PTAP 1300 Unit 4: Communication in Physical Therapist Assistant Study Guide
The Therapeutic Relationship in Physical Therapy
Success in the PT/PTA therapeutic relationship is contingent upon the provider conveying specific attitudes and actions:
Valuing the patient/client.
Remaining attentive to the patient/client's needs.
Acknowledging the patient/client's message.
Genuinely empathizing with the patient/client.
Expressing a clear desire to provide the patient/client with the very best care.
Purpose and Scope of Communication in Health Care
Communication serves several vital functions in the healthcare setting:
Understanding the patient and his/her condition.
Establishing a rapport with the patient.
Relaying information to the patient and others involved in their care.
Providing motivation.
Collaborating with other health care professionals regarding patient care.
Providing in-services to others regarding specific topics.
Understanding the Patient Experience and Role
Learning about the patient involves gathering varied information:
History of present illness.
Medical history and prior level of function.
Social history and cultural background.
The ways in which the condition affects the individual's life.
Patient goals and values.
Communicating respect and caring through both words and actions.
The patient role involves several significant challenges and losses:
Loss of privacy.
Loss of independence.
Loss of the comfort of home.
Possible losses associated with illness: financial stability, independence, relationships, employment, and self-image.
Appropriate PTA responses to the patient role:
Maintain privacy through draping, pulling curtains, closing doors, and knocking before entering.
Offer the patient choices whenever possible (e.g., specific times for treatment).
Attend to the patient's physical comfort.
Help the patient re-evaluate what is possible within the context of their current abilities.
Avoid telling the patient that everything will be exactly the same as it was before.
Possible privileges or gains from the patient role:
Social gain: Receiving attention when previously isolated.
Financial gain: Accessing benefits or workers' compensation.
Escape (avoidance): Using illness to avoid dealing with work or family stress.
Psychological and Behavioral Patient Presentations
Malingering: Feigning symptoms long after they are gone. This is a deliberate act where the patient is fully aware they are not ill. These patients may benefit from psychological evaluation.
Conversion Reaction: A psychiatric disorder (also known as Conversion Disorder) where the symptoms or illness are very real to the patient, despite no organic cause.
Establishing Therapeutic Rapport and Managing Barriers
Therapeutic Rapport concerns:
Instances where "over" dependence may become a problem.
The risks of over-identification and pity.
Managing patient loneliness.
The PT-patient relationship should foster patient independence rather than over-dependence on the therapist.
Managing Non-Therapeutic Relationships:
Redefine the parameters of the relationship by staying focused strictly on treatment goals.
Keep communication less personal.
Limit ideas and judgments to treatment-related matters only.
In extreme cases, it may be necessary to ask another professional to treat the patient.
Barriers to establishing rapport:
Fear: Both professionals and patients may be afraid to discuss certain situations, leading to a lack of openness.
Prejudice: Pre-conceived notions about individuals can impair communication.
Depersonalization: Referring to a patient as a disability rather than a person.
Patronizing: Particularly in geriatric care, professionals may use "baby talk," treating adults like children.
Types and Components of Communication
Verbal communication.
Nonverbal communication (body language and facial expression).
Written communication:
Patient education materials.
Communication boards and texting.
Patient care documentation.
Effective Listening Techniques and Barriers
Principles of effective listening:
Focus full attention on the patient so they feel free to talk.
Smile and maintain eye contact.
Observe nonverbal messages.
Ask the patient to clarify meanings of words or feelings.
Confirm the patient's message.
Take notes as necessary.
Use nonverbal cues such as nodding the head.
Do not interrupt abruptly.
Practice empathy.
Barriers to effective listening:
Listener's set: Thinking you know what the speaker will say before they say it, or forcing an idea into a familiar context to understand it.
Sensory overloading: Failing to package material in manageable components.
Environment: Lack of a quiet space.
Verbal and Nonverbal Communication Dynamics
Successful verbal communication depends on:
The provider's vocabulary, clarity of voice, and clarity of purpose.
Organization of material.
The attitude of the provider.
The tone and volume of the provider's voice.
The degree to which the patient/client listens.
Effective listening involves both closed and open questions.
Body Language attributes:
Appearance (professional dress and grooming).
Postures (open vs. closed).
Gestures and demonstrations.
Facial expressions.
Eye contact, glances, and gazes.
Proximity.
Touch (manual) and tactile cueing.
Sign language.
Delivery can be both intentional and unintentional.
Nonverbal Skills:
Maintain direct eye contact.
Interact at the same physical level as the patient.
Use touch to signal caring or comfort.
Monitor patient gestures, facial expressions, tone of voice, alertness, and fatigue.
Posture Communication
Open Postures (conveys willingness to receive message):
Arms at sides.
Legs uncrossed.
Erect posture.
Facing the other person.
Positioning at eye level (avoiding being significantly above or below).
Head and face upright and direct.
Nodding or smiling.
Closed Postures (conveys unwillingness or rejection):
Arms and legs crossed.
Head down or turned away.
Rolling eyes or looking away.
Frowning or shaking the head.
Turning away.
Slumped posture.
Cultural Considerations in Physical Therapy Communication
Be aware of cultural variations in nonverbal communication, including postures and proximity.
Specific cultural examples:
Gestures: Meanings vary significantly across cultures.
Eyes cast downward: May be a sign of respect in Asian cultures.
Touch: Male-to-female touching may be inappropriate in Muslim cultures.
Hand Gesture Etiquette:
India: Hand over the nose can mean "you can't fool me"; licking the middle finger and rubbing it against an eyebrow means "you're gay" (also in Lebanon and Pakistan).
Brazil: Putting a cold lobe can mean "good luck"; a thumb against the teeth can mean "I don't know."
Indonesia and Rural India: Specific pointing gestures may vary; thumb against teeth in Indonesia can mean "nothing."
Japan: Hand over/under fist means "good luck."
China and US: Palm toward self with the number five means "five."
Australia/UK: Palm toward self with two fingers is offensive ("up yours"), while palm outward is "two."
France: An eyelid pull can mean "look out for him."
Zero/Nothing: In Europe/US, this is the OK sign; in Mediterranean/Turkey, it can be an insult regarding sexual orientation; in Brazil, it is a vulgar gesture.
Patient Confidentiality and Ethics
Hippocratic Oath: Professionals must keep secret what they see or hear during treatment that should not be spread abroad.
AMA Code of Ethics (Section 9): Confiences should not be revealed unless required by law or to protect the welfare of the individual or community.
Reasons for maintaining confidentiality:
Respects patient privacy.
Encourages patients to seek care.
Fosters trust in the doctor-patient relationship.
Prevents discrimination based on illness.
Meets patient expectations.
HIPAA (Health Insurance Portability and Accountability Act): A law requiring protected health information to be kept confidential.
Exceptions to confidentiality:
Disclosure mandated by statute (e.g., adult or child abuse).
Disclosures to prevent harm to self or others.
Duty to inform victims or take steps to avert foreseeable harm (Tarasoff).
Informed Consent and Advanced Directives
Required elements of informed consent:
Clear description of proposed intervention.
Reasonable alternatives.
Risks, benefits, and concerns of the intervention.
Assessment of patient understanding.
Patient's voluntary acceptance of the intervention.
The patient must be competent and able to deliberate.
Informed consent components: Nature of treatment, risks, alternatives, benefits, and opportunity for questions.
Advanced Directives: Patients make wishes known in advance if they become incapacitated.
Living Will (Health Care Directives).
Durable Power of Attorney for Health Care Decisions.
Do Not Resuscitate (DNR) Form.
Allow a Natural Death (AND).
Principles of Patient Education
General recommendations for instruction:
Use lay terminology appropriate to the patient's background.
Use varied educational methods targeting different learning styles.
Divide learning into manageable parts.
Relate current learning to past knowledge.
Control the environment.
Provide written materials to enhance recall.
Observe patient performance and ask questions to gauge understanding.
Provide feedback to improve performance.
Allow adequate practice time and reduce feedback as independence grows.
Monitor compliance and provide motivation.
Domains of Learning: Bloom's Taxonomy
Cognitive Domain (Knowledge):
Surface Learning: 1. Recall data, 2. Understand.
Deeper Learning: 3. Apply (use), 4. Analyze (structure/elements), 5. Synthesize (create/build), 6. Evaluate (assess/judge).
Focuses on recalling facts and breaking down ideas to form new structures.
Affective Domain (Attitude):
Surface Learning: 1. Receive (awareness), 2. Respond (react).
Deeper Learning: 3. Value (understand and act), 4. Organize personal value system, 5. Internalize value system (adopt behavior).
Focuses on accepting and integrating values into a belief system.
Psychomotor Domain (Skills):
Surface Learning: 1. Imitation (copy), 2. Manipulation (follow instructions).
Deeper Learning: 3. Develop precision, 4. Articulation (combine/integrate skills), 5. Naturalization (automate/expert).
Focuses on motor responses to meet situational demands.
Strategies for Motor Learning and Feedback
Phases of Motor Learning:
Cognitive: Patient thinks about the activity while listening and watching instructions.
Associative: Patient begins to judge their own performance and thinks about correct execution with fewer cues.
Autonomous: The patient is independent.
Extrinsic Feedback (provided by therapist):
Forms: Verbal, tactile, or visual cues.
Frequency: High in cognitive phase, decreasing in associative phase, negligible in autonomous phase.
Intrinsic Feedback (developed by patient):
Critical for independence and important in the associative phase.
Includes kinesthetic feedback (feeling the movement) and visual feedback (using a mirror to self-correct).
Therapists should allow patients time to evaluate and self-correct rather than jumping in immediately.
Communicating with Special Populations
Older Adults: Assess readiness to learn, prepare a conducive environment, adjust to learning styles (e.g., larger pictures), and encourage family participation.
Hearing Impaired: Move close to the face, use tactile cues for attention, speak clearly and slowly (not high volume), do not exaggerate pronunciation, eliminate background noise, and ensure a well-lit environment for lip reading.
Non-English Speaking: Use certified translators if possible, respect cultural beliefs regarding volume and gestures, pronounce names correctly, greet in native language/smile, and identify the cultural decision-maker.
Visually Impaired: Introduce everyone in the room, ask before assisting, provide directions, use large fonts ( point or larger) or Braille, and provide clear concise instructions with pictures.
The Home Exercise Program (HEP)
Goals: Reinforce therapeutic goals and enhance active involvement.
Basics:
Keep it simple and customize for the individual.
Provide written instructions with pictures or drawings.
Ensure materials are large enough to see.
Include the facility phone number and the name of the PT/PTA.
Include safety instructions: do not work through pain, go slowly, and stop if pain occurs.
Motivation and Verifying Understanding
Motivation is most successful when:
Positive rapport exists.
The therapist knows the patient's goals/values.
Family/friends are involved.
Praise is consistent but not constant.
Caring, honesty, and enthusiasm are displayed.
Setbacks are explained as normal.
Goals are divided into smaller parts.
Methods of verifying understanding/compliance:
Ask the patient to perform the activity without cueing.
Ask the patient to explain precautions.
Ask the patient to keep an exercise log.
Professional Collaboration and Conflict Resolution
The PTA must explain their role to patients, family, nursing, other health care professionals, and new PTs. This ensures patients receive the appropriate care from the appropriate individual.
Collaboration involves: PT, PTA, PT aides, Nursing, OT, Speech Pathology, Physicians, Patients/Families, and Social Workers.
Conflict Resolution techniques:
Use "I" statements.
Find a pool of shared meaning.
Set ground rules.
Practice mutual respect and do not interrupt.
Stick to facts over emotions.
Reach a resolution all parties can live with.
Use an intermediary if necessary.
True Colors: Personality and Work Styles
Developed by Don Lowry, True Colors is a metaphor for personality and learning theory to promote appreciation of individual differences and team building.
Orange Personality:
Traits: Quick-witted, charming, spontaneous, impulsive, generous, impactful, optimistic, eager, bold, playful, risk-taking, active, energetic, adaptable, carefree, open-minded, good at negotiating.
Values: Fun, variety, stimulation, skill, resourcefulness, courage.
At work: Enthusiastic, great under pressure, prefers lively/risky jobs, restless with limits, action-oriented.
Leadership: Expects quick action, assumes flexibility, works in the "here and now."
Famous examples: Winston Churchill, James Dean, Amelia Earhart, Ernest Hemingway, St. Francis of Assisi, Garfield.
Gold Personality:
Traits: Consistent, loyal, thorough, traditional, cooperative, dependable, prepared, punctual, faithful, stable, organized, caring, efficient, concrete, dutiful, scheduled, goal-oriented, dedicated, responsible.
Values: Rules, authority, right/wrong, belonging, home, family, tradition.
At work: Provide stability, handle details, work before play, practical, prefers established routines/the "right" way.
Leadership: Expects punctuality and loyalty, assumes the "right" way, rules-oriented, threatened by change.
Famous examples: Queen Victoria, Florence Nightingale, George Washington, Joan Rivers, Henry Ford, Harry Truman, Mother Teresa.
Green Personality:
Traits: Analytical, future-oriented, conceptual, objective, calm, collected, inventive, logical, perfectionistic, abstract, free thinker, hypothetical, investigative, clever, level-headed, philosophical, visionary, innovative, curious, concise.
Values: Knowledge, understanding, own standards, intelligence, fairness, justice.
At work: Analytical/creative focus, visionary, independent, perfectionist, works well with complex strategies, prefers minimum structure.
Leadership: Expects competence, analytical, encourages change for improvement, constantly "in process."
Blue Personality:
Traits: Kind, sympathetic, personal, warm, gets involved, needs harmony, idealistic, spiritual, sincere, people-person, peacekeeper, flexible, imaginative, nurturing, social, communicative, compassionate, caretaker.
Values: Uniqueness, authenticity, meaning, integrity, unity in relationships.
At work: Focuses on people and relationships, prefers supportive/harmonious environments, dislikes competition/conflict, promotes individual expression.
Leadership: Expects others to express views, assumes "family spirit," democratic/unstructured approach, encourages change via human potential.
Famous examples: Emily Dickinson, Isabel Myers-Briggs, Oprah Winfrey, Gandhi, Mozart, Abraham Lincoln, Martin Luther King.