When interviewing a patient, which of the following is recommended?

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Collecting patient data is a core step in the nursing process. Often referred to as a nursing health assessment interview, nurses—and nursing students enrolled in nursing programs—must systemically collect patient health information so patients can receive the care they need.

While it’s tempting to think otherwise, health assessment in nursing is so much more than asking questions. It’s the gateway to building an effective nurse–patient relationship that will make patients feel at ease, supported, and empowered.

Whether you’re just learning how to become a nurse in a nursing program or are an RN reviewing best practices in your field, you’ll benefit from knowing about some of the most effective health assessment interview techniques. They include:

• Active listening
  Nurses must do more than simply listen when conducting a health history assessment—they must actively listen. Active listening involves fully comprehending what a patient is communicating through both verbal and nonverbal cues (such as body language), as well as the patient’s emotional state. Complete concentration is essential during a nursing assessment. Listen carefully, using verbal and nonverbal prompts to encourage the patient to expand on his or her symptoms and the circumstances surrounding them.
• Adaptive questioning
  Also referred to as guided questioning, adaptive questioning helps you encourage a patient to fully communicate without interrupting the flow of his or her narrative. Start with general questions, making them more specific as you move through the interview. Health assessments in nursing require questioning that elicits a graded response versus a yes or no reply. A series of questions, asked one at a time, often helps patients open up, as does offering multiple choices for answers. Request additional information when necessary by asking the patient to clarify their statements. Repeating his or her statements (a technique called echoing) is also helpful, as is using verbal and nonverbal continuers, such as nodding your head or saying things like “go on.”
• Nonverbal communication
  Nursing assessments also require that you be in tune with a patient’s nonverbal communication, such as posture, eye contact, facial expression, and the like. Reading and understanding these nonverbal cues help nurses understand patients more fully, and using nonverbal communication of their own—such as mirroring a patient’s position or using therapeutic physical contact (placing a hand on the patient’s arm, for example)—can further augment the health history assessment.

• Empathy, validation, and reassurance
  Empathy is key in nursing health assessments, as it demonstrates that you understand and care about what a patient is experiencing and helps establish a trusting nurse–patient relationship. Empathic responses during a health history assessment interview can be both verbal (“I understand”) and nonverbal (such as offering a tissue if the patient is crying). Beyond being empathic, be sure to validate patients’ feelings to help reassure them that their emotions are natural and reasonable and their problems are understood and will be fully addressed. 
• Partnering and summarization
  Another essential element of a nursing health assessment is expressing to the patient that you are committed to forging a continuing partnership dedicated to his or her wellness. Even if you’re still enrolled in a nursing program—such as a Bachelor of Science in Nursing or RN program—as a student, this support can make a tremendous difference in a patient’s life. As you conduct your interview, summarizing what the patient has said is also helpful, as it demonstrates that you’ve been listening and can fill in holes in the patient’s story.
• Transitions and empowerment
  Health problems can elicit feelings of anxiety in patients. One way to put their fears at ease is to use transitions during their health history assessment to let them know what they should expect next, such as a change in subject matter or a physical examination. Patients also feel vulnerable when they’re experiencing health problems, making it essential to empower them with the idea that their participation in the process and working closely with their medical team can make a positive difference in their outcomes.

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Copyright February 2014 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93.

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Clinical decision-making Counseling Medical informatics