources does the patient have? Have I got sufficient time to spend with the patient? Can someone else look after my bleep for an hour? Are there any what if questions I should prepare myself for?

The physical setting The ideal setting is: A private room that is reasonably comfortable Free from interruptions Has a calm ambience Obvious things you should NOT do: Dont give bad news at he end of physical examination while the patient is still undressed Dont give bad news in corridors and over the telephone Dont pace around, keep looking out the window or become distracted by activities nearby

Talking to the patient and responding to their concerns Breaking bad news requires: Empathy I realize this probably comes as a shock to you Starting with what the patient or relative already knows or understands Did Dr Radian discuss with you what he had in mind in sending you to this clinic? Have you had any thought about what this may be? What first went through your mind when you found the lump?

Talking to the patient and responding to their concerns Breaking bad news requires: Finding out what they want to know It is helpful to us to hear from you what you want to be told about your condition. Is there anything you would prefer not to be told? What would you like to be told about the diagnosis? Do you want to know all the details about the diagnosis, tests and treatment, or do you just want to have an outline of what is going on? Active listening and giving information Eliciting the patients own resources for coping How did you deal with it? How might this experience help you in what we have been discussing today?

Talking to the patient and responding to their concerns Breaking bad news requires: Instilling realistic hope Yes, there are some unpleasant side effects. Im not sure that we need to consider that at this stage. We should first see whether a series of injections will help. We hope that things will get better after this course of treatment

Arranging follow-up or referral A plan should be made for follow-up contact to contain some of their anxiety and provide a further opportunity to address concerns In some cases it may be appropriate to make referral to another professional, such as psychologist or counselor

Feedback and handover to professional colleagues It is good to practice to inform colleagues about the meeting with the patient, summarize what the patient, and others, have been told and understand, and what possible problems or reactions can be expected Discussion and consultation with colleagues can also make the task of giving bad news easier

What if the patient cries? Usually, you should give them some tissues, or pause, or say I can see you are very upset Touching may also be helpful After a few moments, you should continue talking and remains sympathetic by saying: I am sorry to have to give you this news. Its not easy for me. Were you expecting to hear this?

What if the patient becomes angry or violent? You should stand up and it is important to be at their eye level and show your preparedness You should be polite and firm You might say: Im sorry to have to give you this news. I realize that you werent expecting to hear this. However, you may also want to speak to someone else and get their opinion I can see that you are upset and annoyed. I would be happy to try and answer any of your questions

What if patient threatens suicide? If the patient hints at suicide, make your concerns explicit For example: I was wondering where youre going from here? Open discussion about suicidal feelings can be containing for the patient and conveys that you are not afraid to confront sensitive issue The patient should not be discharged or left alone

The end

by suryanto department of nursing faculty of medicine university of brawijaya © 2011

Documents

patient slide

interview slide

good communication skills

good communication important

methods of communication

anxiety slide

family slide

acceptable slide