comfort* communication (narrative) orientation and opportunity mindful presence family openings...
TRANSCRIPT
COMFORT*• Communication (narrative) • Orientation and opportunity• Mindful presence• Family• Openings• Relating• Team
* Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford.
Objectives
• Understand the duality of task and relational communication
• Discover foundations of narrative clinical practice
• Learn to practice person-centered messages
Task CommunicationThe content of the message•Teaching - confirm and explain bad news
•Advocating - share information with healthcare team (Price, et al., 2006; Radziewicz & Baile, 2001)
•Coordinating - mobilize needed resources (Pavlish & Ceronsky, 2009)
Relational Communication
The relationship between the people as conveyed by the message
•Caring - provide patient/family support
•Sharing - emotional reactions and providing opportunities to process the bad news (Warnock, et al., 2010)
Narrative Nursing• Being with and relating to others while honoring
their voice & lived experience
Bearing Witness:1. Recognize individuality2. Understand life prior to illness3. Refocus beyond medical information
Kendall, 2007; Hess, 2003
Recognize Individuality
DeconstructionActive listeningUse adjectives to describe patient uniqueness
to others
Your Role: • Listen for vulnerabilities/uniqueness• Identify story structure– Who are the main people involved?
Recognizing Individuality
• “Tell me about times when you aren’t thinking about illness/your loved one’s disease.”
• “How would you describe this illness/the shared experience of illness?”
• “Is there anything else that could explain your/his/her illness?”
• “I’m wondering if there is more to this than meets the eye.”
• “Who else is involved in your/his/her illness?”
Understand Life Prior to Illness
ExternalizationSolicit/employ information– Encourage reflection– Incorporate psychosocial history in diagnostic
assessment
Your Role:Encourage sharing to identify and address feelings• Adopt multiple perspectives– What are the relationships between the people
involved?
Understanding life prior to illness
• “How has your illness (or his/her illness) affected your life and your relationships?”
• “How do you think ignoring this will affect your life?”
• “How does your illness (or his/her illness) reflect on you as a person?”
• “How do you see the future?”
• “How are you affected by others’ opinions?”
• “What do you think influences this experience?”
Go Beyond Medical Facts
Re-authoring Help revise and widen narrative lens beyond illness Solicit history to understand illness Help patient/family understand and accept current
circumstances
Your Role:• Consider the mental health of patient/family member• Creative skills (What solutions can be drawn?)• Tolerate uncertainty as you listen to the story
Going beyond medical facts
• “What people in your life are supporting you?”
• “What do you think needs to happen in order for you to be able to care for your loved one/yourself?”
• “What needs to change?”
• “What does your success in solving problems related to care say about your abilities?”
• “How is this experience affecting your life?”
Person-Centered Messages (PCM)*
• Speaking in a supportive way to validate and affirm patient/family
• Support is conveyed with clear language
– Be realistic, yet supportive– Focus on the patient’s feelings
*Burleson, 1994
Practicing Person-Centered Messages
• Explicitly recognize and acknowledge the patient/family’s feelings but does not elaborate on those feelings.
• Provide an elaborated acknowledgement and explanation of the patient/family’s feelings
• Help the patient/family to gain a perspective on his or her feelings
Person-centered messages
From the following, choose the most person-centered message:
(a) “I can see why you are upset. That’s a normal reaction.”(b) “I’m so sorry this has happened. Did you think this was coming?”(c) “Let’s talk about your treatment from this point forward. Can I see you tomorrow?”
Examining person-centered messages
(a) “I can see why you are upset. That’s a normal reaction.”
(b) “I’m so sorry this has happened. Did you think this was coming?”
(c) “Let’s talk about your treatment from this point forward. Can I see you tomorrow?”
When discussing bad news…
• Clearly explain prognosis, elaborate• Respond to impact on life• Show clear respect for feelings• Integrate life/work into decision-making• Address pain, family role in care• Plan, present team structure,
hospice/Advance directives (if appropriate)
The unique role of the nurse
• Presence before, during, and after bad news• Vulnerable to questions from patient/family– provide supplemental information– assess information needs– clarify misunderstanding– educate
• Your role is to validate bad news to aid in patient/family acceptance.
Challenges for the nurse
• Physician assumptions about your role, knowledge
• Not being present for bad news delivery• Not knowing all of the patient/family
information when confronted• Ambiguity about your role on the team and
appropriate communication topics to discuss
Breaking Bad News Scenarios for the Nurse
• Over the phone“I know this is not ideal, but I can talk to you now over the phone about your health and we can meet together tomorrow to talk more.”
• Nurse not present during bad news disclosure“Since I was not here for the news, can you tell me how the conversation with the team went? [response]. Now, as I listened to you these are the questions I think you still have [relay concerns], is that right?”