Establishing Rapport Building Relationships

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Establishing Rapport Building Relationships

• Evelyn Kemp, Psy.D. Kathleen L. B. Beine,
  M.D.
• Forrest Lang, M.D.
• Department of Family Medicine
• Susan M. Grover, Ph.D., R.N.
• College of Nursing
• Revised by Sue Grover Chris Dula, 2014
• East Tennessee State University

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RAPPORT Definition

• Rapport a harmonious or sympathetic relation or
  connection.
• May occur in a single encounter
• Time alone is not sufficient to establish
  rapport
• Different from
• Trust Confidence in the professionals
  demonstration of competence.
• Charisma Magnetic charm or appeal.

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BUILDING RAPPORT SKILLSVERBAL COMMUNICATION

• SKILL Introduction and personal remarks
  Icebreakers/social conversation
• SKILL Pats on the back
• SKILL Expressions of caring, collaboration, and
  commitment
• R.1 pharmacist commitment
• 4. SKILL Concluding with collaborative comments

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BUILDING RAPPORT SKILLSNON-VERBAL COMMUNICATION

• Between 65 and 90 of communication is thought
  to be nonverbal (Birdwhistell, 1970 Hall, 1966).
  
• Ivey and Ivey (2002) considered attending
  behaviors to be the foundation of interviewing
  and suggested four dimensions have been supported
  by research and to some extent, cross-culturally
• 1. eye contact
• 2. body language
• 3. vocal qualities
• 4. verbal tracking

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BUILDING RAPPORT SKILLSNON-VERBAL COMMUNICATION

• Non-verbal communication elements include such
  things as
• Handshakes, nods, use of hands while talking
  (gestures)
• Voice tone, speed, pauses (para-linguistics)
• Distance, culturally appropriate eye contact,
  body position (e.g., leaning in, open posture)
  (proximics).
• In reviewing the research literature, Libero,
  Stevens and Kana (2014) concluded that Body
  postures can convey the emotional states of
  others.., help people infer others feelings and
  intentions.., formulate appropriate social
  responses.., regulate ones own emotions.., and
  help detect deception and threat
• R.2 pharmacist non-verbal

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BUILDING RAPPORTthroughout the interview

• Beginning
• A rich combination of verbal and non-verbal
  connections are possible and desirable, but often
  absent or superficial.
• Throughout
• Whenever the patient reveals something personal,
  expresses feelings, or demonstrates knowledge
  about his/her illness. (These opportunities are
  often missed.)
• Conclusion
• A final opportunity to cement the relationship.

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SKILL IcebreakerOften clinicians are concerned
that icebreakers will take too much time.

• R.3 Introduction - Mrs. Jones
• Questions to Consider
• 1. Estimate the time this type of initial
  greeting / introduction might take.
• 2. What are the pros and cons of using
• an icebreaker?
• Think of some examples of icebreakers.

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Answer 1

• Typically, personal and collaborative talk takes
  about 30 seconds.
• In the video clip you just saw with Mrs. Jones,
  the greeting and reconnecting with this
• established patient took 23 seconds.
• There is research that indicates that using
  Rapport Building improves both efficiency (time
  management) and quality in patient interviews.
  (Mauksch LB, Dugdale DC, Dodson S, Epstein R,
  Arch Intern Med. 2008)

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Answer 2 Pros and Cons of Icebreakers

• Advantages
• Shows interest in the patient as a person.
• Helps calibrate future communication by
  identifying the patients level of intelligence,
  communication style, language, comfort,
  spontaneity, etc.
• Potential Disadvantages
• Can appear insincere if overdone.
• May be inappropriate in some situations (e.g.,
  emergencies, when breaking bad news.)

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Answer 3 Examples of Icebreakers

• What have you been up to lately?
• Hows work (school, hobby) going?
• How are things in your family?
• Thats a lovely pin youre wearing.
• From your shirt it looks like you're a Braves
  fan?
• I see you have a book with you. What are you
  reading?

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Pats on the back

• Verbal or actual pats on the back for positive
  health behaviors increase the likelihood of that
  behavior recurring in the future. There are
  frequent opportunities to provide the patient
  with a touch of approval. Much of the time, these
  opportunities are missed.

R.4 Mrs. Rogers Question to consider What
happened to positively affect rapport?
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Verbal Skill Pats on the back

• In the previous interview the clinician
• Recalls a previous conversation.
• Pats patient on back, Thats wonderful
• Notes patients success with weight loss.
• Look for the chance to say
• Im impressed with what you know.
• Youve really learned a lot about your illness.
• Youre handling a difficult situation well.
• Youre doing a good job!

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SKILL Collaborative Comments

• Statements of interviewers realistic personal
  commitment to help, or comments that stress the
  willingness to be collaborative in the plan
  development (shared decision-making).
• The commitment referred to here goes beyond the
  usual responsibility of the healthcare
  professional to make a diagnosis, order tests,
  provide information, dispense or write
  prescriptions.
• Use the pronoun I, rather than We, as this is
  a personal commitment.

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EXAMPLES Collaborative Comments

• Lets work together to get your illness under
  control. (collaboration)
• Id like to help in any way I can. (commitment)
• Im interested in doing everything I can to help
  you through this difficult time. (caring and
  commitment)
• R.5 Personal Commitment-Lab Test

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Unconditional Positive Regard (UPR)

• Two clusters of interpersonal behaviorare
  clearly associated with good therapy
  outcomes (1) Rogerianempathy, non-possessive
  warmth, positive regard, and genuineness and (2)
  therapeutic alliance. (Keijsers, Schaap
  Hoogduin, 2000, p.264)
• In the 1960s, Dr. Carl Rogers found
  Unconditional Positive Regard builds rapport and
  enhances the therapeutic alliance. UPR is a
  patient experience facilitated by a caring and
  non-judgmental clinician, including
• Supporting the patient no matter what s/he says
  or has or has not donealways treating the
  patient with overt respect and resisting any
  impulse to negatively judge the patient
• Attempting to empathetically understand the
  patients view (trying your very best to put
  yourself into their shoes)
• Holding conflicting biases/values/beliefs in
  reserve and conveying positivity and hopefulness
  to the patient.

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NEGATIVE SPEAKDistancing the Patient and the
Provider

• Unfortunately, there are comments or expressions
  that criticize, belittle, or show disrespect to
  the patient. There are remarks that convey
  unwanted advice. Comments can range from mildly
  offensive or insensitive to being unequivocally
  rude or insulting (e.g., racist, sexist, ageist,
  or biased in any way)
• Examples of negative speak may include
• You worry too much.
• You got upset over nothing.
• Youve got to cooperate.
• Id like you to be more responsible.
• The problem is you dont take your health
  seriously.

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NEGATIVE SPEAK Examples

• R.6 Diabetic log R.7 Pharmacist
• Note that all of these remarks and those in the
  previous slide begin or imply that you . . .
  should, you need to . . . , you ought to . .
  .
• The implication is clear that the speaker is
  conveying superiority to the patient.

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SKILLS Non-Verbal Rapport

• Review the following three interview situations.
• In each the words are the same.
• Analyze and identify what observable non-verbal
  elements result in the different messages.
• R.8 N/V 1
• R.9 N/V 2
• R.10 N/V 3

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SKILLS Non-Verbal Rapport

• ANSWERS
• The positive or negative non-verbal elements
  include
• Tone of voice - excited vs. disinterested
• Body lean - leans forward vs. back
• Eye contact - present vs. absent
• Focus of attention - patient vs. chart

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SKILLS NON-VERBAL RAPPORT(Note These behaviors
vary by culture)

• Shake hands with patient initially
• Use appropriate eye contact (avoid gt 5-7 seconds,
  which may be interpreted as staring some
  cultures find direct eye contact disrespectful)
• Sit at same level as patient
• Lean slightly toward patient
• Respect personal distance (in US, one arms
  length)
• Respect and consider carefully use of touch
• Avoid furniture barriers between you and patient
• Avoid reading the chart while interviewing
• Limit written notes during interview (key facts
  is acceptable)
• For information on cultural differences, click
  here

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SKILL Touch

• A form of non-verbal communication that can be
  extraordinarily powerful, but not without risks.
• A deeply personal response when words are
  inadequate. REMINDER It is about the patients
  perspective, needs, feelings.
• Can convey empathy, often better than words.
• In using, consider CAREFULLY AND IN ADVANCE, the
  patients and your age, gender, social/cultural
  background, and the current situation.
• Use thoughtfully, judiciously, consciously. If
  touching, use the flat of the hand on the arm,
  shoulder or hand.
• Do not touch distrustful, reserved, angry or
  psychotic patients.

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Establishing Rapport Relationship
BuildingQuestions to Consider

• If building rapport with patients is so effective
  and time-efficient . . .
• Why does it sometimes not happen?
• What are the potential barriers?

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ANSWERS

• Our professional role often requires such intense
  cognitive, sensory and perceptual focus that our
  normal, human responses may get lost.
• Gender issues, age issues, cultural issues may
  create a fear that expression of personal
  interest and concern for the patient may be
  misinterpreted and attract unwanted personal
  advances.
• The interviewer may have negative personal
  feelings or experiences with regard to the
  patient or clinical situation (counter-transferenc
  e).

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SKILL Advanced Rapport The Heart-sink Patient

• They have been called hated patients, thick
  chart patients, crocks, turkeys, and
  gomers, to name a few. The British call them
  heart-sink patients because your heart sinks
  when you see their names on the schedule.
• One clinicians heart-sink patient might not be
  anothers.
• Heart-sink patients constitute at least 15 of
  the patient population. (Jackson JL, Kroenke K.
  Arch Intern Med. 1999)
• Heart-sink patients pose a major challenge to
  rapport building.
• An Unconditional Positive Regard outlook helps
  clinicians to realize that difficult patients
  still need help, to avoid resenting patients
  resistance and/or inappropriate interpersonal
  style, and to understand such elements are just
  part of a clinical picture.

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Sources of Frustration with Heart-sink Patients

• Seven sources of frustration (Levinson W, Stiles
  WB Med Care 1993)
• Lack of trust and agreement
• Too many problems a barrage of complaints
• Feelings of distress prompted by practitioners
  emotional response to patient
• Lack of understanding due to confusing history
• Patient non-adherence
• Demanding, controlling, or manipulative behavior
• Special problems, e.g., substance abuse and
  chronic pain
• In the following slides, we will explore ways to
  build rapport with two types of challenges.

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SKILL Advanced RapportChallenge 1Patient
with Chronic Pain

• Mrs. Strawbridge has just moved to your
  community. As part of the initial history, she
  describes her migraine headaches and requests a
  prescription for narcotics.
• Watch this video to see what might happen
• R.11 Chronic Migraine Headaches

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Mrs. StrawbridgeChronic Migraine Headaches

• What makes this patient potentially a
  heart-sink patient?
• How do you personally feel about her?
• What kind of buttons might she push, at least for
  some providers?
• How might having an Unconditional Positive Regard
  orientation help avoid heart-sink and improve
  interactions?
• What kinds of things might you have done in this
  situation to build rapport?
• R.12 Alternative approach
• What differences did you see?
• What else might you have done?

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Mrs. StrawbridgeChronic Migraine Headaches
Answers

• This patient may be categorized as a heart-sink
  patient because
• Lack of trust and agreement
• Feelings of distress prompted by practitioners
  emotional response to patient
• Requesting narcotics in an insistent manner
• Chronic pain
• The provider may feel this patient is being
  demanding or manipulative.

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SKILL Advanced RapportChallenge
2Non-Adherent Patient

• Mr. Webb has severe COPD/Emphysema and continues
  to smoke 1-2 packs of cigarettes/day. During his
  current hospitalization for an acute exacerbation
  of his COPD, he spent a short time on the
  respirator followed by several days of Bi-Pap
  therapy. He was just transferred out of critical
  care, and the nurse informs you that Mr. Webb was
  discovered smoking in the bathroom.
• Click on the following video to see one way to
  respond
• R.13 Non-adherence
• What about this patient might make your heart
  sink? What did you notice that might damage
  rapport?
• R.14 Answers

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Non-adherent Patient Alternative Approach

• R.15 Alternate Approach
• What techniques did you notice the doctor using
  that might have helped build rapport with the
  patient?

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Mr. Webb - Alternate Approach

• Answers
• Self-reflection, acknowledging feelings to
  oneself.
• Eliciting the patients perspective.
• Acknowledging the patients frustration.
• Taking a collaborative approach to treatment.

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SKILLS When your heart-sinks

• Identify the buttons that have been pushed in
  you. Pause.
• Reframe What is the patients behavior that
  causes the negative reaction? What underlying
  interest of the patient may be driving this
  behavior (e.g., fear, sadness, loss, being
  overwhelmed, recent or past negative experiences
  aka transference) ? Keep Unconditional Positive
  Regard in mind, and try to adopt that positive
  mindset.
• Talk with colleagues, rather than talking about
  the patient.
• Consider that the problem may be your stuff
  and not about the patient (this is called
  counter-transference and will be discussed in
  greater detail later, in the Addressing Feelings
  module).

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Rapport Building Summary of Skills

• Verbal Rapport Building
• Introductory personal remarks
• Pats on the back---here we mean verbal, but
  these may also be real pats (in appropriate
  situations).
• Statements of your personal support,
  collaboration, and commitment.
• Concluding personal remarks
• Non-verbal Rapport Building
• Gestures (handshakes, etc.)
• Voice tone, speed, interest (para-linguistics)
• Eye contact, lean, body position (proximics)

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How Will I Be Graded on an OSCE?Establishing
Rapport, Rating Descriptions

• 5 Demonstrates rapport-building skills such
  that most patients would subsequently go out of
  their way to tell friend or family about this
  interviewer with extraordinary interpersonal
  skills. Usually include two or more elements of
  positive speak and expressions of non-verbal
  interest that are exceptionally warm.
• 4 Notably warm and makes effective connection
  via identifiable elements of both verbal and
  non-verbal connection
• 3 Clearly, professional, respectful and
  interested but minimal or ineffective specific
  verbal or non-verbal efforts to make a more
  personal connection.
• 2 For the most part professional and
  respectful. Absent of specific effective efforts
  at rapport building. Present are some comments,
  expressions or non-verbal behaviors, which might
  have a negative reception by a least some
  patients.
• 1 Absent are positive elements of relationship
  building. Present are clearly negative comments
  or expressions, which would leave many patients
  with negative feelings about the interviewer.
• 5 100 4 90 3 80 2 70 1 60

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Module Quiz

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