Modes of Communication

Original Editor - Robin Tacchetti based on the course by Jason Giesbrecht
Top Contributors - Robin Tacchetti, Jess Bell, Naomi O'Reilly and Tarina van der Stockt

Introduction

Communication is defined as the process of sending and receiving messages to share skills, knowledge and attitudes.

Communication in healthcare involves transmitting and receiving information between clinicians and their patients. Good communication is a fundamental clinical skill that helps establish the therapeutic relationship between the clinician and their patients. Research shows that clinicians who explain, listen and empathise with their patients can enhance a patient's health status, functioning and overall satisfaction with their medical care.

Historically, healthcare settings have focused on direct face-to-face communication to relay information. Direct communication now also includes video conferencing. This approach allows patients to not only hear the information, but to see the clinician's facial expressions and body language. These additional non-verbal cues help the patient to better understand the meaning behind the clinician's words.

It is suggested that direct interactions in healthcare may have decreased with technological advances while indirect interactions (emails, texts etc) between providers and patients have increased. Written communication has specific advantages. It has educational value (e.g. specific patient information can be provided in letters), it is easily distributed, traceable, has medico-legal value and is now more immediate (e.g. emails).

Active Listening

Effective oral communication requires active listening. Listening is an emotional and intellectual process that involves more than the physical process of hearing. It requires concentration and hard work.

Hunsaker and Alessandra suggest that when someone is listening, they will fall into one of the following four categories:

1. Non-listener
2. Marginal listener
3. Evaluative listener
4. Active listener

The level of concentration and sensitivity required of the listener is different for each of these categories. Our communication becomes more effective and the level of trust increases as we move up through these levels.

The most effective level of listening is called active listening. This form of listening typically requires a non-hurried interaction between two people. Active listening requires the listener to give their full attention to the speaker without interruptions. The listener must listen for the feeling, intent and content of the speaker. Active listeners signal that they feel the speaker is saying something important and interesting through verbal cues (questions) and with non-verbal cues. Non-verbal cues that are used in active listening include:

• eye contact
• attentive silence
• minimum verbal encouragement
• appropriate body movement and posture
• facial expressions
• demonstrating an interest in what the speaker is saying
• reflecting back the speaker's feelings and content
• summarising the speaker’s words and their purpose

Active listening is a critical part of communication between a healthcare provider and a patient. Medical active listening means more than simply listening to the patient. To be an effective active listener, healthcare providers must do the following:

1. Reflection: confirm your understanding by paraphrasing or repeating what the patient has said
2. Clarifying: ask questions to better understand what the patient said
3. Summarising: provide a brief summary of what the patient said
4. Empathising: attempt to understand the patient's feelings and perspectives
5. Non-verbal cues: pay attention to body language, tone of voice and facial expressions
6. Avoid interruptions / distractions: allow patients to finish without interruption / distractions

Communication Modes

Communication between patient and provider should be involve two-way dialogue of mutual respect. Effective communication between both parties should incorporate the following components:

1. exchange of information
2. ability to speak and listen without interruption
3. ability to express their opinions
4. ability to ask questions for clarity

There are three modes of communication: verbal, non-verbal and visual.

1. Verbal Communication

Verbal communication is delivered through spoken words or written language, so it encompasses both oral and written forms of language. Written communication is generally used to relay information in a permanent manner. With advances in technology, written communication has increased over recent years. Examples of written communication include emails, text messaging, electronic medical records, reports etc. Oral communication, also known as spoken communication, includes telephone calls, face-to-face interactions, video conferencing, etc.

Both verbal and non-verbal (see below) communication can be influenced by a number of factors including the volume and pace of an interaction, the spatial proximity, the style of communication (e.g. friendly vs. authoritative) and the degree of physical contact.

2. Non-Verbal Communication

Non-verbal communication is the expression of information through the body, face or voice. It provides a way to convey emotion and information without using words. It can give the listener additional information, which sometimes may even contradict the spoken message.

It includes a wide range of physical signs such as:

• facial expressions / gestures
• body language / posture
• eye contact
• shrugging
• pointing

It is also important to note that the listener will also display non-verbal cues and should consider how they might be interpreted or perceived by others. Non-verbal communication also includes paraverbal communcation. This refers to voice attributes such as the inflection of voice, tone, rhythm, intonation, and verbal flow. Paraverbal communication can also have an emotional effect.

** Please note that individual and cultural differences can impact non-verbal communication as different cultures and people may have different norms and conventions for non-verbal cues.

3. Visual Cues

Visual communication delivers messages through visual cues such as illustrations, videos, charts and diagrams. Visual communication can be an effective tool when it is difficult to relay messages through words. Often times, a single diagram, illustration or photograph can relay complex information in a more succinct manner than words. Additionally, if there is a language barrier between provider and patient, visual cues can act as a universal language. Visual cues may allow patients to understand more easily and retain more information than written or spoken words.

Summary of Cues

Communication Cues in Healthcare

Non-Verbal	Shows awareness of the non-verbal communication of both the patient and the healthcare professional (e.g. eye contact, gestures, facial expressions, posture) and responds to them appropriately. Actively listens, including using, interpreting, and responding appropriately to body language.
Verbal	Uses techniques of active listening (e.g. reflection, picking up patient's cues, paraphrasing, summarising, verbal and non-verbal techniques). Uses appropriate volume, clarity and pace when speaking. Presents expert knowledge effectively (e.g. presenting patient and clinical details to others, speaking in front of a group, presenting scientific data). Shapes a conversation from beginning to end with regard to structure (e.g. introduction, initiating the conversation, gathering and giving information, planning, closing interview, setting up the next meeting, time management.
Written	Knows about the importance of supplementing verbal information with diagrams, models, written information and instructions and applies the information appropriately. Uses appropriate tone, language and content in written communication. Maintains clear, appropriate, accurate records (written or electronic) of clinical encounters and plans.

Barriers

Even when we understand effective communication practices, there are always barriers to communication within the healthcare setting. These barriers can limit or prevent the patient from expressing their healthcare needs and / or limit the provider from giving critical information in a clear, concise manner.

One of the most common barriers for providers are institutional barriers such as staffing shortages and high workloads, which ultimately leading to burnout. Providers suffering from burnout will have difficulty with active listening as they are already stressed and may not be as generous with their attention. High caseloads creates limits time to interact with each patient as the providers are concerned about seeing all their patients on their caseload. As their interaction time is decreased, patients might not have the opportunity to provide all the details the provider needs to care for them appropriately. Decreased interaction time also may inhibit the patient from having the opportunity to ask questions which could alter their adherence to treatment or medication.

Another barrier to communication which could lead to poor adherence in treatment is a poor communicator or language barrier. Someone who can not explain clearly or speak the patients language could alter how a patient understands what their interventions are and how to perform them correctly. Hiring translators and interpreters would assist with interactions when language barriers exist.

Cultural differences between provider and patient may cause a communication barrier. Cultural differences could alter the interaction by not understanding factors such as personal proximity, touch, or body language.

Environmental challenges which may hinder communication between provider and patient. In a medical setting, the physical distance between the provider and the patient's bedside may be too far weakening the connection and not allowing the patient to engage fully. In addition, the rooms may be noisy, messy and/or dark increasing distractions during provider/patient interactions. If there is a lack of privacy that can keep a patient from communicating important details the provider might need. The environment for verbal communication should be in a caring surrounding. This allows the patient to feel physiologically and psychologically safe.

Patient Satisfaction

Healthcare communication interactions that are respectful enhance patient engagement in decision making, increase patient adherence to treatment and patient satisfaction and reduce anxiety and uncertainty. The Institute for Healthcare Communication has summarised below how poor communication between clinician and provider can not only set up barriers and adverse consequences, but decrease patient satisfaction.

Diagnostic Accuracy

1. Patients feel they often are not provided enough opportunity to discuss their history due to interruptions which may compromise clinical decision making and diagnostic accuracy
2. Interruptions may make the patient reticent to offer additional information as they might feel what they are saying is not important

**. Interruptions cause essential information to potentially be excluded and can hinder the diagnosis and patient/provider relationship

Adherence

Adherence in healthcare refers to the extent to which a patient’s behaviour corresponds with agreed upon recommendations from their provider. In medicine, patient adherence is a big problem. One study cited the following reasons why Americans report not adhering to their clinician's advice:

• 7% reported they did not understand what they were suppose to do
• 25% found the instructions too difficult to follow
• 39% disagreed with what the clinician wanted to do (in terms of recommended treatment)
• 27% were concerned about cost
• 20% felt it was against their personal beliefs

Patient Satisfaction

Patient satisfaction can be linked to good communication. The Institute for Healthcare Communications found the following 18 core factors that are components of patient satisfaction:

• Expectations: allowing the patient an opportunity to tell their story
• Communication: increased patient satisfaction was seen when members of the healthcare team:
  • explained information clearly
  • took the patients problem seriously
  • tried to understand the patient’s experience and
  • provided viable options for intervention
• Control: patients that are encouraged to express their expectations, concerns and ideas felt more patient satisfaction
• Decision-making: acknowledging mental and social functioning increased patient satisfaction
• Time spent: increase in length of the healthcare visit time correlated with improved patient satisfaction rates
• Clinical team: patients value the team who the clinician works with
• Referrals: patient satisfaction increases when the healthcare team initiates referrals relieving patient responsibility
• Continuity of care: continuity of care with the same healthcare provider increases patient satisfaction
• Dignity: healthcare providers that treat patients with respect and who are invited to partner in their healthcare decisions report greater satisfaction

Factors Leading to Good Communication

Rehabilitation professionals can attain the necessary communication skills through experience, age and accumulated knowledge. Communication is encouraged through verbal skills in the physiotherapist/patient relationship. Ruso et al., 2017 performed a literature review and determined that the below factors help build good communication between physiotherapist and patient:

• using respectful greetings to the patient
• expressing ideas in a direct way using short phrases
• use of positive phrases and words
• avoiding the use of adjectives as much as possible
• keeping the patient abreast from the beginning about expectations, techniques, rules, recovery, etc.
• explaining technical terms to avoid misunderstanding - adapting language to the education and understanding of the patient
• avoiding placing the patient in an embarrassing or uncomfortable situation
• using professional and respectful language
• flexibility
• using jokes when appropriate
• use of an interpreter when necessary
• identifying and decreasing communication barriers
• use of active listening technique
• repeating when necessary

Ruso et al., 2017 also identified ways to encourage non-verbal communication within the therapeutic relationship:

• being aware of the non-verbal cues you as the provider are displaying during the meeting
  • looking at the clock, expression on your face, etc.
• awareness of your own nonverbal bias
  • obese patient, poor hygiene patients, etc.
• awareness of patient's non-verbal responses
  • using those cues to makes decisions

Resources

• Using empathy in communication
• Communication Skills

References

• Hall, M. L., & Dills, S. (2020). The limits of “Communication mode” as a construct. Journal of Deaf Studies and Deaf Education, 25(4), 383-397. https://doi.org/10.1093/deafed/enaa009