The importance of difficult conversations

Last week I was speaking at a healthcare conference in London run by HC-UK. The majority of delegates were senior clinicians and management from NHS Trusts and private healthcare providers. At the end of my presentation, I asked for questions. There were some very good questions (some of which I’ll come back to in future blogs) and one that stood out for me was a question from a clinician who heads up an NHS Trust team. He asked, “how do I deal with the problem of my staff not knowing how to have difficult conversations with families after a serious incident?”

I asked him how they were handling it at the moment. He replied “current policy is that the nursing staff and clinicians who have been involved in the patient’s care speak to the staff member designated as investigator, who then speaks to the family. But often the investigators and staff are not sure how to have these difficult conversations and it ends up being put off, sometimes for weeks and that just seems to make the situation worse.” He added “the real problem is that staff lack confidence in speaking to families and they’re not sure how to do it. They’re worried about getting it wrong and ending up making the situation much worse, so they just put it off as long as possible”.

And I started to wonder how many other Trusts were doing the same thing………

At a Making Families Count training event we talk about the importance of good communication with families after a serious incident, particularly as these are difficult conversations and it’s so important to get them right. One of my colleagues points out the death of a loved one can be “the worst possible thing that could happen to the family and contacting the family promptly is not going to make things worse”. And yet time and time again, families tell us weeks or sometimes months pass before the Trust writes to them. The family perceives this delay by the healthcare provider as a clear message “this death is not important to us”.

This is the beginning of the family becoming further traumatised and battle lines being drawn up as the family and the Trust take up “them and us” positions. They end up entrenched at opposite ends of the spectrum, attacking, defending. Unnecessary additional anguish is created.

We realise that this is not the intention of the Trust, but your perception is reality. Do the staff benefit from this? No way! The staff are often left feeling guilty, undermined, under-confident and dreading a similar event in the future. Ending this pattern is so simple. Good training in positive family engagement empowers staff and gives them confidence. Good engagement with the family after a serious incident, and especially after a death, makes it far more likely the family will feel supported (and very importantly, listened to) and the staff will learn – and take the learning forward into work in the future.

Do you work in healthcare? Have you or the people you work with had training in having those difficult conversations with families after a patient safety incident? Do you and they feel confident to have those conversations, knowing you’re getting it right? I can’t condense a whole day’s training into a few lines but I would say, first and foremost, early contact is essential. Offer the family a meeting before the investigation begins but make sure the meeting is on the family’s terms; don’t force them to meet your timescales and consider any constraints they may have in attending. Structure meetings around what the family can cope with and avoid putting them in a position where they feel overwhelmed and further traumatised in order that you follow your policy and process. Ensure the family feels they are in a position to influence the investigation which should answer all their questions.

Be well prepared when you go to meet with the family (and in all communication with them). Make sure you’re familiar with the family culture and dynamics and check to see what contact the family has had with your organisation prior to this.

At all times be open and transparent with the family and if you can’t share information with them at that time, explain that and explain why. Never make promises you can’t keep and be clear about the length of time the investigation is going to take. Don’t forget to take minutes of every meeting and ensure the family receives a copy of the minutes.

Offer the family meaningful involvement in the investigation and discuss ways they can share information with you. Some families like to be asked to provide a photograph and pen portrait of their family member – this humanises the investigation and reminds everyone why they’re there.

Be calm and acknowledge the family’s anger and distress. Often anger reflects their great emotional pain, their concerns and their fears. Don’t be afraid to set boundaries during the investigation and in your early conversations talk about how the process is going to work and ensure they are supported. Have you offered the family independent support and/or advocacy?

Don’t use meaningless and empty phrases like “I’m sorry you feel like that” and always show compassion and empathy.  How would you be feeling in the same circumstances?

Ensure all colleagues involved with the investigation are supported themselves and are properly trained in supporting families through investigations.

These are a few of the points which we recommend in getting difficult conversations right during a patient safety investigation but remember, no matter how many times you may have had these conversations, for each family, it’s their first. They will never have experienced anything like this before and for them, this is their world entire. Don’t lose sight of that and remember the MFC mantra “how would you like to be treated if it was you?”

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