EXECUTIVE SUMMARY

Poor communication can lead to surgical mistakes and other medical errors, so organizations need to find ways to help staff improve their communication and relational skills among colleagues.

• People learn better communication skills more readily when they can practice them.

• Researchers developed a game that uses two communication tools: PEARLS and Ladder of Inference.

• Healthcare workers can learn and practice better communication skills while playing this game: “PEARLS and Ladder.”


Surgical mistakes often result from communication problems between physicians, nurses, and other staff. Miscommunication also contributes to lower workplace efficiency and poor staff morale.

Communication tools can help surgery teams improve their communication skills and lead to better outcomes. The challenge is finding a way to teach staff how to improve their skills.

“How do we help the frontline professional teams in healthcare make improvements while providing care?” asks Marjorie Godfrey, PhD, MS, BSN, FAAN, co-director of The Dartmouth Institute Microsystem Academy. “We have a disciplined methodology. In some of our work, we found that communication between doctors and nurses was not very good. Research shows that if you want to have excellent patient care and outcomes, teams have to have good relationships.”

Communication is a huge challenge and essential for effective teams. Some organizations direct employees to take formal communication courses. “Most people who take our communication course say how it permeates their entire life,” says Godfrey, an instructor at The Dartmouth Institute for Health Policy & Clinical Practice. “One woman had a blowout fight with her sister 10 years ago. The woman worked carefully with the [communication] books. Then, she engaged in conversation with her sister and moved things along a bit.”

“There are tons of examples of medical errors caused by miscommunication,” observes Julie K. Johnson, MSPH, PhD, professor of surgery at Northwestern University. “It’s the No. 1 cause of medical errors.” (Read more on this subject at: http://bit.ly/3bOCTmm.)

Educating staff about effective communication skills works best when employees can practice the skills they are learning, according to Godfrey. “We had exercises in how to do that. Then, in thinking about it, we thought, ‘How about we come up with a game?’”

The communication solution is a game called “PEARLS and Ladder,” inspired by the children’s board game “Chutes and Ladders.” The game uses two empathic, nonjudgmental communication tools: PEARLS and Ladder of Inference. PEARLS stands for Partnership, Empathy, Apology/Acknowledgement, Respect, Legitimation, and Support. The Ladder of Inference refers to people de-escalating their negative assumptions and thoughts about an interaction (i.e., take things down the ladder). Instead of assuming someone meant harm, the person talks with their colleague to find out why the other person’s response was not as expected.

Godfrey practices these communication skills at work and home. She provides this example of how the Ladder of Inference can work to prevent misunderstandings and arguments: “My husband is a really gabby guy, and goes to the local café in the morning to get coffee, have breakfast, and it goes on forever,” Godfrey says. “One time, we were traveling somewhere, and he was going to the café for coffee for me, and I said, ‘Please don’t have breakfast; I’m leaving in 15 minutes.’”

Forty-five minutes later, and her husband still had not returned with her coffee. “In my old world, I would have jumped all over him,” Godfrey says.

Instead, she waited calmly until he walked in the door, and she asked how he was, waiting for him to explain. He told Godfrey that he had traveled to the other side of town to buy her favorite cappuccino.

“This one story reminds me to take a breath and ask questions before jumping to a conclusion,” Godfrey observes. “I think he was just showing his love for me, and I could have lost that moment.”

The game takes communication skills-building and role-playing to a new level. “Traditionally, there is role-playing, where we sit at a table, and I tell you about a scenario where I was under conflict, and it didn’t go so well,” Godfrey explains. “If I had used the PEARLS of apology, it might have had a different outcome.”

The game’s scenarios are healthcare-related, but players can refer to experiences in their own lives as they describe potential solutions. “We found that people will use the PEARLS and Ladder skills as a shorthand way to talk about their communication patterns,” Johnson says. “They might say, ‘I just needed someone to help me come down the ladder.’”

People testing the communication game say they love it, but they also have offered suggestions that have improved the tool, Johnson notes. “We’ve refined the game, and received input on what works well and what can be done differently,” she explains.

For instance, the original game did not include situations involving thanking colleagues or acknowledging when someone was helpful. Some game testers, including physicians, nurses, social workers, pharmacists, and others, said they wished the game included more scenarios that were positive so they could practice thanking colleagues and giving staff positive feedback. “We thought that was a great suggestion,” Johnson adds.

The game can be played in about an hour, which makes it feasible for a regularly scheduled meeting or lunch hour. It provides a novel way for healthcare workers to see the problems with their own ways of communicating and interacting with each other.

“In healthcare, people might say harsh things or not respond or listen to people’s emotions,” Godfrey says. “Game players critique what the person said and discuss it.”

Players learn that simply acknowledging a person’s emotions can change the dynamic. “One of the scenarios in the game involves a surgeon who is very frustrated because when he was on call, he was called to speak with families that were upset about the care their loved ones were receiving. He never knew what to say to them,” Godfrey explains.

The surgeon learned through the PEARLS tool that all he needed to do was show he heard their concerns. He could say, “Anyone who has gone through what you’re going through with your loved one would feel the same way.”

Those words demonstrated empathy, and it defused the families’ anger. “It decreases emotion and anger and does something productive,” Godfrey says.

“Communication seems like an easy thing to do, but it trips us up most of the time,” Johnson says. “At our center, we teach a master’s course in quality and safety. One thing we work on is improving communication and focusing on the relationship.”

When healthcare professionals work on their communication skills, they are working on improving their relationships with their colleagues and patients. “We’re at the end stage of finalizing the game board and game pieces,” Godfrey says. “It’s a new framework for communication and provides people with practice in talking with one another.”

As the game was pilot-tested, the interest was so high among some communities, including healthcare professionals around the world, that people suggested the game developers create a family version, Godfrey notes. “Everyone would like a family version to build more empathic communication and build relationships, instead of tearing them down,” she adds.