The Interrelationship of Professional Ethics and Communication

Original Editor - Andrea Sturm

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Effective communication is fundamental to providing high-quality patient-centred care. This article examines how communication—which includes verbal and non-verbal communication and the complex dynamics of therapeutic touch—can influence patient outcomes and play an important role in ethical decision-making in rehabilitation practice.

Ethics and Communication in Rehabilitation Professions

Communication is a core professional competency that underpins ethical care delivery. Professional bodies across rehabilitation disciplines consistently emphasise this principle in their standards and frameworks.

The Standards of Physical Therapy Practice of World Physiotherapy identifies communication as "an integral element of every patient/client and professional encounter and facilitates the provision of effective and appropriate" physiotherapy.

Similarly, the World Federation of Occupational Therapists establishes that occupational therapists have "a responsibility for truthful, open and accurate communications." The Royal College of Occupational Therapists incorporates communication as a core principle, emphasising that communication should be clear, open, effective, and professional towards colleagues and patients. Therapists should reflect on the significance and impact of their verbal and non-verbal communication while remaining sensitive to the diversity of backgrounds, experiences and needs of those they communicate with.

The code of ethics of Speech Pathology Australia requires members to "communicate in a respectful and professional way" when providing accurate and timely information to clients and colleagues.

This convergence across professions demonstrates that ethical communication isn't merely professional etiquette—it represents a fundamental responsibility that enables quality patient-centred care.

Communication and Ethical Decision-Making

Professional standards provide clear professional expectations, yet rehabilitation professionals regularly encounter ethical dilemmas where communication becomes complex and challenging. Not all moral contradictions within therapeutic relationships can be resolved immediately; ethical reflection is needed to find solutions and explore alternatives to established practices. This process reveals existing moral tensions that must be appreciated and addressed through ongoing communication.

Sustaining ethical practice requires an enhanced capacity for discourse and communication about the moral dimensions of health and human life. Ethical practice thrives on the ability to express and discuss moral concerns. However, in healthcare settings, it can be challenging to find the time and space for such discussions. Communicating about ethically complex situations—such as truth-telling at the end of life or whistleblowing on unethical practices—can also be inherently uncomfortable. These conversations disrupt established practices and expose underlying tensions. Additionally, individuals differ in their communication abilities and preferred methods of expression.

An international study by Sturm et al., involving 555 physiotherapists from 72 countries, identified five overarching factors that play a role in ethical decisions made by physiotherapists:

• individual factors about the physiotherapist, such as their knowledge, experiences, values, communication skills, and moral intentions
• relational factors, including aspects of the therapeutic relationship, power asymmetries, the existence or lack of a supportive network, and characteristics of the patient
• organisational factors, such as organisational group norms and culture, the existence of a code of ethics, and workplace multidisciplinarity, and external pressures
• situational factors, including the options available in a situation or possible consequences of the decision, finances, and characteristics of the setting and issue
• societal factors, including the national and cultural context, politics or religion, the healthcare system, and the environment

It's particularly significant that communication emerged as both an individual competency and a vital relational element within therapeutic relationships. Additionally, miscommunication between physiotherapists and other healthcare professionals was identified as one of the top five ethical challenges across all World Physiotherapy regions, directly impacting patient care quality. These findings underscore the interconnected nature of communication skills and ethical practice.

Therapeutic Impact of Communication

Communication between a rehabilitation professional and a patient can itself be regarded as therapeutic.

Rehabilitation professionals can achieve so much through communication. They can educate, empower and motivate patients through skillful communication, building trust and demonstrating empathy. However, poor communication strategies can disempower patients and reinforce problematic power imbalances. Our communication can directly influence what and how much a patient reveals about their health. Kleiner et al. looked specifically at the qualities of a "good" physiotherapist. They found that patients perceive a therapist's communication skills as a central feature of good physiotherapy. Patient outcomes were found to be influenced not only by specific interventions but also by non-specific effects, such as the characteristics of the physiotherapist and the "quality of the therapeutic alliance".

The qualities of the treating physiotherapist—particularly their communication skills, including listening, empathy, friendliness, confidence and encouragement—directly influence interactions.

When rehabilitation professionals take the time to explain treatment approaches, provide clear treatment options and share their reasoning for self-management strategies, patients feel empowered to take an active role in their recovery. This empowerment through communication serves as both a therapeutic tool and a pathway to better outcomes.

Effective communication extends beyond the patient-therapist relationship. Communicating with colleagues and other members of the multidisciplinary team is crucial for coordinated care, as well as advocating for patients within the broader healthcare system.

Culturally Competent Communication for Rehabilitation Professionals

Culturally competent communication has been identified as an essential requirement by various rehabilitation professions, including audiology, occupational therapy, physical and rehabilitation medicine, physiotherapy, psychology, prosthetics and orthotics, rehabilitation nursing and speech and language therapy/pathology.

This emphasis on culturally competent communication reflects the recognised importance of communicating and collaborating with patients to define their rehabilitation needs and goals for better outcomes. Organisations such as World Physiotherapy and the World Federation of Occupational Therapists frame this idea in their educational frameworks.

"Communicate clearly, accurately, understandably, effectively in a culturally-competent manner to create trust and an appropriate environment for physiotherapy intervention, empowerment and collaboration to enable good outcomes, both in person and when working remotely." -- World Physiotherapy

"Knowledge of the characteristics of therapeutic relationships and communication processes." -- World Federation of Occupational Therapists

Rehabilitation professionals must have the ability to show cultural humility as part of their communication skills. Cultural humility requires rehabilitation professionals to actively demonstrate humility in their patient interactions. This means being able to recognise that they are not the expert on the patient's lived experiences and that they (clinicians) are willing to self-reflect on their patient interactions. It involves considering the cultural worldviews of others to form meaningful and respectful relationships. Cultural humility requires reflection on one's own behaviours, thoughts and feelings about patients' cultural views of the world. Healthcare professionals must also be committed to learning about humility and respect for others. World Physiotherapy illustrates the theme of cultural competency as follows:

"Practice using a culturally-competent, person-centred approach with respect for all forms of inclusion, diversity, dignity, privacy, autonomy, and human rights of the client, or legal guardian, who is seeking services regardless of whether the services are provided in person or remotely."

Rehabilitation professionals must also seek to understand the patient's perspective when developing treatment goals and plans. The International Society of Physical and Rehabilitation Medicine (ISPRM) highlights this requirement in their standards:

"Demonstrate interpersonal and communication skills that result in effective exchange of information and collaboration with patients, their families and other health professionals."

If you are interested in exploring the different perspectives of patients and healthcare providers, please see: Ethical Reasoning Bridge.

Being culturally competent extends beyond individual interactions; it also includes advocacy responsibilities—for the patient, their family and for the rehabilitation profession itself. Both patients and rehabilitation professionals need the appropriate services and resources to support rehabilitation needs.

"Advocate for improved societal health and wellness of individuals, the general public, and society, emphasising the importance of physical activity and exercise and the facilitation of such activities, and for the inclusion of both the client’s and physiotherapist’s perspective in decision-making."

"Human rights advocacy as a core principle across all areas of practice and in relation to disability issues and equitable access to all service."

The Ethics of Touch

Touch in rehabilitation practice has profound psychosocial and therapeutic significance that extends beyond assessment and interventions.

Patient Perspectives on Touch

Patients consider several important factors related to touch during treatment.

Which body parts are involved (both the patient's and the physiotherapist's): for example, when a physiotherapist is helping a patient who has had a stroke to learn to walk again, the therapist may need to support the patient's affected side with their entire body or physically guide movement patterns through body contact.

Duration and pressure of touch: some treatments may involve prolonged, intense and sometimes painful contact. This requires careful attention to the patient's non-verbal distress signals.

Does movement happen during touch? A patient will assess if a difficult or painful therapeutic activity will actually lead to the functional or movement improvements they want to achieve.

Privacy and presence of others: treatment may sometimes occur in common rooms, such as a rehabilitation gym area, where patients remain clothed, or in more vulnerable settings, such as the intensive care unit (ICU).

Quality of the therapeutic relationship: patients assess whether they feel comfortable with their therapist, who may repeatedly cross into their personal space.

Treatment environment and circumstances: patients may have concerns about whether the treatment space provides enough privacy and whether their dignity can be preserved during the assessment of sensitive areas, like the pelvis.

Physiotherapists can develop a form of active listening through touch. They not only listen with their hands, but often with their whole body. This is a skill that comes with experience; newly qualified physiotherapists often struggle with the appropriate application of touch and only focus on the immediate treatment area, thus missing the broader, more nuanced responses of the patient. Mastering this skill tends to depend on practical experience rather than formal training.

Types of Touch

Touch can be broadly classified into therapeutic touch and non-therapeutic touch.

Therapeutic touch includes diagnostic, interventional, assisting and informative touch. Diagnostic touch occurs when a patient is assessed and key information is collected to form a diagnosis. Interventional touch occurs during direct treatments aimed at healing. Assisting touch is when specific movements are supported by a rehabilitation professional, such as helping a patient transfer from their bed to a wheelchair. Informative touch is used to gather information during treatment or help patients understand symptoms occurring during therapy.

Non-therapeutic touch includes caring, relationship building, security providing and preparatory touch. Caring touch refers to providing consolation, encouragement or empathy through touch, such as a reassuring hand on the shoulder. Relationship building includes social gestures like shaking hands when greeting a patient. Touch that provides security gives a patient confidence or a sense of safety, even when it is not physically necessary for treatment. Preparatory touch includes touch that helps get patients ready for therapy, such as helping a patient remove or put on their shoes.

Touch and Communication

Buono et al. conducted a systematic review on the use of touch in healthcare and highlighted the following key elements.

What is communicated via touch?

Touch can provide reassurance, show empathy and foster communication. However, it can also be seen as a "destabilising tool" used to control and coerce a person; therefore, consent and verbalisation of the intent of touch are crucial.

Which types of touch tend to be perceived as communicative?

Diagnostic or procedural (therapeutic) touch is most commonly used. However, research shows that touch that is mostly expressive and non-necessary (i.e., non-therapeutic) has a communicative value. Procedural touch is used for medical and rehabilitative purposes and non-necessary touch helps to create an emotional connection and a shared sense of physical presence between patients and healthcare professionals.

What affects the use and communicative effectiveness of touch?

The effectiveness of touch as communication depends on several factors, such as the healthcare professional's role and experience, the gender of the professional and patient, personal preferences, cultural factors and the emotional state of both parties.

How is touch-mediated communication structured?

Touch is a collaborative, adaptive practice where the healthcare professional and patient are active participants in shaping the interaction. Rather than being a uni-directional action, touch is shaped by real-time adjustments based on "bodily, affective and contextual feedback." Patients are active participants—their bodily responses and feedback continuously influence how touch unfolds, as both parties respond to verbal and non-verbal cues. This highlights that touch serves multiple functions and it can easily transfer between therapeutic and non-therapeutic touch within a single interaction.

If you'd like to learn more about touch, you can read Buono et al.'s systematic review here.

Getting in Touch with Patients

Ahlsen and Nielsen shed light on how physiotherapists in Norway can get "in touch" with patients through verbal and non-verbal communication. In a qualitative observational case study, they explored which aspects of clinical communication could create connection, promote patient participation and facilitate opportunities for patients to share what seems important to them. In this study, "touch" encompassed both physical touch and relational touch (i.e., the contact that occurs during communication).

In their study, Ahlsen and Nielsen referred to Halliday's three metafunctions of human communication—ideational, interpersonal, and textual metafunctions—which are always present when humans communicate.

The ideational metafunction relates to the content of our language, representing the world in the broadest sense, including our own consciousness.

The interpersonal metafunction involves touch and establishing connections. It focuses on how language affects the listener and forms relationships between the speaker and listener. By using verbal and non-verbal resources, humans connect with each other and establish various types of relationships. This metafunction encompasses the expression of personalities and personal feelings, as well as forms of interaction and social interplay with others in the communication context.

The third metafunction is the textual metafunction. It creates coherence between the ideational and interpersonal metafunctions. This metafunction includes the flow of information in a text, such as how language is used to create coherence in a conversation or a letter, and enables the speaker to organise their message in a way that makes sense in the context.

Ahlsen and Nielsen identified a diverse range of verbal and non-verbal techniques that were employed by the physiotherapist in their case study to connect with their patient.

The physiotherapist got "in touch" with the patient by being attentive. Attentiveness can be achieved by looking at the patient while they are speaking, encouraging participation, and giving time and space for a patient's interruptions. These techniques signal to patients that what they want to say is more important than the healthcare professional's comment or action. Ahlsen and Nielsen also found that this approach can decrease the power imbalance between the physiotherapist and patient during a clinical encounter. This contributes to equality, which is a core feature of patient-centred care, and can help a patient feel more relaxed.

The physiotherapist also used repetition and unfinished sentences to connect with the patient. Repetition is a linguistic tool that allows speakers to create content, establish relationships, show acceptance of others and demonstrate engagement. It fulfils all three metafunctions (ideational, interpersonal and textual) and connects different parts of a conversation, bonding people "to the conversation and to each other". A conversation is composed of sentences, and both the speaker and the listener can collaboratively construct each sentence. This happens when the speaker starts a sentence (for example, an unfinished sentence) and the listener completes it, thus expressing the full thought.

Ahlsen and Nielsen also found that the use of touch and gaze helped the physiotherapist in the case study connect with the patient. In this instance, the physiotherapist used physiotherapeutic and relational touch, which helped the physiotherapist make meaning of and confirm what the patient said. It also served as a comforting action, allowing the physiotherapist to demonstrate care and understanding. The physiotherapist also employed gaze very actively in their interactions with the patient: they demonstrated their attentiveness and interest in what the patient said through gaze. This helped establish and maintain contact with the patient. It is important to note that all therapists and patients were of Norwegian origin in Ahlsen and Nielsen's study. There might be culturally different expectations or norms in the area you work, which need to be taken into account.

If you would like to read Ahlsen and Nielsen's complete case study, please click here.

Conclusion

Effective communication in rehabilitation practice is key to ethical, patient-centered care. Ethical dilemmas do arise, and communication in these scenarios can be complex and challenging. Various factors play a role in ethical decision-making and rehabilitation professionals need to be aware of the therapeutic impact of communication. Culturally competent communication is important and should be demonstrated daily in interactions with patients and colleagues. The significance of touch should never be discarded and rehabilitation professionals should be aware of the types of touch and the messages that are conveyed through touch.