Communication Skills
Train the Trainer Teaching Pack
This document is to help you deliver the 3 hour session on communication skills which has the following learning objectives.
Describe the barriers to effective communication
Discuss the impact of blocking behaviours on communication
Describe the key verbal and non-verbal skills required for communicating with patients and families
Describe the key verbal and non-verbal skills required for giving information to patients and families
Outline a model for structuring the interview
Describe a stepped approach to managing strong emotions e.g. anger and the task of Breaking Bad News
If you require any help or further information please contact Sandra Winterburn at the email address below.
Suggested Timings for this session
Introductions of self and participants. Importance of names.
Identification of individual & overall learning objectives / 15 mins / 1-3
Setting the Scene- Why teach about communication skills?
Evidence base and complaints / 10 mins /
4 & 5
Barriers to communication / 15 mins /
6 & 7
The importance of non- verbal communication
Exercise followed by discussion / 15 mins /
8 & 9
Blocking Behaviours
Role play demonstration of an interview that inhibits communication includes leading and multiple questions, use of technology, minimising /normalising and poor non-verbal communication. Use workbook as a resource for more information on these. / 20 mins / 10
Workbook resource
Key communication skills
After role play demonstrating Blocking behaviours ask group to identify what skills should be used in order to facilitate communication. Role play these and prompt discussion on effectiveness / 20 mins / 11
Workbook resource & Appendix 1
Present slides on the structure of an interview and discuss with group / 15 mins / 12-16Appendix 2
Skills for Information Giving
Use the Chinese whisper exercise and discussion / 20 mins / 18 &19
Appendix 3
Challenging communication –Managing Anger
/ 25 mins / 21-28
Videos
Appendix 4
Challenging communication- Breaking Bad News / 25 mins / 29-38
Appendix 5
Appendix 1: Core skills
Process Skill / Examples / ImpactOpen
and
Closed questions / “Can you tell me about the pain you have been having?”
“Do you ever wake up with a headache in the morning” / -Using open questions first enables you to obtain a picture of the patient’s problem from their perspective.
-Closed questions clarify points or screen for areas not yet mentioned after first getting a wider view of the problem
Signposting / “Is it ok if we now move on to talk about your lifestyle as this might help me understand what might be causing your ….. ?” / -Helps the patient understand where the interview is going and when moving to different parts of the consultation.
Summarising / “So the pain started 12 hours ago and has now improved but you are worried the vomiting is now getting worse” / -Demonstrates you have been listening.
-Gives the patient the opportunity to confirm or correct your interpretation.
-Allows you to clarify and order your thoughts.
-Summarizing emotions allows you to show you are interested in the illness and not just the disease aspects of the patient story.
Screening / “Is there something else that’s a concern for you at the moment?”
“Is there something else you think I have missed?” / -Useful to consider after the patient has described their presenting complaint.
-Allows the interviewer to discover the patient’s full problem list and then plan the rest of the consultation appropriately (set the agenda).
-Helps patients to reveal their important concerns early on.
Clarifying / “Can you tell me more?”
“Could you explain what you mean by light headed?”
“When you say dizzy do you mean the room actually spins around?” / -Useful when patient statements may have 2 meanings
-Improves accuracy
-Demonstrates you are listening
-Gives the patient an explicit opportunity to explain further
Example Questions for asking about the Patients perspective- ICE
Appendix 2: The Calgary Cambridge Model to structure Interviews.
Ref: Silverman, Kurtz and Draper
Whilst there are many consultation models on offer this training is based on the Cambridge-Calgary consultation model described in the book Skills for Communicating with Patients. The model was developed by its authors to organise communication skills within a structure that is comprised of several objectives or outcomes and supported by many different skills that help achieve them. Neither the objectives or skills are arbitrary – they are based on forty years or more of evidence-based research and on the basic established principles that govern all forms or effective communication. See page below for a detailed description of the 71 different skills that underpin this model.
INITIATING THE SESSION
Establishing initial rapport and setting the Agenda for the interview
1. Greets patient and obtains patient’s name
2. Introduces self, role and nature of interview
3. Demonstrates respect and interest, attends to patient’s physical comfort Identifying the reason(s) for the consultation
4. Identifies the patient’s problems or the issues that the patient wishes to address with appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)
5. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response
6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything else……?”)
7. Negotiates agenda taking both patient’s and physician’s needs into account
GATHERING INFORMATION
Exploration of patient’s problems
8. Encourages patient to tell the story of the problem(s) from when first started to the present in own words (clarifying reason for presenting now)
9. Uses open and closed questioning technique, appropriately moving from open to closed
10. Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on afterpausing
11. Facilitates patient's responses verbally and non–verbally e.g. use ofencouragement, silence, repetition, paraphrasing, interpretation
12. Picks up verbal and non–verbal cues (body language, speech, facialexpression, affect); checks out and acknowledges as appropriate
13.Clarifies patient’s statements that are unclear or need amplification (e.g.“Could you explain what you mean by feeling overwhelmed")
14. Periodically summarises to verify own understanding of what the patient hassaid; invites patient to correct interpretation or provide further information.
15. Uses concise, easily understood questions and comments, avoids oradequately explains jargon
16. Establishes dates and sequence of events
Additional skills for understanding the patient’s perspective ICE
17. Actively determines and appropriately explores:
• patient’s ideas (i.e. beliefs re cause)
• patient’s concerns (i.e. worries) regarding each problem
• patient’s expectations (i.e., goals, what help the patient had
expected for each problem)
• effects: how each problem affects the patient’s life
18. Encourages patient to express feelings
PROVIDING STRUCTURE
Making organisation overt
19. Summarises at the end of a specific line of inquiry to confirm understanding before moving on to the next section
20. Progresses from one section to another using signposting, transitional statements; includes rationale for next section
Attending to flow
21. Structures interview in logical sequence
22. Attends to timing and keeping interview on task
BUILDING RELATIONSHIP
Using appropriate non-verbal behaviour
23. Demonstrates appropriate non–verbal behaviour
• eye contact, facial expression
• posture, position & movement
• vocal cues e.g. rate, volume, tone
24. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport
25. Demonstrates appropriate confidence
Developing rapport
26. Accepts legitimacy of patient’s views and feelings; is not judgmental
27. Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledges patient's views and feelings
28. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self-care; offers partnership
29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination
Involving the patient
30. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now is....”)
31. Explains rationale for questions or parts of physical examination that could appear to be non-sequiturs
32. During physical examination, explains process, asks permission
EXPLANATION AND PLANNING
Providing the correct amount and type of information
33. Chunks and checks: gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to proceed
34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information, discovers extent of patient’s wish for information
35. Asks patients what other information would be helpful e.g. prognosis
36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely
Aiding accurate recall and understanding
37. Organises explanation: divides into discrete sections, develops a logical sequence
38. Uses explicit categorisation or signposting (e.g. “There are three important things that I would like to discuss. 1st...” “Now, shall we move on to.”)
39. Uses repetition and summarising to reinforce information
40. Uses concise, easily understood language, avoids or explains jargon
41. Uses visual methods of conveying information: diagrams, models, written information and instructions
42. Checks patient’s understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary
Achieving a shared understanding: incorporating the patient’s perspective
43. Relates explanations to patient’s illness framework: to previously elicitedideas, concerns and expectations
44. Provides opportunities and encourages patient to contribute: to askquestions, seek clarification or express doubts; responds appropriately
45. Picks up verbal and non-verbal cues e.g. patient’s need to contributeinformation or ask questions, information overload, distress
46. Elicits patient's beliefs, reactions and feelings re information
Planning: shared decision making
47. Shares own thinking as appropriate: ideas, thought processes, dilemmas
48. Involves patient by making suggestions rather than directives
49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences
50. Negotiates a mutually acceptable plan
51. Offers choices: encourages patient to make choices and decisions to the level that they wish
52. Checks with patient if accepts plans, if concerns have been addressed
CLOSING THE SESSION
Forward planning
53. Contracts with patient re next steps for patient and professional
54. Safety nets, explaining possible unexpected outcomes, what to do if plan isnot working, when and how to seek help
Ensuring appropriate point of closure
55. Summarises session briefly and clarifies plan of care
56. Final check that patient agrees and is comfortable with plan and asks if anycorrections, questions or other items to discuss
OPTIONS IN EXPLANATION AND PLANNING (includes content)
IF discussing investigations and procedures
57. Provides clear information on procedures, eg, what patient might experience,how patient will be informed of results
58. Relates procedures to treatment plan: value, purpose
59. Encourages questions about and discussion of potential anxieties or negativeoutcomes
IF discussing opinion and significance of problem
60. Offers opinion of what is going on and names if possible
61. Reveals rationale for opinion
62. Explains causation, seriousness, expected outcome, short and long termconsequences
63. Elicits patient’s beliefs, reactions, concerns re opinion
IF negotiating mutual plan of action
64. Discusses options eg, no action, investigation, medication or surgery, non-drugtreatments (physiotherapy, walking aides, fluids, counselling, preventivemeasures)
65. Provides information on action or treatment offerednamesteps involved, how it worksbenefits and advantagespossible side effects
66. Obtains patient’s view of need for action, perceived benefits, barriers,motivation
67. Accepts patient’s views, advocates alternative viewpoint as necessary
68. Elicits patient’s reactions and concerns about plans and treatments includingacceptability
69. Takes patient’s lifestyle, beliefs, cultural background and abilities intoconsideration
70. Encourages patient to be involved in implementing plans, to take responsibilityand be self-reliant
71. Asks about patient support systems, discusses other support available
References:
Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford)
Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)
Appendix 3: Information giving Exercise. The Crash
Use the exercise below or a story of your own choosing
Objective
This exercise demonstrates what happens when information is retold from person toperson without the benefit of being able to ask questions or receiving writteninstructions. It explores how much information is remembered accurately, how much it may be understood /altered in the retelling. This exercise involves the whole group although only five will be involved in the retelling of the story.
It takes approximately 20minutes.
Setting up the Exercise
Take a least one copy of your chosen story to the training
Set up two chairs at the front of the room.
•Ask for five volunteers. Explain that three of them will leave the room and that each one will come back in turn and will be told a story which they will then tell the next person who enters the room. Ask them to agree the order in which they will come back into the room.
•For the participants not involved in the story telling you could allocate specific roles so they become active listeners and participants. For example which parts of the story always get retold accurately, which parts get lost and which parts get confused.
•Sit the two volunteers who have remained in the room in the chairs at the front of the room and give a copy of the story to one of the 2 volunteers. This volunteer will read the story from the script to the other volunteer and the rest of the group.
•When the first story teller has completed the story ask them to take a seat with rest of the participants. Take the written story from them Invite the first of the three volunteers outside of the room to return and take the empty seat at the front.
•Ask the second volunteer who listened to the story to retell it to the participant who has just seated themselves. If participants ask state they must not write any notes or ask questions.
•When the story telling is complete.
•Invite the fourth of the volunteers outside the room to come in and take the vacated seat. It is now the turn of the previous listener (the third volunteer) to retell the story.
•When they are complete again ask them to rejoin the group. Invite in the last of the volunteers outside the room to come in and listen to the story from the last listener.
•For the last volunteer they retell the story to the group.Ask the last participant to read the story again to the rest of the group asking is this the story you just heard?.
Debriefing Notes
Discuss with the group how the information changed.
Consider the following questions-.
What was included what was left out ?
– Usually the title the beginning and the end tend to be remembered
-What happened to the more difficult middle part? Sometimes there can be
fabrication to make sense out of parts less understood
Were there particular words which seemed to be remembered?
What happened to the detail?
What would have made it easier to remember?
Was the story changed in its meaning?
Clinical relevance:
Amount of information which can be assimilated check/ summarise
? Remember only the beginning and the end.
Role of written information in improving recall
? Importance of having a relative/carer present
If the same words tend to be remembered – why – use language
relevant/appropriate for your patient
How patients might relay results of conversation to carers etc.
What are the specific skills we would teach to students?
Acknowledgements to Connected Advanced Communication skills programme for this material.
Appendix 4: Manging Anger
Purpose of anger – may serve a collective as well as individual purpose
New Scientist article w
Anger in the consultation
Leeds Children’s Heart Surgery Review March 2014 – see Family experience report for trigger statements
NB Cambridge Calgary skills key but the following mnemonics may be helpful:
RAGE (Recognise, Acknowledge/Apologise, Gather information, Empathise and Explore)and
LEAPS (Listen, Empathise, Ask, Paraphrase and Summarise)
Avoid “Blocking behaviours” described in Advanced Communication Skills Handbook such as: multiple questions, leading questions, interrupting, selective attention to cues, premature advice or reassurance, normalising, minimising and using jargon.
Self management
TED lectures – Brad Bushman – neurobiology of anger – link between anger and hunger
Thomas Kilman (on line questionnaire ) – different individual preferences to deal with conflict – may be helpful in knowing own tendency and that there are other ways /skills in choosing the right approach at the right time. Types include: competing, collaborating, compromising, avoiding and accommodating.
Appendix 5: Breaking Bad News
•S= setting Consider: Preparation-what do you need to know? Privacy, involving significant others, environment and avoiding interruptions
•P= Perceptions
“Before you tell ask” open ended questions to create a reasonably accurate picture of the persons starting point e.g. “what have you been told so far?” “What is your understanding of the reasons we did the scans?”
•I= Invitation how much and what sort of information does the individual want?
Advise them that they can ask questions as go along.
•K= Knowledge and information giving
Fire a ‘warning shot’ to lessen the shock such as “I am afraid the scans were not as we had hoped” or “I’m sorry to tell you…” Avoid Jargon/technical language. Chunk and Check. Adjust speed depending on reaction.