Critical Reflection Essay on Communication

Introduction

Communication has been suggested to be a factor in establishing effective relationships between clinicians and patients (Pizzari et al., 2002). Additionally, poor clinician-patient communication may contribute to poor treatment adherence, which in turn can lead to adverse patient health outcomes (Safran et al. 1998; Wilson et al. 2007).

Previously in physiotherapy studies, patients who had a positive relationship with their physiotherapists felt more inclined to attend their clinic appointments and complete their rehabilitation activities during these sessions (Pizzari et al., 2002). In turn, adherence to exercise programs was shown to be profoundly greater when the physiotherapists communicated positively with the patient and asked for continued feedback about their progress and treatment (Sluijs et al., 1993a).

Therefore, a link emerges between communication and adherence. During this essay, I will explore this link and critically reflect on the learning experience (LE) underpinning this connection. The Gibbs reflective model (1988) will be used to structure the essay (see Figure 1) with a critical appraisal of 2 papers completed via the CASP system (CASP, 2018; CASP 2018). The first was a qualitative study by Cooper, Smith, and Hancock, 2008, and the second was a randomized control trial (RCT) by Lonsdale et al., 2017.

Description

The LE I will be reflecting on occurred during a lecture titled ‘Communication processes in healthcare’ on the 8th of October 2018. The lecture aimed to introduce and discuss the importance of communication while identifying how it can link to a patient's experience of healthcare. The lecturer introduced a definition of communication and how the communication process can be broken down into stages.

One of the main parts of the lecture that raised my awareness as to just how important communication will be to my future practice was a discussion about the components of skilled communication. This generated a key thought ‘How much does skilled communication affect a patient and does it affect a patient's adherence (PA) to treatment?’ Which I have based my LE on. In a review article Haskard Zolnierek and DiMatteo, 2009, concluded that there was a 19% higher risk of non-adherence to treatment among patients who experienced poor communication from the physician. Healthcare adherence is defined by the World Health Organisation as,

‘the extent to which a person’s behavior… corresponds with agreed recommendations from a health care provider’ (Sabaté, 2003, p.3).

The lecture preceded to link effective communication to biopsychosocial (Engel, 1977) and patient-centred models of healthcare. Interestingly, several authors have previously recommended clinicians need to develop their ability to communicate to deliver effective patient-centered care (PCC) (Potter, Gordon, and Hamer, 2003), (Östlund, Elisabet Cedersund, 2001). In turn, PCC built on solid communication pathways is important in improving PA to medical treatment (Harmon, Lefante, and Krousel-Wood, 2006). Communication is a recognized component of the PCC model in physiotherapy (Cooper, Smith, and Hancock 2008).

Importantly, the link between communication, PCC, and adherence cannot be discussed without reference to a psychological model. According to self-determination theory (Ryan and Deci, 2000), people have psychological needs for three innate psychological stages;

1. autonomy (controlling their behavior)
2. competence (the need to effectively function in the current environment)
3. relatedness (the need for a sense of belonging).

When clinicians support their patients' psychological needs through PCC, this could lead to the patient being more autonomously motivated, possibly generating desired behavior changes (Ng et al., 2012). In contrast, a controlling environment may involve disregarding patients' views, poor communication and listening. Potentially, pressuring patients into making decisions without sufficient consultation, leads to poorer motivation and therefore lower long-term adherence to treatment (Haskard Zolnierek and DiMatteo, 2009).

Feelings

Before my LE I had some appreciation that PCC would enhance PA to treatment, however, on reflection, I underestimated how fundamental effective communication was in this relationship. I had previously been made aware PCC was multifactorial and involved many concepts (Cornwell and Goodrich, 2011) from a previous lecture. Critically, I had not considered how my ability to communicate effectively would be to provide PCC while on placement or in future work.

During the lecture, I found it intriguing to relate the content to my previous interaction with clients as a personal trainer. I realized I was trying to relate to the lecture as a physiotherapist providing a service, rather than from the patient’s point of view. As soon as I changed my perspective my main LE immediately became a lot clearer to me.

My reaction to the lecture initially was one of anxiety. This was due to my difficulty in fully processing verbal information and unfamiliar words provided verbally. This generated thoughts such as ‘How will this affect the patient I see? Will I be more focused on taking accurate notes than on my body language? Will my clinical educator think I am not interested and disengaged if I do not write down information correctly?’ I felt like the prospect of this weakness was going to undermine my success as a physiotherapist. The lecture content and my reflection prompted me to seek a formal assessment of my communication abilities. I have since been diagnosed with dyslexia and the verbal processing issue has been identified allowing management strategies to be implemented with my personal tutor and disability adviser.

On the whole, I feel more positive about my ability to enhance a patient’s health outcomes and adherence to treatment through effective communication. I think the LE came exactly at the right time for me to seek the additional support I will need to provide this.

Evaluation

I recognize my initial judgment of this LE generated many negative thoughts. However, while undergoing this reflection process, I can see just how vital this LE will be to my future as a physiotherapist.

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I now understand how a lack of adherence to long-term treatment can result in poor patient health outcomes and unnecessarily high costs in health care treatment (Sabaté, 2003) and how adherence is underpinned by truly effective communication (Lonsdale et al., 2017). Therefore, I can see how PCC and good clinician-patient relationships may help patients engage to a higher level with their rehabilitation or adhere to treatment advice (Fuertes et al 2007). This experience has significantly impacted me as it is now clear to me how the relationships between me and my future patients can be affected positively or negatively by my ability to communicate. Crucially, I feel I now have the tools and understanding to begin to implement effective communication strategies to provide PCC. These include increasing patient input, use of open-ended questions, practicing active listening, verbal and non-verbal alignment, and addressing the patient's needs from a biopsychosocial perspective

Overall, I recognize this LE will continue to develop as I move through my physiotherapy career, I will see many examples of effective and ineffective communication strategies employed by clinical educators and other physiotherapists. I will try to continue to reflect on these experiences and build my communication strategies. Furthermore, for me to develop from a novice to an expert physiotherapist my ability to effectively communicate my clinical reasoning to patients will be a critical factor (Rivett and Jones 2004) throughout my career.

Analysis

Even though, initially, I had some concerns about my ability to communicate effectively due to my undiagnosed dyslexia, I feel as a direct consequence of this reflection I am more aware of the communication strategies available to me to ensure I deliver PCC. Having a basic understanding of these strategies has increased my confidence in communicating as a physiotherapist, which will only enhance my LE while on placement (Delany & Bragge, 2009). Additionally, poor adherence in a clinical setting seems common (Haskard Zolnierek and DiMatteo, 2009), therefore developing multiple communication strategies for different patient groups will be crucial to ensure I can affect PA positively.

As previously discussed, according to the self-determination theory (Ryan and Deci, 2000), positive and motivational communication can lead to autonomous motivation in a patient which in turn could increase PA to physiotherapy treatment. For example, while addressing a patient’s lack of motivation towards their subscribed exercises in a rehabilitation setting. I feel able to educate the patient as to the benefits of the exercise, potentially leading to the patient feeling empowered. This conversation could further develop a stronger patient-therapist bond. This bond is fundamental in patients completing their rehabilitation (Pizzari et al., 2002), highlighting how PCC and communication may be key to PA treatment. However, in healthcare generally, research has highlighted practitioners often do not adopt a PCC approach and therefore miss the chance to build patient autonomous motivation (Holden et al 2009, Butow and Sharpe 2013). This factor, along with others such as low self-efficacy and lack of interest, could potentially all cascade from a poor PCC. A diminished patient-therapist bond seems very likely to impact negatively a PA's treatment and ultimately their recovery. My awareness of this cascade effect has been highlighted by this critical reflection.

During the following critical analysis, I will explore the two underlying themes within this critical reflection. Firstly, how is PCC in physiotherapy underpinned by effective communication, and how does communication skills training in line with the self-determination theory affect PA in physiotherapy?

Cooper, Smith, and Hancock (2008), conducted a qualitative in a physiotherapy setting, to define what patient-centeredness was from a patient’s perception while suffering chronic lower back pain (CLBP). Twenty-five patients who had not received physiotherapy treatment in the previous 6 months for CLBP but had all suffered from CLBP at this time were interviewed in a semi-structured format. The study identified 6 patient-reported dimensions of patient-centeredness shown in Figure 2.

Effective communication was identified as the common theme in all dimensions. The authors suggest that improved communication skills alone could facilitate greater PCC in physiotherapy for those suffering from CLBP.

Interestingly, over half of three-quarters of the participants were female (n=20). A generalization, therefore, was made that views on communication and its underpinning of patient-centeredness were matched between genders. However, this was unavoidable due to the self-selecting recruitment process. Another potential oversight was the possible use of non-verbal communication during the interviews by the interviewer. The interviewer was a physiotherapist, interviewing about issues surrounding physiotherapy. The authors did not control for the ‘interviewers’ non-verbal reactions to positive/negative views around their profession. Potentially reactions could have acted as some form of bias possibly skewing patients' answers to subsequent questions. Also, due to the relatively small sample size and specific client group, the generalization of the results to the real world may be questioned.

Despite the limitations, the study used appropriate data collection/analysis methods, and recruitment strategies and had a clear objective from start to finish. I feel this results in a somewhat convincing and valuable conclusion, by addressing the 6 dimensions of patient-centeredness, with particular attention to communication, physiotherapists can improve patient experiences of CLBP. For my future practice, it appears clear enhancing my communication skills will influence my ability to provide PCC to this client group.

Lonsdale et al., (2017) conducted a cluster RCT, to assess how communication skills training based on the self-determination theory could affect PA to home-based rehabilitation (HBR) for patients with CLBP. Participants (n=255) were randomly assigned to a control or intervention group. The control group received care from physiotherapists who had completed a 1-hour workshop on CLBP management. The experimental group received care from physiotherapists who had completed 8 hours of communication skills training from an intervention called Communication Style and Exercise Compliance in Physiotherapy (CONNECT). Therefore, the physiotherapists were not blinded by the intervention. Groups had similar demographic, clinical, and outcome characteristics. It was found the experimental group self-reported adherence to HBR was higher than the control group. However, this was a weak positive effect with significant effects found at weeks 1,4,12 but not 24. Suggesting PA generally decreased over time, however, physiotherapists with communication skills training slowed this rate of decline. The weak positive effect could be due to weeks 1,4 and 12 on average only 69% of patients completed the follow-up appointments. Potentially, along with a relatively small sample size, this could have underpowered the study. These factors could translate into the CONNECT training method being incorrectly identified as only having moderate effects on psychological factors for behavioral change (motivation) and only a small effect on PA to HBR.

In my opinion, the reason why this study is of clinical importance is that the authors did not attempt to standardize the method of physiotherapy treatments and allowed the physiotherapists to act as autonomous practitioners. This means the study applies to real-world physiotherapy practice and consequently, the somewhat positive results are worth application. Therefore, in my future practice, I will actively seek communication skills training, as I feel this could affect PA to treatment, especially in this clinical group.

This analysis has emphasized to me, just how essential the LE was to my development as a physiotherapist. Through this section, I have learned that PCC is multidimensional, however, my communication will impact all the dimensions, in turn, impacting my ability to promote PA to treatment.

Conclusion

The physiotherapist's role involves delivering a service built on accountability, clinical effectiveness, and evidence-based practice. To adhere to these concepts, it has been shown critical reflection is fundamental (Donaghy and Morss, 2000). This reflection was vital in identifying how clinically important communication will be in my future practice. I feel that it highlighted some personal areas for development in communication, but most importantly it allowed me to begin the process of addressing them. I feel because of this my level of performance as a physiotherapy student during placements will be much improved, as I will put greater emphasis on my communication with patients. This emphasis will be essential in fostering a strong physiotherapist-patient bond, providing PCC, and potentially influencing patient outcomes through improved treatment adherence (Lonsdale et al., 2017), (Cooper, Smith, and Hancock, 2008). Also, I will be in line with the Chartered Society of Physiotherapy (CSP) codes of professional practice that state members must put the needs of their patients at the center of their decision-making (CSP, 2013).

Enhancing my communication skills will now be at the forefront of my continued professional development. Without this reflective practice, I feel I would not have reviewed this LE. Thus, letting this LE pass without giving it any clinical significance. Potentially, leading to poorer personal adherence to the concepts of accountability, clinical effectiveness, and evidence-based practice.

Action plan

Moving forward, I will continue to take every opportunity to develop my understanding of the communication strategies that enhance PCC. This includes motivational interviewing techniques, body language development and most importantly developing strategies to record and interpret large amounts of verbal information quickly. I will achieve these by practicing clinical scenarios with fellow students during practical sessions, asking for advice from my clinical educators or personal tutor regarding communication, and bringing these strategies into my personal life and work. I will further research communication skills training such as CONNECT which specifically looks at PA to rehabilitation exercises. Given this area appears poorly understood in physiotherapy. Lastly, given the obvious benefits to me, I will continue to practice critical reflection regularly throughout my studies and career development.

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