A University of Derby academic is among a team of researchers and professionals providing guidance to clinicians who are likely to be having – and training people who will have – difficult conversations with patients suffering from COVID-19 or those closest to them.
Sharan Watson, Programme Leader for PG Cert Palliative Care, has supported Professor Ruth Parry, an expert in healthcare communication and interaction at Loughborough University, to outline a series of evidence-based principles, known as The Framework, along with the help of Loughborough University’s Becky Whittaker, and Dr Ruth England, of the Royal Derby Hospital.
The team, led by Ruth, shared the recommendations with NHS Health Education England and these have been used to develop a series of open access resources that aim to support healthcare staff who will be having difficult conversations in relation to the coronavirus.
The Framework, which has also been added to the International Association for Hospice and Palliative Care’s COVID-19 resources list*, is based on research by Professor Parry and other communication scientists worldwide who have recorded and analysed thousands of difficult conversations across various health and social care settings in the UK, Australia, Japan, and the US.
The team say the guidance steers away from providing recommended phrases or scripts as it is important to equip health workers with the tools to communicate flexibly according to individual circumstances.
Having a conversation by phone, one where the staff member who is to do the talking is wearing PPE (Personal Protection Equipment), and with people who have varying degrees of knowledge and distress, are all examples of circumstances that can impact how a conversation should be constructed.
Giving difficult news over the phone or when wearing Personal Protection Equipment are circumstances that staff would normally want to avoid – in normal circumstances, the health services strive to ensure that these difficult conversations are led by highly experienced professionals, face-to-face, and in calm environments.
The team divided the principles into key areas for making a difference when delivering emotive and unwelcome conversations. They include (with a brief overview of what they cover):
- Prepare yourself and the environment as best you can
Health workers should clarify in their mind what they want to say and why, and find a comfortable and private setting, as best they can.
- Start the conversation with ‘signposting’
Conversations should be started by giving the person on the receiving end an outline of what will follow – for instance, if it is an update, and/or that there is a decision to be made.
- How to show compassion and empathy throughout
This can be portrayed through tone of voice, phrases that attend to emotion, and showing understanding without claiming one can possibly fully understand how the person on the receiving end is feeling.
- What does the person you are talking to know, expect, and feel?
Health workers should find out what the person they are talking to already knows and how they feel about it as this will help them fit what they go on to say to the individual person they are talking to.
- Are they with someone, can they talk to someone afterwards?
If this is a phone call, finding out who is with a person or who they could talk to afterwards is important, but this question should not be asked right at the start of a conversation as it could easily be heard as very bad news. Even when there is very bad news to come, building towards it gradually is better than clearly signalling it from the start; a gradual move towards the news reduces the risk of sending the person on the receiving end into severe shock.
- Bring the person (further) towards an understanding of the situation – how things are, what has happened or is likely to happen
From the evidence base, the advice is to describe some of the things that are wrong with the unwell person, in such a way that the person speaking is forecasting that bad news is going to come. The point is to bring about gradual recognition, rather than shock.
Deliveries should be modified to be softer and more lilting if this happens. Speakers should allow silence, repeat brief further sympathy – ‘I’m so sorry’, and acknowledge the distress before moving on and giving more information
- Moving towards the end of the conversation with ‘screening’ – ‘are there things you would like to ask, that I have not said, or explained enough?’
Phrases like ‘anything else’ should be avoided because, in some circumstances, this can be interpreted as the speaker not expecting there to be anything else. Offering ‘Are there things I have not covered or explained enough?’ removes the implication that the person has not understood things.
- Moving towards the end of the conversation with words of comfort and attention to what happens next
If possible, health workers should try to deliver something that is of comfort and that they can say truthfully. They should also explain what happens next, advise who the person they are talking to can contact for support and, if necessary, explain how pain or other symptoms will be controlled.
The team has also provided advice to help somewhat reduce the emotional burden on the healthcare worker – for example, they recommend they find someone to debrief with before and after a difficult conversation.
Of the importance of the guidance and what she hopes it will achieve, Professor Parry said: “Healthcare workers are now having to have break bad news and have difficult conversations on an unprecedented scale.
“The kind of research I do makes it possible to pin down, to articulate, precisely how skilled, compassionate healthcare staff communicate, and pass this on to others.
“I hope that our guidance will help all staff having to break bad COVID-19 news to patients or their loved ones, to feel confident and able to communicate well, whilst looking after their own wellbeing.”
Sharan Watson, who has a clinical background in specialist palliative care, is currently on a part-time secondment with Loughborough University as part of the Real Talk Conversation Analysis Research Team.
She said: “Being asked to support Professor Ruth Parry at this time is a credit to true multi-organisational collaboration for the greatest good.
“We are all passionate about supporting and providing advice to our front line clinicians, which is even more imperative during the challenging times that our health and social care professionals are currently facing.”
*The full guidance document has been shared on the Real Talk website – a platform for communication training resource designed to use in face-to-face training events for health and social care staff. View the guidance document in PDF format.
View the ‘Discussion of Unwelcome News during Covid-19 Pandemic: a framework for health and social care professionals’ document.
A series of short videos have also been produced to guide conversations about using the framework, community, breaking bad news and ceilings of treatment.