Giving feedback (6.46 mins)

Note on using this video

Read the background information to understand the scenario context. On watching the video, observe the communication skills used to achieve the intended outcome. While individuals may use different words and phrasing, the videos illustrate important core communication skills. There may be some areas of the conversation where other skills could have been used or the skills could have been used differently.

The communication skills sheet overleaf includes some examples of different wording for particular skills.

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 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 viewers reflect on core communication skills and how these skills are used with different emphasis in different situations. 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 the particular skills you want learners to observe.

Supporting materials

Visit our webpage for supporting materials on communication skills for Giving Feedback.

Click this link to download the Debrief in PDF format

Background

Professor Mary Higgins is a Consultant Obstetrician & Gynaecologist in a large maternity hospital. Yesterday in theatre she observed her fellow consultant Dr John Costello being abrupt with his registrar Dr Janette Laffan and later she saw Dr Laffan in tears in the theatre changing rooms. Professor Higgins has decided she needs to raise her observations with Dr Costello and is going to meet him in his office.

Note 1: The cup of coffee intervention (seen in this video) is the one recommended by the healthcare organisation at Vanderbilt in the US and is known as the ‘Vanderbilt’ intervention. It involves either arranging a conversation with the person oneself or enlisting a senior manager to do this. The approach involves four steps:

1. Describe the behaviour
2. State your concerns
3. Invite a response
4. Conclude

The aim is to raise awareness, encourage reflection and reinforce expected standards of behaviour without being judgemental.

Note 2: There are many different models for giving feedback. The Calgary-Cambridge Guide is the preferred communication skills framework in the HSE and is the framework used for this conversation. It may help to think of communication skills as tools in a toolbox, to be applied as and when needed.

Clips

There are three clips in this scenario.

FIRST CLIP​
INITIATE THE CONVERSATION
00:14 – 01:15

Mary uses good communication skills to build rapport with John (Greeting and attending to comfort; Acknowledging emotions; Agenda setting; Seeking permission and Demonstrating empathy).

SECOND CLIP​
SHARE/GATHER INFORMATION
01:16 – 06:18

Mary delivers the unwelcome information in a step by step and sensitive way, she 1. Describes the behaviour, 2. States her concerns, 3. Invites a response and conveys empathy. Mary gives John time to respond and actively listens to him.

THIRD CLIP​
CLOSE THE CONVERSATION
06:19 – END

Mary invites John to give her feedback in the future and they close the conversation.

Communication Skills

FIRST CLIP​
INITIATE THE CONVERSATION
00:14 – 01:15

This is the start of a conversation between Professor Mary Higgins and her colleague Dr John Costello. In this clip:

• Mary enters the room with a cup of coffee in her hand and greets John.
• By asking John if he has a moment and signposting (“ I want to talk to you about something ”), Mary makes it clear that there is a specific issue she wants to discuss. Largely through her tone of voice, Mary conveys to John that the conversation will entail participation and collaboration between both parties.
• Mary positions herself so she is fairly close to John and can look directly at him. She places a coffee cup on the desk with (“ Thought you could do with one of those ”). With this positioning of herself and bringing the coffee, she shows she is attending to his comfort and open to an empathic conversation.
• John responds with (“ Thanks Mary. I haven’t had time for a break at all. It’s been a crazy day ”). Mary acknowledges (“ Yeah, the hospital’s really busy at the moment. Everyone’s under pressure ”) in a way that shows she notices how he is feeling and that his feelings are valid. Even very early on in the conversation, a skilled listener can pick up important hints about the person they are talking with.
• In a signposting and permission-seeking move, Mary says (“ That’s what I want to talk to you about today John, If you had a moment?” ) Notice she words this as a question, John could in theory refuse this... but he confirms nonverbally (nodding) and turning towards her that he is happy for her to proceed.
• In chunks, at a slow pace, Mary describes what she has observed (“ I’ve been a bit worried about the atmosphere in theatre... yesterday when I came in, people seemed... upset... I wanted to talk to you about that...is that something you have the headspace for at the moment? ”). In this way, Mary gives John a second opportunity to refuse... John confirms that he is happy to proceed (“ Sure ”).
• By using and slightly emphasising the term ‘at the moment’ – which she does both now and later in this conversation – Mary sensitively conveys her empathy for how busy and stressed John appears to be at the present time.
• Although she is initially providing information to John, Mary also uses silence and non- verbal encouragers (eye contact, leaning, warm expression, nodding) to encourage John to share how he is feeling. He responds with (“ I know things haven’t been great in theatre... I can’t remember the last time we finished on time ”).

SECOND CLIP​
GATHERING INFORMATION
01:16 – 06:18

In this clip, Mary describes John's behaviour, states her concerns and invites a response from John. She listens to understand what he is saying and any underlying messages and emotions.

• Mary builds on what John has said by adding more specific information about what she has observed ("Yesterday, when I was in theatre, it seemed to me that you were stressed").
• Mary then moves to on from John's observed behaviour to her concerns ("seemed that maybe you were giving the reg a... hard time "). In giving feedback (essentially bad news) this step by step progression works to gradually take John into a more full understanding of the seriousness of the conversation. This approach reduces the likelihood that John will dispute the observations and Mary's interpretation... which would make carrying on the conversation more difficult.
• Waiting until this point in the conversation to more directly describe John's behaviour and her concerns also means Mary has been able to observe that whilst not happy with hearing this feedback, John seems to be able to take in what he is being told.
• As in several other places in this conversation, Mary acknowledges John professionalism (" I know how supportive you are of the trainees and how much you want to improve them "). In this way Mary softens the bad news element of her feedback by showing that she appreciates John's strengths and that this current behaviour is out of character. Mary then pauses and uses active listening (nodding, leaning in, making eye contact) to show she is attentive to John and encouraging him to respond to what she has said.
• Rather than bluntly tell John that his behaviour is not acceptable, Mary continues her step-wise approach. She first acknowledges the importance of feedback and that she herself has received feedback in work. Then she cautiously outlines the skills need to provide effective feedback, ("it's how you do it... we both know... using the right skills can result in action and improvement...").
• Mary explains more about the importance of feedback, ("aims to improve patient safety and outcomes "). She continues to express empathy, to validate John, and to link what she is talking about to his professionalism ("things I know you care about").
• Silence, verbal ("mm-mm", Uh-huh ") and non- verbal encouragers (eye contact, nodding) encourage John to respond to what Mary has said.
• John responds with, (" I hadn't expected this feedback from you?").
• With gentle, non-judgmental tone, Mary uses an open question, ("what's your take on it ") to attain John's views on the situation and behaviour that she is describing.
• John responds by being defensive and slightly angry and Mary responds to his emotions in several ways – firstly by staying calm and not disputing what John says. Instead she redirects the conversation using good non-verbal communication and staying on message ("... John I'm talking about you..."). She validates his professionalism by acknowledging that he is... ("someone who cares about patients and their outcomes...").
• By acknowledging and validating how he feels, she builds the relationship with John and encourages him to participate in the conversation.
• Mary then moves the conversation forward, ("For the last couple of weeks... it seems to me... that you have been quite stressed... people are tiptoeing about you... not making a great atmosphere to work with").
• Mary uses an open question ("What's going on?"). This gives John freedom to tell Mary whatever he feels comfortable telling her, helps to build affiliation and establishes John as an equal partner in the conversation.
• Mary uses silence, verbal ("mm-mm") and nonverbal encouragers (nodding, leaning, eye- contact) to give John a safe space to respond ("It's hard to hear your feedback...I appreciate you letting me know").
• John reflects back to Mary what he is hearing, ("...that there is an issue with how I am talking to the junior staff... it's making people on the team feel stressed and uncomfortable"). Giving John the space to repeat is useful because it shows Mary that John has heard exactly what she has said. It also gives Mary the opportunity to add further information. (Note: If John had not been so forthcoming Mary could have said something like... ('so can you tell me what you think of what I've said').
• Mary again builds affiliation by reminding John that she knows he cares about these things and ("I know you care about these things"). She reinforces his autonomy in relation to what happens next ("I know you would reflect on this feedback").
• Mary provides ongoing cues throughout the interaction that she is listening, ("Ok" and "Mm-mm", maintaining eye-contact, nodding and leaning), her tone of voice and body language imply an interested and caring attitude. These skills enable her to encourage John to respond ("I didn't realise my behaviour was having this kind of impact") and share his concerns ("I have been under a lot of pressure lately").
• Mary uses a step-by-step approach towards the sensitive matter of what is stressing John – this is an important skill. Mary first step is to convey, with empathy, that she recognises how difficult this is for John ("I'm really sorry to hear about that").
• Demonstrating empathy can help to absorb some of the tension in healthcare conversations and gives John permission to feel and to express his concerns. Mary validates what John is feeling ("I know you've been under a lot of stress..."), this skill enables her to convey that John's emotions are understandable and reasonable, which gives John encouragement and permission to say more.
• In her next step, she works to find out what John is thinking about next steps She does so by using an open question ("What do you think would help?"). This also invites John's collaboration in working to solve the problem. That is, in responding to Mary's relatively broad question about what might help, John himself raises a key, sensitive matter ("I know I'm struggling"), rather than Mary directly imposing this topic on him.
• Mary and John are now clearly 'on the same page' – both now talking about John's struggles and how Mary and the team can support him ("What can we do to help?"). John remains silent and Mary shares her thinking about a possible option for John ("One of the things I am thinking... is that maybe a little bit too much at the moment?"), her tone of voice and body language imply an interested and non-judgemental attitude. These skills enable her to encourage John to consider thinking about taking a break from his clinical lead role to allow him to concentrate on his family at the moment.
• Mary uses silence, verbal ("mm-mm") and nonverbal encouragers (nodding, leaning, eye- contact) to give John a safe space to respond ("I thought I'd be able to take on the leadership role... it's just not working out as I had hoped").
• Mary uses an evocative question to guide John to reflect on a possible option which may be difficult for him to say out loud ("Do you need to maybe take a step back from that (leadership role) at the moment?").
• John responds by articulating his concern about taking this option ("People will think I am a failure..."). Using the words ("I think people are more likely to think you are strong"), Mary offers a reframe for how John is approaching the situation. John responds ("Maybe I could take a step back for a while...") and supports him to move the conversation towards thinking about next steps ("So practically speaking..."). We see and hear towards the end of this clip John's relief in having the opportunity to talk about his concerns and plan next steps to manage these ("I'm really grateful you dropped by... I'm beginning to feel less anxious already...")

THIRD CLIP​
​CLOSE THE CONVERSATION
06:19 – END

In this clip, Mary invites John to give her feedback in the future if he notices that her behaviour does not meet expected standards. They close the conversation.