By Suryanto Department of Nursing Faculty of Medicine
University of Brawijaya 2011
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Contents Concept of communication Admitting patients to
hospital Introducing self to colleagues Giving information Treating
grieving patient and family
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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
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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
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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
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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
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Factors which influence nurse- patient communication
Patient-related factors Nurse/doctor-related factors The interview
setting: requirements
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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
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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)
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The interview setting: requirements Privacy Comfortable
surroundings An appropriate seating arrangement
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Guidelines for conducting an interview Beginning the interview
The main part of the interview Ending the interview
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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
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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
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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
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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
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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.
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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
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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
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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-to-
day life and relationship
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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?
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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?
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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
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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
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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
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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
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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?
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Past medical history You should obtain information about the
patients: Previous general health Previous illness Admissions to
hospital Operations Accidents and injuries Pregnancies
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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?
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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?
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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.?
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Social history Patient profile Lifestyle Sources of stress
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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?
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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
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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?
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Any question?
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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
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Giving information The aims Guidelines for giving information
to a patient
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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
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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
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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?
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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?
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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?
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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.
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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?
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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
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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.
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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?
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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?
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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?
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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?
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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
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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?
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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?
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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
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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
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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
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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?
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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
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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