Interpersonal Skills

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Interpersonal Skills

• Health Psychology

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student doctors

• Although student doctors found chemistry and
  biology relatively easy dealing with their
  patients is not so easy.
• Battenburg and Gerritsma (1983) student doctors
  found it hard to
• 1. hard to initiate conversation
• 2. decide on diagnosis
• 3. cope with patients emotions

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Patients

• Perhaps patients also find it difficult to talk
  to doctors and therefore avoid going to see them.
• Patients make 11 Lay consultations for every one
  consultation with a doctor (Scambler and Scambler
  1984).

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Pitts (1991)

• Pitts (1991) suggests there are three reasons for
  going to the doctor
• Persistence of symptoms
• Critical incident - e.g. pain gets worse
• Expectation of treatment

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Kent and Dalgleish (1996)

• Kent and Dalgleish (1996) two types of patient
  satisfaction that should be considered
• Cognitive satisfaction how happy the patient is
  with the treatment etc.
• Emotional satisfaction how happy the patient is
  with the doctors level of interest and concern.

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What patients like

• People often judge the adequacy of their care by
  criteria that are irrelevant to the technical
  quality of the care. What people do know is
  whether or not they liked the practitioner
  whether he or she was warm and friendly or cool
  and uncommunicative. (Feletti, Firman,
  SansonFisher, 1986 Scarpaci, 1988 Ware et al.,
  1978).

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Patients are poor judges

• Even more significant, since people are poor
  judges of technical quality of care, they often
  judge technical quality on the basis of the
  manner in which care is delivered (BenSira, 1976,
  1980). For example, if a physician expresses
  uncertainty about the nature of the patient's
  condition, patient satisfaction declines

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Mooney, K. M., 2001

• Mooney, K. M., 2001, 'Predictors of patient
  satisfaction in an outpatient surgery clinic.
  Plastic Surgical Nursing, 21, 3, 162-4

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Aim

• To investigate which elements of the
  patient-practitioner relationship lead to
  satisfied patients.

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Participants

• An opportunity sample of 345 patients (96 per
  cent of those asked to participate) attending an
  out-patient plastic surgery clinic.
• Informed consent was obtained.

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Procedure

• The participants were required to evaluate items
  such as how long they waited to get an
  appointment, time spent waiting at the surgery
  before the doctor was seen, the explanation given
  about any procedures undergone, the technical
  skills (thoroughness, competence and carefulness)
  of the practitioner and the interpersonal skills
  (courtesy, sensitivity, friendliness etc.) of the
  practitioner on a 5-point scale ranging from poor
  to excellent.

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Results

• 60 per cent rated their overall level of
  satisfaction as excellent and 30 per cent as very
  good. The quality of interaction with the
  practitioner received the highest individual
  rating, while those concerned with the facilities
  and access to services were rated lower. The
  interpersonal skills of the doctor were found to
  contribute more to patient satisfaction than the
  technical skills of the doctor and were
  considered to be a better predictor of patient
  satisfaction.

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Smucker, D. R., Konrad, T. R., Curtis, P., Carey,
T. S., 1998

• , 'Practitioner self-confidence and patient
  outcomes in acute back pain', Archives of Family
  Medicine, 7, 223-8

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Participants

• 189 doctors and chiropractors, randomly selected
  from licensing databases in North Carolina, USA,
  who regularly treated patients for lower back
  pain. Informed consent was obtained.
•  

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Procedure

• The medical practitioners were sent a postal
  questionnaire to complete. The questionnaire
  contained ten items such as, 'I lack the
  diagnostic knowledge and tools to treat someone
  with lower back pain', 'I know exactly what to do
  to treat someone with lower back pain' and 'I
  feel very comfortable treating people with lower
  back pain', which assessed their self-confidence
  (the first four items on the scale) and attitudes
  (the next four items on the scale) in dealing
  with patients with lower back pain.

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Procedure

• The last two items dealt with knowledge of the
  progression from acute to chronic low back pain
  and patient satisfaction with treatment. The
  practitioners had to use a 5-point Likert scale
  (1 strongly agree, 5 strongly disagree) to
  record their level of agreement with each
  statement. The scores for the first four items
  were added together to generate a self-confidence
  score for each practitioner and those for the
  next four yielded an attitude score. The last two
  items were treated individually.

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Procedure

• The medical practitioners were also asked to
  provide contact details of any patients who came
  to them for treatment for lower back pain and had
  not yet received any treatment. Additionally, all
  the patients had to own a telephone and be able
  to speak English. A total of 1633 patients were
  recruited and informed consent was obtained from
  them. The patients were telephoned immediately
  after their initial visit to their practitioner,
  and again after two, four, eight, 12 and 24 weeks
  or until they had fully recovered from this
  episode of lower back pain.

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Procedure

• The length of time until they had returned to a
  level of functioning equal to that before the
  onset of the lower back pain was recorded.
• The practitioners' self-confidence scores were
  then compared with the length of time taken by
  the patients to return to the same level of
  functioning as prior to the lower back pain.

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Results

• 179 (95 per cent) of the 189 practitioners sent
  the questionnaire returned it, and of these 162
  (86 per cent - 107 doctors, 55 chiropractors)
  completed all ten items.
• A strong correlation was found between scores on
  the first four items (measuring self-confidence)
  and the next four items (measuring attitudes) for
  both doctors and chiropractors. The relationship
  between the item dealing with patient
  satisfaction and the self-confidence score was
  higher for the chiropractors than the doctors.

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Results

• Despite differences in levels of self-confidence
  and attitudes among the health practitioners,
  there was no significant relationship for either
  of these factors with the length of time it took
  patients to recover functionality. Thus it is not
  possible to use a practitioner's level of
  self-confidence or attitude as an indicator of
  the speed of recovery from lower back pain.

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Ogden et al (2002)

• Ogden et al (2002) explored the impact of the way
  in which uncertainty was expressed (behaviourally
  versus verbally) on doctor's and patient's
  beliefs about patient confidence. Second the
  study examined the role of the patient's personal
  characteristics and knowledge of their doctor as
  a means to address the broader context.

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Ogden et al (2002)

• Matched questionnaires were completed by GPs
  (n66, response rate92) and patients (n550,
  response rate88) from practices in the
  south-east of England.

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Ogden et al (2002)

• The results showed that the majority of GPs and
  patients viewed verbal expressions of uncertainty
  such as Let's see what happens' as the most
  potentially damaging to patient confidence and
  both GPs and patients believed that asking a
  nurse for advice would have a detrimental effect.

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Ogden et al (2002)

• In contrast, behaviours such as using a book or
  computer were seen as benign or even beneficial
  activities. When compared directly, GPs and
  patients agreed about behavioural expressions of
  uncertainty, but the patients rated the verbal
  expressions as more detrimental to their
  confidence than anticipated by the doctors.

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Ogden et al (2002)

• In terms of the context, patients who indicated
  that both verbal and behavioural expressions of
  uncertainty would have the most detrimental
  impact upon their confidence were younger, lower
  class and had known their GP for less time.

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Barnett (2002)

• Barnett (2002) has found that a quarter of
  surgeons are brusque, unsympathetic or impatient
  when they break bad news to patients. Family
  doctors are better at breaking bad news, but most
  patients are told by surgeons (86). 106 cancer
  patients were interviewed. 94 of these had been
  told by doctors and the rest by family members.

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Barnett (2002)

• The patients were asked to rate the way the news
  was delivered in four categories positive,
  neutral, negative and very negative. In 26 per
  cent of the cases, memories of the moment were
  negative or very negative. There were also
  complaints about the lack of clear, simple
  information. (The Times 01-07-02)

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Doctors are sometimes accused of not listening

• Beckman and Frankel (1984) studied 74 visits to
  the doctor. In only 23 of the cases did the
  patient have the opportunity to finish his or her
  explanation of concerns.
• In 69 of the visits, the doctor interrupted,
  directing the patient towards a particular
  disorder.

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Doctors are sometimes accused of not listening

• Moreover, on average doctors interrupted after
  their patients had spoken for only 18 seconds.

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Doctors can be trained in Non-Verbal Communication

• Birdwhistell (1970) estimated that only 30 to 35
  of the social meaning of a conversation is
  carried by words alone.
• Non-verbal communication includes features of
  speech such as
• tone of voice,
• inflection,
• rates of speaking,
• duration and pauses.

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non-verbal communication

• Other forms of non-verbal communication are
  conveyed by gestures, dress, physical proximity,
  facial expressions, posture and orientation.

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Argyle (1975) four major uses

• To assist speech, for example in synchronising
  conversation or supplementing speech by putting
  stress on certain words, or pausing between words
  or varying the tone and speed of speech
• As a replacement for speech
• To signal attitudes, e.g. trying to look cool
• To signal emotional states, i.e. we can tell how
  a person is really feeling by looking at their
  facial expression or posture.

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• Exercise

• On the card in front of you is written an
  emotion. You have to stand up in front of the
  group and communicate this emotion non-verbally,
  that is you must not use any words. You can
  communicate vocally by altering such things as
  the pitch, tone and volume of your voice by
  counting from 1 to 5 whilst using any other
  non-verbal channel. Other members of the group
  write down the emotion they think is being
  demonstrated as each member takes his turn.

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Emotional words

• Fear, Disbelief, Sadness, Dominance, Boredom,
  Disgust, Interest, Shame, Anger, Surprise, Love,
  Embarrassment, Admiration, Happiness

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Smiling a lot can make people happy.

• Zuckerman et al (1981) divided males and females
  into three groups.
• The first group saw a film of a pleasant scene.
• The second group were shown a film of a neutral
  scene.
• The third group were shown a nasty film.

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Within each group

• a third were asked to suppress their facial
  expressions,
• a third were asked to exaggerate their facial
  expressions
• and the other third were not asked to do anything
  apart from watching the film.

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Results

• The people who exaggerated their facial
  expressions showed higher levels of arousal and
  reported stronger positive or negative emotional
  reactions, compared with the other two groups.
• So making patients smile will make them feel
  happier about themselves.
• Learning to suppress facial expressions at times
  of stress could reduce stress.

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Doctors dress.

• McKinstry and Wang (1991) Pictures of same doctor
  dressed formally or informally.
• Pictures of formally dressed doctors rated
  higher for the amount of confidence the patients
  had in them, and on how happy they would be to
  see them.
• Older and professional-class patients
  particularly preferred the formally dressed
  doctors.

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Touch

• Jourard (1966) considered where it is acceptable
  to be touched and by whom.
• Doctors need to be careful not to alarm the
  patient by touching them in a 'no go' area
  without their permission.

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Cultural differences

• Jourard (1966) also found cultural differences in
  the amount of touching. Observing people in cafes
  around the world he counted the number of times
  people touched each other during the course of
  one hour. His results were

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Touch
Place Number of touches
San Juan (Puerto Rico) 180
Paris 110
London 0
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British Nurses

• Davitz Davitz (1985) report that American
  patients' perceptions of British nurses might be
  influenced by different cultural norms
• The expression of a range of emotions on the
  part of American patients, in many situations,
  often made the British nurses uncomfortable and
  even more reserved. It is interesting to note
  that a number of patients whom we interviewed
  judged this discomfort as dislike, insensitive,
  and hard-boiled. 'They're efficient,' noted one
  patient, 'but they're not sympathetic.'

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Whitcher Fisher (1979)

• A second piece of research highlights the status
  differences involved in touching. Whitcher
  Fisher (1979) arranged for nurses to either touch
  or not touch patients while providing them with
  information about impending operations. The
  nurses in the'touch condition'touched the
  patients on the hand whilst showing them a
  booklet describing the operation, whereas those
  in the 'no touch' condition did not touch the
  patients at all. All the nurses were female. The
  patients were asked for their views about the
  hospital and the prospective operation.

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Whitcher Fisher (1979)

• After the operation, the patients' blood pressure
  was measured. Female patients touched by nurses
  reported lower anxiety, more positive feelings to
  the hospital and had lower blood pressure after
  the operation than those not touched. On the
  other hand, male patients who were touched
  reported greater anxiety, more negative feelings
  and higher blood pressure after the operation
  than those who were not touched.

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Whitcher Fisher (1979)

• Whitcher Fisher (1979) suggest that one
  explanation for these results stems from status
  differences. Higher status individuals are at
  liberty to touch lower status individuals, but
  not vice versa. Thus females perceived the
  touching as a sign of caring and warmth males
  perceived it as a threatening gesture, which
  communicated the nurses' superior status in the
  hospital setting.

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questioning

• 1.   the most important part of questioning is
  listening
• 2.   determine the reasons for asking the
  questions
• 3.   do not ask too many questions

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questions fall into the following categories

• closed questions
• open questions
• affective questions
• probing questions
• leading questions

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closed questions

• closed questions are questions which require very
  short answers and are useful for anxious or
  nervous people so that tension can be reduced.
  Asking too many closed questions means that the
  doctor has to ask lots of questions to get
  information and they spend less time listening to
  the patient. As an exercise try asking a friend a
  series of closed questions for as long as
  possible.

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open questions

• open questions give the respondents the
  opportunity to respond in anyway they wish. There
  is no correct answer. A disadvantage is
  curtailing rambling irrelevances, though the use
  of well timed closed questions can bring a
  wandering conversation back to the issue at hand.

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three main types of sequences

• Funnelling. Beginning and interview with an open
  question and gradually becoming more specific.
• Inverse funnelling. Going from specific details
  to general topics.
• The Tunnel. Asking a series of closed questions.

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Jesudason (1976)

• Jesudason (1976) compared open and closed
  questions in finding out what foods were taboo
  during lactation (mothers producing milk for
  their babies) for Indian women. The sample
  consisted of 1151 women who were asked either to
  name the foods that were taboo (open) or were
  read out a list of 12 foods and asked whether
  they ate each food during lactation (closed).

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Jesudason (1976)

• About 53 did not report any food taboos when
  given the question in open form. When these women
  were read the list of 12 foods, 32 considered
  five or more items taboo.

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affective questions.

• affective questions. These are questions about
  the patients feelings and emotions and help to
  communicate concern and empathy.

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Probing questions.

• These questions are used to get a patient talking
  when they are not forthcoming. Hackney and
  Cormier (1979) suggests the use of the "accent"
  and "minimal" prompt. The accent is a short
  re-statement that echoes and focuses a previous
  statement.

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Probing questions.

• The minimal prompts use a large number of
  non-verbal responses such as "uh-huh", "mmm",
  "ah", and "yes, I see." Non-verbal behaviours
  such as leaning forward would also act as
  prompts. A problem with using too many probing
  questions is that the interview can become an
  interrogation.

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leading questions

• Conversational lead.
• Pressurised agreements.
• Hidden subtleties.

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conversational lead.

• This type of leading question is used to
  anticipate agreement with the patient and thus
  convey the impression of friendliness and
  attentiveness. An example would be "isn't she a
  marvellous cook?".

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pressurised agreements.

• This type of question puts pressure on people to
  agree with the questioner. For example "you do,
  of course, brush your teeth every day?". These
  types of questions should be avoided by doctors
  because it leads to invalid responses.

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hidden subtleties.

1. This type of question leads the respondent
   without their knowledge. Loftus (1975)
   interviewed 40 people about headaches and
   headache products, ostensibly for market
   research.

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hidden subtleties.

• They were asked either "do you get headaches
  frequently, and if so, how often?" Or "do you get
  headaches occasionally, and if so, how often?"
• The average number of headaches in the
  "frequently" group was 2.2 Whereas in the
  "occasionally" group it was 0.7 headaches a week.
  

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hidden subtleties.

• The subjects were also asked how many products
  they had tried for the headaches. One group was
  given a choice of one, two, or three Another the
  choice of one, five, or ten. The first groups
  average was 3.3, the second's 5.2. Similar
  effects can be used by substituting "short" with
  "tall" or "the" with "a".

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Savage and Armstrong (1990)

• Savage and Armstrong (1990) found that patients
  were more satisfied with a directed
  consultation rather than a sharing
  consultation.

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Savage and Armstrong (1990)

• Directed consultation statements made such as
  you are suffering from, it is essential that
  you take this medication, you should be better
  in . days, come and see me in . days.
• Sharing consultation what do you think that is
  wrong?, Would you like a prescription?, Are
  there any other problems?, When would you like
  to come and see me again?

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Savage and Armstrong (1990)

• 359 randomly selected patients free to choose
  their doctor. 200 results used.
• 2 questionnaires one immediately and one a week
  later.
• Results overall a high level of satisfaction,
  but higher for directed group. Higher for
  satisfaction with explanation of doctor and
  with own understanding of the problem. More
  likely to report that they had been greatly
  helped.

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The end