Most physiotherapists, if asked, would probably say that they understand the importance of good communication and that they communicate clearly and effectively with their patients. However, research, questions from members of the public, and conversations with other College of Physiotherapists of Alberta staff members, make it apparent that we are not as good at this skill as we think we are.
In conversation with the College of Physiotherapists of Alberta’s Complaints Director, it becomes clear that a common element to the complaints and concerns received from members of the public or from our registrants is missing, poor or ineffective communication.
The need to practice good communication skills with patients and other stakeholders in the provision of patient care has been identified time and time again throughout our journey as students and then as practicing clinicians. There is much evidence supporting the benefits of effective communication between providers and patients on overall patient satisfaction and health outcomes.1 In fact, the effectiveness of a patient-centered care model of practice emphasizes the essential features of health-care communication including the core communication skills of open-ended inquiry, reflective listening, and empathy.1
The importance of communication as a cornerstone of clinical practice and client-centered physiotherapy care is apparent in our Code of Ethical Conduct,2 the Competency Profile for Physiotherapists in Canada (2017)3 and throughout the College of Physiotherapists of Alberta’s Standards of Practice.4 In fact, several Standards of Practice include a requirement to ensure clear, transparent communication at all times and with every client, colleague or any other stakeholder involved in the delivery of physiotherapy services.
Based on experiences with real complaints and concerns, several strategies have been suggested to improve our communication skills with patients to facilitate good outcomes and create trust and improve the therapeutic relationship.
Where miscommunication can happen
A systematic review5 identified some very interesting facts related to physician-patient communication:
- Physicians interrupted their patients’ description of their problems within 18 seconds
- 54% of patient problems and 45% of patients’ concerns were not elicited by the provider or disclosed by the patient
- 50% of the time patients and physicians did not agree on the main presenting problem
The author concluded that problems in physician-patient communication are common. I suggest that anecdotal evidence in physiotherapy would point to a similar conclusion.
Listen and Inform
In every interaction with patients, we must remember the importance of not just asking the right questions, but also listening to the answers. This is true whether we are taking the initial history, evaluating the effects of an intervention or simply asking the patient how they are feeling on a particular day.
The Competency Profile for Physiotherapists3 identifies the ability to “listen actively, to build trust and foster exchange of information” as an entry-to-practice milestone. When you have taken the time to ask the questions it is equally important to take the time to actively listen to the reply and take any steps needed to address the patient’s questions and concerns.
As a physiotherapist, it may be necessary to not just encourage, but to actually facilitate or guide patients to ask questions and provide important information. There is always an inherent imbalance of power in the patient-professional relationship. This may affect patients’ comfort in asking questions that they feel show their “ignorance” or that they are embarrassed to ask. They may feel overwhelmed by what they have been told or by the situation they find themselves in. They may be confused by the process, by working with several different professionals all asking different questions or they may simply not have understood what was said. You may have been rushed in your explanation.
By encouraging the patient to ask questions, guiding the patient through the process of formulating questions, actively listening to what they have asked, and honestly, compassionately and respectfully answering all their questions, the clinician starts to build that essential therapeutic relationship. The need to equalize the balance of power in a relationship, the need to understand and respect the patient’s beliefs, values and morals and the need to ensure trust between the patient and the physiotherapist are all foundational to developing a therapeutic relationship.7 Trust is gained when the patient feels heard, respected and a part of the team.
Ensure the patient understands what you have said
Just because you have said the same thing many times before, does not mean this patient or their family understood it. Remember this is the first time they have heard your explanation. Be patient and take the time to ensure they have understood.
The Communication Standard of Practice4 includes the expectation that physiotherapists “communicate effectively with clients to promote their understanding of proposed services.” Effective strategies to facilitate patient understanding are to use “plain language” and to encourage the patient to ask questions.
Plain language is defined as “communication your audience can understand the first time they read or hear it.”6 Remember that what is plain to one patient may not be plain to another, it is dependent on their culture, background and comfort with the English language. The importance of speaking in plain language and avoiding “physio speak” needs to be considered at all times. Writing in plain language doesn’t mean over-simplifying or leaving out critical information. Using plain language makes critical information accessible and readable for everyone.7 Examples of plain language include using simple words and sentences, avoiding jargon and acronyms, using analogies the patient can relate to and explaining things in a simple, easy to understand way.
Establish clear patient goals
We have heard repeatedly throughout our careers that in order to establish what the patient sees as the issue and what they feel are the goals they wish to achieve from treatment, we must ask the right questions and listen to both the answer given directly and the “between the lines” answers that may not be as obvious. We must also continually check in with the patient as treatment progresses to determine if we are still on the right track. Have the goals or patient situation changed? Have we achieved the stated goals? Should treatment stop?
Having clear, SMART, function-based goals will guide not just our treatment, but our discharge plans as well. A realistic, agreed upon goal may not always be a complete resolution of the problem, but is more often the ability to resume a desired activity or regain functional mobility. With specific goals in mind, that are understood and consented to by both the patient and the physiotherapist the discharge conversation may be easier to navigate. Without clear goals, it can be difficult to identify the end point and facilitate discharge planning with a patient.
You must communicate clearly and with compassion when you have reached the end of treatment whether because the goals have been met, or because no further improvement is expected. Be honest and clearly communicate your assessment findings and your clinical reasoning behind the decision. This will make it easier for the patient to understand and accept your assessment of the situation and the discharge plan.
Understand what consent is and when consent has been given
The Consent Standard of Practice4 identifies the expectation that patients will be informed of the options, risks and benefits of proposed services, asked to provide their consent, and that the physiotherapist will respect their right to question, refuse options and/or withdraw from services at any time.
This means we must take the time to provide all the information required to make an informed decision, allow the patient time to assimilate that information and ask clarifying questions and then listen to and abide by their decision. Remember that the patient has the right to make their own decision, even if we do not agree with it, and we must respect the decision they have made. Because of the underlying power imbalance, you must attend to both the verbal and non-verbal communication of the patient. They may not feel they have the power or ability to say no, but it will often show in the body posture, facial expressions, or compliance with your plan. Physiotherapists need to be sensitive to these signs.
You must make sure you communicate clearly and repeatedly what you are going to do, why you are doing it, what the patient may expect to feel or experience and the risks and benefits of the intervention. Make sure you do this each and every time and at every step in the treatment. It is always better to err on the side of caution and be repetitive than miss something and have a challenging situation occur as a result.
Ongoing education and competence
When thinking about life-long learning opportunities and developing learning plans, it is very easy to find courses related to technical physiotherapy skills. Don’t minimize the importance of the “soft skills” or non-technical skills, including communication. Reflect on your own communication skills and competence and look for educational opportunities that will help you learn to utilize the art of communication to your advantage in every interaction.
- Institute for Healthcare Communication (2011) Impact of Communication in Healthcare. Available at: http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/
- Physiotherapy Alberta College + Association. Code of Ethical Conduct. Available at: https://www.physiotherapyalberta.ca/files/code_of_ethical_conduct.pdf
- National Physiotherapy Advisory Group. (2017). Essential Competency Profile for Physiotherapists in Canada. Available at: https://www.physiotherapyalberta.ca/files/competency_profile_2017.pdf
- Physiotherapy Alberta College + Association. (2017) Standards of Practice. Available at: https://www.physiotherapyalberta.ca/files/standards_of_practice.pdf
- Stewart M A (1995). Effective physician-patient communication and health outcomes: a review. CMAJ: Canadian Medical Association Journal, 152(9), 1423–1433.
- Plain Language Action and Information Network. (2014). What is Plain Language? Available at: http://www.plainlanguage.gov/whatisPL/
- Government of Canada. (2017) Canada.ca Content Style Guide. Version 2.1 Available at: https://www.canada.ca/en/treasury-board-secretariat/services/government-communications/canada-content-style-guide.html
- Physiotherapy Alberta – College + Association. (2017). Therapeutic Relationships Resource Guide for Alberta Physiotherapists. Available at: https://www.physiotherapyalberta.ca/files/guide_therapeutic_relations.pdf
- Alberta Health Services (2016). Health Professions Strategy and Practice. Voice and Choice: Self Reflection in Person & Family Centered Care. Available at: