How do I effectively communicate with frustrated or distressed patients, and how do I document it in the EMR? What if a patient is name-calling or using belittling language?
By Billy Table, PhD
Who is the Think Tank?
The Think Tank is a multi-disciplinary health communication collective with experience and subject-matter expertise to consult on real world communication issues in practice. Every month, we select submissions from health professional stakeholders and explore their patient-clinician and inter-professional challenges. Through Think Tank questionnaires and discussion deep dives, our collective of scholars and health professionals offer practical recommendations, share educational materials, and craft messages that stakeholders can implement in practice immediately.
Think Tank Co-Directors Dr. David Ring and Dr. Billy Table understand that in order to fully view all angles of health issues, scholars and practitioners must bring their knowledge of research and lived experience in healthcare practice to the table. Dr. Ring and Dr. Table provide communication expertise to our colleagues in health care to infuse the Dell Med vision of creating a vital and inclusive health ecosystem. Bringing innovative ideas to practice at an accelerated pace, the Think Tank aims to unpack complex conversations and distill effective and structurally competent applications of “what you could say” and “what you could do.”
Addressing and Documenting Patient Frustration
This month, we tackled the topic of addressing and documenting patient frustration and distress. The following post captures the recommendations that the Think Tank shared via questionnaires and our in-person deep dive discussion.
The stakeholders, two colleagues from social work, asked for strategies to communicate with patients and document behaviors in the following scenarios:
“A) A patient who is frustrated with a current situation, such as employment, anger towards a partner, or even towards the medical system. This patient could be someone who raises their voice and is angry, but not directly at you. We usually sit with them and process their anger. I usually document this by saying something like "Patient expressed frustration with..."
B) A patient who is frustrated with a current situation and is also directing this anger towards you by belittling you, questioning your expertise, name calling, and is verbally abusive. Documentation may look more like, "patient expressed frustration towards SW..." Although I don't think this accurately portrays the extent of the patient's actions and I also want to keep in mind the "strengths-based lens." …along with the fact that this documentation will go into the patient’s record.”
Documentation is an important part of everyday clinical practice, and these stakeholders were interested to learn from the Think Tank’s shared knowledge about how to navigate and memorialize this kind of patient behavior. To provide further context, the stakeholder provided these three major motivations for strategically documenting patients’ behaviors:
- Accurate and detailed notes in the record can help in understanding patients better so we can adapt our approach to provide better care when serving them.
- Notes in the record can help the writer and readers notice patients’ patterns and behaviors, which may be medically significant.
- Notes in the record about the interaction can provide protection for the writer, in case patient makes a formal complaint.
The Think Tank offers strategies for documenting patient behavior in a way that both prepares other healthcare providers (and protects them from future risks), and would be acceptable for a patient to read in an open notes context.
We suggest using third-person descriptions that include clear actions of the patient, e. g. “The patient raised their voice and pounded on the table.” This way, the healthcare provider documents the behavior as accurately as possible. Our stakeholders from social work highlight that their training teaches them to manage their own emotions and to meet patients where they are, and therefore, they
write patient notes in third-person rather than first-person, and avoid mention of their own feelings in the documentation. They added that EMR records are subject to being subpoenaed, thus notes must as clear and factual as possible.
When asked what words they would use to describe Scenario B in the EMR, many Think Tank members agree this behavior could be bullying, and offer more descriptions one could use in describing the behavior in the EMR: verbally abusing, raising voice, ranting, confrontational, aggressive.
Debriefing a difficult interaction before documentation is key. Debriefing or discussing the interaction with your care team can help you document factually and clearly. Our colleague from social work shares that, “Debriefing before documenting helps one process the emotional lift it took to stay regulated when a patient was not. It helps get to the facts versus the feelings, which is what should go in the record.” Through debriefing before documenting, one can discover what they might have missed, and explore what they can do differently in the future.
When communicating with patients who are upset or antagonistic, the Think Tank highlights many tips found in two existing tools: Conflict Aikido and The 10 Domains of De-escalation. Our stakeholders agree that de-escalation strategies are important skills for all providers to have and should be in every healthcare professional’s communication toolkit.
Conflict Aikido involves reflecting back the patient’s point of view, agreeing with some essence of it, and redirecting the conversation by letting them know your intent is to help, and that they need to stop or change their behavior so you can accomplish your goals of the visit together.
Think Tank members agree that their response in the situation would depend on how hostile the patient seemed and how concerned they felt. Our colleague from social work asked: “What can we do to put some space (emotional and physical) between a dysregulated or frustrated patient and the healthcare provider?” There should be clear boundaries and procedures for what behavior they will or will not accept, and what to do and say when boundaries are crossed. The 10 Domains of De-escalation outline verbal and non-verbal strategies for setting boundaries with upset or antagonistic patients:
- Respect personal space
- Do not be provocative
- Establish verbal contact
- Be concise
- Identify wants and feelings
- Listen closely to what the patient is saying
- Agree or agree to disagree
- Set clear boundaries
- Offer choices and optimism
- Debrief the patient and staff
In addition to Conflict Aikido strategies, these domains recommend being concise and clear about limits. A Think Tank member suggests that clinicians can offer choices of speaking with another colleague if available. They could say, for example: “I can see that you are angry with [my whatever they said about the problem]. Would you like to speak with [name a colleague I have set up as a trusting partner] instead? (Alternatively, perhaps you would find it helpful to speak with someone else). Let me call them/go and get them to meet with you.”