What are the steps to becoming an appreciative ally, adopt person-centered care, and move from a top-down stance to a one-down position? It involves making a change in how one interacts with and responds to a patient.
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iStock/monkeybusinessimages, audiology, healthcare, hearing loss
Old habits die hard. We know so much about hair cell damage, new hearing aid technology, cochlear implants, bone-anchored hearing aids (BAHA), and wireless connectivity. The mistake practitioners make in most situations is that they see their task as just supplying information—cold hard facts and descriptions. They want to be Mr./Ms. Informative. However, we often are not comfortable managing patients’ affect or emotional statements. As a result, we are often not tuned in to a patient's feelings during a hearing care visit.
EMPHASIS ON THE AFFECT
Affect or feelings are the major factors that make patients feel connected to us. With any health care provider, patients respond positively to having their feelings acknowledged and validated. Knowing how to address a patient's feelings is a critical skill in clinical care because it reflects the patient's affective experience in relation to their worlds. Patients are looking for the meaning behind the information—for more than just the facts.1 As stated by the famous poet and essayist Maya Angelou: “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
Patients must feel free and safe to share their feelings and thoughts. Front-office staff must be welcoming and friendly. Physical attending is an important building block of hearing care. This involves giving your undivided attention, making eye contact (more challenging now with electronic medical records), fully facing the patient, and leaning forward so your forearms can rest on your thighs. Avoid sitting behind a desk because it creates both a physical and psychological barrier to comfortable communication. Mobile phones must be silenced. Chairs need to be comfortable and have arms. Examination rooms must be neat and private.
MOTIVATIONAL INTERVIEWING
As these behaviors are quite common in health care, a broad variety of management and treatment strategies exists, with most coming from our partners in psychology.1-3 Rollnick, Miller, and Butler3 describe motivational interviewing (MI) as a comprehensive guiding style to behavior change as opposed to direct persuasion. MI is best described as a conversation designed to strengthen a person's motivation for and movement toward a specific goal by eliciting and exploring his or her motivation to change within an atmosphere of acceptance and compassion.
The first change practitioners can make is to resist the fixing impulse. We are often so eager to help patients that we typically rush to introduce a solution when patients are headed down the wrong path. The problem is that this response can often produce a pulling back behavior. It is not because of any major flaw on the part of the patient. There can be a natural tendency to resist persuasion, particularly among those who are ambivalent about something.
Ambivalence is a normal process of thinking about the pros and cons of making a change. It is simultaneously wanting and not wanting something. Rollnick, Miller, and Butler3 explained that patients hear two kinds of talk: change talk, which is the patient's own statements that favor change (“I need to do something about my hearing loss”) and sustain talk, which is the opposite and argues for the status quo (“I hate the thought of people noticing the hearing aids”). If a practitioner employs the fixing impulse, he or she will take up the good side of the argument. The patient then will almost automatically take up the other side.
OARS MICROSKILLS
The microskills employed in MI are best described by the acronym OARS.3 O stands for open-ended questions. These are designed to encourage a full, meaningful answer from a patient using his or her own knowledge and/or feelings. Considered an invitation to talk, these can often elicit unanticipated information. It is the opposite of a closed-ended question that encourages a one-word or short response. Examples are: “How can I help you?” “What are the good things and not so good things about amplification?” “What do you want to do next?”
A stands for affirmations. These statements are about anything positive that is noticed about a patient. They serve to develop a sense of self-confidence, and are very helpful in building the counseling relationship. They can include awards, attempts, prior successes, accomplishments, and achievements. Some examples are: “Thank you for coming in today and choosing us as your hearing care provider,” “You have tried hearing aids in the past. Thank you for your continued commitment to improving your life,” and “I see from your history that you were in the Navy. Thank you for your service.”
R is for reflective listening, which is the most important skill in MI as well as in any type of personal adjustment counseling. It involves understanding what the patient is thinking and feeling, then saying it back to the patient. It is a response to a patient's clear and assertive statement reflecting what he or she just said. The process involves (1) hearing what the patients said, (2) making a guess of what they mean, and (3) stating it back to them. The key to responding to feelings (the hardest part) is to ask yourself, “If I were the patient, how would I feel?”
Finally, S stands for summaries, which are best described as a bouquet—a series of reflections that capture significant parts of a patient's speech, and are typically used at the end of or transitions in conversations. Their intent is to ensure clear communication and allow the patient to hear significant parts of his or her thinking again. Often, the practitioner can clarify the summary by asking, “Did I leave anything out?”
MI takes practice. Stick to the basics. Focus on listening to and reflecting on the patient's responses, especially using feeling statements. Develop a feeling vocabulary. Always keep in the back of your mind, “If I were this patient, how would I feel?” Activate your ambivalence detector! Recognize and utilize change talk. Resist the fixing impulse. And don't forget to ask. Remember that motivation comes from within the patient.
REFERENCES
1. Carkhuff, R. R. (2014). The Art of Helping-9th Edition. Amherst, MA: HRD Press.
2. Amador, X. F. (2012). I AM NOT SICK, I Don't Need Help! New York, NY: Vida Press.
3. Rollnick, S., Miller, W. R., and Butler, C. C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press.
