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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
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- maybe the patient should be referred to a different practice because it might be beyond your scope
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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!
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What is communication?
a dynamic interchange b/w at least two individuals
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What are the contents of communication between at least two individuals?
- verbal components
- non-verbal components
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Clinical reasoning is built on...
information that the patient is willing to share with the therapist
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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
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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
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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
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Reality of bi-culturalism:
- internalization of two cultures
- blending, not replacing
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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
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Striving for culturally sensitive communication:
- our listening skills
- our non-verbal messages
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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
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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
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Message interpretation by listeners:
- 55% of interpretation based on body language
- 38% based on tone of voice
- 7% based on verbal content
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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
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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
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What are the 3 therapeutic listening techniques?
- restatement
- reflection
- clarification
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Restatement:
repeating the speaker's words
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Reflection:
verbalizing the content and implied feelings of the sender
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Clarification:
summarizing or simplifying the sender's thoughts
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Which of the therapeutic listening techniques is more likely to produce a paradigm shift in the listener?
reflection
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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
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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
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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
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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
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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
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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?
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Purpose of starting with the interview:
the interview is the most powerful, sensitivie and versatile instrument available
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Pre-screening:
- patients may have multiple concerns that need additional referrals/modified referral
- patient may be mis-referred and need to go elsewhere
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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A neglected part of habit 2:
handle delicate issues
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Habit 3 of interview process:
empathize with patient (don't sympathize)
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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
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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
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Habit 4 of interview process:
invest at the end
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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
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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
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Adding questions to the 4 habit model:
- open-ended questions
- communicate the plan
- redirection prn
- continual prompts
- summary
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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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