Client Education: It’s Teachable! Effective Communication to Improve Patient Outcomes in Physical Rehabilitation
The SPAW Pet Rehabilitation and Fitness, Physical Rehabilitation and Fitness, Aldergrove, BC, Canada
In the role of veterinary physical rehabilitation, physical fitness, and sports medicine the practitioner assumes the role of both treatment provider and educator. The length and frequency of treatment required provides the ideal environment to develop a strong relationship between patient, client, provider, and clinic. The opportunity to interact consistently with a client can build trust and credibility and place the entire practice in a position to build a lifelong relationship with a client, their current pet(s), and future pets.
Communication research in veterinary medicine has proven that the ‘level of pet care received (is directly) linked to communication skills—Communication by the veterinarian plays a significant role in the strength of the bond between a veterinarian and pet owner. The strength of this bond, or relationship, has a direct impact on the loyalty of a pet owner to a veterinarian and the care pets ultimately receive.’5
Research indicates that the relationship centered ‘communication model is recognized as an important framework for an ideal health-care system because it identifies the nature of relationships as a fundamental component of the successful delivery of high-quality health care.4 ‘Relationship-centered veterinary care is a collaborative veterinarian-client partnership in which there is mutual understanding and recognition of the client’s perspectives and expertise in the pet’s care through shared negotiations and balance of power.’4
Roles in Communication
The physical rehabilitation provider in practice may assume the role of guardian, teacher, or collaborator based on type of communication or interaction taking place or communication style preference.
Guardian: ‘As a guardian the veterinarian is viewed as an expert who makes recommendations that the client is obliged to follow. In this type of interaction there is little discussion of what the client is capable of, desires, or requires. The benefit of this role for the veterinarian is that the clients, theoretically, will do what the veterinarian considers best. An important disadvantage of this role, however, is that because decision-making power is not shared responsibility for treatments outcomes is also not shared. In other words, if the outcome of the treatment is unsatisfactory, the client will likely hold the veterinarian solely accountable.’3
Teacher: ‘As the teacher, the veterinarian is merely a source of data and services. No opinion or recommendation is provided, leaving the client to assimilate the information and make decisions according to the data provided. Veterinarians who serve only in the capacity of teacher may find that their clients seek out multiple opinions from possibly questionable sources. This may adversely affect the health of the patient.’3
Collaborator: ‘Viewed by many as the optimal choice for both veterinary and client, collaborators provide information and education regarding diagnostic and treatment options, and make explicit their professional opinions. Of equal importance collaborators acquire information regarding client preferences, desires, and needs. These perspectives of the client are actively sought, thus allowing any barriers that may impact the diagnosis, treatment, and adherence process to be more readily identified and negotiated. Because collaborators actively encourage client participation in decision making, a partnership in care is formed. Termed relationship-centered care, this partnership is one of shared decision-making responsibility and outcome accountability. Because clients become equal stakeholders in the decision-making process, they are more committed to co-developing feasible strategies for treatment. Ultimately, a collaborative process may produce higher rates of client adherence to proposed treatment plans.’3
Creating engagement while applying reflective listening skills has been proven to improve the relationship between client and care provider and empower the client to become an active participant in the care team. ‘Engagement is the process of making a connection with a client to facilitate the exchange of information. Reflective listening is a skill that uses summarizing, paraphrasing, or hypothesizing to review the information the client has shared, allowing the client to hear his/her own story as understood by the veterinarian. Reflective listening allows the client to add further information, clarify points where the story may be unclear, and correct misconceptions. Perhaps most importantly, the use of reflective listening skills communicates to the client that his/her perspective is recognized and valued, and emphasizes that they are being heard. Empathy is the expression of active concern for and curiosity about the emotions, values, and experiences of another. Empathy suggests an appreciation for what an experience may be like for the client through seeing, hearing, and accepting the client’s perspective and concerns. Open-ended questions allow clients to tell their story in their own words without leading or prompting. The procedure of enlistment includes two processes: decision-making and encouraging adherence.
The goal of these is to encourage client responsibility in making decisions and implementing treatment. Client ‘buy-in’ to the diagnosis promotes great success in treatment adherence and treatment outcomes. The education portion of the interaction process includes providing medical facts, opinions, and options. This includes assessing the client’s perspective of the problem, providing answers to questions clients may have, and assuring the client understanding of what has been discussed in the visit.’3
The Ask-Tell-Ask Technique 1
This approach is based on the notion that client education requires identifying what the client already knows and building on that knowledge. It also works as a way to build a relationship because it shows that you are willing to listen to and negotiate the client’s agenda.
#1 Ask: The goal of this first step is to ask your client to describe his or her current understanding of the issue. This will help you craft your message to account for the client’s level of knowledge, emotional state, and degree of education.
#2 Tell: Chunk and check. Give a portion of the information and then check in with the client to see how he or she is doing. Example ‘Whether a dog develops hip dysplasia is influenced by many things. It might be due to genetics, something in the environment, or even diet. So it’s possible that Chance may even be the only dog from his litter to have clinical signs of hip dysplasia. Does that make sense to you?’ Acknowledge non-verbal cues. ‘You look a little confused, which is not unusual. Many of my clients have a hard time digesting all of this at once, and it’s even more difficult now because it’s happening to Chance.’ Pace yourself and speak in terms clients will understand. Keep in mind that the information is new to them and that medical terminology is frequently like a foreign language.
#3 Ask: Use a rating system to assess understanding. ‘On a scale of 1 to 10, how comfortable are you that you understand wat a total hip replacement will mean for you and Chance?’ Offer to help them clarify what they will share with loved ones about the condition. ‘I know you’ll be talking with your wife about this visit later. Do you want to go through it once so I can help you with anything that you are unclear about?’ Encourage questions by normalizing reactions. ‘That’s a pretty complex topic and most people have many questions about it. It is pretty challenging to explain too, so I want to make sure we are on the same page. Do you have any questions?1
‘Ineffective communication has been found to produce a lack of client understanding or belief in the importance of the veterinarian’s recommendation.’4 How well veterinarians explain the reasons for their recommendations drives the clients’ perceptions of the value and quality of care. Survey results reveal the strong, positive impact that communication and pet interaction have toward clients following the recommendations of a veterinarian. In fact, a main reason cited by pet owners for not following recommendations was that they felt the recommended treatment was not necessary.’5
‘Research suggests that veterinarians’ perceptions of their clients’ needs and expectations with respect to veterinary health care may differ from what those clients actually need or expect when they bring their animals in for care. Pet owners expected their veterinarian to educate them and be an accessible source of information with respect to their pets’ care. A number of participating pet owners expressed an expectation that information related to the process, diagnosis, treatment, and cost be presented up front. Many of the participating pet owners expected veterinarians to provide additional information in the form of written discharge instructions, handouts, pamphlets, or information packets for new pet owners. In particular, owners were seeking information about their pets’ condition or disease, the cost of care, insurance coverage, and emergency contact information in a form that could be readily accessible. On the other hand, not every participating pet owner felt it was the veterinarian’s responsibility to provide this information, and some owners felt they had a responsibility to educate themselves. Some veterinarians suggested that the emerging expectation among pet owners for additional sources of information on procedures, conditions, and medications was being driven by other health-care professionals, such as pharmacists and dentists.’2
Importance of the bond between a client and veterinarian—Findings of the study reveal that communication skills of a veterinarian are a key driver of a strong relationship between pet owners and their veterinarians. The bond between a client and veterinarian is defined as the tangible relationship between a pet owner and veterinarian as a result of the experience the pet owner has had with the veterinarian on the basis of the veterinarian’s communication skills, interaction with pets, and ability to educate the owner about his or her pets’ needs.
Clients who have favorable opinions about their veterinarians in these key areas have a strong relationship and are more loyal. They are also more likely to keep the same veterinarian even if they move 45 minutes away. And, they are less inclined to change veterinarians to get less expensive care. Most importantly, they are significantly more likely to do what their veterinarian recommends, regardless of cost. By far, the most crucial component of a strong client-veterinarian bond is communication, which has a tremendous impact on the care pets receive. Clients who believe their veterinarian does a good job communicating and feel they receive enough pet-care information are more likely to have a strong bond with their veterinarian. Importance of veterinarian communication on the care pets receive—Nearly all owners (98%) agreed that their veterinarian does an excellent job of interacting with their pets. However, this study included several questions to determine what role, if any, other forms of communication with the client might play in the quality of care pets receive. Findings of the study revealed a direct link between how well the client perceived that a veterinarian communicated with their propensity to follow recommendations. Study results indicated that the cost of care was not a major obstacle in preventing most owners from following the advice of veterinarians. Instead, confusion, uncertainty, and misunderstanding played far greater roles in noncompliance. Many clients may not have enough information to make the best decisions for their pet. It may be that pet owners do not grasp the importance or the value of the treatment. This uncertainty and lack of perceived value far outweighed concerns about cost. Approximately 7 in 10 (71%) pet owners who believed their veterinarian did a good job communicating followed the orders of their veterinarians. That number decreased significantly (51%) for clients of veterinarians who were not good at communicating. This demonstrates that good communication can produce a 40% increase in clients who follow recommendations.’5
‘Adherence has been described as an outcome that arises from a collaborative and mutual relationship with the health professional and implies that clients make intentional choices concerning treatment regimens on the basis of the diagnosis and their beliefs about the illness and the accompanying treatment options.’4 ‘To achieve adherence the veterinarian must also assure there is client understanding. Steps the veterinarian may take to help increase the likelihood of adherence include: keeping the regimen simple, writing the regimen out in clear and simple terms, providing pictures if necessary, motivating the client by giving specific information about the benefits of treatment and the risks of not treating or treating inappropriately, preparing the client for side-effects, thoroughly discussing any obstacles they perceive regarding the mutually agreed upon plan, and finally, asking the client for their input and evaluating their conviction to the plan.’3
The theory of multiple intelligences was developed in 1983 by Dr. Howard Gardner, professor of education at Harvard University. It suggests that the traditional notion of intelligence, based on I.Q. testing, is far too limited.
Gardner’s theory initially listed seven intelligences which work together: linguistic, logical-mathematical, musical, bodily-kinesthetic, spatial, interpersonal and intrapersonal; he later added an eighth, naturalist intelligence and says there may be a few more. The theory became highly popular with K–12 educators around the world seeking ways to reach students who did not respond to traditional approaches, but over time, ‘multiple intelligences’ somehow became synonymous with the concept of ‘learning styles.’8 Although very different ‘both multiple intelligences and learning styles can work together to form a powerful and integrated model of human intelligence and learning—a model that respects and celebrates diversity and provides us with the tools to meet high standards.’9
Style or learning style: A style is a hypothesis of how an individual approaches the range of materials. When researchers have tried to identify learning styles, teach consistently with those styles, and examine outcomes, there is not persuasive evidence that the learning style analysis produces more effective outcomes than a ‘one size fits all approach.1
The Mastery Style Learner absorbs information concretely; processes information sequentially, in a step-by-step manner; and judges the value of learning in terms of its clarity and practicality.
The Understanding Style Learner focuses more on ideas and abstractions; learns through a process of questioning, reasoning, and testing; and evaluates learning by standards of logic and the use of evidence.
The Self-Expressive Style Learner looks for images implied in learning; uses feelings and emotions to construct new ideas and products; and judges the learning process according to its originality, aesthetics, and capacity to surprise or delight.
The Interpersonal Style Learner, like the mastery learner, focuses on concrete, palpable information; prefers to learn socially; and judges learning in terms of its potential use in helping others.9
Applying effective communication techniques and education and multiple intelligence theory and learning styles to improve therapeutic exercise outcomes
‘Therapeutic exercises are a daily part of the rehabilitation veterinary technician’s routine. The therapist chooses the exercises, and the technician carries them out. Exercises may focus on improving proprioception, balance, speed, endurance, focal strength, pelvic limb function, forelimb function, neurologic function, or land treadmill endurance training.’7
We know that ‘clear client communication and education are also essential to successful rehabilitation. The owner/handler must be well educated on the exercise program, especially the home exercise program. However, each client’s needs and expectations can vary depending on the time available for home exercises. The client needs guidance for home exercises, and the completion (or not) of home exercises should be documented in the record. Often, printed instructions, as well as verbal and physical directions, need to be provided for the client to completely understand what each exercise entails. This is also documented in the record.’6
Based on the previously discussed research findings, the physical rehabilitation practitioner, client, and pet all benefit when the practitioner makes the conscious choice to provide relationship-centered care by taking on the role of collaborator in communication combined with the use of reflective listening skills. By acquiring information about client perspective, preferences, and needs the practitioner is able to address barriers to treatment and develop a partnership to formulate a collaborative plan that encompasses shared decision-making responsibility and adherence to treatment plan. This approach increases the potential for successful outcome of the treatment plan.
Relationship-centered care allows for the development of trust between client and practitioner. Addressing client learning styles by providing a variety of resource tools and communication methods allows clients to take charge of their own education regarding their pet’s diagnosis and treatment plan. Providing educational resources in a variety of formats allow clients to choose their preferred format for receiving information. Use of words (written and recorded) will appeal to linguistic intelligence; facts, numbers, statistics, protocols, flow charts will appeal to logical-mathematical intelligence; clients strong in bodily-kinesthetic intelligence will appreciate a see one, do one hands-on approach to therapeutic exercise; clients with spatial intelligence may prefer to see diagrams, build therapeutic exercise equipment, or rent equipment to create their own therapeutic exercise activity environments. Self-expressive style will take the goals and create. Clients with high interpersonal intelligence may like to attend group classes or spend time in your centre helping others or write blogs to share their experience. Intrapersonal-intelligence-focused clients will appreciate a practitioner that is focused on how they directly can impact their pet’s recovery and mobility. These clients may appreciate being provided with a chart or diary to record their pet’s progress and details of what they personally did to impact their pet’s recovery. Clients with high naturalist intelligence may appreciate environmentally friendly and natural choice of care for their pet and environmentally friendly choices within your facility. The mastery style learner will appreciate concrete, sequential information. They will appreciate a clear and practical approach to therapeutic exercise. The understanding style learner will appreciate starting with a goal, known as the ‘idea’ and will learn through questioning, reasoning, and trying a variety of approaches to reach the goal. The original ways to reach the goal and delight in surprise and celebrate when they find a way to achieve the therapeutic exercise goal. The interpersonal style learning will focus on concrete information, learning socially and provide the practitioner with feedback in the interest to potentially help others.
1. Bonvicini, Kathleen; Cornell, Karen. Are clients truly informed? communication tools and risk reduction, Compendium. November 2008
2. Coe, Jason; Adams, Cindy; Bonnett, Brenda. A focus group study of veterinarians’ and pet owners’ perceptions of veterinarian-client communication in companion animal practice. JAVMA. Vol 233, No.7, October 1,2008
3. Cornell, Karen; Kopcha, Michelle. Client-Veterinarian Communication: Skills for Client Centered Dialogue and Shared Decision Making.
4. Kanji, Noureen; Coe, Jason; Adams, Cindy; Shaw, Jane. Effect of veterinarian-client-patient interactions on client adherence to dentistry and surgery recommendations in companion-animal practice.
5. Lue, Todd; Pantenburg, Debbie; Crawford, Phillip. Impact of the owner-pet and client-veterinarian bond on the care that pets receive. JAVMA. Vol 232, No. 4, February 15, 2008
6. Goldberg, Mary Ellen. Getting Started in Physical Rehabilitation, Today’s Veterinary Nurse Adapted with permission from the 2015 Tampa AAHA Yearly Conference Proceedings (c) American Animal Hospital Association (www.aaha.org)
7. Coates J. Manual therapy. In: Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley & Sons; 2013:100.
8. Armstrong, Thomas. Multiple Intelligences in the Classroom, 4th Edition Paperback – November 22, 2017
9. Silver, Harvey; Strong, Richard; Perini, Matthew. Integrating Learning Styles and Multiple Intelligences Educational Leadership. Vol 55, No. 1, September 1997.
10. Gardner, Howard, ‘Multiple intelligences’ are not ‘learning styles.’ Washington Post. October 16, 2013.