Unit 2:

INTERVIEWING SKILLS AND HEALTH HISTORY

Topics will be discussed in this lecture
• Interviewing skills
• Phases of the Interview
• The Techniques of Skilled Interviewing.
• Complete Health history
• Genogram
Prepared by: Miss Rabia Hanif
Nursing Lecturer
Sharif College of Nursing
 Subjective data
 Collecting subjective data is an integral part of nursing
health assessment.
Subjective
Subjective data
data consist
consist of sensations
sensationsor
orsymptoms,
symptoms,
Feelings,Perceptions,
Feelings, Perceptions,Desires,
Desires,Preference,
Preference, Beliefs,
Beliefs, Ideas,
Ideas,
Valuesand
Values andPersonal
Personalinformation.
information.

• These types of data can be elicited and verified only by the

client. Subjective data provide clues to possible physiologic,
psychological, and sociologic problems. They also provide
the nurse with information that may reveal a client’s risk for
a problem as well as areas of strengths for the client.
• These information is obtained through interviewing.
Therefore, effective interviewing skills are vital to accurate
and thorough collection of subjective data.
 Interview
• The word interview comes from Latin and middle French
words meaning to “see between’ or “see each other”.
• The word "interview" refers to a structured conversation or
a one-on-one conversation between an interviewer and
an interviewee.
• According to Scott and others, “an interview is a purposeful
exchange of ideas, the answering of questions and
communication between two or more persons”.
Purpose:
o Gather information to base nursing care.
o Establish a helping relationship.
o Identifying health status, concerns, and problems.
o Screening purpose
o Education
 Interviewing
• The process of interviewing is both an art and a skill. It is primarily
patient centered. It “encourages patients to express what is most
important to them.
• They express their personal concerns in addition to symptoms,”
creating a narrative that includes “the personal context of the
patient’s symptoms and disease.”

• Obtaining a valid nursing health history requires professional,

interpersonal, and interviewing skills. The nursing interview is a
communication process that has two focuses:
1. Establishing rapport and a trusting relationship with the client to
elicit accurate and meaningful information.
2. Gathering information on the client’s developmental,
psychological, physiologic, sociocultural, and spiritual statuses to
identify deviations that can be treated with nursing and
collaborative interventions or strengths that can be enhanced
through nurse–client collaboration.
 Phases of the Interview
• The nursing interview has three basic phases: introductory,
working, and summary and closing phases. These phases are briefly
explained by describing the roles of the nurse and client during
each one.

 Introductory Phase
• After introducing himself to the client, the nurse explains the
purpose of the interview, discusses the types of questions that will
be asked, explains the reason for taking notes, and assures the
client that confidential information will remain confidential.
• The nurse also makes sure that the client is comfortable (physically
and emotionally) and has privacy. It is also essential for the nurse to
develop trust and rapport at this point in the interview.
• This can begin by conveying a sense of priority and interest in the
client. Developing rapport depends heavily on verbal and nonverbal
communication on the part of the nurse.
Conti…..
 Working Phase
• During this phase, the nurse elicits the client’s comments about major
biographic data, reasons for seeking care, history of present health
concern, past health history, family history, review of body systems for
current health problems, lifestyle and health practices, and developmental
level.
• The nurse then listens, observes cues, and uses critical thinking skills to
interpret and validate information received from the client. The nurse and
client collaborate to identify the client’s problems and goals. The
facilitating approach may be free-flowing or more structured with specific
questions, depending on the time available and the type of data needed.

 Summary and Closing Phase

• During the summary and closing, the nurse summarizes information
obtained during the working phase and validates problems and goals with
the client. She also identifies and discusses possible plans to resolve the
problem with the client. Finally, the nurse makes sure to ask if anything
else concerns the client and if there are any further questions.
The Fundamentals of Skilled
Interviewing
 The Techniques of Skilled
Interviewing:
1. Active listening
2. Empathic responses
3. Guided questioning
4. Nonverbal communication
5. Validation
6. Reassurance
7. Partnering
8. Summarization
9. Transitions
10.Empowering the patient
 1. Active Listening
o Active listening is the process of closely attending to what the
patient is communicating, being aware of the patient’s emotional
state, and using verbal and nonverbal skills to encourage the
speaker to continue and expand upon important concerns.
• Example: Hmm, go on, I'm listening.

2. Empathic Responses
o Empathic responses are vital to patient rapport and healing. To
express empathy, you must first recognize the patient’s feelings.
o Do not assume you know the meaning of these feelings. Empathy
may also be nonverbal—placing your hand on the patient’s arm or
offering tissues when the patient is crying.

• Example: “How do you feel about that?” or “That seems to trouble

you, can you say more?” "I understand. That sounds upsetting."
 3. Guided Questioning
• Guided questions show your sustained interest in the patient’s
feelings and deepest disclosures. They may help you avoid
questions that pre-structure or even shut down the flow of the
patient’s ideas.
• A series of “yes-no” questions makes the patient feel more passive,
leading to a loss of significant detail.
• Example: "Tell me more about your chest pain."

Types of Guided Questioning

 Moving from open-ended to focused questions.
 Using questioning that elicits a graded response.
 Asking a series of questions, one at a time.
 Offering multiple choices for answers.
 Clarifying what the patient means.
 Encouraging with continuers
 Using echoing
Conti….
Moving From Open-Ended to Focused Questions
• Your questioning should proceed from general to specific.

• Start with the most general questions like, “How can I

help?” and move to still open but focused ones like, “Tell
me more about your experience with the medicine.” Then
pose closed questions like, “Did the new medicine cause
any problems?”

• You should avoid leading questions that include the answer

in the question or suggest your desired response: “Has
your pain been improving?” or “You don’t have any blood
in your stools, do you?” If you ask “Is your pain like a
pressure?” and the patient answers yes, your words may
turn into the patient’s words. Adopt the more neutral
“Please describe your pain.”
Conti….

 Questioning That Elicits a Graded Response

• If necessary, ask questions that require a graded
response rather than a single answer. “How many steps
can you climb before you get short of breath?” is better
than “Do you get short of breath climbing stairs?”

 Asking a Series of Questions, One at a Time

• Be sure to ask one question at a time. “Any
tuberculosis, pleurisy, asthma, bronchitis,
pneumonia?” may lead to a negative answer out of
sheer confusion. Try “Do you have any of the following
problems?” Be sure to pause and establish eye contact
as you list each problem.
Conti…
 Offering Multiple Choices for Answers
• Sometimes patients seem unable to describe their
symptoms without help. To minimize bias, offer multiple
choice answers: “Which of the following words best
describes your pain: aching, sharp, pressing, burning,
shooting, or something else?” Almost any specific question
has at least two possible answers. “Do you bring up any
phlegm with your cough, or is it dry?”

 Clarifying What the Patient Means

• At times, patients make statements that are ambiguous or
have unclear associations. To understand their meaning,
you need to request clarification, as in “Tell me exactly
what you meant by ‘the flu’” or “You said you were
behaving just like your mother. What did you mean?”
Conti….
 Encouraging With Continuers
• Without even speaking, you can use posture, gestures, or words to
encourage the patient to say more.
• Pausing with a nod of the head or remaining silent, yet attentive and
relaxed, is a cue for the patient to continue. Leaning forward, making eye
contact, and using phrases like “Mm-hmm,” or “Go on,” or “I’m listening”
all sustain the flow of the patient’s story.

 Echoing
• A simple repetition of the patient’s last words, or echoing, encourages the
patient to expand on factual details and feelings.

 Patient: “The pain got worse and began to spread.” (Pause)

 Response: “Spread?” (Pause)
 Patient: “Yes, it went to my shoulder and down my left arm to the fingers.
It was so bad that I thought I was going to die.” (Pause)
 Response: “Going to die?”
 Patient: “Yes, it was just like the pain my father had when he had his heart
attack, and I was afraid the same thing was happening to me.”
 4. Nonverbal Communication
o Being more sensitive to nonverbal messages allows you to
both “read the patient” more effectively and send
messages of your own. Pay close attention to eye contact,
facial expression, posture, head position and movement
such as shaking or nodding, interpersonal distance, and
placement of the arms or legs—crossed, neutral, or open.

5. Validation
o Another way to affirm the patient is to validate or
acknowledge the legitimacy of his or her emotional
experience. A patient who has been in a car accident but
has no physical injury may still be experiencing significant
distress.
• Example: “Being in that accident must have been very
scary.
 6. Reassurance
o When you are talking with patients who are anxious or
upset, it is tempting to try to reassure them.
o The first step to effective reassurance is simply identifying
and acknowledging the patient’s feelings. This promotes a
feeling of connection.
• Example: "It'll be okay.“ or Everything is going to be all
right.”
7. Partnering
o When building your relationships with patients, be explicit
about your commitment to an ongoing partnership. Make
patients feel that regardless of what happens with their
illness, you envision continuing their care.
• Example: "We'll work together on this."
 8. Summarization
o Giving a capsule summary of the patient’s story during the
course of the interview serves several functions. It
communicates to the patient that you have been listening
carefully.
• Example: "Now let me make sure I have the full story..."

9. Transitions
o Patients may be apprehensive during a health care visit. To put
them more at ease, tell them when you are changing directions
during the Interview. Make clear what the patient should expect
or do next.
• Example: “Before we move on to reviewing all your medications,
was there anything else about past health problems?” “Now I
would like to examine you. I will step out for a few minutes.
Please undress and put on this gown.”
 10. Empowering the Patient
o Patients also feel vulnerable when they’re experiencing health
problems, making it essential to empower them with the idea
that their participation in the process and working closely with
their medical team can make a positive difference in their
outcomes.

 Principles of Sharing Power

 Evoke the patient’s perspective.
 Convey interest in the person, not just the problem.
 Follow the patient’s leads.
 Elicit and validate emotional content.
 Share information with the patient, especially at transition points
during the visit.
 Make your clinical reasoning transparent to the patient.
 Reveal the limits of your knowledge.
 Nonverbal Communication Vs Verbal
Communication
Nonverbal Communication Verbal Communication

• Appearance • Open-ended questions

• Demeanor • Closed-ended questions
• Facial expression • Laundry list
• Attitude • Rephrasing
• Silence • Well-placed phrases
• Listening • Inferring
• Providing information
 Techniques hinder effective
communication
Nonverbal Communication Verbal Communication

• Excessive or Insufficient • Biased or Leading

Eye Contact Questions
• Distraction and Distance • Rushing Through the
• Standing Interview
• Reading the Questions
The Sequence and Context of the
Interview
 Preparation:
• Interviewing patients requires planning.

• As you launch or renew your relationship with

the patient, consider several steps that are crucial
to success:
1. Reviewing the medical record
2. Setting goals for the interview
3. Reviewing your behavior and appearance
4. Adjusting the environment.
 The Sequence of the Interview:
o Greeting the patient and establishing rapport.
o Establishing the agenda for the interview. Inviting the
patient’s story.
o Exploring the patient’s perspective. Identifying and
responding to emotional cues.

o Expanding and clarifying the patient’s story. Generating

and testing diagnostic hypotheses.
o Sharing the treatment plan.

o Closing the interview and the visit.

o Taking time for self-reflection.
 Clues to the Patient’s Perspective on
Illness
o Direct statement(s) by the patient of explanations,
emotions, expectations, and effects of the illness.
o Expression of feelings about the illness without naming the
illness.

o Attempts to explain or understand symptoms.

o Speech clues (e.g., repetition, prolonged reflective pauses).
o Sharing a personal story.

o Behavioral clues indicative of unidentified concerns,

dissatisfaction, or unmet needs such as reluctance to
accept recommendations, seeking a second opinion, or
early return appointment.
 Seven Attributes of a Symptom
1. Location. Where is it? Does it radiate?
2. Quality. What is it like?
3. Quantity or severity. How bad is it? (For pain, ask for a rating on a
scale of 1 to 10.)

4. Timing. When did (does) it start? How long does it last? How
often does it come?
5. Setting in which it occurs. Include environmental factors, personal
activities, emotional reactions, or other circumstances that may
have contributed to the illness.

6. Remitting or exacerbating factors. Is there anything that makes it

better or worse?
7. Associated manifestations. Have you noticed anything else that
accompanies it?
 Mnemonics for Pain and Symptoms
 To pursue the seven attributes, FOUR mnemonics may help:

1. OLD CARTS
• Onset, Location, Duration, Character, Aggravating/ Alleviating
Factors, Radiation, Timing and severity.
2. OPQRST
• Onset, Palliating/Provoking Factors, Quality, Radiation, Site, and
Timing.

3. SOCRATES
• Site, Onset, Character, Radiation, Associated symptoms,
Time/Duration, Exacerbating and Relieving factors and severity.
4. COLDSPA
• Character, onset, Location, Duration, Severity, Pattern and
Associated factors
 The Guiding Style of Motivational
Interviewing
• “Ask” open-ended questions—invite the patient to consider
how and why they might change.

• “Listen” to understand your patient’s experience—

“capture” their account with brief summaries or reflective
listening statements such as “quitting smoking feels beyond
you at the moment”; these express empathy, encourage
the patient to elaborate, and are often the best way to
respond to resistance.

• “Inform”—by asking permission to provide information,

and then asking what the implications might be for the
patient.
 The Cultural Context of the Interview
• Demonstrating Cultural Humility—A Changing Paradigm.

• Cultural competence is commonly viewed as “a set of

attitudes, skills, behaviors, and policies that enable
organizations and staff to work effectively in cross-cultural
situations.

• Cultural humility is a lifelong process that ensures that

professionals learn about other cultures and are sensitive
to cultural differences.
• It is a process that includes “the difficult work of examining
cultural beliefs and cultural systems of both patients and
providers to locate the points of cultural dissonance or
synergy that contribute to patients’ health outcomes.
 The Three Dimensions of Cultural
Humility
1. Self-awareness: Learn about your own biases;
we all have them.
2. Respectful communication: Work to eliminate
assumptions about what is “normal.” Learn
directly from your patients; they are the experts
on their culture and illness.
3. Collaborative partnerships: Build your patient
relationships on respect and mutually
acceptable plans.
Building Blocks of Professional Ethics
in Patient Care

Nonmaleficence
Beneficence
Autonomy
Confidentiality
 The Tavistock Principles
• Rights: People have a right to health and health care.
• Balance: Care of the individual patient is central, but the
health of populations is also our concern.
• Comprehensiveness: In addition to treating illness, we have
an obligation to ease suffering, minimize disability, prevent
disease, and promote health.
• Cooperation: Health care succeeds only if we cooperate
with those we serve, each other, and those in other sectors.

• Improvement: Improving health care is a serious and

continuing responsibility.
• Safety: Do no harm.
• Openness: Being open, honest, and trustworthy is vital in
health care.
 COMPLETE HEALTH HISTORY
The health history has eight sections:
1. Biographic data
2. Reasons for seeking health care
3. History of present health concern
4. Past health history
5. Family health history
6. Review of body systems (ROS) for current health
problems
7. Lifestyle and health practices profile
8. Developmental level
 Pain
• Pain defines pain as “an unpleasant sensory and
emotional experience” associated with tissue
damage.
Types of Pain: Nociceptive (somatic) pain,
Neuropathic pain, Central sensitization pain,
Psychogenic pain and Idiopathic pain.

o Three scales are common: the Visual Analog

Scale and two scales using ratings from 1 to 10—
the Numeric Rating Scale and the Wong- Baker
FACES Pain Rating Scale.
Genogram