Too direct?

ybq2008 · Jul 11, 2014

Everything is perception. I'm sure you have every good intention and that many of your patients are able to take the feedback and recommendations positively. We also tend to be a little thick-skined as nurses, so certain things don't bother us the way they may bother others and we can come off as being a little direct at times.

One way I frame things with patient education is to have a discussion from a team perspective. I'm a member of your health care team and I have some information and suggestions to offer you to improve your health. We're all human and we all have struggles, so I'm going to be here with you and help you with this in whatever way possible. I think patients take things a bit more positively when they feel like you're informing them of their options and what they could do to optimize their health, but you understand they struggle with other problems that may inhibit their success.

Good luck with whatever you decide to do!

BritFNP · Jul 14, 2014

I am very direct, many patients have told me, "thanks for not bs'ing me". It's all in your delivery..put it in a way that doesn't say, you're fat - diet and exercise, you've made your cholesterol be out of control - here's this pill. Put it in a way that they understand you want them to live a long time. Figure out what is important to them - hobby - grandkids - their band - whatever. I always give people options …do you want to do this or that? (give it three more months of diet+exercise or take a statin). Commending people for the efforts they HAVE made goes a long way too. My patient tells me they smoke 1/2 ppd, but a year ago they smoked a whole pack…you're getting a high five. Maybe next year we will be down to 3-4 cigs a day, or none. Bottom line - no one wants to come back to you if you sound like their mother every time they come in, telling them what they are OBVIOUSLY doing wrong. Touching on the topic is good, stressing the importance is good, and documenting that the patient understands the risks of xyz is good. Bottom line, you cannot really say everything you are thinking - its bad for business. You will figure it out! Good luck!

Trauma Columnist · Jul 14, 2014

I find that I have to adjust my delivery to my audience too.

RN623 · Jul 15, 2014

I appreciate the feedback. As a newer FNP I am realizing more and more how important the presentation, in addition to the content, really is. Thank you for the responses.

Riburn3, BSN, MSN, APRN, NP · Jul 15, 2014

I am very direct, many patients have told me, "thanks for not bs'ing me". It's all in your delivery..put it in a way that doesn't say, you're fat - diet and exercise, you've made your cholesterol be out of control - here's this pill. Put it in a way that they understand you want them to live a long time. Figure out what is important to them - hobby - grandkids - their band - whatever. I always give people options …do you want to do this or that? (give it three more months of diet+exercise or take a statin). Commending people for the efforts they HAVE made goes a long way too. My patient tells me they smoke 1/2 ppd, but a year ago they smoked a whole pack…you're getting a high five. Maybe next year we will be down to 3-4 cigs a day, or none. Bottom line - no one wants to come back to you if you sound like their mother every time they come in, telling them what they are OBVIOUSLY doing wrong. Touching on the topic is good, stressing the importance is good, and documenting that the patient understands the risks of xyz is good. Bottom line, you cannot really say everything you are thinking - its bad for business. You will figure it out! Good luck!

THIS. The first physician I precepted with approached his patients this way, and it has stuck with me ever since. Giving patients a choice and guiding them in their care is so effective. I find when you involve patients in their care instead of telling them what to do, you increase outcomes and compliance rates. Lastly, stating "it's bad for business" puts it in the perfect context. Patients, especially in primary care, are also consumers, and they have a choice in where they go. Laying out the facts is important, but delivery is crucial.

cruisin_woodward · Jul 23, 2014

The PA in our office is VERY direct. Some of his patients LOVE him, other HATE him. There is no in between with him. I am the softer side. I think it just depends. I do discuss weight and nutrition, because, working in ortho, their weight has a lot to do with their pain. And I don't accept, "I can't exercise, so I can't lose weight" as an excuse. I explain to them that weight loss is 80% nutrition, and 20% exercise. They do not like to hear that. I also suggest that they try swimming, or water aerobics.

PG2018 · Jul 23, 2014

Aren't we supposed to be direct?

Why beat around the bushes? If someone is morbidly obese they definitely need to diet and exercise!

There's a local doctor down around my way who had a successful practice for decades until he got tired of being a practice manager as well as a doctor. He quit and works for an ER contract company. That being said, he'll walk into a room with a patient, slam the chart down, and say something like "you're killing yourself, have a look" and walk out. He's as rough as a cobb, but patients love him. Unique guy. On top of doctoring he was a Cobra pilot.

Everyone is different, but I miss a society in which we could tell people what they need to know without having to worry about their self-esteem prior to delivering the point - a time when you could tell someone "no," expect them to stop whatever they're doing, and not have to console because someone told them what to do.

An area school district will not given any student a grade below 50%. The administration's rationale is that they're failing at 50% so why destroy their self-esteem by giving them a zero. This means if they turn in nothing they get 50%, if they get half wrong they get 50%, if they get it all wrong they get 50%. By that same math, shouldn't someone who gets at least half correct get a 100?! PC at its finest.

RN623 · Jul 23, 2014

Again thank you for your responses. I am not a fan of PC-ness. I guess this brings up the subtext of this conversation...patient satisfaction. Now I'm not saying the patient doesn't deserve respect and appropriate care but I don't think patient satisfaction deserves as much attention/emphasis as it does. I'd love to hear others thoughts on this subtopic.

rnsrgr8t · Jul 23, 2014

It is definitely an art that you learn to do. It is hard to tell people things they do not want to hear. When I was a new grad, one of the MD's I worked with gave me good advice. I had a family (I work in peds) that was just refusing to do what I recommended and I was getting frustrated and taking it personally. The MD told me, "The patients come to us because we have expertise on how to treat them. All we can do is give them our recommendations to the best of our ability. It is up to the patient if they are going to listen or not!". You have to balance the best care for the patient and what they want to do. If my patients are resistant to what I recommending, I will give them the rationale behind WHY I recommend what I do (and not something else for example). If there is room for negotiating that is not going to be harmful to the patient, I do it. If they want me to research an option I have not done, I will do that. If there is still pushback/noncompliance I am very direct, especially if it is causing the patient harm. I will explain, again, the rationale behind what my concerns are. I also document like heck, and if I spend a long time with the family, I make sure I document that and bill according to time. I think we have to be willing to bend, a little, if the alternative is reasonable. I think your documentation is the key, so you can show the patient, I discussed this with you on this date, this date etc. This is your labwork/BMP etc on this date etc. It is also important to try to get them to tell you WHY they do not want to do what you are recommending.

As far as patient satisfication, I do the best I can while staying within best practice. If you are late to your appointment with me, I will ask you about it (especially if they are new). Did you get lost? Traffic? etc. I do tell them I need you to be on time. Unfortunately where I work, there is not late policy and the general rule is you have to see them whenever they show up. So I am not going to be supported if I turn away someone who is late. So I am diplomatic about it but I do stress to them I need them to be on time and to call if they are running late. The majority of my patients do end up coming on time.

You call me while on vacation b/c your child has a fever and dysuria and you are requesting I "just call in antibiotics". Not going to happen. No matter how angry you get at me. I will help you find a local urgent care/lab/hospital wherever you are but at bare minimum, urine has to be checked. I will start empiric treatment but still have to check the urine. It is just not good practice b/c you do not know what your are treating.

Same thing for post op pain meds. Parents can call and request refills of their child's pain meds. We are good about treating pain and usually give enough to cover them well in the post op period. so, if they need more, we need to see them b/c something may be wrong. I have made parents mad with this but it is in the best interest of your child.

I am generous when filling out FMLA paperwork for families when their children need surgery etc. I have a reasonable time frame in mind that the parents would need off and I want to make sure they are covered at their job (especially in this economy). However, I have had parents demand I give them a crazy amount of time off. Sorry, not going to happen.

When you are firm and maintain your stance on something, I think you just need to be able to back yourself up. If you documentation is good, you can go back to your supervisors and show them. OK Patient S complained about me. If you look in my documentation, you can see I counseled them on this date, this date, this date. They also have been to 3 different providers and still been noncompliant etc. For me, I am young (considerably younger than anyone else in my division) and look even younger than I am. In the beginning, parents were questioning my knowledge due to my age. I had to prove to them I knew what I was talking about.

You want to be appear confident but not arrogant. You want to be empathetic, but not a doormat! Good luck!

PG2018 · Jul 23, 2014

Again thank you for your responses. I am not a fan of PC-ness. I guess this brings up the subtext of this conversation...patient satisfaction. Now I'm not saying the patient doesn't deserve respect and appropriate care but I don't think patient satisfaction deserves as much attention/emphasis as it does. I'd love to hear others thoughts on this subtopic.

I agree with you. I was skimming the forums the other day and posted a response similar to this. I genuinely feel that satisfaction-based reimbursement is going to irreparably harm the U.S. healthcare system. Already it's causing competent, experienced employees to leave the work place; and reimbursement is heightened by room service rather than treatment. A free cup of hot coffee seems to satisfy patients more than a cured disease.

As RN623 said, I feel everyone deserves respect, but we're overdoing it.

SunnyNP · Aug 4, 2014

Private practice here...remember patients are clients. 4 years concierge medicine and it's all in the delivery and patient perception :)

Mr Anthony Jones, pleasant 41 year old overly nourished male attends our office today for follow-up of hypertension and hyperlipemia.

BMI of 38, attempts of calorie reduction mildly unsuccessful. Education provided.

i dictate in front of my patient to save time using dragon voice software. I then ask them if I forgot anything about our visit today as this is part of their medical record and it should reflect all our "hard work" we are accomplishing together towards better health. Very few complaints here using this system.