When you need to have a quiet word
A communications masterclass at Northumbria University shows nurses and other healthcare professionals how to manage difficult conversations with patients and families. Participants learn to empathise, avoid being defensive and de-escalate emotional situations.
It is the sort of situation that can blow up every day in hospitals across the country – and often, it’s the nursing staff who are in the firing line.
‘The lady’s daughter was very well-spoken normally, but she was effing and blinding,’ ward sister Sharron Surrey recalls. ‘It’s difficult not to take it personally when someone is shouting at you and, subconsciously at least, you probably do feel defensive.
‘But I was able to react calmly, take her to an area where there were no patients and explain to her what the situation was. It worked out very well.’
Ms Surrey is a graduate of Northumbria University’s communications masterclass. Aimed at all health professionals, this course teaches nurses and others how to manage difficult conversations and situations, with the overall goal of improving care for patients and families.
Around 200 people have now benefited from the course, which uses actors and role play to simulate situations in which healthcare staff often find themselves.
Some, like Ms Surrey, were keen to learn how to manage situations in which a patient or relative has become angry or abusive. But the course tackles other challenging issues too, such as how to have conversations about end of life care, how to talk about devastating diagnoses and even how to tell someone that their procedure has been cancelled.
Gillian Walton (pictured), director of programmes in Northumbria University’s department of public health and wellbeing, developed the course in response to requests from hospitals and hospices around north east England.
Carefully briefed actors are used to play the role of patients or relatives, allowing healthcare professionals to try out the best ways to deal with situations they might come across in their working lives. These role-playing sessions are recorded so that participants can see themselves in action, and learn what they have done well and where they could improve.
‘Having effective communication skills is important for nurses, and every healthcare professional,’ says Ms Walton. ‘In fact, I believe communication is one of the most important elements of healthcare, but it’s something we don’t do very well.
‘As patients have higher expectations, getting communication right is going to become even more important.’
Ms Walton also leads a module on managing difficult situations in Northumbria University’s CPD framework, and has been trained as a recognised national advanced communication facilitator by the Department of Health. She says that sometimes staff avoid difficult conversations because they do not know how to handle them – ‘it’s not that they don’t care’.
She believes empathy is the basis of care and communication. By putting yourself in the other person’s shoes, you can look behind their behaviour and de-escalate a potentially difficult situation.
Nurses are, of course, perpetually busy, but Ms Walton points out that getting communications right can save time, as well as improve the work environment and patient experience. ‘If you pick up on the patient’s cues and follow their agenda, it can cut the time you might have spent talking about something they weren’t ready to discuss,’ she says.
It is important to tailor communication to the individual. For example, end of life care might come up in any setting, but particularly in a hospice. Asking open questions and waiting until the patient is ready is crucial. ‘You might say things like “have you thought about what’s going to happen?” or “you know that it’s not going to get better – have you thought about that?”’
Ideally the setting for conversations should be somewhere quiet that you won’t be interrupted.
Have accurate information to hand. Be honest: if you don’t know the answer to something, say so, say you’ll find out, then do so.
Recap and paraphrase to make sure you have understood and ask patients to reflect back so that you know they have understood what you’ve been saying.
Avoid using jargon.
Look behind people’s behaviour: patients and relatives can naturally be feeling anxious and angry. It’s not personal, so don’t get defensive.
Use empathy: it’s frustrating to patients to have an operation cancelled at the last minute; recognise that and say how sorry you are.
Drop a ‘warning shot’ to give patients time to prepare for bad news. For example, you could say ‘you know you’ve been having some tests, well we have the results and it’s not good news’.
Don’t assume that a patient will want to know everything – or nothing – about their condition or prognosis at once. Ask open questions to find out how much they want to know, and make sure they know your door is open if they want to get more information.
Delivering and discussing diagnoses can also make for difficult conversations. ‘You have to give information, but you don’t have to give it all at once,’ says Ms Walton. ‘People can be bamboozled with information overload. You also have to give people time to digest information.’
Ms Surrey, a ward sister at Queen Elizabeth Hospital in Gateshead wanted to take the course as part of her educational development and was open to what she might learn. ‘Communication is an important part of my job – I’m talking to patients, relatives, matrons, bed managers, doctors on busy ward rounds. We have the usual challenging situations, and I felt the course really helped me to deal with them.
‘In particular, it helped me to step outside situations. Something that has really stuck with me is not to take things personally. When someone is aggressive towards you, possibly because they are worried about their relative, or because of something you’ve just told them, it’s hard not to become defensive. The course has helped me to think about the reason behind someone’s behaviour and react more calmly to situations that can be emotionally charged.’
Having done a degree in cancer nursing, Ms Surrey already felt confident in handling difficult conversations in end of life care and delivering bad news, but nevertheless found the class invaluable. She has recommended it to other members of the team on her ward, which combines inpatient beds for medical patients, including rheumatology, haematology and diabetes, with an investigations unit carrying out elective diagnostics and other procedures.
‘We’ve got the usual pressures – not enough time to spend with families, trying to move boarded patients out to get our electives in,’ she says.
‘Many complaints that arise are around communications – I think it’s important for all of us to think about how we communicate.
‘I do feel good communication skills are one of the most important ways to get better patient care’.