Effective Communication Techniques

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Introduction

Resource Aims

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.
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.
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.
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.

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:

1. Understand the importance of effective communication and identify pathways which communication may be influenced.
2. Identify the patients positive and negative emotional triggers and evaluate the impact on physical presentation
3. Analyse the prevailing language/metaphors that exist within healthcare and assess their impact on the bio-psyco-social model of pain.
4. 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.
5. Identify effective communication methods that may be helpful when explaining a diagnosis/treatment to a patient.
6. Reflect upon one's own practice of communication techniques and identify areas requiring improvement

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 (CSP quality assurance standards). It includes the sharing of information, advice and ideas with a range of people, using;

• verbal
• non-verbal
• written and
• e-based

These can be modified to meet the patients preferences and needs.
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).
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.

Communication Pathways to improve health outcomes

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) (Fogarty,1999; Ong, 2000; Schofield, 2003).
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

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.
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.

Communication when addressing persistent pain complaints

Clinical Example: Osteoarthritis

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).
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).

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)
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;

‘why should we exercise when our knees hurt?’ 

In the same study patients were asking

‘if it is wear and tear on the bone, is it helping to do all this exercise, walking and that?’

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).

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.

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).

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).

Following on from this, we may also consider the avoidance model presented by Dekker et al (1993)

This model indicates that a decreased muscle strength as a result of activity avoidance leads to activity limitations (Holla et al, 2012).

Recommendations

'What can us as physiotherapists do to combat these beliefs that may be instilled in patients?'

References

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