Figure 1-1 depicts the three main elements underlying patient-centered care: individualized care, patient involvement, and provider collaboration. Patient-centered care is founded on a two-way partnership between providers and patients (and their families) designed to ensure that (1) the care given is consistent with each individual’s values, needs, and preferences, and (2) patients become active participants in their own care. By improving communication and creating more positive relationships between patients and providers, patient-centered care can improve adherence to treatment plans and thus help achieve higher-quality outcomes. In addition, patient-centered care can help minimize medical errors and contribute to enhanced patient safety.

FIGURE 1-1 The essential elements of patient-centered care.

The patient-provider encounter is at the heart of effective patient-centered care. Such encounters are so commonplace in the daily routine of the respiratory therapist (RT) that we often forget how important these short interactions can be in determining the effectiveness of the care we provide. To that end, this chapter focuses on how RTs can use these encounters to promote high-quality care that is attentive to the needs and expectations of each individual patient.

Individualized Care

Individualized care requires empathetic, two-way communication; respect for each patient’s values and privacy; and sensitivity to cultural values.

Providing Empathetic Two-Way Communication

Underlying patient-centered communication is empathetic and effective communication. Communication is a two-way process that involves both sending and receiving meaningful messages. If the receiver does not fully understand the message, effective communication has not occurred. As indicated in Figure 1-2, multiple personal and environmental factors influence the effectiveness of communication during clinical encounters. Attending to how each of these components may affect communication can make the difference between an effective and ineffective clinical encounter.

FIGURE 1-2 Factors influencing the effectiveness of communication during clinical encounters.

Each party to a clinical encounter brings attitudes and values developed by prior experiences, cultural heritage, religious beliefs, level of education, and self-concept. These personal factors affect the way a message is sent as well as how it is interpreted and received. Messages can be sent in a variety of ways and at times without awareness. Body movement, facial expression, touch, and eye movement are all types of nonverbal communication. Combined with voice tone, nonverbal cues frequently say more than words. Because one of the purposes of the encounter is to establish a trusting relationship with the patient, the clinician must make a conscious effort to send signals of genuine concern, that is, to exhibit compassion and empathize with the patient’s circumstances. Techniques useful for this purpose are facing the patient squarely, using appropriate eye contact, maintaining an open posture, using touch, and actively listening. It also may be helpful to act according to what you would expect from health care team members were you in the patient’s situation (the “golden rule” of bedside care).

One of the most common mistakes made by clinicians during patient encounters is failing to listen carefully to the patient. Good listening skills require concentration on the task at hand. Active listening also calls for replying to the patient’s comments and questions with appropriate responses. Patients are quick to identify the clinician who is not listening and will often interpret this as a lack of empathy or concern. If the patient says something you do not understand, it is best to ask the patient to clarify what was said rather than replying with the response you think is right. Asking for clarification tells the patient that you want to make sure you get it right.

Messages are also altered by feelings, language differences, listening habits, comfort with the situation, and preoccupation. Patients experiencing pain or difficulty breathing will have a hard time concentrating on what you are communicating until their comfort is restored. The temperature, lighting, noise, and privacy of the environment also may contribute to comfort. Patients may communicate their discomfort nonverbally using cues such as sighing, restlessness, looking into space, and avoiding eye contact.

Your use of communication techniques may differ according to the stage of interaction with a patient. Generally, a patient encounter begins with a chart review and then progresses through four additional stages: introductory, initial assessment, treatment and monitoring, and follow-up. Table 1-1 outlines the purpose of these stages and provides example strategies to help ensure effective communication during each major aspect of the patient encounter.

TABLE 1-1

Stages of the Clinical Encounter

Stage	Purpose	Communication Strategies
Chart review (preinteraction)	Identifying key patient information	Apply this information in the introductory and initial assessment stages
Introductory	Introducing oneself Confirming patient identity Clarifying purpose/your role Acknowledging family presence Building rapport Inspecting the patient (initial)	Look and act in professional manner Refer to patient using formal last name Avoid encroaching on personal space Pay attention to nonverbal cues Identify patient emotions Express support and empathy (compassion) React in nonjudgmental way
Initial assessment	Determining patient’s status (interview and physical examination) Determining learning needs Assessing cultural differences Determining appropriateness of orders (new Rx)	Use active listening: • Avoid interrupting the patient • Use body position to indicate interest • Avoid writing while patient is talking • Make eye contact but do not stare • Encourage open expression Reflect what the patient shares Summarize/request feedback Make facilitative responses, e.g., nodding
Treatment and monitoring	Demonstrating/teaching treatment technique Implementing and modifying treatment based on patient’s preferences, monitored responses	Explain therapy in understandable terms Invite questions about the treatment Confirm acceptance of the treatment Assess patient’s concerns, expectations Attend to patient discomfort
Follow-up	Confirming patient response Developing shared goals Assuring follow-up Restoring environment	Invite questions from patient and family Determine information preferences Check the patient’s ability to follow the plan Discuss follow-up (e.g., treatment schedule, what to do if symptoms worsen)

Respecting Patient Needs and Preferences

In addition to effective communication, individualized care requires that providers respect each patient’s needs, preferences, and privacy. Within this framework, we do not, for example, treat “the COPD patient in room 345,” but a patient with COPD, whose ability to cope with its full range of physical and psychosocial consequences is unique. Indeed, effective therapy requires that the individual patient’s response to disease be ascertained as part of the initial patient encounter and, for those with chronic afflictions, be regularly assessed and incorporated into care plans.

Whenever possible, care plans also should reflect each individual patient’s preferences as determined during initial assessment and treatment. For example, after their urgent situation is resolved, patients with asthma should be allowed to participate in deciding which aerosol drug delivery system is best for them. Likewise, a patient with cystic fibrosis should be allowed to participate in selecting from a variety of equally effective positive-pressure devices to assist in airway clearance. Accommodating an individual’s needs during treatment also involves modifying the therapy based on the patient’s response.

Assuring Privacy and Confidentiality

Anyone who has been hospitalized understands the need for privacy. We address privacy concerns in part by respecting personal space. Respecting patients’ privacy rights is both a legal and a moral obligation for health care professionals.

To respect patients’ personal space, one needs to understand both the general and cultural implications of proximity and direct contact. Figure 1-3 depicts the three zones of space commonly associated with the bedside patient encounter.

FIGURE 1-3 Illustration of the social, personal, and intimate spaces characterizing the clinical encounter.

The social space (4 to 12 feet) is used primarily in the introductory stage of the encounter during which you begin to establish rapport. At this distance, you can see the “big picture” and gain an appreciation for the whole patient and the patient’s environment. Vocalizations are limited to the more formal issues, and personal questions in this space are to be avoided because others in the room may overhear the conversation.

The personal space (18 inches to 4 feet) is used primarily during the interview component of the initial assessment, usually after establishing rapport with the patient. This enhanced proximity is generally needed to garner sensitive patient information, such as questions about daily sputum production or smoking habits. To better assure privacy in this space, pulling the bedside curtain may help the patient feel more comfortable about sharing personal information. Most patients also feel more comfortable and confident when your appearance is neat, clean, and professional. Patient trust can be enhanced by assuring appropriate eye contact while in the patient’s personal space.

Intimate space (0 to 18 inches) is reserved primarily for the physical examination component of the initial assessment and the treatment and monitoring stage of the encounter. Generally, moving into such proximity and touching the patient should be done only after establishing rapport and being given permission to do so. Such permission often is obtained by simply requesting consent to listen to breath sounds or check vital signs. Asking permission to move into the intimate space communicates both your respect for patient privacy and your willingness to share responsibility for decision making. Minimal eye contact is used in this space. Verbal communication with the patient should be limited to simple questions or brief commands, such as, “Please take a deep breath.”

Be aware that some patients may respond poorly to encroachment into their space. Gender, age, race, physical appearance, health status, and cultural background are among the many factors that may influence a patient’s comfort level when you enter the intimate space. Should the patient’s words or nonverbal responses indicate hesitancy with your actions, be prepared to move more slowly and communicate your intent very carefully.

SIMPLY STATED

The social space (4 to 12 feet) is for introductions, the personal space (18 inches to 4 feet) is for interviewing, and the intimate space (0 to 18 inches) is for physical examination.

In regard to maintaining confidentiality, all health professionals become privy to sensitive patient information. For example, your chart review may reveal that a patient under your care has a history of drug abuse or has been diagnosed with a sexually transmitted disease. This information is private and not for public knowledge. You have both a legal and a moral obligation to keep this information in strictest confidence and share it only with other health professionals who have a need to know, such as the patient’s nurse or attending physician. Most often, violations of patient confidentiality occur in public spaces when a clinician discusses a certain patient with other caregivers while being overheard by visitors. A good basic rule to follow is to discuss your patient’s health status only with other members of the health care team who need to know such information and only in a private area where visitors are not allowed.

Family members and visitors often ask questions about the patient’s diagnosis but always should be referred to the attending physician. This should be done in a way that does not alarm or offend those asking the questions. Most people will appreciate an honest response in which you tell them that privacy rights prevent you from discussing the patient’s diagnosis with others.

Your legal obligations regarding patient information are specified under the privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA). These rules establish regulations for the use and disclosure of Protected Health Information (PHI). PHI is any information about health status, provision of health care, or payment for health care services that can be linked to an individual. Examples of PHI include names and addresses, phone numbers, e-mail addresses, Social Security and medical record numbers, and health insurance information. Under the law, patients control access to their PHI. For this reason, use or disclosure of PHI for purposes other than treatment, payment, health care operations, or public health requires patient permission. Table 1-2 provides summary guidance on key privacy and security considerations under HIPAA.

TABLE 1-2

Do’s	Don’ts
Do access only that information needed to perform your job Do keep voices low when discussing patient issues in joint treatment areas Do provide only the minimal needed information on request Do position workstations so that the screens are not visible to prying eyes Do keep patient information on whiteboards to a minimum Do place fax machines used to receive PHI in secure locations	Don’t discuss a patient’s PHI with people with no need to know Don’t share your computer passwords and log-on information Don’t leave a computer unattended without logging off Don’t discuss a patient’s PHI in public settings where you can be overheard Don’t communicate PHI by methods that the patient has not approved Don’t leave a patient’s paper records open and available for prying eyes

Do’s

Don’ts

Do access only that information needed to perform your job

Do keep voices low when discussing patient issues in joint treatment areas

Do provide only the minimal needed information on request

Do position workstations so that the screens are not visible to prying eyes

Do keep patient information on whiteboards to a minimum

Do place fax machines used to receive PHI in secure locations

Don’t discuss a patient’s PHI with people with no need to know

Don’t share your computer passwords and log-on information

Don’t leave a computer unattended without logging off

Don’t discuss a patient’s PHI in public settings where you can be overheard