In this day of selivering bad news, I thought that this article that I saved from last year would be a great refresher. Food is food regardless of the source.
The Rules for Delivering Bad News to Patients
August 27, 2019
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I've talked to some colleagues recently who've been a little down about their roles as nurse practitioners. Working in family practice, they have found themselves in the position of delivering bad or upsetting news to their patients. Cancer diagnoses were fortunately made rather than missed, but letting a patient know they've got a serious, life-altering illness or condition is tough, not to mention, this is not something most of us as NPs learn to do in school.
Have you ever found yourself in the position of delivering difficult news to patients? How did you feel? Having such conversations as nurse practitioners can make us anxious or awkward. Some of us approach these discussions emotionally while others appear detached and robotic in their delivery of the news. Delivering bad news is an unavoidable part of our jobs as nurse practitioners but that doesn't mean we get used to it. Fortunately, however, conducting serious conversations is a skill that can be learned and there are many guidelines out there to help healthcare providers hone this skill set.
Rule #1: Know what constitutes bad news
Sometimes I share information with a patient that I perceive as not a big deal. Then, the patient starts to freak out. Or cry. Or to have some other sort of emotional reaction that I didn't anticipate. Bad news doesn't have to be a terminal diagnosis. It can be related to anything surrounding a diagnosis such as timing, personal or professional consequences. Breaking a metatarsal and wearing a boot, for example, may not be too bad in the grand scheme of things, but breaking your foot the day before your wedding is pretty disappointing.
Rule #2: Full disclosure is best
In the past, healthcare providers operated on a more guarded front. In the 1800's, for example, the American Medical Association even encouraged physicians to avoid sharing news that discouraged patients. Today, however, studies (not to mention ethics!) show that most patients prefer full disclosure. It's our duty as nurse practitioners to share up-front, honest information rather than sugar coat our delivery with excessive optimism, withhold details, or give false hope. Share news with the patient directly rather than directing it toward family members. Honest, trustworthy information is empowering!
Rule #3: Prepare yourself
Anticipate the conversation you're about to have with your patient. You may even wish to practice your delivery with a colleague. Prepare yourself to feely badly as you share the news. And, don't forget that silence is OK. Avoid the temptation to fill gaps in your conversation rather let the patient process and take the time to formulate questions.
Rule #4: Frame the conversation
Framing the news you're about to share is essential. Your patient may or may not be expecting to hear something difficult. And, the way you set up your conversation has an impact on the patient's reaction. Using the word "serious" (ex. "I have some serious news to share...") is better than using the word "bad". "Serious" creates a more constructive framework that inspires action and empowerment as opposed to the word "bad" which indicates the situation is helpless. Even if you're delivering a terminal diagnosis, your patient can choose how to react and what steps they wish to take in response.
Rule #5: Think SPIKES
There are a few well-known methods for delivering serious news to patients, my favorite of which is the SPIKES method. This algorithm lays out considerations for nurse practitioners and other healthcare providers in these situations. Here's the SPIKES protocol:
Setup - Think through the conversation you're about to have, anticipating questions the patient might ask beforehand. Prepare for an emotional reaction. Gather any necessary resources that might be helpful for the patient.
Perception - Gauge the patient's understanding and perspective on the news you have shared. This is best accomplished by asking questions like "What did you take away from what I just shared with you?" or "What are your expectations of treatment?". This way you know you are both on the same page as far as understanding the medical outlook, next steps and goals.
Invitation - Encourage the patient to think further about their care going forward. Find out how much information the patient wants about his or her medical condition as well as who he/she would like to be included in decision making such as family members.
Knowledge - This step has to do with how you as a provider deliver information. The best practice is to deliver the headline first, followed by the details. Communicate using language that matches the patient's level of education and medical knowledge. Be direct in your delivery, avoid skirting the main message.
Empathy - Understandably, patients get emotional about serious news. Anticipate such a reaction and display empathy. Naming the patient's emotions can help. Asking "Can you tell me more about what you mean by that?" will also help you determine how the patient feels about the situation.
Summarize and Strategize - Make a plan for the next steps in both treatment and communication with your patient. Express support and encourage the patient to tell friends and family the news to develop a personal support system. Talk about how the patient can act on this news to accomplish his or her treatment and lifestyle goals going forward.
Have you ever delivered bad news to a patient? How did it go?
Here are the details of my offer. There really wasn’t much to it and I have no idea where to start with negotiations and what I need to bring up. My concern is that the salary is a little on the low side. Any advice or thoughts would be appreciated!
24 days PTO
5 days CME
New grad dermatology offer in the Northern Virginia area. Solo MD practice with 4 PAs (1 is leaving and another is leaving in a few months). Only the MD has an MA who brings back pts, scribes and assists with procedures. No Mohs in office. PAs see approximately 15 pts per day at 30 minute intervals - bring pts back to rooms, turnover rooms, perform beta-hcgs without assistance. Location, providers and support staff are great - shadowed with the practice following interview.
Offered a 1-year contract for $48/hr, 36 hours/wk, work 8AM - 5 PM (1 hr for lunch flexing every other Friday), no weekends or holidays, no call. Paid bi-weekly. Compensation while training will be $25/hr for the first 4-weeks of employment, increasing to $30 thereafter (no longer than 12 weeks) with a retention bonus after 1-year to compensate for pay-cut during training period.
Productivity bonus begins after 1-year of employment: annual bonus of 5% of the aggregate amount in excess of 3x calculated annual salary.
PTO - 83.2 hours (2 weeks) covers vacation, sick leave, CME travel; increases to 3 weeks after 1-year
Annual stipend - $1,000 covers licensure, CME (to include travel and lodging expenses), uniforms, dues, books.
401k - dollar for dollar matching up to 4%
Malpractice insurance - provided but no details written in the contract; verbally told that there is no tail coverage but did not seem to know if policy was claims made vs occurrence.
No dental, health, vision. Currently covered under spouse's plan.
Restrictions: no moon-lighting, 2-year non-compete with other derm offices within a 20 mile radius.
Offered Urgent Care position at $58/hr, ~32-36 hrs/wk to include two Fridays and one-two weekends a month. 2 months training at full pay. Non-training shifts will be from 2 PM -10 PM; working with another PA/NP in house at all times - can work solo after 1 year. Paid time and a half for holidays worked. No call. Salary growth of 3-6% annually plus RVU bonus.
PTO - 84 hrs; plus 3 months maternity leave through disability
401K - 100% vested after 1 year, 3-6% match after 1 year
Profit sharing - 1500 hours (not really sure what this means...need to do some research)
Malpractice insurance - occurrence policy. No tail coverage.
Health insurance provided.
Licensure fees, membership dues covered.
I like both practices and need some feedback. I like staying busy, doing procedures and developing relationships with patients. I do no like the UC hours to include shift time, weekends and holidays - spouse works 9AM-5PM and want to have more time together. Derm location is closer to home, less charting, predictable schedule. I want to renegotiate the derm offer to match the hourly compensation of the UC offer - hoping to get at least $53/hr, ask for 20% rather than 5% annual bonus with a goal stipend of $2500. Any tips of advice of any sort would be greatly appreciated. Thank you.
Hi, I am a third year pa student & graduate in May 2020 (3 more months!) I just got my first job offer, which also happens to be my dream job, and I’m very excited about it. I want to share the good news with family and friends on social media, but I want to do it tastefully and with proper etiquette. What is safe/not safe to say publicly?
I am graduating from my program next month, and have an offer from a cardiology office in Lakeland, FL. I have received the contract to review and would like some thoughts about the terms of this 1 year contract:
salary - 90K for 1st year with the potential for incentive bonus
benefits starting after 90 days of employment
1-2 years of employment - 2 weeks PTO, 3-4 years of service = 3 weeks paid time off per year 4+ years of service = 4 weeks paid time off per year
$1,500 CME allowance with an additional week off for CME
The downside: No tail coverage provided
12 month non-compete including a 12 mile radius from any of their offices (they have several), but I am under the understanding it is just related to other cardiology practices.