Dealing with challenging patients
Communication Skills
Demanding and unreasonable patients
(or patients with a high IQ)
Challenges:
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Lack of experience
Emotional patients
Intimidating patients
Lack of background to
patients’ demands
• Money
• Resources
• Conflicting messages from
other healthcare
professionals
What to do:
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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
Patients with dementia or psychosis
Challenges:
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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:
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•
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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
Patients with multiple or
complex problems
Challenges:
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Time limitations
Spotting the red flag
Satisfying the patient
Lack of experience
What to do:
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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
Relatives of patients
Challenges:
What to do:
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Different agendas
Multiple people present
Family feuds
Emotional state
Unrealistic expectations
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:
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No transference / countertransference
Don’t break patient confidentiality
Don’t make unrealistic promises
Don’t take sides
Patients with personality disorders
Challenges:
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Communication issues
Consent / capacity
Unpredictable
Staff safety
What to do:
• Stay very calm
• Involve Psychiatry
What not to do:
• Don’t confront patient
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
Manipulative patients
Challenges:
What to do:
• Make team members
aware
• They say the right
things to get what they • Involve other
want
healthcare professionals
• They have knowledge of • Negotiate
the system
What not to do:
• Don’t confront them
• Don’t pander
Suicidal patients
Challenges:
What to do:
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Defensive medicine
Risk
Sustaining empathy
Prejudice
Establishing trust
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:
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•
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Don’t give tips
Don’t dismiss concerns
Don’t be judgmental
Care with prescribing
DNAR (Do Not Attempt Resuscitation)
patients
Challenges:
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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
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
Child patients / patients with low IQ
What to do:
What not to do:
• Non-verbal
communication
• Charts, pictures, toys
• Examples, e.g. on teddy
• Use mother / carer
• Don’t patronise
• Don’t speak really
slowly
• Don’t use complicated
language / jargon
Patients who speak a different language
What to do:
What not to do:
• Use qualified interpreters
• Ask patient to summarise
• Non-verbal
communication
• Don’t use children to
translate
• Don’t speak only to
interpreter
• Don’t use too many
closed questions
Patients who have difficulties in
expression (e.g. dysphasia, deafness)
What to do:
What not to do:
• Check understanding
• Non-verbal
communication, e.g.
blinking, writing
• Collateral history
• Don’t rush
• Don’t presume the
patient is dumb
Patients with communication barriers
Challenges:
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Misunderstandings
Frustration
Harder to build rapport
Time – takes longer
Interpreters (dilution of
communication,
confidentiality)
• Cultural issues
FY2 communication:
Useful tools from the field of
Psychology
Dr Julie Highfield
Clinical Psychologist
Cardiac Rehab and Renal Services- UHCW
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.
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?
Self-regulatory model of illness behaviour (Leventhal)
Thoughts about health
threat:
What is it?
Cause?
Consequences
How long for?
Cure/ control
Stage 1: The patient
interprets
their illness
Emotional response
to health threat:
-Anger
-Anxiety
-Depression
Stage 2:coping
Style:
Approach
Avoidance
Stage 3:
Appraisal
Was my
coping strategy
effective?
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
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 by
others)
 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 and
abandonment)
 it is another punishment (PAST experiences of abuse)
Non compliance can also be a way of self-destructing, arising from hopelessness
Motivational Interviewing
Miller and Rollnick
Motivational 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 persuasion
NOT advice giving
BUT:
1) Open-ended questions
2) Affirmations
3) Reflective listening
4) Summaries.
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
Stages of Change
Prochaska and DiClemente (originally 1982) produced a
model of behaviour change that is used within Motivational Interviewing.
Not linear, but dynamic:
1.
2.
3.
4.
5.
Pre-contemplation: not intending to make changes
Contemplation: considering a change
Preparation: making small changes
Action: engaging in a new behaviour
Maintenance: sustaining the change over time
Thus different approaches by HCPs to patients needed
according 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
Transtheoretical Model of Change
(Prochaska & DiClemente, 1983)
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”
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
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
Considering patient interactions
•
Their effect upon us and how we affect
them!
1. Transactional analysis
2. Reciprocal Roles (CAT)
3. Transference
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. ADULT
3. 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
TA: ward example
Patient:
“There really
is nothing to
worry
about!”
parent
adult
child
“Could you explain
the procedure
again? (I’m
frightened)”
Professional:
parent
adult
child
The patient asks an adult question, but is dismissed. The patient may then act
“childishly” as a result
TA: ward example (part 2)
Patient:
Professional:
parent
adult
child
parent
“Could you explain
the procedure
again? (I’m
frightened)”
“Certainly…”
adult
child
The patient asks an adult question, and is treated like an adult. The
interaction continues in an adult-adult manor”
Drama Triangle- part of Transactional
Analysis
If we go above and
beyond the call of duty
with patients, we may fall
into rescuer role.
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”
Transference and Countertransference
• 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.
Reciprocal Roles (CAT)
patient:
Team:
non compliant
sabotage treatment
demanding
“rubbish” treatment
Frustrated
Irritated
Rejecting
Cynical
Critical of each other
High self efficacy
Internal locus of control
Empowered
Able to make choices
Helpless
Needy
Stringently compliant
Informing
Non persecutory
Clear boundaries and contract with patients
Helpful but not controlling
Containing
Heroic
Over-involved
Break boundaries
Help too much
Foster dependence
The way in which we respond affects the patient, and the patient’s response affects
us. (from Ryle)