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.

Communication Modes

Clinical communication interactions that are respectful enhance patient engagement in decision making, increase patient adherence to treatment and patient satisfaction and reduce anxiety and uncertainty. Medical communication between patient and provider should entail a two-way dialogue of mutual respect. Effective communication between both parties would 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.

Active Listening

Effective oral and non-verbal communication requires active listening.. Active listening is a critical component of good communication which involves giving the speaker your full attention without distractions or interruptions. Active listening is more than simply listening to the speaker. The components below detail what is involved in active listening:

1. Reflect: confirm your understanding by paraphrasing or repeating what they have said
2. Clarify: ask questions to better understand what they said
3. Summarise: provide a brief summary of what they said
4. Empathise. 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

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. High caseloads creates limited time to interact with each patient as the providers have too many patients to attend to in a day. 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. In addition, the patient may not have the opportunity to ask questions which could alter their adherence to treatment or medication. Decreased time with patients is not the only barrier leading to misunderstood treatment and medication instructions. A poor communicator or language barrier 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. Language barriers may accompany cultural or value norm differences. In this scenario, providers may not understand factors such as personal proximity, touch, or body language. Lastly, there are environmental challenges which may hinder communication between provider and patient. In a medical setting, the 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 interactions. Lastly, the lack of privacy 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.

Physiotherapy and Communciation

Physiotherapists 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 physio 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 thepatient
• avoiding placing the patient in an embarrasing 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 as seen below:

• 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 noverbal bias
  • obsese patient, poor hygiene patients, etc.
• awareness of patient's non-verbal responses
  • using those cues to makes decisions

Exline (1971) has categorised most of

these elements into two main groups,

affihative and dominant. Both of these can

be observed m a therapeutic setting

(Gallois et al 1979) Affiliative behaviours

are related to intimacy, are generally

regarded as being more feminine and

include, for example, touch, close

proximity, smilmg, friendly tone of voice

and eye contact.

Dominant behaviours are concerned

with power and influence, considered to

be more masculine, and include speaking

loudly, and for long periods of time,

interrupting, avoidance of eye contact and

attempts to be influential (Strongman

1979).

Since physiotherapy is primarily a

female profession, affihative behaviours

can be assumed to be more evident. Males

as well as females require treatment

however, so a more dominant style is

adopted, possibly to maintain professional

status (Gallois et al 1979) H owever Gallois

also found that affiliative behaviour was

more effective for successful treatment

Two non-verbal cues, touching and

close proximity, are usually considered

socially unacceptable unless in conditions

of intimacy, though there are cultural

variations However these two cues are

essential m a physiotherapeutic setting if

the physical care of the patient is to be

complete

Touch and Proximity

The physiotherapist's handling of a

patient cannot occur unless the space

between them is eliminated, and 'the

logical end of proxemics is touching'

(Weitz 1974). A thorough and accurate

physical examination must occur for

appropriate treatment to be carried out.

The patient's perception of the therapist's

feelings is altered by good or poor

handling. Touching can occur too within

the therapeutic process and indicate

encouragement, support or canng which

enhance the patient's perception of

rapport. Handling a patient's belongings

can also indicate to him whether a canng

relationship exists; throwing clothes

carelessly to one side, or pushing shoes

away with one's foot clearly might cause

the patient to perceive a fundamental

carelessness and could lead to feelings of

rejection.

Another aspect of touch is its

enhancement ofself-concept or self-worth

After an amputation, for example, the

patient's self-esteem can be devalued while

he adjusts to the loss of a limb The

physiotherapist's handling of the part

without aversion and withcareand interest

indicates that the physiotherapist accepts

the patient unconditionally (Pratt 1978)

This form of touch is termed 'acceptance'

by Perry (1974).

Sensitivity to 'non-touch' is important

in, for example, the treatment of a patient

with spinal injury. Adaptations of

kinaesthetic sense and balance reactions

are necessary in order to include the

wheelchair as a compensatory device for

paralysis of limbs If the wheelchair is

moved or tilted unexpectedly from behind,

the patient is unbalanced which gives rise

to anxiety and possible loss of trust in the

physiotherapist.

Facial Expression

Facial expression conveys a multitude

of meanings and much is revealed to both

patient and therapist, particularly at the

beginning of a treatment session The

benefits of smiling and a pleasant facial

expression need not be mentioned, since

so many examples of the effect on us of a

pleasant or unpleasant expression can be

brought to mind The same is true of

patients in their encounters with

physiotherapists

Much research has been undertaken in

the study of facial expression, notably by

Shapiro et al (1968), Ekman and Fnesen

(1971) and Dittman (1972, cited by Weit?

1974) Gallois et al (1979) found that

smiling at the patient by the physio-

therapist did not often occur during treat-

ment even though female physiotherapists

tended to smile more often than male

physiotherapists This could indicate that

females display more affihative behaviour

than males. Until the physiotherapist/

patient relationship is well established,

however, each will respond to the more

obvious cues — 'words, stereotypes, facial

expressions and gestures'(Dittman 1972)

A facial expression of genuine interest

and concern conveyed to the patient is

undoubtedly of value this cue when

integrated with the other non-verbal

elements, leads to rapport and trust in the

physiotherapist, so that the patient is

motivated to comply with instructions and

advice

Eye Contact

Eye contact is taken to be a signal of

either dominance, as in a stare, or intimacy

as in affiliative behaviours (Exline 1971),

Gallois et al (1979) found that long gazes

did occur, possibly as a means of signifying

dominance, or as a result of mixed sex

interactions as a sign of affiliation. How-

ever eye contact also suggests interest in, and

respect for the patient (Banville 1978) and

can be regarded as a significant factor in

the total non-verbal communication A

physiotherapist who leans forward, nods

the head appropriately, listens attentively

and maintains eye contact (La Crosse

1975) emanates warmth and regard for the

patient who responds appropriately.

Conversely, minimal eye contact with

frequent glances away from the patient

might indicate disinterest and boredom.

Gestures and Posture

Adjuncts to speech are gestures which

2 0 The Australian Journal of Physiotherapy Vol. 28, No 4, August 1982

mplify or modify verbal cues, involuntary

gestures reveal much about the patient,

particularly if the facial expression and

verbal content are guarded Leakage will

occur subconsciously (Ekman and Fnesen

1969). This term can be defined as

incongruity between two non-verbal

messages' for example, the facial

expression may display confidence but the

fingers may be tapping nervously.

Posture reveals tension or relaxation

(Strongman 1979); a patient could feel

more comfortable with the physiotherapist

sitting beside him in a position of co-

operation than in a face-to-face

confrontative or competitive situation

(Strongman 1979), though some

treatments necessitate such a position

Observation, Listening, Use of Silence

It is in these situations that the

physiotherapist requires skills in

observation and listening. The patient's

posture reveals the current state of mmd;

for example, a slumped position could

indicate depression whereas constant

postural shifts reveal agitation and

anxiety The cues are always observable

Listening is of great importance and can

reveal much to the physiotherapist who,

by emitting non-verbal cues, enables the

patient to talk freely if he wishes. Total

listening implies understanding of feelings

as well as content (Sutchffe 1970, Banville

1978) Positive regard, communicated to

the patient, helps him to restore feelings of

impaired self-concept, and to accept

himself as he is whatever his disability

Listening skills should be combined

with the understanding of the potency of

silence, A patient may have gained a

valuable insight into his problems through

the facilitation of the interactive process

and needs some time to reflect An

awareness of this need overcomes the

natural desire on the part of the

physiotherapist to break the silence,

unwittingly putting an end to the

therapeutic or healing process (Enelow

and Swisher 1972, Meares 1969)

Tone of voice

Since verbal communication is also an

essential part of the physiotherapist/

patient interaction, the tone of voice is of

great significance Mehrabian and Ferns

(1967) found that inconsistencies in vocal

and verbal messages led to an

interpretation from the tone of voice, not

content This was borne out by Milmoe

etal (1967) who found that alcoholics

responded more effectively to a physician

whose tone of voice intimated concern and

anxiety than when the tone of voice

expressed anger or matter-of-factness

These findings can be directly related to the

physiotherapeutic environment, where

instructions will be listened to more

attentively if the patient perceives concern

for his welfare Variations in the tone of

voice are very important in most

therapeutic situations, as for example in

effecting a voluntary response from a

poorly motivated patient, or producing

successful relaxation.

Patient anxiety

The one to one relationship experienced

by a patient and his physiotherapist can be

effectively utilised in a calm and unhurried

way. The time spent during treatment can

be lengthy, the average time taken for

application of a technique being half-an-

hour DiMatteo (1979) states that

satisfaction with the interaction resulted

not from the actual time taken, but from

the patient's perception of the time being

enough With the establishment ofrapport

(Meares 1969) the patient may feel

encouraged to express anxieties and fears

without feeling the pressure of imminent

dismissal. This is of great therapeutic

importance. Frequently the physio-

therapist is the only member of the helping

professions with time potentially available

for the patient to ventilate feelings related

to his disability, work or other areas of

anxiety; 4the opportunity is there' (Pratt

1978).

It is sometimes felt that every minute of

the allotted time for treatment must be

spent on techniques designed to

rehabilitate muscles, nerves, joints or other

physical disabilities However, it is of little

value to treat the effect without

understanding the cause. Denstad in 1974

(cited by Pratt 1978) suggests that 'the

problems concerning the patient's

expectations of being the passive receiver

are reduced when the patient is treated

from the onset as a participant in his

therapy and not as an onlooker'. In other

words, if a patient is made aware that his

tension headaches are related to external

factors and that modifying steps would

reduce stress and thereby the headache,

treatment will be far more effective.

Shafar and Ruddick (1976, p.82) cite

Cooksey (1969) as stressing *the large

number of cases with disorders of the

musculo-skeletal system where pain and

disability are accentuated by disturbances

in mental functioning Anxiety reactions

invariably accompany the stress of

sickness and injury, and it would appear

that many doctors are insufficiently

concerned with the outcome of

explanations offered to the patient.

Palliative physiotherapy for lengthy

periods, culminating in discharge with

relief only serves to aggravate the pre-

existing anxiety and reinforces

psychological factors, especially when a

component of anger, resentment and

feeling of rejection is present'.

If a physiotherapist is aware that every

patient who comes for treatment

experiences anxiety and that this anxiety

varies in type and intensity for the patient,

then her treatment and interpersonal

relationship can be greatly enhanced and

lead to achievement of goals.

Conclusion

Social skills can be learned and it is less

helpful to the patient for the physio-

therapist to rely on instinct and experience

in order to understand his non-verbal

behaviour. Effective understanding and

use of non-verbal skills in the therapeutic

setting should be employed to achieve

successful outcome. A patient who has

confidence and trust in the physiotherapist

is far more likely to comply with

instructions and implement treatment

(Davis and Kenyon 1981, DiMatteo 1979)

than a patient who perceives lack of

interest or antagonism, even though the

verbal instructions may be identical. It

may be assumed that the motivated patient

is the one who volunteers the information

that he has performed the exercises at

home; the non-motivated patient will

The Australian Journal of Physiotherapy Vol. 28, No. 4, August 1982 2 1

amplify or modify verbal cues, involuntary

gestures reveal much about the patient,

particularly if the facial expression and

verbal content are guarded Leakage will

occur subconsciously (Ekman and Fnesen

1969). This term can be defined as

incongruity between two non-verbal

messages' for example, the facial

expression may display confidence but the

fingers may be tapping nervously.

Posture reveals tension or relaxation

(Strongman 1979); a patient could feel

more comfortable with the physiotherapist

sitting beside him in a position of co-

operation than in a face-to-face

confrontative or competitive situation

(Strongman 1979), though some

treatments necessitate such a position

Observation, Listening, Use of Silence

It is in these situations that the

physiotherapist requires skills in

observation and listening. The patient's

posture reveals the current state of mmd;

for example, a slumped position could

indicate depression whereas constant

postural shifts reveal agitation and

anxiety The cues are always observable

Listening is of great importance and can

reveal much to the physiotherapist who,

by emitting non-verbal cues, enables the

patient to talk freely if he wishes. Total

listening implies understanding of feelings

as well as content (Sutchffe 1970, Banville

1978) Positive regard, communicated to

the patient, helps him to restore feelings of

impaired self-concept, and to accept

himself as he is whatever his disability

Listening skills should be combined

with the understanding of the potency of

silence, A patient may have gained a

valuable insight into his problems through

the facilitation of the interactive process

and needs some time to reflect An

awareness of this need overcomes the

natural desire on the part of the

physiotherapist to break the silence,

unwittingly putting an end to the

therapeutic or healing process (Enelow

and Swisher 1972, Meares 1969)

Tone of voice

Since verbal communication is also an

essential part of the physiotherapist/

patient interaction, the tone of voice is of

great significance Mehrabian and Ferns

(1967) found that inconsistencies in vocal

and verbal messages led to an

interpretation from the tone of voice, not

content This was borne out by Milmoe

etal (1967) who found that alcoholics

responded more effectively to a physician

whose tone of voice intimated concern and

anxiety than when the tone of voice

expressed anger or matter-of-factness

These findings can be directly related to the

physiotherapeutic environment, where

instructions will be listened to more

attentively if the patient perceives concern

for his welfare Variations in the tone of

voice are very important in most

therapeutic situations, as for example in

effecting a voluntary response from a

poorly motivated patient, or producing

successful relaxation.

Patient anxiety

The one to one relationship experienced

by a patient and his physiotherapist can be

effectively utilised in a calm and unhurried

way. The time spent during treatment can

be lengthy, the average time taken for

application of a technique being half-an-

hour DiMatteo (1979) states that

satisfaction with the interaction resulted

not from

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