skills for working with challenging patient scenarios
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Al is sa Perrucc i , PhD, MPHWomen’s Opt ions Center /6G
Biannua l NP/PA/CNM Pro fess iona l Pract ice 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
10/17/2012
LEARNING OBJECTIVES
Alissa Perrucci, PhD, MPH 3
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
10/18/2012
AT THE WOMEN’S OPTIONS CENTER
Alissa Perrucci, PhD, MPH 4
Listen.Do not assume!Self-reflect.
10/17/2012
APPROACH
Alissa Perrucci, PhD, MPH 5
The patient has the answer
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FUNDAMENTAL PRINCIPLE
Alissa Perrucci, PhD, MPH 6
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
10/17/2012
LISTEN
Alissa Perrucci, PhD, MPH 7
Being open to, curious about, fascinated with, and interested in the patient’s process – but not personally invested in the outcome (the decision)
10/17/2012
LISTEN
Alissa Perrucci, PhD, MPH 8
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
Alissa Perrucci, PhD, MPH 9
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?”
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OPEN-ENDED QUESTIONS
Alissa Perrucci, PhD, MPH 10
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
10/17/2012
DO NOT ASSUME
Alissa Perrucci, PhD, MPH 11
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.”
10/17/2012
DO NOT ASSUME
Alissa Perrucci, PhD, MPH 12
Not assuming means you are free to inquire, investigate, and learn from the patient
10/17/2012
DO NOT ASSUME
Alissa Perrucci, PhD, MPH 13
What scenarios are hard for me?What particular decisions do I want patients to make?What decisions do I think are foolish?
10/17/2012
SELF REFLECT
Alissa Perrucci, PhD, MPH 14
Level 1: Validate and normalize.Level 2: Seek understanding.Level 3: Reframe.
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FRAMEWORK
Alissa Perrucci, PhD, MPH 15
Removing shame, stigma, and judgmentListening, hearing, and acknowledging“The patient is unique, but not alone”
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VALIDATE AND NORMALIZE
Alissa Perrucci, PhD, MPH 16
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
Alissa Perrucci, PhD, MPH 17
Witness, hold and surviveThere is no solving here
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SEEK UNDERSTANDING
Alissa Perrucci, PhD, MPH 18
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?
10/17/2012
SEEK UNDERSTANDING
Alissa Perrucci, PhD, MPH 19
Attend to the exceptional statement It may be buried within a litany of congruous statements
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SEEK UNDERSTANDING
Alissa Perrucci, PhD, MPH 20
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
Alissa Perrucci, PhD, MPH 21
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
Alissa Perrucci, PhD, MPH 22
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
10/17/2012
WAYS TO REFRAME
Alissa Perrucci, PhD, MPH 23
Alissa PerrucciWomen’s Options Center/Ward 6G
perruccia@obgyn.ucsf.edu415-206-4027
Decision Assessment and Counseling in Abortion Care: Philosophy and Practice (Rowman & Littlefield, 2012)
10/17/2012
THANK YOU
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