De-escalating Angry Caregivers: A Novel

Communication Framework and Toolkit for Pediatricians

April 7, 1:15-3:15pAPPD 2017

1

Welcome

• Sarah Hilgenberg, MD• Alyssa Bogetz, MSW• Kevin Chi, MD (PGY3)• Rebecca Blankenburg, MD, MPH

Disclosures

The authors have no financial relationships or conflicts of interest to disclose.

Acknowledgement of study funding:1. Association of Pediatric Program Directors Special Projects

Grant2. Society for Simulation in Healthcare Novice Research Grant

Objectives

• Describe evidence-based fundamental communication skills• Describe a 9-step communication framework for de-

escalating an angry caregiver*• Apply the de-escalation framework to 3 cases• Create an action plan for implementation into practice and/or

teaching• Discuss “train-the-trainer” tips

*Caregiver is defined as a parent, guardian or adult in a similar role

Agenda

Topic TimeIntroduction to De-escalation 1:15-1:35 pmFundamental Communication Skills 1:35-1:459-Step De-escalation Framework 1:45-2:00Practice Cases and Debrief 2:00-2:50Action Plan 2:50-3:05Conclusion and Evaluation 3:05-3:15

Activity 1: Prior De-escalation Experience

Using the worksheet provided:

a) Think-Pair-Sharei. Describe an encounter with an angry caregiverii. Communication successes iii. Communication challenges and/or opportunitiesiv. Share your experiences with a partner at your table

b) Large Group Discussion

15 mins

Fundamental Communication Skills

Activity 2: Fundamental Communication Skills

a) Break into groups of 3-4b) Using the worksheet provided, compile a list of fundamental

communication skills that you employ or would ideally employ in your clinical practice with all caregivers

10 mins

Fundamental communication skills

VERBAL NONVERBALIntroduce yourself, role on team Attend to caregiver’s comfortAsk preferred name, relationship to patient Position yourself on same levelSet expectations if necessary (time, agenda)

Maintain eye contact

Use concise, easily understood language Maintain open postureRemain professional and respectful Listen actively

Minimize distractions (TV, pager, phone)Avoid interruption (*with exceptions)

Cohen 1996, Kurtz SM 2003, Makoul 2001, Novack et al 1986

Framework for De-escalating Angry

Caregivers

9 De-escalation Skills1. Prepare yourself2. Actively elicit and explore the caregiver’s perspective3. Acknowledge and restate the content of the caregiver’s concern,

check accuracy4. Acknowledge stated emotion or inquire about unstated emotion5. Express empathy or understandability of the caregiver’s emotions6. Negotiate a mutually acceptable plan of care7. Provide closure8. Use silence to facilitate the caregiver’s expression of thoughts and

feelings9. Care for yourself

1. Prepare yourself (and environment)

• Put aside other obligations• Focus attention on current issue• Gather most up-to-date information• Assess your own personal issues, values, biases, motives and

assumptions, reactions to stress going into encounter• Is this a trigger for you?• If you don’t know, what will you do if it becomes a trigger?

• Try to create non-judgmental mindset• Invite key members of team

Weeks 2001Leebov and Rotering, 2014

1. Prepare yourself (and environment)

• Privacy• Room configuration, availability• Presence of patient and other occupants

• Language• Time

• Understand your constraints• If relevant, communicate constraints to set expectations

• Number of chairs available• Safe positioning

• Never have your back to any threat• Position yourself between person and door to facilitate quick exit in

event of physical threat

2. Actively elicit and explore the caregiver’s perspective• Approach with curiosity, wonder, without the intention of

changing the caregiver’s perspective or mind• “Could you help me understand what you are going through right

now?”• “What concerns do you have?”• “I wonder if you could help me understand…”• “What other concerns do you have?”

• Ask clarifying open-ended questions/statements if needed• “Tell me more.” “What else can you tell me about that?”

Kurtz et al, 2003, Frankel 1999

3. Acknowledge and restate the content of the caregiver’s concern

• Check accuracy• “What I hear from you is…Did I get that right?”

Breuner 2011Novack et al, 1986

4. Acknowledge stated emotion or inquire about unstated emotion• “I hear you saying that you are frustrated.”• “Can you tell me more about how you are feeling?”

• Consider what emotions or other factors may be underlying and fueling the caregiver’s response

Novack et al, 1986

5. Express empathy or understandability of caregiver’s emotions (when appropriate)

• “I imagine that you were upset about X. I’m disappointed, too.”

• Avoid trying to fix or dispel emotion• You don’t have to agree with someone to express this

• CAUTION:• “I understand…” • “I’m sorry.” (consider “I wish”)• Reassurance

Brody 2009, Novacket al 1986, Quill 2001

5. Express empathy…and when NOT to

• Caregiver has lost control, cannot listen, threatens your safety• Take a step back, create breathing room, excuse yourself• React mindfully, framing response in outcome you desire• “It’s hard for me to really hear you when you use that language. It

prevents me from supporting you the way that I want to.”

• Describe conditions in which you will engage• “I am willing to continue this conversation as long as you exhibit the

same respect towards me as I am giving you.”• If disruption continues, “I will have to call security if you continue to

disrupt our ability to deliver safe care.”

• Develop plan to return, follow through

Breuner 2011DocCom

6. Negotiate a mutually acceptable plan of care

• Discuss the plan• Actively seek the caregiver’s perspective about the plan• Check for caregiver’s acceptance

• “How does that sound?”• “Does that sound reasonable?”• “What do you think about this plan?”

• Consider support colleague involvement

Kurtz et al, 2003

6. How to end a conversation when you haven’t negotiated a mutual plan

- Acknowledge the emotion- “I know this has been a difficult conversation. It’s really important

to me to try to find a way to move forward in the care of your child.”

- “It’s been my experience that when there is this much emotion, it’s difficult to problem solve and move forward. So I am going to step out and come back. It’s my sincere hope that we can figure out a solution.”

- Return- Acknowledge any contribution you may have played- Try to start over

7. Provide closure• Use open-ended questions to inquire about concerns or other

issues • “Is there anything else?” versus• “What else can I help you with?”

• Summarize or ask the caregiver to summarize plans• Clarify follow-up if needed• Acknowledge the caregiver• Close interview

• “Thank you for letting me know. I am glad that you brought that to my attention.”

• “I appreciate your time. I will return.”Makoul, 2001Novack, 1992

7. Provide closure: common ground with an angry caregiver

• “Let’s get back to how we can best take care of your child.”• “We both want the best for ____ .”

8. Use silence to facilitate caregiver’s expression of thoughts and feelings

• Allow time and space• Try not to interrupt

9. Care for yourself

• Self-care• Eat well, exercise, etc.

• Maintain self-awareness• Be aware of your own emotions• Recognize every experience as an opportunity to learn• Recognize the value of your own experiential knowledge

• Reflect• Think critically about how situation unfolded, what might have gone

better

• Seek feedback• Seek mentorship

Stewart 2003, Novack1997, Breuner 2011

ACTIVITY 3: Framework Application to Cases and Small Group Discussion

• 3 scenarios• 3 roles

• Physician• Caregiver• Observer

• 12 minutes to practice and discuss each scenario

36 minutes

9 De-escalation Skills1. Prepare yourself2. Actively explore and elicit the caregiver’s perspective3. Acknowledge and restate the content of the caregiver’s concern,

check accuracy4. Acknowledge and restate or name the expressed emotion5. Express empathy or understandability of the caregiver’s emotions6. Negotiate a mutually acceptable plan of care7. Provide closure8. Use silence to facilitate caregiver’s expression of thoughts and

feelings9. Care for yourself

ACTIVITY 3: Framework Application Large Group Discussion

a) Overall experience

b) Lessons learned

20 minutes

Curriculum Study

StandardizedPatientExercise

Intervention Control

Retro-Pre-Post-Self-Assessment

SPEvaluation

SPEvaluationStandardizedPatientExercise

Debrief Debrief

• Randomized controlled trial (RCT)

• 84 residents (PGY1-5)• 43 intervention, 41

control

• 6 half days Aug-Sept 2016

SP= standardized patient actors

Main Outcomes and Curriculum Evaluation• RCT results

• SP-rated pre- vs. post-test means increased significantly for intervention PGY1s in overall performance (p=.01) and de-escalation skills (p=.03)

• Self-assessed de-escalation skill means increased for all intervention residents (PGY 1 p=.001, PGY2 p=.03, PGY3+ p=.02)

• Curriculum survey results• 95% (41/43) intervention residents “will apply the skills learned in my

clinical practice” vs 78% (33/41) controls• 93% (40/43) reported that their “ability to de-escalate angry caregivers

will improve as a result of participating” vs 78% (32/41) controls

ACTIVITY 4: Action Plan

Using the handout provided, complete an action plan for personal implementation of the framework and associated communication skills and/or teaching of this framework and skills to trainees.

a) Write 1-2 SMART goals for implementationb) Anticipate barriersc) Brainstorm solutions to barriers

7 minutes

Helpful Resources

• Philosophy, handbook, policies, procedures• Training program• Hospital • Social work, psychology, psychiatry• How to call a code to get security• “Contract”/Collaborative Partnership Guidelines

• University (if applicable)• Physician, non-physician wellness programs

• DocCom• http://webcampus.drexelmed.edu/doccom/user/

Take Home Points

• De-escalating an angry caregiver is hard• Not every encounter will go well• Some caregivers will leave angry• You have permission to leave especially if you feel mistreated• Try to engage the caregiver as a human being • Remain authentic to yourself while trying to adapt to

caregiver’s needs• Be sincere• Follow through on your word

Mathieson 2012

Questions?Please take 1-2 minutes to complete the

workshop evaluation at your table.

Add your email to the sign-in sheet for more materials.

Thank You!And special thanks to:

My co-investigators:

Alyssa BogetzBecky BlankenburgDavid Gaba

Immersive Learning Center:

Valerie WeakDrew NevinsLexi BuchananKaren Thomson-Hall

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