Communication Assessment Guide: Appendix 1

The Communication Assessment Questionnaire

1. Your Name: _____________________________

The purpose of this questionnaire is to help us understand how you approach interpersonal communication. The questionnaire has two parts. The first part asks you to describe two people whom you know well. The second part asks you what you would say in two separate interpersonal communications.

Part 1: Role Impression Tasks

We want to learn how people describe others whom they know. In your own words, indicate the characteristics that a set of individuals have in common and those they do not share.

Spend a few moments looking over this list, mentally comparing and contrasting the people you have in mind for each category. Think of their habits, their beliefs, their mannerisms, their relations to others, any characteristics they have that you might use to describe them to other people.

Please choose a real person that fits each of the two different categories below. In the blank space beside each category below, please write the initials, nicknames, or some other identifying symbol for a person you know who fits into that category. Be sure to use a different person for each category.

2. A person your own age whom you like: _____________________________

3. A person your own age whom you dislike: _____________________________

When you've spent a few moments thinking about these people, please go to the next page.

4. Please look back to the first sheet and place the symbol you have used to designate the person in category 1 here: _____________________________

5. Now describe this person as completely as you can, so that a stranger might be able to determine the kind of person he or she is from your description. Do not simply put down those characteristics that distinguish him or her from others on your list, but include any characteristics that he or she shares with others as well as unique characteristics. Pay particular attention to habits, beliefs, ways of treating others, mannerisms, and similar attributes. Please do not spend more than five (5) minutes describing this person.

This person is:
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

6. Please look back to the first sheet and place the symbol you have used to designate the person in category 2 here: _______________________________

7. Now describe this person as completely as you can, so that a stranger might be able to determine the kind of person he or she is from your description. Do not simply put down those characteristics that distinguish him or her from others on your list, but include any characteristics that he or she shares with others as well as unique characteristics. Pay particular attention to habits, beliefs, ways of treating others, mannerisms, and similar attributes. Please do not spend more than five (5) minutes describing this person.

This person is:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

Thank you. That completes this part of the task.
Please proceed to the next part of the survey.

 

Part 2: Role Scenarios Tasks

Please describe how you would handle several different interpersonal communications. In this questionnaire, you will find descriptions of two different situations. Read each description carefully and try to imagine yourself actually being in the situation. After you read the description, in your own words, write what you would actually say to handle the situation. Do NOT describe the general action you would take.

When you have finished reading these instructions, go to the next page and begin.

8. Scenario 1: Non-Clinical Situation, Group Project

Imagine that you have been asked to head a small working group within your organization. When your group was assembled, you were pleased to see that a colleague named Ron had been assigned to your group. Ron is known to be a very bright and creative fellow who was part of another highly successful group in the Association. However, Ron has been causing some problems. Ron often arrives late to group meetings; once he showed up halfway through the meeting and was clearly unprepared.

You overheard two members of the group discussing Ron's behavior. One group member, Marsha, was wondering why Ron had not been removed from the group yet; the other team member, Bill, speculated that Ron has been having some problems at home and suggested that everyone should cut him some slack.

Next week your group is expected to complete an important project so that the results can be passed along to other members of the organization. Each team member is responsible for a different part of the project, but Ron happens to be responsible for the two most important parts. Your group is scheduled to meet tomorrow to do any last minute coordination that may be required. Based on that timetable, you gave the head of your Association your personal guarantee that the project would be done by Monday.

Ron calls you today and says he doesn't have his sections finished and probably won't be able to finish them before the meeting. He says he just needs more time.

What would you say to Ron? In the space below, write what you would say. Do NOT describe the general action you would take—instead, write the exact words you would actually say to handle this situation.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

9. Disclosure Situation, Immediately After Event

Mary is a 39-year old mother of two small children who has presented to the hospital's GI suite to undergo a procedure under moderate [procedural] sedation. Her parents, Bill and Beth, accompany her. Toward the end of the procedure, the nurse notices that Mary has become "blue" and stops the procedure. She also notices that Mary is not breathing and her EKG shows a heart rate of less than 30. The nurse calls for a code blue response while the team involved in the procedure begins to administer CPR. When the code team arrives, there are some delays in providing appropriate care as different physicians argue about the proper course of treatment. Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood oxygen level.

During the resuscitation efforts, information obtained from the devices monitoring Mary's EKG, blood pressure, and blood oxygen levels reveals a period of approximately 7 minutes during which she may not have been breathing adequately, possibly from too much sedation medication during the procedure. The nurse involved in monitoring Mary appears visibly shaken and states that she was distracted during the procedure trying to obtain different pieces of equipment for the procedure.

Bill and Beth are in the waiting room. They have heard the overhead call of code blue and have seen many people running to the procedure area.

You have been asked to go to the waiting room and speak with Mary's parents. You approach them.

In the space below, write what you would say. Do NOT describe the general action you would take—instead, write the exact words you would actually say to handle this situation.
_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

Thank you for completing these tasks!

Return to Contents
Proceed to Appendix 2

Return to CANDOR Contents

Page last reviewed February 2017
Page originally created April 2016
Internet Citation: Communication Assessment Guide: Appendix 1. Content last reviewed February 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5-guide-ap1.html