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 the process of sending and receiving messages to share skills, knowledge and attitudes. Communication is a fundamental clinical skill as it helps to establish the therapeutic relationship between clinicians and their patients. There are many benefits of effective communication in healthcare, including improved health status, functioning and patient satisfaction.

Historically, healthcare settings have focused on direct face-to-face communication to relay information (i.e. in-person appointments). Direct communication now also includes video conferencing. This approach allows patients to hear the information and see the clinician's facial expressions and body language. These 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. patient information can be provided in letters), 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 far more than just the physical process of hearing. It requires concentration and hard work.

Hunsaker and Alessandra suggest that when someone is listening, they 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 differs for each category. 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 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 show interest in what the speaker is saying through verbal cues (e.g. asking questions, summarising the speaker's words and their purpose, etc) and non-verbal cues (eye contact, attentive silence, appropriate body movement and posture, facial expressions, etc).

Active listening is critical to communication between a healthcare provider and a patient. To be an effective active listener, healthcare providers can follow these steps:

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

Effective communication between patient and provider requires a two-way dialogue where each party respects the other. Both parties will be able to:

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

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

1. Verbal Communication

Verbal communication is the transmission of information through spoken words or written language.

Written communication is primarily used to convey information in a permanent manner. Technological advances have increased the use of written communication over recent years. Examples of written communication include emails, text messaging, electronic medical records, reports etc.

Oral communication, or 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 range 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, sometimes contradicting 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 important to note that listeners also display non-verbal cues and should consider how others might interpret or perceive them.

Non-verbal communication also encompasses paraverbal communication - i.e. voice attributes such as the inflection of voice, tone, rhythm, intonation, and verbal flow. Like other forms of communication, paraverbal communication can 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 Communication

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

Summary of the Three Modes of Communication

The following table summarises the three modes of communication.

Modes of Communication in Healthcare and Associated Skills

Modes of Communication	Skills
Non-Verbal	Shows awareness of the non-verbal communication of 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, and 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 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 can be barriers to communication within the healthcare setting. These barriers can limit or prevent a patient from expressing their healthcare needs and / or limit the provider from giving critical information clearly and concisely.

Communication barriers in healthcare can include:

• Institutional barriers such as staffing shortages and high workloads, which can ultimately lead to burnout.
  • Providers experiencing burnout may have difficulty with active listening as they are already stressed and may not be as generous with their attention.
  • High caseloads reduce the time available for each patient interaction.
  • As patients receive less time, they may be unable to provide all the details the clinician needs to ensure appropriate care. In addition, they may not have the opportunity to ask questions which could reduce adherence to treatment or medication.

• Poor communication skills by the healthcare provider or language barriers. These barriers can affect treatment adherence and outcomes.
  • They can limit the patient's ability to understand an intervention and what they need to do.
  • Hiring translators and interpreters can help when language barriers exist.

• Cultural differences between the provider and patient may cause a communication barrier as there are different norms and conventions across cultures (e.g. eye contact, touch, or body language).

• Environmental challenges can hinder communication between providers and patients.
  • Hospital rooms may be noisy, messy and/or dark. These factors can act as distractions during a provider/patient interaction.
  • A lack of privacy may mean a patient is unwilling to communicate relevant details. To encourage sharing, the patient needs to feel physiologically and psychologically safe.

Patient Satisfaction

Respectful interactions between providers and patients 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 explored how poor communication between clinicians and patients can create barriers, lead to adverse consequences and decrease patient satisfaction.

Diagnostic Accuracy

The majority of our diagnostic decisions come from the subjective interview / history taking. However, it has been found that patients frequently are not given the opportunity to discuss their history, often because of interruptions, which may reduce diagnostic accuracy and impact clinical decision-making.

• If interruptions occur, patients may be more reluctant to provide additional information as they might feel that what they are saying is unimportant.
• Interruptions may mean that the patient does not include essential information, and this can impact diagnosis and affect the patient/provider relationship

Adherence

Adherence in healthcare is "the extent to which a patient’s behavior corresponds with agreed upon recommendations from a healthcare provider." Patient adherence is a significant problem in healthcare. One study in America on patient adherence found the following:

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

Patient Satisfaction

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

• Expectations: patients value having the opportunity to tell their story
• Communication: patient satisfaction increases when healthcare team members:
  • explain information clearly
  • take the patient's problem seriously
  • attempt to understand the patient's experience
  • suggest appropriate / viable treatment options
• Control: patients who are given the opportunity to express their expectations, concerns and ideas are more satisfied with their care
• Decision-making: patient satisfaction increases when healthcare providers acknowledge mental and social functioning (as well as physical functioning)
• Time spent: longer healthcare visits correlate with increased patient satisfaction
• Clinical team: patients also value their clinician's team
• Referrals: patient satisfaction increases when healthcare providers initiate referrals for the patient (rather than them having to do it themselves)
• Continuity of care: patients value working with the same healthcare provider
• Dignity: patient satisfaction increases when they are treated with respect and invited to be a partner in their healthcare decisions

Factors Leading to Effective Communication

Rehabilitation professionals can attain the necessary communication skills to enhance the therapeutic process through experience, age and accumulated knowledge. In 2017, Rusu et al. conducted a literature review on the patient-therapist relationship and found several factors can enhance communication between physiotherapist and patient, including the following:

• greeting the patient respectfully and using names rather than words like "dear"
• directly expressing ideas and using short phrases
• using positive phrases and words
• avoiding the use of adjectives as much as possible
• keeping the patient informed about expectations, techniques, recovery, etc, from the beginning
• explaining technical terms to avoid misunderstanding - adapting language to suit the patient
• using professional and respectful language
• being flexibility
• using jokes when appropriate
• using an interpreter when necessary
• identifying and decreasing communication barriers
• using active listening techniques
• repeating when necessary

Rusu et al. also identified ways to encourage non-verbal communication to enhance the therapeutic relationship:

• being aware of the non-verbal cues you, as the provider, are displaying during the meeting
  • e.g. looking at the clock, the expression on your face, etc.
• being aware of your non-verbal biases
  • e.g. obesity, poor hygiene, etc.
• being aware of the patient's non-verbal responses and using these cues to make 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