PPwOA Week 3 Cue Cards
Communication in Healthcare and Therapeutic Practice
Purpose of lecture: explore why communication is crucial for health professionals, how we communicate, aims of therapeutic communication, structure of healthcare communication, and nonverbal skills.
Why learn communication as health professionals:
Everyone can communicate in daily life, but health care requires different skills due to context and stakes.
Poor communication is linked to adverse outcomes: complaints, delayed diagnosis, legal issues, fatalities.
Effective communication is a complex, ongoing professional development goal.
Skills involved in health care communication: verbal, nonverbal, and written; these are not typically learned in everyday life.
Benefits of effective communication:
Optimizes therapeutic relationships and improves client outcomes.
Research shows improvements in recovery rates, fewer adverse outcomes, increased motivation.
System-wide: reduced costs, greater professional satisfaction.
What good communication looks like in health care:
Explore and understand the experiences, perspectives, and needs of the other person (person-centered care).
Communication is often transactional: involves establishing a relationship, sending/receiving messages, and continual processing to achieve mutual understanding (shared understanding).
As a health professional, your role is to form the relationship and negotiate until mutual understanding is achieved.
Factors shaping communication:
Internal and external factors, common to all encounters, and those specific to therapist and client.
These factors can facilitate or impede relationship building and mutual understanding.
Aims of a therapeutic communication encounter:
Develop mutual understanding → establish a therapeutic relationship → deliver person-centered care.
Mutual understanding provides a foundation for a therapeutic relationship.
A therapeutic relationship is built on respect, empathy, trust, rapport, active listening, and collaboration to produce desired change.
Change is based on the client’s unique circumstances and goals.
Person-centered care (PCC):
Also known as patient-, client-, family-, or community-centered care.
Place the person at the center of care; involve them in planning and decision making.
Foundations: mutual understanding and therapeutic relationship enabling shared decision making.
Mutual understanding in detail:
Respect of self and others is fundamental to ethical practice.
Respect is demonstrated through unconditional acceptance of all individuals regardless of appearance, ability, status, beliefs, culture, socioeconomic status, or past acts.
Empathy is the direct, clear, and accurate recognition of another’s emotions and the expression of that understanding.
Health professionals must accurately identify, acknowledge, validate, and accept the other person’s reality.
Empathy and disempowerment:
People seek health care because they cannot or find it difficult to manage aspects of life; clinicians should understand life experiences and needs to provide meaningful help.
Expressing empathy is both verbal and nonverbal; requires personal and professional skills.
Building trust and rapport:
Practice empathy and self-reflection on your own skills; understand emotions; seek to see the world from the client’s perspective.
Acceptance of how the client feels is foundational to trust.
Trust is built by being open, honest, humble, kind, and reliable.
Therapeutic relationship and collaboration:
Positive client-professional connection (rapport) enhances collaboration, engagement, persistence, and attainment of client-centered goals.
Do not use the therapeutic relationship to manipulate decisions; maintain genuine desire to collaborate.
The client-focused aim is to listen, understand, respect, and share knowledge to enable better health, functioning, participation, and well-being.
Foundations of PCC and shared decision making:
Mutual understanding and therapeutic relationship enable shared decision making.
Emphasis on understanding the person, their abilities, strengths, beliefs, feelings, needs, and desires to design appropriate interventions.
CalgaryCambridge Guide to a Medical Interview (adapted): overview of therapeutic encounter
Overall aims of a clinical encounter are visible on the outside; steps are inside the model.
Phases: Introduction; Gathering information; Explanation and planning; Closing the encounter.
Phase 1: Introduction
Introductions set the tone and establish reliability and trustworthiness.
Acknowledge client vulnerability and uncertainty; introductions help address questions like: Can they help me? Do I trust them? Do they care? Will they take my concerns seriously? Will they help me achieve my goals?
Phase 2: Gathering information
Collect information from multiple sources (case notes, referral letters, prior physiotherapy input) and primarily from the client through assessment.
SOAP format used to structure data.
Verbal techniques: appropriately timed questions, clarifying statements, paraphrasing, summarizing, signposting to guide the conversation.
Nonverbal techniques: active listening, appropriate silences, eye contact, open body language.
Question types:
Open questions: provide detailed information in the client’s words; begin with how, what, can you tell me about…
Closed questions: discrete yes/no information; useful for screening or communication barriers (e.g., dyspnea, aphasia).
Probing questions: elicit more detail about a topic already discussed; often begin with phrases like "so… tell me more about" or "what happened before that?" etc.
Clarifying questions: deepen understanding and avoid assumptions; ensure mutual understanding.
Avoid leading questions which bias responses (e.g., "Isn’t it a lovely day?" or evaluative prompts like "You’re in good general health, right?").
Elicit client beliefs, reactions, and feelings; summarize at the end of a line of questioning and preview next steps.
Explanation and planning: provide the correct amount and type of information; use chunks and checks; incorporate visual or written aids; confirm understanding.
Shared decision making: share thinking, invite client input, collaborate on plan, discuss choices, confirm client comfort with the plan, invite further discussion.
Phase 3: Explanation and planning
Provide explanations and future plans; ensure client understanding; check comprehension.
Phase 4: Closing the session
Do not leave the session hanging; discuss next steps, future plans, and the client’s understanding of the session.
Establish a clear action plan for if things worsen at home (what to do).
Nonverbal communication skills
Environment, body language, and voice are critical; nonverbal cues can affect trust and engagement.
ISBAR mnemonic for handover (verbal and written communication)
ISBAR stands for: Identify, Situation, Background, Assessment, Recommendation.
Purpose: standardised format to transfer information concisely; reduces miscommunication and hierarchy; creates a shared mental model.
Example: physiotherapist in ED communicates with physician about discharge planning for a patient with a recent fall, including vitals, pain levels, imaging results, functional status, and recommended next steps.
ISBAR is essential in practice and will feature in assessments.
Practical note on ISBAR
Standardised handover improves information transfer and reduces hierarchical barriers; consistent format used across verbal and written communication.
Introduction to the physical examination in musculoskeletal physiotherapy (MSK)
Series aims: understand why examinations occur before interventions; plan and conduct examinations; learn components tailored to MSK; determine information gained from each component.
Core philosophy: testing hypotheses from subjective examination during the objective exam; gather evidence to support or negate hypotheses; iteratively refine hypotheses across visits.
Practical considerations:
Do not perform every possible test on day 1; too many tests can worsen outcomes or obscure interpretation.
Avoid excessive information in early sessions; plan to test hypotheses progressively.
Consider irritability and how easily symptoms are provoked (concepts to be discussed later).
Use a structured approach to decide how hard to probe (pressure/force), and consider potential red flags or serious pathology requiring referral.
Hypothesis-driven testing: compare observed findings with those predicted from subjective history; plan which tests to perform to confirm or refute hypotheses.
“Comparable sign” concept: can you reproduce the patient’s symptoms with a movement; if a movement is easy to reproduce, you may adjust the test intensity accordingly.
Start by establishing resting symptoms before initiating examination; use the data from subjective to shape objective testing.
Asterisk sign: mark the most important physical examination findings for reassessment (asterisk next to a finding).
Planning for ongoing exams: identify tests not completed in the first session for subsequent sessions.
Goals and management: discuss short- and long-term goals; decide on management plan in collaboration with patient before starting treatment.
Observation and functional assessments (MSK series, Lecture 2)
Observation purpose: obtain general information about functional deficits and to guide the rest of the physical examination.
Look for:
Habitual or protective movement patterns (e.g., limp after ankle sprain, head tilt when standing).
Posture and body holding: standing, sitting, and general movement.
Gross changes in skin or skin appearance (e.g., shiny skin in cardiovascular disease; hair loss indicating systemic conditions).
Localized skin changes, swelling, temperature changes, scars.
Muscle contour differences and asymmetry; bony landmarks alignment.
Willingness to move; protective postures; fear or pain limiting movement.
Observe from multiple directions (laterality, anterior, posterior) to capture full movement patterns.
Observe both with awareness and while the patient is distracted (to detect habitual patterns).
Observation and disrobing: observe skin and movement to an appropriate degree; if a client is unwilling to disrobe sufficiently, observation may be limited.
Functional movements: assess how impairments affect function; more meaningful to clients to convey progress than small ROM gains.
Reassessment role: functional movements help differentiate sources of symptoms and track changes over time.
Examples of functional tests by region:
Lower limb: squats, steps, hops, gait pattern.
Upper limb: overhead activities, grip strength.
Planning functional assessment: use subjective clues of what worsens or improves symptoms to guide tests; tailor tests to patient’s reported activities.
Approach to movement demonstrations: ask patient to perform a movement and describe sensations during the task; break movements into components if needed to identify the problematic segment.
Common scenarios: lawn bowls movement; chair transfer; variations in height/firmness of chairs.
Observation and functional assessments: key takeaways
Time management and clear purpose are essential; be systematic and efficient.
Introduction to physiological movements: active vs passive movements
Physiological movements occur along anatomical axes (e.g., flexion, abduction).
Active movements: performed by the patient using their own muscles; passive movements: therapist performs the movement for the patient.
Purpose of assessing active ROM: determine available movement for function and identify which structure (joint, muscle, or nerve) is involved; helps with planning and re-evaluation.
Purpose of assessing passive ROM: evaluate joint/soft tissue constraints when the patient is fully relaxed; muscle contraction should not contribute to pain in passive tests.
Key outcomes from ROM testing:
Range: how far the joint can move.
Quality: smoothness, rhythm, symmetry, and any deviations.
Symptom response: pain or other symptoms that arise during movement; important to record exact onset and progression.
End range testing and overpressure:
Active ROM should be tested from neutral position; give clear verbal cues and demonstrations.
If active ROM is pain-free and full, a gentle overpressure at the end of ROM (with patient relaxation) can be used to assess end feel and additional mobility.
If pain arises before end of ROM, avoid overpressure.
How to perform ROM assessments:
Start from anatomical neutral; instruct clearly (e.g., for shoulder flexion: "bring your arm up over your head and out in front of you").
Consider speed, repetition, and positioning; adjust as needed to reproduce symptoms in a controlled way.
Consider combined movements or positional holds to reproduce symptoms (e.g., flexion with horizontal flexion).
Use joint compression or distraction as needed to test hypotheses about joint involvement.
Active vs passive ROM interpretation:
If pain is reproduced in active ROM but not passive ROM, muscle or nerve involvement may be implicated.
If pain is reproduced in passive ROM, a non-contractile structure (joint, capsule, ligament) is likely involved.
End feel concepts
End feel: the qualitative sensation at the end of ROM as you approach end range.
Types of end feel:
Bony end feel: hard, abrupt stop (e.g., elbow extension with bone-on-bone contact).
Soft tissue end feel: soft, springy limit due to muscle or soft tissue compression.
Muscle (stretch) end feel: a stretch-limited, springy sensation due to tight muscle.
Observational cues: end feel helps infer what is limiting the movement; confirm with overpressure when appropriate and pain-free active ROM is achieved.
Practical tip: always consider what the end feel should feel like anatomically; if it doesn't, it may indicate abnormal pathology.
Accessory movements (joint play)
Definition: movements that are crucial for full physiological movements but cannot be voluntarily controlled (e.g., roll, slide, spin).
Role: accessory movements support physiological movements; if limited, they can restrict movement and cause pain.
Assessment: performed passively; rely on joint anatomy to guide expected movement and resistance.
Evaluation focus:
Direction and amount of glide or rotation relative to adjacent bone positions.
Symptom reproduction and alignment with subjective findings.
Movement diagrams: a visual map of the relationship between signs (sensations felt by the clinician) and symptoms (client-reported pain or paresthesias).
Movement diagrams: purpose and use
A diagram maps the relationship between signs (e.g., tissue resistance) and symptoms (e.g., pain) to visualize interaction between symptom onset and mechanical resistance.
Benefits:
Visualizes relationships between symptoms and movement.
Aids clinical reasoning and communication between clinicians.
Guides treatment planning and selection of grades of movement.
Typical elements:
Pain, tissue resistance, muscle spasm as the core signs; other symptoms (pins, needles, numbness) may be included.
P1, P2 for pain; R1, R2 for resistance:
= onset or increase in pain to manual pressure
= maximum pain tolerable (stop) (often represented as tenten in scale)
= onset or increase to tissue resistance to manual pressure
= maximum resistance, end of available glide
End feel characteristics and their relation to symptoms.
How to interpret movement diagrams:
Use them to track stiffness over time (day-to-day or week-to-week) and to communicate findings to colleagues.
They help determine whether the movement should be targeted with a particular grade of mobilization.
Application scope:
Particularly useful in mechanical, non-inflammatory presentations; less informative for pure inflammatory conditions.
Practical implications and ethical considerations
Always prioritize patient safety: avoid provoking symptoms beyond what is tolerable, especially early in care.
Build trust through clear communication, respect, and shared decision making.
Use standardized formats (e.g., ISBAR) to ensure clear handover and reduce risk of miscommunication.
Recognize the limits of observation; ensure privacy and comfort during disrobing for assessment.
Maintain patient-centered focus: explain findings, discuss implications, and involve the client in decision making.
Summary of key concepts and terms
Transactional model of communication: relationship building + ongoing message exchange to achieve shared understanding.
Mutual understanding: foundation for therapeutic relationship and PCC.
IsBAR: Identify, Situation, Background, Assessment, Recommendation – a standardized handover format.
P1/P2 and R1/R2: markers for pain onset and resistance during palpation/pressure; used in movement diagrams.
End feel: qualitative end-range sensation that indicates why movement stops (bony, soft tissue, muscle).
Movement diagrams: visual tool linking signs to symptoms for assessment and planning.
Real-world relevance
Effective communication improves patient outcomes, adherence, and satisfaction; supports better clinical reasoning and safer care.
System-level benefits include reduced costs and improved inter-professional collaboration.
Next steps in learning
Master the Calgary Cambridge components and ISBAR for clinical encounters.
Practice identifying and documenting P1/P2 and R1/R2 during ROM and joint play assessments.
Develop skills in observation and functional testing with a focus on patient comfort, safety, and functional relevance.
Learn to construct and interpret movement diagrams for various MSK presentations.