Skills for Working with Challenging Patient Scenarios

Skills for Working with Challenging Patient Scenarios Alissa Perrucci, PhD, MPH Women’s Options Center/6G Biannual NP/PA/CNM Professional Practice Group Conference October 18, 2012

Learning Objectives • Describe a new technique for better “listening” • Articulate a new open-ended question that you can apply in your conversations with patients • List one way to “validate” and one way to “normalize” in conversations with patients Alissa Perrucci, PhD, MPH

At the Women’s Options Center • Decision assessment and counseling • Philosophy of the decision assessment • Decision conflict • Decision ambivalence • The approach and framework is applied across all pregnancy decision-making issues Alissa Perrucci, PhD, MPH

Approach • Listen. • Do not assume! • Self-reflect. Alissa Perrucci, PhD, MPH

Fundamental principle The patient has the answer Alissa Perrucci, PhD, MPH

Listen • Listening means shutting up! • How do we open conversations with our patients? • We announce the result, give a medical explanation of the facts, provide a list of options, and then ask a closed-ended question: “Would you like to proceed with X or with Y?” • What if we… • Announced the result and defined medical terminology • Gave a brief explanation • Checked in with the patient • How are you doing with this information? • What feelings are coming up for you? • Validate the feelings that you see and hear • Let the patient lead Alissa Perrucci, PhD, MPH

Listen • Being open to, curious about, fascinated with, and interested in the patient’s process – but not personally invested in the outcome (the decision) Alissa Perrucci, PhD, MPH

Listen • Asking open-ended questions instead of closed-ended questions • When you get the “wrong” answer to a closed-ended question you find yourself behind the eight ball • Why not start with an open-ended question? Alissa Perrucci, PhD, MPH

Open-ended questions • What thoughts do you have about what you might do? • What was it like for you to make the decision to do X? • What would be good about [choosing option A]? What would not be good? • Let’s go back to the moment when [you first got your diagnosis]. What did you think [feel]? • Revisiting a past decision without appearing judgmental • “How’s it been for you since deciding X?” • “How have you been feeling about proceeding with Y?” • “What was it like for you at that moment when you chose Z?” Alissa Perrucci, PhD, MPH

Do not assume • That you and the patient share the same understanding of medical terminology, feelings or beliefs • Remember to define test results – a “positive” result for some conditions is good and for others is bad • Your pregnancy test result came back positive – that means you are pregnant. • Seek understanding of feelings and beliefs: • I’d feel guilty if I didn’t choose to have the surgery • I’ve always been against abortion • I don’t believe in taking medications Alissa Perrucci, PhD, MPH

Do not assume • That you “know best” • Not assuming means taking a step back from “professional mode.” You do not have The Answer, nor are you obligated to find it for the patient. • “Nurse, what would you do if you were me?” • Normalize the desire to know • Validate the desire for an end to the uncertainty • “You know, a lot of patients have asked me that. It’s okay to wonder what I would do. Probably right now it seems like it would be helpful to know what I would do but it would be momentary relief. You have the answer to what is the best way for you to go. I will be here as your guide.” Alissa Perrucci, PhD, MPH

Do Not Assume • Not assuming means you are free to inquire, investigate, and learn from the patient Alissa Perrucci, PhD, MPH

Self Reflect • What scenarios are hard for me? • What particular decisions do I want patients to make? • What decisions do I think are foolish? Alissa Perrucci, PhD, MPH

Framework • Level 1: Validate and normalize. • Level 2: Seek understanding. • Level 3: Reframe. Alissa Perrucci, PhD, MPH

Validate and normalize • Removing shame, stigma, and judgment • Listening, hearing, and acknowledging • “The patient is unique, but not alone” Alissa Perrucci, PhD, MPH

Validate and Normalize • It’s okay to cry here • I can tell that you’re angry • That’s okay; everyone is scared • You know, lots of people have asked me that question • That’s not a strange question at all; I’m so glad you’ve asked Alissa Perrucci, PhD, MPH

Seek understanding • Witness, hold and survive • There is no solving here Alissa Perrucci, PhD, MPH

seek understanding • Can you say more about that? • What is that like for you? • How do you feel about that? • How’s that been for you? • What’s been going on for you? Alissa Perrucci, PhD, MPH

Seek Understanding • Attend to the exceptional statement • It may be buried within a litany of congruous statements Alissa Perrucci, PhD, MPH

Reframe • She is a good person making a moral decision • As you learn from the patient, you and he discover strengths, resources and wisdom Alissa Perrucci, PhD, MPH

Reframe • Reassure the patient that he is a good person no matter what decision he makes • Let her know that she is not “wrong” or “bad” if she chooses one alternative over the other • Remind the patient that he can change his mind later and that is okay Alissa Perrucci, PhD, MPH

Ways to reframe • You are really brave; I’m proud of you • What you are sharing with me is very intense, and I am honored to be present with you during this experience • I see someone who is trying to take care of his family • What I hear is that you are making this decision because you care about your child’s well-being • You are making changes in your life; it’s hard and there have been set backs, but you are continuing to move forward Alissa Perrucci, PhD, MPH

Thank You Alissa Perrucci Women’s Options Center/Ward 6G perruccia@obgyn.ucsf.edu 415-206-4027 Decision Assessment and Counseling in Abortion Care: Philosophy and Practice (Rowman & Littlefield, 2012) Alissa Perrucci, PhD, MPH

Skills for Working with Challenging Patient Scenarios