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doi: 10.2522/ptj.
Originally published online April 3, 2007
PHYS THER. 2007; 87:586-594.
Lisa Roberts and Sally J Bucksey
Practice?
Communicating With Patients: What Happens in
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Communicating With Patients:
What Happens in Practice?
Lisa Roberts, Sally J Bucksey
Background and Purpose Communication is the most important aspect of practice that health care profession- als have to master. The purpose of this study was to measure the content and prevalence of verbal and nonverbal communications between physical therapists and patients with back pain.
Subjects Seven physical therapists and 21 patients with back pain participated in this study.
Methods The first interaction following the initial assessment was recorded with a video camera. The outcome measures were the Medical Communications Behavior System (verbal communication) and frequencies of nonverbal behaviors (affirmative head nodding, smiling, eye gaze, forward leaning, and touch). Semistructured interviews were undertaken with the physical therapists to determine the perceived influence of the video camera.
Results A total of 2,055 verbal statements were made. Physical therapists spent approxi- mately twice as much time talking as patients, with content behaviors (such as taking history and giving advice) comprising 52% of verbal communications. The most prevalent nonverbal behaviors were touch by physical therapists (54%) and eye gaze by patients (84%).
Discussion and Conclusion The prevalence and content of communication can be measured with video analysis and validated tools. Communication is an extremely important but underexplored dimension of the patient-therapist relationship, and the methods described here could provide a useful model for further research and reflective practice.
L Roberts, PhD, MCSP, is Superin- tendent Physiotherapist, Physio- therapy Department, Southampton University Hospitals NHS Trust, Southampton, Hampshire, United Kingdom, and Senior Lecturer, School of Health Professions and Rehabilitation Sciences, Southamp- ton University, Southampton, Hamp- shire, United Kingdom.
SJ Bucksey, MSc, MCSP, is Physio- therapy Manager, West Dorset Hospitals NHS Trust, Dorchester, Dorset, United Kingdom. She was a student in the School of Health Professions and Rehabilitation Sci- ences, Southampton University, when this work was completed. Address all correspondence to Mrs Bucksey at: sally.bucksey@wdgh. nhs.uk.
[Roberts L, Bucksey SJ. Communi- cating with patients: what hap- pens in practice? Phys Ther. 2007; 87:586 –594.]
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586 f Physical Therapy Volume 87 Number 5 May 2007
the setting of physical therapy be- cause of insensitivity within the cod- ing categories.
Therefore, the search continues for an appropriate, validated tool for measuring the communication that takes place during clinical encoun- ters. Only when the content of this communication is known can clini- cians establish ways to optimize the relationship, maximize the non- specific treatment effects (eg, the patient who experiences less pain during a consultation with a warm, empathetic health care profession- al), and enhance the patient’s expe- rience. Given this context, the pur- pose of this study was to measure the content and prevalence of the verbal and nonverbal communica- tions that occur between physical therapists and patients with low back pain in an outpatient setting.
Method Study Design A pragmatic, prospective, observa- tional study was undertaken in an acute care hospital and in a Primary Care Trust in southern England to identify the verbal and nonverbal communications that occur between physical therapists and patients with low back pain during treatment ses- sions. The study design included mixed methods (quantitative and qualitative), as outlined in the Figure.
Participants All physical therapists (n16) work- ing in the participating departments were given an information sheet out- lining the study. Clinicians whose caseload did not include patients with low back pain were excluded (n2), ensuring that all participating therapists were currently treating pa- tients with low back pain. In addi-
tion, any clinicians who had specific knowledge of the outcome measures to be used were excluded (n1) to minimize bias attributable to prior knowledge of the communication categories.
In an outpatient setting, people with low back pain are among the most prevalent consumers of physical therapy. Although it is essential to build rapport and develop a strong patient-therapist relationship, there are additional physical barriers that can present a challenge in this pop- ulation. First, patients frequently ex- perience discomfort when sitting (eg, to give a history), and the ther- apist must remain sensitive to this situation. Second, some components of the initial assessment and subse- quent treatment may involve palpat- ing the spine (which usually occurs with the patient lying prone). This scenario potentially limits the oppor- tunities for demonstrating nonverbal behaviors, such as eye gaze, thereby increasing the need for skillful verbal communication.
Therefore, we decided to limit the patient population to any adult pa- tients referred to the physical ther- apy departments with a diagnosis of low back pain. The duration of back pain was not specified in the inclu- sion criteria, and patients were eligi- ble to participate whether or not their symptoms were referred into the lower limb, as these factors were assumed not to influence the com- munication occurring during the in- teraction. Patients with signs and symptoms suggesting possible seri- ous spinal pathology were excluded, as were people whose first language was not English, because of the ex- ploratory nature of the study.
Of the 13 physical therapists (4 men and 9 women) who agreed to take part in the study, 7 female clinicians (2 employed by an acute care hospi- tal and 5 employed by the Primary
Figure. Summary of study design. GPgeneral practitioner.
588 f Physical Therapy Volume 87 Number 5 May 2007
Care Trust) successfully recruited patients. Their mean number of years of qualification was 9 (range 0.5–33 years), with 3 clinicians (43%) at the more experienced (se- nior I) grade, 3 (43%) at the senior II grade, and 1 (14%) at the least expe- rienced (staff) grade. Twenty-one pa- tients reporting low back pain were recruited for the study (12 men [57%] and 9 women [43%]). The mean age of the patients was 48 years (range21–76 years).
Data Collection To measure communication, it is necessary to directly observe the interaction taking place between the physical therapist and the patient.^26 This interaction can be recorded with either videotapes or audio- tapes, although videotape recording has the advantage of being able to record nonverbal communication in addition to verbal utterances. Con- versely, recording patients in a state of undress may deter potential par- ticipants and could raise ethical is- sues. For the purposes of this study, recording nonverbal communication was a priority; therefore, with ex- press (written) consent from both parties, the interaction between the physical therapist and the patient was recorded with videotape dur- ing the first treatment session follow- ing the initial assessment. This ses- sion was chosen because it was a less structured encounter than the initial assessment but was still early enough in the patient’s treatment to capture the developing therapeutic relationship.
A tripod-mounted Sony camera (model CCD-FX200E/FX270E)* was placed centrally along the side par- tition of the treatment cubicle to maximize the view of both the pa- tient and the clinician as discreetly as possible. Because of ethical con-
straints, the camera was manually operated by the researcher, who was present in the treatment cubicle (and confined the videotape record- ing to the head and neck of partici- pants throughout the data collection process).
Following the treatment session, a brief, semistructured interview was undertaken with the physical thera- pist to determine the perceived in- fluence of the presence of the man- ually operated video camera, in comparison with the therapist’s usual practice.
Outcome Measures Verbal communication. In order to explore the interaction between the physical therapist and the pa- tient, a validated outcome measure of verbal communication, the Medi- cal Communications Behavior Sys- tem (MCBS), was used.^27 The MCBS was developed to measure the com- munication occurring in situations involving multiple health care pro- viders^27 and has categories for infor- mational (content), relational (affec- tive), and negative behaviors for both clinicians and patients. These categories were subdivided further into 13 clinician behaviors, 7 patient behaviors, and 3 miscellaneous cate- gories (Tab. 1). In order to maintain the use of the measure in its original form, the term “behavior” was adopted throughout instead of the term “communication.”
Psychometrically, the interrater reli- ability of the MCBS, assessed with the Pearson correlation coefficient, was greater than .70 for all behaviors occurring more frequently than 2% of the time during an observational study of 101 genetic counseling ses- sions.^27 Factor analysis was done and was found to provide some construct validity, supporting the a priori organization of the behaviors into informational, relational, and negative behaviors (but with further
subdivisions for informational behav- iors).^27 In addition, criterion validity has been determined with the Roter Interaction Analysis System.^27
Trends in nonverbal communica- tion. The frequencies of the 5 non- verbal behaviors—affirmative head nodding, smiling, eye gaze, forward leaning, and touch— described by Heintzman et al^28 were recorded at 40-second intervals for both the physical therapist and the patient. This outcome measure was devel- oped in the field of business and was subsequently used by Caris- Verhallen et al^6 in the settings of home nursing and care of older peo- ple; the interrater reliability of the nonverbal behaviors was calculated, using the Pearson correlation coeffi- cient, to be between .70 and .98.
Data Analysis To determine the content and prev- alence of the verbal and nonverbal communications that occurred be- tween the physical therapists and the patients, the primary analysis in- volved classifying the verbal commu- nication by use of the MCBS and measuring the frequencies of non- verbal behaviors at 40-second inter- vals. The videotapes were analyzed by a trained, independent assistant, who classified the verbal utterances into the categories shown in Table 1. An interrater reliability exercise for coding these categories was done by the researcher and the indepen- dent assistant using the Pearson correlation coefficient with 3 pilot therapist-patient dyads.
In addition to recording the frequen- cies of the MCBS categories, we re- corded the durations of the treat- ment sessions in minutes and seconds. Because of variations in the length of the treatment sessions, the propor- tion of time that the physical thera- pist and the patient spent talking was determined as a percentage for each category.
- Sony Corp, Pipers Way, Thatcham, Berk- shire, United Kingdom RG19 4LZ.
May 2007 Volume 87 Number 5 Physical Therapy f 589
Perceived Influence of the Camera on Communication Although the physical therapists re- ported that the more times they were videotaped, the easier they found it to relax, the majority con- sidered that they had decreased the amount of “non–physical therapy chat” that occurred, in comparison with their usual practice; this finding resulted in an underrepresentation of this aspect of communication dur- ing this study.
Perceived Influence of the Camera on Behavior As determined by the thematic anal- ysis, 5 of the 7 physical therapists considered that the presence of the manually operated video camera in- fluenced their behavior. They identi- fied 3 areas of perceived changes in their behavior: the extent of treat- ment planning beforehand, the se- lection of treatment techniques, and a reduction in the amount of time during which the patient was in a state of undress. With regard to treat- ment planning, one clinician re- marked: “I think that the thought of the video camera makes you think what you are going to include in the treatment so that you are absolutely clear about what you are going to do in the treatment session before you go in.”
Discussion This exploratory study was designed to measure the content and preva- lence of the verbal and nonverbal communications that occur between physical therapists and patients with low back pain in an outpatient set- ting. For the 2,055 verbal statements recorded, the ratio was 2:1 in favor of the physical therapists. This ratio differs from that found in previous research by Ong et al,^29 who re- ported that, in a doctor-patient on- cology setting, patients and doctors communicated relatively equally dur- ing their consultation. The higher percentage of physical therapist con-
tent communication in the present study may have been attributable to the fact that, after the initial assess- ment, the first treatment session usually involved giving advice and information (eg, about posture, ergo- nomic and lifestyle factors, and other forms of self-management); discuss- ing psychosocial factors; explaining the risks, benefits, and alternatives of any treatments offered; gaining consent for any techniques per- formed; and evaluating their out- comes. Physical therapists are likely to have longer appointment times than doctors, make fewer referrals to other health care professionals, and spend more time applying treat- ments; these factors may account for the differences between the studies.
Previous research showed that con- siderable affective behaviors are re- quired for an effective interaction be- tween a physical therapist and a patient.^30 In the present study, these behaviors were shown to be less common than content behaviors; a possible explanation is that a consid- erable amount of advice still was be- ing imparted to the patients during the early sessions. It is possible that affective behaviors become more
prevalent in subsequent sessions, when the therapeutic relationship is more established; this issue is wor- thy of further research. A more likely reason for the underrepresentation of empathic behaviors in the present study, however, was the presence of the video camera, as the therapists reported that this decreased the amount of nonclinical communica- tion that occurred. This potential limitation also was identified in pre- vious studies.31,32^ It is not known from the present study what influ- ence the camera was perceived to have on the patients’ communica- tion, as this factor was not measured; this issue is worthy of further research.
Further analysis of the data showed that sex (of the patient) made little difference in the categories of verbal communication recorded in the present study. From the pool of 4 male and 9 female physical thera- pists, only 7 female clinicians suc- cessfully recruited patients into the study. Therefore, it was not pos- sible in the present study to explore the content and prevalence of inter- actions involving male clinicians and to compare them with those in-
Table 2. Medical Communications Behavior System Categories as Percentages of Total Communication a Category Frequency (%) Physical therapist Content behaviors 1,065 (51.8) Affective behaviors 272 (13.2) Negative behaviors 0 (0.0) Patient Content behaviors 541 (26.3) Affective behaviors 43 (2.1) Negative behaviors 13 (0.6) Miscellaneous 121 (5.9) Total statements 2, a (^) Frequency of each verbal behavior that occurred during the 21 interactions as a percentage of the total communication. Miscellaneous behaviors included social salutations and nonclassifiable utterances (eg, “ouch”).
May 2007 Volume 87 Number 5 Physical Therapy f 591
volving female clinicians. This is a topic for further research, as other studies showed that, in general, women (both patients and health care professionals) spoke more dur- ing a medical interaction than men^33 and that female-female interactions were likely to result in greater frequen- cies of affective communications.^34 The present study also showed that experienced physical therapists dem- onstrated affective behaviors more readily than their junior colleagues. A possible explanation is that therapists with less experience often lack confi- dence in their clinical abilities and so tend to focus on treatment techniques rather than on more affective compo- nents, such as patients’ feelings. This notion is supported by the qualitative work carried out by Jensen et al,^35 and such sentiments are likely to be com-
pounded by the presence of the video camera.
During the 21 treatment sessions observed, the numbers of nonverbal behaviors recorded at 40-second in- tervals for patients and physical therapists were 40 and 652, re- spectively (a ratio of 1:16). Caris- Verhallen et al^6 and Ambady et al^26 considered that viewing sections of an interaction is an adequate indica- tion of the interaction as a whole, and in the present study, 468 time points were sampled. The results showed that the physical therapists demonstrated nonverbal behaviors that facilitated rapport building, such as eye contact and head nod- ding. This finding is in accordance with the findings of previous re- search carried out in the health care
field,^6 which suggested that nurses use mainly eye gaze, head nodding, and smiling to establish a good rela- tionship with their patients.
With regard to touch, Gyllensten et al^36 suggested that physical thera- pists use touch to positively influ- ence their relationship with pa- tients. Perhaps not surprisingly, the highest proportion of nonverbal be- havior recorded for clinicians in the present study was represented by touch, a result that may have been expected as a consequence of the hands-on contact that occurred during physical therapy treatment sessions. Unfortunately, it was not possible to determine whether ther- apists used affective, rather than therapeutic, touch to facilitate rela- tionships with their patients be- cause of the lack of sensitivity in the single category “touch” in the out- come measure chosen. Within the nursing literature, the category “touch” has been subdivided into 2 catego- ries: instrumental touch, which is de- fined as deliberate physical contact necessary to perform a task, and af- fective or expressive touch, which is relatively spontaneous and not nec- essary for the completion of a task.^6
In future research measuring interac- tions within the setting of physical therapy, we recommend that touch be subdivided into instrumental touch (eg, executing a manual ther- apy technique), demonstration (eg, when therapists demonstrate on themselves how to modify an activity or perform an exercise), and affec- tive touch (eg, making tactile con- tact with a patient to offer reassur- ance). Any changes in the outcome measure would require revalidation prior to use.
The results also indicated that the physical therapists and the patients demonstrated high proportions of eye contact (156 and 36 times, re- spectively). Therapists learn at an un-
Table 3. Nonverbal Behaviors28, a
Behavior Description Eye gaze Either the patient or the physical therapist gazes directly at the face of the other party. Affirmative head nodding Head nods are defined as nodding one or more times as a sign of attentiveness in conversation or as reinforcing what has been spoken. Smiling Smiling in this context is an expression of friendliness. Laughing aloud, in response to a joke, is not considered a nonverbal communication and is coded in the verbal part of the observation scheme. Forward leaning Forward leaning is defined as posture that involves bending forward or sitting closer to the patient when it is not necessary to carry out a physical therapy task. This position conveys involvement and a concentrated focus on the interaction partner. Touch Either the physical therapist or the patient has physical contact with the other party. a (^) Types of nonverbal behaviors recorded at 40-second intervals.
592 f Physical Therapy Volume 87 Number 5 May 2007
Ethical approval for this study was granted by the Southampton and South West Local Research Ethics Committee.
This article was received March 9, 2006, and was accepted January 8, 2007.
DOI: 10.2522/ptj.
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594 f Physical Therapy Volume 87 Number 5 May 2007
doi: 10.2522/ptj.
Originally published online April 3, 2007
PHYS THER. 2007; 87:586-594.
Lisa Roberts and Sally J Bucksey
Practice?
Communicating With Patients: What Happens in
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