Alissa Perrucci, PhD, MPH Women’s Options Center/6G Biannual NP/PA/CNM Professional Practice Group...

Al i ssa Perrucc i , PhD, MPHWomen’s Opt ions Center /6G

Biannua l NP /PA/CNM Profess iona l Pract i ce Group ConferenceOctober 18 , 2012

SKILLS FOR WORKING WITH CHALLENGING PATIENT

SCENARIOS

Alissa Perrucci, PhD, MPH 2

Describe a new technique for better “listening”Articulate a new open-ended question that you can

apply in your conversations with patientsList one way to “validate” and one way to “normalize”

in conversations with patients

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LEARNING OBJECTIVES


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

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AT THE WOMEN’S OPTIONS CENTER


Listen.Do not assume!Self-reflect.

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APPROACH


The patient has the answer

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FUNDAMENTAL PRINCIPLE


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

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LISTEN


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

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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?

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LISTEN


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 fi rst 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?”

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OPEN-ENDED QUESTIONS


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

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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.”

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DO NOT ASSUME


Not assuming means you are free to inquire, investigate, and learn from the patient

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DO NOT ASSUME


What scenarios are hard for me?What particular decisions do I want patients to make?What decisions do I think are foolish?

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SELF REFLECT


Level 1: Validate and normalize.Level 2: Seek understanding.Level 3: Reframe.

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FRAMEWORK


Removing shame, stigma, and judgmentListening, hearing, and acknowledging“The patient is unique, but not alone”

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VALIDATE AND NORMALIZE


It’s okay to cry here I can tell that you’re angryThat’s okay; everyone is scaredYou know, lots of people have asked me that questionThat’s not a strange question at all; I’m so glad

you’ve asked

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VALIDATE AND NORMALIZE


Witness, hold and surviveThere is no solving here

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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?

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SEEK UNDERSTANDING


Attend to the exceptional statement It may be buried within a litany of congruous statements

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SEEK UNDERSTANDING


She is a good person making a moral decisionAs you learn from the patient, you and he discover

strengths, resources and wisdom

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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

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REFRAME


You are really brave; I’m proud of youWhat 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 familyWhat I hear is that you are making this decision

because you care about your child’s well-beingYou are making changes in your life; it’s hard and

there have been set backs, but you are continuing to move forward

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WAYS TO REFRAME


Alissa PerrucciWomen’s Options Center/Ward 6G

[email protected]

Decision Assessment and Counseling in Abortion Care: Philosophy and Practice (Rowman & Littlefield, 2012)

10/17/2012

THANK YOU

Alissa Perrucci, PhD, MPH Women’s Options Center/6G Biannual NP/PA/CNM Professional Practice Group...

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