Professional skills- 2 part two 2010- 2011

1. Professional skills- 2part two2010- 2011 By Dr. Aziza Rajab Assistant professor Head of Nursing dep. King Abdul Aziz University

2. Professional skills- 2 course contents • empathy, sympathy and empowerment • Doctor-patient Relationshipbuilding a rapport with patients • How to Interview Patient • Principles of taking medical history from patient. • Who are the difficult / patients( angry, anxious, demanding, fearful ), and how to deal with them. • Strategies for effective consultation. • Principles of Breaking bad news • How to apply the steps of breaking bad news in clinical setting

4. Lecture 1empathy, sympathy and empowerment By Dr. Aziza Rajab Dr. Hashim Fida Assistant professor Assistant professor Head of Nursing dep. Family & community health King Abdul Aziz University king Abdul Aziz University

5. What are the importance of empathy and sympathy? • Can not build rapport or gain trust without showing those feelings • Back bone for establishing and solidifying helping relationship • Help in developing mutual understanding • Guide us to build appropriate perceptions • Help us to understand the message

6. how to differentiate between empathy and sympathy? • Sympathy is to identify and communicate that you understand the patients feelings. ( e.g. I understand what you are saying, I know how you are feeling) • Empathy is to share his/her feelings ( e.g. I do feel exactly what you feel )

7. What is empowerment? • Empowerment is helping others to trust themselves, to identify, know, and believe in them selves and their abilities • Enable others to act independently for him/her self, choose and decide for them selves. • Enhancing people’s creativity, cooperation, inspiration, and productivity.

8. How to be sympathetic ? • Try to listen effectively, • try to understand and perceive things as they are • Try to accept the feelings and point of views without changing them, stop them, or judge them, • try to pay attention • Try to be consistent • Try to reflect on the patients feeling verbally by summarizing, paraphrasing to show your caring attitude to patient • Try to be genuine and sincere in your relation with patient • Try to Respect and accept patient feelings • Try to set limits ( I don’t have time now but we will talk next visit)

9. What are the type of empathic responses that we should avoid? • Judging response: to evaluate another’s feelings: Tell patients in various ways that they should not feel discouraged or frustrated, they shouldn’t worry ,they shouldn’t question their treatment by other health professionals. Any message from you that indicate you think patient is wrong or bad, will make patient think and feel that you are not worth his trust and he cant build confidence for a helping relationship.

10. 2. Advising response: we can offer quick solution to another person’s concern with or without correct perception to his exact needsThe best source of solution to the problem is always within the patient him/her self.Rely on other for advise may keep patients dependent this is against the empowerment idea we talked earlier When there are times when patients are not capable of coping or understanding or deciding for a solution to their problem, you should walk them and direct them to the solution without dictating it to them. It has to be and show that it is coming from them not you.

11. 3. Reassuring response: telling patients who is facing surgery do not worry, every thing will be fine, you will turn out just fine.It may seems to be helpful but it is conveying that the person should not feel upset , scared of the procedure, and concerned about the outcomes.You should tell the patient with exact words what is the procedure steps briefly in understood words, explain the risk in an honest words, state the expected outcomes, and the assurance part has to be in the part how practices, competent you are, how careful you will be, and how common this procedure is, and that his fear is very normal to feel.

12. 4. Distracting response: changing the subject, or cutting off patient’s talk or feeling just because we don’t know how to response to themWe might direct the communication to topics we feel comfortable with such as medication regimens and so forthThese responses tend to convey to patients that we are not listening, or we don’t want to listen.

14. Lecture 2Doctor-patient Relationshipbuilding a rapport with patients ? By Dr. Aziza Rajab Dr. Hashim Fida Assistant professor Assistant professor Head of Nursing department Family & community health King Abdul Aziz University king Abdul Aziz University

15. Doctors’ Mission Doctors’ primary goals are: • To treat and cure where possible • To bring relief in suffering • To help the patient cope with illness, disability and death.

16. Doctor- patient relationship • The doctor – patient relationship is built on : • Honesty • Confidentiality • Trustand reliability

17. How to enhance doctor- patient relationship ? • Developing rapport to enable the patient to feel understood, valued and supported. • Encouraging an environment that maximizes accurate and efficient information gathering, planning & and explanation. • Using the verbal responses and non verbal behaviors appropriately • Involving the patient so that he/she understands and is comfortable with the process of interview and the consultation. • Increasing both the physician’s and the patients’ satisfaction with the communication. • Developing and maintaining a continuing relationship of trust & respect over time.

20. Why doctors Communicate? • Gain Mutual trust & respect • Exchange information • Ask your seniors • Do your share of work • Interview and consult patients • Conduct Seminar & workshops

21. with whom doctors Ccommunicate? • patient • family • physician • health care administrators • Media • psychologist • nurse • social worker • Dietician • Pharmacist • others

22. Communication & Medical care • Good communication should be established on admission between clients, family and the treating multidisciplinary team. • Client & family are encouraged to participate and verbalize in the ward round discussion about: • Offered medical care & treatment • Rehabilitation • Follow- up/re-admission plans • Doubts & worries.

23. Communication & Medical care • Proper information to clients and family regarding services available and how they can utilize them. • Information should be made available on: • Health Education/ Counseling & Psychiatry. • Endocrine, Metabolic, Neurology & nephrology. • Cardiology, Respiratory, GIT & hematology. • Nutrition, Immunization & ambulatory care. • Infections & infection control. • Clinical pharmacy & therapeutics. • Hygiene and Safety.

24. We need to communicate to build a trust relationship with whom ? • Patients & care-givers • Nurses & auxiliary staff • Colleagues • Administrators • Evidence in court • Reporting research findings • Talking to the media • Public at large

25. How can doctors build a positive rapport with their patients ?

26. What is rapport? Rapport is the ability to connect, the ability to trust, the ability to express feeling and thoughts, the ability to understand, the ability to accept the other as is without judgment, and the ability to exchange information honestly and freely during formal or informal interviews. It is the process of creating a goodwill between the interviewer and the interviewee.

27. How can we build a rapport? • Using therapeutic communication techniques • Use the non verbal body language ( time, space, touch, smile, eye contact, dress, distance, location, expressions, grooming), and the verbal ( the way we talk and address each other, the tone, voice, words used), and the formality levels should be used appropriately as needed to enhance connectivity. • Avoid being judgmental, labeling, and criticizing • Empower patients and lower their feeling of powerlessness, helplessness, dependability. • Show sympathy and empathy as needed.

28. How do I know that there is a positive rapport between me and the other party? • When the interviewer and the interviewee share a similar world view or situational view • When we are not jugging the person but rather trying to understand them more • When we are able to express and communicate our thoughts and feeling without fear or criticism to the other person • When we mutually are understood correctly.

29. What are the doctors attitude and behaviors that can damage a helping relationship and obstruct you from building rapport? • Stereotyping: seeing a patient as a person with stereotype behavior, then ,most probably you as a doctor will fail to listen without judgment, and your judgmental thoughts will reflect in your behavior & words , and patient will not build trust, there won’t be no rapport. we must see patient as an individual and accept him/her as is

30. 2. . Depersonalizing :if we focus our communication on specific problems and cases only, without taking the patient and his culture, background, thoughts& feeling in account, then we are really not understanding the person as a whole, and trying to implement solutions that are inapplicable because we don’t have enough connectivity with patient to comprehend the big picture about his/her circumstances.

31. 3.Controling : doctors usually try to run the show when it comes to diagnose and treat patients, they rely on what they know more to decide for care, rather than trying to understand more from the patient about his feelings and thoughts about the disease it self and their preferences of the treatment. Increased levels of patients participation and control over the health care interventions, usually empowers patients, and gives positive results that includes improved health, less complications & general quality of life positive outcomes.

32. Lack of communication and poor doctor- patient relationship : why? • Clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, seldom on their suffering. • Some of them view suffering as beyond their professional responsibilities. • If clinicians feel unable to, or simply do not want to, address the powerful issue of patient suffering, it is appropriate to refer the patientto another professional on the healthcare team who is more comfortable in this area.

33. Lecture 3How to Interview Patient By Dr. Aziza Rajab Dr. Hashim Fida Assistant professor Assistant professor Head of Nursing dep. Family & community health King Abdul Aziz University king Abdul Aziz University

34. What is an interview? Professional Interview in the medical field is an interpersonal communication method and process to gather or/ and exchange information by using therapeutic communication techniques. It is one of the most common methods used in patients assessment

35. with whom and why to do Interview ? • The medical interview is the usual communication encounter between the doctor and the patient. • It can be classified according to the purpose of the interview into 4 types: • History taking • Breaking bad news • Consultations • Obtaining informed consent

36. What are the steps of the interview? • Determine the purpose of the interview ( job interview, patient assessment, …) • Determine the objectives of the interview • Pre- research the topic and the person • Prepare the questions and the context • Organize the interview (opening, body, and closing) • Record and document the interview

37. What are the differences between formal and informal interview? • In the Informal interview: there is small social talks at the beginning to get self comfortable, oriented, and prepare to be ready for the real sensitive issues. • In the formal interview: the interviewer takes more direct, focused, serious, and in-depth elaborative approach to patients concerns and complains.

38. What are the Components of effective interview? • Differentiate between therapeutic and non therapeutic communications • Establish rapport • Prepare the environment, choose right time, get client comfortably situated • Listen instead of just hearing • Differentiate between empathy sympathy • Avoid being superficial and routines, Get to the sensitive issues

40. How therapeutic comm. Is different than social comm. Therapeutic communication characteristics unlike the social interactions, must be : • Goal oriented, planned, and focused on specific objectives. • Leagal accountability and responsibility for the given information. • Credibility of information and good reputation of the informer. • Mutual understanding between all parties involved in the communication.

41. Strategies to conduct an interview? 1-Use open ended questions always that makes the person think and elaborate on the question, and encourage the patient to tell their own story, specially in the start, such as: What exactly happened, how do you feel about it , why do you think this is the problem, can you explain to me this, can you talk more on this… (this will be time consuming at the beginning of the interview and hard to control, but that is ok because you want to build trust and understand your patient well(

42. Strategies to conduct an interview? Cont. 2. Lower patients defensiveness by: • Asking proper type of questions such as the what? and how? • Minimize the why question, it makes patients feel that they need to give justifications always and that might intimidate them, and make them feel guilt and responsible for what ever situation they are facing - Use silence to allow patient to finish answering before asking next question and to avoid feeling of being interrogated

43. Strategies to conduct an interview?Cont. 3. Use closed ended questions appropriately only when you need to establish factual details quickly such as :does it hurt you when you cough? The yes and no answer gives you the exact information that you need for understanding the problem , but they often will not allow patients concerns and anxieties to be expressed.

44. Strategies to conduct an interview?Cont. 4- use probing questions for clarification and verification of information: ( e.g. for clarification: exactly what do you mean by that? ) ( e.g. for verification : did I hear you say that you do not take your medication at all?)

45. Strategies to conduct an interview?Cont. 5. Do not Use and avoid leading questions such as ( e.g. I think your pain increases at night ?) They specify the answer you expect to get, there is no advantage of using it. 6- always listen and use silence and touch whenever needed to express sympathy and keep building trust 7- accept and respect patients

46. Strategies to conduct an interview?Cont. 8- summarize : always summarize to patients what has been discussed in brief and points ( e.g. so we can conclude from our session today that you agreed to control your diabetes by measuring blood sugar twice a day, eat seven small meals instead of three big ones, and walk at least half an hour daily, right? Is there something else?)

47. Critical thinking questions • What are the most important concepts doctors need to take in consideration in building a helping relationship with patients? • What are the main obstacles in building a rapport in any interpersonal relationship?

48. Lecture 4Taking History By Dr. Aziza Rajab Assistant professor Head of Nursing dep. King Abdul Aziz University

49. What are the reasons for history taking? • For understanding the patient holistically, and has a complete picture • Serve as the mean to start building rapport, relationships and trust • To gather detailed specific information • To identify the problem / problems • To make proper conclusions about patient’s condition • To make accurate diagnosis about patient disease

50. Where can we take history? • In the out patient clinic when the patient comes for the first time or after a long absent from a periodic appointments. • In the in-patient different hospital units, after the patient been hospitalized and arrived in the unit clerking or history taking is a must.