What people are saying about Silva Lining’s Care Plan

Silva Lining’s Care Plan…. Three brains, two bodies, one secret plan: an absurd journey into the invisible world of carers. Written and directed by Elspeth Penny

See Silva Lining’s Care Plan trailer

Developed in collaboration with University of Nottingham, based on real care diaries, Silva Lining’s Care Plan shines a light on the experiences of paid carers of individuals with dementia.

What people are saying:

“Silva Lining’s Care Plan is a wonderful and moving exploration of the complex relationship between carer and cared for. Both heart-rending and laugh-out-loud, it takes you on a roller-coaster of an emotional journey through Silva Lining’s story, with many an amusing aside from her Brain.” Alex Coulter, Director, Arts & Health South West. Chair, Culture, Health and Wellbeing Alliance

 “This play must be watched/shared with carers old and new and care agencies. Good to see a positive care/relationship and the importance of getting it right. Very powerful. I was completely engaged for the whole piece” Claire Angerson, Person Centred Planning, Bristol Community Links North. “Sticking up for carers” Anonymous carer

 “Professional carers are hidden from view, yet are at the heart of support to people with disabilities or disabling illness, particularly dementia, helping them to live at home as long as possible. This play portrays the complex relationship between a carer and a woman – a retired doctor – living with dementia. Mutual respect, misunderstandings, anger, beauty, frustration, jokes and, above all, love, drew me into this poignant play with beautiful acting and even a brain puppet.”Gene Feder, Professor of primary health care Centre for Academic Primary CarePopulation Health Sciences, Bristol Medical School, University of Bristol

 “Everyone involved as Commissioners of care services or as carers should immerse themselves in this play.  You will forever see “Caring” in a new light. I was immediately captivated by the scene and the setting – familiar to me as a GP. Difficulty in gaining access to the patient’s house using door codes has been part of my lived experience for many years. The conversation between Silva Lining and her carer, the profound insights and astonishing puppetry engaged me throughout.” Dr Malcolm Rigler FRSPH, Health Ambassador at: www.patients-association.com

Opportunities to see the play:

Tandem Conference on Sept 20th

Nottingham Contemporary on Sept 21st

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“Letter to my grandchild”, for the older person who would like to get connected the easy way.


At the end of 2017, I ran a pilot project at 65 High Street, Nailsea, inviting participants to throw themselves into technology, sometimes for the first time. They’d create something creative and satisfying – a photo book letter to their grandchild or any young person, including some written text in the form of brief stories. It was a project that pushed both participants and myself out of our comfort zones, but the results were more than worth it. Part of the course was looking at imaginative story creation, construction and structure and other exercises I’ve used in previous creative writing courses. This was an essential part of the course, though because of time constraints, in most sessions this became secondary to the IT skills learning.

Nailsea town Clerk Ian Morrell and I have been in conversation for several years over the importance of arts-in-health, and ways of introducing some creative and community activities skills to address wider community needs in the town. All this whilst providing something which Nailsea residents themselves would welcome, enjoy and accept. The council were due to launch their new resource – 65 High Street, an informal community digital hub supported by The Good Thing Foundation. I wanted to invent a course to work into this launch, and encourage people through the door. The course was free except for a small contribution to the cost of printing the books.

Nine beautiful, ambitious photos books have been made, a plethora of skills have been learned and a community has been created, both live and online. We had a Christmas party where participants received their books, shared mince pies and drinks.

Much of the feedback, and a lot of anecdotal comments during the course are helpful to learn from and take forward, including comments about the space and having an assistant in the room: all to be considered carefully in developments of the course. All ten participants would recommend a friend to come on the same course, or already had. Participants also expressed that they wanted another ongoing course for themselves.

Everyone, naturally, had sessions that were more pleasurable or useful for them than others. However, those who came regularly and experienced the week by week build up of skills, expressed appreciation at the planning and teaching – ‘It was a great course. Elspeth kept the momentum going well.’

Gratifying for me of course, but the most rewarding thing of all was to see the end products, the books, and to see the faces of the participant learners when they received them. One, aged 85, who had arrived with few technical skills, created a stunning 50 page photo book, printed multiple times for her grandchildren. Her family commented that she generally found the Christmas period hard, but this year was different: she’d loved researching, gathering materials and learning the skills to make the book and her spirits were high. Another wrote to me to say she’d given the books to her grandchildren and they’d loved them. I bet.

 I regularly asked participants what it was they wanted to get out of the sessions and what they were learning. Three areas quickly showed themselves to be important, so I concentrated on these:

  1. Learning technical skills
  2. Finding more creative ways of making photo books, and learning story-telling skills
  3. Being part of a community, countering loneliness and isolation.

Some participants would have, no doubt, preferred the sessions to stay on one or other of the points above, but everyone understood that we were a reasonably large group with different needs; we could have spent each two hours going down 15 different routes. Everyone in the feedback forms said they’d achieved a) some said they’d achieved b) and the majority ticked c).

My personal interest lies most firmly in b) and c). I don’t particularly enjoy IT myself, except in so much that it can enable creativity and enhance communication. So why did I run this course? I believe that sometimes the best people to teach a subject are those who find that subject challenging: they don’t take the learning steps for granted. If you can keep in mind the achievement of the result of your labour, i.e. a beautiful photo book of your life that you’ve made yourself, then you are more likely to sidestep your own horror of technology. To enhance the learning experience for the participants, I invited in an IT teaching expert twice in the process. He did a grand job and I learned a lot from him, for example how to effectively address those in the group who are living with conditions that inhibit learning. Humour and gentle repetition are large factors in this.

At the beginning of the workshops it was clear that most participants were bemused by the ipads, and the app. By the end, some of them were irritated by the constraints of both. This could be said to be a mark of how much they’d learned: they were keen to get onto the next level of learning. One participant bought a tablet after the second session and she went on to take great advantage of the facilities at 65 High Street, learning many IT skills.

On asking learners to write about what they’d learned, these were some of their comments:

‘I learned ever such a lot about myself doing this course’

‘Being an absolute novice at technology I was really thrilled to discover that it’s not so frightening after all.’

‘I learned so much from the way the book was made.’

‘How lovely to look back on family experiences’.

‘I learned the concept of the make up of a book. I would love to do more in the future.’

Several of the participants have offered to be volunteers for further sessions, which could be a good way of reusing the skills they have learned and for them to cement their own skills and learn some more. Creating photo books in time for Christmas presents was a good motivator and goal.

So, my tips for future similar projects are…

Explore several different photo apps. The one we used provided a simple way to get to grips with the technology of the ipad (when the app was working), though I think for some people it was a bit pedestrian, and this may be because it was developed for care homes.

Ensure you have an extra person in the room to help with minor (but very time consuming) niggles that people have with problems on the app, or just simple technical issues people have with their own devices. Things like not remembering their passwords, not getting past an Apple ID screen. I’d originally planned for teenagers or grandchildren to join the sessions to act as technical advisors. The sessions were held on school days so this wasn’t possible if we were to complete before Christmas. Minor technical hitches were frustrating. It would have been easier if all of the devices that we were using had been the same. Another reason I needed more help was that some learners had memory problems, others coordination challenges, and the range of ability ranged from one end to the other.

Provide alternative activities for learners who are not so open to creative activities. The first session involved making hand written letters to a grandchild was a great way of setting up ideas for the course for most people, and set off imaginations. People took photos of the letters and used them in their books. Another time I will provide an alternative activity, as one person made it clear that being creative wasn’t their cup of tea.

Learners were invited to contribute to pay for the printing of their photobook. I took participants’ advice and went to local printer Adroit, who gave a great price for a spiral bound photo book. This did mean more work for me but meant we were able to order multiple copies.

It’s essential to ensure that all participants can hear properly. Table layout helps, plus if possible choose a space with appropriate acoustics.

Working in pairs to explain what each person is doing helps consolidate learning.

On a course like this, which builds knowledge week to week, people need to be encouraged to come every week. I wonder whether a small financial contribution would help?

One learner, a retired teacher, wrote to me afterwards: ‘I think up to 12 people all with different skills and needs is a lot to be expected of you.’ I think she was probably right! However, I trust that some of the above considerations would make another course not only possible and easier to manage, but be even more successful.

As an arts-in-health practitioner, I was a bit frustrated not to have much time on the storytelling aspects of the course. However I loved pioneering this project, and in particular working with these wonderful people. It was rewarding to see important events in their life emerge visually on the screen, then printed in a book, to celebrate with them along with the welcoming staff at 65 High Street and to feel I was part of the beginning of something new for them.


“So – was it therapeutic?”

I met Jessa Fairbrother today at a nourishing movement workshop called Flummery Room run by Brenda Waite at The Island in Bristol. Beautiful sessions: Brenda is generous and gentle in how she leads and she manages to encourage us to give something of ourselves, without even asking. Working together, our bodies moving in space to silence or music, we explore repetition, pauses, distance, folding and unfolding. All of us in the group have a chance to get to know ourselves better and to perhaps discover something about each other too. All of this is beyond words, although words are not banned, and they may appear at times in the space too. Something is freed up and we remember how to play again.
At the end there is a chance to talk to some of the other participants; I like that the talk comes after the getting to know another person a little through their movement and how they move with others.
Jessa told me a little about her work – photographs, embroidery, her themes – I became curious. Now home, I’m meant to be sanding down my front door ready to be painted, but how much more enjoyable it is to be reading some of Jessa’s blog posts – nuggets of inspiration and observation. Here is one.


Persephone: Jenny Joseph

RIP Jenny Joseph.

Jenny Joseph’s Obituary in The Guardian

Jenny Joseph is a name I’m familiar with. It’s on the spine of a book that’s always on my book shelf, and is now on my bedside table, to read for the first time as an adult.  When I was 15, Neil Astley of the newly formed Bloodaxe Books asked me whether I’d like to be on the cover and the back of Jenny’s new book ‘Persephone’.

The pouty photos were taken and tinted by Irene Reddish, and I got paid something like £60 (this was a lot to me, we’re talking about June 1986). Unusually, there’s also a photo story in the middle, with models – my friends – Diana and Judith Taylor, Farne Conway, Fay Gilder, Thomas Gilder and my first boyfriend’s dad, Roger Neville. My life mentor and friend Moira Conway took the pictures for the photo story in the coffee shop of my mother’s bookshop, The Bookhouse, in Newcastle Upon Tyne.


‘Great Cultural Knock About!’ Narrative – and Theme… my BEEF workshop feedback

Theme is one of my favourite subjects to teach as it informs the heart of any piece of creative work, whether it be film, fiction writing, theatre, photography, non fiction, textile work… you name it. Plus it’s about emotion, which is the cornerstone of creating anything meaningful. This workshop, and my recent Creative Sparkle workshops have taken me back to the material I taught on the Narrative MA module at Norwich University of the Arts (I loved that job!).

Film maker Dr Vicki Smith asked me to run a workshop at BEEF over the summer. A privilege to be running the first in a series at BEEF’s current home: The People’s Republic of Stokes Croft.

BEEF – Bristol Experimental and Expanded Film – describes itself as ‘a film and sound collective with an analogue heart’, it’s well worth looking up and getting involved in. Vicky is a true experimental film maker and thinker and it’s been great to get to know her through this.

It’s a joy working with creative people, giving them a pile of tools to explore and improve their work and sharing stories. In these workshops – there is a cultural knock about, as one of the workshop attendees wrote in their feedback. Indeed – I view any workshop as essentially being a process of, ‘I am nourishing you and you are nourishing me.’

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More about the workshop details:

Details: SATURDAY 30th July  at BEEF’s current home: The People’s Republic of Stokes Croft, 14 Hillgrove St, Bristol.

This set of workshops may be taken singly or together. Close attention will be paid to the role of sound and the senses in experimental film, the advantages and creative applications of different film formats and the consideration of audience.

10-12 am: Elspeth Penny: Narrative – Communicating through Media

A narrative is the unfolding of a structured communication to an audience. Story, genre, time, space, theme, style, plot, characterisation and dialogue, sound, movement, image. This workshop uses practical exercises to explore theme – and how a well worked out theme affects everything we communicate.

Elspeth Penny makes films, tv, literature, theatre…. always ideas led. An experienced creative workshop leader, Elspeth has taught for over fifteen years, including running an MA module in Narrative at Norwich University of the Arts, and loves to work with people of any age and level of experience.

More at:  http://www.beefbristol.org/portfolio/break-the-rules-beef-experimental-film-workshops/


Now for the feedback.

Thank you to all of the participants who gave feedback:


Very open and dynamic in approach. It did need more time perhaps! Good location and resources. Made me think more about the direction of my work and how to develop it.


The exercises were good and energizing and brought the group together in a dynamic and creative way. The film and book examples were well chosen. The exercise at the end of using colours, projection and camera to rapidly explore a filmic theme was really fun and a great idea for an explorative tool.


– The creative exercises are very inspiring and helpful.

– The drawing on overhead and filming is brilliant help to see your theme in action.

– It could be an hour longer.

– Please do more of these workshops.


Really stretched by boundaries.

Felt like I could think more freely.

Very interesting.

Wow have something/pointers to take away and follow up.



Good points.

  1. Great cultural knock about
  2. Made me relax and share
  3. Great set of tool kit to go away with that could be transferred to all/most creative processes.
  4. Great sense of security in the group.

Points to improve

?? Too much in 2 hours. Needs a day.

Thanks all.


Note to self: Don’t try to do too much in an hour!

Thanks to Vicky and Esther for your help in planning and on the day.



Letter to my lungs: Spring 2016


Breathe Easy, the Forest of Dean April 19th 2016

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‘My Dear Breath, I have lived with you for 83 years, the first 23 were good! but you have been unkind’ – one eighty-five year-old, Clare, writes to her own breath in large pink letters – she’s been using Beetroot ink and a feather to write with. She tells me she had Asthma since she was a child, ‘I used to wonder if I’d wake up dead.’


It’s the first time I’ve been to the Forest of Dean. I get to Great Oaks Hospice, Coleford an hour early. A man is cleaning a lawn mower, whistling away, and I feel at ease. I consider how I’d not mind spending time at any hospice if I could hear someone going about his tasks so happily. He helps me carry in four boxes and several bunches of different coloured rolled up paper into a warm open room in the basement. I set up, ready for the Breathe Easy group to arrive.

I have arranged to do something for the first half of the meeting for Forest of Dean Breathe Easy group. Mike Green is Secretary of the group – he and his wife greet me, then the participants begin to arrive.

‘This looks interesting, intriguing!’ says one slim friendly man, Archie. The table is all set with tablecloth, homemade inks, pens, pencils, chalks, charcoal. There is something about him that reminds me of my Geordie grandfather Grumpy. Grumpy had chronic bronchitis from years of dedicated smoking and spent the last fifteen,or was it twenty years of his life? – looked after by Gran – he was largely bedridden towards the end.

As we start the workshop, there are six people at the table, and a few more trickle in until we are thirteen.

I introduce myself and tell the group how I have developed my letter-writing project Scent (www.scent.buzz). I warm up with a drama exercise using the breath, play a specific kind of consequences, appropriate for the group, ask everyone to write five messages to their five-year-old self in the past, then ask everyone to write a letter to their own breath.

Mark is a jovial man whom I immediately feel at ease with: he chats to me about parenting boys and various theatre pieces he’s seen.

‘I wrote a letter to my lungs actually,’ he tells me. He has written, ‘We are behind you with this’ at the bottom of his chosen piece of humble white A4 paper. He continues – ‘It has helped me to be less critical of myself. That’s because of the five messages that you asked us to write to ourselves as a child.’

It’s harder to be mean to a child, so addressing ourselves this way does tend to help us be more compassionate with ourselves.


‘My letter is basically all about what breath and I can do together’, Clare tells me, with a little regret in her voice. She then says more cheerfully, ‘This is another way we look at ourselves and our illnesses – there is a lot we can do without medication.’

Everyone reacts to the workshop in their own individual way. Participants talk to their breath in tones ranging from kindness and friendship to reprimand, such as Clare’s, ‘But you have been unkind.’

There’s a discussion in the group about whether keeping the letters is a good idea. I suggest that they might like to pin them up to remind themselves.

I know from previous groups that people have admitted that they think their partners will laugh at them if they pin them up. It’s not out of unkindness, but perhaps out of embarrassment about expressing emotions or needs.

Mark tells me that he’ll take it home and throw it out, the way everything else goes in his house. One participant suggests to him that he might benefit from seeing it – why not put it on your wall?’ He considers it, then he says that he’d like to keep it for a while.

Here’s another thoughtful extract.

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It’s tea and raffle time. I am offered a raffle ticket, but I say that I wouldn’t like to win and take away the prize from one of the others. The raffle master insists. Luckily I don’t win.

‘I think we all enjoyed that and wish you were here for longer. Perhaps you could come back?’ Mike tells me.

‘That was tremendous. I really did get a lot from that’, Carol says as I’m leaving.

A few days later I get a letter through the post from Mike:

‘Your workshop last Tuesday gave our Breathe Easy members food for thought and a creative outlet not experienced often enough on third Tuesdays in the Acorn Suite. I hope you agree that the varied response, in words and images, is proof of the value of the afternoon to those present, not least the fun of it.

Mary tells me that the procession of the exercises led her to realise she could rise above negativity and begin again to enjoy life.’

I am both moved and humbled, in particular by Mary’s feedback. To me it shows that this is not just simply about letter writing and communicating to some part of yourself, as profound as that might be. It’s also a procession of exercises, a progression of ideas, a transition which participants can go through. If it helps a single person to ‘begin again to enjoy life’ then it’s worth doing.



Thank you to: Mike Green, chair of the Forest of Dean Breath Easy group for all his help and for the photos (when I discovered I’d left behind my camera); all the participants, whose names have been changed for purposes of privacy; Great Oaks Hospice, Coleford for their welcome; Dr Alice Malpass, NIHR Research Fellow for referring me to Forest of Dean Breath Easy group after we both delivered talks at the Life of Breath research group; Jess- Farr Cox; Philosopher Professor Havi Carel,  http://www.lifeofbreath.org/ for inviting me to talk at her Wellcome Project Funded project research group in Bristol.

Elspeth’s letter writing project Scent can be found at http://www.scent.buzz or via http://www.2buproductions.org




Winter Cave Poems: Diary of a Caving and Creative Writing Project

December 2015 –  January 2016

This is an account of a project where I took three groups of children through evening tiredness after a day at school, and travelled deep down Goatchurch Cavern in The Mendips. I witnessed them enjoy the sensations of a damp but not watery cave, become familiar with the habitat of bats and cave spiders and become at ease in amongst rocks and edges in what, for the children, essentially became a stone play park for an evening. I then led writing workshops with them.

Caving Elspeth Penny

Photo: Gabriel Gilson

  1. Planning the project: how it came about.
  2. Caving.
  3. Workshops: I am going to describe what I did in the workshops, with the hope that this might be interesting and useful for others, including here a few examples of the writing.
  4. Additional writing (in the end notes) and more photos.
  1. Planning the project: how it came about

 Late November 2015

I am commissioned in late November, over tea at my house with Stuart Bardsley of Discovering Blackdown Project http://www.discoveringblackdown.org.uk, to take groups of children down a Mendip cave, then run educational creative workshops with them.

The aim is to bring awareness to the Mendips, in particular Blackdown (the highest hill in the Mendip Hills, Somerset), to the children. It’s all funded by the Heritage Lottery Fund, so it’s free for the children. I have heard from a caving friend that December is a good month to cave – caving instructors and caves are less busy.

Mid December

  • I have asked Robin of Somerset Adventures to be the professional caver in charge of the activity (for two reasons: 1. I met him randomly on a walk as he emerged from Goatchurch Cavern, along with a boy whose inspired Grandad had employed Robin for the day. Robin is an ex GP and since I often work with GP’s, I am intrigued about his shift in career. I also think this bodes well for trip safety.
  • I have got most of the Scouting leaders on board and they have sent out emails to parents. Pip Riley is asking the boys in Scouts who she thinks will benefit most from the offer.
  • We have full sets of children (with a waiting list) who all want to go caving in the ten days before Christmas… all of which I thought was a long shot.
  • Robin and I decide on exploring Goatchurch Tavern. The trips have been divided up so that it’s three groups of eight children, mixed ages and a mix of girls and boys. I have made an effort to encourage girls to come: in spite of the Brownies not taking part officially, two Brownies will be able to come with Cubs, and three guides have signed up.
  1. Caving

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Photo: Gabriel Gilson

Even though some of the children have been down Goatchurch Cavern before, Robin brings new stories and takes us down new passages, or familiar ones in a different way, so that there is a feeling of real adventure to the evenings.

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Photos: Gabriel Gilson


  • I decide, after three damp, dark physical evening caving trips, at the time of year I could be late shopping and wrapping up presents, that caving is the perfect feral, healthy antidote to all things Christmas. It’s deep below the earth and there are no tinny renditions of Rudolf the Red Nosed Reindeer, or images of Santa anywhere to be seen *note to self to do this again next Christmas*.
  • Things I don’t enjoy: disciplining bundles of over excited kids who won’t go one at a time, but instead tumble over each other seemingly head first into holes – “X jumped on Y’s head Miss, and then Y Kicked Z”; running, chasing naughty boys who hurtle too fast towards the pitch black road (once we’ve got out of the cave); asking the children to listen, endlessly.
  • More things I enjoy: sloshing through streams on the way up to the cave; slipping down dark passages and squeezing myself through crevices in a hard hat and overalls; being held by rock; persuading my knees and muscles to navigate challenging climbs; the pleasure of physical capability; the hidden wildlife and physicality of being far beneath the earth; those still moments when Robin describes how to navigate the next passage, hard hats on children, tiny red lights flashing.
  • I take voice recordings just after the caving, where I ask the children for their impressions, and to state colours, smells and sounds that they’ve seen.
  • There are no injuries. Caving is, as Robin says, actually pretty safe.
  • In Arthur’s words. “That caving was so amazing. I did all the challenging things. The belly dip was awesome. Probably the best of the lot.”


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Photo: Gabriel Gilson

  1. Workshops exercises and writing

January 2016

By the third week of January, all the writing workshops have been completed.

This is how the numbers panned out.

  • Workshop 1: 7 cubs
  • Workshop 2: 8 scouts
  • Workshop 3: 14 guides (12 of which hadn’t attended this caving trip, but most had been caving other times).
  • Workshop 4: 2 brownies and 1 cub at my kitchen table.

So the workshops….

The Cubs are raucous but engaged.

“This is fun,” says Jaiden, to the boys next to him, during an exercise we’re doing, which makes me happy.

Another boy says to me at the beginning, ‘I can’t really write, can I do pictures instead?’, to which I answer, ‘Of course.’ However, the boy gets really absorbed into the writing, especially with his own unusual rhythmic poem, which he’s reluctant to stop.

The Scouts are animated and excited throughout the workshop and produce excellent writing.


At the end they perform some of their writing to the rest of the Scouts, which goes down well.


The Guides are more distracted at first. This is in part because I have asked the whole group to take part, 14 girls in total, when only two of them had actually been caving and it takes a while to ‘catch them up’ on the caving experience. I also regret using a long thin table, which wasn’t as conducive to intimate work as the round tables in the other groups. Mid way through I change position to some low stools, which helps, and also I do a bit of stand up drama work which relaxes everyone. The guides settle in, with the help of their leader and we get some good work out of them.

Workshop exercises

Here, I will describe what I do in the workshops.

Then I will follow up by sharing some of the children’s work. A couple of things to say about this. I’m not correcting spelling mistakes in their writing: it’s written here as they wrote it. Also, there wasn’t time to edit any of the work in the workshops, so this is how it comes out first time.

Task 1: To warm up, we remember the trip using photographs and the voice recordings that I took just after the caving.

I ask the group to stand up and ‘send a word round the circle’. One person chooses a word, (in this context a caving related word) such as rock, then the next person has to ‘catch it’ and send it on to the next person, by saying it in much the same way that it has been said. This way, the exercise is about listening, rather than reinvention: it becomes quite hypnotic and rhythmic. It is a good antidote to over excitement in a group.

Task 2. The writers start to gather words and ideas… I emphasise that the point here is the quantity, not the quality of the writing. It’s ok not to spell things well, or worry about what the writing looks like, because it’s about the ideas being free to come through. (Grammar and spelling can always be corrected later if necessary).

Task 3. Focusing on creating a sense of place. I ask the children, without thinking too much about it, to write down answers to these prompts: One thing you saw when caving; Two colours; Two tastes; Three sounds; Four smells and Five textures.

I like Scarlett’s answer to ‘One thing you saw’ – it was, ‘Bats like pencil sharpeners’ and William wrote down: ‘A caramel waterfall’ to describe the ‘limestone waterfalls’, which Robin had shown us, which had formed over thousands of years of dripping water.

I asked the cubs to write down their emotions, and I had a whole range: Excited, Scared, Happy, Sad, Tired. Another Cub said, “I felt really quite (sic) and very nervous. Sounds around me were cool. I heard rocks.” (Dilan)

For more examples, see end note [i]

Task 5. This exercise is about focusing on creating characters: including the question of whether to write in first person or third person?

I say: “Looking at the caving experience, whose point of view can you look from? The ideas can be as imaginative as you like.”

Some of the ideas are The Dark, Bones, The Handrail, The Air

I fire out a lot of questions. I ask the children to write down answers without thinking too much about it. The aim is to build a whole character, with a path… what do they look like, history, desires, looks etc in order to bring them to life. The aim is also to excite their imaginations.

Here is an example, again from Bede, who is looking from the point of view of “The Cave’s Mouth, which has seen many people passing by.”

What do they look like? Bede: Grey and jagged.

Who are their friends? Bede: Hates all.

What is their job? Bede: Sits still.

What do they want more than anything else? Bede: Peace and quiet.

What do they have in their pockets? Or if they don’t have pockets, what would they put in a pocket if they could? Bede: Stories, stalactites.

What game would they like to play? Bede: Sleeping lions.

What is the worst thing that could happen? Bede: Nothing.

Task 6. A writing exercise focusing on Goatchurch Cavern.

This goes like this:

  • Write a list of five things that you saw in the cave
  • Then five textures
  • Five emotions
  • Write a stanza using these lists. Use a specific amount of words on each line: 1357531. Having strict rules for a task always forces writers to become very inventive.
  • Share the poems. To the reader: Never apologise for your work, just read it.
  • To everyone else: Pick out one thing you liked about the piece and share that.

The results are as follows, and I think show how the children are empathizing with different parts of the cave, exploring their own relationship to the landscape and to themselves:

Bede: Scout


Annoyed and sharp

Why to me, you come

To explore my expanse of cavernous depths

Then you go away

Part of me


For other examples see end note[ii]

Task 7: What am I?

This is about reading out some writing to the rest of the group, without saying who the character/ the point of view is, and allowing the audience to guess.

The Scouts are the only group that do this. They all go through their cave characters, and the other Scouts (who hadn’t done the workshop), listen, guessing.

What am I? by Oliver

I have red stuff pouring out of me and I can no longer do anything. I used to have friends and would swoop around in the darkness collect my food. One day I was going around my dayly bisnis when splat! And I suddenly went to a cloudy palace! I can fly again. All the food in the world was there I could just do nothing all day, No hunting! But the best, bit, the best bit was I had no flees. I was so full of myself I crashed smack bang in the face against a piller and was out cold. Once I had come back to my sences a spiky tooth, horned figure stood over me. The devil! Noooo!

What am I? by Bede

How dareth thou take thy presence nearth thine as all thine wants to do is sleep and lye. Stories and stalactites in harmony, peace and quiet for eternity.

(Trespassing travelers strolled arrogantly into thine mouth.’

Answer: A cave’s mouth

For others, see end note[iii]

Task 8: Sticky notes and Free writing

Everyone writes someone they’d like to take down a cave on one sticky note and lay them out on the table next to each other. For the next sticky note, everyone writes down what that person wants more than anything else, and puts that sticky note underneath another random one. The following sticky notes all have words on them, all which make up the character, but are randomly laid underneath the others. Next, everyone picks one vertical column of stickies, and write about that.

IMG_5349.jpgIMG_5341 (1).jpg

I also asked the guides to write freely for three minutes from a point of view of their choice. Here are some of the results:

Her small blak eyes surveyed her pray as they strolled past. They were loud and obnoxious. She stretched her wings and readied herself for attack one let out a high piched squeel and shone a bright light onto her body. The dark spikes of her fur distorted her shadow. Irritated that she had been disturbed, she flew at them, fangs ready to peirce their veins. (Unknown Guide)

Other examples, see end note [iv]

Task 9: Group writing


I asked Scouts and Guides to choose their best phrases, or get partners to do the same, then I gave them a minute only to put all the phrases together to make a poem or a story.

The Scouts created this one:

It was just another day in the cave when a bat pooped on me. The revenge of the pole adventures began!

Joining an underground river seemingly for ever,

There is someone who randomly talks when we turn lights off.

The cave at just the right angle for the next time to happen,

Lumpy –Shapeless-Rocky,

Where shadows do not dance.

Cave, party he hated.


This came from the smallest group, the three Brownies/Cubs:

Drop eats a bit of air – Bob had given him some because, Drop’s helmet looks like bowling balls. It is very rocky in the cave.


Other examples, see [v]

Task 10. This task was just for me. I wanted to create a piece of writing, which tumbled out of the landscape, the children and the caves.

See end note [vi]

Finally, it’s early February and I have been handed some handwritten accounts of the caving trip by two of the boys who didn’t make the writing workshop.

Wojtek Aleksinska (Scouts) wrote:

The Caving trip was thrilling and fascinating. I have been caving four times before and I never have been on a better caving trip. The two hours of caving were definitely worth it. Not only this caving expedition has been challenging and fun but we all learned about the caves and the things inside them. I also really enjoyed the absaling from one hole to another and the climbing upwards to the other part of the cave. The moment when we had to crawl through a tiny tunnel was the most cool because I have never done it before. In all for me it was an amazing expireance and I would love to do it again.

Bartek Aleksinska (Scouts) wrote:

I very much enjoyed the caving trip that took place at Burrington Coombe. I have been caving quite a lot however I still found it very fun, interesting exciting and adventurous. I was very interested in all of the shapes and object there were down the cave like animal bones and bats. I was also very sapprised in how small gaps we squished through. Further more I found it really fun sliding down the steep slopes. It was by all means the best caving trip I’ve been to.

DSC02653 edit

Photo: Gabriel Gilson


End notes: additional writing

[i] For an example of a full list, Bede, one of the Scouts wrote:

Two colours: Absence of light, Absence of black

Two tastes: Mud, Dampness

Three sounds: Bats, Dripping, Scuffling

Four smells: Mud, Watery mud, Viscous mud, Water

Five textures: Tough, Smooth, Viscous, Runny, Smooth as ice.


Other example of smells were: Mud, Water, Pungent, Musty (George)

Smoke, Fresh dirt, Mud, Water (unnamed Scout)


Other examples of textures were: Smooth, Grainy, Rough, Rigid, Wavey (George, Scout)

Grayscale, Earth, Rough, Sharpened, Chlorophil. (Unknown Scout)

Rough, Bumpy, Jiggered points, Smooth ((Hannah, Guide)



William: Cub


Out of breth

I was relly relly scared

Desperat to get out of the cave

I want to get out

I’m nerly ther



George: Scout


I get annoyed

When we turn lights off

There is someone who always randomly talks

They annoy me so much

I wish they



Scarlett: Brownie


Scattering themselves everywhere

Creeping in the darkness, terrified

Spiders crawling at the top of

The cave, feeling weird and excited

Scattering themselves everywhere



Natasha: Guides


Small human being

Shouldn’t have come to my

Glorious cave and yell very loudly, slowly

Hate him, hate him so

Much hate



Annabel: Guide (unfinished)


Lonely Black Darkness

This is where I live

Lonely, on my own. In complete darkness.


Gabi: Guide


In a cave

Eating a nauciating orange banana

While flying through the black dark sky

After finishing the organge banana

He flew back



Unnamed Guide:


The eyes red

Alone cold, have alone cold

Room, cold, sadness, life, cave, dark

Alone, cold, have alone cold,

The eyes red


What am I?


Jaiden: Cubs


Just sitting there

Ten pound note in my hole

I never move away from stuff


(Written from the point of view of Air)



What am I? (by unnamed Scout)

But when though comes to thine

It is sleep that thine pines,

Until thou goes away

Hine shalt not sleep another day.

Answer: A dead bat


What am I? (by unnamed Scout 1)

I fall from the sky, I peirce into the ground, unless the ground is non-permable, then I become surface runoff. I go into a flow of H2O, I heat and rise to the sky and repeat?

What am I?

Answer: I am a raindrop


What am I? (by unnamed Scout 2)


in places

around the world

helps people and life-forms

every-where such as around the nose.

Answer: Air


What am I? (by Scarlett)

The animal went into the cave and there he has his birthday party. He brings his most precious thing – a nut – and sings ‘America’. He climbs into a tent and turns into a poo. ‘Daddy’ he yells, eating a cabbage.

Answer: A cat.


What am I? (by Arthur)

Oh my friend James, he got washed away, I could not do anything! I curse my web of spider form. The flood killed him, brought him down, oh how I whish him not his spider body, and come back in my time instead.’

Answer: A spider’s web.



Thirteen year old Cece whose favourite song was adele was about to go down a mysterious gloomy cave for a very sad occasion a funeral. (Hannah, Guide)


Down a deep dark cave, that stretched for miles, bubbles, the welly only wanted one thing and that was to be free. Bubbles didn’t like caves but he was being forced to go down it. One thing stood in his way and that was the tight holes he had to go down. (Maya, Guide).


Deep in the shadows of the caves at Burrington Hole, within the porous bubbles and deep cracks of the cave wall lives a very small creature. Silence… the mystical Mendip snail. All is quiet. She is suddenly woken from her winter’s slumber by a light beaming into the hollow. She pokes her head out of her pointed shell, and surfaces into a darker hiding spot… (fragment from Aimee-Claire: Leader, Guides)


Bubbles was a welly

He went to a party for Nelly

In a cave with this lucky pillow

But he wanted to be in Madrid with silk pillows (Jasmine: Guide).


Woody (Cubs) wrote:

I was in the cave

I was in the cave

I was feeling hard

Rough stone

I was in the cave

I was in the cave

I was hearing silence


William (Cubs):

All wanted was silen please god give me real silence. Then all of a sudden I heard this clump of children wich sounded like a herd of eliphents.


Ollie (Cubs) wrote:

‘rock toc a rock dog for

in his pocets were

His hands and

Met a dat fkiw



This was the Guides’ group writing



Down a deep dark cave that stretched for miles

Thirteen year old cece who’s fav song was adele was about to go down a mysterious gloomy cave.

One day while eating a nauseating orange banana he died… RIP Nigel.

He saw, as he opened his eyes, a raging hen party,

Gras was scarce over the colder months,

There was nothing she loved more than cudding her teddy who reminded her soooo much of cleanliness.

Finally Fernando the uicorn realized his cave was much too small and he needed to buy a mansion in spae with Ronaldo the hamster.

Endless dripping of the water off rocks

… and a pool that he went under water in.

His wife Izzy was 1

We kept on playing weels on the Bus.

Can stil bring it like Kim Karasian,

That poor little mole called Cece

Partying til the very end.


And also from the Guides:

There once was a mole called Cece

Who had a twin sister called Mimi

In the kitchen they would bake

While eating sour cake

Listening to the song No Diggity.

She went to a cave for her death

And with her was Beth

That poor little mole called Cece.





Cave offering, by Elspeth

Torn I go,

In December,

Down the giant staircase,

Two hundred,

And fifty,

Thousand years old.

A lesser horseshoe clings on tight.

Torn I go,

A rock like a worn out dashboard

Rolled up wrinkles, a frozen waterfall,

A bony vegetable smell.


Torn I go,

Down The Drunkard’s alley,

Black burned chocolate marks,

Sooty Victorian deposits.

Tender leap over an ochre crease,

Stalectites (tight to the ceiling),

Brightening with all their shininess.

Torn I go,

Down The Coffin,

Dead air chambers,


Cold boulder, columns forming,

An old man’s face.


Torn I go,

Down The Squeeze,

Calcit and Moonmilk deposits.

There’s a bit of a drop-off,

Where life’s been taken out by volcanic ash.

Torn I go,

Down The Badger Pit,

Down Hobbit stairs,

Down The Diamond Chamber,

Down a shallow descending sandy slope.



Wave by wave, I inch up,

Reach up whole bodied,

Past acrid bat bones and

Hand-like prints in cold stone.

I rise,

Piece by piece,

Our guide tells of,

Bones of lion, woolly mammoth,

Dragged into corridors,

Past veins below earth,

Walls of enfolded seashells,

Clogged by mud.


See ghost cavers, clothed capped,

Trouser legs tied with string,


Ladies in wet through knitted skirts,

Hanging from old hemp rope,


Hands, arms, feet and spade,


Painting sooty letters,

On sloping shelves,


An amber glow of candles, or carbide lights on belts.


For today’s bright torches, kids’ voices.


Slipshod I fell,

The tremor in my back,

Broken by the violent flood,

The cold breaking my resolve.

Clearing, I

Flood out the dust,


Torn I go,

Clearing, I

Reach up whole bodied,

Hand into notch,

My torso hugging slimy walls.


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Photos: Gabriel Gilson




How to Break Bad News in a medical consultation: an introduction

By Elspeth Penny

Breaking bad news is one of the hardest things a junior doctor, nurse, doctor, consultant or indeed any medical practitioner needs to do. On top of this, to do it well involves a great deal of skill and empathy, and can be very stressful for all involved, including the breaker of bad news. Thankfully there are some very useful guides, procedures and tips that can aid this process and allow the practitioner to do the most important thing of all in any medical consultation, which is to listen well.

I was invited in Spring 2015 to talk about How to Break Bad News at The Bristol Patient Safety Conference 2015 by the conference director Kate Dougherty. I’m a communications specialist and writer, and have been a consultant, simulated patient/role-player and facilitator in five different South West medical schools for over ten years and am planning a PhD in the area of Arts and Health. Kate was interested in my simulated patient work and thought that inviting me to talk would add a different perspective for the delegates. All the other speakers were or had been health professionals, including Dr Mike Durkin, National Director of Patient Safety NHS England, who gave the keynote address.

I decided to invite my colleague Professor David Radstone to join me. David is an eminent oncologist who teaches Diagnosing Death communication skills at the Peninsula Medical School, Exeter. As his simulated patient aid for a number of years, I have had many discussions with him about breaking bad news.

Kate told me about the delegates: “There will be a lot of nurses at different levels including patient safety leads, directors of nursing, people working in governance and risk management as well as junior doctors. So my first instinct would be to make it relevant to everyone and then provide some additional useful tips for junior docs if David feels their situation is unique.”

I set to writing a script for the talk, sometimes using David’s words from teaching sessions, which are often humorous. This is more or less a transcript of that script, with a few additions. For the next conference we spoke at together, the 4th Annual SAS Doctors’ Conference, Health Education South West 2015, we adopted a different approach. We workshopped scenarios, asking delegates to volunteer as the breakers of bad news, which allowed us to add insights in along the way. Delegates were typically highly level, experienced professionals trained overseas, who felt that they had gained useful insights on the topic and would like to know more. This account of our talk at The Patient Safety Conference, wilI, I hope be of use to all medics seeking an overview of the subject.

The Talk

David: I’m David. They chose me to do this because I’m near to death – the oldest member of the faculty. The students are young and for them death is probably a long way away. However, they need to be aware that there are certain expectations and they need to be prepared to deliver bad news. If they are unlucky, some seniors may ask them to tell the relatives, but the seniors ought to be doing this themselves. But it will be real to the students and fairly shortly.

Elspeth: Just to add, David is also a solicitor, on top of being a Consultant Oncologist – so he regularly prepares medico-legal reports for patients, and has a unique perspective as a consequence.

We’re going to go straight into a role-play, which is a slightly embellished word for word transcript script of a real student’s attempt to break bad news to me in role (here as Mrs Jones). Students are not usually as bad as this by the way:

Role-play 1:

Confident, verging on arrogant student, sits too close, gives an intense stare, which has a patronizing effect.

Student: So Mrs um (looking at notes), Mrs Jones, I realise this is going to be a shock for you, however I think it’s best to, how shall I put it? – break the news straight away, and say that I’m afraid the tests have come back to say you have breast cancer.

Mrs Jones: Oh…

Student: (not pausing) I realise this is a very sensitive issue for you Mrs Jones, looking at your mother’s history… your mother died of cancer I believe.

Mrs Jones: Yes… I….

Student: (not waiting) … but let me reassure you Mrs Jones, that treatments are always developing and whilst your mother’s illness and sad death will have made you sensitive to this diagnosis, we will do our utmost to give you the treatments we think best for you Mrs Jones. (Pause).

Mrs Jones: (Speechless)

Student: What are your emotions around this?

Mrs Jones: I don’t know what to say.

Elspeth: (to audience) Can anyone spot what went wrong there….?
Examples of things that went wrong.
• He didn’t allow sufficient response time
• Information was not given in manageable chunks and understanding was not checked
• It’s as though he has a manual in front of him ‘what are your emotions around this?’
• Assuming her response/preempting.

It’s easy to see mistakes when you’re watching, and to work out what they are once you’ve been working for a number of years in this field, but we all need to remember that it can be stressful for medical professionals to deliver bad news.

So why train in communication skills? As The Medical Protection Society say on their web-site, “Doctors who received training to improve their communication skills report a significantly lower rate of difficult interactions”, and there is a real need to communicate well for legal reasons. “Various communication interventions have been investigated. Communication training for health care professionals has been shown to have a significant effect on their communication skills”

There are other reasons too of course – as David once said to a group of students when we were working on a breaking bad news teaching session together, “There are people whose possibility of life is dependent on your ability to communicate.”

David: Our litigious culture however, has changed the way communications are considered and how they’re delivered. For example, managers might pressurize you into apologizing for what is essentially a misunderstanding rather than a mistake, or for a real mistake. Rightly so, you may say, but of course the fact is – if you apologise, you’re less likely to be sued.

Elspeth: Poor patient communication costs the UK NHS billions in inefficient working, poorer patient outcomes and unnecessary patient litigation, and is a significant contributing factor to NHS negligence liabilities – currently exceeding £21billion (nearly 20% of the UK health budget).

David: I had a recent complaint, which upset me, where I gave bad news to the patient, which he was relatively fine about at the time – no signs he took it badly. It was a family friend who wrote the letter of complaint. The family themselves were telling their Dad to “Man up” and after I had a phone call with them said they didn’t want to continue the complaint. It was a confusing situation, and in the end I can only think that the family friend just felt helpless, wanted to help and this is the way they saw fit.

It’s difficult to communicate bad news effectively, often for fear of escalating conflict. This can lead to frustration and dissatisfaction for the patient and may affect patient care and give rise to complaints.

Elspeth: We are going to start to look at:
1) why complaints arise in breaking bad news scenarios
2) techniques to handle communicating bad news effectively
3) and manage your own internal response.

Firstly. Why situations arise.
As a simulated patient and communications consultant, I see a lot of mistakes….

Sometimes there are cultural or language issues. I liked the way a Chinese student said to my character, “I’d love it if you reduced your smoking”: it was refreshingly personal, though when she said : “Your husband would too”, it suggested she had an insight into the dead, since my character’s husband had died.

There’s also the problem of over-doing communication. “I’m just going to have a chat with you and ask some questions, then I’ll have a chat with the Doctor and have a chat then I’ll come back to you and have another chat.”

Or over-sharing. “I know this is hard for you. My Mum died last year and the doctor was quite kind, but I cried for a week and felt terrible for months and then to top it all, I got a complaint about my communication skills when I delivered bad news! Can you believe it?”

In an obsetetric and gynaecological history taking session, a student asked me: “How much are you having sex”?
“A couple of times a week?” I said.
“So you’re giving it a good go?” he said.

In another, a student doctor said at the end of breaking bad news to a patient, that she had rheumatoid arthritis, said, “Fingers crossed, it won’t get too bad.”

David: Secondly. Let’s look at some techniques to handle communicating bad news effectively.
The Calgary Cambridge method, developed by Jonathan Silverman et al, is taught in 70% of UK medical schools. It gives us excellent microskills, nuts and bolts tools. Most of you in the room will know it, and you will have been taught how to go through the steps. For example the acronym ICE – Ideas, Concerns and Expectations, along with signposting and summaries. The summaries are a great place to put in open questions to get any missing information.

There is also the acronym SPIKES – a bit less general than Calgary Cambridge and used predominantly at the Peninsula Medical School for breaking bad news purposes. For example – in setting up the interview, make sure you sit down and involve significant others.

Elspeth: Interestingly, Spikes were invented by Rob Buckman, who is a comedian as well as being an oncologist.
The acronym is essentially this:
S – setting up the interview, including providing a quiet space
P – assessing the patient’s perception
I – obtaining the patient’s invitation (how much does the patient want to know?)
K – giving knowledge and information to the patient
E – addressing the patient’s emotions with empathetic responses
S – strategy and summary

I actually think comedy’s a good way to learn. We have made a few films, for a digital personalized learning app, Thumbpie, which is an online communications training tool that we’re developing. In one of the films I am playing the patient, and the doctor, played by another actor, Anita Parry, made some key mistakes:
• She didn’t know her patients name
• She was in a rush
• She was not prepared in regard to the clinical situation, records and patient
• She doesn’t give the information she needs to
• She has unconvincing empathy
• She doesn’t listen

Elspeth: Done with a lot of natural talent, these methods – Spikes, Calgary Cambridge and others, can be very effective, but for some people it doesn’t quite work. So what I’m interested in why or how you can go through the motions of the method but something still isn’t quite working. So what’s that element? Is it that some people don’t actually have much empathy? Or know how to generate empathy?
David: Yes, I think that’s true
Elspeth: They can’t actually do it.
David: Yes, although they try. And my prime example is a doctor of oncology in palliative care! You could see him struggling and going through the methods, like clockwork, like a robot, because you could actually see him thinking, “I’ve got to smile, I’ve got to hold the hand”.
Elspeth: The methods can help him though?
David: Well it was better than nothing.
He could actually go through that process and I think people felt that he was aristocratic, which he was, intellectual, which he was, and that this was just his rather aristocratic intellectual persona, and patients didn’t find it grating, it wasn’t hostile.
Elspeth: It was just part of him.
David: It was just part of him, yeah. Patients are kind. They realise it’s not an easy task.
So what else needs to be considered? There’s also a need to get behind these tools.

Elspeth: A very sad story – a mother who shared with me that she got the news that her newborn twin girls were dying told me that the wonderful medics gave her three things. Directness, clarity and humanity.
I think those words are very helpful for medics. Directness, clarity and humanity.
It’s also important to be able to see the dynamics of the people in the room. And to understand the feelings that patients arouse in medics and use this to help them. Barry Bub’s book “Communication Skills That Heal’ looks at patterns of lamentation, such as anger and other emotions. He says listen, listen and listen some more. He talks about recognising and responding to a lament. This involves acknowledging the sadness, naming the losses and allowing the person to move on with a new perspective. He defines healing as removing barriers to allow people to make their own steps forward. It’s a little like providing a wailing wall.

David: The third thing we want to look at is the important issue of health practitioners’ health and wellbeing. This is important because you cannot help your patients if you’re not at peace with yourself in this situation.

Elspeth: Another useful tool is The Drama Triangle, developed by Stephen Karpman with Gill Edwards’ insights, a psychological and social model of human interaction . This tool helps illuminate consultations, helps avoid both complaints and emotional exhaustion, and perhaps helps maintain professional detachment in a consultation. It’s well worth looking at. This is about roles in a consultation, and a triangle of dependency that can arise.
The medic can become the Rescuer to the patient who becomes the Victim: a power imbalance. But the medic can also want the approval of the patient, and it doesn’t take long – just half a second, and the Victim (patient) can change their mind about the Rescuer, take back their power and change role into Persecutor: “You nasty person, you took my power and abused me, now I’m going to abuse you.” This dynamic can certainly lead to the burnout of the medic, and dissatisfaction for both parties.

There’s also the reality of a tight schedule and other patients in the waiting room. Jon Vickery, who teaches clinical skills in Plymouth and Exeter, told me how he broke bad news to parents to tell them their child was dead, and the next patient complained about the fifteen minute extra wait and how much his thumb was hurting. It takes a degree of professionalism and maturity to be able to hold back what you’re really thinking in a situation like that.

David: That is our job. Dealing with difficult interactions with patients can be a significant cause of stress, yet the nature of all clinical jobs makes these encounters unavoidable.

1. Be honest
2. Don’t impose your personal view in the situation (or make assumptions)
3. Always do your best (and no regrets)

Elspeth: Andrew Tressider, a GP I also have worked with, talks of how important it is to protect yourself before going into consultations. There are many tools out there to help you and which one works for you is a personal choice.

And so to another role-play….

David: This one is about Duty of Candour.

Role Play 2

David: Are you feeling any better since we took the fluid off your lung Mrs Taylor?

Mrs Taylor: Yes, a lot better thanks.

David: That’s good news.

Mrs Taylor: But my husband insisted I ask you a question about it.

David: Of course.

Mrs Taylor: Why didn’t you pick up that I had fluid round my lung last week?

David: Good point. We did do an x-ray last week, but that x-ray report got missed. The fluid was clearly a significant cause of your breathlessness.

Mrs Taylor: So you made a mistake?

Elspeth: (to audience) – Do you think he should now apologize?

There is a resounding ‘Yes’ in the audience.

Elspeth: Kate, the organizer of the conference, has requested that we do a model role-play session. That’s puts the pressure on in front of an audience, but let’s give it a go… So David, would you like to give me some bad news…

David: This is a scenario, similar to one we often use at the Peninsula Medical School.

Role Play 3

This isn’t a complete account of the role-play, but David and I improvise a breaking bad news scenario, where David gives my character Jan the news that the life support machine that her husband is on needs to be switched off. David sensitively but directly tells Jan that her husband has had a brain stem bleed and that the tests overnight have shown that he is actually dead. They will need to switch the machine off.
Jan – in shock – doesn’t quite understand this, as her husband seems to be breathing and his heart is beating. “Can’t they do anything? Are they sure the tests are correct?” David tells her that two consultants have checked the results of the tests, that he’s very sorry but repeats the words, “Your husband is dead”, so that there is no ambiguity in what he’s saying. David skillfully brings the consultation to a close, ensuring that Jan’s sister is going to be contacted and that Jan has some time to herself with her husband. Typically David and I role-play Jan’s next appointment to talk about organ donation, but we don’t have time at the conference to do this.

The audience is very quiet after this role-play, and some of them have been moved to tears. It’s a moving scene, but illustrates well what needs to happen in such a scenario to ensure clarity and humanity in what is a very difficult consultation for the patient’s wife and also for the medic.

It is worth introducing the idea here of the medic as an actor. Professor McManus says that ‘Acting may ultimately be the salvation of doctors at risk of professional burn-out.
This subject needs greater exploration than is possible here, but it’s worth saying that it has long been recognized that there are many similarities between medicine and theatre. Having been a theatre director and actor, and having studied Stanislavski in the pursuit of discovering artistic ‘truth’, it is curious for me to be seeing his name recommended in medical journals.
For some medics, the idea that they might be acting when they are delivering a medical consultation is not a comfortable thought, nor might it be comfortable for their patients. It’s worth then considering that from the perspective of social psychology or anthropology, all people adopt different roles in different social situations in any case, and the best we can do as social beings is to learn to play the best role we can in any given situation.

David: To summarise then:
We’ve looked at how challenging it is to deliver bad news effectively.
1) why complaints arise,
2) techniques to handle communicating bad news effectively
3) and deal with the effects on you, as a giver of bad news.

Elspeth: By learning the communication skills needed using the variety of methods we’ve briefly looked at here, the breaker of bad news can hopefully create the most empathetic and nurturing situation for patient as possible, and then be ready to move on to the next patient.


Annual Bristol Patient Safety Conference 2015 http://www.bristolpatientsafety.com

Wells T, Falk S, Dieppe P. The Patients’ written word: a simple communication aid. Patient Education and Counseling Elsevier, July 2003

Baile WF, Kudelka AP et al Communication skills training in oncology

Cancer 1999;86:887-97. Fallowfield L, Jenkins V, et al Efficacy of a Cancer Research UK communications skills training model for oncologists: a randomized controlled trial. Lancet 2002;359:650-6

Silverman J, Kurtx S, Draper J. Skills for Communicating with Patients 1 Feb 1998

Kurtx S, Silverman J. Teaching and Learning Communication Skills in Medicine, Second Edition

Gott, M. Teaching and Learning Communication Skills in Medicine 1 Jan 1960

A Game Free Life, Stephen B Karpmann M.D http://www.KarpmanDramaTriangle.com
McManus IC, Vincent CA, Thom S, Kidd J. Teaching communication skills to clinical students. BMJ 1993;306

Also https://www.ucl.ac.uk/medical…/1994-Lancet-Editorial-DeptOfTheatrical…

Benedetti J. Stanilavski: an introduction. London: Methuen, 1989.

Berne E: Games People Play: The Psychology of Human Relationships, 2010
by Eric Berne

Thank you to Dr Malcolm Rigler for the references.

Please contact me if you’d like a PDF of this article with marked footnotes.