The purpose of this assignment is to acknowledge and critically analyse the key skills required to perform a patient-centred interview; where any discrepancies between theory and practice will be noted. Episodes of critical reflection will be integrated using the literature to offer evidence to question and/or support my clinical interview. Furthermore, I will explain what has been learnt both professionally and personally, and so recommendations for the development of clinical practice will be offered based on the issues demonstrated (Reid, 1993).
In this paper, since I will be using a reflective narrative to critically evaluate my video-taped clinical assessment, the first person will be used. I will not feign an objective account to, what is, a personal and professional experience of a clinical assessment of a simulated patient called ‘Jo’. The strength being it can enhance the readability and the accessibility of the paper through directly expressing my cognitions and feelings (Webb, 1992; 2002; 2006). This could be deemed an ‘optimal’ way to communicate in a reflective analysis (Winslow and Guzzetta, 2000).
I will analyse the essential skills necessarily for a patient-centred interview under the following sections: content (introduction to the session; information gathering; problem formulation; and decision making) and process (interpersonal skills). In Smithies (2006) unpublished thesis it was suggested that these ‘skills’ are necessary for a successful patient-centred assessment; to support the patient to tell their story in a manner suitable for a semi-structured interview schedule.
Patient centred Interview
The concept of patient-centred interviewing was first discussed, in relation to the medical profession, by Balint (1964) who contrasted patient-centred medicine with illness-focused medical care provision. This patient-centred approach to care is increasingly being advocated as the NHS Plan identified that it should ‘shape its services around the needs and preferences of individual patients, their families and their carers’ (DH, 2000. p. 4). As a result such teaching has been incorporated onto the low-intensity training curricula where it is a central component of the ABC-E Model of Emotion (Briddon et al, 2008). It is now a term which is widely cited, nonetheless, no ultimate definition of patient-centred care has been offered. It could be seen as ‘understanding the patient as a unique human being’ (Balint, 1969); hence rather than seeing the patient as a condition (e.g. the depressed patient) it enables the identification of the patient’s problems using a biopsychosocial perspective.
Patient-centred interviewing is seen as an alternative to practitioner-centred approaches e.g. the biomedical model (Mead and Bower, 2000). It is generally viewed, within the literature, as an effective framework however limited evidence has been offered; where it is suggested that there is a small, but significant, relationship between patient-centred interviewing and subsequent patient outcomes (Roter et al, 1995) and patient satisfaction (Smith et al, 1995; Kinmonth et al, 1998; Pill et al, 1998). Furthermore, it is recognised that the majority of studies are geared at General Practitioners (GPs) (Lewin et al, 2001). For that reason it is difficult to generalise such findings to any other profession, including that of the newly developed Psychological Wellbeing Practitioner (PWP) role.
Introduction to Session
The first few minutes of a patient-centred assessment are crucial to the efficacy of the interview and are often well recalled by patients (Newell, 2000). This is since particular attention is paid to the preparatory stages of the interview (Faulkner, 2002). It is of particular relevance as it is suggested that for novice practitioners, like myself, it provides the opportunity to apply a structured format (through using a prompt sheet) in order to enhance performance with minimal effort (Newell, 1994).
The opening phase of the interview should include: the establishment of the patients full-name and preferred name; the practitioners name and an outline of role of the PWP; the aims, agenda and duration of the assessment; and an exploration of the limitations of confidentiality. In fact, whilst all parts were included in this section I failed to thoroughly involve the patient in negotiating the agenda. It is recommended that a mutual agreement is made from the outset to ensure that the session covers the pertinent issues raised by the patient (Westbrook et al, 2008).
In the opening I addressed the limits to and expectations of confidentiality (e.g. ‘Whatever we discuss is confidential however if you are at risk to yourself, or anyone else, then I would have to break that, is that ok?’) which is essential for the relationship to be therapeutic (Szmukler and Holloway, 2001; Jenkins, 2004; Jenkins, 2005). In the role-play I felt that rather than ensuring the patient would feel safe to divulge possibly distressing information I took a formal and rigid approach. In order to address this, I introduced the concept of engaging the patient even in the case of specific risk being identified; as managing risk includes actively involving the patient in the dynamic and evolving process (DH, 2007). For example, ‘I just want to ensure you that I would inform you of any actions that I would take. So you would be aware, nothing behind your back’.
Information gathering must be patient-centred and delivered ‘… in a way which fits with the beliefs and prior knowledge of patients – and arriving at a shared decision between patient and worker in as collaborative a manner as possible’ (Richards and Whyte, 2009. p. 5). In order to do so, structured interviewing is employed focusing on the ‘here and now’ which includes the four ‘Ws’ i.e. What is the problem? (‘Would you like to summarise in a nut shell what things are like for you right now?’) Where does the problem occur? (‘Are there any places that you notice that you feel a bit better?’) When does the problem happen? (‘Are there any times in the day that you feel particularly better?’) With whom is the problem better or worse? (‘Who has a positive impact on your life?’) (Richards and McDonald, 1990). These broad questions do not restrict the discourse, but firmly reveal what problems are concerning for the patient (Faulkner, 2002).
It is also appropriate to obtain information in terms of autonomic, behavioural and cognitive phenomena; as well as contextual and modifying factors currently impacting on the problem (Richards and Whyte, 2009). In some cases of depression there is a clear connection to an adverse life event such as an illness, bereavement, money worries or a culmination of problems; in other circumstances there will be no clear cause (Briddon et al, 2003a). To deliver patient-centred care practitioners need to take into account not only social and psychological needs, but other important issues such as: drugs and alcohol intake (‘And any illicit or recreational drugs?’ or ‘Do you drink?’); spirituality (‘And how do you address spirituality?’); and sexuality (‘And in terms of an intimate relationship with Alistair?’) (Sainsbury Centre for Mental Health, 2001).
A vital aspect of the Improving Access to Psychological Therapies (IAPT) initiative is collecting routine outcome measures as part of the minimum data set (NHS, 2008a) This includes the PHQ-9 and the GAD-7 which are utilised for assessing patient progression. In the context of the therapeutic relationship it is important to provide feedback of what these scores mean (Richards and Whyte, 2009). For example in the role-play I acknowledged that the ‘referral says that you have been suffering with the symptoms of depression and kinda the questionnaire that you have filled in suggest that your suffering with those symptoms and the feelings associated with anxiety and depression’. I further asked ‘how did you find it to fill in?’ in order to seek the patient’s perspective. It would have been appropriate if I had highlighted the scoring to show Jo her baseline measure, and I should have been honest in telling her that she was ‘moderately’ depressed and anxious.
A core skill for all mental health professionals is to conduct a risk assessment encompassing: risk of suicide; harm to others; and self-neglect (DH, 1999; Hope, 2004). The most important factor associated with suicide is the presence of a mental illness such as an affective disorder; where 24% of completed suicides had been in contact with a mental health service in the year preceding death (Appleby et al, 1999). It is suggested, therefore, that it is necessary to discuss the topic explicitly but in a sensitive and effective manner (NICE, 2009). Assessment and identification of suicidal risk should look in detail at the actions (current and past), ideation (thoughts), plans (including specific access to means) and any preventative/protective factors which will establish the seriousness or lethality of the ideation (Beck, 1975). An effective therapeutic relationship will acknowledge the intensely painful situation another human is enduring alongside an objective assessment of risk through encouraging the patient to explore their narrative (O’Rourke and Bailes, 2006; Lakeman and FitzGerald, 2008). I attempted do so by identifying the fact that ‘when people are feeling low they can have thoughts because it’s so intensely painful they can have thoughts about taking their own life. Have you had thoughts like this before?’. Unfortunately, I failed to address the implications of alcohol and cannabis use on the lowering of inhibitions and possible increased risk of suicide (Hawton and van Heerigen, 2009).
In order to elicit information ‘funnelling’ is recommended (Kahn and Cannell, 1957) beginning with a broad open question, and leading to closed questions to confirm and clarify specific details (Burnard, 1996). It allows the patient to take control and choose the topics they want to discuss (Burnard, 2002). An example of funnelling is:
When people are feeling low it can impact physically, have you noticed any changes?
Suppose just really tired and lethargic and not sleeping well at all.
So when you say not sleeping well?
I just keep waking up just disturbed sleep every night.
And how many hours do you have a night at the moment?
I don’t know about 4 to 5.
4 to 5 that’s not a lot really.
I don’t know it’s quite tricky cos I keep waking up and going off and waking up but it’s around that.
So it’s around that then? And when you are feeling your normal self how many hours would you have then?
Say 7 to 8.
A patient-centred problem statement should explain and describe the patient’s current problem in a focused manner using the patient’s own words (Briddon et al, 2003b). A problem statement has three functions: it draws a line under the information gathering section; shifts from fact-finding to collaboration; and provides a reference point for future contacts (Richards and Whyte, 2009). In delivering Jo’s problem statement I feel I said ‘too much’, for instance:
‘It sounds as if you have been feeling quite low, around 3 weeks and it worse in the morning but it doesn’t necessarily get better but in terms of that horrible feeling in the morning it kind of dissipates a little. And that you feel a bit better when you are around Alliaster but not really when you around you friends. Your sleep is quite disturbed now and your appetite is not quite as good as it used to be and so as a result you have stopped going out as much as you would normally go out and going for walks with Alliaster and you have some quite self critical and I’m going to go to what they were cos it’s good to kind of capture what you said rather than mine ‘like you should be back at work’ and that your ‘a failure’ and ‘feel quite hopeless right now’. It seems to have started after getting the flu and then after that you realised that we were feeling quite low. That it has impacted on certain things at home and at work in terms of that you have not been able to do certain things like doing the spare room and get that sorted as at least half of it is done and that you want to get back to work. Does that sound an accurate picture?’.
In order to understand and manage emotion Lang’s (1971) ABC model offered a three systems approach: autonomic, behavioural and cognitive. Briddon et al (2003b) offered a further system including environmental components of a patient’s difficulties. The ABC-E Model of Emotion, provides a biopsychosocial aid to look at the links between emotion (such as anger, sadness, guilt, anxiety, etc) and the maintaining factors to a ‘vicious’ cycle (Briddon et al, 2008). It particularly helpful for the therapeutic relationship to illustrate the process with a diagram (as shown in Figure One on page 22) in order to educate the patients regarding the relationship between what we think, what we do and how that impacts on us physically (Padeskey and Mooney, 1990).
Lam and Gale (2000) suggest that through understanding the ABC-E concept it can improve a patient’s motivation to learn about how to change, where Alford and Beck (1997) suggest that it is imperative that the rationale behind the therapy is entirely understood by the patient as this can impact on the therapeutic efficacy. For example, the patient’s problems were related to depression so I stated ‘so if we were to explain it in terms of your sleep, you have a reduction in sleep which means that were feeling quite tired and you don’t want to go out any more and that leads to the thought that you a failure and you feel hopeless and that leads to the argument with Alistair and you feel like things aren’t quite like they used to be. Does that seem quite right to you?’. I feel, however, that my lack of specialist knowledge limited the efficacy of this process (Maphosa et al, 2000).
Shared Decision Making
Since the late eighties government reforms have indicated a move towards the concept of partnership in treatment between professionals and patients; through encouraging self-determination through identifying an individual’s strengths and weaknesses (DH, 1989; DH, 1991; SCMH, 2001; Hope, 2004; DH, 2009). This shared decision-making ensures that effective goals are identified by the patient in negotiation with the PWP (Newell, 2000). In the future I would aim to gauge the goals utilising the acronym SMART (i.e. specific, measurable, achievable, realistic and time-bound); in order to drive the intervention and motivate the patient to achieve the desired behaviour (Fennel, 1999). This would develop further from the questioning I began in the session as I only established that Jo wanted to ‘… get back to things like going out and back to work and just feeling better about myself’.
A failure of my role-play could be associated to the fact that, having come from professional nurse training, such a culture and organisation engenders a task-orientated approach represented by my need to ‘fix’ things (Wilkinson, 1991a). As such rather than seeing the patient as an individual, with their own individual needs, I felt like I had to take control in order to address the issues head-on. However, it is vital to treat all patients, irrespective of diagnosis, as autonomous individuals where it is essential to respect the choices they make (Beauchamp and Childress, 2001). For this reason rather than imposing are own assumptions and personal understanding, I should continue to ask the patient questions such as ‘Is that a concern for you, the drinking?’ and ‘So is that something that you would like to look at?’.
It is suggested that there is a higher acceptance and a greater likelihood of individuals partaking in treatment if shared decision-making is utilised (Orlando and Meredith, 2002). Furthermore, it is indicated that there are better outcomes than if the patient were alone in the process (Bedi et al, 2000). In fact ruptures are likely to form from in the current therapeutic alliance if the goals are not decided in a shared process (Watson and Greenberg, 2000). This could be due to the fact that patient’s value having a sense of control; but also they value having guidance, advice and direction from a practitioner (Lovell et al, 2008). This could be due to the underlying expectation of professional paternalism and passive patients (Charles et al, 1999). I indicated that the patient would be the expert indirectly by saying: ‘… I work with people with anxiety and depression to help self manage their condition’ and that ‘… but what it doesn’t say it what it means to you. You know you are not symptoms, so hopefully today we will be able to gauge that and get a picture for what things are like for you right now. And then hopefully work together to get better’.
Communication and Interpersonal Skills
Patient-centred communication ‘… invites the patient to participate in decision-making and, in case of differences, includes the option to negotiate about the differences’ regarding their own care (Langwitz et al, 1998). The government and professional guidelines suggest that competence in effective communication is high on the agenda within the NHS; hence for the advancement of communication skills practitioners must partake in training (DH, 2003; QAA, 2004; DH, 2004). For this reason, a standard curriculum for all PWPs exists where students must fulfil set criteria in order to gain competency (Richards and Whyte, 2009).
Rogers (1961) believed that there were four components to ensure that the relationship would be therapeutic: warmth, empathy, genuineness and non-judgemental respect for another individual. These could be deemed a pre-requisite for communication to be patient-centred, as the SCMH (2001) identified such ‘skills’ should be adopted by all mental health practitioners. This is significant as we may encourage a patient to be involved in the shared decision-making process, but this can only be successful if it is done within the context of such ‘core’ skills (McCabe and Timmins, 2006). This is reiterated by the fact that patients often describe practitioners in terms of personal qualities (e.g. pleasant, caring and honest) (Lovell et al, 2008). Hence, from a patient’s perspective a good practitioner is valued in terms of attitudes and feelings rather than their technical competence (Mead and Bower, 2000; Gask et al, 2003; Lovell et al, 2008).
In practice we use the term ‘interpersonal skills’ but a more appropriate term would be ‘communication skills’; it appears that within the literature that authors use the two interchangeably where they are seen as the elements that enable individuals to convey messages effectively with each other as highlighted in the role-play through: active listening (effective summarising throughout), non-verbal communication (nodding, maintaining adequate eye contact, moving closer when I described the ABC-E concept, etc), instilling hope (‘Well hopefully we can work on that and that can change and mood can lift, and it’s good that you want to want, that quite a good sign, while you’re feeling hopeless right now, you can see that there is a future’), etc (Cassee, 1975).
It may not be possible to change our own belief systems but ’empathy’ and ensuring ‘rapport’ are achievable at some level by all through communication skills training (Norfolk et al, 2007). For example, in acquiring empathy it has moral, emotive, cognitive and behavioural components (Morse et al, 1992). It may be possible, therefore, to learn the behavioural aspects such as communicating empathic understanding (e.g. ‘So that’s another pressure on you’ and ‘That’s not a lot really’) but changing interpersonal qualities could be intangible.
In looking at the session structure there was a definite conscious cognition of just wanting to ‘get through’ the assessment within the 40 minute timeframe. As a result I felt I adopted ‘blocking behaviours’ to avoid an open dialogue aimed at avoiding the expression of any kind of strong emotion such as: premature reassurance, jollying along, closed questioning, etc (Wilkinson, 1991a; 1991b; Booth et al, 1996; Wilkinson et al, 2008). Most notably I did so when I overlooked the impact on sexuality as Jo highlighted that ‘I do want to you to know it (sex) is a problem for us’; but I continued straight away by saying ‘And are you particularly religious’. This resulted in my not exploring issues in great enough depth. I would hope that through practising the interview with simulated patients (or with colleagues) that it would lead to the acquisition of effective communication skills and the relinquishing of such blocking behaviours. It is vital to note that the IAPT programme, however, does place a lot of demands on time so this role-play could in fact mirror real-life.
In summary, the patient-centred assessment can exist as part of treatment rather than just as part of the information gathering process. Emphasis has been placed on valuing the patient’s perspective; understanding a patient as an individual; sensitive and comprehensive risk assessment; negotiation and shared decision-making; and using effective communication skills. This is not dissimilar to Mead and Bower (2000; 2002) who identified five conceptual dimensions required for patient-centred care including the: biopsychosocial perspective; ‘patient-as-person’; sharing power and responsibility; the therapeutic alliance; and the ‘practitioner-as-person’.
I feel that I lacked the appropriate skills to deliver a patient-centred assessment; as I hadn’t had the opportunity to do so in my clinical setting. Therefore, my inability to form a therapeutic alliance could be due to my own self-doubt. It is claimed that perceived self-efficacy is related to an individual’s belief that they have the capacity to learn and therefore perform specific behaviours (Bandura, 1977). Therefore, my own uncertainty regarding how effectively I could perform the assessment could have significantly impacted on my ability to successfully perform the assessment.
In my case, this role-play merely highlights the fact that it is imperative that as a trainee PWP I understand the limitations of my practice in order to be a safe practitioner. I must continue to utilise self-reflection, incorporate feedback from my clinical supervisor and more experienced colleagues. This informal (DH, 2008) and formal (NHS, 2008b) ‘support’ is vital in order for communication skills to be adequately transferred into the workplace; offering an invaluable gateway through which I can maintain my own sense of personal wellbeing and reduce ineffective or harmful practice.
A question raised by the role-play is that can actual behaviours, as observed through the simulated patient interview, be transferred into actual clinical practice where ‘real’ patients are unique, complex and challenging e.g. would the same positive results occur in a naturalistic setting. A strength, on the other hand, is that it provides a ‘safe’ environment for skills practice; since no patient is put at risk from a junior PWP. However, the artificial nature of the simulation, the huge pressure placed upon me by my employer to pass, my limited knowledge base and the limited time-frame deemed me somewhat ‘useless’. Indeed anxiety can act as a barrier to delivering effective care, as it can be difficult to recognise another individual’s distress when you are in a state of worry (Jourard, 1964). Hence, I feel that personally rather than learning how to effectively deal with the complexities raised in an initial assessment I have learnt to prepare and pass a clinical assessment under exam conditions.
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