Clinicians’ strategies for managing their emotions during difficult healthcare conversations

https://doi.org/10.1016/j.pec.2016.06.017Get rights and content

Highlights

  • Clinicians report various strategies to manage emotions in difficult conversations.

  • Five categories of strategies were identified.

  • Self-care strategies were the most commonly reported.

  • Strategies extend to periods before, during, and after difficult conversations.

  • Existing strategies may help to inform future educational interventions.

Abstract

Objectives

To examine strategies employed by clinicians from different disciplines to manage their emotions during difficult healthcare conversations.

Methods

Self-report questionnaires were collected prior to simulation-based Program to Enhance Relational and Communication Skills (PERCS) workshops for professionals representing a range of experience and specialties at a tertiary pediatric hospital. In response to an open-ended prompt, clinicians qualitatively described their own strategies for managing their emotions during difficult healthcare conversations.

Results

126 respondents reported emotion management strategies. Respondents included physicians (42%), nurses (29%), medical interpreters (16%), psychosocial professionals (9%), and other (4%). Respondents identified 1–4 strategies. Five strategy categories were identified: Self-Care (51%), Preparatory and Relational Skills, (29%), Empathic Presence (28%), Team Approach (26%), and Professional Identity (20%).

Conclusions

Across disciplines and experience levels, clinicians have developed strategies to manage their emotions when holding difficult healthcare conversations. These strategies support clinicians before, during and after difficult conversations.

Practice implications

Understanding what strategies clinicians already employ to manage their emotions when holding difficult conversations has implications for educational planning and implementation. This study has potential to inform the development of education to support clinicians’ awareness of their emotions and to enhance the range and effectiveness of emotion management during difficult healthcare conversations.

Introduction

Conversations are the most commonly performed ‘procedures’ in healthcare [1]. Information is transmitted directly through conversation; patients learn of diagnoses, of prognoses, of treatment options. They receive orientation to, or alienation from, an often unknown and intimidating world of medicine [2]. And like any procedure, a conversation may go smoothly or there may be complications. The clinician may perceive that (s)he has performed well when in fact the patient and family are left distraught and overwhelmed; or the clinician may perceive that (s)he has performed poorly when in fact the patient and family are immensely grateful [3], [4], [5], [6], [7], [8], [9], [10]. Patient and family perception of how clinicians communicate information, regardless of the news that is shared, has clearly been demonstrated to affect their satisfaction, understanding, and ability to adjust to the clinical situation [11], [12], [13], [14], [15]. How these conversations are remembered has been shown to affect patients’ and families’ appraisal of the quality of healthcare received [16], [17], [18].

Challenging healthcare conversations also impact clinicians. A recent study demonstrated that clinicians experience significant emotion distress before communicating difficult news [19]. In a commentary article, clinicians recounted their emotions including: the need to rescue the patient, a sense of failure and frustration when the illness progresses, feelings of powerlessness against illness, fears of becoming ill oneself, and/or desire to separate from and avoid patients to escape these distressing feelings [20]. Given that nearly all clinicians must regularly engage in difficult conversations, it is surprising that there is little standardized training for healthcare professionals to learn how to better attend to their emotions. In this context we hypothesized that practicing clinicians, regardless of discipline and level of experience, will have developed their own strategies for managing their emotions during difficult healthcare conversations.

So why do clinicians have a difficult time with emotions during healthcare conversations? Buckman [9] discusses anxieties and fears that doctors have when it comes to breaking bad news, including fear of being blamed or fear of not knowing all the answers. Clinicians are typically confronted with and forced to come to terms with many of their own emotions and/or values during challenging healthcare conversations [15], [21], [22], [23], [24], [25]. However, clinician emotions have received relatively little attention, and providers may have little training related to recognizing, identifying, and attending to their own emotions [26], [27]. When it comes to dealing with their own emotions, in the hospital and clinic environment healthcare providers find themselves learning to be objective and even detached from emotions [28]. However, there is wide empirical evidence suggesting that being detached from one’s own emotions can have negative consequences on health and psychological well-being [29]. Bakker and Heuven [30] found for policemen and nurses, that emotionally demanding interactions can affect performance and even lead to job burnout. Moreover, emotional detachment may have downstream negative consequences on patients and families, particularly when emotional detachment leads to empathy degradation [31].

We have previously demonstrated a range of emotions identified by clinicians as impacting their care delivery during difficult conversations [32]. Across disciplines and experience levels, clinicians identified five predominant emotions in these clinical scenarios: anxiety, sadness, empathy, frustration, and insecurity. These emotions subjectively influenced the quality of care delivered; empathy and anxiety more so than the others. We also noted sparse literature on clinicians’ ability to recognize and manage emotions during difficult healthcare conversations, and that there is even less available research on heightening awareness or the benefit of educating clinicians on how to recognize and attend to their emotions when interacting with patients and their families.

In an effort to inform development of educational materials to enhance effective clinician emotion recognition and management, the Program to Enhance Relational and Communication Skills (PERCS) through the Institute for Professionalism and Ethical Practice (IPEP) at Boston Children’s Hospital (BCH), a tertiary care pediatric hospital, conducted a study to assess the frequency and impact of clinicians’ emotions during difficult healthcare conversations, to ask clinicians across disciplines and experience levels to reflect through personal narratives on how these emotions affect care delivery, and to qualitatively examine clinicians’ strategies for managing emotions during difficult conversations. Here we report specifically on the strategies that clinicians from a range of disciplines have developed to manage their emotions during these challenging conversations.

Section snippets

Methods

Data were collected from healthcare providers representing a range of specialties and experience levels who voluntarily attended 13 Program to Enhance Relational and Communicational Skills (PERCS) workshops, offered by the Institute for Professionalism and Ethical Practice (IPEP) at Boston Children’s Hospital (BCH) from September 2013 through May 2014. PERCS is a well-validated, simulation-based educational approach designed for interprofessional participants to improve their confidence and

Results

In total 152 participants from a range of specialties, including Cardiovascular and Critical Care, Neonatal Intensive Care, Neurology, Palliative Care, Psychiatry, and Radiology returned completed pre-questionnaires. Among these 126 (83%) interprofessional participants responded to the open-ended question on strategies/approaches/advice, comprising our study cohort. Among this study group of 126 respondents, 83 (66%) were females, 40 (32%) were males, and 3 (2%) did not specify gender.

Discussion and conclusion

Our study of practicing clinicians from a range of disciplines revealed five primary types of strategies for coping with their emotions during challenging clinical conversations. The most common strategy in our study, used by half of respondents, was self-care. The implication is that self-care is critical for the emotional well-being of the healthcare provider and that, by extension, self-care may be critical in the effort to successfully take care of others.

Clinicians in this study typically

Conflict of interest

None of the authors had any potential conflicts of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Role of funding

No financial support was provided for this research and/or preparation of this article.

Acknowledgements

We would like to thank the entire staff at the Institute for Professionalism and Ethical Practice, as well as all the participants in the workshops for this study.

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