Physiotherapy 95 (2009) 294–301
Teaching and learning communication skills in physiotherapy:
What is done and how should it be done?
Ruth H. Parry a,∗ , Kay Brown b
a
Collaboration for Leadership in Applied Health Research and Care, Business School and School of Community Health Sciences,
University of Nottingham, Nottingham NG7 2TU, UK
b Rotherham Community Health Centre, NHS Rotherham PCT, Greasbrough Rd, Rotherham, S60 1RY, UK
Abstract
Objectives To survey practice and opinion regarding school-based teaching of communication skills, to summarise relevant research evidence
from physiotherapy and beyond, to reflect on practice in light of evidence, and to propose associated recommendations.
Design Survey using customised questionnaires. Basic descriptive statistical analysis and thematic content analysis were used. The results
were compared with evidence from systematic reviews to derive recommendations.
Survey participants and setting Educators in all UK centres delivering physiotherapy qualifying programmes in 2006.
Results A response rate of 69% was achieved. The majority of respondents reported delivering communication-specific modules. Lecturing
was common, and more experiential methods were also used. Assessment was mainly by written work. Educators commented on challenges and
strategies involved in student engagement, provision of authentic experiences, availability of teaching time and expertise, and physiotherapyspecific teaching resources. Evidence from allied health profession, medical and nursing education research emphasises the importance of
experiential teaching, formative feedback, observational assessment and a substantial evidence base on which to ground course content. In
physiotherapy, the latter is emerging but incomplete. There are also gaps in direct evidence about advantages or otherwise of stand-alone
modules and benefits of pre-qualification communication training. Evidence suggests that effective training requires substantial teaching time,
expertise and a body of empirical research on specific communication practices and their effects.
Conclusion Curriculum designers and educators should endeavour to maximise the degree to which training in this area is experiential,
provide training when students have already had some contact with patients, and assess students by observation if at all possible. Due to gaps
in the evidence, some important questions about optimal practice remain unanswered.
© 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Physiotherapy; Survey; UK; Communication skills teaching; Communication skills assessment; Communication skills research
Introduction
The aims of this article are to report aspects of recent
practice in teaching communication skills in UK qualifying programmes for physiotherapy and aspects of educators’
views on this area of teaching; to summarise existing
research-based evidence relating to effective practice in this
area; and to consider how UK practice, as reported in
the survey, relates to existing research evidence. On this
basis, proposals are made for how communication skills
training can be further developed to maximise the likeli∗
Corresponding author. Tel.: +44 777 13 88 699.
E-mail address: ruth.parry@nottingham.ac.uk (R.H. Parry).
hood of producing qualified therapists able to practise and
reflect on effective interpersonal clinical communication. The
paper reviews relevant evidence about clinical communication skills and training in those skills; reports the method and
findings of a recent survey of UK school-based communication skills training; and analyses these in relation to one
another.
Communication skills: evidence
Physiotherapy relies on verbal and non-verbal communication between therapists and service users, their associates,
and other health and social care workers. Skilled and appropriate communication underpins effective practice [1–3], is
0031-9406/$ – see front matter © 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.physio.2009.05.003
R.H. Parry, K. Brown / Physiotherapy 95 (2009) 294–301
a key professional competence [4,5], and is highly valued by
physiotherapy recipients [6–8].
Academic interest in physiotherapy communication has
been longstanding [9,10]. In recent years, empirical studies
have been identifying and describing various communication
practices and skills, and exploring how they work, why they
do and do not get used, and so on. These studies fall into three
broad types, as follows.
(1) Qualitative observational studies that look closely at
communication practices within video-recorded consultations from a broadly critical standpoint [e.g. [11–13]].
A feature of these studies is that they see the asymmetries between patients’ and therapists’ contributions
within clinical consultations as inherently problematic
and negative, and this viewpoint underlies their analyses
and findings.
(2) Qualitative observational studies that draw on other perspectives and methods, particularly the social scientific
approaches of micro-ethnography and conversation analysis [14–18]. Like the critical observational studies, these
use an inductive approach, deriving general descriptions and understandings about communication practices
by qualitatively analysing individual recorded consultations. The conversation analytic approach in particular
differs from critical studies in its perspective on communication asymmetries. In conversation analytic studies,
asymmetry is viewed as integral to professional health
care and is understood as collaboratively achieved—both
patients and therapists contribute (ten Have [19] provides a clear demonstration and discussion, and Pilnick
and Dingwall [20] give a useful overview of the debate
on asymmetry). Analysis in this approach also prioritises examination of sequences of communication, and
identifying and describing both therapists’ and patients’
contributions.
(3) Quantitative observational studies [e.g. [21–23]] use
a deductive rather than an inductive approach to
developing knowledge and understandings about communication. Inductive studies examine data without
assuming a priori categories, whereas deductive reasoning starts by making decisions about a framework of
categories, with this framework then applied to observed
or recorded data. Some of these studies in physiotherapy have designed a customised communication coding
instrument [21,22], whereas others have adopted and
applied a previously designed instrument [23].
Moving from the methods to the scope and findings of
these studies, most have documented aspects of physiotherapy communication in stroke rehabilitation [12,17] or
outpatient musculoskeletal settings [11,14,21,23]. As such,
substantial areas of practice remain largely unexplored.
Aspects of communication that have been described include:
the prevalence of touch [23]; how therapists provide instructions and corrections [14]; how patients demonstrate learning
[14]; how patients and therapists interact about goal set-
295
ting [17] and during history taking [11]. Whilst these skills
are clearly relevant to many areas of physiotherapy, general
and specialism-specific skills remain undocumented. Furthermore, whilst non-verbal aspects of communication are
absolutely vital to practice, efforts to document and understand them are at a rather early stage [23,24]. There are other
limitations in the existing research: some of it focuses on
single components of communication and omits how these
fit and function together [22,23], and there has been limited
attention to patients’ contributions and the way in which these
shape what therapists say and do [21,22].
As well as research on the components and patterns
of physiotherapy communication, some work has also
been undertaken on its effects. In particular, studies have
shown that therapists’ communication affects the way in
which patients experience their condition [25,26]. However,
although it has been strongly argued that communication is
important for long-term outcomes of physiotherapy treatment [27,28], there is currently no robust empirical evidence
on the impact of communication practices on physiotherapy
patients’ long-term outcomes.
Therefore, whilst studies have made a significant start on
documenting the components and effects of the communication practices that comprise physiotherapy, there is some
way to go in order to construct a comprehensive and detailed
framework that describes and explains this complex field.
Communication training: policy, practice and evidence
Professional and regulatory bodies see the development of
effective communication practice as an important aspect of
pre-qualification physiotherapy education [4,29]. Nevertheless, it has been argued that this area tends to be overlooked in
a curriculum where time pressures ‘may encourage a narrow
focus on physical rehabilitation’ [3].
Recent research by the first author collated evidence about
communication skills training for allied health professionals
(AHPs) [30]. It included a systematic review of studies on the
effects of interventions designed to influence communication
practice amongst pre- and post-qualification AHPs, including physiotherapists. Five studies fulfilled the rather broad
inclusion criteria, all found positive effects. The most robust
evidence came from two studies that used within-subjects
controlled designs—in essence, a series of single case experiments [31,32]. Both evaluated interventions for qualified
AHPs in brain injury rehabilitation settings, and involved
experientially-based training and observational assessments.
In both studies, the training programmes and assessment
schedules were based on substantial prior evidence about
the content and effectiveness of specific skills. Both studies
found positive effects on participants’ practice behaviours; in
addition, the study that measured patients’ outcomes found
positive effects [32].
As robust evidence about communication training and its
effects in AHPs is limited, a parallel review was conducted
on indirect evidence from medicine and nursing. Echoing the
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R.H. Parry, K. Brown / Physiotherapy 95 (2009) 294–301
evidence in AHPs, this found ‘fairly strong evidence for positive effects of interventions that target specific skills and that
are designed on the basis of clear empirical research’ [30].
The indirect evidence also indicates that for training to be
effective, it must include experiential opportunities to practise communication and feedback; that ‘learners need to be
ready and motivated for change and training’, and that training is more likely to be effective when delivered to those who
have some clinical experience. In the medical education literature and beyond, it is widely held that the gold standard
for assessing communication skills learning entails observing
and measuring actual behaviour in real-life situations [33],
although simulated scenarios and patients are often used and
regarded by many as an acceptable substitute, particularly
in undergraduate training [34,35]. Unfortunately, students’
performance in written assessments cannot be assumed to
have any relationship with their actual communication performance in practice [33,36,37]. Unsurprisingly in light of
all this, effective teaching and assessment of communication
skills is time consuming and expensive [38,39]. It is also
important to note that although research evidence generally
supports communication-specific training for qualified practitioners, there is little strong evidence of its effects when
delivered to pre-qualification practitioners.
Despite this gap, teaching of communication skills is
firmly established in undergraduate medicine [40]. Communication’s place in the medical curriculum has grown
against a backdrop of detailed documentation of the skills
and practices that comprise doctor–patient communication,
particularly in primary care [41,42]; and substantial evidence
that certain communication practices affect healthcare quality and outcomes [43,44]. Delivery of modules that focus
specifically upon health communication skills is the norm
in medical schools [40,45,46]. Well-established frameworks
that describe communication and thereby underpin teaching
are available [47], and it is common for this training to include
interactions with simulated patients [33–35,48].
The survey
Against this backdrop, this article reports the results of a
survey of contemporary physiotherapy teaching and learning
about clinical communication in qualifying programmes in
the UK. The survey aimed to gather information about how
communication teaching was delivered, and the respondents’
accumulated experiences and views on teaching and learning
in this area.
Survey method
A questionnaire was developed on the basis of current
guidance [49–51]. Selection of question themes and content was shaped in consultation with physiotherapy educators
and students, and also by reviewing prior surveys of medical
schools [46,52] and drawing on existing knowledge about
Table 1
Summary of questionnaire topics.
Numerical and categorical responses sought on:
• The full programme’s duration and intake
• Whether any modules/units within the programme were
designed to provide teaching about clinical communication
skills and/or communication skills as their primary or major
secondary focus
• For modules with primary or secondary focus on
communication:
– duration
– teaching modalities
– assessment strategies
Free-text responses sought on:
• The formal title, written aims and learning outcomes of
communication-specific modules
• Recommended texts and materials
• Other means by which clinical communication skills were
integrated into the curriculum (responses on this were
sought from both those who did and did not provide specific
communication skills modules)
• Respondents’ views, experiences and ‘ideal world’ aspirations
in this area of teaching
• Recent and planned changes in curriculum affecting this area
communication skills training and evaluation within physiotherapy [3,30] and beyond [33,36].
A first draft of the questionnaire was sent to volunteers
from the physiotherapy higher education and research sectors
recruited via the interactive Chartered Society of Physiotherapy (CSP) site (http://www.interactivecsp.org.uk/). They
were asked to complete the questions and provide comments.
The content and layout of the instrument was revised on
the basis of this exercise. These revisions included allowing
respondents to describe relevant modules in terms of those
with a primary focus on communication, and those with a
significant communication component but where this was not
the sole focus.
Both email and postal copies of the questionnaire and
accompanying invitation letter were distributed to each of
the 36 centres listed in 2006 by the CSP as offering qualifying programmes. Where possible, the authors identified
individual staff known to be interested in research and/or
communication teaching, and sent questionnaires directly to
them. It was not possible to do this for six of the 36 centres, so
the questionnaire was sent to the contact addresses published
in the CSP’s list. Repeat questionnaires and letters were sent
out to non-responders 2 months after the first mailing, and
again 3 months later. The first mailing of questionnaires was
in August 2006, and the final reply to a subsequent reminder
was received in December 2007. Therefore, the data spanned
two academic years. In anticipation of this, questions were
asked about recent and planned changes to the curriculum.
Responses indicated no substantial changes between the 2
years.
The full questionnaire is available on request from the
corresponding author. The areas it covered are summarised
in Table 1. Numerical and categorical responses were entered
R.H. Parry, K. Brown / Physiotherapy 95 (2009) 294–301
297
into a custom-designed Excel spreadsheet, and frequencies
or ranges of responses were calculated. Free-text responses
were collated in word-processed documents and tables, and
analysed through thematic content analysis [53].
Table 2
Reported timing, teaching modalities and assessment in the 18
communication-specific modules.
Findings
Teaching modalities and
resources
Twenty-five of the 36 recipient higher education centres
(69%) responded to the questionnaire. The non-responders
were widely geographically spread; four were programmes
where the questionnaire had not been addressed to a specific
individual, and seven had been addressed to named individuals.
Eighteen of the respondents (72%) reported that their programmes included modules with a primary or secondary
focus on communication. Analysis of the formal aims and
learning outcomes suggested that most modules concentrated
on theoretical knowledge about communication practices
and skills, and on inculcating the ability to describe and
reflect on them. The aims of less than half (7/18) of the
programmes explicitly referred to the provision of opportunities to practise, develop and demonstrate communication
skills. Quoting one example, the module aimed to provide
students with ‘an opportunity to explore, understand, and put
into practice known and new communication skills’. Only
two programmes included learning outcomes that explicitly
referred to the ability to communicate effectively and appropriately, presumably because of the difficulty in measuring
with validity whether such an aim had been achieved [54].
Outcomes and assessments mainly focused on students’ ability to describe and reflect on practices, rather than on their
practical communication proficiency; a matter returned to
below.
Table 2 describes the timing, teaching modalities and
assessment methods reported for the communication-specific
courses. Most were delivered early within the training programme, formal lectures predominated over practical and
experiential learning, and a minority included any practical
assessment of learning. Respondents listed numerous supporting textbooks and some peer-reviewed papers. The most
frequently cited texts besides policy documents [4,55] are
listed in Table 3. Only one of these texts had a sole focus on
physiotherapy skill and practice.
All seven respondents who reported that their programmes
did not include communication-specific modules responded
to a question which asked about other means by which clinical communication skills were integrated into the curriculum.
Whilst the question was not designed to elicit substantial
detail, all seven mentioned that communication skills were
overtly assessed within practically-based examinations in
their programmes. Two reported that their curriculum was
structured according to a case- or problem-based learning
framework, with attention to communication integral within
the framework.
Year in which delivered
Year one
Year two
Year three
(Total = 18)
15
1
2
Lectures
Small group discussions
Role play
Simulated or actual patients
Videos of simulated scenarios
Videos of actual patient
treatments
18
17
15
5
8
4
Essay only
Essay plus oral viva or
pre-prepared presentation
Essay plus practical
18
4
Assessment formats
4
Educators’ comments on challenges and strategies in
this area
The questionnaire was successful in eliciting responses on
these matters from most respondents: 14/18 gave responses
to questions about their views on the challenges in this area
and on how they dealt with, or would like to deal with, these
challenges. Reported challenges included students’ failure
to appreciate the value and importance of communication
teaching and learning, and hence a lack of efforts and engagement in this area. Several respondents saw this as arising
from students’ failure to recognise that everyday communication skills differed from those used in the workplace. One
response referred to students’ ‘inflated self-efficacy for communicating’ and another summarised as follows: ‘Students
do not perceive the subject as a priority and therefore often
fail to participate fully in tutorials, seminars etc.’. Those who
reported their attempts to deal with this challenge mentioned
including the following in their courses: the research evidence of associations between communication and outcomes;
Table 3
Most frequently mentioned supporting textbooks on communication for
communication-specific modules (in alphabetical order).
• Burnard P. Effective communication skills for health
professionals, 2nd ed. London: Stanley Thornes; 1997 [58]
• Dickson D, Hargie O, Morrow N. Communication skills training
for health professionals. London: Nelson Thornes; 1996 [59]
• French S, Sim J. Physiotherapy: a psychosocial approach, 3rd ed.
London: Elsevier; 2004 [60]
• Ley P. Communicating with patients. London: Nelson Thornes;
1990 [61]
• Reynolds F. Communication and clinical effectiveness in
rehabilitation. Edinburgh: Elsevier Butterworth Heinemann;
2005 [3]
• Silverman J, Kurtz S, Draper J. Skills for communicating with
patients. Abingdon: Radcliffe Medical Press; 1998 [62]
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a requirement that students read accounts of patients’ experiences of health care; and references to research findings
about patients’ preferences and needs in the area of communication and support from professionals. Another strategy
was to require students to keep logs and write accounts of
their own skills and experiences; this seemed ‘to help at
least some to pick up on areas of weakness and to challenge
any cosy assumption that they are fully prepared to relate to
patients/clients’.
Other frequently reported challenges concerned the difficulties of providing sufficiently authentic experiences in
academic settings, and of integrating placement and schoolbased learning on the topic. In dealing with these challenges,
some respondents reported including patients’ and simulated
patients’ contributions, and using reflective feedback sessions and placement journals. Other reported concerns and
difficulties were lack of time, resources, staffing and expertise for both teaching and assessment. Several respondents
reported that although they did not include formative individualised feedback and assessment of actual communication
proficiency, they would do so in an ideal world.
Discussion
There is a small body of direct evidence in allied health
professions and a larger body of indirect evidence in medicine
and nursing which suggests that communication training can
have a positive effect on therapists’ practice and patients’
outcomes. This evidence points to the importance of designing teaching and assessment on the basis of clear empirical
evidence about the content and effects of practices. It indicates that it is important for learners to be motivated for
change and development of their communication, and that
training should be experientially based and include formative feedback. The evidence also indicates that some form
of assessment of actual conduct is far preferable to written
assessments. Finally, effective training and valid assessment
are time consuming, require considerable teaching expertise
and, as a result, are expensive.
This recent survey of school-based communication skills
teaching within UK physiotherapy qualifying programmes
found that the majority of programmes offered specific standalone communication-specific modules, with a minority
addressing communication skills solely through other forms
of integration in the curriculum. Reported communicationspecific modules were mainly delivered before students had
much clinical experience, largely relied on delivery through
lectures, and assessed outcomes via written or oral reports
about communication rather than by actual communication
practice.
Comparing practice reported in the survey with the existing evidence indicates that there is room for improvement
in terms of: delivering at least some of the communicationrelated training later rather than earlier within training
programmes; designing training to be primarily experien-
tial rather than lecture based; and assessing students’ actual
performance. This is likely to be more costly than current
practice and to require further development of educators’
expertise. Responses to those sections of the questionnaire
that sought educators’ experiences and views indicated that
there is some recognition and awareness of the shortcomings
of current practice and of alternatives that would improve
practice. The fact that the educators expressed these views
suggests that significant constraints other than educators’
knowledge are impacting the quality of provision in this area,
these might include strategic, organisational and financial
constraints.
There are significant areas where it is difficult to make
clear recommendations because of major gaps in available
evidence. Three of these gaps are listed below, along with
suggested considerations for educators to draw on when
developing both overall strategy and specific courses. The
first gap is the absence of evidence about effectiveness of
training in healthcare communication skills for student practitioners; the robust evidence all derives from interventions for
qualified practitioners. Therefore, decisions about whether
to actually attempt to teach this area have to be made in the
light of current policy guidance; this clearly recommends that
the development of communication skills should be attended
to in qualifying programmes. Another relevant point is that
teaching healthcare communication is regarded as best practice in medical training. Finally, it seems reasonable to argue
that given evidence that training post qualification can have
positive effects, pre-qualification training has a good chance
of being effective provided it is designed in accordance with
best-available evidence.
The second gap in evidence concerns the value of
communication-specific modules as opposed to approaches
which rely solely on integration within other modules
and teaching. All the evidence located by the authors
derived from communication-specific courses/modules, and
no comparisons between approaches were found. Thus,
there is insufficient evidence to recommend for or against
communication-specific modules. On the other hand, it could
be argued that a benefit of specific modules is that they provide a clear mechanism and designated space for delivering
the types of course content, teaching modalities and overt
assessment that are supported by best-available evidence.
The third gap is in the basic evidence about the contents
and effects of physiotherapy-specific communication practices and skills. As discussed, this type of evidence is vital
in grounding effective training. Whilst useful information is
now available on physiotherapy skills and their effects, there
is still a long way to go. There is room for synthesis of existing evidence from physiotherapy and related areas, and for
documentation of basic and specialist physiotherapy communication practices. It is suggested that inductive observational
studies would be better suited to this work at present than
deductive coding studies. This is suggested because of the
relatively early stage of progress in documenting precisely
which communication skills are used, and the significance
R.H. Parry, K. Brown / Physiotherapy 95 (2009) 294–301
and effects of these. Deductive, coding studies would be premature because they unavoidably rely on some ‘givens’, some
a priori assumptions about components of communication
and their significance. As argued elsewhere [56], conversation analytic approaches, which are not based on an inherently
critical stance towards professionals and their practice, seem
to be particularly well suited to the endeavour. Improving
the empirical evidence base on physiotherapy communication would not only support better course content, it would
also help resolve the problems associated with the lack of
credibility of communication training that exists in some
quarters. It could also contribute to increasing the availability
of physiotherapy-specific teaching materials.
This study has a number of limitations, particularly with
regard to the scope and methods of the survey reported.
One-third of qualifying programmes did not respond to the
questionnaire, and no data are available to ascertain whether
these differed in relevant features from the responders.
Although the letter which accompanied the questionnaire was
designed to encourage accurate reporting, without additional
fieldwork it cannot be judged whether respondents may have
overplayed or underplayed the extent of teaching within their
programmes. As noted, some responses pertained to one academic year and some to the following year. Respondents
were asked about significant changes in programmes and
did not report large-scale changes, and there was no change
in policy or other development that would have made this
likely. After the first pilot of the questionnaire, it was decided
not to include questions about communication teaching and
learning during clinical placement. This area is undoubtedly
important, has been subject to some previous examination
[57] and was mentioned by most of the respondents. However, further fieldwork would be needed before a targeted and
relevant survey instrument could be designed. Similarly, the
questionnaire gathered little detail in terms of how communication skills were integrated within other teaching; more
detailed fieldwork would be needed to design appropriate
survey questions.
Conclusion
This is an area of teaching that is demanding in terms
of teaching skills, resources and student engagement. It
is also demanding because of the complex nature of this
aspect of clinical skill, its integration with all other areas
of physiotherapy, and also the challenges of its assessment. There are some clear pointers available to educators
and curriculum designers within the existing literature on
education and practice, and this paper has made some associated recommendations. These include recommending that
teaching should: be delivered as much as possible after
placements have started; include experiential opportunities
and formative feedback by expert staff; be based as far
as possible on existing empirical knowledge about physiotherapy communication; use strategies directed at engaging
299
students; and include practical observational assessment of
students’ learning. Implementation of these recommendations will require some commitment of time and expertise
within physiotherapy qualifying programmes. Significant
gaps in the evidence are also noted, and these pose challenges for teachers, students and academic researchers in this
field.
Acknowledgements
The authors would like to thank the physiotherapist educators who spent time commenting on the initial draft of the
questionnaire, and all those who provided responses in the
main survey. Meredith Newman and two anonymous reviewers read and commented very helpfully on an earlier version
of this manuscript.
Ethical approval: The study did not require health-servicesbased ethical approval since it involved survey of the
higher education sector rather than the National Health
Service. The proposal underwent internal ethical review
within the Institute for Science and Society, University
of Nottingham, and the study conduct complied with the
British Sociological Association’s Statement of Ethical Practice (http://www.britsoc.co.uk/equality/Statement+Ethical+
Practice.htm).
Funding: This work was conducted as part of a programme
of research funded by a postdoctoral fellowship awarded
by the National Coordinating Centre for Research Capacity Development (National Institute of Health Research) UK
(Fellowship Number NCCRCD PDA/N&AHP/PD02/038).
The sponsor commissioned peer review of the proposal but
had no other involvement in study design and analysis.
Conflict of interest: None declared.
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