Some of these concepts are self-evident but all require some exploration, largely because they are automatic processes about which we make unconscious choices. We will deal with each in turn by exploring them in general terms and by looking at some specific examples from clinical contexts.
Setting and Scene
‘Setting’ refers to place, for example, a ward office or a consulting room. ‘Scene’ refers to the psychological arena that would have an impact on linguistic features like formality. Accordingly, a case meeting in a conference room would have a different scene from a retirement gathering in the same setting.
Participants
This refers to speakers and their audience(s), all of whom may be represented by some or all of the people in the setting. For example, part of a preoperative briefing might be addressed to medical staff, but nursing and other staff may also hear it. It would be rare for participants to include those who were not legitimate members of the potential audience, such as other patients’ visitors. Rights to speak should be granted to all participants. Among the challenges of delivering participation rights is that of the authority gradient and both formal and informal hierarchies. There are well-documented circumstances in which people feel reluctant to speak up because of the status of other members of the group. The other issue in relation to participation is that of confidentiality: clearly, there are some issues that should not be addressed in public spaces or common areas, where incidental participation could occur.
Ends
These are the purposes, goals and outcomes of interaction and will depend on the level of formality of the gathering. An informal meeting at the end of a shift would be quite different from a formal event, which would almost certainly have an agenda and minutes.
Act Sequence
Even informal discussions have a sequence and, at its most basic level, this is recognised as turn-taking behaviour. Within most meaningful utterances there is a natural sequence, which might be ‘telling the story’. However, in the words of E. M. Forster (1927), ‘The king died and then the queen died is a story. The king died, and then the queen died of grief is a plot,’ and this is a subtlety to look for in act sequences. In some respects, this can be epitomised by the development of sequential acronyms (S-BAR is an example, see Chapter 9); other less rigid models might be determined by conventions of reporting events and consequences. An example might be a junior doctor discussing a case with a senior and following a sequence (e.g. name, presentation, history, clinical findings, social and family circumstances, diagnosis, plan).
Key
This can represent the emotional tone of an utterance and has to be in accordance with the key that has emerged from the intended discourse or the discourse thus far. For example, flippant comments or asides would not be appropriate during an encounter breaking bad news.
Instrumentalities
This refers to the style of speech or, in linguistic terms, the register. This can determine, for example, the level of informality, tolerance of slang or acronyms, or the use of inappropriately complex or scientific language.
Norms
Norms are the social behaviours that emerge from interactions (in stark contrast to ground rules, which are externally imposed behaviours and rarely fully adhered to). They are the product of subtle negotiation when groups first come together and, once established, are quite difficult to disobey. While in some settings, where there is clear seniority with an associated expectation of leadership, the responsibility may be clear. In a small, more informal group, however, it is a shared responsibility to ensure that productive norms emerge. In established settings, an authority gradient may be overtly or covertly expected.
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