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Validating the Patient Narrative When Assessing CIC

Monica Nandwani, DNP, RN, FNP-BC

Nurse Practitioner

Monica Nandwani, DNP, RN, FNP-BC: consultant/advisor/speaker: Phathom, Salix.

View ClinicalThoughts from this Author

Released: January 27, 2023

Key Takeaways

  • Effective communication with your patient can enhance shared decision-making.
  • Two models—“I’m Late” and SHARE—can be implemented to help with patient communication.

Constipation is a multisymptom condition that can include abdominal pain, bloating, distension, infrequent stools, hard stools, and straining, to name a few. Therefore, the patient’s narrative—or the history of their present illness—is critical to informing healthcare professional (HCP) decision-making and individualizing therapy.

Despite this—and the patient’s narrative being one of the most important tools in our toolbox—the literature has highlighted that, on average, HCPs interrupt their patient’s initial statement within the first 22 seconds. Therefore, we need to be mindful about allowing our patients to share their illness context, experiences, and symptoms, as well as the impact the illness is having on their lives. This will allow us to determine which diagnostic tests and treatment options would be most appropriate and provide the best path for the patient.

Of interest, the literature also shows that if we allow our patients to share their narrative uninterrupted, they usually do not speak for more than 2 minutes. Often, we want to get this critical information, and we might interject when our patients are sharing their narrative. It is important, however, to keep in mind that if we let them speak in an uninterrupted manner, we can gather important information.

Two useful paradigms that I have leveraged to help improve the patient–HCP relationship are the “I’m Late” mnemonic from the Rome Foundation and the SHARE approach from the Agency for Healthcare Research and Quality (AHRQ).

“I’m Late” Mnemonic
The “I’m Late” mnemonic was published in the Rome Foundation working team report reviewing evidence and recommendations on communication skills and the patient–HCP relationship.

“I’m Late” stands for:

  • Impression: Investing in that first impression—that first visit—sets the tone for the relationship that you will have with your patient and potentially their family or caregivers. Remember that this relationship can span years or even decades and will involve ongoing conversations.
  • Minute: This actually should be 2 minutes of silence—in other words, resisting the urge to interrupt and allowing the patient’s narrative to unfold. This will facilitate gathering valuable information.
  • Listen: Active listening and using nonverbal signs of listening such as eye contact, mirroring, and nodding encourage your patient to share key information.
  • Acknowledge: Acknowledging that symptoms are real and the impact they can have on your patient’s quality of life demonstrates empathy. Constipation can be very debilitating and can lead to missed days of work (absenteeism) or reduced effectiveness or efficiency at work (presenteeism).
  • Touch: Keep in mind the therapeutic effect of touch and the role that rituals such as the physical examination can have on that patient‒HCP relationship.
  • Empathize: Reflect on and validate your patient’s experience through statements such as: “This must be really difficult time for you. Let’s work together on how we can improve your symptoms.”

SHARE Approach
The SHARE approach is the AHRQ’s 5‑step resource for enhancing shared decision-making. The AHRQ website includes a wealth of information, including examples of dialogue, tool kits, and a workshop curriculum.

SHARE stands for:

  • Seek your patient’s participation. Let your patient know that they have options, and partner with them in the decision‑making process. Use statements such as, “Let’s review the testing and treatment options so that we can find the path that works best for you.”
  • Help your patient explore and compare treatment options. Discussing risks and benefits of treatment options and evidence-based data with your patient involves them in decision-making and fosters trust. Summarize the options discussed in the after-visit document and share this with the patient as a reference. Be mindful that we review a lot of information during the clinic that may be new to our patient, so having a summary for the patient to reference can be very helpful. Avoid medical jargon during these discussions; use language that the patient can understand, and supplement with visual aids if available. Knowing what options are available, including new or upcoming therapies that might be in the pipeline, empowers our patients in their decision-making. Include details such as the risks and benefits, what is known vs unknown, and alternatives.
  • Assess your patient’s values and preferences. This is critical to providing patient‑centered care. Ask open‑ended questions such as, “As we review the different treatment options, what is most important to you?” Ask the patient: “What would you like to focus on? What are your goals? Is there anything that might be a barrier to reaching those goals?” It is very important to gain the patient perspective. Patients engaged in shared-decision making are more likely to remain adherent, which can affect outcomes and impact patient satisfaction.
  • Reach a decision with your patient, first asking whether they are ready to decide or if they need more time to consider the options. Assess for signs of decisional conflict such as being unable to decide or verbalizing uncertainty regarding the choices. Patients receive new or additional information during the clinic visit, and they might need time to digest the various options. It may take several visits, depending on patient preferences. It may help to say: “These are your options; these are the risks and the benefits. If you feel like you need some time to think about that, let me know. We can revisit a decision at a later time.” On the other hand, if they are clear about their goals, you can partner with them to reach a decision, taking into account their values and preferences. Once you have jointly reached a decision, verify next steps, and schedule a follow-up visit to assess response.
  • Evaluate your patient’s decision. See how they have responded to the treatment option path that was decided. Recognize that there may be barriers that can impact their choices. Revisit the decision to determine if adjustments are needed or whether alternative options need to be explored. When patients have a chronic disease, such as chronic idiopathic constipation, partnering with them for shared decision-making is important because their symptoms can evolve, their preferences can change, and their response to therapeutic options can be variable.

Why is it important to use the SHARE approach? We know that patient adherence to treatment is enhanced by shared decision-making. A positive patient‒HCP relationship establishes trust, builds confidence, and facilitates collaboration. It can influence both patient and HCP satisfaction by providing a sense of connection. 

Using the Models Effectively
It can be difficult for patients to talk about their bowel habits. Understandably, this may be a very private matter, or perhaps they are unaware of how to accurately describe what they are experiencing. Making the patient comfortable by asking open‑ended questions about symptoms and discussing patterns that might be seen with chronic idiopathic constipation can help elicit details from the patient.

I also find that providing a comprehensive review of treatment options can help with shared decision-making. First, however, one needs to determine what the patient’s goals and preferences are, as well as how much information the patient wants. Some patients want to hear all the available options, but others may prefer to rely on the HCP’s direction and recommendations. It also is important to set realistic goals and empower the patient to take responsibility. I often frame this discussion as: “These are the 5 options, and these are the pros and cons of each. Are you ready to make a decision, or do you need time to think about which path you would like to take?”

Finally, we need to determine whether the treatment options we provide fit the patient’s needs, individual situation, and lifestyle. The options must be feasible for their circumstances. If not, it can be challenging to adhere to the recommendations, and they will therefore not be set up for success. This is where shared decision-making is critical.

In summary, tools are available to help HCPs optimize communication and the patient–HCP relationship, which can impact patient adherence to treatment and clinical outcomes.

Your Thoughts?
What models for patient interaction do you use effectively? Join the conversation by sharing a comment.

Provided by Clinical Care Options, LLC in partnership with Practicing Clinicians Exchange.

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