I have the privilege of reviewing manuscripts for several nursing journals, and I spent some time this weekend reviewing a gastroenterology-related manuscript. I was struck by one of the study findings that revealed patients who live with chronic disease often do not communicate their true health-related experiences. Unless their provider asks specific questions, patients don't offer as part of their response the challenges they face. Many patients think if you have a chronic disease, you should expect to have issues, so they don't bring those issues up to their care provider. That's not the first time I've seen issues in communication between patients and their providers in gastroenterology literature. In fact, we have published several articles in Gastroenterology Nursing addressing similar findings (e.g., Annells, 2007; Dudley-Brown & Baker, 2012; Taylor-Young & Hildebrand, 2009).
This lack of communication is certainly not the result of disinterested care providers. In fact, providers often ask patients sincerely, "How are you doing?" If the patient says great, this is usually the end of that dialogue; however, in caring for an older adult parent, I've quickly learned that's not always the "real" story! When assessing how a patient is coping with their health, whether a chronic condition, recent complaint of symptoms, or even the phenomenon of aging, healthcare providers (including nurses) need to ask the right questions persistently to accurately understand their patient's health status.
An excellent article by Uitterhoeve, Bensing, Dilven, Donders, deMulder, and van Achterberg (2009) describes the importance of responding to patients' cues. These authors found that oncology nurses' cue responding is independently and moderately related to patient satisfaction with communication. They note that patients may not express their concerns and emotions directly (or spontaneously) but often will provide indirect cues that something is worrying them.
So what is the "right" question? For starters, the right question probes for the patient to elaborate on their circumstance. An example would be "Tell me what a 'typical' day is like for you." Probing further, you might ask "Tell me what a 'bad' day is like for you" and then ask questions to determine how often bad days occur, how the patient manages bad days, why the patient does not report bad days, and so on.
Additionally, many patients with chronic illness, including pain, have a tendency to minimize their symptoms. This experience is described in research as a "response shift" (Rapkin & Schwartz, 2004), where the individual essentially resets their "normal" button to accommodate for what they believe is the "new" normal due to their circumstance. We can acknowledge that this approach demonstrates the individual's attempt to self-regulate his or her response to a change in health status, but unfortunately that response may also contribute to our inability to truly assess and respond to symptoms we might be able to improve if we only knew about them.
Let's face it: We are often rushed to assess our patients. We engage them in conversation while we are multitasking the typical routines of preparing for their procedure, connecting them to the monitor, accessing medications for presedation, and a myriad of other "routine" tasks. Asking the "right" questions also involves asking in the right way at the right time. To do that, we have to be engaged with patients. We have to really listen, make eye-to-eye inquiry, show sincere interest in getting to the "real" answer, and communicate through our engagement that we want to know in depth and fully about the patient's health status.
Patient satisfaction should certainly be a priority of all nurses and care providers, but with the recent attention to government reimbursement to hospitals tied to patient satisfaction scores, more attention is being focused on patient satisfaction. Interestingly, one decade ago, Johannsson, Oleni, and Fridlund (2002) identified in an integrative literature review eight domains that have an influence on patient satisfaction with nursing care, including communication and information, participation and involvement, and interpersonal relations between nurse and patient. More recently, Boulding and colleagues (2011) found that higher patient satisfaction scores and satisfaction with discharge planning was associated with decreased hospital readmission rates. These researchers emphasized the importance of patient-centered education and care to enhance patient satisfaction.
Patient-centered translates for me to mean care that involves establishing a professional relationship with the patient-engaging with the patient, showing a sincere interest, and asking the right questions. As you work with patients in the routine of your day, I challenge you to be more attentive to asking the right questions so that you can be assured of your patient's actual health status in relation to symptom management and adaptation to altered health status. Ask probing questions, listen attentively, and seek to maximize the patient's experience living with health-related changes. Sometimes it's all about the question!
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