Clinical: Lecture 3

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brau2308
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171350
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Clinical: Lecture 3
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2012-09-17 17:38:19
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clinical process
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review of lecture 3 from clinical process
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  1. A therapist uses the HOAC II to develop a problem list. (S)he performs the correct examination procedures appropriately, but does not come up with a workable PTD/OPP. What should the therapist do? Does this mean the HOAC II did not 'work'?
    • go back because you may of missed something
    • OR
    • maybe the patient should be referred to a different practice because it might be beyond your scope
  2. A short therapist is assigned to gait train a tall/heavyset patient in FWB with a rolling walker. The patient has a healing ulcer on the R med. malleoli and puts most of the weight along the lateral during foot flat stage. Think about the therapist's options for where to stand:
    • shorten stride to avoid turning ankle
    • stand on R side moving ant/post as he moves
    • use a belt!
  3. What is communication?
    a dynamic interchange b/w at least two individuals
  4. What are the contents of communication between at least two individuals?
    • verbal components
    • non-verbal components
  5. Clinical reasoning is built on...
    information that the patient is willing to share with the therapist
  6. What providers say and what the client hears depend upon...
    • who the patient is and what the patient values
    • how well the therapist listens without filters
  7. Why wouldn't patients tell us everything that might help them?
    • culture
    • our habits related to listening
    • our non-verbal messages
    • listening and understanding are not the same
    • understanding requires a paradigm shift
  8. The issue of racial ethnicity:
    • political and socio-cultural process of categorizing people
    • links typical attributes of a population subgroup to human qualitites of intelligence, morality and personality traits
    • more common with visible characteristics
    • stigmatism when actions dictated by beliefs in stereotypes and myths
    • those with invisible cultural traits may choose to hide--become "invisible" as a result
  9. Reality of bi-culturalism:
    • internalization of two cultures
    • blending, not replacing
  10. What can our profession do to address the issue of cultural differences?
    Striving for cultural competence:
    • acknowledging that patient/client's values and beliefs may differ from yours
    • allowing for variance w/in cultural group according to level of acculturation
    • willingness to find a middle ground or to give ground if possible
  11. Striving for culturally sensitive communication:
    • our listening skills
    • our non-verbal messages
  12. Personality differences may affect communication
    Extraverts:
    • energy tends to increase and even become more enthusiastic as conversation develops
    • speak more loudly and rapidly
    • use more arm gestures and facial expressions
  13. Personality differences may affect communication
    Introverts:
    • energy decreases as conversation progresses, as though its being drained from them
    • tend to hesitate and think before speaking
    • appear aloof and reserved
  14. Message interpretation by listeners:
    • 55% of interpretation based on body language
    • 38% based on tone of voice
    • 7% based on verbal content
  15. What is rapport?
    • a condition of mutual trust and understanding
    • results support that interpersonal interaction w/ pts is a critical aspect of pt care although a more serious medical outcome may not make patients more inclined to file a claim...a less severe outcome may not...prevent a claim when relationship is poor
  16. Successful rapport building requires therapeutic listening:
    • process in which listener is intent upon learning the thougts and feelings of the person talking
    • also known as active listening
    • CANNOT happen during multi-tasking or through electronic media communication
  17. What are the 3 therapeutic listening techniques?
    • restatement
    • reflection
    • clarification
  18. Restatement:
    repeating the speaker's words
  19. Reflection:
    verbalizing the content and implied feelings of the sender
  20. Clarification:
    summarizing or simplifying the sender's thoughts
  21. Which of the therapeutic listening techniques is more likely to produce a paradigm shift in the listener?
    reflection
  22. What is involved in therapeutic listening?
    • suspending your thoughts and paying careful attention to the other person
    • empathy, rather than sympathy
    • understanding, rather than judgment
  23. Why is rapport sometimes hard to develop?
    • the therapist perceives a shared situation differently from the patient
    • one of the most important aspects of effective communication is the awareness that no 2 people have the same paradigm. In other words, no 2 people think exactly alike
  24. Paradigm:
    • a perception, assumption, or frame of reference
    • the way an individual "sees" the world, in termsof perceiving, understanding and interpreting
    • defined by individual's knowledge, values, patterns of thinking, culture, and social programming
  25. Paradigm shift:
    • the ability to see a situation in a different way from how one originally perceived it
    • an ability to break w/ current way of thinking
    • requires enough maturity to accept that there is more than one interpretation of a situation
  26. The ICF facilitating a paradigm shift:
    • previous models focused more on impairment or limitation
    • ICF asks "Who is this patient? What can he do now and would he change what he does/the way he does what he does, if he could?"
    • Think of looking through a kaleidoscope--same view but the picture changes when you shift your lens a little
  27. Establishing rapport requires the following skills:
    • a willingness to listen more than talk
    • an acceptance of the patient as the expert in reference to their condition
    • an awareness that the patient's condition may be influenced by culture or personal beliefs that you may not know about
    • Ask what can you do? What do you want to do?
  28. Purpose of starting with the interview:
    the interview is the most powerful, sensitivie and versatile instrument available
  29. Pre-screening:
    • patients may have multiple concerns that need additional referrals/modified referral
    • patient may be mis-referred and need to go elsewhere
  30. The 4 Habits Model template (for interview process):
    • place questions into framework that encourages pt disclosure
    • 1. Invest initially --1st contact is crucial
    • 2. Elicit the patient/client's perspective
    • 3. Demonstrate empathy (not same as sympathy)
    • 4. Invest in the end
  31. Habit 1 (of interview process):
    • initial investing
    • starts w/ intake forms
    • What important info does this intake form provide?
    • Could this form impact the development of rapport?
  32. Habit 1: Initial Investing
    • discover why the patient seeks care
    • establish rapport
    • introduce yourself to all who accompany the patient
    • be transparent
    • start with partially open ended questions
    • avoid overly focused questions in initial interview stages
    • use nonverbals
    • use encouraging verbals
    • include transitions
    • use redirection and continual prompts repeatedly to elicit all concerns
    • add therapist's observations about potential issues
    • confirm that all concerns were expressed by patient and understood by you
  33. Habit 1: Initial Investing
    Finally, summarize the list of things you'll address in the visit:
    • use patient's words where possible to prove you were listening
    • allows them to correct any misstatements
    • cues you to clarify anything confusing
    • ask them once again if they want to add anything
  34. TIPS for Habit 1: Initial Investing
    • use formal titles
    • steady eye contact with serious face
    • avoid wide-open, unstructured queries
    • expect more than one issue
  35. Habit 2 of the interview process:
    • elicit the patient's perspective
    • OT-occupational profile essential here
    • PT-consider the triangle of person, task and environment
  36. Habit 2: Elicit the patient's perspective
    need to discover what patient wants/needs/hopes to do that (s)he can't do because that is driving desire to receive services. Must understant patient's supports and barriers. Ask, do you think OT/PT can address all your concerns. Let them explain
  37. Habit 2: when patients identify their issues, it is rarely done in order of their perceived priority:
    • late arising concerns-serious, time intensive problem brought up at end of session
    • incomplete data gathering leading to incorrect diagnosis
    • patient frustration/anger b/c not getting any better
    • failing to identify hidden agenda that might explain atypical statements
    • discuss concerns about how therapy for their condition will impact their life
  38. Habit 2: sometimes the therapist is the barrier to information sharing
    • can't let go of traditional conceptĀ  that is a single, clear reason for therapy
    • assumption that the referring dx or the first problem mentioned must be most important to the patient
    • unwillingness to probe for unspoken problems b/c of impairment based view of patient needs
    • make it clear that patient needs to hurry
    • body language cues patient that we disapprove of their story
  39. A neglected part of habit 2:
    handle delicate issues
  40. Habit 3 of interview process:
    empathize with patient (don't sympathize)
  41. Habit 3: Empathize with patient
    • make patient feel as if you view them as an important human with worthwhile concerns
    • address emotions as they arise
    • don't ignor crying patient
    • follow up on any brief/tentative statements about worries or fears
  42. Habit 3: Try these communication techniques:
    • Reflection--"I can see that you are..."
    • Legitimation--"I can understand why you feel..."
    • Support--"I want to help."
    • Partnership--"Let's work together..."
    • Respect--"You're doing great"
    • not every empathetic response works in all situations but each conveys deep personal concern
  43. Habit 4 of interview process:
    invest at the end
  44. Habit 4: Invest at the end:
    • time to honestly share info
    • "This is what I think is going on and here is how I have come to that conclusion"
    • empower pt as person on team who makes decisions
    • Maximize likelihood of success
    • find out what excuses they might allow to get in the way
    • probe for support system who can help achieve goals
  45. Problems? Try these tips:
    • interview feeling scattered? try giving a roadmap
    • pt won't stop talking? try giving a signal
    • pt hostile or overly negative? try asking about what you see
  46. Adding questions to the 4 habit model:
    • open-ended questions
    • communicate the plan
    • redirection prn
    • continual prompts
    • summary
  47. In summary:
    • communication (verbal/nonverbal) is essential part of successful interview
    • therapist 1st responsibiltiy is to est rapport that respects cultural differences
    • Pt interactions involve more than just asking the right questions--therapist must create a physical and verbal environment that is conducive for sharing info

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