Please interview a family friend or relative outside your immediate family (i.e., not parents and siblings) who has experience with nurses, clinical care, and/or medical settings. Your interviewee should be of legal age (18 or older) and should be fully aware of the purpose of the interview and the fact that it is a course assignment. Grandparents, aunts, and uncles are great candidates for an interview. Interviewing classmates or close friends may not yield particularly interesting or fruitful results.The purpose is for you to try out some of your interview skills as discussed in Coulehan and Block (2001) and Bickley & Szilagyi (2003) (e.g., such as active listening, empathy, open invitations, and prompts). It is best to conduct the interview face to face, but a phone interview is acceptable. Please avoid email interviews.Please ask questions related to each of the following areas. Remember to ask open-ended questions, avoiding “yes or no” questions. Before the interview, you should brainstorm a few questions under each area. For example, for #1 in the areas below, good questions might include “Describe your eating habits,” “How often do you exercise,” and “Tell me how you know you are sick.”How does the interviewee describe their overall health?How has experiences with clinical care impacted the interviewee’s life/quality of life?How does the interviewee define “health”?What is the interviewee’s present experience with clinical care?What have been some of the interviewee’s meaningful (positive or negative) interactions with nurses and doctors?Please remember to begin the interview explaining the format of the interview and end the interview by thanking the individual for their time. The interview should be between 15 and 30 minutes long. Please take some notes during the interview so that you can objectively report on the exchange. If you have a smartphone, using your audio recorder might be helpful so that you can listen to your interview again, but make sure that you have been granted permission by your interviewee.The Health History and Clinical Care Perspectives NarrativeAs you write your narrative, remember to let the interviewee’s words inform the story rather than your judgements of their words. Your narrative should include the following four sections, as first-level headings. Notice that section 2 (interview findings) and section 3 (significance) should have level two headings as well. There is a sample Clinical Care Perspectives Narrative located in this module.Interview Setting: Please describe who you interviewed, why you selected this person, how you set up the interview, where the it took place, how long it took, and other relevant information you feel is required to understand the setting of this interview. Please DO NOT provide identifying information (e.g., name, address, social security numbers, etc.).Interview Findings: Please briefly describe one element of this experience that interested you. Pick something that interested, surprised, or puzzled you. What was your reaction (thoughts, feelings, or concerns)? There are no right or wrong answers.How does the interviewee describe their overall health?How have experiences with clinical care impacted the interviewee’s life/quality of life?How does the interviewee define “health”?What is the interviewee’s present experience with clinical care?What have been some of the interviewee’s meaningful (positive or negative) interactions with nurses and doctors?Significance: How did this interview change (or not) your thoughts or feelings about patient perspectives of clinical care? Here are a few questions to help you answer the previous question:What assumptions had you made about patients’ and their perspectives on clinical care?How do your experiences shape your understanding of the patient experience?How was this interviewee’s experience important for them?Future Application: What new insights did you gain for future patient interactions? How could you apply those insights as both a student and a nurse?Grading RubricYour assignment will be graded upon the following criteria: Each criteria have a specific point value (see criteria) and will be graded as either exceptional, satisfactory, needs improvement, or unsatisfactory. Each assessment level provides a percentage of the points possible to earn (e.g., an exceptional focus, purpose, or thesis might be worth 90% of the 20 points possible to earn, which equals 18 points). It is possible to earn exceptional in one criteria (e.g., an exceptional focus, purpose, or thesis) and earn unsatisfactory in the other criteria (e.g., extremely limited vocabularly)CriteriaExceptional90-100%Satisfactory80-89%Needs Improvement70-79%Unsatisfactory60-69%Focus, Purpose, or Thesis(20 Points)Engaging and full development of a clear thesis as appropriate to assignment purposeCompetent and well developed thesis; thesis represents sound and adequate understanding of the assigned topicMostly intelligibleideas; thesis may be weak, broad, or only indirectly supportedIdeas are simplistic, showing signs of confusion, misunderstanding, of the prompt; thesis is essentially missing or not discernableIdeas, Support, and Development(20 Points)Consistent evidence with originality and depth of ideas; ideas work together as a whole; main points are sufficiently supported with evidence; support is valid and specificIdeas supported sufficiently; support is sound, valid, and logicalMain points and ideas are only indirectlysupported; support isn’t sufficient or specific, but is loosely relevant to main pointsLack of supportfor main points; frequent and illogical generalizations without supportOrganization and Paragraphing(20 Points)Organization is sequential and appropriate to assignment; paragraphs are well developed and appropriately divided; ideas linked with smooth and effective transitionsCompetentorganization, without sophistication. Competent paragraph structure; lacking effective transitions.Limitedattempts to organize around a thesis; paragraphs are mostly stand-alone with weak or non-evident transitionsOrganization, if evident is confusing and disjointed; paragraph structure is weak; transitions are missing or inappropriateAudience, Tone, Point-of-View(10 Points)Clear discernment of distinctive audience; tone and point-of-view appropriate to the assignmentEffective and accurate awareness of general audience; tone and point-of-view are satisfactoryLittle or inconsistentsense of audience related to assignment purpose; tone and point-of-view not refined or consistentLacks awarenessof a particular appropriate audience for assignment; tone and point-of-view somewhat inappropriate or inconsistentSentence Structure (Grammar)(10 Points)Each sentence structured effectively, powerfully; rich, well-chosen variety of sentence styles and lengthEffective and varied sentences; errors (if any) due to lack of careful proofreading; syntax errors (if any) reflect uses as colloquialismsFormulaic or tedious sentence patterns; shows some errors in sentence construction; some non-standard syntax usage.Simple sentencesused excessively, almost exclusively; frequent errors of sentence structureMechanics and Presentation(10 Points)Virtually free ofpunctuation, spelling, capitalization errors; correct APA formatContains only occasionalpunctuation, spelling, and/or capitalization errors. Few formatting errors.Contains several (mostly common) punctuation, spelling, and/or capitalization errors. Several errors in formatting.Contains many and serious errors of punctuation, spelling, and/or capitalization; errors severely interfere with meaning; formatting weak.Vocabulary and Word Usage(10 Points)Exceptional vocabulary range, accuracy, and correct and effective word usageGood vocabulary range and accuracy of usage.Ordinaryvocabulary, mostly accurate; some vernacular terms.Extremely limited vocabulary; choices lack grasp of diction; usage is inaccurate.
coulehan___block__2001_.pdf
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sample_clinical_care_perspectives_narrative.docx
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C
Interviewing and
the Health History
H
A
P
T E
R
2
The health history interview is a conversation with a purpose. As you learn
to elicit the patient’s history, you will draw on many of the interpersonal
skills that you use every day, but with unique and important differences. Unlike social conversation, in which you can freely express your own needs and
interests and are responsible only for yourself, the primary goal of the clinician–
patient interview is to improve the well-being of the patient. At its most basic
level, the purpose of conversation with a patient is threefold: to establish a
trusting and supportive relationship, to gather information, and to offer information.1–3
Relating effectively with patients is among the most valued skills of clinical
care. As a beginning clinician, you will focus your energies on gathering information. At the same time, by using techniques that promote trust and
convey respect, you will allow the patient’s story to unfold in its most full
and detailed form. Establishing a supportive interaction helps the patient feel
more at ease when sharing information and itself becomes the foundation
for therapeutic clinician–patient relationships.4 Because illness can make patients feel discouraged and isolated, “A feeling of connectedness with the
doctor, of being deeply heard and understood, reduces this feeling of isolation and despair. This feeling is the very heart of healing.”5
This chapter introduces you to the essentials of interviewing. It emphasizes the
approach to gathering the health history, but covers all the fundamental habits
that you will continually use and refine in your conversations with patients. You
will learn the guiding principles for skilled interviewing and how to forge trusting patient relationships. You will read about preparing for the interview, the
sequence of the interviewing process, important interviewing techniques, and
strategies for addressing various challenges that may arise in patient encounters. To help you navigate this journey, look over the Interviewing Milestones,
on the next page, that mark the complex tasks of a skilled interview.
As a clinician facilitating the patient’s story, you will come to generate a series of hypotheses about the nature of the patient’s concerns. You will then
test these various hypotheses by asking for more detailed information. You
will also explore the patient’s feelings and beliefs about his or her problem.
Eventually, as your clinical experience grows, you will respond with your
CHAPTER 2 ■
INTERVIEWING AND THE HEALTH HISTORY
23
Interviewing Milestones
Getting Ready: The Approach to the Interview
Taking time for self-reflection. Reviewing the chart. Reviewing your clinical
behavior and appearance. Adjusting the environment. Taking notes.
Learning About the Patient: The Sequence of the Interview
Greeting the patient and establishing rapport. Inviting the patient’s story.
Setting the agenda for the interview. Expanding and clarifying the patient’s
story. Creating a shared understanding of the patient’s concerns. Negotiating a plan. Following up and closing the interview.
Building the Relationship: The Techniques of Skilled Interviewing
Active listening. Guided questioning. Nonverbal communication. Empathic responses. Validation. Reassurance. Partnering. Summarization.
Transitions. Empowering the patient.
Adapting Your Interview to Specific Situations
The silent patient. The confusing patient. The patient with impaired capacity. The talkative patient. The angry or disruptive patient. Interviewing
across a language barrier. The patient with low literacy. The deaf or hardof-hearing patient. The blind patient. The patient with limited intelligence.
The patient seeking personal advice.
Sensitive Topics that Call for Special Skills
The sexual history. Mental health. Alcohol and drug use. Family violence.
Death and dying.
Societal Aspects of Interviewing
Achieving cultural competence. Sexuality in the clinician–patient relationship. Ethical considerations.
24
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
understanding of the patient’s concerns. Even if you discover that little can be
done, encouraging the patient to discuss the experience of illness is itself therapeutic, as shown by the words below from a patient with long-standing and
severe arthritis:
The patient had never talked about what the symptoms meant to her. She had
never said: “This means that I can’t go to the bathroom by myself, put my
clothes on, even get out of bed without calling for help.”
When we finished the physical examination I said something like: “Rheumatoid
arthritis really has not been nice to you.” She burst into tears, and her daughter did also, and I sat there, very close to losing it myself.
She said: “You know, no one has ever talked about it as a personal thing before.
No one’s ever talked to me as if this were a thing that mattered, a personal event.”
That was the significant thing about the encounter. I didn’t really have much
else to offer. . . . But something really significant had happened between us,
something that she valued and would carry away with her.6
As you can see from this story, the process of interviewing patients requires a
highly refined sensitivity to the patient’s feelings and behavioral cues and is
much more than just asking a series of questions. This process differs significantly from the format for the health history presented in Chapter 1 (p. 5).
Both are fundamental to your work with patients but serve different purposes:
■
The health history format is a structured framework for organizing patient
information in written or verbal form for other health care providers; it focuses the clinician’s attention on specific kinds of information that must
be obtained from the patient.
■
The interviewing process that actually generates these pieces of information
is much more fluid and demands effective communication and relational
skills. It requires not only knowledge of the data that you need to obtain
but also the ability to elicit accurate information and the interpersonal skills
that allow you to respond to the patient’s feelings and concerns.
Underlying the new interviewing skills that you will learn is a mindset that
allows you to collaborate with the patient and build a healing relationship.
Different Kinds of Health Histories. As you learned in Chapter 1,
the kinds of information you seek varies according to several factors. The
scope and degree of detail depend on the patient’s needs and concerns, the
clinician’s goals for the encounter, and the clinical setting (e.g., inpatient or
outpatient, amount of time available, primary care or subspecialty).
■
For new patients, regardless of setting, you will do a comprehensive health
history described for adults in Chapter 1.
CHAPTER 2 ■
INTERVIEWING AND THE HEALTH HISTORY
25
GETTING READY: THE APPROACH TO THE INTERVIEW
■
For other patients who seek care for specific complaints (e.g., cough,
painful urination), a more limited interview tailored to that specific problem may be indicated, sometimes known as a problem-oriented history.
In a primary care setting, clinicians frequently choose to address issues of
health promotion, such as tobacco cessation or reduction of high-risk sexual
behaviors. A subspecialist may do an in-depth history to evaluate one problem
that incorporates a wide range of areas of inquiry. Knowing the content and
relevance of all the components of a comprehensive health history enables you
to select the kinds of information most helpful for meeting both clinician and
patient goals. Be assured that you will fully gain the knowledge of what types
of information to pursue, and when to pursue them, as you deepen your clinical experience.
GETTING READY: THE APPROACH TO THE INTERVIEW
Interviewing patients requires planning. You are undoubtedly eager to begin
your relationship with the patient, but first consider several steps that are
crucial to success: taking time for self-reflection, reviewing the chart, setting
goals for the interview, reviewing your behavior and appearance, adjusting
the environment, and being ready to take brief notes.
Taking Time for Self-Reflection. As clinicians, we encounter a wide
variety of individuals, each one unique. Establishing relationships with people from a broad spectrum of age, social class, race, ethnicity, and states of
health or illness is an uncommon opportunity and privilege. Being consistently
respectful and open to individual differences is one of the clinician’s challenges. Because we bring our own values, assumptions, and biases to every
encounter, we must look inward to clarify how our own expectations and reactions may affect what we hear and how we behave. Self-reflection is a continual part of professional development in clinical work. It brings a deepening
personal awareness to our work with patients, which is one of the most rewarding aspects of patient care.
Reviewing the Chart.
Before seeing the patient, review the medical
record or chart. Doing so helps you gather information and plan what areas
you need to explore with the patient. Look closely at identifying data such
as age, gender, address, and health insurance, and peruse the problem list,
the medication list, and details such as the documentation of allergies. The
chart often provides valuable information about past diagnoses and treatments, but do not let the chart prevent you from developing new approaches
or ideas. Remember that information in the chart comes from different observers and that standardized forms reflect different institutional norms.
Moreover, the chart is not designed to capture the essence of the unique individual you are about to meet. Data may be incomplete, or even disagree
with what you learn from the patient—understanding such discrepancies
may prove helpful to the patient’s care.
26
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
GETTING READY: THE APPROACH TO THE INTERVIEW
Setting Goals for the Interview. Before you begin talking with the
patient, it is important to clarify your goals for the interview. As a student,
your goal may be to obtain a complete health history so that you can submit
a write-up to your teacher. As a clinician, your goals range from completing
forms needed by health care institutions to following up on health care issues
to testing hypotheses generated by your review of the chart. A clinician must
balance these provider-centered goals with patient-centered goals. There can be
tension between the needs of the provider, the institution, and the patient
and family. Part of the clinician’s task is to consider these multiple agendas.
By taking a few minutes to think through your goals ahead of time, you will
find it easier to strike a healthy balance among the various purposes of the interview to come.
Reviewing Your Clinical Behavior and Appearance. Just as you
carefully observe the patient throughout the interview, the patient will be
watching you. Consciously or not, you send messages through both your
words and your behavior. Be sensitive to those messages and manage them
as well as you can. 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. Reactions that betray disapproval, embarrassment, impatience, or boredom block
communication, as do any behaviors that condescend, stereotype, criticize, or
belittle the patient. Although these types of negative feelings are at times unavoidable, as a health care professional, you must take pains not to express
them. Guard against these feelings not only when talking to patients but also
when discussing patients with your colleagues.
Your personal appearance also affects your clinical relationships. Patients find
cleanliness, neatness, conservative dress, and a name tag reassuring. RememCHAPTER 2 ■
INTERVIEWING AND THE HEALTH HISTORY
27
LEARNING ABOUT THE PATIENT: THE SEQUENCE OF THE INTERVIEW
ber to keep the patient’s perspective in mind if you want to build the patient’s
trust.
Adjusting the Environment. Try to make the interview setting as private and comfortable as possible. Although you may have to talk with the patient under difficult circumstances, such as in a two-bed room or the corridor
of a busy emergency department, a proper environment improves communication. If there are privacy curtains, ask permission to pull them shut. Suggest
moving to an empty room instead of talking in a waiting area. As the clinician,
it is part of your job to make adjustments to the location and seating that make
the patient and you more comfortable. These efforts are always worth the time.
Taking Notes. As a novice, you will need to write down much of what
you learn during the interview. Even though experienced clinicians recall
much of the interview without taking notes, no one can remember all the
details of a comprehensive history. Jot down short phrases, specific dates, or
words rather than trying to put them into a final format, but do not let notetaking or written forms distract you from the patient. Maintain good eye
contact, and whenever the patient is talking about sensitive or disturbing
material, put down your pen. Most patients are accustomed to note-taking,
but for those who find it uncomfortable, explore their concerns and explain
your need to make an accurate record.
LEARNING ABOUT THE PATIENT:
THE SEQUENCE OF THE INTERVIEW
Once you have devoted time and thought to preparing for the interview, you
are fully ready to listen to the patient, elicit the patient’s concerns, and learn
about the patient’s health. In general, an interview moves through several
stages. Throughout this sequence you, as the clinician, must always be attuned
to the patient’s feelings, help the patient express them, respond to their content,
and validate their significance. A typical sequence follows.
The Sequence of the Interview
■
■
■
■
■
■
■
■
Greeting the patient and establishing rapport
Inviting the patient’s story
Establishing the agenda for the interview
Expanding and clarifying the patient’s story
Generating and testing diagnostic hypotheses
Creating a shared understanding of the problem
Negotiating a plan (includes further evaluation, treatment, and patient
education)
Planning for follow-up and closing the interview
As a student, you will concentrate primarily on gathering the patient’s story
and creating a shared understanding of the problem. As you become a practicing clinician, reaching agreement on a plan for further evaluation and treat28
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
LEARNING ABOUT THE PATIENT: THE SEQUENCE OF THE INTERVIEW
ment becomes more important. Whether the interview is comprehensive or
focused, you should move through this sequence with close attention to the
patient’s feelings and affect, always working on strengthening the relationship.
Greeting the Patient and Establishing Rapport. The initial moments of your encounter with the patient lay the foundation for your ongoing relationship. How you greet the patient and other visitors in the room,
provide for the patient’s comfort, and arrange the physical setting all shape
the patient’s first impressions.
As you begin, greet the patient by name and introduce yourself, giving your
own name. If possible, shake hands with the patient. If this is the first contact, explain your role, including your status as a student and how you will
be involved in the patient’s care. Repeat this part of the introduction on
subsequent meetings until you are confident that the patient knows who
you are: “Good Morning, Mr. Peters. I am Susannah Martinez, a third-year
medical student. You may remember me. I was here yesterday talking with
you about your heart problems. I am part of the medical team taking care
of you.”
Using a formal title to address the patient (e.g., Mr. O’Neil, Ms. Washington)
is always best.7,8 Except with children or adolescents, avoid first names unless
you have specific permission from the patient or family. Addressing an unfamiliar adult as “granny” or “dear” can depersonalize and demean. If you are
unsure how to pronounce the patient’s name, don’t be afraid to ask. You can
say: “I am afraid of mispronouncing your name. Could you say it for me?”
Then repeat it to make sure that you heard it correctly.
CHAPTER 2 ■
INTERVIEWING AND THE HEALTH HISTORY
29
LEARNING ABOUT THE PATIENT: THE SEQUENCE OF THE INTERVIEW
When visitors are in the room, be sure to acknowledge and greet each one
in turn, inquiring about each person’s name and relationship to the patient.
Whenever visitors are present, you are obligated to maintain the patient’s confidentiality. Let the patient decide if visitors or family members should remain in the room, and ask for the patient’s permission before conducting
the interview in front of them. For example, “I am comfortable with having
your sister stay for the interview, Mrs. Jones, but I want to make sure that
this is also what you want” or “Would you prefer if I spoke to you alone or
with your sister present?”
Always be attuned to the patient’s comfort. In the office or clinic, help the patient find a suitable place for coats and belongings. In the hospital, after greeting the patient, ask how the patient is feeling and if you are coming at a
convenient time. Arranging the bed to make the patient more comfortable
or allowing a few minutes for the patient to say goodbye to visitors or finish
using the bedpan demonstrates your awareness of the patient’s needs. In any
setting, look for signs of discomfort, such as shifting position or facial expressions showing pain or anxiety. You must attend to pain or anxiety first,
both to encourage the patient’s trust and to allow enough ease for the interview to proceed.
Consider the best way to arrange the room and how far you should be from
the patient. Remember that cultural background and individual taste influence
preferences about interpersonal space. Choose a distance that facilitates conversation and allows good eye contact. You should probably be within several
feet, close enough to be intimate but not intrusive. Pull up a chair and, if possible, sit at eye level with the patient. Move any physical barriers, like desks or
bedside tables, out of the way. In an outpatient setting, sitting on a rolling
stool, for example, allows you to change distances in response to patient cues.
Avoid arrangements that connote disrespect or inequality of power, such as
interviewing a woman already positioned for a pelvic examination. Such
arrangements are unacceptable. Lighting also makes a difference. If you sit between a patient and a bright light or window, although your view might be
good, the patient may have to squint uncomfortably to see you, making the
interaction more like an interrogation than a supportive interview.
As you begin the interview, give the patient your undivided attention. Spend
enough time on small talk to put the patient at ease, and avoid looking down
to take notes or reading the chart.
Inviting the Patient’s Story. Now that you have established rapport,
you are ready to pursue the patient’s reason for seeking health care, designated
the chief complaint. Begin with open-ended questions that allow full freedom
of response: “What concerns bring you here today?” or “How can I help
you?” Helpful open-ended questions are “Was there a specific health concern
that prompted you to schedule this appointment?” and “What made you decide to come in to see us today?” Note that these questions encourage the patient to express any possible concerns and do not restrict the patient to a
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