Why do conversations with patients and families become difficult?
Most conversations go smoothly. A few become hard because emotions are high, expectations differ or something has gone wrong. Typical examples are a relative angry about a delay, a patient wanting an antibiotic or scan that is not indicated, a family disagreeing with a treatment decision, or someone upset by how they were spoken to.
Behind most anger sits another feeling: fear, grief, helplessness, exhaustion or not being listened to. A son shouting that nobody is doing anything for his mother may be frightened she is dying. If you respond only to the shouting, things tend to escalate. If you respond to the fear, they often settle.
Notice your own reaction
When someone is angry with us, we feel threatened. Common reactions are to defend ourselves, over-explain, blame the system or a colleague, or withdraw. These are human, but they leave the other person feeling unheard. Noticing your reaction, taking a breath and slowing down are the first skills. If you feel unsafe, your safety comes first.
What is a simple structure for a difficult conversation?
- Find the right place: Move away from a busy corridor or bay if it is safe to do so. Sit down if you can. Privacy lowers the temperature and protects confidentiality.
- Listen first: Let the person tell the whole story. Use short prompts such as "go on" or "what happened next?". Do not interrupt to correct details.
- Summarise: Repeat back the key points and ask if you have understood. This shows you heard and often calms things quickly.
- Respond to the emotion: Acknowledge the feeling before explaining anything. If the emotion returns, acknowledge it again.
- Explain honestly: Say what you know, what you can do, what you cannot do and why. Apologise where something has gone wrong.
- Agree next steps: Agree who will do what and by when. Then keep your promise, or go back promptly if you cannot.
What is the NURSE approach to responding to emotion?
NURSE is a published set of responses to emotion, described by Back and colleagues in 2005 for serious illness conversations. It is now taught widely for complaints and disagreement too. It is a menu, not a script, and you rarely need all five.
| Response | What you do | Example phrase |
|---|---|---|
| Naming | Tentatively name the emotion you see | "It sounds as though you're really worried about her." |
| Understanding | Show you understand why they feel this way | "Waiting all day without an update, I can see why you're fed up." |
| Respecting | Recognise their effort, care or strength of feeling | "You've been here every day. It's clear how much you care." |
| Supporting | Say what you will do and that you'll stay involved | "I'll find out what's happening and come back to you myself." |
| Exploring | Ask an open question about the concern underneath | "What's worrying you most right now?" |
- Offer names for emotions tentatively. "You're angry" can sound like a judgement.
- Avoid "I know how you feel". Most people find it dismissive.
- Do not follow an empathic phrase with "but". It cancels what you just said.
- Use the responses to understand the person, not to close them down.
How do you calm an angry relative?
Here is a common scenario. Tariq's father was due home from a surgical ward this morning. It is now mid-afternoon, his discharge letter has not been written and nobody has explained why. Tariq arrives at the nurses' station, voice raised: "I've been here since nine. Does anyone here actually know what's going on?"
Nurse: "Please don't shout at me. The doctors are in theatre and I've got seven other patients. It's not my fault, you'll have to wait."
Nurse: "I can see you've had a really long, frustrating day. Can we sit in the side room so I can hear you properly?" [Listens] "So you were told he'd be home this morning, you've been waiting since nine, and no one has explained the delay. I'm sorry, that's not good enough. His letter still needs a doctor to finish it. I'll bleep the registrar now, ask for a time, and come back to you by half past three either way."
The weak response reacts to the tone, defends and blames colleagues, and offers no plan. The stronger one names the feeling, moves to a private space, summarises, apologises for the experience, explains honestly and gives a specific next step with a time.
How to apologise well
A sincere apology is powerful, and saying sorry is not an admission of legal liability. The professional duty of candour, shared by the UK healthcare regulators, expects you to be open and to apologise when things go wrong. Make it specific and do not shift blame. "I'm sorry nobody kept you updated" works. "I'm sorry you feel that way" usually makes things worse.
What should you do when someone wants to make a complaint?
- Try to resolve concerns early. Many settle with a conversation, an explanation and an apology.
- If the person wants to complain formally, explain how, and give details of PALS or your organisation's equivalent.
- Never discourage a complaint or suggest it will affect care. Professional standards are clear that it must not.
- Do not speculate about colleagues or promise outcomes you cannot control.
- Tell your manager and document the conversation factually.
In England, NHS complaints should normally be made within 12 months of the event or of the person becoming aware of it, although organisations can accept later complaints where it is still possible to investigate. If someone remains unhappy after the organisation's final response, they can ask the Parliamentary and Health Service Ombudsman to look at it. Scotland, Wales and Northern Ireland have their own processes and ombudsmen, so check your local policy.
How do you handle disagreement or requests for treatment that isn't appropriate?
The aim is not to win. It is to understand the worry, share your reasoning honestly and reach a decision together where you can. Asking about ideas, concerns and expectations often reveals what is really driving the request.
Patient: "I need antibiotics, I always get them." GP: "It's viral. Antibiotics won't do anything. It'll clear up on its own."
Patient: "I need antibiotics, I always get them." GP: "You sound really fed up with this. What worries you most about it?" Patient: "My daughter's wedding is on Saturday." GP: "That makes sense. This looks viral, so antibiotics wouldn't help and could cause side effects. Let's talk about what will ease the symptoms before Saturday, and the signs that would mean you should come back sooner."
Under GMC guidance on decision making and consent, patients can refuse treatment but cannot insist on treatment the clinician believes is not in their clinical interest. Explain your reasons, explore values and goals, discuss what options are available, and offer a second opinion where appropriate.
For adults who lack capacity, decisions are made in their best interests under the Mental Capacity Act 2005, which includes consulting those close to them. Families cannot insist on a particular treatment, and even an attorney for health and welfare cannot require a clinician to provide treatment that is not clinically appropriate.
- Prepare: agree the message with the senior clinician and team beforehand.
- Explore: ask what the family understands and hopes for, and what the patient would have wanted.
- Explain: share the clinical picture in plain language, including uncertainty.
- Focus on what will continue, such as comfort and symptom control, not only what will stop.
- If you cannot agree, say so honestly and offer more time, another meeting or a second opinion.
When should you set a boundary or end the conversation?
Compassion does not mean accepting abuse. If behaviour becomes threatening, discriminatory or abusive, name the behaviour, its effect and what you need: "I want to help, but I can't while you're shouting at me. Can we talk calmly?" If it continues, end the conversation and get help from a senior colleague or security.
- Keep yourself near an exit and do not let anyone stand between you and the door.
- Know how to call for help, including any alarm system.
- Do not carry on if you feel unsafe. Leave and get help.
- Report violence, abuse and discriminatory behaviour through your incident system and seek support.
Escalate to someone senior when the issue is outside your role, cannot be resolved, raises a safety concern, or when the person asks for someone senior. Escalating is not failing. Tell the person what you are doing and when they will hear back.
How should you document a difficult conversation?
Write a factual, objective record: who was present, the concerns raised, information given, any apology, the plan and any remaining disagreement. Describe behaviour rather than labelling people.
Aggressive son. Shouting at staff. Complained about everything. Told to go to PALS.
15:05. Spoke with patient's son in side room, HCA present. He was upset that discharge was delayed and said no one had explained why. Apologised that he had not been updated. Explained discharge letter awaiting medical review. Agreed I would contact registrar and update him by 15:30. PALS details given at his request. Nurse in charge informed.
Leah, an occupational therapist, assessed a patient as needing a perching stool and rails before going home. His wife said the team was being overcautious and making him dependent. Leah first explained the assessment at length, which made things worse. When she asked what worried the wife most, she learned she was afraid of strangers' equipment taking over their home. Leah acknowledged this, explained the falls risk simply, and offered a joint home visit so they could choose where equipment went. In her reflection she noted that she now explores concerns before explaining.
Getting better at difficult conversations
These conversations get easier with practice and feedback. Pick one habit to work on, such as summarising before explaining, or using one NURSE response before giving information. Watch how experienced colleagues handle hard moments, and debrief afterwards when a conversation has been tough.
Our course Difficult Conversations with Patients and Families covers the NURSE approach, anger and complaints, disagreement, boundaries and documentation, with worked dialogue and reflective prompts. If you also share serious news, Breaking Bad News Training (SPIKES) covers that conversation in detail.
Frequently asked questions
How do you deal with an angry patient or relative?
Stay calm, move somewhere private if safe, and let them speak without interruption. Summarise what you heard and acknowledge the feeling before explaining anything. Then be honest about what you can do, apologise if something went wrong, and agree a specific next step with a time. Get help if you feel unsafe.
What does NURSE stand for in communication?
NURSE stands for Naming, Understanding, Respecting, Supporting and Exploring. It is a set of verbal responses to emotion described by Back and colleagues in 2005. You choose the responses that fit the moment rather than reciting all five in order.
Is saying sorry an admission of liability?
No. An apology is not an admission of legal liability. UK healthcare regulators expect professionals to be open and apologise when things go wrong, as part of the professional duty of candour. Make the apology specific, such as "I'm sorry nobody updated you".
What should I say when a patient demands treatment I don't think is right?
Ask what they are hoping for and what worries them. Explain your reasoning honestly in plain language, discuss the options that are available, and offer a second opinion where appropriate. GMC guidance says patients can refuse treatment but cannot insist on treatment that is not clinically appropriate.
Can I end a conversation if a relative is abusive?
Yes. Calmly name the behaviour and what you need. If it continues, end the conversation, get help from a senior colleague or security, and report the incident. Your safety comes first, and you can offer to continue later once things are calmer.
How long does someone have to make an NHS complaint?
In England, complaints should normally be made within 12 months of the event or of becoming aware of it. Organisations can accept later complaints where it is still possible to investigate. Unresolved complaints can go to the Parliamentary and Health Service Ombudsman. Other UK nations have their own processes.
How should I write up a difficult conversation in the notes?
Record facts: time, who was present, concerns raised, information given, any apology and the agreed plan. Describe behaviour instead of using labels such as aggressive. Use the person's own words for key statements where helpful, and note who you informed.
Related courses
Difficult Conversations with Patients and Families
This course gives you practical, published approaches for conversations that involve anger, disagreement, complaints or expectations that cannot be…
Breaking Bad News Training (SPIKES)
This course teaches a structured, compassionate approach to breaking bad news using the six-step SPIKES framework. Each step is explained with worked…
SBAR Handover Training
This course teaches you to use SBAR (Situation, Background, Assessment, Recommendation) for clear, structured handover and escalation. It shows how…
Sources and further reading
- Good Medical Practice (2024). General Medical Council.
- Decision making and consent. General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Openness and honesty when things go wrong: the professional duty of candour. General Medical Council and Nursing and Midwifery Council.
- NHS Complaint Standards. Parliamentary and Health Service Ombudsman.
- Mental Capacity Act 2005 Code of Practice. Office of the Public Guardian.
- Approaching difficult communication tasks in oncology (2005). CA: A Cancer Journal for Clinicians.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
More guides
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