Introduction

Communication is sending and receiving information between two or more people. The
person sending the message is referred to as the sender, while the person receiving the
information is called the receiver. The information conveyed can include facts, ideas,
concepts, opinions, beliefs, attitudes, instructions and even emotions.

Types of Communication
Methods of communication vary, and you are almost certainly familiar with all of them. Let's
take a look at some of the primary methods.

 Verbal communication is simply sending a message through a spoken language that is

understood by both the sender and receiver of the message. Examples of verbal
communications include face-to-face talking, listening to a lecture or seminar, and
listening to a television program. In fact, if you are listening to this lecture, you are
engaged in a verbal form of communication.
 Written communication is sending a message by the use of symbols that are
understood by both the sender and receiver of the message. If you are reading the
transcript of this lecture, you are engaged in written communication.
 Body language is a form of nonverbal communication that can be used to send a
message. You can often tell if your lecturer is pleased or upset simply by looking at
his facial expressions, posture and gestures. For example, a flushed face may mean
embarrassment; a clinched fist may indicate anger; and the rolling of one's eyes may
signal disbelief or annoyance.

In a nutshell, communication can be categorized into three basic types:

(1) Verbal communication, in which you listen to a person to understand their

meaning;

(2) Written communication, in which you read their meaning; and

(3) Nonverbal communication, in which you observe a person and infer meaning.
Each has its own advantages, disadvantages and pitfalls.

Communication Skills

1. Listening

Being a good listener is one of the best ways to be a good communicator. No one likes
communicating with someone who only cares about putting in her two cents and does not
take the time to listen to the other person. If you're not a good listener, it's going to be hard to
comprehend what you're being asked to do.
Take the time to practice active listening. Active listening involves paying close attention to
what the other person is saying, asking clarifying questions, and rephrasing what the person
says to ensure understanding ("So, what you're saying is…"). Through active listening, you
can better understand what the other person is trying to say, and can respond appropriately.

2. Nonverbal Communication

Your body language, eye contact, hand gestures, and tone all color the message you are trying
to convey. A relaxed, open stance (arms open, legs relaxed), and a friendly tone will make
you appear approachable and will encourage others to speak openly with you.

Eye contact is also important; you want to look the person in the eye to demonstrate that you
are focused on the person and the conversation (however, be sure not to stare at the person,
which can make him or her uncomfortable).

Also, pay attention to other people's nonverbal signals while you are talking.

Often, nonverbal signals convey how a person is really feeling. For example, if the person is
not looking you in the eye, he or she might be uncomfortable or hiding the truth.

3. Clarity and Concision

Good communication means saying just enough – don’t talk too much or too little. Try to
convey your message in as few words as possible. Say what you want clearly and directly,
whether you're speaking to someone in person, on the phone, or via email. If you ramble on,
your listener will either tune you out or will be unsure of exactly what you want. Think about
what you want to say before you say it; this will help you to avoid talking excessively and/or
confusing your audience.

4. Friendliness

Through a friendly tone, a personal question, or simply a smile, you will encourage your co-
workers to engage in open and honest communication with you. It's important to be nice and
polite in all your workplace communications. This is important in both face-to-face and
written communication. When you can, personalize your emails to co-workers and/or
employees – a quick "I hope you all had a good weekend" at the start of an email can
personalize a message and make the recipient feel more appreciated.

5. Confidence

It is important to be confident in your interactions with others. Confidence shows your

coworkers that you believe in what you’re saying and will follow through. Exuding
confidence can be as simple as making eye contact or using a firm but friendly tone. Avoid
making statements sound like questions. Of course, be careful not to sound arrogant or
aggressive. Be sure you are always listening to and empathizing with the other person.
6. Empathy

Even when you disagree with an employer, coworker, or employee, it is important for you to
understand and respect their point of view. Using phrases as simple as "I understand where
you are coming from" demonstrate that you have been listening to the other person and
respect their opinions.

7. Open-Mindedness

A good communicator should enter any conversation with a flexible, open mind. Be open to
listening to and understanding the other person's point of view, rather than simply getting
your message across. By being willing to enter into a dialogue, even with people with whom
you disagree, you will be able to have more honest, productive conversations.

8. Respect

People will be more open to communicating with you if you convey respect for them and
their ideas. Simple actions like using a person's name, making eye contact, and actively
listening when a person speaks will make the person feel appreciated. On the phone, avoid
distractions and stay focused on the conversation.

Convey respect through email by taking the time to edit your message. If you send a sloppily
written, confusing email, the recipient will think you do not respect her enough to think
through your communication with her.

9. Feedback

Being able to appropriately give and receive feedback is an important communication skill.
Managers and supervisors should continuously look for ways to provide employees with
constructive feedback, be it through email, phone calls, or weekly status updates. Giving
feedback involves giving praise as well – something as simple as saying "good job" or
"thanks for taking care of that" to an employee can greatly increase motivation.

Similarly, you should be able to accept and even encourage, feedback from others. Listen to
the feedback you are given, ask clarifying questions if you are unsure of the issue, and make
efforts to implement the feedback.

10. Picking the Right Medium

An important communication skill is to simply know what form of communication to use.

For example, some serious conversations (layoffs, changes in salary, etc.) are almost always
best done in person.

You should also think about the person with whom you wish to speak, if they are very busy
people (such as your boss, perhaps), you might want to convey your message through email.
People will appreciate your thoughtful means of communication and will be more likely to
respond positively to you.

Before patient care communication can be fully understood, one must know the ethics of
professionalism.

Ethics of Physiotherapy

Introduction

Ethics derives from, the Greek word “ethicos” which means arising from custom or from the
French word “ethos” meaning custom. According to Websters’s dictionary ethics is a concept
that deals with moral issues of good and bad, based on societal norms. Ethics, is the code
written or unwritten that guides the behaviour of human beings, in the context of different
cultures and situations. This moral code may vary from society to society. However there are
certain aspects that hold good in every situation. The application of these principles would be
dependent on the person and the situation. In short it is a judgment call.

Ethics in physiotherapy can be defined as the moral code of conduct that defines the
relationship between the therapist and her patient or client, and the therapist and other
healthcare professionals based on mutual respect and trust.

Professional Ethics

Ethical dimensions in professions are needed to

1. Have clear boundaries
2. Have commonly accepted norms of behaviour
3. Enhance respect within and outside the profession
4. Protect the rights of the consumer/ client
5. Protect the rights and privileges of the professional

Principle

1. Autonomy

Autonomy of the client/ patient to opt for or out of any treatment options is available to him.

2. Beneficence

Duty of the health provider to ensure that the client in her care is assured of all the benefits of
her professional knowledge to help the person overcome their dysfunction.
3. Justice

Duty of the health provider to ensure that justice is done to the individuals in her care. This
involves equal and unbiased care, respect for autonomy, and the duty to provide the correct
information to the best of her knowledge if called upon by a court of law.

4. Non-maleficence

Oldest principles of medical behaviour- do no harm.

5. Confidentiality

 Discuss only aspects of the patient that are important to the treatment of the individual
 Discuss aspects of care only in a confidential atmosphere and as much as possible
without use of the patient’s name or other identification.
 In addition ensure that the discussion does not involve anyone who cannot contribute
to the enhanced care of your patient.
 Ensure that patient records are not deposited in places of public access.
 Do not discuss one patient’s condition (1) with another patient (2) without the consent
of the first party
 Sometimes it may be necessary to withhold information from members of the
patient’s family if so requested

6. Dissipation of knowledge:

 The patient has a right to information pertaining to his condition.

 The patient also has the right to make an informed choice of treatment options
available to him as also the right to change providers if he so wishes.

Ethical Values

Respect

Physiotherapists are respectful of the differing needs of each individual and honour the
patient’s right to privacy, confidentiality, dignity and treatment without discrimination.

Excellence

Physiotherapists are committed to excellence in professional practice through continued

development of knowledge, skills, judgment and attitudes.
Autonomy and Well Being

Physiotherapists are at all times guided by a concern for the patient’s well-being. Patients
have the right to self-determination and are empowered to participate in decisions about their
health-related quality of life and physical functioning.

Communication, Collaboration and Advocacy

Physiotherapists value the contribution of all individuals involved in the care of a patient.
Communication, collaboration and advocacy are essential to achieve the best possible
outcomes.

Honesty and Integrity

Each physiotherapist’s commitment to act with honesty and integrity is fundamental to the
delivery of high quality, safe and professional services.

Ethical Principles

Ethical Principle 1:

Physical therapists respect the rights and dignity of all individuals All persons who seek the
services of physical therapists have the right to service regardless of age, gender, race,
nationality, religion, ethnic origin, creed, colour, sexual orientation, disability, health status or
politics.

Patients/clients have the right to:

• Services of good quality

• Information
• Informed consent
• Confidentiality
• Access to data
• Health education
• Choose who, if anyone, should be informed on his/her behalf

Physical therapists have the absolute responsibility to ensure that their behaviour is at all
times professional, ensuring that the potential for misconduct cannot arise.

Physical therapists have the right to expect co-operation from their colleagues.

Physical therapists shall apply sound business principles when dealing with suppliers,
manufacturers and other agents.

Ethical Principle 2:
Physical therapists comply with the laws and regulations governing the practice of physical
therapy in the country in which they work. Physical therapists will have a full understanding
of the laws and regulations governing the practice of physical therapy.

Physical therapists have the right to refuse to treat or otherwise intervene when in their
opinion the service is not in the best interests of the patient/client.

Ethical Principle 3:

Physical therapists accept responsibility for the exercise of sound judgement Physical
therapists is professionally independent and autonomous practitioners. Physical therapists
make independent judgements in the provision of services for which they have knowledge
and skills and for which they can be held accountable. For each individual accepted for
service, physical therapists undertake appropriate examination/evaluation to allow the
development of a diagnosis. In light of the diagnosis and other relevant information about the
patient/client, especially the patient’s/client's goals, physical therapists plan and implement
the intervention.

When the goals have been achieved or further benefits can no longer be obtained, the
physical therapist shall inform and discharge the patient/client. When the diagnosis is not
clear or the required intervention/treatment is beyond the capacity of the physical therapist,
the physical therapist shall inform the patient/client and provide assistance to facilitate a
referral to other qualified persons. Physical therapists shall not delegate any activity which
requires the unique skill, knowledge and judgement of the physical therapist.

The physical therapist will consult with the referring medical practitioner if the treatment
programme or a continuation of the programme is not in accord with the judgement of the
physical therapist.

Ethical Principle 4:

Physical therapists provide an honest, competent and accountable professional service

Physical therapists ensure patients/clients understand the nature of the service being provided,
especially the anticipated costs, both time and financial.

Physical therapists undertake a continuous, planned, personal development programme

designed to maintain and enhance professional knowledge and skills.

Physical therapists maintain adequate patient/client records to allow for the effective
evaluation of the patient’s/client's care, as well as the evaluation of the physical therapist's
practice.

Physical therapists do not disclose any information about a patient/client to a third party
without the patient’s/client's permission or prior knowledge, unless such disclosure is
required by law.
Physical therapists participate in peer review and other forms of practice evaluation, the
results of which shall not be disclosed to another party without the permission of the physical
therapist.

Physical therapists shall maintain adequate data to facilitate service performance

measurement and shall make that data available to other agents as required by mutual
agreement.

The ethical principles governing the practice of physical therapy shall take precedence over
any business or employment practice, where such conflict arises the physical therapist shall
attempt to rectify the matter, seeking the assistance of the national physical therapy
association if required.

Physical therapists shall not allow their services to be misused.

Ethical Principle 5:

Physical therapists are committed to providing quality services.

Physical therapists shall be aware of the currently accepted standards of practice and
undertake activities which measure their conformity.

Physical therapists shall participate in ongoing education to enhance their basic knowledge
and to provide new knowledge. Physical therapists shall support research that contributes to
improved patient/client services. Physical therapists shall support quality education in
academic and clinical settings.

Physical therapists engaged in research shall abide by the current rules and policies applying
to the conduct of research on human subjects shall ensure:

• The consent of subjects

• Subject confidentiality
• Safety and well-being of subjects
• Absence of fraud and plagiarism
• Full disclosure of support, and
• Appropriate acknowledgement of assistance
• That any breaches of the rules are reported to appropriate authorities
Physical therapists shall share the results of their research freely, especially in journals and
conference presentations.

Physical therapists in the role of employer shall:

• ensure all employees are properly and duly qualified, ensuring compliance with statutory
requirements
• apply current management principles and practices to the conduct of the service, with
particular attention to appropriate standards of personnel management
• ensure implementation and monitoring of appropriate policies and procedures
• ensures appropriate evaluation and audit of clinical practice • provide adequate
opportunities for staff education and personal development based on effective performance
appraisal

Ethical Principle 6:

Physical therapists are entitled to a just and fair level of remuneration for their services
Physical therapists should ensure that their own fee schedules are based on reasonable
considerations.

Physical therapists should attempt to ensure that third-party fee schedules are based on
reasonable considerations. Physical therapists shall not use undue influence for personal gain.

Ethical Principle 7:

Physical therapists provide accurate information to patients/clients, other agencies and the
community about physical therapy and about the services physical therapists provide.

Physical therapists shall participate in public education programmes, providing information

about the profession. Physical therapists have a duty to inform the public and referring
professionals truthfully about the nature of their service so individuals are more able to make
a decision about the use of the service.

Physical therapists may advertise their services. Physical therapists shall not use false,
fraudulent, misleading, deceptive, unfair or sensational statements or claims.

Physical therapists shall claim only those titles which correctly describe their professional
status.

Ethical Principle 8:

Physical therapists contribute to the planning and development of services which address the
health needs of the community.

Physical therapists have a duty and an obligation to participate in planning services designed
to provide optimum community health services. Physical therapists are obliged to work
toward achieving justice in the provision of health services for all people.

CPA Code of Ethics

A professional association’s code of ethics sets out the ethical principles governing the
conduct of that association’s members. The code must reflect societal ethics of the time, as
well as the value systems and moral principles of the members as a collective group. A code
of ethics can also encompass the scopes of practice of the profession and of the individual
member.

While a code of ethics can provide guidance, it cannot offer definitive resolution to all ethical
questions and situations that might arise. Differences of opinion as to what constitutes ethical
behaviour are inevitable, and such differences must be respected as much as possible. In
addition, society and the practice of physiotherapy are sufficiently complex and changing that
situations posing ethical dilemmas and questions not necessarily covered in a code of ethics
may arise. In such situations, it is the duty of each member to act in an ethically responsible
manner, and members are encouraged to seek additional advice or consultation when deemed
necessary.

Specifically, the Code is based on the following ethical values and professional principles:

 Respect and dignity: to acknowledge, value and appreciate the worth of all
patients/clients
 Respect for patient/client autonomy: to respect a patient/client’s or substitute decision
maker’s right to make decisions
 Beneficence: to provide benefit to patients/clients
 Non-maleficence: to do no harm to patients/clients
 Responsibility: to be reliable and dependable
 Trustworthiness and integrity: to be honest and to be trusted
 Professionalism: to be a good citizen/member in good standing of the professional
association

Responsibilities to the patient/client

1. Act in a respectful manner and do not refuse care/treatment to any patient/client on

the grounds of race, religion, ethnic or national origin, age, gender, sexual orientation,
social or health status.
2. Act to promote the health and wellbeing of patients/clients, while respecting their
rights, dignity, needs, wishes and values.
3. Respect the patients/clients/substitute decision-makers’ rights to be informed about
the effects of treatment, any inherent risks, and alternative treatment options.
4. Give patients/clients/substitute decision-makers the opportunity to consent to or
decline treatment or alterations to a treatment plan.
5. Will not treat patients/clients when the diagnosis or continuation of physiotherapy is
not warranted or is contraindicated.
6. Respect the confidentiality, privacy, and security of patient/client information in all
forms of communication.
7. Practice in a safe, competent, accountable and responsible manner within their
individual scope of practice.
8. Take responsibility for the patient/client care delegated to physiotherapist assistants
and students.
 9. Take all reasonable steps to prevent harm to patients/clients. Should harm occur
disclose it to the patient/client/substitute decision-maker.
10. Communicate effectively and respectfully, and practice cooperatively with colleagues,
other health professionals and agencies for the benefit of patients/clients.

Responsibilities to society

1. Earn the respect of society, the profession, and other health professions through their
conduct.
2. Recognize their responsibility to improve the standards of health care and the
wellbeing of society.
3. Commit to maintaining and enhancing the reputation and standing of the
physiotherapy profession, and to fulfilling the broader social responsibilities that their
physiotherapy role places on them.
4. Comply with all legislation and regulatory requirements that pertain to the practice of
physiotherapy.
5. Report to the appropriate authorities any member of the profession who appears to be
practicing in an incompetent, unsafe, illegal or unethical manner.

Responsibilities to the profession

Accept responsibility for upholding the integrity of the profession, and act with integrity
in all professional activities.

1. Commit to maintaining and enhancing the reputation and standing of the

physiotherapy profession by treating everyone with dignity and respect in all
interactions.
2. Strive for excellence in whatever role/area in which they practice.
3. Enhance their expertise through lifelong acquisition and refinement of knowledge,
skills, abilities and professional behaviours.
4. Recognize their responsibility to share evidence-informed and clinical best practices
in physiotherapy with each other and other health care professionals.
5. Be willing and diligent preceptors of students.
Patient Care Communication

Clinical competence is the ability to integrate several important clinical skills – history-
taking, problem-solving, assessment and knowledge – all underpinned by effective
communication.

Communication with others is an innate skill that is variably developed in all human beings.
This introduces students to the exploration of the communication that occurs between health
professionals and patients.

It aims to provide students with a basic understanding of different modes of communicating

and to enable critical analysis of health professional–patient interactions. Students will also
be introduced to the concept of a structure for interactions and consultations, with activities
and topics for reflection to assist the concepts discussed. The skills learned from this
courseare transferable to many areas of work including communication in teams, teaching
and social interaction. .

Communication is often taken for granted as it is a part of daily life. In the healthcare setting
particularly, it can have disastrous outcomes when it is ineffective. It is accepted that history-
taking is far more important than examination in making a diagnosis (Hampton et al. 1975),
yet it is only recently that communication has been recognized as a clinical skill that, like all
other clinical skills, should be formally taught (Duffy 1998)

Given that effective communication has long been recognized as the cornerstone of high-
quality care, it follows that patient assessment – the first part of the clinical process – requires
practitioners to be skilled communicators.

This is particularly important when initiating a patient encounter. At these times, anxiety and
uncertainty are often high – even among people experienced in using the healthcare system.
Sensitive, responsive and thoughtful communication helps to address the anxieties and ensure
that the care the patient subsequently receives meets both their needs and aspirations.

What is assessment? The term ‘assessment’ is used so frequently in healthcare that it is easy
to assume everyone understands it in the same way – an assumption far from the truth. Some,
for example, see assessment as a very formal and structured activity involving interviewing
and examining a patient, identifying signs and symptoms, proposing a diagnosis and possibly
treatment or a treatment plan. Others see it as a less formal but ongoing process whereby data
about a patient is gathered and analysed as the patient–practitioner relationship develops.

Different models may be adopted and these influence not only the type of information
collected, but how it is collected. Some would argue that every PT–patient encounter
involves assessment. In fact, even a simple ‘hello’ can be assessed. Just one word can reveal
a vast amount about the person who has spoken it, from their mood or need to engage others,
to their understanding of time and whether it is an appropriate moment to speak.

We hear a voice and a message, not just words but emotions, accents and tones. Sometimes
we can even guess at the thoughts behind them! This type of assessment tends to go on
subconsciously, but should not be underestimated since it involves the subtle, almost intuitive
reading of cues – the essence of effective communication.

Generally, the term ‘assessment’ is used in Physiotherapy to describe the first phase of the
Physiotherapy process, where data is collected so a diagnosis and plan of treatment can be
developed and goals set.

Modes of communication

Communication is usually divided into two categories, verbal and non-verbal. There is also
an equally important third category, known as ‘paralinguistic’ or ‘paraverbal’. All three
modes of communication are usually used together. Mehrabian’s (1981) research into body
language and non-verbal communication found that only 7 per cent of a message is conveyed
by the actual words we speak, 38 percent by paralinguistic features (e.g. tone and pitch) and
55 per cent by other non-verbal factors. Verbal communication In this category of
communication, the actual words used are considered.

Clinicians need to choose their words carefully so that they match the patient’s ability to
understand them. This is particularly important when giving information to patients. It is very
easy to slip into medical jargon, especially when explaining a complex situation which may
only be partially understood by the general population. The possibility for misunderstanding
is increased when either party does not have English as a first language, and is even more
likely when neither speak English fluently. Even when English is spoken fluently, accents,
dialects, euphemisms, colloquialisms and acronyms can obscure the understanding to the
point where the patient may be disappointed, alienated or, worse still, their healthcare may be
compromised.

Patient perspective A 65-year-old widow has just started a new relationship and had sexual
intercourse for the first time after many years which resulted in vaginal prolapse. As she
waits to see the Physiotherapist in the walk-in centre, she may be thinking: ‘How am I going
to tell the young clinician what’s wrong with me and how it happened? I hope she doesn’t say
she can’t deal with it and that I have to see the doctor...

Activity: When the widow sees the PT she says, ‘It’s me down below.’

What do you think the patient means? Can you think of any other colloquialisms or
euphemisms that could obscure something that you would need to tell the patient? Write them
down

Paraverbal Communication

Paraverbal communication can be described as the attributes that ‘dress’ the words. For
example, the volume at which an assessment is conducted might have to be high because the
patient is hard of hearing. However, it is possible that the PT may raise their voice in
response to a patient speaking loudly, which could inflame an already tense situation.
The volume of the consultation is important as it is already difficult in many healthcare
settings to achieve privacy. The tone of voice is also important as this can impart an
unintentional message which reflects how the sender is feeling, despite trying to be neutral.
For example, when a long-standing patient says to the PT, ‘You must be so fed up seeing
me!’, the PT may try to answer politely but the tone of voice may convey boredom. The
emphasis on a particular word could have significant meaning.

Reflect on the conversation below and think about what meanings there might be to the
patient’s response.

Reflection point: Consider what you might be able to infer from the following.

PT: I’m wondering if your father has ever hurt you?

Patient: No, not him!

Speed of speech is another characteristic that can emphasize the meaning provided by the
words. For example, it is quite normal for adolescents to speak very quickly and use jargon to
the point where adults find it difficult to understand them. In a different context, for example
on a mental health ward, fast speech is described as ‘pressured speech’. Health professionals
often do not tolerate pauses and silences when interacting with patients. This may be due to
time pressure, but it is still vital to recognize the need to develop sufficient rapport for a
‘companionable silence’.

Silences often seem longer than they actually are, yet it is important to appreciate that health
professionals ask complex questions which patients need time to reflect on.

Non-verbal communication

The terminology used in describing non-verbal communication is not rigid. Non-verbal

communication can be described as those messages that are transmitted without using any
words. Non-verbal communication is very powerful – a look, a gesture, facial expression or
touch can set the tone for an encounter before a word is uttered. Many researchers agree that
the receiver of the message will usually pay more attention to the non-verbal than the verbal
communication. Thus as health professionals it is essential to consider the non-verbal
messages we transmit, and to be sensitive to those we receive from others.

Positioning is another issue that is not always sufficiently considered. Health professionals
are now advised to arrange the assessment area so that they are the same height as patients in
order to minimize perceptions of superiority or inferiority.

In hospital settings, staff often stand by the bedside while they discuss sensitive issues with a
patient. While time is often short, it is worth making the effort to find a chair and sit down
next to the patient, at least for important discussions such as care and treatment options.

Ambulatory patients have more control and may position their seat closer than the health
professional finds comfortable. They may use it to be threatening or familiar, depending on
how they perceive they will get what they want. However, it is important for individuals to
consider safety issues when designing consultation areas. Many consulting rooms are
arranged so that the patient is between the health professional and the door. On the other
hand, if there are several chairs in the room the patient may choose a seat at a distance from
the consulter. While this may be a simple mistake, it should alert the health professional to
pay more attention to the patient’s feelings about personal space.

Gestures may convey nervousness or mean very little unless read as part of the whole
communication. McNeill (2005) showed that gesturing is an active part of both speaking and
thinking. Gestures may be culturally influenced, thus it is worth spending time to interpret
them correctly as they may reveal what a patient is thinking but not necessarily saying.

Reflection point Have you observed different cultural behaviours? For example: Men kissing
each other on the cheek in greeting. People expecting to shake hands. Being asked by
relatives not to tell a patient when the diagnosis is terminal. Can you think of any others?

Much has been written about eye contact, but care must be taken not to put meaning where it
does not exist. In western culture it is acceptable, indeed expected, that eye contact will be
made. In some cultures it is rude for younger people to make eye contact with their elders,
while in others men and women do not make eye contact unless they are very close relatives.

Generalizations are dangerous and it is perfectly reasonable for a western woman to not make
eye contact because she is shy, not because she is depressed.

‘Body language’ includes all the attributes described above as part of non-verbal language. It
is also used to describe the message given by the way the body is used when communicating.
Thus, in addition to the behaviours described above, whether the legs are crossed or not,
whether the head is nodded or shaken, can give messages to the other person.

Touch is another form of non-verbal communication that needs to be used judiciously.

Appropriately expressed, it can convey empathy more eloquently than words. However,
healthcare professionals are increasingly wary of touching patients when it is not part of
recognized treatments such as bathing, applying dressings and giving an injection, in case it is
misconstrued. There is a dearth of research evidence on which to base touch as a therapeutic
communication (Gleeson and Timmins 2005).

Active listening

Active listening is a core skill in communicating with patients. It is important to contemplate

what the patient’s words and body language really say, and to listen to the answer. The
simple wisdom of the old adage, ‘when communicating, never forget we have two ears, two
eyes and only one mouth’ remains as sound as ever.

To develop trust and gather meaningful information generally involves giving full attention,
asking open-ended questions, listening carefully and concentrating on what is being said.

Listening skills need to be developed so that patients can tell their story in sufficient detail to
facilitate good quality care. Often described as active listening.There are many ways to
communicate to a person that we are giving them our full attention. These simple behaviours
can help us to create the comfortable, secure and relaxed atmosphere that enables a patient to
talk freely.

The acronym SOLER is used to summarize some of the important behaviours – as follows:

S = squarely face the person. Facing them in this way makes your posture say ‘I am ready to
listen to you’.

O = open your posture. This is a non-defensive position – it shows you are open to the other
person’s words. Crossed arms and legs can represent less involvement.

L = lean forward to the other person. This again shows that you are listening.

E = eye contact maintained. As you listen, use your eyes to show you are looking at the
person. In this way, they know you are concentrating on what they are saying.

R = relax while attending. It is entirely possible to be both concentrating and relaxed. In turn,
this will help the other person to feel comfortable and relaxed.

A clinician is not required to sit silently while the patient rambles for an indefinite period of
time. The listener needs to give non-verbal messages which encourage the patient to share,
while feeling safe and cared for. The patient also needs to know that the listener will not
judge and will be honest.

While listening, the information received needs to be processed, sorted and used to plan the
next step of the interaction while demonstrating that the patient has the listener’s full
attention. Interestingly, ‘silent’ and ‘listen’ are anagrams of each other, and this corroborates
Morton Kesley’s statement that listening is being silent in an active way (Kelsey 1976).

In summary, it is important for the clinician to appreciate that communication consists of

sending messages between the patient and the healthcare professional. There could be many
factors in both parties that result in the message that is received being very different from the
intended message sent. It is by learning to read the non-verbal language of patients, and the
health professional being aware of the non-verbal messages they might be transmitting, that
truly effective communication can occur.

Building relationships

It can be daunting for patients to see health professionals arrive with a clipboard and set of
notes. Not knowing what to expect or being concerned that others will overhear can inhibit
communication, so it is important to explain briefly that assessment involves discussion of
personal information that will be kept confidential.

A comfortable environment is essential – preferably a private and soundproof room (Barnes

2009). The clinician should position themselves at the patient’s level, so there can be good
eye contact and the ‘safe’ closeness that is necessary to share personal information. Sharing is
an important concept here – the emphasis is on establishing a rapport where patients feel they
are collaborating with the clinician, not being subjected to an interview or test.

Although many patients expect clinicians to take the lead, ‘supported participation’ and
partnership usually make for the most effective care, so it is often worth showing patients the
relevant forms, and in some cases sitting side by side to address the various requirements.
General questions about name, address and other biographical details are always essential, so
they are the usual starting point.

Within seconds, however, a conversation can begin – asking a person how they like to be
addressed, for example, will demonstrate respect for their choices and can pave the way for a
relaxed conversation. The more experienced a clinician becomes, the less they need to refer
to pre-printed forms. In fact, as confidence develops, one can listen and observe more,
concentrating less on documentation and much more on what the patient says and how they
appear or are behaving. This does not mean that documentation is not a vital part of
assessment – quite the reverse. Record-keeping is critical to effective communication (Ellson
2008). However, if clinicians spend time actively listening, observing the patient and
conversing with them, then the records produced are likely to be a more accurate reflection of
the patient’s needs.

Effective questioning is a skill worth developing and the use of both open and closed
questions is useful in the assessment process. An open question will enable the patient to start
where they like and that may provide very useful information. An open question will enable a
patient to offer their own perspectives, opinions and feelings, which will support the
healthcare professional in undertaking assessment. Closed questions are also useful and can
be used to elicit particular details or explore specific issues. They would generally follow the
use of open questions in an assessment process.

Reflection point ‘Would you mind telling me about your pain?’ is an example of an open
question. ‘How long have you had your pain?’ is an example of a closed question.

Think about the different answers you would get to each type of question and how they might
affect your relationship with a patient you have just met. Picking up cues Attending to the
comfort of the patient, picking up on non-verbal cues and managing your own non-verbal
cues all contribute to the building of rapport. Patients may, for example, give non-verbal cues
that they are very uncomfortable discussing sensitive matters on an open ward, so the
veracity and depth of information obtained may be poor.

Physical discomfort such as being too short to sit comfortably in the chair provided may not
be easily resolved, but acknowledging that there is a problem coupled with an apology that it
cannot be rectified will make the person feel valued.

The choice of words and phrasing is important. Using expressions like ‘holistic assessment’
can be disconcerting, and ambiguous questions should be avoided. It is usually better to use
the patient’s own words, keeping language simple and concise. Of course, assessment does
not only involve questioning and interviewing. Sometimes we need to examine the patient
and this need to be explained so that the patient can give consent.

In his five-step consultation model, Roger Neighbour (2005) urges the health professional to
stop momentarily and ask if they are in good enough shape to move to the next patient. Issues
left over from a previous consultation or encounter may be a block to building rapport in the
current one. Providing structure When undertaking consultation and assessment, using a
structure to guide the process can also help the health professional develop their skills in time
management. This ensures that the time a clinician has with a patient is used effectively and
important elements are not overlooked.

At the risk of stating the obvious, staff who smile, introduce themselves and engage patients
with appropriate eye contact and an open posture are likely to make a real difference as far as
patients are concerned. Vignette A home visit Consider the following situation. Mr Carter has
arrived at the doctor’s surgery and needs to find out how he can request a home visit for his
wife, as he has been unable to get through to the surgery by telephone. When he arrives, two
receptionists are sitting at the reception desk. One receptionist is talking on the telephone and
the other is looking intently at her computer screen. The practice nurse is also in reception but
has her back turned, filing a set of notes. As Mr Carter approaches the desk, the receptionist
on the telephone holds up her hand in a ‘stop’ gesture and then points to the touch-screen
where patients are expected to ‘check in’ on arrival for their appointments. She continues her
telephone conversation but nudges the other receptionist to get her attention – unsuccessfully.
Mr Carter waits a couple of minutes before the other receptionist sees him and asks how she
can help him. Patient perspective Mr Carter might be thinking, ‘I really can’t cope with this.
My Anne is really unwell and I need to get back to her. Now I am here they don’t even want
to speak with me. I don’t need to use the machine as I don’t have an appointment. I bet
they’ll tell me the doctor is too busy to come home to Anne. I think I’ll hang around in the
corridor and see if I can catch the nurse for a quick word.’

Reflection point Think about how patients and visitors are greeted in the service in which you
work.

Setting the agenda

Having greeted a patient, the next part of assessment involves establishing any immediate or
‘emergency’ needs. These obviously take precedence, although much depends on the issues
bringing the patient to the care service. A person with severe pain or shortness of breath, for
example, will clearly be unable to answer lots of questions and in some circumstances it may
be inappropriate to do much more than a visual assessment and baseline observations before
treatment is commenced. For the majority of patients, however, it is entirely appropriate to
begin a more in depth assessment shortly after or as part of the initial meeting.

With introductions made, the next step may need to be the negotiation of an agenda as it is
important to work out and agree what can reasonably be covered in the time available. Often
the health professional will work on the first problem presented by the patient. Starfield et al.
(1981) found that in 50 per cent of visits patient and doctor do not agree on the main
presenting problem. Their findings confirm that practitioner–patient agreement about
problems is associated with a better outcome as perceived by the patient. In addition, they
indicate that practitioners also report better outcomes under the same circumstances.
Sometimes the patient may separate symptoms and present them individually, while together,
as a clinical pattern, they may suggest a single diagnosis. For example, eliciting a list of
symptoms such as tiredness, nausea, slight right upper abdominal pain, dark urine and light-
coloured stools immediately leads one to think of liver-related disorders. Delving deeply into
the first symptom of tiredness at the outset could mean that the health professional does not
get all the other symptoms in good time and the consultation travels down a very different
path.

Gathering information

Once the agenda is set, it is important to explore each item in turn to develop and test the
patient’s thoughts about a provisional diagnosis. Most health professionals are good at
learning the specific ‘scientific’ questions that relate to a symptom. These ‘systematic
questions’, as they are called, are very useful as they give clinicians a structure that helps
them practise safely and not miss any dangerous symptoms.

However, it is also really important to understand how the patient views what is going on.
Disease as diagnosed is very different from illness as lived, and people respond differently.
The acronym ICE (ideas, concerns and expectations) is often used glibly without putting the
skills required into practice.

Activity With a colleague, ask each other the following questions and discuss the effect on
each of you and what you think the effect might be on your patients. ‘What are your ideas,
concerns and expectations?’ ‘It would help me to understand the problem better if I knew
what you are thinking about all this?’

‘Is there anything concerning you about what is going on?’ ‘Is there anything in your mind
that you think we might do to help this problem?’

Finally, it is important to put all the information gleaned into the patient’s context, so that the
treatment suggested is accepted by the patient. For example, telling a man to take time off
work without realizing he is the sole breadwinner, with an employer who does not pay sick
leave, just will not work. It is vital to learn enough about the patient as a person by gathering
appropriate background information. If the information required is very personal, it helps to
tell the patient why and to signpost and perhaps normalize that part of the consultation.

For example, in a sexual health clinic: ‘I am now going to ask you a series of personal
questions that we ask everyone with your kind of problem. It will help us decide what further
tests you may need, if you need any at all . . .

’Physical examination clinicians in their daily roles examine patients. It may be an everyday
activity such as inspecting a wound or taking readings of vital signs, or indeed, for those
working in extended roles, listening to the patient’s chest or undertaking a vaginal
examination prior to taking a swab or cervical cytology. The patient needs to give explicit
consent.

The clinician needs to explain to the patient what the examination entails and obtain the
patient’s agreement. If there is a procedure linked with the examination then that needs to be
explained before starting. The clinician needs to consider whether the offer of a chaperone is
appropriate.

Offering help with dressing sensitively, for example, may be overlooked when time is short.
It is often assumed that an elderly person will welcome help with undressing, but if this is not
the case they are robbed of their dignity. This scenario may diminish any rapport that may
have been built up in the earlier part of the interaction.

Explanation and planning

This is the part of the assessment where the health professional collates the information,
comes to an idea of what is going on and needs to enter into a discussion with the patient
about what might be wrong, what can be done, and what the patient thinks and will agree to,
so that a plan can be made.

This can be the most time-consuming part of the consultation/assessment as it is what the
patient is really waiting for – or fearing. Apart from using plain language without jargon, the
PT has to ensure that the patient does not get lost and has ample opportunity to ask questions,
while avoiding being patronizing. Health professionals need to practise explaining risk until
they find a form of words that patients can relate to.

Many patients access the internet prior to their appointment or admission which makes this
part of assessment much more of a discussion and negotiation than it used to be. When the
patient and the health professional are speaking in equal proportion, or if the patient is
speaking more, it means that the patient is engaged in the development of the plan and
therefore it is more likely to be executed.

A lecture ending with ‘Any questions?’ leaves the stunned patient with very little
understanding or recall. Information must be broken up into manageable chunks, with time
for the patient to digest and question before moving on to the next bit. It is also necessary to
find out where the patient is starting from, otherwise unnecessary information may be given,
without addressing the patient’s real information needs.

Activity; Mrs Brown has just been diagnosed with type 2 diabetes and has been sent to you
as a PT to learn how to manage her disease. Diabetes is a huge topic for a patient to learn
about. Think for a minute about how you would undertake this task. It would be helpful to
role-play with a colleague. Think about how you would start and how would you decide what
to tell her. If she were obese, as is likely, it might be obvious to you that she has to lose
weight. But how do you know that is her priority?
Closing the session

This section overlaps with the previous one. Having developed a plan for managing the
problem with the patient, a plan for the future needs to be made. What does the patient need
to do? When does the patient need to come back, if at all?

‘Safety netting’ is a phrase that is often bandied about, but to be performed well it has to be
more detailed than, ‘If it doesn’t get better, come back.’ Most patients may not realize when
their symptoms become dangerous. Equally, and detrimentally for the healthcare system, if
they do not have clear guidance they may come back too soon, straining resources.

Patient perspective; Alfonso Vadini, a 46-year-old man, passed blood in his urine and went to
his local accident and emergency (A&E) department because he was so alarmed. His father
died of prostate cancer and Alfonso knew he had blood in his urine. He saw a nurse
practitioner who diagnosed a urine infection, gave him five days’ supply of antibiotics and
told him to see his GP if it did not get better. Six days later, his urine was still dark, but there
was no blood. On reflection Alfonso realized he had been feeling tired for a few months. He
might have been thinking, ‘I wish the hospital had not been busy that night, I could not say
how worried I was. The nurse might have thought I was being weak. What did she mean by
“better”? I am “better” but not quite well. I don’t want to waste anybody’s time’.

It is also very useful to offer clearly-written evidence-based information for the patient to
take away. Encouraging the patient to read the information and note any questions or
concerns to discuss on a return visit is not only reassuring for the patient, but also helps to
build rapport. It gives the patient permission to ‘not understand or remember fully’. It can
also empower patients to take more control of a chronic condition if they have a written plan
– for example, asthma management plans which guide the patient to increase or reduce
medication according to the severity of their symptoms. Once the interaction has ended, it is
important for the health professional to take stock momentarily to see if there is anything that
might be carried over into the next consultation. Is there a fear that something was forgotten
or should have been done differently? Was a practical skill mastered after many failed
attempts? Is a comfort break needed? If all these aspects are not addressed, the next
assessment can be a disaster, because of tensions or emotions within the health professional.
While it may seem a luxury, this brief self-check could save a lot of time in the future.

Conclusion

Effective communication with patients is a huge topic, underpinned by a vast body of

research. It is a skill set that needs to be continually brushed up and developed throughout
any health practitioner’s career. This note has only highlighted the most important topics and
concepts for the student clinician: learn to listen actively; always try to keep the patient’s
perspective in mind; be aware of how your communication skills can be affected by your own
emotions and thoughts; identify potential learning from every human interaction regardless of
the setting.