Generic capability 3
The third generic professional capability needed by an expert rehabilitation professional is the ability to establish and maintain, over time, good communication with a patient, their family, and the other individuals and teams involved with them. All healthcare professionals need this capability. It is, however, both more important and often more complex 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 a patient’s condition. For some patients, indeed, it is their communication difficulty that requires the most input from the rehabilitation service. A MindMap summarising this capability is shown below and available for download here. The capability must be seen in the context of the other six generic capabilities (here) and the seven specific rehabilitation capabilities (here).
Table of Contents
Generic capability three - comunication
Social interaction depends on communication. All social animals communicate to an extent; alarm calls, sounds proclaiming territory belongs to someone, and calls for a mate are all used to communicate. Humans communicate all the time, not just by talking, but through a vast 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 refers to all aspects of communication.
For example, being empathetic and showing empathy, is an integral part of rehabilitation. (here) It is not sufficient to talk using empathetic phrases. The person must also appear compassionate and do so consistently and not only when directly discussing the situation with the patient.
All healthcare professionals naturally need good communication skills. The benefits of good communication in healthcare are recognised, and NHS England’s recent publication, Improving communication between health care professionals and patients in the NHS in England Findings of a systematic evidence review and recommendations for an action plan, gives evidence derived from a systematic review. The GMC document, Generic professional capabilities framework, also emphasises the essential need for “communication and interpersonal skills” as a part of every professional’s training.
Academic studies also emphasise that healthcare professionals must make good relationships with their patients and that this depends on interpersonal communication. Furthermore, good communication between healthcare professionals is crucial for effective teamwork.
Three communication partners
A rehabilitation professional must communicate effectively with at least three classes of people.
The first and most apparent is the patient, who has a disability or other problem being addressed by the rehabilitation team.
The second and equally important group are family members, friends and other people directly or indirectly involved with the patient and their rehabilitation. These people are not healthcare professionals.
The other professionals involved in the patient’s rehabilitation are the last group, easily overlooked when considering communication about a patient. Although I classify them as healthcare professionals because their involvement is professional, many will not be working in the healthcare system, and the professionals may be unusual in healthcare. For example, social workers are now rarely an integral part of any healthcare team in the UK.
Many patients involved in rehabilitation will be experiencing stress, not necessarily severe but sufficient to affect their function. Stress may arise from a vast 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 income. Poverty, societal disadvantage, stigmatisation, and discrimination are everyday experiences for many disabled people. These all reduce their flexibility and resilience in communication.
Most patients with 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 ability 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 by 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 minimises the ability to gesture; facial burns and scars reduce facial expression etc.
Alteration in speech is a prominent cause of communication difficulty. This extends beyond the mechanical aspects, which are often a significant problem in themselves; we all judge people on how their speech sounds, usually unfavourably, and rehabilitation professionals must guard against this normal human phenomenon.
Loss of language is another apparent cause. It includes not only an inability to appreciate the symbolic significance of words. Still, it may also extend to a broader failure to appreciate the symbolic meaning of some gestures, symbols, and behaviours.
Last, many conditions affect communication indirectly but significantly. 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 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 refrain from discussing communication 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 stages, families can be pretty stressed because of the stress of providing long-term care and support. 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 dysfunctional, with poor relationships between different groups and with the patient, which may make it more difficult for a healthcare professional to communicate.
Third, family members themselves may have a condition affecting their communication.
Others - professionals
The third group that the rehabilitation professional will be communicating with is other professionals – in the home team, rehabilitation teams, healthcare, and 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 other jargon and not know rehabilitation jargon, may not know anything about the condition and may have a different culture or ethos concerning patient care. The rehabilitation professional needs to explore the assumptions and expectations of other professionals and adapt their communication to the audience.
Second, and conversely, the other profession may use jargon and make assumptions about the patient or 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 their assumptions so that the other professional can adapt what they say.
The critical 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;
- continuously checking assumptions, both their own and those of others;
- always confirming understanding, both their own and that of others.
The behaviours required in this capability all relate to the following:
- 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 psychiatry involves formal training and feedback on communication. I am unaware of video-recorded interviews being used to train rehabilitation professionals to communicate 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 to be clear and effective in their 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 and cognition. or speech, and then adapting communication to overcome the obstacle 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 contact with a patient and family in the face of challenging behaviours;
- sharing information, appropriately to the need and circumstances, with all parties involved;
- constantly checking that others have understood communication 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 primarily involves knowing about people and building a good relationship with them. For example, it is helpful to write in the notes at least one hobby or area of interest the patient has so that, when seen two months later, the professional can ask about or 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 diagnosing and adapting to impairments that may impede communication. The expert rehabilitation professional knows:
- the many different impairments that 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 to maintain contact 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 other contextual changes may facilitate impaired communication.
Many of the skills will already be known to the professional, but it is essential to improve the craft as much as possible and use it whenever needed. Some people are taught or have acquired the skills but need to remember to use them.
The critical skills needed are that the expert rehabilitation professional will be able to:
- recognise and diagnose the most common impairments limiting communication with a patient
- use straightforward, common technological aids for communication;
- establish a good inter-personal relationship with a patient and 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 establishing and maintaining 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 extensive 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. Given the importance of communication in rehabilitation and the many different problems that can arise, it is surprising that specific communication training is not given.