CALMER: A barrier-informed communication toolkit to improve clinician confidence in difficult conversations under pressure

Introduction

Effective communication with patients and families is central to safe, person-centred care, particularly in geriatrics where fluctuating capacity, ReSPECT/ceiling-of-care decisions, uncertainty and family involvement are common. Local feedback identified that clinicians often face difficult conversations under significant ward pressure, with barriers including limited time, uncertainty about plans, medico-legal anxiety and emotionally charged interactions. This QIP aimed to develop a practical, sustainable communication toolkit to support clinicians before, during and after difficult family conversations.

Method

A paediatrics/geriatrics-informed QIP was undertaken, followed by wider rollout to resident doctors to assess transferability across rotations. Baseline anonymous surveys explored confidence across nine communication domains, perceived barriers and free-text feedback. The intervention was a three-page CALMER communication pack delivered through teaching and QR access. It included a pre-conversation workflow checklist using T-SPACE, the CALMER framework for structuring conversations, and a barriers page incorporating a Privacy Ladder, CLEAR documentation prompt and clinician reflection.

Results

Baseline responses (n=64) demonstrated reduced confidence in safeguarding/capacity, unrealistic expectations, distressed relatives, ceilings-of-care/ReSPECT and documentation. Post-intervention responses (n=30) showed confidence ≥4/5 across all domains, ranging from 63.3% to 93.3%, with an overall mean confidence score of 4.17/5. The largest improvements were seen in safeguarding/capacity (+35.2 percentage points), unrealistic expectations (+29.2 percentage points), and distressed relatives (+27.8 percentage points). Confidence was highest for escalation (mean 4.57/5; 93.3% ≥4/5) and documentation (mean 4.43/5; 83.3% ≥4/5). Acceptability was high, with mean usefulness scores of 4.30 - 4.67/5, including structure 4.50/5, documentation 4.43/5, practical use under pressure 4.37/5 and recommendation to others 4.67/5.

Conclusion

CALMER translates complex communication principles into ward-usable frameworks for difficult conversations under pressure. It is feasible, acceptable and clinically relevant, with greatest improvement in high-risk geriatric communication domains. Next steps include induction-pack embedding, senior clinical champions and feedback-led refinement to support broader validation.