Communication in Physical Therapy in the Twenty-First Century



Communication in Physical Therapy in the Twenty-First Century


Helen L. Masin




Objectives


After reading this chapter, the reader will be able to:


image Define the components of communication


image Recognize the role of the affective domain in communication


image Use rapport in building effective communication


image Recognize effective communication in a multicultural health care environment


image Discuss high- and low-context communication assumptions


image Recognize the culture of medicine


image Discuss differences in communication across generations


image Recognize differences in religious, spiritual, agnostic, and atheistic orientations


image Respond effectively to patients/clients with visual or auditory impairments or both


image Respond effectively to patients/clients and their caregivers and families


image Respond effectively with other members of the health care team


image Develop effective communication as a student in both the classroom and the clinic


image Recognize the role of digital communication in education and health care



Key Terms



Physical therapy practitioners of the twenty-first century agree that communication is integral to the successful practice of physical therapy. The purpose of this chapter is to provide you with both a theoretical and practical background for developing the communication skills you will need to become an effective physical therapist (PT) or physical therapist assistant (PTA) in the twenty-first century. In the spirit of communication, this chapter is written in a more personal tone. Reflective questions and actions are embedded throughout the chapter (rather than placed at the end) to promote a more direct consideration of the theory or application of the skill and the art of therapeutic communication.


The American Physical Therapy Association (APTA) has defined a clear vision1 for the profession in the twenty-first century (Box 7-1). This has had an impact on goals and action in practice, education, and research as well as professional behaviors.



BOX 7-1   American Physical Therapy Association Vision Sentence for Physical Therapy 2020


Physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumer and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.


From American Physical Therapy Association (APTA): APTA Vision Sentence for Physical Therapy 2020 and APTA Vision Statement for Physical Therapy 2020, HOD P06-00-24-35, House of Delegates Policies, Positions, and Guidelines, Alexandria, Va, 2009, APTA.


Similar values and behaviors are recognized by the Section on Health Policy and Administration of APTA in the development of Leadership, Administration, Management, and Professionalism (LAMP) skills set forth by the Section.2 These skills are promoted in a LAMP document and annual LAMP Summit meeting. In the core values and beliefs of the 2002 LAMP Summit, all PTs, not just managers, must have LAMP skills to become effective professionals.2


In the rapidly changing health care environment, LAMP skills affect the physical therapy profession’s ability to influence large organizations such as local, state, and national agencies. LAMP skills are the basis for developing such leadership behaviors as networking and political activism, which promote the growth of the profession.


In the educational environment, LAMP skills can best be integrated into the educational experience when they are woven throughout the curriculum. Academic and clinical faculty can model the LAMP skills in the classroom and thereby provide students with role models for learning these behaviors in both the classroom and the clinic.


A recent Delphi study by Lopopolo, Schafer, and Nosse3 revealed that the top-ranked LAMP skills identified by respondents were communication, professional involvement and ethical practice, delegation and supervision, stress management, reimbursement sources, time management, and health care industry scanning. All of the respondents were experienced managers and members of APTA who were familiar with the content of the LAMP skills. Of the top-ranked LAMP categories, communication had the highest median score and was therefore the most important category. The findings indicated that beginning PTs need “extensive knowledge” of communication techniques and should be “skilled” in applying these techniques in a clinical environment. These skills are essential in both the clinical management and the patient care aspects of physical therapy. To develop the knowledge and skill essential in communication, you need to appreciate what is involved in effective communication.



What Is Communication?


What does communication mean to you? Write down your definition of communication before reading further.


As defined in Webster’s II New Collegiate Dictionary,4 communication is “the act or process of communicating; transmission. To communicate is to make known; to transmit to others; to have an interchange; as of ideas or information.” There are many types of communication skills, including skills in verbal and nonverbal interactions and reading, writing, and listening. Communication can occur between individuals, within an individual, or among a group of people.



Verbal and Nonverbal Communication


What happens during communication between individuals? Both verbal and nonverbal elements of communication occur simultaneously. You can hear what each person is saying when individuals talk to each other. You can observe their body language and note whether what they are saying matches their body language. The verbal and nonverbal systems together transmit a message.


Think of a recent conversation you had with a friend. What did the friend say to you? What did his or her gestures and facial expressions convey to you? Were the verbal and nonverbal messages similar? How do you know?


Communication may occur within an individual, and this is called internal dialogue.5 It is “heard” only by the individual himself or herself and may affect his or her nonverbal communication to other people. Internal dialogue may occur when the individual is alone, with another person, or in a group of people.


Think of a time when you were meeting with your academic advisor. You were listening to her words, but you also “heard” yourself talking to yourself about what you wanted to do over the weekend. The professor noticed that you were not attending to the conversation, but she did not know what was causing your lack of attention. Your lack of attention may affect your interactions with her in future conversations. What assumptions might she have made regarding your lack of attention? How do you know?


Communication may also occur in a group. In a group interaction, multiple speakers may be conveying information both verbally and nonverbally.


Think of a time when you were listening to a professor lecture about a topic in physical therapy. The professor asks several questions of the class. Some students are enthusiastically raising their hands to answer, but others appear to be dozing. What assumptions do you think the professor might make regarding the differing communications by these students? How do you know?


Communication occurs every time we interact with one another. Communication occurs whether or not words are spoken. One cannot not communicate.


Think of a time when you met someone but did not speak to him or her. What assumptions did you make about that person? What cues did you notice about the person to make those assumptions?





Listening


Listening is a foundational communication skill for your success as a professional. Whether you are actively listening when interviewing a client or listening to a colleague request your input, your ability to listen actively will let the speaker know that you have understood his or her intended meaning. According to Davis,6 active listening requires practice and is not easy. It contains three elements: restatement, reflection, and clarification. Restatement involves repeating the words of the speaker as you have heard them. Reflection involves verbalizing both the content and the implied feelings of the sender. Clarification involves summarizing or simplifying the sender’s thoughts and feelings and resolving unclear verbalizations by the sender.


As a physical therapy professional, you can develop skill with all five types of communication. You can benefit from understanding the impact of verbal and nonverbal communication on yourself, your colleagues, your patients, and their families. In addition, you can enhance your skills in reading, writing, and listening. According to Davis,6 communication by practitioners may enhance or detract from their therapeutic presence in their interactions. As a practitioner, you can learn the communication skills that enhance your therapeutic presence and thereby promote healing.


Visualize yourself as a student at your first clinical internship. You are meeting with your first client for the first time. What types of communication occur between you and this new client? How do you know?



Professional Behaviors (Formerly Known as Generic Abilities) and Communication


The original research was conducted by use of a Delphi study with clinical educators from the University of Wisconsin in Madison. Clinical educators were asked to identify the behaviors essential for physical therapy professionals that were not explicitly part of the profession’s core of knowledge and technical skills but were required for success in the profession. Ten essential skills were identified. Each of these behaviors can be related to the development of effective communication skills. Through mastering each of these behaviors, you demonstrate the behaviors of a physical therapy professional and thereby enhance your communication with your clients, their families, and your colleagues.7


This research has recently been updated to address the changing scope of the physical therapy profession in response to increased autonomy and the new graduates from the Millennial generation (born 1980 to 2000). The 10 professional behaviors (formerly known as generic abilities) have remained the same as those identified in the original research; however, the rank order has changed, and they are now referred to as professional behaviors for the twenty-first century8 (see Boxes 7-2 and 7-3). These behaviors have also been recommended as essential for the development of LAMP skills for practicing clinicians.2



BOX 7-2   Professional Behaviors




Critical Thinking—The ability to question logically; identify, generate, and evaluate elements of logical argument; recognize and differentiate facts, appropriate or faulty inferences, and assumptions; and distinguish relevant from irrelevant information. The ability to appropriately utilize, analyze, and critically evaluate scientific evidence to develop a logical argument, and to identify and determine the impact of bias on the decision making process.


Communication—The ability to communicate effectively (i.e., verbal communication, nonverbal communication, reading, writing, and listening) for varied audiences and purposes.


Problem Solving—the ability to recognize and define problems, analyze data, develop and implement solutions, and evaluate outcomes.


Interpersonal Skills—The ability to interact effectively with patients, families, colleagues, other health care professionals, and the community in a culturally aware manner.


Responsibility—The ability to be accountable for the outcomes of personal and professional actions and to follow through on commitments that encompass the profession within the scope of work, community, and social responsibilities.


Professionalism—The ability to exhibit appropriate professional conduct and to represent the profession effectively while promoting the growth/development of the Physical Therapy profession.


Use of constructive feedback—The ability to seek out and identify high-quality sources of feedback, reflect on and integrate the feedback, and provide meaningful feedback to others.


Effective use of time and resources—The ability to manage time and resources effectively to obtain the maximum possible benefit.


Stress management—The ability to identify sources of stress and to develop and implement effective coping behaviors; this applies for interactions for: self, patient/clients and their families, members of the health care team and in work life scenarios.


Commitment to learning—The ability to self direct learning to include the identification of needs and sources of learning; and to continually seek and apply new knowledge, behaviors, and skills.


Adapted from May W, Kontney L, Iglarsh A: Professional Behaviors for the 21st century, 2009-2010. Unpublished research project.



BOX 7-3   Levels of Professional Behaviors for Students and Professionals in Communication


Beginning Level







Adapted from May et al. Professional Behaviors for the 21st Century, 2009-2010



Building Affective Communication Skills


Three domains of learning have been described. The cognitive domain9 involves knowledge, application, analysis, synthesis, and evaluation, and deals with didactic learning. The psychomotor domain10 involves perception, guided response, complex overt response, and adaptation, and deals with “hands-on” skills. Skills in the affective domain are considered among the most difficult to teach because this domain deals with attitudes, values, and character development, which influence all the other professional skills.11 This also applies to communication skills. Communication falls within the affective domain.


The mastery of affective behaviors develops over time. May and colleagues7 described beginning, developing, entry-level, and post–entry-level professional behaviors related to the generic abilities in their initial research. In the updated research, the 10 behaviors still have specific behaviors associated with performance at each level of development; however, the descriptors for the levels have changed to beginning, intermediate, entry-level, and post–entry-level behaviors. The current levels start with the beginning level, in which behaviors are consistent with those of a learner in the beginning of the professional phase of physical therapy education and before the first significant internship. This is followed by the intermediate level, in which behaviors are consistent with those of a learner after the first significant internship. The third level is entry level, in which the behaviors are consistent with those of a learner who has completed all didactic work and is able to independently manage a caseload with consultation as needed from clinical instructors (CIs), co-workers, and other health care professionals. The fourth level is post–entry level, in which the behaviors are consistent with those of an autonomous practitioner beyond entry level (see Box 7-3).8


Because many beginning PTs and PTAs are young adults, they are learning attitudes, behaviors, values, and character attributes that lay the foundation for their professional development.12 According to Davis,6 when students fail to acquire the behaviors on their own, faculty members should assist them in developing these behaviors. When students face challenges in the affective domain, faculty may assist them in learning professional behaviors through self-assessment using the generic abilities and guided discovery during advisory sessions with a faculty member.13


Faculty can also assist students in developing their affective communication skills by teaching them how to recognize and use rapport in their interactions. When building rapport, the professional must be aware of both verbal and nonverbal components of communication (Box 7-4).14 These are further described later.



BOX 7-4   Verbal and Nonverbal Components of Communication























Verbal Components Nonverbal Components
Language Gesture
Pacing Posture
Tonality Haptics
Intent Proxemics
Speed of communication Oculesics


In verbal communication you can recognize a variety of communication patterns by listening to the speaker.14 The language patterns of the speaker may help you to identify his or her learning style. For example, a speaker may say “That sounds good” when hearing about the prescribed exercise program. This suggests an auditory learning pattern. Auditory learners may prefer to learn the exercises by hearing you describe how to perform them. The pace of the speaker might include long or short pauses between words or thoughts. The tonality of the speaker might be high pitched and nervous or low pitched and calm. The intent of the speaker might be to request help or demand service. The speed of the communication might be fast, slow, or variable. Through paying attention to these patterns, you can build rapport by matching the client’s verbal pace, tonality, intent, and speed.


In nonverbal communication you can recognize the gestures, postures, haptics, proxemics, and oculesics of the speaker.14 Haptics involve the use of touch as part of a communication pattern. For some people, touching during speaking is an important cue. Others might consider touching to be rude. Proxemics is the distance between the speaker and the listener. Appropriate distance between speaker and listener varies depending on the cultural background of the speaker. Oculesics is the use of eye contact or gaze aversion. In some groups direct eye contact is a sign of respect for the speaker, whereas in other groups gaze aversion signals respect. As a professional you must learn the nonverbal cues that specifically apply to the patients you serve.


Rapport is an important characteristic of communication. Rapport is defined as an interaction marked by mutual collaboration and respect but not necessarily indicating agreement.5 When people are in rapport, they have behavioral patterns that become similar in nature.


The first of the three primary types of rapport is cultural rapport, which is established by using the form of dress or greeting appropriate to the setting. For example, you might wear a lab coat in an acute care clinical setting but a polo shirt and khaki pants in an outpatient orthopedic clinical setting. You might use a traditional greeting style appropriate for the culture of your patient, such as touching the patient’s cheek or shaking hands with the patient (Figure 7-1).


image
Figure 7-1 Cultural rapport. A, Both participants use a common Latin American greeting of touching each other on the cheek. The participants are “in sync” and building rapport with each other. B, Both participants use a common North American greeting of shaking hands. The participants are “in sync” and building rapport.

Remember a clinical situation in which you thought your clothing was appropriate for the particular clinical setting. How did you know?


The second type of rapport is verbal rapport. This is established when you use the same or similar descriptive phrases and conversation content as the person with whom you are speaking. For example, you might work with a client who asks to “see you do the exercises” before performing them. You might respond by “showing” the patient/client how to do the exercise and using verbal language patterns related to visual descriptors, such as “How does this look to you?”


Remember a situation in which you were talking with a patient/client and the conversation seemed to flow very easily. What type of language patterns was the patient/client using? What type of language patterns were you using?


The third type of rapport is behavioral. This is established when you mirror the posture and body movements of the person with whom you are speaking. You may also match the person’s voice tonality and tempo. For example, you might be working with a toddler in an early intervention program for your pediatric clinical rotation. You could squat or kneel at the eye level of the toddler to build behavioral rapport. Another example might be matching the posture while the person is sitting in a chair (Figure 7-2). To break rapport, you can mismatch the posture of the listener by not mirroring it (Figure 7-3).


image
Figure 7-2 Building behavioral rapport. The speaker seated on the left matches the body posture and eye contact of the listener seated on the right. The participants are “in sync” and building rapport with each other.

Related posts:

Physical Therapy for Integumentary Conditions American Physical Therapy Association Roles and Characteristics of Physical Therapists Physical Therapy for Pediatric Conditions Physical Therapy for Musculoskeletal Conditions The Physical Therapist Assistant

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Mar 13, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Communication in Physical Therapy in the Twenty-First Century

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