Establishing Rapport Building Relationships

Evelyn Kemp, Psy.D. & Kathleen L. B. Beine, M.D.

Forrest Lang, M.D.Department of Family MedicineSusan M. Grover, Ph.D., R.N.

College of Nursing

Revised by Sue Grover & Chris Dula, 2014

East Tennessee State University

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 professional’s demonstration

of competence. – Charisma: Magnetic charm or appeal.

BUILDING RAPPORT SKILLS:VERBAL COMMUNICATION

1. SKILL: Introduction and personal remarks Icebreakers/social conversation

2. SKILL: “Pats on the back”

3. SKILL: Expressions of “caring, collaboration, and commitment”

R.1 pharmacist commitment

4. SKILL: Concluding with collaborative comments

BUILDING RAPPORT SKILLS:NON-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

BUILDING RAPPORT SKILLS:NON-VERBAL COMMUNICATION

Non-verbal communication elements include such things as:

1. Handshakes, nods, use of hands while talking (gestures)

2. Voice tone, speed, pauses (para-linguistics)

3. 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 one’s own emotions.., and help detect deception and threat…”

R.2 pharmacist non-verbal

BUILDING RAPPORTthroughout the interview

BeginningA rich combination of verbal and non-verbal connections are possible and desirable, but often absent or superficial.

ThroughoutWhenever 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.

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?

3. Think of some examples of icebreakers.

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)

Answer 2: Pros and Cons of Icebreakers:

• Advantages– Shows interest in the patient as a person.

– Helps calibrate future communication by identifying the patient’s 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.)

– “What have you been up to lately?”– “How’s work (school, hobby) going?”– “How are things in your family?”– “That’s a lovely pin you’re wearing.”– “From your shirt it looks like you're a Braves

fan?”– “I see you have a book with you. What are you

reading?”

Answer 3: Examples of Icebreakers:

“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?

Verbal Skill: “Pats on the back”

In the previous interview the clinician:

1. Recalls a previous conversation.

2. Pats patient on back, “That’s wonderful…”

3. Notes patient’s success with weight loss.

Look for the chance to say:

“I’m impressed with what you know.”

“You’ve really learned a lot about your illness.”

“You’re handling a difficult situation well.”

“You’re doing a good job!”

• Statements of interviewer’s 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.

SKILL: Collaborative Comments

EXAMPLES: Collaborative Comments

• “Let’s work together to get your illness under control.” (collaboration)

• “I’d like to help in any way I can.” (commitment)

• “I’m interested in doing everything I can to help you through this difficult time.” (caring and commitment)

R.5 Personal Commitment-Lab Test

Unconditional Positive Regard (UPR)“Two clusters of interpersonal behavior…are clearly associated with [good therapy] outcome[s]: (1) Rogerian…empathy, non-possessive warmth, positive regard, and genuineness; and (2) therapeutic alliance.” (Keijsers, Schaap & Hoogduin, 2000, p.264)

In the 1960’s, 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:

1. Supporting the patient no matter what s/he says or has or has not done…always treating the patient with overt respect and resisting any impulse to negatively judge the patient;

2. Attempting to empathetically understand the patient’s view (trying your very best to put yourself into their shoes);

3. Holding conflicting biases/values/beliefs in reserve and conveying positivity and hopefulness to the patient.

“NEGATIVE SPEAK”Distancing 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.”

– “You’ve got to cooperate.”

– “I’d like you to be more responsible.”

– “The problem is you don’t take your health seriously.”

“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.

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

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

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

• Shake hands with patient initially• Use appropriate eye contact (avoid > 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 arm’s 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

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 patient’s perspective, needs, feelings.

• Can convey empathy, often better than words.

• In using, consider CAREFULLY AND IN ADVANCE, the patient’s 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.

Establishing Rapport & Relationship Building

Questions to Consider

• If building rapport with patients is so effective and time-efficient . . .

• Why does it sometimes not happen?

• What are the potential barriers?

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-transference).

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 clinician’s “heart-sink” patient might not be another’s.

• “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.

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 practitioner’s 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.

SKILL: Advanced RapportChallenge # 1

Patient 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

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?

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 practitioner’s

emotional response to patient– Requesting narcotics in an insistent manner– Chronic pain– The provider may feel this patient is being demanding

or manipulative.

SKILL: Advanced RapportChallenge # 2

Non-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

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?

Mr. Webb - Alternate Approach

Answers• Self-reflection, acknowledging feelings to oneself.

• Eliciting the patient’s perspective.

• Acknowledging the patient’s frustration.

• Taking a collaborative approach to treatment.

SKILLS: When your “heart-sinks”

• Identify the buttons that have been pushed in you. Pause.

• Reframe – What is the patient’s 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).

Rapport Building Summary of Skills

Verbal Rapport Building:1. Introductory personal remarks2. “Pats on the back”---here we mean verbal, but these may also

be real pats (in appropriate situations).3. Statements of your personal support, collaboration, and

commitment.4. Concluding personal remarks

Non-verbal Rapport Building:1. Gestures (handshakes, etc.)2. Voice tone, speed, interest (para-linguistics)3. Eye contact, lean, body position (proximics)

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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