Amy Stevens is a Public Health Consultant who works as the Public Health Lead at Bevan, a UK social enterprise providing health and wellbeing services to inclusion health populations
Healthcare professionals sometimes have to ask potentially sensitive and difficult questions in order to identify and meet the wellbeing needs of their patients. For example, questions around mental health, sexual health, domestic violence and pregnancy planning. These may arise from the person’s presenting complaint but sometimes they are asked as part of new patient health checks or as part of Making Every Contact Count approaches. How a patient reacts to potentially sensitive questions will depend on their life experiences, their cultural and religious backgrounds and personal beliefs. What may seem like a relatively neutral question to one person could be triggering, traumatic or offensive to another. The power imbalance present in consultations can exacerbate the discomfort felt by patients when being asked sensitive questions, it can increase their sense of vulnerability and disempowerment.
What may seem like a relatively neutral question to one person could be triggering, traumatic or offensive to another.
Sensitive questions can be particularly difficult for inclusion health populations who are more likely to have experienced trauma and adversity. Social marginalisation and past experience of discrimination by professionals or authority figures can make it hard to trust healthcare professionals with sensitive information. Cultural backgrounds can be a barrier to conversations about mental health due to associated stigma; religious beliefs can make conversations on sexual health taboo; and language barriers can impede the quality of the relational connection between patients and healthcare providers.
Recognising this, Bevan (a UK social enterprise providing health and wellbeing services to inclusion health populations) worked with lead experts by experience from inclusion health groups. We asked people with lived experience of forced migration, homelessness and sex-work their ideas on how best to approach sensitive conversations to ensure patients feel safe, comfortable, respected, listened to and cared for. This was a quality improvement project to inform how Bevan staff should approach sensitive conversations with the populations it serves. Thematic analysis of the 30 interview responses identified the following asks of health professionals: Build trust; Listen with compassion; Approach sensitive questions with care and consideration; Act.*
Build trust
“You need time at the start to build rapport and trust before sharing something difficult.”
A relationship of trust between health professionals and patient is needed to facilitate sensitive conversations. People want consistency in health professionals, they don’t want to have sensitive conversations with a stranger. They need to be reassured that they are in a safe place and that what they share is confidential. Respondents across inclusion health population groups expressed fear and suspicion over what was written in their medical notes and how this may be used and by whom. Meeting communication needs was stated as a prerequisite for trust, both in terms of addressing language barriers and explaining things in a way that can be easily understood. People need to feel comfortable, respected and understood; a sense of being stereotyped or judged is a barrier to trust.
Listen with compassion
“If you are face to face the health professional can see the pain the patient is facing when they are talking and be able to respond to this.”
Once sensitive questions have been asked it is important to give people the time they need to answer.
People said that being listened to by someone who shows compassion makes it easier to have sensitive conversations. They want health professionals to show they are listening through verbal and non-verbal response. Health professionals who look at their computer screen, type or interrupt leave people feeling unheard. Once sensitive questions have been asked it is important to give people the time they need to answer.
Approach sensitive questions with care and consideration
“At the start of consultations you can tell patients that you are open to talking about anything that might be difficult or sensitive to talk about. Put the power in their hands.”
In general people are open to being asked sensitive questions if it will enable healthcare professionals to address their needs. But where questions appear unrelated to their presenting complaint they want the reason for the questions explained. Questions should be culturally responsive and trauma informed. People want health professionals to read their medical notes so that they are aware of any previous trauma and avoid repeating sensitive questions. Sometimes people aren’t ready to have sensitive conversations but respondents want to be offered information, a help line, or a future appointment so that they know where they can go for help.
Act
“You need to know the answers to any problems you identify.”
Respondents felt healthcare professionals should only ask sensitive questions if they are going to act on what they hear. Services need to be available to address any needs identified by the questions. People want reassurance, positivity and support.
Coproduced guidance for healthcare professionals informed by the interviews is available at: https://www.wearebevan.co.uk/our-services/sensitive-conversations/.
Deputy editor’s note: These reflections are based on a quality improvement project to inform how Bevan staff should approach sensitive conversations with the populations it serves. It is not presented as research and shared with the permission of Bevan.
Featured Photo by Matt Collamer on Unsplash
