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== Introduction  ==
== Introduction  ==


=== Resource Aims  ===
Effective communication techniques in a healthcare setting have been developed on the basis that physiotherapists are in a unique position as part of a multidisciplinary team in that they can have substantially more contact time with patients than other members of the team. This means the physiotherapist is more appropriately positioned to develop a deeper patient-therapist relationship and in doing so educate and empower the patient of their physical condition and management.


Effective Communication Techniques in a healthcare setting has been developed on the bases that physiotherapists are in a unique position as part of a multidisciplinary team in that they can have substantially more contact time with patients than other members of the team. This means the physiotherapist is more appropriately positioned to develop a deeper patient-therapist relationship and in doing so educate and empower the patient of their physical condition and management.<br>Communication is an important tool in a healthcare setting that when used effectively can educate, empower and de-threaten common health issues patients present with in practice. However, if it is used ineffectively it can have detrimental effects creating fear, confusion and anxiety in patients as well as encouraging resistance to lifestyle changes and healthy behaviours.<br>It can be overwhelming for newly qualified or student physiotherapists as they must deal with such a broad range of conditions as well as differences in patient personalities, beliefs and motivation. This resource pack uses specific physical conditions as examples, however the communication strategies can be adapted and applied effectively across the broad range of physical conditions dealt with by physiotherapists.<br>This resource tool is in no way comprehensive and does not aim to cover every physical and mental condition dealt with by physiotherapists. For this reason, this tool is limited to communication around physical conditions and does not include information on communicating with mental issues or learning problems. It is a guide with suggested examples which can be adapted and applied to different situations with regards explaining and treating physical conditions. Included are further readings, reflection sections and relevant continuous professional development recommended to encourage the reader to actively engage with and consolidate their learning.<br>
Communication is an important tool in a healthcare setting that when used effectively can educate, empower and de-threaten common health issues patients present within practice. However, if it is used ineffectively it can have detrimental effects creating fear, confusion and anxiety in patients as well as encouraging resistance to lifestyle changes and healthy behaviours.  
 
=== Audience  ===
 
The Resource is aimed at student/ recently qualified physiotherapists. However, this should not be exclusive as other healthcare professionals, academics or individuals with an interest in the topic may extract relevant and useful information.
 
=== Learning Outcomes  ===
 
Learning Outcomes:
 
<br>
 
#Understand the importance of effective communication and identify pathways which communication may be influenced.
#Identify the patients positive and negative emotional triggers and evaluate the impact on physical presentation
#Analyse the prevailing language/metaphors that exist within healthcare and assess their impact on the bio-psyco-social model of pain.
#Understand how assessment and explanation of disorders/pain needs to vary for different patients and select an appropriate communication technique with which to carry this out.
#Identify effective communication methods that may be helpful when explaining a diagnosis/treatment to a patient.
#Reflect upon one's own practice of communication techniques and identify areas requiring improvement


== Importance of Good Communication  ==
== Importance of Good Communication  ==


=== Introduction  ===
Communication is an interactive process which involves the constructing and sharing of information, ideas and meaning through the use of a common system of symbols, signs. and behaviours<ref name="CSP" />. It includes the sharing of information, advice, and ideas with a range of people using:
 
Communication is an interactive process which involves the constructing and sharing of information, ideas and meaning through the use of a common system of symbols, signs and behaviours (CSP quality assurance standards). It includes the sharing of information, advice and ideas with a range of people, using;


*verbal
*Verbal
*non-verbal  
*Non-verbal  
*written and
*Written
*e-based
*E-based


These can be modified to meet the patients preferences and needs. <br>Skilled and appropriate communication is the foundation of effective practice and is a key professional competence (See CSP core competency for communication and AHP standards of proficiency) which is highly valued by physiotherapy recipients (Parry, 2009). Effective communication requires consideration of the context, the nature of the information to be communicated and engagement with technology, particularly the effective and efficient use of Information and Communication Technology (CSP quality assurance standards [See fig 1.2).<br> Numerous studies have confirmed the importance of communication between physiotherapist and patient and interventions to enhance practice - some of which will be discussed throughout this learning resource.<br>  
These can be modified to meet the patient's preferences and needs.  
<div class="row">
  <div class="col-md-6">'''Figure 1 - CSP quality assurance standards (2012)'''<br>[[Image:Standards.jpg]]</div>
  <div class="col-md-6">'''Figure 2 - HCPC standards of proficiency (2013)'''<br>[[Image:HCPC.jpg|border]] </div>
</div>


=== Communication Pathways to improve health outcomes  ===
Skilled and appropriate communication is the foundation of effective practice and is a key professional competence (See&nbsp;CSP: quality assurance standards<ref name="CSP">Quality Assurance Standards for Physiotherapy Service Delivery. (2012). Chartered Society of Physiotherapy (CSP).</ref>&nbsp;and&nbsp;HCPC: Standards of Proficiency<ref name="HCPC">Standards of Proficiency - Physiotherapists. (2013). Health and Care Professions Council (HCPC).</ref> figure 2, above) which is highly valued by physiotherapy recipients<ref name="Parry and Brown">Parry RH, Brown K. Teaching and learning communication skills in physiotherapy: What is done and how should it be done?. Physiotherapy. 2009 Dec 1;95(4):294-301.</ref>. Effective communication requires consideration of the context, the nature of the information to be communicated and engagement with technology, particularly the effective and efficient use of Information and Communication Technology.
== Benefits of Good Communication  ==
Effective communication does not only improve understanding between health professionals and patients but it can also have a positive impact on health outcomes.  To understand why communication may lead to [[Communication to Improve Health Outcomes|improved health outcomes]] researchers have identified direct and indirect pathways through which communication influences health and well being.<ref name="Street et al.">Street Jr RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient education and counseling. 2009 Mar 1;74(3):295-301.</ref>.<br>


To understand why communication may lead to better improved health outcomes researchers have identified pathways through which communication influences health and well being and can be simplified in figure 1.3 as proposed by Street (2009).  
==== Direct Pathways ====
Talk may be therapeutic, meaning, a physiotherapist who validates the patients perspective or expresses empathy may help a patient experience improved psychological well being. Leading to the patient experiencing fewer negative emotions (e.g. fear and anxiety) and more positive ones (e.g., hope, optimism and self-worth).  


==== Direct Pathways  ====
Non-verbal behaviours such as touch or tone of voice may directly enhance well-being by lessening anxiety or providing comfort<ref name="Henricson et al.">Henricson M, Ersson A, Määttä S, Segesten K, Berglund AL. The outcome of tactile touch on stress parameters in intensive care: a randomized controlled trial. Complementary therapies in clinical practice. 2008 Nov 1;14(4):244-54.</ref><ref name="Knowlton and Larkin">Knowlton GE, Larkin KT. The influence of voice volume, pitch, and speech rate on progressive relaxation training: application of methods from speech pathology and audiology. Applied psychophysiology and biofeedback. 2006 Jun 1;31(2):173-85.</ref><ref name="Weze et al.">Weze C, Leathard HL, Grange J, Tiplady P, Stevens G. Evaluation of healing by gentle touch in 35 clients with cancer. European journal of oncology nursing. 2004 Mar 1;8(1):40-9.</ref>
 
Talk may be therapeutic, meaning, a physiotherapist who validates the patients perspective or expresses empathy may help a patient experience improved psychological well being. Leading to the patient experiencing fewer negative emotions (e.g. fear and anxiety) and more positive ones (e.g., hope, optimism and self-worth) (Fogarty,1999; Ong, 2000; Schofield, 2003).<br>Non-verbal behaviours such as touch or tone of voice may directly enhance well-being by lessening anxiety or providing comfort (Henricson 2008, Knowlton 2006, Weve 2004 )  


==== Indirect Pathways  ====
==== Indirect Pathways  ====


In most cases, communication affects health through a more indirect or mediated route through proximal outcomes of the interaction, such as;  
In most cases, communication affects health through a more indirect or mediated route through proximal outcomes of the interaction, such as;  
*satisfaction with care
*motivation to adhere
*trust in the clinician and system
*self efficacy in self care
*clinician – patient agreement and
*shared understanding
This could affect health or that could contribute to the intermediate outcomes (e.g., adherence, self-management skills, social support that lead to better health (see Figure 2) (stewart 1995). A physiotherapists clear explanation and expression of support could lead to greater patient trust and understanding of treatment options. This in turn may facilitate patient adherence to recommended therapy, which in turn improves the particular health outcome. Increased patient participation in the consultation could help the physiotherapist better understand the patient’s needs and preferences as well as discover possible misconceptions the patient may have about treatment options. The physiotherapist can then have the opportunity to communicate risk information in a way that the patient understands. This could lead to mutually agreed upon, higher quality decisions that best match the patients circumstances.<br>An article by Street et al (2009) explores these pathways to further broaden your knowledge. A link to this article can be found in ‘Further Reading’ section below.<br>
=== Further Reading  ===
== Communication during Examination and Assessment  ==
=== How Communication can impact the patient  ===
The Macey Model of Doctor-patient Communication is a communication skills model that illustrates fundamental processes applicable to every meeting between physician and patient, and represents a complete set of core skills (see fig. 1.4). Although this tool was developed for doctors, the model provides an overall framework for systematically teaching vital communication elements.<br>The medical interview, particularly the subjective assessment, will determine the quantity, quality and accuracy of data that the physiotherapist will elicit. In turn, this will affect both the approach to the problem and the consequent care of the patient (Macey 2004). Ensuring that we communicate effectively will directly influence the patients behaviour and well being for


*Satisfaction with care  
*Satisfaction with care  
*Adherence to treatment plans
*Motivation to adhere
*Recall and understanding of the information given
*Trust in the clinician and system
*Coping with the diagnosis
*Self-efficacy in self care
*Quality of life and even state of health
*Clinician - patient agreement
 
*Shared understanding  
(Ong et al 1995).<br>Table 1 briefly describes how communication may influence physical and psychological health of the patient.<br>
 
=== Patient Learning Styles  ===
 
Miscommunication between patients and physiotherapists is often documented when it comes to diagnosis explanation and treatment advice (Gill &amp; Maynard, 2006, Donovan 1991) . Patients will describe symptoms in “lay” terms while physiotherapists often return feedback based on biomedical symptoms and processes of the condition using medical terms without taking into account the gap in the level of knowledge on the subject between the patient and themselves (Gill &amp; Maynard, 2006, Donovan 1991). Research believes that this may be because physiotherapist’s often forget to take into account the difference in literacy levels between themselves and their patient, or they don’t know how to describe a condition outside of the medical model they have been taught during training. (Sullivan et al, 2001).<br>Studies show that literacy levels in some countries can be as low as age 10, (Weiss et al 1995). According to the Organisation for Economic Co-operation and Development, the UK is now ranked 22nd in a study of 24 EU countries in terms of literacy with a national literacy age of 10 years old.<br>In addition to this English is not everyone’s first language. According to the 2011 UK census 92% of residents acknowledged English as their first language and of the 8% remaining (3.3 million people), only 79% claimed they could speak English well or very well (National Office of Statistics 2011).<br>Both of these factors may cause difficulty and confusion when trying to speak to a patient about their diagnosis and to make an informed decision around treatment options
 
=== What is Learning  ===
 
By getting a better understanding of patient’s learning styles and acknowledging the difference between lay and medical terminology, we can provide effective education which, in return, may increase the compliance and cooperation of patients. (Donavon, 1991).<br>Before educating the patient it is crucial that the following aspects are assessed:
 
*Patients needs
*Patients concerns
*Patients motivation and readiness to learn
*Patients preferences
*Patients support network
*Patients barriers and limitations to learning (mental health status, learning difficulties)
 
(Stromberg, 2005)<br>Patient behaviour is determined by several factors such as family and work commitments (Stromberg, 2005). Patients will often weigh up these factors and consider various options before settling on the choice most suitable to their personality and lifestyle (Stromberg, 2005).<br>Learning is defined as a process in which knowledge is created through the transformation of experience (Cassidy, 2004; Hauer et al, 2005). Individuals use learning to manage and adapt to everyday situations, giving rise to different types of learning styles (Cassidy, 2004; Hauer et al, 2005) .Through various research and studies, learning styles have been organised and categorized into levels, suggesting an individual’s capacity for flexible and adaptive model learning (Cassidy, 2004; Hauer et al, 2005). These levels are ranked in descending order of stability and are listed as:
 
*Personality traits
*Information processing
*Social interaction
*Instructional preference
 
(Cassidy, 2004; Hauer et al, 2005)<br>For instructional preference. Russel (2003) put together the below table which identifies three types of learning styles: Visual, Auditory &amp; Kinesthetic .
 
<br>
 
The most common learning theory model in application is Kolb’s four stages of experiential model (1984), which, as the names suggest is based around four stages. The ideology is that individual’s transition from phase to phase in their learning process (Cassidy, 2004; Hauer et al, 2005). Very little research is available on the application of these teaching models to a healthcare setting perspective. <br>Figure 3: Kolb’s four stages of experiential model.
 
<br>
 
#<u>'''Concrete experience:'''</u> The patient learns of their diagnosis for the first time from the physio or they could have some previous knowledge or experience of the condition, possibly from news articles or friends or family members with experience or knowledge of the condition. This stage helps the patient to grasp what their diagnosis and prognosis is.
#<u>'''Reflection on experience:'''</u> The patient will go away and review and reflect on the experience and their understanding of their diagnosis.
#<u>'''Abstract conceptualisation:'''</u> The patient learns from the experience of their treatment and diagnosis.
#'''<u>Experimental experience</u>''': The patient will plan and adapt to the arising situation and try out what has been learned in terms of education and treatment. <br>(Spencer, 2003)<br><br>
 
== Explaining Diagnosis  ==
 
=== Breaking "Bad" News  ===
 
=== Use of Metaphors in explaining diagnosis  ===
 
“The medical profession has for a long time largely neglected the influence that language itself has in shaping and conceptualising medical practice” (cite)<br>Why is this? Over the past 3 decades there has been a growing body of evidence that has looked at the role of metaphors in healthcare(Loftus 2011). Historically metaphors were thought of being misleading and potentially counter productive for cognitive reconceptualising(Sontag 1978). Contemporary literature is much more welcoming of metaphors, especially within pain management. Now the research debate has shifted toward how metaphors should be applied in clinical practice rather than if metaphors are true or not. (Loftus 2011; &amp; Stewart 2014)<br>We know that each and every patient that is seen comes with a very individual set of life experiences and different ways of shaping understanding of their “impairments" (Loftus 2011). Language and more specifically metaphors can aid in this process to promote advancement of a more meaningful understanding of diagnoses, avoidance of persistent pain, and self management strategies.(Loftus 2011) Despite these potential benefits, physiotherapists need to be aware of the chance of misinterpretations some patients might take from these metaphors.
 
In the busy environment of clinical practice(rephrase), physiotherapists can’t loose sight of the real people at the heart of the healthcare system(Stewart 2014). Due to the often complex idiosyncratic nature of bio-psycho-social pain, physiotherapists often use metaphors to try and create an “unique” reconceptualisation of what is really going on with the patients body.( Sullivan, 1995)
 
If we examine metaphors separate from the healthcare environment we know that metaphors can facilitate new ways of visualising the world and how we act within it. As a child we are always using our imagination or past experiences to create meaning of new experiences we face on a everyday basis. Physiotherapists must aid the patient to find meaning in the dialogue of personal, cultural, and physical experiences that have made up their lives(Gifford 1997).<br>Now if we integrate pain for example into this situation we can argue that pain is essentially an interpretation by that individual, it can be said that the only way to adequately understand pain is through metaphor itself(Stewart 2014). Ideally a set of metaphors that address the neurobiological contexts as well as the sociocultural contexts of their lives without looking at them dualistically but instead cohesively(Loftus 2011). <br>
 
==== Commonly used Metaphors in practice  ====
 
Over the years the use of metaphors have been looked at by many different research papers and some that are continually being used in practice produce poor patient outcomes. Below we will look at a few of the common metaphors being used across healthcare and analyse how they may benefit or be harmful to the patient.
 
===== The Body is a Machine  =====
 
 
 
*This often implies that the patients are handing over their bodies to a health professional to locate the damage and administer treatment to repair the damage. Much like a car garage.
 
 
 
*Encourages us to think in a Dualistic way (BIOMEDICAL VS. BIO-PSYCHO-SOCIAL) , although if we recognise that social interaction, self interpretation and meaning are important; we must look for more adequate metaphors.
 
(Loftus 2011)<br>
 
===== Medicine is War/ Military Metaphors  =====
 
 
 
*Can imply that the patients are being passive and the doctors are warriors.
 
 
 
*Allows patients and clinicians to think that the patient has failed rather than the treatment.
 
 
 
*These metaphors can also lead some clinicians to think of themselves as a poor “soldier” and decrease confidence.
 
 
 
*Military metaphors can direct pain reconceptualisation away from bio-psycho-social evidence and think the war can be won with biomedical means of treatment.
 
(Loftus 2011;Louw 2011;Stewart 2014)
 
===== Brain as a Computer  =====
 
 
 
===== Journey Metaphor  =====
 
=== Advice and Cautions  ===
 
== Communication when addressing persistent pain complaints  ==
 
=== What is Pain?  ===
 
=== Every Chronic Pain was once Acute  ===
 
=== Neuroscience Education  ===
 
=== Explaining Pain: How to do it in under 10 minutes  ===
 
=== Clinical Example: Osteoarthritis  ===
 
<br>When explaining a condition such as osteoarthritis to a patient we must consider what their viewpoint of the condition must be. Osteoarthritis is a condition of cartilage degeneration, subchondral bone stiffening and active new bone formation (Heuts et al, 2004).<br>Osteoarthritis is a complex sensory and emotional experience. An individual’s psychological characteristics and immediate psychological contest in which pain is experienced both influence their perception of pain (Hunter 2008).
 
Research has utilised qualitative methods and focus groups to establish the patient’s point of view. A common theme that is emerging is that patients are sometimes dissatisfied with the overall level of understanding, help and information that is given to them by healthcare professionals (Hill et al 2011). Patients also expressed concern that there was a lack of understanding by healthcare professionals as to the impact that osteoarthritis can have on an individual’s life (Hill et al 2011).
 
As physiotherapists, we must be aware of current and alternative treatments for OA (hydrotherapy, acupuncture etc) as contradictory information being given to the patient from different sources may lead to confusion as to what exactly they should be doing (Hill et al 2011).<br>
 
Somers et al (2009) highlights that patients may adopt certain attitudes towards pain; Patients who are pain catastrophizing tend to focus on and magnify their pain sensations. This group of patients tend to feel helpless in the face of pain. Patients who adopt this stance report higher levels of pain, have higher levels of psychological and physical disability.
 
The second stance is patients who have pain related fear. They have a fear of physical activity as a result of feeling vulnerable to pain during activity. This group are more likely to engage in avoidance behaviours such as avoiding movement (Somers et al, 2009)<br>We as physiotherapists must remember that OA patients with a fear of engaging in painful movements may be hesitant to engage in physical activity. This can contribute to a vicious cycle of a more restricted and a physically inactive lifestyle which will lead to increased pain and disability (Somers et al 2009).
 
Hendry et al (2006) conducted qualitative research on primary care patients with OA. They found that personal experience, aetiology of arthritis and motivational factors all influenced compliance rates towards physical activity. Some patients believed that their joint problems were a direct result of heavy physical activity (Hill et al 2011). This is where we as clinicians must be aware that patients may present questions such as;
 
<br>'''‘why should we exercise when our knees hurt?’'''&nbsp;
 
<br> In the same study patients were asking
 
<br>'''‘if it is wear and tear on the bone, is it helping to do all this exercise, walking and that?’'''
 
<br> As physiotherapists we must be careful with our choice of words, phrases such as ‘wear and tear’ may be misinterpreted by some patients and lead to further maladaptive behaviour. Grive et al (2010) established that an ongoing concern of musculoskeletal professionals is that the use of this ‘wear and tear’ explanation often leads to decreased physical activity to avoid further ‘wearing of the joint’.
 
A unique approach adopted by a number of patients in the same study by Grive et al (2010) was the ‘use it or lose it’ approach. This simply put was use the joint or lose your functional ability. As physiotherapists we could utilise a similar approach to get our patients to comply with the physical exercise that we have prescribed as an intervention. Through effective communication we can increase a patient’s self efficacy and reduce their level of physical disability (Hunter 2008). Patients with higher self efficacy for pain control had higher thresholds for pain stimuli (hunter 2008). Can we as physiotherapists use this to our advantage to increase patient’s compliance to exercise?


Exercise has been shown to have a positive effect on functional ability in patients with OA (Heuts et al, 2004). We as physiotherapists must consider the role of pain related fear in patients with OA and investigate different treatment approaches to combat this behaviour (Heuts et al, 2004).<br>  
This could affect health or that could contribute to the intermediate outcomes (e.g., adherence, self-management skills, social support that lead to better health<ref name="Stewart">Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ: Canadian Medical Association Journal. 1995 May 1;152(9):1423.</ref>.


[[Image:Activity avoidance.PNG|border|right|300x300px|Dekker (1993) Activity Avoidance Model]]Scopaz et al (2009) suggests psychological factors such as anxiety, fear and depression may also be related to physical function in patients with OA of the knee.  
A physiotherapists clear explanation and expression of support could lead to greater patient trust and understanding of treatment options<ref name="Street et al." />. This in turn may facilitate patient adherence to recommended therapy, which in turn improves the particular health outcome. Increased patient participation in the consultation could help the physiotherapist better understand the patient’s needs and preferences as well as discover possible misconceptions the patient may have about treatment options<ref name="Street et al." />. The physiotherapist can then have the opportunity to communicate risk information in a way that the patient understands. This could lead to mutually agreed upon, higher quality decisions that best match the patients circumstances<ref name="Street et al." />. Key factors of [[Communication to Improve Health Outcomes|communication to improve health outcomes]]:
* Examination and Assessment - using clear concise language and allowing the patient time to talk will influence the quantity, quality and accuracy of data
* Respect Clients individuality and background - adjusting tone and level of language as well as using lay terms rather than medical terms can help improve understanding and make patients feel at ease<ref name="Gill & Maynard">Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ: Canadian Medical Association Journal. 1995 May 1;152(9):1423.</ref><ref name="Donovan">Donovan J. Patient education and the consultation: the importance of lay beliefs. Annals of the Rheumatic Diseases. 1991 Jun;50(Suppl 3):418.</ref>
* Respect a patients space - do not invade their space without first asking permission
* Be open and create a relaxed atmosphere
* Be attentive - Look at the patient when they are talking
* Environment - Provide the patient with an area that is private and away from noise and interruptions
<div>
== Communicating Sensitive Issues  ==


Further to this, a model of fear avoidance suggests that patients can either be adaptive and non-adaptive in their approach to their pain and functional ability (Scopaz et al, 2009).  
Primary care providers and particularly physiotherapists are often faced with sensitve issues within their daily practice.  One example is dealing with obesity and encouraging patients to take a more active approach in the management of obesity<ref name="Stafford et al.2002">Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician activities related to obesity management. Archives of Family Medicine. 2000 Jul 1;9(7):631.</ref>. However physiotherapists have encountered many challenges related to addressing obesity with patients<ref name="Alexander et al 2007" />. Given that obesity is becoming an epidemic in many nations throughout the world, the need to understand how, when and with whom to have these discussions which becomes essential in order to provide effective care for obese patients. There is a growing need for the training of physiotherapists in areas such as weight loss counseling in order to reduce the barriers encountered when discussing obesity <ref name="Alexander et al 2007">Alexander SC, Østbye T, Pollak KI, Gradison M, Bastian LA, Brouwer RJ. Physicians' beliefs about discussing obesity: results from focus groups. American Journal of Health Promotion. 2007 Jul;21(6):498-500.</ref>.


This model indicates that anxiety + fear avoidance beliefs are significant predictors of self report physical function in patients with knee OA (Scopaz et al, 2009).  
Wadden &amp; Didie<ref name="Wadden and Didie 2003)">Wadden TA, Didie E. What's in a name? Patients’ preferred terms for describing obesity. Obesity Research. 2003 Sep;11(9):1140-6.</ref> reported that patients observed the terms obesity and fatness to be very undesirable descriptors used by their physicians when discussing their body weight. Other terms such as large size, heaviness and excess fat were also highlighted as undesirable. The use of these terms by physicians can be interpreted as offensive or hurtful by the patient and lead to a breakdown in communication.<br>The study reported that weight was the most favourably rated term to be used by physicians as it is easily understood and non judgemental. Another term which was viewed as favourably, as it was non judgemental was BMI, however it is found to be not universally known.


Following on from this, we may also consider the avoidance model presented by Dekker et al (1993)<br>  
Johnson<ref name="Johnson 2002" /> reported that some patients preferred to be described as plus sized, large or even fat. By embracing these terms these patients are motivated to remove the negativity and stigma related to them.<br>Wadden and Didie<ref name="Wadden and Didie 2003">Wadden TA, Didie E. What's in a name? Patients’ preferred terms for describing obesity. Obesity Research. 2003 Sep;11(9):1140-6.</ref> reported the most beneficial approach would be to ask the patient how they feel and their thoughts towards their weight. Using this approach the physiotherapist should seek the patients consent and come to an agreement to address and discuss the issue. Caution should be taken to avoid reiterating the hazards obesity has to the patients health. Wadden et al<ref name="Wadden et al 2000">Wadden TA, Anderson DA, Foster GD, Bennett A, Steinberg C, Sarwer DB. Obese women's perceptions of their physicians' weight management attitudes and practices. Archives of Family Medicine. 2000 Sep 1;9(9):854.</ref>, reported obese patients often experience a feeling that care providers seldom understand how much they suffer with their weight issues. Utilising the conversation approach also allows the physiotherapist to show respect and empathy to the patient by focusing on the positive steps they may have taken previously to tackle the issue. <br>  


This model indicates that a decreased muscle strength as a result of activity avoidance leads to activity limitations (Holla et al, 2012).
=== The Issue With "Calling It As It Is"  ===


==== Recommendations ====
This approach fails to avoid the degrading and offensive terms, used by the public, and causes more negative effects than beneficial effects <ref name="Johnson 2002" />. It is a challenge for obese individuals to understand the medical implication of these terms as they cannot separate them from the degrading aspects of the terms used by the public.Using a confrontational approach instead of a discussion with the patient is far more likely to negatively affect the patient’s moral, feelings and confidence. Johnson<ref name="Johnson 2002">Johnson, C. Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. 2002. New York, NY: Guilford Press, pp.480-493.</ref> reports that care providers who approach the issue by attempting to 'break through the patient’s denial of their weight issues, are more likely abolishing the patients trust and their motivation to return for future sessions and care. This is the most common outcome when individuals are advised to battle their obesity by losing weight, to avoid the ominous medical consequences. <br>More desirable and beneficial outcomes can be achieved through the use of motivational interviewing and discussions with patients in need of weight management compared to a confrontational approach&nbsp;<ref name="Miller and Rolnick 2002">Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. Book Review.</ref><ref name="Wadden and Didie 2003" />.<br>


'''What can us as physiotherapists do to combat these beliefs that may be instilled in patients?''''''<br> '''
=== Teaching Tools  ===


[[Image:Reccomendations.png|center|500x300px]]
Tools such as the video below can be used in teaching and motivating patients on lifestyle and behaviour change.&nbsp;


<br>
{{#ev:youtube|aUaInS6HIGo|700}}
 
== Sensitive Issues: Obesity  ==
 
=== Introduction  ===
 
=== The issue with "Calling it as it is"  ===


== Motivational Interviewing  ==
== Motivational Interviewing  ==


=== Introduction  ===
Evidence has shown that patient-centred approaches to health care consultations are more effective than the traditional advice giving, especially when lifestyle and behaviour change are part of the treatment<ref name=":0">Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient education and counseling. 2004 May 1;53(2):147-55.</ref>.
 
=== Theoretical Bases  ===
 
=== Principles of MI  ===
 
=== MI Techniques  ===
 
=== Summary  ===
 
== How to best Implement MI  ==
 
=== Useful Questions  ===
 
=== Step 1: Practice using a Guiding Style  ===
 
=== Step 2: Develop Useful Strategies  ===
 
==== Agenda Setting: Deciding What to Change  ====
 
==== Pro's &amp; Con's: Deciding Why the Change  ====


==== Assess Importance and Confidence  ====
In the past, healthcare practitioners encouraged patients to change their lifestyle habits through provision of direct advice about behaviour change<ref name=":1">Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. Bmj. 2010 Apr 27;340:c1900.</ref>. However, this has proven to be unsuccessful, as evidence show success rates of only 5-10%<ref>Rollnick S, Kinnersley P, Stott N. Methods of helping patients with behaviour change. British Medical Journal. 1993 Jul 17;307(6897):188-90.</ref>&nbsp;. Additionally, this can put a strain on the patient-therapist relationship with the patient perceiving this style as being lectured on their lifestyle choices<ref>Stott NC, Pill RM. ‘Advise yes, dictate no’. Patients’ views on health promotion in the consultation. Family Practice. 1990 Jun 1;7(2):125-31.</ref>.


==== Exchange Information  ====
Patients can also feel that the therapist is not considering the personal implications the change may have on their life, as they are just placing emphasis on the future benefits and not recognising the initial struggle the patient may have to go through<ref name=":0" />. Such an encounter can risk the patient becoming resistant to change or further increasing their resistance to change<ref>Miller WR, Rollnick S. Motivational interviewing: Helping people change. Guilford press; 2012 Sep 1.</ref>. This resistance to change was seen as a personality trait that could only be dealt with by direct confrontation which potentially placed a further strain on the patient-therapist relationship <ref>Miller WR. Motivational interviewing: III. On the ethics of motivational intervention. Behavioural and Cognitive Psychotherapy. 1994 Apr;22(2):111-23.</ref>.


==== Setting Goals  ====
Research has shown that patient-centred approaches have better outcomes in terms of patient involvement and compliance<ref name=":0" /> <ref>Ockene JK, Kristeller J, Goldberg R, Amick TL, Pekow PS, Hosmer D, Quirk M, Kalan K. Increasing the efficacy of physician-delivered smoking interventions. Journal of General Internal Medicine. 1991 Jan 1;6(1):1-8.</ref>. The key feature to these approaches is that the patient actively engages in discussing a solution for their problem<ref name="Emmons & Rollnick">Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. American journal of preventive medicine. 2001 Jan 1;20(1):68-74.</ref>.


=== Step 3: Skillfully respond to and change patients language  ===
[[Motivational Interviewing]] (MI) is based off Miller &amp; Rollnick’s (1991)<ref>Miller, WR., Rollnick, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press</ref> experience with treatment for problem drinkers and is becoming increasingly popular in healthcare settings. The model views motivation as a state of readiness to change rather than a personality trait<ref name=":2">Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: helping patients change behavior. Guilford Press; 2008.</ref>. As such, motivation can fluctuate over time and between situations. It can also be encouraged to go in a particular direction. By taking this view , a patient’s resistance to change is no longer seen as a trait of the person but rather something that is open to change<ref name=":1" />. Therefore, the main focus of MI is to facilitate behaviour change by helping the patient explore and resolve their ambivalence to the change<ref name=":1" />.


=== Challenges faced by PT's when using MI  ===
While MI is patient centred and focuses on what the patient wants, thinks and feels, it differs slightly from other patient-centred approaches as it is directive<ref name=":0" />. In using MI there is the clear goal of exploring the patient’s resistance to change in such a way that the patient is likely to change their behaviour in the desired direction<ref name=":0" />. <br>The focus of Motivational Interviewing is to:
* Assist the patient in examining their expectations about the consequences of engaging in their behaviour.
* Influence their perceptions of their personal control over the behaviour through use of specific techniques and skills.<ref name=":2" />.
&nbsp;A benefit to this approach is that time can be saved by avoiding unproductive discussion by using rapid engagement to focus on the changes that make a difference<ref name=":1" />. For more on this topic see [[Motivational Interviewing]]


=== Examples in Practice  ===
</div>


== References  ==
== Conclusion ==
<div>


References will automatically be added here, see [[Adding References|adding references tutorial]].  
Communication is more than just what we say, it matters how we say it too. It is important that communication is good, clear and compassionate in a healthcare setting.  The style in which we communicate may differ between individual patients due to learning styles, literacy levels or the level of understanding the patient has of their condition and the anxiety they may present with. 


<references />
== References  ==
<references /></div>
[[Category:Osteoarthritis]]
[[Category:Obesity]]
[[Category:Pain]]
[[Category:Primary Contact]]
[[Category:Rehabilitation Foundations]]
[[Category:Mental Health]]
[[Category:Communication]]
[[Category:Current and Emerging Roles in Physiotherapy Practice]]
[[Category:Queen Margaret University Project]]

Latest revision as of 11:22, 16 November 2023

Original Editor - Robyn Holton, Frank Ryan, Shawn Swartz, Elaine McDermott, Noel McLoughlin, Zeeshan Mundhas part of Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice Project

Top Contributors - Elaine McDermott, Frank Ryan, Robyn Holton, Shawn Swartz, Kim Jackson, Lauren Lopez, Admin, 127.0.0.1, Zeeshan Hussain Mundh, Noel McLoughlin, Simisola Ajeyalemi, Rucha Gadgil, Aimee Tow and Jess Bell  

Introduction[edit | edit source]

Effective communication techniques in a healthcare setting have been developed on the basis that physiotherapists are in a unique position as part of a multidisciplinary team in that they can have substantially more contact time with patients than other members of the team. This means the physiotherapist is more appropriately positioned to develop a deeper patient-therapist relationship and in doing so educate and empower the patient of their physical condition and management.

Communication is an important tool in a healthcare setting that when used effectively can educate, empower and de-threaten common health issues patients present within practice. However, if it is used ineffectively it can have detrimental effects creating fear, confusion and anxiety in patients as well as encouraging resistance to lifestyle changes and healthy behaviours.

Importance of Good Communication[edit | edit source]

Communication is an interactive process which involves the constructing and sharing of information, ideas and meaning through the use of a common system of symbols, signs. and behaviours[1]. It includes the sharing of information, advice, and ideas with a range of people using:

  • Verbal
  • Non-verbal
  • Written
  • E-based

These can be modified to meet the patient's preferences and needs.

Figure 1 - CSP quality assurance standards (2012)
Standards.jpg
Figure 2 - HCPC standards of proficiency (2013)
HCPC.jpg

Skilled and appropriate communication is the foundation of effective practice and is a key professional competence (See CSP: quality assurance standards[1] and HCPC: Standards of Proficiency[2] figure 2, above) which is highly valued by physiotherapy recipients[3]. Effective communication requires consideration of the context, the nature of the information to be communicated and engagement with technology, particularly the effective and efficient use of Information and Communication Technology.

Benefits of Good Communication[edit | edit source]

Effective communication does not only improve understanding between health professionals and patients but it can also have a positive impact on health outcomes. To understand why communication may lead to improved health outcomes researchers have identified direct and indirect pathways through which communication influences health and well being.[4].

Direct Pathways[edit | edit source]

Talk may be therapeutic, meaning, a physiotherapist who validates the patients perspective or expresses empathy may help a patient experience improved psychological well being. Leading to the patient experiencing fewer negative emotions (e.g. fear and anxiety) and more positive ones (e.g., hope, optimism and self-worth).

Non-verbal behaviours such as touch or tone of voice may directly enhance well-being by lessening anxiety or providing comfort[5][6][7]

Indirect Pathways[edit | edit source]

In most cases, communication affects health through a more indirect or mediated route through proximal outcomes of the interaction, such as;

  • Satisfaction with care
  • Motivation to adhere
  • Trust in the clinician and system
  • Self-efficacy in self care
  • Clinician - patient agreement
  • Shared understanding

This could affect health or that could contribute to the intermediate outcomes (e.g., adherence, self-management skills, social support that lead to better health[8].

A physiotherapists clear explanation and expression of support could lead to greater patient trust and understanding of treatment options[4]. This in turn may facilitate patient adherence to recommended therapy, which in turn improves the particular health outcome. Increased patient participation in the consultation could help the physiotherapist better understand the patient’s needs and preferences as well as discover possible misconceptions the patient may have about treatment options[4]. The physiotherapist can then have the opportunity to communicate risk information in a way that the patient understands. This could lead to mutually agreed upon, higher quality decisions that best match the patients circumstances[4]. Key factors of communication to improve health outcomes:

  • Examination and Assessment - using clear concise language and allowing the patient time to talk will influence the quantity, quality and accuracy of data
  • Respect Clients individuality and background - adjusting tone and level of language as well as using lay terms rather than medical terms can help improve understanding and make patients feel at ease[9][10]
  • Respect a patients space - do not invade their space without first asking permission
  • Be open and create a relaxed atmosphere
  • Be attentive - Look at the patient when they are talking
  • Environment - Provide the patient with an area that is private and away from noise and interruptions

Communicating Sensitive Issues[edit | edit source]

Primary care providers and particularly physiotherapists are often faced with sensitve issues within their daily practice. One example is dealing with obesity and encouraging patients to take a more active approach in the management of obesity[11]. However physiotherapists have encountered many challenges related to addressing obesity with patients[12]. Given that obesity is becoming an epidemic in many nations throughout the world, the need to understand how, when and with whom to have these discussions which becomes essential in order to provide effective care for obese patients. There is a growing need for the training of physiotherapists in areas such as weight loss counseling in order to reduce the barriers encountered when discussing obesity [12].

Wadden & Didie[13] reported that patients observed the terms obesity and fatness to be very undesirable descriptors used by their physicians when discussing their body weight. Other terms such as large size, heaviness and excess fat were also highlighted as undesirable. The use of these terms by physicians can be interpreted as offensive or hurtful by the patient and lead to a breakdown in communication.
The study reported that weight was the most favourably rated term to be used by physicians as it is easily understood and non judgemental. Another term which was viewed as favourably, as it was non judgemental was BMI, however it is found to be not universally known.

Johnson[14] reported that some patients preferred to be described as plus sized, large or even fat. By embracing these terms these patients are motivated to remove the negativity and stigma related to them.
Wadden and Didie[15] reported the most beneficial approach would be to ask the patient how they feel and their thoughts towards their weight. Using this approach the physiotherapist should seek the patients consent and come to an agreement to address and discuss the issue. Caution should be taken to avoid reiterating the hazards obesity has to the patients health. Wadden et al[16], reported obese patients often experience a feeling that care providers seldom understand how much they suffer with their weight issues. Utilising the conversation approach also allows the physiotherapist to show respect and empathy to the patient by focusing on the positive steps they may have taken previously to tackle the issue.

The Issue With "Calling It As It Is"[edit | edit source]

This approach fails to avoid the degrading and offensive terms, used by the public, and causes more negative effects than beneficial effects [14]. It is a challenge for obese individuals to understand the medical implication of these terms as they cannot separate them from the degrading aspects of the terms used by the public.Using a confrontational approach instead of a discussion with the patient is far more likely to negatively affect the patient’s moral, feelings and confidence. Johnson[14] reports that care providers who approach the issue by attempting to 'break through the patient’s denial of their weight issues, are more likely abolishing the patients trust and their motivation to return for future sessions and care. This is the most common outcome when individuals are advised to battle their obesity by losing weight, to avoid the ominous medical consequences.
More desirable and beneficial outcomes can be achieved through the use of motivational interviewing and discussions with patients in need of weight management compared to a confrontational approach [17][15].

Teaching Tools[edit | edit source]

Tools such as the video below can be used in teaching and motivating patients on lifestyle and behaviour change. 

Motivational Interviewing[edit | edit source]

Evidence has shown that patient-centred approaches to health care consultations are more effective than the traditional advice giving, especially when lifestyle and behaviour change are part of the treatment[18].

In the past, healthcare practitioners encouraged patients to change their lifestyle habits through provision of direct advice about behaviour change[19]. However, this has proven to be unsuccessful, as evidence show success rates of only 5-10%[20] . Additionally, this can put a strain on the patient-therapist relationship with the patient perceiving this style as being lectured on their lifestyle choices[21].

Patients can also feel that the therapist is not considering the personal implications the change may have on their life, as they are just placing emphasis on the future benefits and not recognising the initial struggle the patient may have to go through[18]. Such an encounter can risk the patient becoming resistant to change or further increasing their resistance to change[22]. This resistance to change was seen as a personality trait that could only be dealt with by direct confrontation which potentially placed a further strain on the patient-therapist relationship [23].

Research has shown that patient-centred approaches have better outcomes in terms of patient involvement and compliance[18] [24]. The key feature to these approaches is that the patient actively engages in discussing a solution for their problem[25].

Motivational Interviewing (MI) is based off Miller & Rollnick’s (1991)[26] experience with treatment for problem drinkers and is becoming increasingly popular in healthcare settings. The model views motivation as a state of readiness to change rather than a personality trait[27]. As such, motivation can fluctuate over time and between situations. It can also be encouraged to go in a particular direction. By taking this view , a patient’s resistance to change is no longer seen as a trait of the person but rather something that is open to change[19]. Therefore, the main focus of MI is to facilitate behaviour change by helping the patient explore and resolve their ambivalence to the change[19].

While MI is patient centred and focuses on what the patient wants, thinks and feels, it differs slightly from other patient-centred approaches as it is directive[18]. In using MI there is the clear goal of exploring the patient’s resistance to change in such a way that the patient is likely to change their behaviour in the desired direction[18].
The focus of Motivational Interviewing is to:

  • Assist the patient in examining their expectations about the consequences of engaging in their behaviour.
  • Influence their perceptions of their personal control over the behaviour through use of specific techniques and skills.[27].

 A benefit to this approach is that time can be saved by avoiding unproductive discussion by using rapid engagement to focus on the changes that make a difference[19]. For more on this topic see Motivational Interviewing

Conclusion[edit | edit source]

Communication is more than just what we say, it matters how we say it too. It is important that communication is good, clear and compassionate in a healthcare setting. The style in which we communicate may differ between individual patients due to learning styles, literacy levels or the level of understanding the patient has of their condition and the anxiety they may present with.

References[edit | edit source]

  1. ↑ 1.0 1.1 Quality Assurance Standards for Physiotherapy Service Delivery. (2012). Chartered Society of Physiotherapy (CSP).
  2. ↑ Standards of Proficiency - Physiotherapists. (2013). Health and Care Professions Council (HCPC).
  3. ↑ Parry RH, Brown K. Teaching and learning communication skills in physiotherapy: What is done and how should it be done?. Physiotherapy. 2009 Dec 1;95(4):294-301.
  4. ↑ 4.0 4.1 4.2 4.3 Street Jr RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient education and counseling. 2009 Mar 1;74(3):295-301.
  5. ↑ Henricson M, Ersson A, Määttä S, Segesten K, Berglund AL. The outcome of tactile touch on stress parameters in intensive care: a randomized controlled trial. Complementary therapies in clinical practice. 2008 Nov 1;14(4):244-54.
  6. ↑ Knowlton GE, Larkin KT. The influence of voice volume, pitch, and speech rate on progressive relaxation training: application of methods from speech pathology and audiology. Applied psychophysiology and biofeedback. 2006 Jun 1;31(2):173-85.
  7. ↑ Weze C, Leathard HL, Grange J, Tiplady P, Stevens G. Evaluation of healing by gentle touch in 35 clients with cancer. European journal of oncology nursing. 2004 Mar 1;8(1):40-9.
  8. ↑ Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ: Canadian Medical Association Journal. 1995 May 1;152(9):1423.
  9. ↑ Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ: Canadian Medical Association Journal. 1995 May 1;152(9):1423.
  10. ↑ Donovan J. Patient education and the consultation: the importance of lay beliefs. Annals of the Rheumatic Diseases. 1991 Jun;50(Suppl 3):418.
  11. ↑ Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of physician activities related to obesity management. Archives of Family Medicine. 2000 Jul 1;9(7):631.
  12. ↑ 12.0 12.1 Alexander SC, Østbye T, Pollak KI, Gradison M, Bastian LA, Brouwer RJ. Physicians' beliefs about discussing obesity: results from focus groups. American Journal of Health Promotion. 2007 Jul;21(6):498-500.
  13. ↑ Wadden TA, Didie E. What's in a name? Patients’ preferred terms for describing obesity. Obesity Research. 2003 Sep;11(9):1140-6.
  14. ↑ 14.0 14.1 14.2 Johnson, C. Obesity, Weight Management and Self-Esteem. In: Wadden, T.A. and Stunkard, A.J Handbook of Obesity Treatment. 2002. New York, NY: Guilford Press, pp.480-493.
  15. ↑ 15.0 15.1 Wadden TA, Didie E. What's in a name? Patients’ preferred terms for describing obesity. Obesity Research. 2003 Sep;11(9):1140-6.
  16. ↑ Wadden TA, Anderson DA, Foster GD, Bennett A, Steinberg C, Sarwer DB. Obese women's perceptions of their physicians' weight management attitudes and practices. Archives of Family Medicine. 2000 Sep 1;9(9):854.
  17. ↑ Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. Book Review.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient education and counseling. 2004 May 1;53(2):147-55.
  19. ↑ 19.0 19.1 19.2 19.3 Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. Bmj. 2010 Apr 27;340:c1900.
  20. ↑ Rollnick S, Kinnersley P, Stott N. Methods of helping patients with behaviour change. British Medical Journal. 1993 Jul 17;307(6897):188-90.
  21. ↑ Stott NC, Pill RM. ‘Advise yes, dictate no’. Patients’ views on health promotion in the consultation. Family Practice. 1990 Jun 1;7(2):125-31.
  22. ↑ Miller WR, Rollnick S. Motivational interviewing: Helping people change. Guilford press; 2012 Sep 1.
  23. ↑ Miller WR. Motivational interviewing: III. On the ethics of motivational intervention. Behavioural and Cognitive Psychotherapy. 1994 Apr;22(2):111-23.
  24. ↑ Ockene JK, Kristeller J, Goldberg R, Amick TL, Pekow PS, Hosmer D, Quirk M, Kalan K. Increasing the efficacy of physician-delivered smoking interventions. Journal of General Internal Medicine. 1991 Jan 1;6(1):1-8.
  25. ↑ Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. American journal of preventive medicine. 2001 Jan 1;20(1):68-74.
  26. ↑ Miller, WR., Rollnick, SR. 1991. Motivational Interviewing: preparing people to change behaviour. New York: Guilford Press
  27. ↑ 27.0 27.1 Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: helping patients change behavior. Guilford Press; 2008.
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