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A script for a Clinical Interview for First Appraisal using a participative action methodology

Eugenia Gil García,¹ María Escudero Carretero,² Mª Angeles Prieto Rodríguez,³ Joan Carles March Cerdá^4
1 Nursing Degree, Degree in Political Science and Sociology ; Doctor by the University of Granada, Lecturer at the Health Sciences University College, University of Jaén. ² Doctor in Sociology, Degree in Gender and Development Studies. Consultant, Andalusian Public Healthcare School, Granada. ³ Nursing Degree, Degree in Sociology, Master's Degree in Public Health and Health Management. Lecturer at the Andalusian Public Healthcare School, Granada. ⁴ MD, Lecturer and Consultant. Master's Degree in Public Health and Health Management. Andalusian Public Healthcare School, Granada (Spain)

Mail delivery: Eugenia Gil García. Escuela Universitaria de Enfermería Universidad de Jaén. Paraje Lagunillas. Edificio B-3. 23071 Jaén, España

Manuscript received by 24.05.2006
Manuscript accepted by 9.10.2006

Index de Enfermería [Index Enferm] 2007; 57: 09-12

How to cite this document

Abstract

Introduction: The aim of this article is to describe the participative action methodology process undertaken during the years 2002 and 2004, among male and female nurses of the Reina Sofía Hospital in Cordoba (Spain), as part of their training for carrying out the Clinical Interview for First Appraisal.
Methodology: The process included training workshops in which 430 professional nurses from the Reina Sofía Hospital took part. Main content: reflecting upon the importance and utility of the interview, practicing interviewing and communication techniques and drafting an interview script. The learning methodology was based on the experience and knowledge of the participants, and on implementation and training in the material. Findings: these can be summed up as follows: 1. Acknowledgement of the utility of the interview as first contact between the nurse, the patient and his relatives. 2. Importance of the script as an essential tool for drafting a quality-based interview. 3. The need to prepare an interview in order to carry it out as part of a care-based conceptual framework. 4. The use of open questions as a tool for focusing on the patient's concerns; and 5. The need to train the nursing staff in communication skills.
Conclusions: The Action-Participation-Research is shown to be a useful tool for improving and facilitating the adaptation to new working methods. Being able to reflect together on the importance of the interview and its script, as a working tool, was highly valued by the participants, who unanimously recognise that after the workshops carrying out the Clinical Interview for First Appraisal has been easier and more productive.
Key-words: Cript for the Clinical Interview. Clinical Interview for First Appraisal. Action-Participation-Research. Practicing interviewing. Communication skills.

Introduction

    Disciplines such as sociology, social psychology or anthropology have reflected upon the importance that first encounters have in a communication process¹. In a Nursing Care Process, the first clinical appraisal is the first key moment in the patient-nurse encounter and relationship. Therefore, it is essential to be aware of and obtain maximum profit from it as it allows us to carry out the planning and nursing, and through them, improve the quality of care. This was the reason why a group of professionals from the Reina Sofia University Hospital (HURS) of Córdoba and the Andalusian Public Health School (EASP) set up, at the beginning of 2002, a project which had as its general objective an improvement of the initial clinical appraisal carried out by male and female nurses in different hospital units.
    On the other hand, at different levels of care there have been several attempts to introduce the Nursing Care Process (PAE), whose initial phase is to implement a first clinical appraisal of the patient. After revising the specialised literature we have realised that the introduction of this method has an uneven acceptation at all levels of care. The nurse's first appraisal is more often done at primary care level, particularly with patients with chronic pathological processes, and in home visits².
    Mena, Navarro and Macías did research, within the context of a hospital, which showed that 50% of nurses "often" do a first clinical appraisal and 40% only "sometimes". The reasons that justify not carrying out the first appraisal is that they consider the appraisal registers to be useless and inefficient³. The main impediment for introducing the nursing process occurs when the professionals don't perceive it as whole but as a series of stages that aren't linked⁴. This is the reason why we have to persevere in explaining to the nursing professionals the reasons for and the importance and usefulness of the Clinical Interview of First Appraisal (ECVI).
    Taking into account these limitations, our objective was focused on finding out the training needs, skills and relational competences of the nursing professionals at the HURS. Considering their experience, we reflected upon the importance of a first appraisal for carrying out quality nursing tasks. We used as a theoretical framework the human basic needs model as proposed by Virginia Henderson.^5,6 We focused on adapting the ECVI questions to the 14 basic needs established by the author.
    As methodology we used the Action-Participation Research (IAP) theoretical and methodological model which originated in the 1970's. One of its key aspects is to make participation possible and value the experience of people which are part of a studied community in an open and process-driven research context where the results are introduced in the process and then analysed in depth.^7,8 The members of the community become managers of their own research process, they are empowered and take over operative (know how), logical (understanding) and critical (judgemental) control. The method's basic objective is to produce a specific type of knowledge that aims at being critical, objective and participative. In order to achieve this it is conceived as a cyclical and constructive, thinking and action process where the priority lies in reflection and a dialogue with reality, in order to achieve its transformation.
    Despite the fact that the advantages of this methodological model haven't been sufficiently exploited in our professional field, some nurse teams have made important contributions. For example, a team of female nurses from the Hospital General Universitario de Valencia used this methodology to unify the nursing knowledge and jargon, and to identify the care needs of patients that have been in hospital for some time.⁹
    Thus, Action-Participation-Research methodology develops a threefold objective: firstly, to share experiences between nursing staff from different hospital units of the purpose, importance and usefulness of doing a good ECVI with their patients; secondly, to acquire training and skills to carry out a quality-based ECVI and thirdly, that different hospital units agree on a unified ECVI script.

Methodology

    In order to attain the objectives we set, we organised participative workshops with nursing staff from different units of the HURS. The approach was fundamentally practical, understanding workshops as an interactive space for sharing experiences and progressing, by taking into account the participants needs. Consequently, the building of knowledge was implemented within the workshops starting from our experience and knowledge of the participants, and constantly putting into practice the developed knowledge. The teaching staff had a twofold role: on the one hand, we acted as process facilitators, and on the other we contributed, reminded participants of and systematised some basic communication techniques and skills. The workshops started in 2002 and ended at the end of 2004. 430 male and female nurses from the four hospital centres of the HURS, as well as from all the hospital's areas, units and services took part. Out of 430 nursing professionals, 60 were supervisors. The chosen place for the training workshops were rooms with teaching, computer, and audiovisual tools. Registration for the workshops and their organisation was carried out in the nursing teaching department of the HURS. The pedagogical aspects such as programming and teaching were conducted by staff from the EASP.
    Each workshop was organised for groups of fifteen people over three sessions: two in which the contents were developed and coached, and a practical session consisting of the recording of a clinical interview for first appraisal in a real context.
    The workshop contents were developed around three axis: to reflect, debate, and consider the usefulness of the ECVI; to study in depth interviewing and communication techniques in order to carry out a ECVI with more confidence and ease, and the writing of an interview script which is the basic tool for carrying out a quality-based ECVI (see Table 1).

Results and discussion

    The Research-Action-Participation process undertaken by the different hospital units provided a series of results. We will now introduce the learning process and conclusions from the best workshops by those who participated in them.
    1) The process of reflection on the purpose of doing a first appraisal of the patients resulted in various contributions. Male and female nurses considered that safeguarding this first contact improved the future relationship with their patients, and it became for them a reference point. The ECVI is also highly valued as an information source that contributes in planning and carrying out their jobs. On the other hand, they also point out how difficult it is to 'break the ice' sometimes and face some questions or issues.
    2) Setting up the workshops allowed an interview script, accepted by all the admission units, to be drafted, see Table 2. There was unanimous consideration of the interview script as an essential tool for carrying out a good clinical interview. All the participants affirmed that it was easier to tackle the interview with the script: by knowing, preparing and practising how to ask about the most difficult issues. "Good, much better with the script, now I know how to introduce some issues that before I didn't even ask about because I didn't know about them. Now, I do the interview with more confidence, with my script" (Female nurse, Cardiology).
    3) The participants underlined the importance of training in communication skills for interviewing and the necessity of using such resources as active listening (silences), empathy (to put yourself in the place of the other), non-verbal language (looks, gestures, postures) at a first meeting, since they foster the patient's confidence and security. The importance of smiling, greeting and introducing yourself (name and post at the hospital) was also highlighted as a means for welcoming and receiving a patient at the admissions unit: "What a difference it makes knowing a few tricks to deal with their silence, to make the silent ones talk or to 'shut up' those who won't stop talking. Now it is easier to conduct the interview" (Male nurse, Oncology).
    4) The ECVI process must be carried out when the nurse in charge considers it most appropriate, within the first 24 hours after admission and always in a relaxed atmosphere, avoiding any unnecessary interruption.
    5) Starting an ECVI after careful preparation, which includes a detailed reading of the patient's clinical records, was considered essential. This would allow the nurse to know the patient's ailments in detail and the collected information can be used to help the patient realise that we know his case and avoid tiring him with redundant questions.
    6) It is more likely that our questions will be more welcomed if both the interviewee and the interviewer are aware of the purpose and importance of them. This is why we underlined the advantages of starting the interview with a brief but careful explanation of our objectives, the usefulness that this information will have for the patient's recovery: "When you introduce yourself and explain carefully what we are going to do, why, what the point of all the questions is, how important that information is in order to take care of him, the patient responds and answers willingly" (Male nurse, Paediatrics).
    7) The importance of asking open questions during the interviewing process was asserted, they allow us to focus the conversation-interview on the patients concerns and minimise any assumptions or stereotypes coming from the professionals: "I never realised the amount of closed questions we used to ask. Of course, that conditions the answers. Now after training, I realise just in time and try to avoid them. The script has been extremely useful" (Female nurse, Internal medicine).
    8) Once all the necessary information has been obtained, the ECVI should end with a new open question that would allow the patient or caregiver to elucidate any relevant doubts, questions or issues. It is advisable to leave an "open door" in order to continue obtaining relevant information.
    9) In the case of any patient suggesting it or if he isn't in optimal condition for being interviewed, either because of his age or the disease, the first appraisal should be carried out using the information provided by the main caregivers.
    10) The first appraisal is more complete and makes more sense if it is done from within a nursing conceptual framework. In this case, as we mentioned in the introduction, we adopted framework 14 from Virginia Henderson's Care Needs used at the HURS.

Conclusions

    The Action-Participation-Research methodological process is effective for agreeing on or mainstreaming knowledge, practices and language. It has great potential for improving contact among professionals, sharing experiences, expectations, and demands, or sorting out concerns.
    The difficulties of nursing appraisal and the need for a standardised language, in common with care plans has been manifested in several research papers.¹⁰ We believe that a participative process favours systematic and common thinking, and improves adaptation to changes and the implementation of new working methods. Practicing an interview, recording it on video and analysing it in class was very useful as a tool for thinking about the opportunities that just such a first communicative encounter between the nursing staff and the patient or relative brings, as well as fostering an atmosphere of confidence and respect. It was also shown to be an extremely efficient pedagogical tool in appraising the importance of interviewing, and how formulating questions guides or conducts the communicative process itself. Open questions foster confidence and security as they help the patient to focus on his concerns. On the contrary, closed questions can break communication, and even influence the information we obtain. The recordings were particularly relevant in highlighting the importance non-verbal language acquires in the communication process. We are mean the tone of voice, looks, gestures, postures. and how these can be used to carry out the clinical appraisal.
    Lastly, we wish to highlight the average time taken by the nurses to do a good ECVI: between 7 and 12 minutes. In that time it is possible to obtain enough quality information based on the 14 care needs proposed by Virginia Henderson and to begin, through it, the Nursing Care Process. During this time the patients also obtain information on the nursing staff's role and about their constant care-giving work.

Bibliography

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