Guidelines of an Effective Interview and Health
As nurses,
History
Health history Interview
 the health history interview is a
conversation with a purpose. As you
learn to elicit the patient's history, you
will draw on many interpersonal skills
that you use every day but with
important differences
 unlike social conversation in which you
can freely express your own needs and
interests, the primary goal of the nurse
patient interview is to improve the well-
being of the patient at its most basic
level
 the purpose of conversation with a
patient is three-fold to establish a
trusting and supportive relationship, to
gather information and to offer
information
Interviewing process
 the process of interviewing patients
requires sensitivity to the patient's
feelings and behavioral cues and is
much more than just asking a series of
questions
Health History Format
 is a structured framework for organizing
patient information in written or verbal
form for other healthcare providers
 it focuses the nurse's attention on
specific kinds of information that must
be obtained from the patient
Interviewing Process
 that actually generates the pieces of
health information is much more fluid
and demands effective communication
and relational skills
 it requires not only knowledge of the
data needed but also the ability to elicit
accurate information and the
interpersonal skills that allow you to
respond to the patient's feelings and
concerns
Phases of the Interview
Pre-interview
 this is to set a stage for a smooth interview
 Take time for Self-Reflection.
we encounter of a wide variety of patients
each one unique because we bring our own
values, assumptions, and biases to every
encounter. We must look inward to clarify
how our own expectations and reactions
may affect what we hear and how we
behave. Self-reflection is a continual part of
professional development in clinical work. It
brings a deepening personal awareness to
work with patients, which is one of the most
rewarding aspects of patient care
 Review the Medical and Nursing records.
Before seeing the patient, review the
medical and nursing records. This helps
gather information and plan what areas you
need to explore with a patient. Look closely
at identifying data such as age, gender,
address, and health insurance and per used
problem list, the medication list, and details
such as the documentation of allergies
 Set goals for the interview. Goals range
from completing forms for healthcare
institutions to following up on healthcare
issues to obtaining a basis for developing a
plan of care. A nurse must balance these
provider-centered goals with patient-
centered goals
 Review clinical behavior and appearance.
Just as a nurse carefully observes the
patient throughout the interview, the patient
will be watching the nurse consciously or
not, the nurse sends messages through
both words and behavior, postures,
gestures, eye contact and tone of voice all
convey the extent of interest, attention,
acceptance, and understanding. The skilled
interviewer seems calm and hurried even if
time is limited
 Adjust the environment. Make the interview
setting as private and comfortable as
possible. As the nurse, it is part of your job
to make adjustments to the location and
seating that make the patient and you more
comfortable. These efforts are always
worth the time
 Take notes. No one can remember all the
details of a comprehensive history. Jot
down short phrases, specific dates or
words but do not let note-taking or written
or electronic forms distract you from the
patient. Maintain good eye contact and
whenever the patient is talking about
 sensitive or disturbing material, put down
your pen or move away from the keyboard
Introduction
 this is to put the patient at ease and
establish trust
 Greet the patient and establish rapport.
The initial moments of an encounter with
the patient lay the foundation for an
ongoing relationship. How you greet the
patient and other visitors in the room
provide for the patient's comfort, and
arrange the physical setting all shape the
patient's first impressions. As you begin,
greet the patient by the name and introduce
yourself giving your own name. If possible
and culturally appropriate, shake hands with
the patient. If this is the first contact,
explain your role including your status as a
student and how you'll be involved in the
patient's care, Provide the patient with
undivided attention, spend enough time on
small talk to put the patient at ease and
avoid looking down to notes to take notes,
rather read the chart or scan a computer
screen. In a first meeting, demonstrate
interest in the patient as a person
 Establish the agenda for the Interview.
Once rapport has been established, the
nurse is ready to pursue the patient's
reason for seeking health care. This reason
is traditionally designated “the chief
complaint” but when there are three or four
reasons for the visit, the phrase “presenting
symptoms” may be preferable. Begin with
open-ended questions that allow full
freedom of response such as what
concerns bring you today or how can I help
you
A mnemonic corresponding to emotional
cues is NUSR.
N- Naming (ex. that sounds like a scary
experience
U- Understanding or legitimization (Ex. It's
understandable that you feel that way)
ReS- Respecting (Ex. You've done better
than most people would do with this
Working
 this is to obtain patient information
 Invite the patient story. Once the agenda
has been elicited, negotiated, and
prioritized, invite the patient story by asking
about the foremost concern and saying “tell
me more about” Continue to encourage the
patient to tell his or her story in his or her
own words using a non-focusing approach.
Avoid biasing the patient's story. Inject no
new information and do not interrupt. Lean
forward as you listen and add continuous
such as nod in your head and phrases like
uh-huh, go on, or i see.
 Identify and respond to the patient's
emotional cues. Emotional distress is
frequently associated with illness. Respond
immediately when you hear an emotional
cue. Appropriate response techniques
include reflection, synonyms, and feedback
indicating support and partnership
 Expand and clarify the patient story. After
eliciting the patient story as fully as
possible in a non-directive manner and
exploring the patient's lived experiences of
the illness, guide the patient to elaborating
on the areas of the health history that see
most significant. Clarify the attributes of
each symptom. Whenever possible, use the
patient's words making sure you clarify their
meaning. Do not use medical jargon
 Generating and testing diagnostic
hypothesis. The skills of diagnostic
reasoning are developed over time with
practice. As the history is gathered, one
develops and tests hypothesis about the
patient's problems. Identifying the
attributes and details of the patient's
symptoms is fundamental to recognizing
patterns of problems and generating
nursing diagnoses.
 Create a shared understanding of the
problem. Recent literature makes it clear
that delivering effective health care requires
exploring the deeper meanings patients
attached to their symptoms , disease or
illness. Distinction model helps to
understand the full impact of the patient.
This model acknowledges the very different
yet complementary perspectives of the
nurse and the patient
 Negotiate a plan. Learning about the
effects of the illness gives the nurse and
the patient the opportunity to create a
 complete and congruent picture of the
problem. This multifaceted picture then
forms the basis for planning furthering for
evaluation (Example, physical examination,
laboratory tests, or consultations, and
negotiating a nursing care plan)
Mnemonic FIFE. This is for the patient's
perspective on illness
F- Feelings. The patient's feelings including
fears or concerns is the first half
I- Ideas. The patient's ideas about the
nature and cause of the problem
E- Effect of the problem on the patient's life
and function and
E- Expectations of the disease of the
clinician or of health care often based on
prior personal or family experiences
Termination
 Let the patient know that the end of the
interview is approaching to allow time for
the patient to ask any final questions. Make
sure the patient understands the mutual
plans you have developed. As you close
 Summarize important points. Summarizing
the patient's problems and reviewing the
plan of care and follow-up are helpful.
Address any related concerns or questions
that the patient raises
 Discuss plan of care. The patient should
have a chance to ask any questions
 Give patient chance to ask questions.
However, the last few minutes are not the
time to bring up new topics. If that happens
and the concern is not life-threatening,
simply assure the patient of your interest
and make plans to address the problem at a
future time
Therapeutic Communication Techniques
The nurse employs these interviewing skills to
achieve the tasks described in the phases of
interviewing more effectively. Practice
improves interviewing skills. Being observed
and recorded during an interview allows for
feedback from an experienced interviewer
Techniques of Skilled Interviewing
Active Listening
 is a process of closely attending to what the
patient is communicating, being aware of
the patient's emotional state, and using
verbal and non-verbal skills to encourage
the speaker to continue and expand. This
takes practice. It is easy to shift into
thinking about the next question or the
nursing diagnosis.
Guided Questioning: Options to Expand and
Clarify the Patient's Story.
 There are several ways you can ask for
more information from the patient without
interfering with the flow of the patient's
story. The goal is to facilitate the patient's
fullest communication. Learning the
following techniques encourages patient
disclosures while minimizing the risk for
distorting the patient's ideas or missing the
significant details.
Non-Verbal Communication
 Communication that does not involve
speech occurs continuously and provides
important clues to feelings and emotions.
Becoming sensitive to nonverbal messages
allows the nurse to both read the patient
more effectively and send messages.
 Pay close attention to eye contact, facial
expression, posture, head position and
movements such as shaking or nodding,
interpersonal distance, and placement of
the arms or legs, crossed neutral or open.
Be aware that some non-verbal language is
universal and some is culturally bound
Emphatic Responses
 Conveying empathy greatly strengthens
patient rapport. As patients talk, they
may express with or without words,
feelings that they may or may not have
consciously acknowledged to provide
empathy. First, identify the patient's
feelings at first. This may seem
unfamiliar or uncomfortable when you
sense important, but unexpressed
feelings from the patient's face, voice,
words, or behavior inquire about them,
rather than assuming that you know
how the patient feels. You may simply
ask how did you feel about that. Unless
you let the patients know that you're
 interested in feelings as well as facts,
you may miss important insights
Validation
 another important way to make a patient
feel affirmed is to validate or
acknowledge the legitimacy of the
emotional experience
Reassurance
 the first step to effective reassurance is
simply identifying and acknowledging
the patient's feelings. This promotes a
feeling of connection. When you are
talking with patients or anxious or upset,
it is tempting to try to reassure them.
Moreover, premature reassurance may
block further disclosures, especially if
the patient feels that the nurse is
uncomfortable with the anxiety or has
not appreciated the extent of the
patient's distress
Summarization
 Giving a capsule summary of the
patient's story during the course of the
interview serves several different
functions.
 It communicates to the patient that you
have been listening carefully.
 It identifies what you know and what you
do not know
 can be used at different points in the
interview to structure the visit especially
at times of transition
 this technique also allows you to
organize your clinical reasoning and to
convey it to the patient making their
relationship more collaborative. It is also
a useful technique for learners when
they draw a blank on what to ask the
patient
Transitions
 Patients have many reasons to feel
vulnerable during a healthcare visit to
put them more at ease, tell them one
when you are changing directions during
the interview just as clear signs along
the highway, give a sense of confidence
the signposting gives patients a greater
sense of control as you move from one
part of the history to the next and on to
the physical examination.
 Orient the patient with brief transitional
phrases.
Empowering the Patient
 Patients have many reasons to feel
vulnerable. They may be in pain or
worried about a symptom, they may be
unfamiliar or overwhelmed with
accessing the healthcare system.
Differences of gender ethnicity race or
class may also contribute to power
differentials, however, ultimately the
patients are responsible for their own
care. Patients are self-confident and
understand the recommendations are
most likely to adopt offered advice,
make lifestyle changes, or take
medications as prescribed.
Adapting the Interview for Special Patients
 Interviewing patients may precipitate
behaviors and situations that seem
perplexing or even vexing
 Your ability to handle these situations
will evolve throughout your career.
Always remember the importance of
listening to the patient and clarifying the
patient's concerns
The Silent Patient
 Silence has many meanings and many
purposes. Patients frequently fall silent
for short periods to collect thoughts,
remember details, or decide whether you
can be trusted with certain information.
The period of silence usually feels much
longer to the nurse than it does to the
patient.
 The nurse should appear attentive and
give brief encouragement to continue
when appropriate.
 During periods of silence, watch the
patient closely for nonverbal cues such
as difficulty controlling emotions.
Silence may be part of the patient's
culture or would be the patient response
to how you're asking questions
The Confusing Patient
 Some patients present a confusing area
of multiple symptoms. They seem to
have every symptom that you ask about
with these patients. Focus on the
meaning or function of the symptom
emphasizing the patient's perspective
and guide the interview into a
psychosocial assessment. The patient's
manner of relating to you may also
seem peculiar, distant, aloof or
 inappropriate symptoms may be
described in bizarre terms. Perhaps
there is a mental status change like
psychosis or delirium a mental illness
such as schizophrenia or a neurologic
disorder. Such patients give histories
that are inconsistent and cannot provide
a clear chronology about what has
happened. Some may even make up
information to fill in the gaps in their
memories.
The Patient with Altered Capacity
 Some patients cannot provide their own
histories because of delirium from
illness, dementia, or other mental health
conditions. Under these circumstances
you need to determine whether the
patient has a decision-making capacity
or the ability to understand information
related to health to make health choices
based on reason and a consistent set of
values and to declare preferences about
treatments. The term capacity is
preferable to the term competence,
which is a legal term. You do not need to
consult psychiatry to assess capacity
unless mental illness impairs decision
making. For patients with impaired
capacity, you will often need to find a
surrogate informant or decision maker
to assist with the history. Check whether
the patient has a durable power of
attorney for health care or a health care
proxy. If not in many cases, a spouse or
family member can present or represent
the patient's wishes can fill this role
The Talkative Patient
 The guerrillas rambling patient may be
difficult to interview especially when
faced with limited time and the need to
get the whole story several techniques
are helpful. Give the patient free reign
for the first five to ten minutes, listening
closely to the conversation. Perhaps, the
patient simply needs a good listener and
is expressing penned up concerns or the
patient's style is to tell stories. In some
cultures, social conversation of various
lengths before getting down to business
is considered polite.
 Focus on what seems most important to
the patient. Show your interest by asking
questions in those areas
 Interrupt only if necessary but be
cautious.
 Learn how to set limits when needed
and remember that part of your task is
structuring the interview to gain
important information about the
patient's health. A brief summary may
help you change the subject yet, validate
any concerns
 Finally, do not show your impatience. If
time runs out, explain the need for a
second meeting. Setting a time limit for
the next appointment may be helpful
The Crying Patient
 Crying signals strong emotions ranging
from sadness to anger or frustration.
 If the patient is on the verge of tears,
pausing gentle probing or responding
with empathy gives the patient
permission to cry.
 Usually crying is therapeutic as is your
quiet acceptance of the patient's
distress or pain. Offer a tissue and wait
for the patient to recover make a
supportive remark like “I am glad you
are able to express your feelings.” Most
patients will soon compose themselves
and resume their story. Aside from an
acute grief or loss, it is unusual for crime
to escalate and become uncontrollable
The Angry or Disruptive Patient
 Many patients have reasons to be angry.
They are ill, they have suffered a loss,
they lack their custom control over their
own lives, and they feel powerless in the
health care system. They may direct this
anger toward the nurse more often.
However, patients displace their anger
onto the nurse as a reflection of their
frustration or pain
 Accept angry feelings from the patients.
Allow them to express such emotions
without getting angry in return. Avoid
joining such patients in their hostility
toward another provider or the agency,
even when privately you may feel
sympathetic.
 You can validate their feelings without
agreeing with their reasons. After the
 patient has calmed down, help find
steps that will avert such situations in
the future. Some angry patients become
over overtly disruptive, before
approaching such patients alert the
security staff. As a nurse, maintaining a
safe environment is one of your
responsibilities. Stay calm, appear
accepting, and avoid being
confrontational in return, keep your
posture relaxed and non-threatening,
and your hands loosely open.
The Interview Across a Language Barrier
 If your patient speaks a different
language, make every effort to find an
interpreter. A few broken words and
gestures are no substitute for the full
story. the ideal interpreter is a neutral
person who is familiar with both
languages and cultures
 Recruiting family members or friends to
serve as interpreters can be hazardous.
Confidentiality and cultural norms may
be violated, meanings may be distorted,
and transmitted information may be
incomplete. As you begin working with
the interpreter, establish rapport and
review what information would be most
useful. Explain that you need the
interpreter to translate everything not to
condense or summarize
The Patient with Low Literacy
 Before giving written instructions,
assess the patient's ability to read.
Literacy levels are highly variable and
marginal reading skills are more
prevalent than commonly believed.
Explore the many reasons people do not
read (language barriers, learning
disorders, poor vision, or lack of
education)
 Lack of reading skill may explain why
the patient has not taken medications
as prescribed or adhered to
recommended treatments. Respond
sensitively and do not confuse a degree
of literacy with a level of intelligence.
The Patient with Impaired Hearing
 Communicating with the deaf presents
many of the same challenges as
communicating with patients who speak
a different language.
 Find out the patient's preferred method
of communicating, ask when the hearing
loss occurred relative to the patient's
development of speech and what
schools the patient attended. These
questions help determine whether the
patient identifies with a deaf culture or
the hearing culture.
 If the patient prefers sign language, find
an interpreter and use the principles
identified earlier.
 Written questionnaires are also useful.
Hearing deficits vary if the patient has a
hearing aid. Make sure that the patient
is using it and it is working. Speak at a
normal volume and wait and do not let
your voice trail off at the ends of
sentences. Avoid covering your mouth
or looking down at papers while
speaking.
The Patient with Impaired Vision
 When meeting with a blind patient shake
hands to establish contact and explain
who you are and why you are there.
 If the room is unfamiliar, orient the
patient to the surroundings and report if
anyone else is present. It still may be
helpful to adjust the light.
 Encourage visually impaired patients to
wear glasses whenever possible.
Remember to use words because
postures and gestures are unseen.
The Patient with Cognitive Disabilities
 Patients with moderate cognitive
disability can usually give adequate
histories. In fact, you may even be able
to emit their disability from their
evaluations.
 If you suspect problems however, pay
special attention to the patient's
schooling and ability to function
independently. If you are unsure about
the about the patient's level of disability,
make a smooth transition to the mental
status examination
 Assess simple calculations, vocabulary,
memory, and abstract thinking. For
patients with severe cognitive
disabilities, you will have to turn to the
family or caregivers to elicit the history.
 Identify the person who accompanies
the patient but always show interest in
the patient first. Establish rapport, make
eye contact, and engage in simple
conversation. As with children, avoid
talking down or using affectations of
speech or condescending behavior. The
patient, family members, caregivers, or
friends will notice and appreciate your
respect.
The Patient who is Under the Influence of
Alcohol or Drugs
 The patient who is under the influence
of alcohol or drugs presents a unique
challenge to the nurse depending on the
quantity of alcohol consumed and the
type of drugs ingested. The patient can
have several central nervous system
depression or the patient can be very
disruptive with CNS stimulation. The
patient's judgment may be impaired
which can lead to the physical harm to
those in the immediate environment. For
this reason, when you have a violent or
agitated patient, security personnel
should be alerted and stationed nearby.
 Patients under the influence of some
drugs may have been known to have
superhuman strength and are capable of
inflicting serious physical harm on
themselves and others. To care for this
person, place yourself at a safe
distance, remain calm and provide care
in a non-threatening manner.
The Patient with Personal Problems
 Patients may ask you for advice about
personal problems that fall outside the
range of your clinical expertise. Should
the patient quit a stressful job, for
example, or move out of the state.
Instead of responding, ask about the
different approaches the patient has
considered and related pros and cons.
Others who have provided advice and
what supports are available for different
choices. Letting the patient talk through
the problems is more valuable and
therapeutic than the any answer that
you could give.
The Patient who is Very Ill
 Patients who are very sick may not have
the strength or ability to go through the
entire interview process.
 Collect pertinent data from the patient
and defer the remainder of the interview
until later.
 If a patient is very sick, it may be
necessary to interview a family member
or significant other. Show respect for
the patient by asking permission to do
this and by allowing the patient to be
present during the interview. Allow the
patient to participate as much as
possible in answering the questions and
giving information.
The Older Adult
 Interviewing the older adult may require
additional time for question
interpretation and patient responses. It
may be necessary to schedule more
than one interview for older patients
because they may have multi-system
changes or complaints (a weakened
physical condition or a cognitive
impairment)
 It may be necessary to interview an
older patient's family member or
caregiver to assess the patient's past
and present health or illness status. As
in any interview situation, when the
patient is assisted by another individual,
include the patient and assess the
quality of interaction between the two
Sexuality in the Nurse-Patient Relationship
 Nurses of both genders occasionally
find themselves physically attracted to
their patients, similarly patients may feel
or may make sexual overtures or exhibit
flirtatious behavior toward the nurses.
The emotional and physical intimacy of
the nurse patient relationship may lend
itself in the into these sexual feelings.
 If you become aware of such feelings in
yourself, accept them as a normal
human response and bring them to
conscious level so they will not affect
your behavior. Denying these feelings
makes it more likely for you to act
inappropriately.
 Any sexual contact or romantic
relationship with patients is unethical.
Keep your relationship with a patient
 within professional bounds and seek
help if you need it. Sometimes, nurses
meet patients who are frankly seductive
or make sexual advances. It is tempting
to ignore this behavior because you're
not sure that it really happened or are
hoping it will just go away calmly, but
firmly make it clear that your
relationship is professional, not
personal. If unwelcome overtures
continue, leave the room and find a
chaperone to continue the interview.
 You have to keep your relationship
within professional bounds.
Non-Therapeutic Interviewing Techniques
Requesting an Explanation
 Questions that begin with “why” are
often perceived by the patient as
challenging or threatening. Such
questions ask the patient to provide a
reason or justification or personal
beliefs, feelings, thoughts, and behaviors
and imply criticism.
 If patients are unable to provide these
answers, either from lack of sufficient
knowledge, or because the answer is not
known to the patient; he or she can feel
inadequate defensive or angry. Some
questions are really unanswerable and
that individuals are frequently unaware
of why they do things. Asking the patient
to describe the feelings, beliefs, or
behaviors is preferable to asking why.
Providing a description about what
happened often helps a patient
elaborate
Probing
 Repeated or persistent questioning of
the patient about a statement or
behavior increases patient anxiety and
can cause confusion, hostility, and a
tendency to withdraw from the
interaction
 This patient withdrawal and the
increasing periods of silence resulting
from it can escalate the nurse's anxiety.
Anxious nurses tend to become more
active and more directive in the
interview. A helpful rule of thumb for
nurses to use in identifying probing is to
pay particular attention to their own
behavior or feelings
Offering False Reassurance
 False reassurances are vague and
simplistic responses that question the
patient's judgment, devalue, and block
patient feelings, and communicate a
lack of understanding and sensitivity on
the part of the nurse.
 This behavior often increases patient
anxiety. A more valuable nursing
response would be to first acknowledge
personal feelings of anxiety and then to
acknowledge the patient's feelings
Giving Approval or Disapproval
 During health assessment interview,
nurses can feel pressured to comment
judgmentally in a patient's statements,
feelings, or behaviors especially if these
contradict the patient's personal
feelings or beliefs. Telling a patient
what's right or wrong is moralizing. This
may limit the patient's freedom to
 verbalize or behave in certain ways that
might not please the nurse
 These comments given hinder the
nurse's attempts to establish rapport,
support patient competence, and
facilitate communication. When there is
concern that the patient's expressed
beliefs or personal behaviors are ill-
informed, harmful, or destructive, the
nurse might more effectively explore the
source of the belief or the impact of the
patient's behavior on others
Defending
 Occasionally, patients who have had
previous stressful or unpleasant
experiences with physicians,
hospitals ,or other agents of the
healthcare system will engage in
criticism or verbal attack. It is not
helpful for the nurse to defend the
object of the attack. Defending implies
that the patient has neither the right to
hold such opinions or feelings, nor the
right to express them especially if
they're hostile or angry
 Defending is not therapeutic because it
requires the nurse to speak not just for
herself or himself, but for others
something that nurses truthfully and
realistically are not able to do
Advising
 Consistently, telling a patient what to do
does not foster competence. Advising
encourages patients to look to others
for answers, deprives them of
opportunities to learn from past
mistakes, and discourages independent
judgment
 It is important that the nurse does not
reinforce such dependence but rather
support the patient's healthy functioning
as much as possible
 TYPES: Exploring, Reflection
Using Problematic Questioning Techniques
1. Posing Leading Questions
a. Example: “You've never had any type of
sexually transmitted diseases, have you, Miss
Jenkins?”
2. Interrupting the Patient
a) Changing the subject or interrupting
prevents completion of an idea and introduces
a new focus
3. Neglecting to Ask Pertinent Questions
a) Do not let patient’s outward physical
appearances, personalities, or social standing
distract you from ascertaining pertinent
information
4. Engaging in Talkativeness
 may indicate nervousness and
uncertainty on the part of the interviewer
5. Using Multiple Questions
 may confuse patients by asking several
questions all at once
6. Using Medical Jargon
 can be anxiety provoking for the patient
7. Being Authoritative
 the use of authority as a healthcare
professional can be a problematic
technique. This though can be a
reinforcement on a patriarchal nurse
patient relationship. But it can be an
effective communication technique
negative use of authority: “I’ve been a
nurse, Mr. Haddad, for over 10 years,
and I think I know what is best for you. –
positive use of authority: “As your
health care provider, knowing about your
previous heart attack, history of high
blood pressure, and family history of
 stroke, I would suggest you consider
stopping smoking.”

8. Having Hidden Agendas

 frequently, patients seek health care for
one problem but actually are concerned
about other problems
 the patient may believe that the
overriding concern is embarrassing,
private, or insignificant.
 the nurse should deal with the patient's
concerns in the best way possible then
follow up when indicated