The third generic professional capability needed by an expert rehabilitation professional is the ability to establish, and to maintain over time, good communication with a patient, with their family, and with the other individuals and teams involved with them. This capability is obviously needed by all healthcare professionals. It is, however both more important and often more difficult in rehabilitation practice. The importance arises from the central feature of rehabilitation, the need to involve and engage the patient and others actively in the process. The difficulty arises from the high frequency of barriers to good communication, often associated with whatever condition a patient has. For some patients, indeed, it is their communication difficulty that requires most input from the rehabilitation service. A MindMap summarising this capability is available here. The capability must be seen in the context of the other six generic capabilities (here) and the seven specific rehabilitation capabilities (here).
Social interaction depends on communication. All social animals communicate to an extent; alarm calls, sounds proclaiming territory belongs to someone, calls for a mate are all used to communicate. Humans communicate all the time, not just by talking, but through a huge variety of means – what they wear, how they move, facial expressions, newspapers they read – almost all behaviours communicate something, in addition to achieving a more explicit goal.
This extended nature of communication must be kept in mind when considering this capability, which is formally expressed as “The expert rehabilitation professional is able to establish and maintain effective communication with all patients, and their families, and with all other people, teams, and organisations involved with the patient’s rehabilitation.” It involves more than talking and listening, it involves more than writing and reading, it is referring to all aspects of communication.
For example, being empathetic, showing empathy, is an important part of rehabilitation. (here) It is not sufficient simply to talk using empathetic phrases. The person must also appear empathetic in their manner, and they need to do so consistently and not only when directly discussing the situation with the patient.
Naturally all healthcare professionals need good communication skills, as indeed all people do. However people working within rehabilitation need above average skills for various reasons, to be discussed next.
The key attitudes that a rehabilitation professional needs to be effective in this capability are:
- awareness of the importance of all non-verbal, non-linguistic aspects of communication
- active listening to and evaluation of all communication from the other person;
- flexibility, adapting communication to the situation;
- always checking assumptions, both their own and those of others;
- always confirming understanding, both their own and that of others.
Many patients involved in rehabilitation will be experiencing stress, not necessarily severe but sufficient to affect their function. The stress may arise from a very large number of causes. Sudden-onset disability is threatening, and initially at least has an uncertain prognosis. Disability usually disrupts previous goals and plans, and is often associated with reduced employment and reduced income. Poverty, disadvantage in society, stigmatisation, and discrimination are common experiences for many disabled people. These all reduce their flexibility and resilience in communication.
Many, probably most patients who have a disorder of the central nervous system have impaired cognitive function: poor memory, reduced concentration, slowness in processing information, less ability to pick up more subtle nuances in behaviours and speech, less able to interpret facial expressions etc. These will additionally reduce communicative functioning.
Mood disturbance – often an aspect of or arising from stress, but unrelated in many patients – also affects communication. Anxiety and depression are associated with reduced cognitive skills, albeit not secondary to cerebral damage. They also affect communication through altering behaviour, and interest in social interaction.
Communication arises from the whole body, not just speech. Thus, any disturbance in motor function can reduce communication by the patient. This is not simply from neurological disorders. An absent arm reduces the ability to gesture; facial burns and scars reduce facial expression etc.
Alteration in speech is an obvious cause of communication difficulty. This extends beyond the mechanical aspects, which are often a major problem in themselves, We all judge people on how their speech sounds, usually unfavourably, and rehabilitation professionals need to guard against this normal human phenomenon.
Loss of language is another, obvious cause, and it includes not only an inability to appreciate the symbolic significance of words, but may also extend to a broader inability to appreciate the symbolic significance of some gestures, symbols, and behaviours.
Last, there are many conditions which affect communication indirectly, but very importantly. Disordered thought processes, including but not restricted to psychosis and delusions; irritability, aggression, fear and other disorders lead to reduced communication; and disinhibition and similar neurological losses can impair communication.
The rehabilitation professional needs to be able to:
- recognise and diagnose the underlying cause(s) for any communication difficulties, usually quite quickly and without expert help;
- alter their communicative approach to increase
- the ability of the patient to understand and act on their communication
- their own ability to understand what the patient is trying to communicate
Others – non-professional
The rehabilitation professional will need to communicate with family members and friends. I will not discuss communicating with other people who may be involved, such as work colleagues.
The first influence to mention, again, is stress. Both in the acute phase, as a result of a sudden change and the associated uncertainty, and in the later phases, because of the stress of providing long-term care and support, families can be quite stressed. This will affect their ability to take on new information. They may also have strong expectations, that will influence their ability and readiness to take on some ideas.
Some families are themselves dysfunctional, with poor relationship between different groups and/or with the patient and these factors may make it more difficult for a healthcare professional to communicate.
Third, family members themselves may have an condition affecting their communication.
Others – professionals
The third group that the rehabilitation professional will be communicating with is other professionals – in the home team, in other rehabilitation teams, in healthcare, and further afield in other organisations and services. A different set of factors need to be considered.
First, professionals from outside the ‘home team’ may have a very different understanding of rehabilitation (even if working in healthcare), may use different jargon and not know rehabilitation jargon, may know nothing about the condition, and may have a different culture or ethos in relation to patient care. The rehabilitation professional needs to explore the assumptions made by and the expectations of other professionals, and to adapt their communication to the audience.
Second, and conversely, the other profession may use jargon, and may make assumptions about the patient or about the rehabilitation professional. Consequently the rehabilitation professional will need to check what is being said, and be prepared to ask for clarification. Further, they need to make explicit all the assumptions that they have, so that the other professional can adapt what they say.
The behaviours required in this capability all relate to:
- maximising the information gleaned from others, while ensuring that it is as close to their intended meaning as possible, and to
- maximising the information given out, while ensuring that it is received accurately.
At the same time, they also relate to the use of all methods needed to improve communication, including (for example) non-verbal cues, altering the physical environment, and providing an emotional atmosphere appropriate to the situation.
These behaviours can be learned. It is interesting that, for example, training in general practice and in psychiatry both involve formal training in and feedback on communication. I am not aware of video-recorded interviews being used to train rehabilitation professionals in communicating better, despite the importance of communication.
Some indicative behaviours expected of an expert rehabilitation professional with this capability are:
- active listening and adapting their communication style to the patient and family, so as to be clear and effective in their own communication;
- communicating effectively with all professional colleagues, across all teams and organisations involved. This includes regular checking of mutual understanding and mutual assumptions;
- identifying any barriers to communication, such as impaired hearing, cognition. or speech, and then adapting communication to overcome the barrier as much as possible;
- using, as needed, non-verbal, technologically-assisted and other adaptive techniques to improve communication;
- sharing decision-making with a patient (and family if wanted), prioritising their wishes and respecting their values;
- maintaining communication with a patient and family in the face of challenging behaviours;
- sharing information, appropriately to the need and circumstances, with all parties involved;
- always checking formally that communication has been understood by others, and that communication received has been understood correctly.
Knowledge and skills
There is much that the professional should, and often will know to optimise communication. It is primarily knowing about people and how to build a good relationship with them. For example, it is useful to write in the notes at least one hobby or area of interest the patient has so that, when seem two months later, the professional can ask about or make a comment on the topic. This immediately makes the patient feel known, and that the professional listened to them. Good politicians do this naturally.
The practical knowledge needed primarily relates to the diagnosis of and adaptation to impairments that may impede communication. The expert rehabilitation professional knows:
- the many different impairments than can influence a patient’s ability to communicate, and how to diagnose them;
- means available to optimise communication with patients with various speech, language, cognitive, and sensory impairment
- methods to manage challenging behaviours in order to maintain communication safely;
- how to communicate complex or specialist information without using jargon;
- the principles of shared decision-making and how to facilitate patient (and family) engagement;
- what equipment and/or other contextual changes may facilitate impaired communication.
Many of the skills will already be know to the professional, but it is important both to improve the skill as far as possible, and to use it whenever it is needed. Some people are taught or have acquired the skills, but seen to forget to use them.
The major skills needed are that the expert rehabilitation professional will be able to:
- recognise and diagnose most common impairment limiting communication with a patient
- use straightforward, common technological aids to communication;
- establish a good inter-personal relationship with a patient and to maintain it over time;
- explain, successfully, complex and specialist information to patients, families and other professionals;
- ask someone to explain or clarify their communication without causing embarrassment or distress;
- manage challenging behaviours sufficiently to maintain open communication over time
This page has described rehabilitation generic capability 3, which is being able to establish and maintain good communication with patients, families and professionals, and organisations, especially in the face of obstacles. It has emphasised the considerable range of problems that may impede good communication, and the very broad range of knowledge and skill needed, a range of knowledge and skills that no single professional will have acquired as part of specific professional training; psychologists are the profession that will have covered most areas. It is surprising, given the importance of communication in rehabilitation and given the many different problems that can arise, that specific training in communication is not given.