Communicating with Patients Experiencing Distress and Anger

Respond to Anger With the NURSE Technique

The acronym NURSE refers to:

Naming

• Be suggestive: “It sounds like you’re worried about your cancer may be recurring”
• Don’t be declarative:  “You’re worried that your cancer may recur”

Understanding

• "I can’t imagine what it is like to…”

Respecting

• Respond to strong emotion with strong acknowledgement: “You have shown a lot of courage through all this.” “I am amazed by how well you have coped with your mother’s illness.”

Supporting 

• Express empathy and understanding of the patient’s situation: “I sense how upset you are feeling about the CT scan results”
• Show willingness to help: “I will be here with you through this.”
• Acknowledge their efforts to cope
• Tell them your availability for them, if you can

Exploring

• "Tell me more about what is affecting you.” or “Tell me more about what upsets/scares you the most”.

If you are not sure why they are upset, ask, “What were you thinking about just now? Can you help me understand what made you cry just now, what’s going through your mind as we talk?”

How would you respond to a frustrated caregiver?

Five strategies to respond to anger

1. Allow the patients to recount grievances
   • Ask open questions: “Tell me what’s wrong.”
   • Avoid leading questions: “Are you upset because the cancer came back?”
   • Don’t be defensive: “We try to provide the best care to patients, but we can’t guarantee that treatments always work”
   • Avoid interruptions (unless needed for control)
2. Work towards a shared understanding of the patients’ experience and emotions
   • Ask open questions
   • Clarify
   • Restate
   • Negotiate the emotion’s name proportional to intensity “Disappointed”, “upset”, “frustrated” or “angry”
   • Avoid giving premature reassurances: “I’m sure you’ll be fine”
3. Empathetically respond to emotion or experience
   • Acknowledge: “I can see..”
   • Validate: “I can understand”
   • Normalize: “Many people..”
   • Praise patient efforts “I appreciate you come and talk to me about this”
   • Apologize if appropriate
4. Explore attitudes and expectations leading to anger
   • Ask open questions
   • Restate
   • Clarify
   • Acknowledge
   • Direct anger constructively
5. Facilitate coping and connect to social support
   • Make partnership statements: “We can talk to the oncologist together.”
   • Express willingness to help
   • Make referrals
   • Explore problem solving approaches or patient’s networks: “Do you have someone you could talk to?”