E X C E L L I N G. Difficult Conversations. Objectives:

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1 E X C E L L I N G in Difficult Conversations Linda J. Keilman, DNP, GNP-BC Michigan State University College of Nursing Objectives: 1. Describe effective communication strategies. 2. Discuss communication protocols and mnemonics that can serve as a stepwise framework for approaching difficult conversations. 3. List positive outcomes that can be achieved through empathy and mattering while balancing realism and hope. 2-way process Verbal & non-verbal components Complex Influenced by the emotions & thoughts of the health care professional, the patient/family Essential for high quality, effective & safe practice of evidence-based health care Building block for creating therapeutic relationships with patients & their families (Rajashree, 2011) Therapeutic Communication Should: Ease suffering Provide education & reassurance Promote understanding Be continuous & ongoing Advocate for Improve communication between the interprofessional team & the patient/family Instill hope 1

2 Courtesy Respect Introductions Uniqueness of all individuals Gender Age Race/Ethnicity Religion/Spirituality Flexible & adaptable Admitting don t have all the answers! Honesty & integrity Therapeutic Holistic Voice tone & quality Person-centered Interactional process Strength versus deficit model Listening component Active, silence, repetition, reiteration, reflection, nodding, smiling, hmmm Requires preparation! Incorporation of ethical principles Respect for autonomy Nonmaleficence Beneficence Justice Confidentiality is an expectation Give broad range time frames Empowerment Emotional attunement Acknowledgement of others needs Self-awareness is key! Be a good person Treat others as you would want to be treated (respect) Be fair Be the best you can be in these situations Simply do the right thing (Browning, 2010) Universal Human Standards or Common-Sense Ethics Physical symptoms Emotions Fear Financial constraints Family dynamics Uncertainty Time constraints Lack of experience or practice Lack of self awareness 2

3 Health issues: Depression Anxiety Substance abuse Dementia Delirium Hearing loss Vision loss Pain Lack of awareness related to: Self * Gender Age Culture Education Literacy Social & economic status Religion/spirituality Feelings, emotions, values, beliefs Not understanding the persons role Not recognizing the importance of the family within the persons life Giving a narrow, predicted time frame for what might happen & when Omniscience ( Latin all knowing ) Making assumptions about the impact of the news or the persons understanding, priorities or readiness to hear difficult news (Edwards, 2010) Giving inappropriate reassurance or false hope Hurrying the conversation Looking at watch Appearing distracted Looking at cell phone or pager messages Sharing difficult or bad news with others before sharing with the individual Agreeing to withhold important information from the individual, based on family wishes 3

4 Unique to every person Related to personal: Values Feelings Beliefs Depends on the relationship & history with the individual rather than the content Level of emotional investment Perception of how the conversation will go Transitions Conditions Emotions Values Beliefs Wants versus Needs (preferences) Goals (wishes) Relationships Professional Listening Acknowledging Attending Silence Containment Acknowledgement Introduction Duration Explanation Thank you Introduce yourself & your role Shake hands Ask for identification & role of family members/friends (write it down) Give complete information Be objective Reframe, educate & normalize Interprofessional approach Always include the person when appropriate Know something about the person! 4

5 Work your schedule around the availability of family members Be prepared Review the medical record & other appropriate information before the meeting No interruptions Cell phone off; have someone cover pages; quiet room away from traffic & noise Rehearse mentally Prepare emotionally & spiritually Consider where & how YOU sit Close to Eye level No barriers between Give a warning Ease in to the topic but don t dawdle! Open-ended questions Address issues as they surface Encourage exploration of feelings & emotions Be open & non-judgmental Do not talk over or around the individual Best to speak in another room Hearing last sense to decrease Help the family to acknowledge their loss & its personal magnitude Offer a non-judgmental presence & acceptance Lay terminology Avoid the words death & dying, end of life, etc. at the beginning of the relationship Encourage family members to be specific ask for examples Affirm the importance of each person s contribution In the beginning don t offer advice or interpretations (even if asked) Go s l o w l y! Schedule a follow-up meeting Take time for yourself! Total focus on the other Person-centered Brings humanism to the conversation Listening component Motivation Accurate understanding of the individual s feelings Effective communication of that understanding back to the individual 5

6 Empathic Statement Examples: I can see how upsetting this is to you I can tell you weren t expecting to hear this I know this is not good news for you I m sorry to have to tell you this This is very difficult for me also I was also hoping for a better result Four C s Concept of Humanism: View individuals holistically & as unique Address the person by name Touch Presence Utilize medications with compassion Provide optimum autonomy Give dignity & respect Show compassion & sensitivity M A T T E R I N G Involves feeling: Important Attached Missed Interesting Depended upon Refers to our belief, right or wrong, that we matter to someone else Motivating 6 Basic Steps For Breaking Bad News Buckman,

7 S: Setting or getting Started Location Privacy Quiet Minimize distractions Involve selected individuals Sit down & get comfortable Eye level Body language Listen Set time limits P: Perception Before you tell ask Listen to response Note language, vocabulary, emotions» Use in your response Look for clues Patient/family perception of situation, condition & seriousness Correct misinformation Tailor the information to what the individual understands I: Invitation & Information Allow the individual to determine ahead of time who they want present during the conversation Ask who should be present? Permission from individual to give them information or to decline receiving it To share information Support or resources Develop/plan the agenda for the meeting ahead of time: Diagnosis Basic Treatment information; Prognosis individualize Support or coping Give the information in small chunks Stop between each chunk to see whether the individual understands or has any questions Translate medical terms in to lay terms that are easily understood If the person does not speak English, use a translator in the room Ensures that communication is accurate & that questions/concerns have been addressed HIPAA Information must be given directly to the patient unless they have expressly given written permission for information news to be given to friends/family K: Knowledge Provide facts after aligning Fire a warning shot 1 st Use the same language the individual uses Use lay terminology Give information in small bytes Clarify understanding Tailor the rate of information sharing Acknowledge/respond to emotions & reactions 7

8 Reinforce & clarify the information frequently Repeat important points Diagrams, written material Check your communication level Adult-to-adult Giving individual permission/signals to ask questions Listen for the agenda Blend your agenda with the reactions E: Empathize & Explore Acknowledge emotions as they arise Empathic Response: 1. Listen for & identify the emotion (or mixture of emotions) 2. Identify the cause or source of the emotion 3. Show the individual that you have made the connection between the above 2 points Validate Identify & acknowledge Express your perception of the individual s emotions Legitimate Acceptable or recognized as genuine Normalize Emotions & feelings are part of the human experience Therapeutic to share & be open S: Strategize & Summarize Ensure understanding Check frequently to make sure everyone is on the same page Give opportunity for questions, discussion, voicing concerns Indicate what can & cannot be done (or fixed) to help the situation Acknowledge feelings & emotions about the undoable or unfixable Leave with clear plan Prepare for the worst & expect the best Coping mechanisms Strengths Sources of support MUTUALITY Next steps Next conversation date Roles Who will do what to prepare (achievable & measurable short-term goals) Vandekieft, 2001; Rabow & McPhee,

9 Advance Preparation Mentally rehearse Identify words or phrases to use or to avoid Practice the conversation Assess patient understanding Build a therapeutic environment/relationship Find a quiet place Use open body language Address all patient fears Communicate well Be direct Frank but compassionate Avoid euphemisms & medical jargon Allow for silence & tears Ensure patient understanding Deal with patient & family reactions Be empathetic Do not argue with or criticize colleagues or other members of the health care team G R I E V _ I N G Encourage & validate emotions Reflect back emotions Ensure accurate interpretation of the news Offer realistic hope according to the individuals goals Address further needs including support Provide written information Use interdisciplinary resources Take care of your own needs Process your feelings Gather Resources Identify Educate Verify Space personal space; stop talking; absorb Inquire Nuts & Bolts the practicalities of situation Give card & access information (Lowry, 2007) B R E A K S Background Issue, culture, ethnicity, religion/spirituality Rapport Unconditional positive regard; no patronizing; provide space for selfdisclosure Explore Start with what the person knows; dynamics of family; coping strategies Announce Warning shot desirable; euphemisms should not create confusion; straight forward terms Right to know vs. the right to refrain from knowing Kindling How your emotions & feelings set the tone Summarize Highlight the main points; nutshell; written; optimistic outlook maintained (Narayanan, 2010) 9

10 F E A R E D Facts Empathy Anger Listen for misinterpretations/misconceptions Recite back Extended family Document After the talk; FEARED format (Walsh, 2002) SPOKES HARD SAFER CONERS Buckman, R. (2010). Practical Plans for Difficult Conversations: Strategies that Work in Breaking Bad News. Baltimore, MD: Johns Hopkins University Press. ISBN-10: N U R S N U R S E Name The person s emotion Understand I can see why you feel this way Respect You ve been through a lot & that takes a lot of courage Support I want to help you get better (Fortin et al., 2012) Name Understand Respect Support Explore Continuously explore an individuals concerns by asking them to share more or elaborate on something they might have shared before (Barnard & Ganca, 2011) B A T H E Background What has been going on in your life? Affect How do you feel about that? Trouble What troubles you the most about this situation? Handling How are you handling this? Empathy That must be difficult (Stuart & Lieberman, 2008) ASK PERMISSION 10

11 Tell What has been observed; issue at hand; reminds us to listen Explain Specificity related to an issue or problem; extract the person s story of the account Lead By example, role modeling; articulate the new behavior Learn The consequence McCullers Varner, 2011 Be prepared for bad reactions Know when to stop the conversation Choose the right time & place Use a respectful tone Watch for body language clues Acknowledge that you both might not be on the same page Be empathetic Maintain eye contact Where attention goes, energy flows! Stay in control of the conversation Realize that sometimes there are underlying issues that are not being discussed Write it out ahead of time Take/jot down basic notes If you are going to do this, tell the patient you are going to be doing this at the beginning Do not interrupt! Don t team up! Everyone 11

12 Ease suffering Provide education & reassurance Promote understanding Continuous & ongoing Advocate for Improve communication between the interprofessional team & the patient/family Instill hope Effective communication is associated with: Improved health outcomes Better quality of care Improved understanding, involvement & co-operation Improved individual & professional satisfaction Reduced medical error & malpractice claims Self-esteem & hope There is no right or wrong way to approach! Try, try again! Practice makes perfect! Do not be afraid to show you are human Emotions Feelings Empathy toward the individual increases their overall satisfaction Conversations about hope & suffering should be a natural part of the caring relationship Aging with Dignity. (2011). Five wishes. Retrieved from Barclay, S., & Maher, J. (2010). Having the difficult conversations about the end of life. British Medical Journal, 341, Barnard, A., & Ganca, L. (2011). Improving communication skills difficult conversations. Continuing Medical Education, 29(7), Black, J. (2011). Difficult conversations: Talking about dying well with dementia. British Journal of Neuroscience Nursing, 7(4), 617. Breaking Bad News: Buckman s 6-Step Guide (S.P.I.K.E.S.). (n.d.). Retrieved from FIMR-buckman6stepguide.pdf Brixey, L. (2004). The difficult task of delivering bad news. Dermatology Nursing, 16(4), ,356. Browning, D.M. (2010). Microethical and relational insights from pediatric palliative care. American Medical Association Journal of Ethics, 12(7), Browning, D.M. (2013). Disclosure of medical mistakes becoming the new cultural norm in health care: Ethics at forefront. Medical Ethics Advisor, 29 (12), Browning, D.M., Meyer, E.C., Truog, R.D., & Solomon, M.Z. (2007). Difficult conversations in health care: Cultivating relational learning to address the hidden curriculum. Academic Medicine, 82(9), Buckman, R. (1984). Breaking bad news: Why is it so difficult? British Medical Journal, 288(1), Buckman, R. (1992). How to break bad news: A guide for health care professionals. Baltimore, MD: The John Hopkins University Press. Buckman, R. (2010). Practical plans for difficult conversations in medicine: Strategies that work in breaking bad news. Baltimore, MD: The John Hopkins University Press. Chambers, B. (2013). Mattering: Applying a social-psychological construct to citizen engagement (unpublished masters thesis). The University of North Carolina, Chapel Hill, NC. Clancy, C. (2014). Critical conversations in healthcare: Scripts and techniques for effective interprofessional and patient communication. Indianapolis, IN: Sigma Theta Tau International. 12

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