Preparing for and managing difficult conversations in healthcare   

Ms Maria Campbell outlines the importance of effective communication   

Doctors have difficult conversations every day. Whether you are discussing a serious diagnosis, addressing sensitive topics or communicating with other healthcare professionals, difficult conversations require doctors to have the required clinical expertise, but they also need to demonstrate empathy, transparency, and compassion.

Effective communication in these situations can be difficult. The complex and unpredictable nature of the healthcare setting, together with workload and workforce demands, diverse cultures, different languages, and more engaged and informed patients can create some challenging communication issues. Where clear and open lines of communication can be established, misunderstandings can often be avoided. Where expectations can be managed, patients are more likely to be satisfied with the care they are provided.

In Medisec, we regularly receive queries from doctors dealing with patients who are angry or upset for a variety of reasons. Effective communication plays a significant role in reaching a satisfactory outcome for patients and doctors alike. This article addresses the importance of effective communication, identifies issues that can contribute to difficult situations arising and provides some key strategies for doctors to develop their communication skills, allowing for better relationships with patients and improved outcomes for all involved.

Why are communication skills so important?

1. Ethical obligations

Doctors have an ethical obligation to communicate clearly with their patients, as outlined in the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (Ninth edition, 2024). Clear guidelines regarding communicating with patients are set out in paragraph 1.1 which states:

“Good communication is central to the doctor-patient relationship and essential to the effective functioning of healthcare teams. Good communication involves listening to patients and colleagues, as well as giving information, explanations or advice. When communicating with patients, you should:

Identify yourself by name and role before you start any consultation, investigation or treatment.

Be honest and give relevant information. You should welcome questions from patients and respond to them in an open, honest, and comprehensive way.”

Clear communication, therefore, is one of the cornerstones of good medical practice and patient safety, and doctors should be mindful of ensuring effective communication in all interactions with patients, their support networks and other healthcare professionals.

2. Patient satisfaction

The nature of work in a healthcare setting means frequent engagement with patients and their families, often in emotionally challenging circumstances. Patients want to feel heard and valued in the process. Adopting a patient-centred approach that considers a patient’s individual situation and demonstrating a willingness to help can go a long way towards achieving a positive outcome. Utilising good communication skills that allow patients to feel that they are working collaboratively with doctors and taking an active role in relation to their own healthcare can also help avoid complaints arising.

3. Preventing complaints and claims

Poor communication is well recognised as a key contributing factor to patient complaints and litigation. In Medisec, we frequently see complaints arising from poor communication with patients. Communication issues also account for the largest category of complaints to the Medical Council. This category of complaints is also on the rise, with an increase from 85 communication related complaints in 2021 to 112 communication related complaints in 2023.

4. Dealing with aggression

Developing good communication techniques is particularly important when dealing with situations, which have the potential to result in aggressive behaviour.

Unfortunately, conflict and aggression in healthcare settings are all too common. Aggressive situations usually start as a minor disagreement that escalate if not managed sensitively and appropriately. Good communication is key to preventing escalation and doctors and their staff must be provided with tools to know how to handle tense and potentially aggressive/violent situations if they arise. Putting practice policies in place and arranging for staff training to manage such situations is particularly important.

Issues that can make conversations more challenging

It is important that you prepare as best you can ahead of challenging conversations. Having an awareness of the contributing factors which may make a situation more difficult will assist in this preparation. Before the conversation occurs, you should consider the following:

1. Patient issues

Patients may respond negatively to a situation due to their underlying medical condition, worries about existing complaints, substance abuse, medication, or psychological factors. Being aware of these factors ahead of a consultation will help you to put plans in place to structure the conversation.

2. Environmental

Communication issues can arise due to language barriers. Before meeting with a patient where you anticipate the conversation may be challenging, it would be helpful to check if an interpreter is required. Using family or friends to interpret is not recommended. It may also be helpful to consider if a longer than routine appointment is required, and to allocate appropriate time accordingly so that you or the patient do not feel rushed.

3. Practice issues

All staff working within the healthcare setting should be aware of the importance of effective communication with patients and its role in improving the patient experience. Delays are inevitable given the demand on resources. If a patient has been waiting a long time, managing expectations can often prevent a situation from escalating. Regular training for all clinical and non-clinical staff should be implemented to ensure that effective communication is achieved.

Tips and strategies when preparing for
a difficult conversation

When you become aware that a difficult conversation may arise, there are some steps and strategies that can be implemented to help manage the situation.

1. Who will attend? 

The patient may wish to have a family member attend the consultation and this should be facilitated if possible. If appropriate, you might consider asking a colleague to join the conversation for support, particularly if the colleague also has a relationship with the patient. You should seek the consent of the patient to have colleagues attend the meeting.

2. Location

Finding a quiet and comfortable place to have a difficult conversation is important. This kind of conversation should not take place in the waiting room, or anywhere where you may be overheard and may make the patient uncomfortable. Interruptions should be avoided unless strictly necessary, and reception staff should be made aware of this ahead of time.

3. Body language

Encourage the patient to take a seat and, if they do, you should also sit down. This simple step shows that you are taking time to address the issue.

Pace, pitch, and tone are all important when engaging in a difficult conversation. Lower your voice and slow your speech using respectful tones. Body language can be very important in these situations and can help to build a connection with the patient. It is important to keep eye contact (without staring), and to use open body language. Avoid defensive, paternalistic or power type stances, eg, hands on hips, arms crossed etc.

4. Technique

There are many different approaches to managing a difficult conversation. One such method is the four-step CALM model by Armstrong D (2014) aimed at resolving conflict, and which can be used for any challenging situation.

Compose: Adopt a relaxed pose, keep good eye contact with the patient. Use open body language to stay engaged and demonstrate your composure and readiness to respond positively. Remember to focus on the underlying interests, needs, and concerns of the patient. Remember, in most situations you are not being criticised personally.

Attention: Give the patient your undivided attention. Remain focused and avoid any distractions. Avoid interruptions, allow the patient to finish speaking. Remember people are much more likely to listen to what you have to say if they feel they have been listened to in the first instance.

Listen: Use active listening skills so that you understand what the patient is saying. Identify key emotional words such as ‘angry’, ‘disappointed’, ‘hurt’; these emotions may need to be addressed as much as the situation that gave rise to the conflict. Ask clarifying questions, paraphrase, and summarise their points to confirm understanding – for example, “What I’m hearing is…” or “You’re saying that….”

In addition, often using the patient’s name may help to establish a good rapport.

Moving on: Respond positively to what the patient has told you and lay the foundations for moving forward. Where appropriate, apologise and discuss and agree on a way forward if something went wrong, whether there is an explanation, and what can be done to put things right.

Next steps

As the conversation is drawing to a close, you should summarise what was discussed and outline the next steps, including any safety-netting required. Check the patient understands and agrees with the approach. 

After any difficult conversation, we recommend that you discuss and analyse the incident. If several staff members have been involved, it can be cathartic for colleagues to talk freely about the situation. This can also provide an opportunity to discuss the approach taken and any required improvements in responding to similar incidents in the future. 

Summary

Effective communication is a cornerstone of patient care and can be a vital tool in enhancing the patient experience, particularly in a difficult situation. It is important to use communication skills to the best of your ability to ensure that a patient feels acknowledged and understood. This can go a long way in building a better functioning and more pleasant healthcare environment for all involved.

Please do not hesitate to contact Medisec for specific advice relating to challenging situations that may arise in your practice.

References available on request

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