Note on using this video
Read the background information to gain an understanding of the scenario context. On watching the video, you might feel that while many of the skills are good, perhaps there are some that you might do differently. To support your thinking on this, the communication skills sheet overleaf includes some examples of different wording.
As in any acted version of a healthcare conversation, you will notice that the video does not capture the full nuance of real-life communication. Instead, it highlights in a simplified, sometimes repeated manner, skills that are known to make healthcare conversations easier and more effective. The intention is not to teach skills ‘by rote’ and to learn wording by heart, but rather to help engage viewers in reflecting on what they communicate and how they do so.
The video includes multiple phases and skills. If you are using it in a teaching session, It can be useful to think in advance about particular skills you want learners to look out for.
Supporting materials
Visit our webpage for supporting materials on communication skills for shared decision-making.
Click this link to download the Debrief in PDF format
Background
Mrs Caoimhe Doherty and Sean her 10-year son are consulting with Clinical Nurse Manager Joppa Lynne Paris. Sean has had recurrent attacks of fairly severe tonsillitis over the past two years causing him to miss school and requiring antibiotics from his general practitioner (GP). Today he is well and physical examination shows enlarged tonsils. He is otherwise well.
A note on the particular type of shared decision in this scenario
This scenario features a decision in which there are two treatment options, and equipoise between them (i.e. it is not clear that one is better than the other, and each has pros and cons). Different challenges can arise, and some different communication skills are needed where there are multiple options, where one option is clearly preferable, and where there is only one option.
Clips
There are five clips in this scenario.
FIRST CLIP
INITIATE THE CONVERSATION
00:00 – 00:43
Joppa uses good communication skills to build rapport with Caoimhe and Sean.
SECOND CLIP
SHARE YOUR THINKING
00:44 – 01:44
Joppa identifies that there is a choice to be made at this consultation and describes how she, Caoimhe and Sean will go through the pros and cons of each option.
THIRD CLIP
EXPLORE OPTIONS
01:45 – 04:54
Joppa describes the two treatment options and clearly communicates the risks and benefits of each option. She uses a slow pace and small chunks to give the information to Caoimhe and Sean and regularly pauses to check understanding.
FOURTH CLIP
NEGOTIATE THE PLAN
04:55 – 05:45
Joppa confirms the decision by asking Caoimhe and Sean to describe the option that has been chosen.
FIFTH CLIP
CHECK WITH THE PATIENT
05:46 – END
Joppa checks that Caoimhe and Sean are happy with the plan by inviting questions, observing Caoimhe and Sean’s nonverbals and agrees next steps.
Communication Skills
FIRST CLIP
INITIATE THE CONVERSATION
00:00 – 00:43
- Joppa starts the conversation with a warm greeting (“Good morning, is it Mrs Doherty?”... “and this must be Sean”), and she identifies herself by name and establishes her role (“My name is Joppa, I’m one of the paediatric nurses…”). She uses positive nonverbals to build rapport with Caoimhe and Sean (eye contact, leaning, sitting at the same level, warm facial expression and tone of voice).
- Joppa clarifies the agenda for this conversation, (“I’m just going to have a chat with you for a few minutes...then we’ll think about how we can help you best?”). She uses active listening skills (eye contact, nodding, sitting at the same level, warm facial expression) to listen to Caoimhe’s story. This helps to build rapport and trust and helps the rest of the conversation to flow more smoothly.
SECOND CLIP
SHARE YOUR THINKING
00:44 – 01:44
- Joppa empathises with Caoimhe (“I can see you’re worried about Sean…”). Because practitioners cannot know precisely how a patient or a parent feels, it can be helpful to use alternative wording to what we see in this video: something like ‘It sounds like you’re worried’, or... “I can imagine that you’re worried about Sean”. By avoiding sounding like they definitely know what the patient or parent is feeling, the practitioner can show they are trying to understand, whilst not claiming to know precisely what is being felt. This avoids suggesting they know the patient’s feelings better than the patient themself knows them.
- She then makes it clear that there is a decision to be made between two options, this ensures clarity for Caoimhe and Sean that there is a healthcare choice to be made, and it also helps convey the decision as shared, rather than a recommendation to be made by Joppa alone. (“So Caoimhe there are two main options of treatment for Sean…”)
- Joppa signposts how the consultation will proceed, (“I will talk about each of them in turn, and then we can go from there…”)
- Joppa provides ongoing cues throughout the interaction that Caoimhe’s input in the decision making process is important, (“Is that ok?”)
- Joppa summarises the starting point for the decision around Sean’s tonsillitis, (“So for children like Sean, under 16 years of age, we have two options…”) and pauses using non-verbal encouragers (eye contact, nodding), giving Caoimhe space to respond and then identifies the emotion that she sees (“I can see you’re worried about Sean and the impact the recurrent tonsillitis is having on him”), and she shows she has picked up that Sean missing school is a particular concern for Caoimhe.
- She again signposts how the conversation will proceed, (“That’s why we need to work together and to go through the choices carefully…”).
- Joppa also indicates that any decision made today is not a fixed one (“Whatever we decide today can be changed depending on how Sean gets on.”). This ensures that Caoimhe understands that there is future flexibility, and doing this can help the person feel under a bit less pressure.
THIRD CLIP
EXPLORE OPTIONS
01:45 – 04:54
- Joppa continues to structure the conversation for Caoimhe and Sean using signposting (“…there are two main options of treatment”). This clarifies for Caoimhe and Sean how the conversation will proceed and promotes collaboration with Caoimhe and Sean feeling a partner in the conversation with Joppa.
- Joppa lists the two choices (“the first one is called watchful waiting”... and the...“second one is a tonsillectomy”).
- Joppa provides further structure by telling Caoimhe and Sean that she will now go through the two options and implies that the options are relatively balanced – rather than one being clearly preferred (“there are pros and cons to both of these options and we’ll go through them now”).
- Joppa describes the options in plain language (“So the first one is called watchful waiting…”). She uses numerical data to describe outcomes and risks (“So about 30 out of 100 children like Sean… and... “this can happen to about one in every 100 children”). Using numbers is preferable to using descriptive words because different people can interpret terms, for example - unusual and common in different ways.
- Describing the approach as watchful waiting, and clearly explaining reasons for it, helps reduce the chance that Caoimhe will hear what is proposed as ‘doing nothing’.
- Joppa explains the options in the context of what Caoimhe has already told her (“So it’s basically what you’ve been doing with Sean”). This kind of repetition can be useful because it shows that Joppa has heard what Caoimhe and Sean have said and gives her an opportunity to say more about the decision or to ask further questions. Joppa uses plain language (“With this option, Sean may still have some sore throats…”) when talking about the risks.
- Joppa continues to build rapport with Caoimhe by using her name during the conversation (“That’s a good question, Caoimhe”).
- Joppa validates what Caoimhe is feeling (“it does sound frightening…”), this skill enables her to convey that Caoimhe’s concerns are understandable and reasonable, which gives Caoimhe encouragement and permission to express her concerns.
- Joppa demonstrates active listening, by acknowledging and responding to Caoimhe’s concern about bleeding with (“it does sound frightening… but these are very rare”).
- Joppa emphasises partnership in the decision-making process, using words like (“Sean, do you have any questions for me?”). This promotes collaboration with Caoimhe and Sean feeling involved in the decision-making process.
- Note in this video, Joppa uses the phrase “do you have any questions?”, even though this is what most communication guidance recommends, we now know from communication science that using the word some is rather more likely to get patients to answer in the positive. This is because ‘any’ pushes for - is tilted towards – the negative (for instance ‘I don’t have any pain’ makes sense, whereas ‘I have any pain’ does not). So an alternative Joppa could have used is ‘Sean do you have some questions for me?’.
FOURTH CLIP
NEGOTIATE THE PLAN
04:55 – 05:45
In this clip, Joppa summarises the decision:
- Joppa summarises the two options again, and she leaves space for Caoimhe confirms her understanding of the options, (“so continue on as we have been or go for the operation…”).
- Joppa invites Caoimhe and Sean to ask questions (“I’ve given you a lot of information today, you must have questions? What questions do you have for me?”) and uses silence and non-verbal encouragers (eye contact, nodding), encouraging Caoimhe and Sean to ask questions. This wording encourages them to ask questions more strongly than does wording such as ‘any other questions?’.
- She encourages partnership/shared decision making (“So Caoimhe, I would like us to make a decision together”) and explains to Caoimhe and Sean that the decision is not urgent and can be reviewed again (“I would like you to go home and speak to your husband and Sean about this”).
FIFTH CLIP
CHECK WITH THE PATIENT
05:46 – END
In this clip, Joppa checks that Caoimhe and Sean are comfortable with the plan and that she can close the consultation.
- Joppa offers written material to Caoimhe and Sean to take away (“So here is a leaflet about everything that we talked about”).
- Joppa signposts that she is making a record of their discussion in the notes and the decision that they made (“I’ll make a record in Sean’s notes about our conversation today”).
- Joppa puts a safety net in place (“I’ve put my number in the back of the leaflet for you, so if you have any questions...”).
- Joppa moves towards the end of the consultation a warm closing... (“It was lovely to meet you both”).