Common Factors | Fall 2022

It’s Time to Talk

Empathy training and practice are key to being prepared
for the crucial moments after a harm event.

The man in the video is visibly agitated, expressing anger and frustration about his chronic pain after a surgical incident. The clinic administrator tries repeatedly to reason with him. “You’re not listening!” the man shouts.

Did the administrator manage to turn this increasingly hostile meeting into a productive discussion? In a role-playing video presented during Constellation’s April 2022 webinar, “Communicating After Harm Events: Applying Learnings to Real-Life Scenarios,” the answer was yes, but only because the administrator had training in empathetic communication.

Traci Poore,

Sr. Risk Consultant

Michael Turturici, CPHRM, LSS GB
Risk Consultant

Most clinic administrators, clinicians and care team members, however, haven’t had that sort of training, according to Traci Poore, JD, CPHRM, the senior risk consultant for Constellation who played the administrator in the video exercise. Poore and webinar co-presenter Michael Turturici, also a risk consultant, explain in the webinar that how to have empathetic discussions isn’t usually taught in medical or nursing school, leaving many clinicians ill-prepared to navigate the often emotionally charged aftermath of a harm event. This lack of training can lead to potential misunderstandings, mistrust, negative experiences and, ultimately, possible legal actions.

In an informal poll during the webinar, only 21% of participants said their organizations provide any type of training to help care teams communicate with patients, families and senior living residents after a harm event. Fortunately, Constellation’s risk consultants and our early intervention program, HEAL, can provide resources to help clinicians prepare for these sensitive and challenging conversations.
“Care team members participating in these conversations really need to be coached in a supportive environment,” Turturici says in the webinar.

Using several real-case scenarios, Poore and Turturici define empathetic communication and explore how care teams can not only train but also practice these tough discussions. That’s the best way, they say, to learn the skills required for those crucial moments after an accident or mistake happens in a clinic, hospital or senior care setting.

Defining empathetic communication
After a harm event, patients, senior living residents and families need truthful, accurate and timely information about what happened. And they need to know that the initial conversation is just that: a first step. It’s important for them to understand that the care team will include them in ongoing conversations about future care and about the investigation into the event. Simple steps like exchanging contact information will reassure them they’ll remain in the loop.
“Patients and families need assurances that they are your priority,” Turturici says.

Just as important is a heartfelt apology. “They want to hear we’re sorry for what happened and what they are going through,” Turturici explains, adding that expressing remorse can go a long way toward maintaining trust.

To help shape these difficult initial conversations, Poore and Turturici emphasize keeping the focus on what the patient and family need. They suggest using the following five-step action plan.

  1. Acknowledge: Share the objective facts of what is known about the event at that time, while also acknowledging the emotions surrounding the event. Allow time for and invite questions; it’s okay not to have all the answers, but be sure patients, families and residents know to expect answers as soon as they are known. Avoid speculation and blame, and do not minimize emotions.
  2. Show compassion: Invite and accept the feelings of all parties. Give them your full attention by sitting down, turning off your phone and minimizing other interruptions. Make eye contact and avoid defensive body posture, such as crossed arms or legs.
  3. Focus: Ensure the focus remains on medical care needs, ongoing care and realistic expectations, and again allow time for the patient, resident or family to process and ask questions.
  4. Assure: Set up a next meeting, and provide a contact person that is readily available should the patient, resident or family have additional questions or needs. Explore what nonfinancial support might be needed, and show the patient, resident or family they are high-priority by setting follow-up expectations.
  5. Apologize: Research indicates that patients, residents and families value a sincere and honest apology. A sincere apology does not necessarily mean admitting liability, but rather simply recognizing the adverse impact of the event on the patient, resident or family

Emotions, finances and legalities
An initial conversation may be the first time a patient, resident or family learns about the harm event, and it’s often difficult to predict how they will react. Everyone responds differently to upsetting news, and how they react will depend on their communication style, their knowledge of medicine, their understanding of medical processes and, of course, their emotional state.

Turturici recommends using clear language and avoiding medical terms and jargon. As mentioned in the five-step action plan detailed above, acknowledging emotions such as anger, frustration or fear is paramount so the patient, resident or family feel heard. 

Statements like “I understand how you feel,” “I know what you’re going through,” or “I know how hard this is” can be presumptive and create or escalate anger or other emotions in a patient, resident or family member. Avoid being defensive, as defensiveness may be construed as arguing. Trying to establish who’s right or wrong can also backfire, heating up a discussion already fraught with emotion.

Obviously, emotions can move quickly into negative territory. The clinician leading the discussion can and should set limits as to what is tolerated. The care team should feel safe, with full access to exits and, if needed, security nearby but outside the room. Always include more than one team member in these scenarios; the discussion leader might choose a patient advocate or a nurse to help manage emotions and to help keep track of the conversation. One of the most useful tools is the pause, Turturici says. If the emotions are such that the conversation becomes counterproductive, it’s appropriate to set up a time to regroup and continue the discussion later. During the video mentioned at the beginning of this article, Poore manages to diffuse the patient’s anger by first taking a break, then acknowledging that she’s been taking the wrong approach with the patient.

“I’m a factual communicator,” Poore says. “I like logic. I take the emotion out when I have conversations or if I’m in a difficult kind of scenario. I really had to reroute my style of communication to meet this patient where he was.” 

Poore’s efforts resulted in a fruitful discussion of how the care team could best support the patient, by providing information and referrals for ongoing care to try to resolve his chronic pain. 

But what if a patient, resident or family member demands a lawyer be present? A request for an attorney or a threat to sue often masks underlying feelings of fear, guilt and lack of control. The key is to remain neutral, acknowledge the request and offer a choice along the lines of an example presented in the webinar: “I respect your right to consult an attorney. Would you like to know what our plan is going forward before we involve counsel, or would you like to have this conversation later?” 

Poore suggests reiterating that this communication is not meant to prevent the patient or resident from seeking legal advice, but to disclose information about the event and the plan going forward.

Training, practice and feedback
Following is a basic role-playing exercise (based on two real-case scenarios, with potential responses provided) that was used for training purposes in the April webinar for administrators, clinicians and care teams. In the webinar, Turturici and Poore boil down the elements of the training to three basic components: discuss, practice and give feedback.

Case 1:
A 14-year-old boy is examined in a primary care clinic for a sports physical. The boy’s parents consent to him receiving care alone in the room. During the examination, the boy points out a skin lesion that is bothering him, and the clinician who is examining him removes it. The lesion is sent to pathology, and the results return as cancerous. However, the results are not communicated to the boy or his parents. Six months later, the pathology report is discovered when the boy returns along with his parents to be examined for a sports injury. Upon hearing about the delay in diagnosis, the boy’s parents want to know if this six-month delay will make a difference in his treatment plan and prognosis.

The possible responses:
In this real-case scenario, what would be the best response for the clinician to give?
A. “I recommend we get a specialist involved to better understand the impact and what to do next. Would you be OK with me referring you to a specialist?”
B. “Six months is a very short amount of time considering the skin lesion was present for years. I suspect there will be no difference.”
C. “I did some research and I’m certain there is no difference in the treatment plan or prognosis.”
D. “I don’t know. I recommend you speak with a specialist.”

Case 2:
Patient A is a 56-year-old post-op patient on medication for mild chronic hypertension. Patient B in the next room is being treated with the same medication at a higher dose, as well as some additional medications for other chronic conditions. Unfortunately, Patient A receives all of Patient B’s medications and as a result has altered vital signs requiring extended hospitalization for further observation. Patient A seems calm and accepting of the mistake, but their spouse is angry and crying. The spouse wants the nurse who administered the medications to be fired, and wants a new nurse assigned to ongoing care.

The possible responses:
In this real-case scenario, what would be the best response for the clinician to give?
A. Ignore the spouse, as the patient is your main priority.
B. Assure the spouse that if a different care team is what the patient feels is best, you will accommodate them to the best extent possible.
C. Assure the spouse that the care team is competent, well trained and ready to continue care.
D. Inform the spouse that with current staffing levels, change in staffing would be difficult to accommodate.
E. Inform the spouse that there have been other problems with the administering nurse, and that you will investigate immediately.

The training exercise:
If you would like to try these exercises on your own: Gather a group of five or six care team members and assign them one of the two scenarios above to role-play. Decide who will play what roles, such as patient or family member, administrator, patient advocate or social worker, nurse manager, and doctor or other care team member. Before beginning the exercise, the team should discuss the potential issues and reactions that might arise in a conversation immediately following a harm event, and they should consider appropriate responses based on the five steps of the Communication Action Plan (see page 14).
The best responses: If you choose to try this exercise, find the answers at the bottom of this article.
Repeated practice of these and other role-playing scenarios will help team members become more comfortable having difficult conversations with patients. Just as crucial is being able to give and receive honest and constructive feedback.
“It’s really important to digest what happened in each scenario,” Poore says. “What do you feel like you could do better?”
Being able to discuss how the exercise went, what went well and how team members can improve are key elements in feeling confident when a care team faces a real harm event in the future.

The Early Intervention HEAL Prepare Toolkit
The communication training and instruction used in these role-playing scenarios is available to Constellation customers. Constellation’s early intervention program, HEAL, is an innovative partnership that is leading the way in the medical professional liability (MPL) insurance industry. HEAL helps care teams and organizations prepare for harm events before they happen, ensuring that people and processes are in place for an effective response. We know that unexpected outcomes, mistakes and harm events are inevitable. How we react in the first moments determines whether we preserve trust, communicate, learn and improve.

When harm events occur, HEAL offers a better way forward with transparency, compassion and the goal of early resolution. HEAL enables care teams and organizations to move forward after harm events to heal, learn and improve.

Members of the Constellation team have been formally trained in empathetic communication. To learn more, watch the April 2022 webinar, “Communicating After Harm Events: Applying Learnings to Real-Life Scenarios,” and access HEAL Prepare Toolkit resources by signing in to ConstellationMutual. com > Risk Resources > HEAL Prepare Toolkit > Unit 3: Communicating After Harm Events.

How Constellation Helps Clinics and Their Care Teams
Constellation provides best practice guidance and communication training with roleplaying scenarios, in which clinicians, clinic administrators and care teams can practice empathetically communicating after an unanticipated harm event. This innovative training involves a series of role-playing exercises and includes curveballs reflective of real-life situations. The training provides an interactive, hands-on experience for participants to ensure they’re prepared for harm event conversations.

Case examples: The answers
Below are what Poore and Turturici recommend as the best possible responses to the real-case scenarios detailed in the article, along with key takeaways about each situation.
Case 1: Answer: A. “I recommend we get a specialist involved to better understand the impact and what to do next. Would you be OK with me referring you to a specialist?” In this example, the answer doesn’t speculate about what treatment could have happened during the delay, but it acknowledges that consulting a specialist could be a potential option. It also invites the parents to have a voice in the decision.
Case 2: Answer: B. Assure the spouse that if a different care team is what the patient feels is best, you will accommodate them to the best extent possible.
In this particular case, you should acknowledge the spouse’s feelings and assure the spouse and patient that your priority is maintaining ongoing care. Ultimately, it’s the patient’s decision, and you will support whichever decision the patient and spouse work out together, even if you believe a staffing change isn’t really necessary. Never discuss staffing issues, competencies, training or discipline with a patient, resident or family member.