Assessment Techniques: Communication and Active Listening
Upon completion of this chapter, the nurse will:
1. Summarize the major senses used to provide patient/client care
2. Compare techniques used to provide traditional care with those used to provide telenursing care
3. Analyze the importance of effective communication when providing telephonic patient/client care
4. Examine the impact of distractions on active listening in telenursing
5. Demonstrate approaches to overcome communication and active listening challenges when communicating with a patient/client through telenursing
SENSES USED IN PATIENT/CLIENT CARE
The major senses are vision, hearing, touch, smell, and taste. Of these, the nurse providing traditional hands-on care uses sight, hearing, touch, and smell. These senses are well developed in nurses—finely tuned by constant assessment, reassessment, and evaluation of care.
Of these senses, the predominant one is sight. Nurses:
Observe during a general survey
Examine the skin
Analyze posture and gait
Notice improvement or changes in physical status
The next most often used is touch. Nurses use touch to:
Assess skin turgor and condition
Pinpoint areas of pain
Estimate muscle tone and atrophy
Determine degree of edema
Imagine trying to console distressed patients without being able to touch them. You might question your effectiveness if you could not hug them good-bye as they left the hospital on discharge or hold their hand during a painful bedside procedure. Supporting the patient’s psychosocial domain relies heavily on the sense of touch.
The next sense that is used extensively in patient care is hearing. Without this sense, nurses would not be able to:
Auscultate lung and heart sounds
Hear the anxiety in the patient’s voice
Analyze speech patterns associated with disease processes and conditions
Respond to audible changes in breathing patterns and respiratory rates
Answer patient questions
The sense of smell is used by nurses, but to a lesser extent in the provision of patient care. This sense is often used to reinforce information provided through other senses and helps the nurse to:
Detect specific odors associated with disease processes, such as ammonia in liver disease and ketones in diabetic ketoacidosis
Discern an infection within a wound
Taste is seldom, if ever, used in nursing care.
REVIEW OF TRADITIONAL ASSESSMENT TECHNIQUES
Early in our education, nurses learn the four techniques of assessment:
These techniques capitalize on the use of the senses. For inspection, the nurse relies on the sense of sight. Smell is used to a certain extent during inspection and provides additional clues and indicators about health status, ability to provide self-care, and ability to maintain a safe home environment. Touch is used when assessing the skin, muscle tone, and other related general body structures. Without touch, the nurse would not be able to adequately inspect.
Touch is the primary sense used in palpation. Here, the hands are placed on various body areas to identify organ structures and boundaries. Palpation is also used to validate or support data collected through inspection. Without palpation, it would be impossible to:
Determine the presence and size of masses
Estimate the depth of edema
Evaluate joint function
Discern soft tissue swelling
Although percussion uses the hands to elicit a tone from a body area, the sense of hearing is predominant when using this technique. If hearing were absent, repeatedly striking over a body part would provide no useable information for the nurse. Of the assessment techniques used by nurses, percussion is most likely the one least applied. This is because it is instructed to be used primarily when assessing the lungs. Although instructed on the value of percussion when assessing other major body organs, the average nurse usually does not rely on percussion when assessing other thoracic and abdominal structures.
The final technique, auscultation, is often augmented with a stethoscope. Nurses auscultate for:
The purpose in reviewing the traditional assessment techniques has not been to encourage or reinforce their use in patient/client care. Rather, it is to emphasize how important the use of the senses is when determining patient care needs and to set the stage for how these assessment techniques will need to be altered when working in telenursing.
SENSES USED IN TELENURSING
Telenursing is unique in that the traditional approaches to assessment—inspection, palpation, percussion, and auscultation—need to be altered or cannot be used. Take a few minutes now and perform this exercise:
Envision yourself sitting at home when the phone rings. The person on the line identifies herself as being with a health insurance plan or other care delivery system provider. She has your name, address, age, gender, and information about your health plan or employer. She begins talking to you and starts asking questions that expect you to divulge personal health information. Do you trust this person? How can you trust this person? Why is she talking to you? What health problem do I have that my doctor didn’t tell me about? Should I answer this person’s questions? Is this a scam or an attempt to steal my identity?
How comfortable were you when reading through that exercise? Would you talk to someone over the telephone about your health and care needs without seeing the person or understanding why the call was taking place? Would you be tempted to hang up and contact your health plan to find out what’s going on or report the call to some authority?
As you might have concluded, the sense of sight is not an integral part of telenursing. You will not be able to “see” the patient to:
Read nonverbal communication cues
Examine the skin
Determine the color of skin tone
Observe for diaphoresis
Visually inspect the ankles for edema
Notice nail clubbing or the presence of a barrel chest
Identify a spinal deformity, which could negatively impact respiratory excursion or gastrointestinal functioning
Identify basic body shape that might indicate a potential risk for the development of metabolic syndrome or type 2 diabetes mellitus
Analyze gait and stability with walking
Discern patterns of bruising that might indicate a specific disease process from those obtained from a fall or episode of abuse
Estimate the ease or challenges to complete instrumental or traditional activities of daily living
Recognize sensory deficits through the use of a hearing aid or reading glasses
As you can see, the list of areas in which the sense of sight is used when assessing can go on and on. The sense of touch, however, is also absent in telenursing. Without this sense, you will not be able to:
Feel skin temperature
Palpate edematous areas
Determine the point of maximum impulse when conducting a cardiac assessment
Estimate organ borders
Palpate subcutaneous emphysema
Reach for the patient’s hand during times of stress
Before you run from the room screaming or slam the book closed, take a deep breath. Telenursing does not use rudimentary nursing assessment skills and techniques. Your skills will not be “lost” over time. You will learn new skills and techniques to replace those that rely on the primary senses of sight and touch. And you will learn to engage the patient/client to assist you during the assessment process.
FOCUS ON THE SENSE OF HEARING
In telenursing, the sense of hearing is predominant. Overall, you will be conducting patient interviews over the telephone and listening for patient responses. Of course, it is more involved than this statement, but to state the process in simple terms, in telenursing the mechanism of patient care is provided through talking and listening. Outstanding communication skills are essential.
When approaching a patient/client in a face-to-face setting, the nurse needs to keep in mind:
Physical body language
Tone and tempo of speech
In telenursing, the nurse needs to be aware of:
Tone and tempo of speech
Obviously, facial expressions and physical body language will not be involved in telenursing; however, keep in mind that these areas add to the quality of communication. When they are absent or not used, communication may falter or totally fail. To overcome the absence of these areas, the nurse needs to focus solely on the quality of verbal communication.
As a review, communication begins with a sender delivering a message to a receiver who, in turn, accepts the message and makes a response provided in the form of feedback. Effective communication needs a sender, a message, and a “willing” receiver. When starting out in telenursing, a willing receiver might be the most challenging part.
From the brief exercise explained earlier, how many people willingly answer the telephone and talk to someone they don’t know about personal health information? How many television commercials have been created that warn older adults about potential telephone scams? How willing would you be to spend time with someone you don’t know talking about the intimacies of your health problems and concerns?
In telenursing, the sender, or the nurse, has to be prepared to overcome these challenges. The nurse must use a tone that is pleasant and welcoming. Words must flow conversationally and not sound like someone reading a “script.” The purpose of the call must be explained immediately before the patient hangs up thinking you are a telemarketer or someone trying to scam you into providing personal information to steal your identity.
Immediately upon the call being answered, the nurse needs to:
Ask to speak to the patient
Validate that the person on the phone is indeed the patient
Provide nurse’s full name
Identify the company that the nurse is representing
Explain the purpose of the call
The patient will undoubtedly have questions:
How did you get my name and telephone number?
Who are you again?
Who are you with?
Why are you calling me?
Yes, you did just provide all of this information when beginning the call; however, the patient was not hearing everything. Expect to repeat your opening statements over and over again. Remember, patients have no idea who you are. They will be concerned that their telephone number and personal health information is “floating” out there and will express caution and concern. You need to calm patients down and not feed into their anxieties. This means talking slowly, succinctly, and professionally. This is no time to inject humor or make light of the situation.
Answering the patient’s questions accurately and calmly is the best approach to secure his or her tentative trust at this time. Be sure to:
Repeat your name
State the organization you are with or representing
Explain the purpose of your call