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It takes two

The physio-patient relationship may be inherently physical, but don't forget verbal skills are at its core too. Catherine Blackledge uncovers the value of the art of communication

Ruth Parry spends hours analysing conversations: poring over the delicate dance of words, the nuances implied by tone, volume and rhythm, and the subtle exchange of head and body movements. With the help of a video camcorder and the research technique of conversation analysis, she is deciphering the complex and collaborative production that is commonly known as communication.

Dr Parry's specialty is the interplay between physiotherapist and patient. As she recognises, the intricacies of the lay person-practitioner dialogue are a rich and, for physiotherapy, relatively unmined information source.

Following precisely what happens when two people talk to each other during a treatment session offers vital clues as to why patients are involved or not in their care. And as involving patients in decision-making about their health and healthcare is high up on the government's NHS agenda, there is some urgency to finding out what is currently happening and why.

One focus of Dr Parry's work is the setting of goals and how to facilitate patient involvement in this. There is some evidence that rehabilitation effectiveness increases when patients are included in goal setting. Yet, research from Dr Parry in stroke rehabilitation, and elsewhere, reveals patients are not involved consistently or substantially in this process. The question is why?

The answer is complex. 'There are lots of reasons - practical reasons,' says Dr Parry, who works as a postdoctoral research fellow at the University of Nottingham. 'It takes a lot of time and effort explaining what we mean by goals and also eliciting a response from people who are often not familiar with physiotherapy; and incorporating this response into goals takes time and effort too.'

She feels goal-setting is a very complicated activity: 'It sounds simple when you write it down as a policy, but it's not that straightforward in reality? Communication-wise, it can be quite a sensitive and difficult area.

'My view is that patients and clinicians are very skilled in their communication. Thus, if therapists or patients are not doing something that increases patient participation, there are probably very good reasons why not.'

The etiquette of sharing control
Dr Parry's work recognises the social constraints on client participation in goal setting. One of these is the way that patients' physical incompetence is managed.

Research in physiotherapy and speech and language therapy indicates that through particular patterns of communication, therapists and patients protect one another and the therapeutic process as a whole from the problematic and threatening implications that may arise when areas of patients' physical or 'personal' incompetence become apparent.

These potential implications are that failures of achievement represent either a failure of patients' efforts in therapeutic activities, or they indicate a failure of cooperation with the therapist and therapy. Another possibility is that they represent a failure of the therapeutic process itself. Each of these is an emotionally challenging situation to face.

Setting goals can be a tricky area, as it entails acknowledging, 'exposing' and to some extent emphasising some area of physical incompetence. As Dr Parry notes of her profession: 'Something we don't appreciate is the very difficult job we do - telling patients what they've done wrong and helping them to do better. It's very easy to upset people and offend them.'

Other powerful social constraints operate. Studies confirm that patients can be reluctant to express their views for fear of disturbing the power balance in the practitioner-patient relationship. That is, they may withhold input because they feel it preserves the clinical relationship as one in which both parties treat the clinician as providing expert and authoritative treatment and care.

Sharing control of the decision making process can be just as difficult for physios as for patients. Angela Green is a research and development therapist at the Institute of Rehabilitation, Hull. She also cites cultural reasons as part of the reluctance to share control. 'We are as a profession very much driven along the medical model still? we do see ourselves as an authority and it can be quite difficult to hand control back to patients and feel we've done our job properly.'

Ms Green's research is also looking at the factors that influence the degree to which different physios involve their patients in their consultation. As she explains, her research is stimulated by the fact that 'there is a duty placed upon us by Department of Health policy, the CSP and the HPC [Health Professions Council] to be patient-centred and there's a lot of confusion about what that means? I'm trying to find out where physios are at present.'

Her results, although preliminary, are fascinating. Questionnaire responses from over 700 physios underline the importance that physiotherapists place on a patient-centred approach to care. However, the research indicates that one in five physiotherapists do not feel comfortable asking patients questions of a psychosocial nature, such as 'So how does that make you feel?'

Perhaps more surprising, her study shows 20 per cent of physios do not believe they should be interested in what treatment the patient wants. 'This may indicate that, as a profession, we are not all suitably prepared to embrace the concept of offering patients choice,' Ms Green comments.

Watching the physios
Video footage of physios and patients forms a key part of her investigations. For Ms Green this involves showing physios with different levels of experience videoed vignettes of therapeutic practice. The aim of the study is to determine whether physios are able to recognise good practice in patient involvement.

Her initial results reveal that some newly qualified physios, perhaps understandably, are not as good at recognising good practice. However, she has identified another group, who also have recognition problems, despite having more experience. Explaining why this might be, Ms Green says: 'Perhaps therapists start to develop more habitual practice? they start to move away from recognising the patient as an individual and move towards more routine care.'

Both Angela Green and Ruth Parry believe there is a need and an opportunity for physiotherapists to have more training around communication skills. Dr Parry is in the initial stages of developing a communication training programme for junior physios. She says: 'On a broad level, in terms of physiotherapy, I'm not sure there is always an emphasis on communication. Certainly, traditionally, physiotherapy has overlooked this area and research priority-wise it would be helpful to increase this.'

She adds: An awful lot of therapists are very good at what they do, they're fantastic communicators. The difficult thing at the moment is how to identify what that is: it can seem almost magical. But these are skills that we can teach and learn.'

In terms of involving patients more in decisions about their healthcare, Ms Green comments: 'There is a role here for therapists to have more training. It's not what you do, but how you do it. Patients may be offered choice, but if it's not supported, patients can feel they're carrying the full burden of the choice. That can be anxiety-
provoking.' However, as she notes, ensuring patients don't feel they are burdened by choice 'is a skill that needs to be developed and supported'.

For both physios, the communication between physio and patient has a unique beauty and value. 'Hopefully the profession will reflect on the importance of communication. It's as important as the interventions we offer,' says Ms Green.

The last word, though, should go to Dr Parry; in recognition of the hours she's spent analysing what physios say to patients and vice versa. When asked what has surprised her about her work, she answers: 'How quick-witted therapists and patients are. It's fascinating how beautifully-skilled we are in communicating with each other.'

Further info:

Parry RH [2004]. 'Communication during goal-setting in physiotherapy treatment sessions', Clinical Rehabilitation, 18, No. 9, 668-682.
Parry RH [2004]. 'The interactional management of patients' physical incompetence: a conversation analytic study of physiotherapy interactions', Sociology of Health & Illness, 26, No. 7, 976-1007.

Potter M, Gordon S and Hamer P [2003}. 'The physiotherapy experience in private practice: the patients' perspective',
Australian Journal of Physiotherapy, 49,

For further person-centred care studies see the Health in partnership website


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