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 good listening skills.
Click this link to download the Debrief in PDF format
Background
Jim Quinn, a seventy year old man, has experienced cardiac arrest at a golf course. He has been resuscitated and is being brought to the ED by paramedics. An ED team awaits his arrival, they comprise: ED consultant Conor Kelly, Caoimhín Fitzpatrick Medical SHO, Tayyba Ishtiaq ED SHO, Adam Carey, ED Nurse and Joppa Lynne Paris ED Nurse. Three different conversations are covered in this video: an Emergency team brief prior to the patient’s arrival, a conversation between two members of the team and the patient’s wife, and a team debrief.
Clips
There are six clips in this scenario.
FIRST CLIP
TEAM BRIEF
00:00 – 02:25
We see a highly structured conversation, led by Conor the consultant. He leads the introductions, summarises the patient’s situation, assigns roles and actions to the team, and provides staff opportunities to raise questions or concerns. Communication skills in the clip also include use of closed loop communication.
SECOND CLIP
INITATE THE CONVERSATION
02:26-03:57
Shows the start of a conversation between Consultant Conor and the patient’s wife Sarah Quinn, ED nurse Joppa sits in. Conor gathers information from Sarah on what she already knows about what has happened. Conor briefly outlines Mr Quinn’s very serious current condition.
THIRD CLIP
GATHER INFORMATION
03:58- 05:25
Conor gathers information about Jim’s health and working life and past medical history from Sarah using broad questions, before focusing in on some key aspects of Jim’s past medical history.
FOURTH CLIP
GIVE INFORMATION
05:26-07:41
Conor goes through with Sarah what has happened to Jim in terms of his heart and his current state and treatment. Conor emphasises that whilst stable, Jim’s state could change. He explains what will happen next, delivering information gradually, step by step, in small chunks, and checking understanding. He once again notes that whilst stable currently, Jim remains critically ill.
FIFTH CLIP
CLOSE THE CONVERSATION
07:42-08:30
Conor prepares Sarah for going to see Jim by pre-warning her of the presence of monitors, drips, and oxygen mask, and also that Jim probably will not speak but may well be able to hear her. He assures her that he is very willing to speak to her again.
SIXTH CLIP
DEBRIEF
08:31-END
Involves Conor leading the short debrief beginning with a broad question ‘How do you think that went?’. He then seeks suggestions as to how things could improve, before thanking the people in the team.
Communication Skills
FIRST CLIP
TEAM BRIEF
00:00 – 02:25
- Consultant Conor leads a highly structured interaction, accomplishing communication actions that are known to improve safety and quality of multidisciplinary team care.
- First, Conor introduces himself and ensures each other team member introduces themselves by name and by role, this helps ensure each person is aware of one another’s overall roles, responsibilities, and expertise. Having each member of the team speak up at this point can support subsequent open communication between team members with differing levels of seniority.
- Next, he describes the patient’s situation briefly but comprehensively (for instance: “he has been successfully resuscitated… He has an output, but he is not yet conscious”).
- He assigns roles and actions to each member of the team in turn. Each time he has told a team member what he would like them to do, the team member repeats back with something like (“OK, so I’ll draw up some meds and pain relief, I’ll get the medical chart, and I’ll update you when the family’s here”). Their repeating back allows Conor to confirm that he and the team member have shared understanding of what is to be done. It also gives the other team members two opportunities to note what each other team member will be doing. The assigning and then the repeating back are part of a skill termed ‘closed loop communication’. (The third stage of closed loop communication is not recorded in this video, but it involves the team member reporting to the leader and rest of the team that they have actually started or completed the task.)*
- Conor then asks the whole team to ensure they all listen to the paramedics’ handover and explains why (“so we can all get the handover together and we don’t have to repeat ourselves”). Here, Conor aims to ensure that this part of the team’s subsequent communication is also well structured; in the busy period of receiving a patient, it is easy for the paramedic’s report to be missed by some members – Conor is encouraging them to prioritise listening to this important handover.
- Conor checks for concerns and questions (“Is everybody happy with all of that”). You might notice that his wording ‘is everybody happy?’ is tilted towards, i.e. hearable as expecting a yes answer - and indeed we hear the team members chorusing ‘yes’. Other ways of wording this kind of question that have been shown in real-life communication to be particularly effective in getting people to speak up with concerns. These alternative wordings include ‘Now, do you have concerns or questions about the plan?’, or ‘Can I check, are there some things I have forgotten to cover?’ or even ‘Now, what did I forget to cover?’. These latter two wordings can be particularly useful because they mean the leader has already conveyed that they may have missed something. This means that if team members have things they want to raise, they are not put in the uncomfortable position of volunteering that leader is at fault – because the leader has already acknowledged that they may have not done something they should have.
- Joppa raises the matter of oxygen, Conor answers briefly and clearly.
* If you have worked with the ‘Skills for clinical consultations’ video, which features a scenario featuring a urology appointment, you will have read about the conversational norm “don’t tell somebody something they already know”. This norm needs some countering in situations where the patient is aware you already know something of their medical history. The team brief and debrief in this Emergency situations video are much more structured communication episodes – formal structuring overrides (and is designed to override) some everyday conversational norms which could get in the way of good clinical communication practice.
SECOND CLIP
INITATE THE CONVERSATION
02:26-03:57
This is the start of a conversation between Consultant Conor and the patient’s wife Sarah Quinn, ED nurse Joppa joins them. Conor gathers information from Sarah about what she already knows about what has happened. Conor briefly outlines Mr Quinn’s very serious current condition.
- Conor and Joppa enter the room and make introductions, they make eye contact with Sarah, have serious but kind facial expressions, and they introduce one another and their roles.
- By asking Sarah if they may sit down next to her, they treat Sarah’s part in what goes on as important, helping give a sense that this is a conversation where each person’s viewpoint is important. This form of asking for permission, even in circumstances where it is very likely someone is already in full agreement can seem odd. In terms of communication skills, this kind of question can be understood as not so much a straightforward request for consent, as a way of the practitioner conveying that the relationship and conversation entail participation, collaboration, and cooperation between both parties, rather than one in which the practitioner is the sole lead who simply imposes what will happen upon the person they are talking to.
- Sarah expresses her worry, and Conor acknowledges (“I can see that you are worried”) in a way that shows he is noticing her emotions and that her emotions are valid. He might even have added that her worry is normal, which would help convey that how Sarah is feeling is to be expected. This can provide some comfort to distressed people, and can help support them to be calm enough to participate in the conversation.
- Conor tells Sarah he has just been with Jim, thus assuring her that he has direct knowledge upon which to base what he then tells her about Jim’s status. By using and slightly emphasising the term ‘at the moment’ – which he does both now and later in this conversation – Conor gives what is termed a ‘warning shot’. That is, he sensitively conveys that whilst Jim is stable now, he could become unstable and thus even more unwell. Warning shots are a relatively gentle and gradual way of helping people come to an understanding of the graveness of the situation.
- Conor now explores Sarah’s understanding of the current situation with a broad question (“what do you know already?”). This kind of broad question allows practitioners to find out not only what someone knows, but also their emotional state, as well as the kind of terminology they use – including their technical knowledge, or lack thereof. Skilled practitioners tailor what they go on to say according to the person’s own terminology, to what the person has shown they know, and to what they have shown they understand.
- Conor conveys active listening (nodding, leaning in, making eye contact) thereby conveying he is attentive to Sarah and encouraging her to say more.
- Sarah says she understands Jim has ‘collapsed’, Conor builds on this by adding more specific information – that Jim has had a heart attack.
THIRD CLIP
GATHER INFORMATION
03:58- 05:25
This clip shows the next stage of the conversation between Conor and Sarah (where Joppa the ED nurse is also sitting in).
- Conor asks Sarah for Jim’s background medical history in such a way that Sarah’s knowledge is treated as important and helpful, and in such a way as to encourage her to give a fulsome answer.
- Conor uses more focused questions to investigate some aspects further (including Jim’s diabetes and his past heart attack).
FOURTH CLIP
GIVE INFORMATION
05:26-07:41
- Conor goes through with Sarah what has happened to Jim in terms of his heart and his current state and treatment. He uses clear, simple terms to try to ensure Sarah is able to follow what he is saying, despite her obviously very worried state.
- Conor moves to say more directly just how unwell Jim is (“he’s still critically ill”). He has gradually moved from ‘stable at the moment’ to ‘critically ill’. In giving bad news, this kind of step by step progression works to gradually take Sarah into a more full understanding of the seriousness of the situation. Often, this gradual step by step movement in giving bad news reduces the likelihood that the relative (or patient themselves) suffer severe distress that would make carrying on the conversation difficult. Waiting until this point in the conversation to more directly say how ill Jim is also means Conor has been able to observe that whilst distressed, Sarah is not overwhelmed by emotion and seems able to take in what she is being told.
- Sarah asks for prognosis (“Do you think he’s going to pull through doctor? To recover from this?”). Her question confirms that she recognises just how serious the situation is. Conor responds by restating the current situation and that things could change. In doing so, he avoids committing a prediction which would be impossible to make with any accuracy at this point.
- He could have acknowledged Sarah’s question somewhat more directly by telling her that it is not possible to answer her question at this point, and he could even have made a ‘wish statement’ – along the lines of ‘I wish I could answer that for you Sarah, but it is not possible to tell yet’ – wish statements can be useful as affiliative and empathic ways of dealing with difficult questions such as Sarah’s. A wish statement from Conor would be a way of conveying that he absolutely recognises her keen wish to know if her husband will survive, and that this is understandable, whilst nevertheless avoiding making a prediction that may end up being erroneous.
- Conor now moves on to inform Sarah that Jim will be moved to a specialist unit at another hospital for other treatments. He paces this information slowly, and in small chunks, helping increase the likelihood that Sarah will be able to follow what is said, despite her understandably distressed state. Where he uses technical terms, ‘angioplasty’, ‘stents’, he checks whether Sarah understands, and builds on what she says so as to ensure her understanding.
- Conor reiterates that Jim is critically ill, that he is stable but may change, and that he will remain so until he has received interventions at the specialist hospital.
- Conor now screens for questions from Sarah (“I’ve shared a lot of information with you there Sarah, can I just check if there’s any questions that you’d like to ask?”) You may well have been taught to use the word ‘any’ in this kind of screening question. However, we now know that it is ideal to avoid the word any if you want to encourage someone to say more. This is because ‘any’ pushes for – it’s tilted towards – the negative (for instance ‘I don’t have any pain’ makes sense, whereas ‘I have any pain’ does not). Alternatives that can work better include: ‘Do you have other questions?’ and ‘Have you some questions or concerns you want to mention?’
- Conor reassures Sarah that they are doing all they can for Jim whilst they await his transfer to the specialist hospital. This is important as people sometimes assume that when some other care or intervention is being awaited, current care involves basically ‘doing nothing’.
FIFTH CLIP
CLOSE THE CONVERSATION
07:42-08:30
- Conor prepares Sarah for going to see Jim by explaining the monitors and drips and oxygen mask, and by explaining that Jim probably will not speak but may well be able to hear her. Rather like a ‘warning shot’, this helps prewarn Sarah, making it less likely that Sarah will become overwhelmed by shock upon seeing Jim.
- Conor assures Sarah that he will remain available to answer questions.
SIXTH CLIP
DEBRIEF
08:31-END
Here we observe the team debrief after Jim has left the ED team’s care. In this clip:
- The whole team treat this as a tightly structured and brief conversation, Conor takes the lead in building this structure. There are of course many occasions in healthcare where conversations work better where they are not formally structured, but briefs and debriefs are more effective where there is a very clear and formal structure and leader.
- Conor introduces the debriefing, (“if we take a minute or two before going back to our other tasks to have a bit of a debrief”) in a way that sets up that what is to come will be a very brief meeting. He then asks a broad question (“How do you think that went?”), sweeping his gaze around the whole team. The broadness of his question enables a wide range of responses, because it does not restrict the focus to one aspect of what happened.
- Conor asks another question which, whilst still fairly broad, is focused on what went less well (“Any suggestions for how we could improve?”). Using we rather than ‘I’ here is helpful, as it does not put the team members in a position of implying in public some shortcoming in the leader. As mentioned above in this briefing sheet, we now know that the word ‘any’ tends to push towards negative rather than positive responses. Alternative wording which might encourage even more responses than we see in this video would be something like ‘What could we improve?’ or “I’d really welcome suggestions for how we could improve”.
- Taybba raises a matter for improvement, and Conor shows clearly that he agrees and appreciates this suggestion – this helps show that he is genuine in wanting to hear from team members about things that could be improved. He also articulates a clear plan to act on this suggestion in subsequent situations.
- One additional element in debriefing, not shown in this video, takes into account that there may be reasons for people not to want to speak up during a team meeting, and that they may have important things to say but would only want to do so in a one-to-one conversation. A subtle way of enabling this is to say something like: ‘If by any chance you think of something later, please do come and find me and let me know’.
- Conor ends the debrief by thanking the staff involved.