NRE Step 2 Communication Stations 2026 — Counselling, Breaking Bad News & Consent

Two candidates sit the same NRE Step 2 breaking bad news station. Both are told: “You are a doctor in a medical ward. The patient has been diagnosed with lung cancer. Please inform the patient of the diagnosis and answer their questions.”

The first candidate enters, sits down, and says: “I have some bad news for you — your scan shows you have lung cancer. We will need to refer you to oncology.” He answers the patient’s questions accurately and leaves within 6 minutes. He scores 9 out of 20.

The second candidate enters, checks the patient is comfortable, and asks: “Before I begin, have the doctors spoken to you about any concerns with your scan?” She listens. She then says: “I have some difficult news to share with you — would you like to hear it now, and would you prefer someone with you?” She delivers the news in small pieces, pauses after each, and responds to the patient’s tears: “I can see this has come as a shock. Take all the time you need — there’s no rush.” She scores 18 out of 20.

The clinical information in both consultations was identical. The score difference came entirely from communication — structure, empathy, patient-centred delivery, and response to emotion. Communication stations in NRE Step 2 are not primarily knowledge tests. They are performance tests, and they reward candidates who have practised the specific behaviours that examiners mark.

Station Type 1 — Breaking Bad News (SPIKES Protocol)

Breaking bad news is the most feared communication station in NRE Step 2 — and the most predictable. The same framework applies to every bad news scenario: cancer diagnosis, terminal prognosis, HIV result, major organ failure, death of a relative, or serious complication of treatment. Learn SPIKES once and apply it everywhere.

The SPIKES Protocol — Step by Step

• S
  Setting Up Create the right environment before saying a single word about the news. Check: Is the room private? Are you sitting at the same level as the patient — not standing over them? Have you offered to have a relative or nurse present? Is there a box of tissues within reach? Have you switched off your pager or phone? “I’d like to have a private conversation with you today — would you be comfortable here, or would you prefer somewhere more private? Is there someone you’d like to have with you?”
• P
  Patient’s Perception — What Do They Already Know? Before delivering any news, establish the patient’s current understanding. This prevents information collision and allows you to start from where the patient is, not where you are. It is one of the most commonly missed steps — and one of the most specifically marked. “Before we talk about your results, can I ask — what have the doctors already told you about what’s been going on? What’s your understanding of why we’ve been doing these tests?”
• I
  Invitation — How Much Does the Patient Want to Know? Ask explicitly before delivering the news. Some patients want full information immediately. Others prefer to receive it gradually or to have a relative present first. Asking respects autonomy and is specifically marked. “I have your test results here, and I’d like to talk you through them. Some of the results are quite significant — would you like me to go through everything now, or would you prefer to have someone with you first?”
• K
  Knowledge — Delivering the News Deliver the news in small, clear pieces using lay language. Use a warning shot before the diagnosis — this prepares the patient psychologically and is specifically marked. Never use euphemisms (“you have a shadow on your scan”) as these create confusion. State the diagnosis clearly but compassionately. “I’m afraid I have some difficult news to share with you.” [pause] “The results of your scan and biopsy show that there is a cancer in your lung.” [pause — allow this to land. Do not continue until the patient shows they have heard it.]
• E
  Emotions — Acknowledge and Respond After delivering the news, stop talking. Watch the patient’s response. If they are silent, give them space. If they are distressed, acknowledge the emotion explicitly before giving any more information. This step is where most candidates fail — they continue delivering information when the patient needs to be heard, not informed. “I can see this has come as a real shock.” [silence — 5 seconds minimum] “It’s completely understandable to feel overwhelmed right now. Take all the time you need.” [offer tissues if distressed]
• S
  Strategy and Summary — Next Steps Only when the patient is ready — not while they are distressed — outline the next steps. Keep it brief. The patient will not retain detailed information immediately after a bad news diagnosis. Offer to write things down or provide a leaflet. Confirm they know who to contact with questions. “When you feel ready, I’d like to explain what happens next — but there’s absolutely no rush. We will refer you to a specialist team who deals specifically with this. You won’t be going through this alone.” [Before leaving]: “Is there anything you’d like to ask me right now? I’ll make sure the nursing team knows you might want to talk further.”

Real Dialogue Example — Cancer Diagnosis Station

Station Type 2 — Informed Consent

Informed consent stations present a patient who needs to consent for a procedure — appendicectomy, cholecystectomy, colonoscopy, cardiac catheterisation, blood transfusion, or similar. Your task is to provide the information needed for the patient to make a genuinely informed, voluntary decision.

The Informed Consent Framework — 7 Components

• 1
  Confirm Capacity Capacity is the foundation of consent. A patient has capacity if they can: understand the information, retain it long enough to make a decision, weigh it to reach a decision, and communicate that decision. Most OSCE patients have full capacity — but mention it: “Before I explain everything, I want to make sure you’re comfortable and understand everything I tell you — please stop me at any point if anything is unclear.”
• 2
  Explain the Diagnosis Briefly confirm why the procedure is needed — many patients arrive for consent without fully understanding their diagnosis. Check: “Can I just check — do you understand why the doctors have recommended this procedure? What’s your understanding of your condition?” “You’ve been diagnosed with appendicitis — which means the appendix, a small pouch attached to your bowel, has become inflamed and infected. Without treatment it could rupture, which would be a serious emergency.”
• 3
  Explain the Procedure Describe what will happen in lay language — what the surgeon does, what anaesthetic is used, how long it takes, what the patient will experience before and after. No jargon. “The operation is called a laparoscopic appendicectomy — this means the surgeon makes three small cuts in your tummy and removes the appendix using a tiny camera and instruments. You will have a general anaesthetic — meaning you will be completely asleep and won’t feel anything during the operation. It usually takes about 30–45 minutes.”
• 4
  Explain the Benefits State clearly what the procedure achieves — why it is the recommended treatment. “The main benefit is that removing the appendix cures the appendicitis — it prevents the appendix from rupturing, which would be much more serious and require emergency surgery with a longer recovery.”
• 5
  Explain the Risks — Common AND Serious This is the most clinically detailed component and the one most commonly incomplete. Cover BOTH common (less serious but likely) AND serious (rare but significant) risks. Use natural language: “The most common things people experience are…” and “There are also some rarer but more serious risks I should mention…” Common: “After the operation most people have some pain and discomfort around the cuts for a few days, some bruising, and a small risk of wound infection — around 5–10% of patients. You may also feel a little sore from the gas used to inflate the tummy during the keyhole procedure.” Serious: “There is a small risk of bleeding that might need a further procedure to stop. Very rarely, nearby structures like the bowel or blood vessels can be accidentally injured — this happens in less than 1 in 100 operations. There is also a risk with any general anaesthetic — your anaesthetist will discuss this with you separately. Finally, if the keyhole approach is not possible — perhaps if the appendix is in an unusual position — the surgeon may need to convert to an open operation with a larger cut.”
• 6
  Explain the Alternatives (Including No Treatment) Informed consent requires that alternatives are presented — even if the procedure is strongly recommended. Always mention the option of no treatment and its consequences. “The alternative to surgery is antibiotic treatment alone — some patients with mild appendicitis improve with antibiotics. However, there is a significant risk of the appendicitis coming back, often worse, and most guidelines recommend surgery as the definitive treatment. The option of doing nothing — not treating it — would allow the appendicitis to progress, which risks the appendix rupturing. This is a serious and potentially life-threatening complication.”
• 7
  Check Understanding, Answer Questions, Confirm Voluntary Decision Consent is not valid if the patient does not understand or feels coerced. Check both. “I’ve covered quite a lot there — just to check I’ve explained things clearly, could you tell me in your own words what the main risks you’ll be considering are?” [listen, clarify if needed] “Do you have any questions at all?” [answer questions] “Are you happy to go ahead with the operation? And just to confirm — this is completely your decision. There is no pressure from us either way.”

Common Consent Scenarios in NRE Step 2

Station Type 3 — Lifestyle & Disease Counselling

Counselling stations present a patient who needs guidance on behaviour change or disease management. The mark sheet assesses: structure, completeness of information, jargon-free delivery, assessment of the patient’s understanding and readiness, and provision of a clear, actionable plan.

Smoking Cessation — The 5 As Framework

• A
  Ask — Establish Smoking Status Always ask, every visit. Do not assume. Quantify: pack-years = (cigarettes per day ÷ 20) × years smoked. Establish current status: still smoking, ex-smoker (how long ago?), never smoked. “Do you currently smoke? How many cigarettes a day, and for how long have you been smoking?”
• A
  Advise — Clear, Unambiguous Advice to Stop The single most effective thing a doctor can do for a smoker’s health. Give direct, personalised advice — not a general health warning. Link it to the patient’s specific condition. “I strongly recommend that you stop smoking. Given your diagnosis of [COPD / heart disease / lung cancer risk], stopping smoking is the single most important thing you can do for your health — more effective than any medication I can prescribe.”
• A
  Assess — Readiness to Quit Use the stages of change model. Precontemplation (not thinking about quitting) → Contemplation (considering it) → Preparation (planning to quit soon) → Action (quit date set or recently quit) → Maintenance. Tailor your approach to the stage. “Have you ever tried to stop smoking before? How did that go? On a scale of 1 to 10, how ready do you feel to try stopping now?”
• A
  Assist — Provide Support Options Cover all available options — pharmacological and non-pharmacological. NRE expects you to name the main NRT options and the prescription medications. “There are several things that can help. Nicotine replacement therapy — patches, gum, lozenges, nasal spray, or an inhaler — helps manage cravings. Patches are used once daily; gum or spray can be used when a craving hits. Prescription medications include varenicline (Champix) — which reduces the pleasure of smoking and cuts cravings — and bupropion (Zyban), which helps reduce withdrawal. Combining NRT with a prescription medication gives the best quit rates. Behavioural support — a stop smoking counsellor or group — roughly doubles your chances of success.”
• A
  Arrange — Follow-up and Support Set a quit date. Arrange follow-up. Provide contact information for support resources. “I’d suggest setting a specific quit date — research shows that having a target date significantly improves success rates. I’ll arrange a follow-up appointment in 2 weeks to see how you’re getting on and adjust support if needed. Would you like me to refer you to the smoking cessation service?”

Type 2 Diabetes Lifestyle Counselling

New diagnosis of Type 2 diabetes is a common NRE counselling scenario. The mark sheet covers: explanation of the diagnosis, lifestyle modification (diet, exercise, weight), monitoring (blood glucose, HbA1c, eye checks, foot care), medication if prescribed, and follow-up plan.

Other Common Counselling Scenarios

Station Type 4 — Explaining a Diagnosis or Investigation

These stations ask you to explain a new diagnosis (heart failure, asthma, epilepsy) or an investigation (MRI scan, colonoscopy, echocardiogram) to a patient with no medical background. The marks are for lay language, completeness, checking understanding, and addressing patient concerns.

The Teach-Back Method — The Most Marked Communication Skill

After explaining a diagnosis or investigation, the teach-back technique confirms understanding and is specifically marked in NRE Step 2. It is not patronising — it is professional communication best practice.

Global Communication Marks — What Every Station Shares

Across all communication station types, a set of global communication behaviours is marked. These apply to every station regardless of content — communication skills, empathy, professional manner, and patient-centredness are assessed as a domain in every OSCE station in NRE Step 2.

Frequently Asked Questions