Dealing with challenging patients Communication Skills.
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Transcript of Dealing with challenging patients Communication Skills.
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Dealing with challenging patients
Communication Skills
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Demanding and unreasonable patients (or patients with a high IQ)
Challenges:
• Lack of experience• Emotional patients• Intimidating patients• Lack of background to
patients’ demands• Money• Resources• Conflicting messages from
other healthcare professionals
What to do:• Nothing• Document everything• Senior support, second opinion• Access ‘ICE’• Avoid ‘maybes’• Explain why for and not for• Avoid personalising conversation
What not to do:• Don’t give in to unreasonable
demands• Don’t argue• Don’t lie, or blag it• Don’t offer temporary measures• Don’t put yourself in danger
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Patients with dementia or psychosis
Challenges:
• Lack of experience• Lack of insight• Aggression – paranoid• Multiple medical problems• Reliance of history from
relatives• Lots of social problems, inc.
alcohol and drugs• Medico-legal issues
What to do:• Safe environment• Chaperone• Low stimulus environment• Excellent communication
skills and patience• Non-judgemental
What not to do:• Don’t ignore physical health• Don’t rush the consultation
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Patients with multiple or complex problems
Challenges:
• Time limitations• Spotting the red
flag• Satisfying the
patient• Lack of experience
What to do:• Give wiggle-room• Reassure• Clinical judgment• Prioritise• Bring back• Safety net• Documentation• Double appointments
What not to do:• Do not ignore / disregard• Do not get frustrated• Do not argue
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Relatives of patients
Challenges:
• Different agendas• Multiple people
present• Family feuds• Emotional state• Unrealistic
expectations
What to do:• Preparation• Ask the patient what they want• Try to identify a point to contact• Suggest a formal appointment• Document conversations• Keep them informed• Nurse present• Keep patient main focus of care• Be honest and realistic
What not to do:• No transference / counter-transference• Don’t break patient confidentiality• Don’t make unrealistic promises• Don’t take sides
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Patients with personality disorders
Challenges:
• Communication issues• Consent / capacity• Unpredictable• Staff safety
What to do:• Stay very calm• Involve Psychiatry
What not to do:• Don’t confront patient
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Prejudiced patients
Challenges:
• Might not agree with treatment
• May compromise their care
• May think they know better
What to do:• Educate them• Time to think• Offer alternative care• Remain unbiased
What not to do:• React to prejudices• Take it personally
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Manipulative patients
Challenges:
• They say the right things to get what they want
• They have knowledge of the system
What to do:• Make team members
aware• Involve other
healthcare professionals• Negotiate
What not to do:• Don’t confront them• Don’t pander
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Suicidal patients
Challenges:
• Defensive medicine• Risk• Sustaining empathy• Prejudice• Establishing trust
What to do:• D/w another medical professional• Risk assessment scoring• Advice from Crisis team• Check previous notes• Ask about protective factors• Let them talk• Good documentation• Keep an open mind
What not to do:• Don’t give tips• Don’t dismiss concerns• Don’t be judgmental• Care with prescribing
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DNAR (Do Not Attempt Resuscitation) patients
Challenges:
• Patient / family refusal• Conflicting opinions in the team• Patient not fully aware of illness• Respect• Experience & information• Emotional / upsetting• Fear of being misunderstood /
passive• Balance between Guidelines
and Policies and Ethics
What to do:• Discuss with seniors, MDU/MPS,
seniors, family, patient• Have a go• Ensure private setting /
chaperone• Document properly, explain
clearly, facilitate audit• Take your time, express empathy
What not to do:• Don’t make decision alone• Don’t act in public• Don’t be lax with documentation
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Aggressive (especially drunk) patients
Challenges:
• Low inhibitions• Low levels of
consciousness• Difficult to treat /
refusals
What to do:• Protocol
What not to do:• Don’t rise to the bait• Don’t miss potential
injuries• Don’t judge them
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Child patients / patients with low IQ
What to do:
• Non-verbal communication
• Charts, pictures, toys• Examples, e.g. on teddy• Use mother / carer
What not to do:
• Don’t patronise• Don’t speak really
slowly• Don’t use complicated
language / jargon
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Patients who speak a different language
What to do:
• Use qualified interpreters• Ask patient to summarise• Non-verbal
communication
What not to do:
• Don’t use children to translate
• Don’t speak only to interpreter
• Don’t use too many closed questions
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Patients who have difficulties in expression (e.g. dysphasia, deafness)
What to do:
• Check understanding• Non-verbal
communication, e.g. blinking, writing
• Collateral history
What not to do:
• Don’t rush• Don’t presume the
patient is dumb
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Patients with communication barriers
Challenges:
• Misunderstandings• Frustration• Harder to build rapport• Time – takes longer• Interpreters (dilution of
communication, confidentiality)
• Cultural issues
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FY2 communication:Useful tools from the field of
Psychology
Dr Julie HighfieldClinical Psychologist
Cardiac Rehab and Renal Services- UHCW
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Areas covered
The following are some ideas from the field of clinical psychology which may help you when considering why some interactions with clients can be difficult. It is not intended as an exhaustive list.
The kinds of things covered are:Some thoughts on why patients may struggle to adhere to your advice. This
includes thinking about how patient represent illness (from Leventhal), and from psychodynamic ideas, and motivation for change (with ideas from motivational interviewing).
Some thoughts on the way in which a patient may act and how this shapes our behaviour and then their behaviour in turn- drawing from Transactional analysis, reciprocal roles (CAT), and transference.
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To help you think about adherence• Self-efficacy: Does the patient believe in her ability to
carry out the required action? How can you encourage this?
• Locus of control: does the patient believe that his health is his responsibility or down to others? This affects what he would be willing to do for himself, and what he expects of you.
• The representation of illness- Leventhal, next slide• Doctor-patient communication (Transactional analysis,
cognitive analytical perspective- see later)• Is the experience of psychological distress impacting
upon a patient’s ability to self manage? Can you ask for advice from psychology related to you area?
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Self-regulatory model of illness behaviour (Leventhal)
Stage 1: The patient interpretstheir illness
Thoughts about health threat:What is it?Cause?ConsequencesHow long for?Cure/ control
Emotional responseto health threat:- Anger- Anxiety- Depression
Stage 2:copingStyle:ApproachAvoidance
Stage 3: AppraisalWas my coping strategy effective?
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Leventhal (cont)
How the person interprets their illness• Identity “what do I have?”• Cause “why did this happen?”• Timeline “How long will I feel unwell?”• Treatment “What is the treatment?”• Curability “Will I be 100% well again?”
• These beliefs shape illness behaviours
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Patients approach to chronic illness:Ideas from a psychodynamic perspective
The symbolic nature of treatment:
it makes me feel different (PAST negative experiences of feeling different and being treated badly for this)
it controls my life (PAST negative experiences of being controlled byothers)
it stops me from being able to do what I would like to – (PAST experiences of restriction)
it means that I will be viewed as “less” (PAST experiences of rejection andabandonment)
it is another punishment (PAST experiences of abuse)
Non compliance can also be a way of self-destructing, arising from hopelessness
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Motivational InterviewingMiller and RollnickMotivational interviewing is a directive, client-centered counseling style for
eliciting behaviour change by helping clients to explore and resolve ambivalence
The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence
NOT persuasionNOT advice giving
BUT:1) Open-ended questions2) Affirmations3) Reflective listening 4) Summaries.
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Principles of MI• Motivation to change is elicited from the patient, and not
imposed from without. • It is the patient's task, not the doctors, to articulate and resolve
his or her ambivalence. • Direct persuasion is not an effective method for resolving
ambivalence. • The style is generally a quiet and eliciting one. • The doctor is directive in helping the patient to examine and
resolve ambivalence. • Readiness to change is not a patient trait, but a fluctuating
product of interpersonal interaction. • Emphasis on freedom of choice rather than doctor as expert
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Stages of ChangeProchaska and DiClemente (originally 1982) produced amodel of behaviour change that is used within Motivational Interviewing.
Not linear, but dynamic:
1. Pre-contemplation: not intending to make changes2. Contemplation: considering a change3. Preparation: making small changes4. Action: engaging in a new behaviour5. Maintenance: sustaining the change over time
Thus different approaches by HCPs to patients neededaccording to stage.
The stages of change model is useful when considering poor health behaviours (e.g. smoking, drinking alcohol). A person is unlikely to take your advice and “give up” until they are ready to do so
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Transtheoretical Model of Change (Prochaska & DiClemente, 1983)
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Stages of change (2)• At different stages, the individual weighs up the costs and benefits in
different ways.• Eg: smoking
1. Precontemplation: “I am happy to be a smoker” “Stopping smoking will make me anxious”
2. Contemplation: “I’ve been unwell, perhaps I should give up smoking”3. Preparation: “I will cut down on smoking”4. Action: “I have stopped smoking”5. Maintenance: “I have stopped smoking for several months, and I feel
healthier”
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MI style questions that may be of use
• What concerns you about …. ?• What is good about the way things are at the
moment? Not so good?• What would be the worst case scenario if you
didn’t make any changes?• If you were going to set a goal, what would it
be?• Acknowledge challenges, emphasise personal
choice, build confidence based on past success
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Cognitive problems• Memory
– Present information first– Provide specific, not general recommendations– Restrict the information to what the patient can process at the time– Organize the information e.g. by importance, time (what to do first,
second), or type (benefits of treatment, side effects)– Use of oral & written information– Repeat important information: if necessary in a follow-up meeting or
by providing an audio tape
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Considering patient interactions
• Their effect upon us and how we affect them!
1. Transactional analysis2. Reciprocal Roles (CAT)3. Transference
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Transactional Analysis
• Arises from Eric Berne• Interactions between people (transactions)• Within transactions, individuals adopt one of three
ego states:1. PARENT (either critical or nurturing)2. ADULT3. CHILD (either free child or adapted)
On a ward, health care profs can find themselves becoming parental. This can mean our patients end up acting in a child ego-state.
Adaptive interactions are adult-to-adult
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TA: ward example
parent parent
adultadult
child child
“Could you explain the procedure again? (I’m frightened)”
“There really is nothing to worry about!”
Patient: Professional:
The patient asks an adult question, but is dismissed. The patient may then act “childishly” as a result
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TA: ward example (part 2)
parent parent
adultadult
child child
“Could you explain the procedure again? (I’m frightened)”
“Certainly…”
Patient: Professional:
The patient asks an adult question, and is treated like an adult. The interaction continues in an adult-adult manor”
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Drama Triangle- part of TransactionalAnalysis
If we go above and beyond the call of duty with patients, we may fall into rescuer role.
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Drama Triangle
It is useful to be mindful of when you are rescuing.
• Risks of rescuing:– End up becoming the victim through constant
focus upon others, or the rescued may point the finger of blame
– Risk ignoring the choices and self-efficacy of others by making decisions for them
– When rescuers are burnt out they become persecutors- “getting my way”
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Transference and Counter-transference
• This will have been covered in previous teaching, but a reminder…..• In every patient interaction, health care professionals may be perceived as
symbolic care givers• They may respond to us as if we are former/ current people in their lives
(e.g. their mother, father, brother etc).• We may in turn respond to this.• It is helpful to be aware of how this may occur, and to not be drawn in to
reacting in a non-professional manner.
• The following slide on reciprocal roles will help you consider this.• For example, a person may expect that we will do everything for them,
and we may be drawn in by their helplessness. Or a patient may expect that we will let them down, and will be dismissive of our treatment, which may lead us to dismiss them in return.
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Reciprocal Roles (CAT)patient: Team:
non compliantsabotage treatment
demanding“rubbish” treatment
FrustratedIrritated
RejectingCynical
Critical of each other
High self efficacyInternal locus of control
EmpoweredAble to make choices
InformingNon persecutory
Clear boundaries and contract with patients
Helpful but not controllingContaining
HelplessNeedy
Stringently compliant
HeroicOver-involved
Break boundariesHelp too much
Foster dependence
The way in which we respond affects the patient, and the patient’s response affects us. (from Ryle)