Essay: PCC in physiotherapy

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 programmes was shown to be to 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 look 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 critical appraisal of 2 papers completed via the CASP system (CASP, 2018; CASP 2018). The first a qualitative study by Cooper, Smith and Hancock, 2008, the second a randomized control trial (RCT) by Lonsdale et al., 2017.
Figure 1. The stages of the Gibbs reflective model (Gibbs,1988)
Description
The LE I will be reflecting occurred during a lecture titled ‘Communication processes in healthcare’ on the 8th October 2018. The lecture aimed to introduce and discuss the importance of communication while identifying how it can link into a patient 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 around the components of skilled communication. This generated a key thought ‘How much does skilled communication really affect a patient and does it affect a patient 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 patient who experienced poor communication from the physician. With healthcare adherence defined by the World Health Organisation as,
‘the extent to which a person’s behaviour… 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 in order to deliver effective patient-centred care (PCC) (Potter, Gordon and Hamer, 2003), (Östlund, Elisabet Cedersund, 2001). In turn, PCC built on solid communication pathways has been shown to be important in improving PA to medical treatment (Harmon, Lefante and Krousel-Wood, 2006). With communication a recognised 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 of their own behaviour)
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 a desired behaviour 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, leading to poorer motivation and therefore lower long-term adherence to treatment (Haskard Zolnierek and DiMatteo, 2009).
Feelings
Prior to 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 providing PCC while on placement or future work.
During the lecture, I found it intriguing to relate the content to my previous interaction with clients as a personal trainer. I released 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 personal 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 recognise my initial judgement 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.
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 patients’ needs from a biopsychosocial perspective
Overall, I recognise this LE will continue to develop as I move through my physiotherapy career, I will see many examples of effective and non-effective communication strategies employed by clinical educators and other physiotherapists. I will try to continue to reflect-in-action around these experiences and build my own communication strategies. Furthermore, for me to develop from a novice to 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 around 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 deliverer PCC. Having a basic understanding of these strategies has increased my confidence to communicate 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 has been shown to be fundamental in patients completing their rehabilitation (Pizzari et al., 2002), highlighting how PCC and communication may be key to PA to 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 on a PA to treatment and ultimately their recovery. My own 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 communication skills training in line with the self-determination theory effects PA in physiotherapy?
Cooper, Smith and Hancock (2008), conducted a qualitative in a physiotherapy setting, with the aim of defining what patient centeredness was from patient’s perceptive while suffering chronic lower back pain (CLBP). Twenty-five patients who had not received physiotherapy treatment in the previous 6 months for CLBP but has all suffered from CLBP in this time were interviewed in a semi-structured format. The study identified 6 patient-reported dimensions of patient-centeredness shown in figure 2.
Figure 2. 6 patient-reported dimensions of patience- centeredness from (Cooper, Smith and Hancock 2008)
Effective communication was identified as the common theme in all dimensions. With the authors suggesting improved communication skills alone could facilitate greater PCC in physiotherapy for those suffering from CLBP.
Interestingly, over half of three- quarters of participants were female (n=20). A generalisation, 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 around 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 as bias possibly skewing patients answers to subsequent questions. Also, due to the relatively small sample size and specific client group, the generalisation of the results to the real world may be questioned.
Despite the limitations, the study used appropriate data collection/analysis methods, recruitment strategies and had a clear objective 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 own future practice, it appears clear enhancing my communication skills will influence my ability to provide PCC to this client group.