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 method of sending and receiving messages to share skills, knowledge and attitudes.

Communication in the healthcare environment entails transmitting and receiving of information between clinician and their patients. Good communication is a fundamental clinical skill that establishes the therapeutic relationship between the clinician and their patients. Studies show that clinicians who explain, listen and empathise with their patients produce a profound effect on their patients health status and functioning as well as overall satisfaction in the medical care.

Historically, medical settings incorporated direct face-to-face communication to relay information. In this format, patients could not only hear the information, but were able to see facial expressions and body language to help better understand the meaning behind the words. Direct interactions are decreasing as indirect interactions like video conferencing increase. Technological advances have also aided an increase in written communication (emails, texts, etc) between providers and patients. Besides patient preference written communication has many other advantages in medical care including it is educational, easily distributed, traceable and can hold medical-legal value.

Active Listening

Effective oral and non-verbal communication requires active listening. Listening is an emotion and intellectual process that involves more than the physical process of hearing. Listening requires concentration and hard work. There are four categories of listening:

1. non-listener
2. marginal listener
3. evaluative listener
4. active listener

Each category requires an appropriate sensitivity and extent of concentration from the listener. As one moves from the first category effective communication increases as does trust.

The most effective level of listening is called active listening. In general, this communication takes place in a non-hurried atmosphere between two people. Active listening is a special communication skill whereby full attention is given to the speaker without interruptions. It requires listening for the feeling, intent and content of the speaker. The listener signifies to the speaker that they are 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
• showing interest in the speaker’s words
• reflecting back feelings and content
• summarising intellectually the speaker’s words and their purpose

Active listening is a critical component of good communication in healthcare between provider and patient. Medical active listening means more than simply listening to the patient. To be an effective active listener, the six following components are necessary:

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

Communication Modes

Medical communication between patient and provider should entail a 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

Medical communication is delivered through three modes, verbal, non-verbal and visual. Verbal communication is delivered through spoken words or written language. Nonverbal communication displays emotional information through the body or face. Visual communication delivers messages through visual cues suck as illustrations and diagrams.. Both verbal and non-verbal communication can be influenced by a number of factors including the volume and pace of the interaction, the spatial proximity, the style of communication (friendly vs. authoritative) and the extent or limit of physical contact.

1. Verbal

Verbal communication encompasses both written and oral forms. 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-t0-face interactions, video conferencing, etc.

2. Non-Verbal

Non-verbal communication is a way of conveying emotion and information without using words. It provides the listener with additional information or even contradicts the spoken message.

It comprises a wide range of physical signs such as:

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

Equally important is to note the listener has their own non-verbal cues and should consider how they might be interpreted or perceived by others. In addition, within non-verbal communication lies paraverbal attributes which include the inflection of voice, tone, rhythm, intonation, and verbal flow. These paraverbal factors relay communication as well.

** Note that individual and cultural differences can impact non-verbal communication due to different norms

3. Visual Cues

Visual communication is a way to deliver messages and ideas through visual cues such as charts, photographs, videos and illustrations. When it is difficult to relay messages through words, visual communication can be a highly productive tool. Often times a single diagram, illustration or photograph can relay information complex information in a more succinct manner than words. Additionally, if there is a language barrier between provider and patient, visual cues can cross the lines to be easily as universal language. Visual cues allow patients to understand easier and retain information greater 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, summarizing, verbal and non-verbal techniques). Uses appropriate volume, clarity and pace when speaking Presents expert knowledge effectively (e.g. presenting a 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 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

Despite understanding good communication practices, there are always barriers to good communication within the healthcare environment. 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 barrier for providers is an institutional barrier of staffing shortages and high workloads 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