A skill for responding to emotion is the use of the NURSE acronym, which stands for name the emotion, understand the emotion, respect the patient, support the patient and explore the emotion further. Statements made by a clinician that name the emotion, show understanding of the emotion, respect for the patient, support the patient, or explore the emotion further help to validate the patient and promote adjustment to serious news that is being discussed. The use of this acronym for responding to emotion is demonstrated in this video.
The clinician is giving the patient the bad news that the chronic kidney function has worsened since a recent hospitalization to the point that a transplant or dialysis need to be considered. The patient clearly has an emotional reaction, both verbally and non-verbally, to this news. Rather than continuing to talk about the next steps (cognitive information), the clinician has responded to the emotion. He has named the emotion that the patient has displayed: “I can see this is really a surprise.” When the patient talks about all that he has done recently to take care of his kidneys, the clinician has responded by showing respect for his efforts: “You’ve been doing a great job.” He has also shown support for the patient: “We’ll work together to get you through this. We’ll work on a plan.” He has also used an “I wish” statement: “I wish I had better news.” “I wish” statements acknowledge disappointment and allow the clinician to join with the patient in recognizing loss. It is not until the patient’s emotions start to subside that the clinician begins to talk about the plan (cognitive information).
This video also demonstrates some essential components of giving bad news to a patient. Once again this involves using the skill of Ask-Tell-Ask. What is primarily demonstrated is the Tell. This should be done very directly and concisely. In this video the clinician tells the patient in a simple, straightforward manner (and without jargon) that his kidney function has worsened significantly. He begins by firing what is known as a “warning shot” to prepare the patient for the news: “Your kidney function has become a lot worse.” He proceeds to tell him that it has worsened to the point that one needs to consider the “next steps: dialysis or a transplant.” Prior to giving the bad news (not shown), the clinician asked the patient how he thinks his kidneys are functioning presently. The patient responded that he wasn’t sure because he has been really focused on his heart issues since being hospitalized for a heart attack. The clinician asks permission to give the patient news about his kidney function before proceeding: “I wonder if it’s all right if we talk about how your kidney function has been doing since your hospitalization?” After the clinician responds to emotion, he provides some information (not shown) about the options for dialysis and transplantation and makes a plan for him to get further education in the near future. He then makes certain that the patient has understood what was discussed by asking the patient what he will tell the family about the discussion today when he returns home. He also asks if the patient has any questions.
To summarize, by using the framework and skill of Ask-Tell-Ask, the clinician is able to ask for understanding of the situation and ask permission to give more information before delivering the bad news. The bad news is delivered succinctly and clearly. After emotion has been acknowledged, the clinician is able to give more information and ultimately ask the patient if he understands what has been discussed before the encounter ends.