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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
- maybe the patient should be referred to a different practice because it might be beyond your scope
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!
What is communication?
a dynamic interchange b/w at least two individuals
What are the contents of communication between at least two individuals?
- verbal components
- non-verbal components
Clinical reasoning is built on...
information that the patient is willing to share with the therapist
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
Why wouldn't patients tell us everything that might help them?
- our habits related to listening
- our non-verbal messages
- listening and understanding are not the same
- understanding requires a paradigm shift
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
Reality of bi-culturalism:
- internalization of two cultures
- blending, not replacing
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
Striving for culturally sensitive communication:
- our listening skills
- our non-verbal messages
Personality differences may affect communication
- energy tends to increase and even become more enthusiastic as conversation develops
- speak more loudly and rapidly
- use more arm gestures and facial expressions
Personality differences may affect communication
- energy decreases as conversation progresses, as though its being drained from them
- tend to hesitate and think before speaking
- appear aloof and reserved
Message interpretation by listeners:
- 55% of interpretation based on body language
- 38% based on tone of voice
- 7% based on verbal content
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
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
What are the 3 therapeutic listening techniques?
repeating the speaker's words
verbalizing the content and implied feelings of the sender
summarizing or simplifying the sender's thoughts
Which of the therapeutic listening techniques is more likely to produce a paradigm shift in the listener?
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
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
- 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
- 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
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
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?
Purpose of starting with the interview:
the interview is the most powerful, sensitivie and versatile instrument available
- patients may have multiple concerns that need additional referrals/modified referral
- patient may be mis-referred and need to go elsewhere
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
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?
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
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
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
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
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
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
Habit 2: sometimes the therapist is the barrier to information sharing
- can't let go of traditional concept 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
A neglected part of habit 2:
handle delicate issues
Habit 3 of interview process:
empathize with patient (don't sympathize)
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
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
Habit 4 of interview process:
invest at the end
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
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
Adding questions to the 4 habit model:
- open-ended questions
- communicate the plan
- redirection prn
- continual prompts
- 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