Communication competency based
Skills of the Calgary-Cambridge observation guide
From Silverman, Kurtz and Draper. Skills for communicating
with patients. Radcliffe. 1998
Contents:
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Initiating the session
- Gathering information
- Building the relationship
- Explanation and planning
- Closing the session
- Options in explanation
and planning
Establishing initial rapport
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Greets patient and obtains patient's name
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Introduces self and clarifies role
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Demonstrates interest and respect, attends to patient's
physical comfort
Identifying the reason(s) for the consultation
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The opening question: identifies the problems or issues
that the patient wishes to address (e.g. 'What would you like to discuss
today?')
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Listening to the patient's opening statement: listens
attentively, without interrupting or directing patient's response
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Screening: checks and confirms list of problems (e.g. 'So
that's headaches and tiredness. Is there anything else you'd like to discuss
today?')
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Agenda setting: negotiates agenda, taking both patient's
and physician's needs into account
Exploration of problems
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Patient's narrative: 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)
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Question style: uses open and closed questioning
techniques, appropriately moving from open-ended to closed
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Listening: listens attentively, allowing patient to
complete statements without interruption and leaving space for patient to
think before answering or go on after pausing
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Facilitative response: facilitates patient's responses
verbally and non-verbally (e.g. use of encouragement, silence, repetition,
paraphrasing, interpretation)
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Clarification: checks out statements which are vague or
need amplification (e.g. 'Could you explain what you mean by light-headed?')
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Internal summary: periodically summarizes to verify own
understanding of what the patient has said; invites patient to correct
interpretation or provide further information
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Language: uses concise, easily understood questions and
comments, avoids or adequately explains jargon
Understanding the patient's perspective
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Ideas and concerns: determines and acknowledges patient's
ideas (i.e. beliefs re cause) and concerns (i.e. worries) regarding each
problem
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Effects: determines how each problem affects the
patient's life
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Expectations: determines patient's goals, what help the
patient had expected for each problem
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Feelings and thoughts: encourages expression of the
patient's feelings and thoughts
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Cues: picks up verbal and non-verbal cues (body language,
speech, facial expression, affect); checks out and acknowledges as
appropriate
Providing structure to the consultation
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Internal summary: summarizes at the end of a specific
line of inquiry to confirm understanding before moving on to the next
section
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Signposting: progresses from one section to another using
transitional statements; includes rationale for next section
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Sequencing: structures interview in logical sequence
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Timing: attends to timing and keeping interview on task
Developing rapport
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Non-verbal behaviour: demonstrates appropriate non-verbal
behaviour (e.g. eye contact, posture and position, movement, facial
expression, use of voice)
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Use of notes: if reads, writes notes or uses computer,
does in a manner that does not interfere with dialogue or rapport
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Acceptance: acknowledges patient's views and feelings;
accepts legitimacy; is not judgmental
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Empathy and support: expresses concern, understanding,
willingness to help; acknowledges coping efforts and appropriate self-care
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Sensitivity: deals sensitively with embarrassing and
disturbing topics and physical pain, including when associated with physical
examination
Involving the patient
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Sharing of thoughts: shares thinking with patient as
appropriate, to encourage patient's involvement, enhance understanding (e.
g. 'What I'm thinking now is...')
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Provides rationale: explains rationale for questions or
parts of physical examination that could appear to be non-sequiturs
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Examination: during physical examination, explains
process, asks permission
Providing the correct amount and type of information
Aims: to give comprehensive and appropriate information
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to assess each individual patient's information needs
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to neither restrict nor
overload
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Chunks and checks: gives
information in assimilable chunks; checks for understanding, uses patient's
response as a guide to how to proceed
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Assesses patient's starting point: asks for patient's
prior knowledge early on when giving information; discovers extent of
patient's wish for information
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Asks patients what other information would be helpful
(e.g. aetiology, prognosis)
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Gives explanation at appropriate times: avoids giving
advice, information or reassurance prematurely
Aiding accurate recall and understanding
Aims: to make information easier for the patient to
remember and understand
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Organizes explanation: divides into discrete sections;
develops a logical sequence
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Uses explicit categorization or signposting (e.g. 'There
are three important things that I would like to discuss. First .. 'Now,
shall we move on to
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Uses repetition and summarizing to reinforce information
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Language: uses concise, easily understood statements;
avoids or explains jargon
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Uses visual methods of conveying information: diagrams,
models, written information and instructions
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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
Aims: to provide explanations and plans that relate to the
patient's perspective of the problem
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to discover the patient's thoughts and feelings about the
information given
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to encourage an interaction rather than one-way
transmission
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Relates explanations to patient's illness framework: to
previously elicited ideas, concerns and expectations
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Provides opportunities and encourages patient to
contribute: to ask questions, seek clarification or express doubts; responds
appropriately
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Picks up verbal and non-verbal cues, e.g. patient's need
to contribute information or ask questions; information overload; distress
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Elicits patient's beliefs, reactions and feelings re
information given, terms used; acknowledges and addresses where necessary
Planning: shared decision making
Aims: to allow patients to understand the decision-making
process
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to involve patients in decision making to the level they
wish
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to increase patients' commitment to plans made
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Shares own thoughts: ideas, thought processes and
dilemmas as appropriate
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Involves patient by making suggestions rather than
directives
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Encourages patient to contribute their thoughts: ideas,
suggestions and preferences
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Negotiates a mutually acceptable plan
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Offers choices: encourages patient to make choices and
decisions to the level that they wish
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Checks with patient: if plans accepted; if concerns have
been addressed
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End summary: summarizes session briefly and clarifies
plan of care
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Contracting: contracts with patient re next steps for
patient and physician
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Safety netting: explains possible unexpected outcomes;
what to do if plan is not working; when and how to seek help
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Final checking: checks that patient agrees and is
comfortable with plan and asks if any corrections, questions or other items
to discuss
If discussing opinion and significance of problems
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Offers opinion of what is going on and names if possible
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Reveals rationale for opinion
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Explains causation, seriousness, expected outcome, short-
and long-term consequences
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Elicits patient's beliefs, reactions and concerns, e.g.
if opinion matches patient's thoughts, acceptability, feelings
If negotiating mutual plan of action
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Discusses options, e.g. no action, investigation,
medication or surgery; non-drug treatments [physiotherapy, walking aids,
fluids, counselling]; preventative measures
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Provides information on action or treatment offered, e.g.
name; steps involved; how it works; benefits and advantages; possible
side-effects
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Obtains patient's view of need for action, perceived
benefits, barriers, motivation
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Accepts patient's views; advocates alternative viewpoint
as necessary
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Elicits patient's reactions and concerns about plans and
treatments, including acceptability
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Takes patient's lifestyle, beliefs, cultural background
and abilities into consideration
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Encourages patient to be involved in implementing plans,
to take responsibility and be self-reliant
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Asks about patient support systems; discusses other
support available
If discussing investigations and procedures
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Provides clear information on procedures, including what
patient might experience and how patient will be informed of results
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Relates procedures to treatment plan: value and purpose
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Encourages questions about, and discussion of, potential
anxieties or negative outcomes
Source: Silverman et al. Skills for communicating with patients.
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