How NPs Can Tackle Difficult Conversations with Patients and Families

Last Updated/Verified: Oct 8, 2020

Being a nurse practitioner is so much more than just assessing, diagnosing, and treating patients. Providers are also regularly responsible for breaking bad news, calming frustrated patients, and explaining the complicated world of treatment plans based on accessibility and insurance requirements. This is a daunting task to add to the already demanding world of medicine. So, what are some approaches that can help lighten this burden? Understanding the source of the problem and creating a game plan to ease the situation is key.

The Root of the Problem

Difficult patient and family interactions come in a variety of shapes and sizes, and they go beyond bearing bad news or discussing potentially ominous test results. Challenging interactions most frequently stem from discrepancies in expectations, perceptions, and communication. Common real-life challenging interactions include:

  • Patients feeling left out of treatment decisions
  • Patients not feeling heard or listened to
  • No concrete answers or diagnosis after a workup
  • Treatment non-compliance
  • Expensive treatment options
  • Delivering bad news

Challenging patient interactions are a multifaceted experience, and these situations aren't only about the provider and patient. In reality, they include a variety of internal and external considerations. Factors that can affect the difficult interactions include:

  1. Environment: The office, clinic, or hospital may not always be able to accomodate the ideal privacy and comfort setting for these discussions.
  2. Audience: The environment where the interaction occurs may have a larger or smaller audience than the patient would like. Patients may or may not want family present, and additional staff members can occasionally be present as part of their daily role.
  3. Empathy: Long working hours, an increased workload, and the frequency of certain interactions may invoke an unintentional lack of empathy from the healthcare provider.
  4. Resources: A lack of staffing, specialists, and diagnostic testing can lead to long wait times, drawn-out workups, and delays of treatment.
  5. Nonverbal communication: Nonverbal communication is equally as important as verbal communication. However, this form of communication is open for interpretation and can lead to incorrect perceptions.
  6. Ambiguous/complicated plans: Treatment plans are not a one-size-fits-all strategy. Sometimes, a full treatment plan cannot be created as it depends on diagnostic results or responses to first-line treatment. These incomplete plans can cause anxiety in patients and families as they do not know what to expect. Overly complex treatment plans can also be overwhelming and confusing to patients and families, potentially encouraging noncompliance.

While the primary goal of a difficult interaction is to create a positive outcome for the provider and patient, that's not always the case. Potential worst-case scenarios include:

  • Consulting "Dr. Google"
  • Frustrations that lead to threats of legal action
  • Failure to accept the diagnosis
  • Lack of trust related to no diagnosis, despite having signs and symptoms
  • Noncompliance
  • Negative focus on continuing symptoms, as opposed to recognizing progress

RELATED: Nurse Practitioner Practice Authority

Managing Difficult Patient Interactions

Nurse practitioners experience difficult interactions on a regular basis. Unlike the doctors and nurses on television, healthcare providers cannot rely on a writing team to deliver an eloquent, jaw-dropping speech to patients and families. So, what's the best way to manage these situations? Should we just accept that they are bound to occur and we have no control over them? Absolutely not. Managing these situations might take a lot of work on our part, but it will ultimately make our daily practice less stressful. Here are some ways to prevent and control a potentially difficult interaction:

  1. Plan your interaction with the patient or family.
  2. Consult a colleague or seek additional training before the interaction.
  3. Create a comfortable environment by introducing all present parties, sitting with the patient, and maintaining eye contact.
  4. Pay attention to your nonverbal communication, as well as the patient and their family.
  5. Ensure everyone's safety and maintain situational control.
  6. Use empathy and active listening to encourage a patient's emotional control.
  7. Provide multiple options to focus on solutions and resolve areas of disagreement.
  8. Avoid using language such as:
    1. "I'm afraid I have bad news."
    2. "This is a terminal disease."
    3. "You are lucky it is only _________."
    4. "There is nothing left for us to do."

After a difficult interaction, it is important to reflect upon the situation – whether it went well or not. If it was a positive discussion, it's helpful to take note of the particular approach and utilize it for future interactions. If the encounter with the patient and family did not go as planned, it's critical to note what didn't go well and develop new approaches for future patient conversations.

Difficult patient interactions will inevitably occur in a nurse practitioner's career. However, it is the NP's responsibility to serve as a trusted resource in their patient's care. Understanding which factors create difficult interactions and customizing the appropriate approach to the patient's needs can help develop a dynamic that fosters the best possible health outcomes.

Andrea Mosher, CPNP