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INTRODUCTION: Clinical medicine and the work of healthcare workers, as well as the results of treatment and medical rehabilitation, are all dependant on the effectiveness of communication throughout this process, as well as on the quality of the relationships between the physician and other healthcare workers and patients and their families, and within the healthcare team itself. Factors that are of importance for effective communication within clinical practice are the atmosphere in which communication unfolds, the manner in which interlocutors relate to each other, the words that are used in communication and the quality of communication on a verbal and non-verbal level. The communication competencies on the basis of which healthcare workers develop their relationships and communication with users of healthcare services should be rooted in research and empirical concepts. Effective communication between healthcare workers and patients increases the possibility of achieving successful cooperation during the treatment and rehabilitation process. A review of published literature has shown that, as of yet, no research related the communication competencies of physiotherapists has been performed in Croatia while, at an international level, scientific papers have been published only in relation to certain thematic areas concerning communication competencies, whether in physiotherapy or clinical practice in general. Woodward et al. (2012) have identified five main categories in the assessment of the quality of communication in physiotherapy: non-verbal communication, manner of the physiotherapist, the language that the physiotherapist uses, hospital organisation and the content of therapy procedures and communication tools. Amoudi et al. (2017) have studied the effect of positive communication skills on reducing pain in orthopaedic patients during physiotherapy in Palestinian rehabilitation centres. The authors state that the communication competencies of physiotherapists play a key role during the physiotherapy programme when it comes to alleviating pain and depression and increasing the motivation of patients. The results of their research showed that 50% of respondents agreed that positive communication skills were of great help in the alleviation of pain, while around 30% of respondents stated that such skills were of moderate help. This means that, to a greater or slightly lesser extent, 80% of patients consider communication during rehabilitation to be of importance for the positive outcome of rehabilitation. Włoszczak-Szubzda and Jarosz (2013) stress that effective communication skills are necessary in order to correctly gather information in healthcare consultations, as well as for adapting to the needs and thoughts of the patients. ˝During physiotherapy and discharge itself, effective communication is necessary for the patient to gain a better understanding of their further progress, lifestyle and behaviour˝ (Włoszczak-Szubzda , Jarosz, 2013; p. 194). Hargreaves (1982) and Ambady et al. (2002) stress that an effective understanding and use of non-verbal communication in a therapeutic environment is necessary in order to achieve a successful rehabilitation outcome. Patients that have confidence in their physiotherapists are more likely to adhere to therapeutic instructions, as opposed to patients who received identical verbal instructions, but sensed the disinterest and absence of their physiotherapists. Doubts in the sincerity and credibility of the sender of the message lead to unsatisfactory interactions. From the research described above, it can be concluded that the communication competencies of physiotherapists are of great importance for both the successful and effective implementation of physiotherapy and the satisfaction of patients.
RESEARCH OBJECTIVES AND HYPOTHESES: The objective of this doctoral dissertation is to clearly define the communication competencies that physiotherapists need to possess in order to communicate successfully, as well as to establish the influence of the assertive communication model on the effectiveness of cooperation with patients and within the healthcare team itself. The dissertation also has three specific research objectives: analysing legal and publicly available documents related to the clinical work of physiotherapists and the formal education of physiotherapists in Croatia; assessing the communication profile of physiotherapists and studying the different aspects of communication competencies: empathy and assertiveness in communication, and tolerance to disagreements at the workplace; researching the effectiveness of communication of users of physiotherapy with their physiotherapists, the manner of physiotherapists during communication, fear of communication and the correlation between the outcome of rehabilitation and the patient’s satisfaction with their communication with their physiotherapist. Research hypotheses: H1: The professional communication competencies of physiotherapists are represented neither in Croatian legal documentation, nor Croatian education documentation. H2: The use of an assertive communication style by physiotherapists significantly increases the effectiveness of cooperation with patients. H3: Physiotherapists with a greater tolerance to disagreements achieve more effective communication within the healthcare team. H4: Developed communication skills in physiotherapists have a positive effect on the outcome of medical rehabilitation. H5: Patients who evaluate worse their communication with a physiotherapist during medical rehab express greater fear of physical therapist, are older (over 58 years of age) and are the lowest in education. This dissertation aims to contribute to the development of communication skills in physiotherapists, which leads to the development of one’s own professional work, both in physiotherapy and clinical practice in general. The outcomes of this research may be of assistance in the evaluation of professional communication competencies related to physiotherapy as well as other healthcare professions, which benefits both patients and physiotherapists within the therapeutic process. The expected scientific contribution of this doctoral dissertation can be elaborated on a theoretical and empirical level: On a theoretical level: the scientific contribution relates to the definition of the communication competencies that are necessary for the effective professional work of physiotherapists, and to the definition of the influence of the assertive model on the effectiveness of communication in the clinical practice of physiotherapists. On an empirical level: the scientific contribution relates to the analysis and application of the results of the conducted research on the communication competencies of physiotherapists, and in the drafting of suggestions for additional training at the level of the formal and informal education of physiotherapists.
RESEARCH METHODS: The subject of the doctoral dissertation is gaining insight into the condition of the objective parameters of the communication competencies of physiotherapists within the Croatian healthcare system. The research used four methods of data collection: 1. Analysis of legal documentation on the physiotherapy profession 2. Questionnaire on the communication competencies of physiotherapists 3. Questionnaire on physiotherapy patients’ views on the effectiveness of communication with their physiotherapists 4. Analysis of courses that are part of the formal education of physiotherapists Analysis of legal documentation was performed with the objective of researching the extent to which the public availability and validity of legal documents that regulate the profession of physiotherapy in Croatia is connected with the definition of the professional competencies of physiotherapists. This analysis encompassed the Act on Physiotherapy, Standards in Physiotherapy Practice and the Code of Physiotherapy Ethics and Deontology. The analysis of the communication competencies of physiotherapists was performed by means of a questionnaire that assessed physiotherapists’ knowledge of and attitude towards communication with users of physiotherapy, as well as towards communication within the healthcare team itself. The objective of this questionnaire was to determine the knowledge and skills that are necessary in order to make communication in the clinical work of physiotherapists as effective as possible (empathy in communication, assertiveness and tolerance to disagreements at the workplace). The analysis of the effectiveness of the communication of patients with their physiotherapists was performed by means of a questionnaire that examined patients’ views of and satisfaction with the communication competencies of their physiotherapists. The objective of this questionnaire, which was filled in by users of physiotherapy, was to examine the effectiveness of their communication with their physiotherapist, their opinions concerning the manner of their physiotherapist during communication, fear of communicating with their physiotherapist and the correlation between the outcome of rehabilitation and patients’ satisfaction with their communication with their physiotherapist. The analysis of courses that are part of the formal education of physiotherapists encompassed the syllabi of the undergraduate and graduate university and professional study programmes in physiotherapy performed at higher education institutions in Croatia, in which course content involving the communication competencies of physiotherapists was the subject of research. RESULTS: In the first part of the research, an analysis of the publicly available legal documentation that regulates the profession of physiotherapy in Croatia was performed: the Physiotherapy Act, Standards in Physiotherapy Practice and the Code of Physiotherapy Ethics and Deontology. The Act on Physiotherapy regulates the content and manner of performing physiotherapy activities, educational standards, prerequisites for performing the profession, obligations, quality control and professional supervision of the work of physiotherapists in the Republic of Croatia. Pursuant to the Physiotherapy Act, in 2018 the Croatian Chamber of Physiotherapists published the Code of Physiotherapy Ethics and Deontology, which defines the principles and rules of conduct for physiotherapists for the purpose of upholding the dignity and reputation of the profession and activity of physiotherapy. The principles of this Code define the importance and role of the physiotherapist in healthcare and in society in general, and they are aimed at providing guidance on how to pursue the profession of physical activity in a responsible and professional manner. Pursuant to the Physiotherapy Act, in 2009 the Croatian Chamber of Physiotherapists issued a document titled ˝Standards in Physiotherapy Practice˝, which were developed in accordance with the recommendations of the World Confederation for Physical Therapy (WCPT) and the European Region of the World Confederation for Physical Therapy (ER-WCPT). Standards in the practice of physiotherapy represent principles for the implementation of physical therapy and requirements that are demanded from physiotherapists in order to provide a high standard of physiotherapy services to the community. The standards represent the professional obligation of the physiotherapy profession in the promotion of the health of individuals and the community at large, all for the purpose of increasing the effectiveness of physiotherapy services, and they encompass: administration and principles in the organisation of physiotherapy practice, communication with patients and within the healthcare team, responsibility towards the community, cultural competencies, documentation, education and training, ethical code, informed consent, legality, management of patient care, personal professional development, quality assurance, research and assisting staff in physiotherapy. According to the analysis performed, it is evident that professional communication competencies have not been defined in Croatian legal documentation. In order to establish the professional communication competencies of physiotherapists, two questionnaires were implemented: (1) Questionnaire on the communication competencies of physiotherapists and (2) Questionnaire on physiotherapy patients’ views on the effectiveness of communication with their physiotherapists. The questionnaires were implemented during a period of 8 months, between 01 May and 31 December 2018, on a sample of 2 test groups in 74 private and public healthcare institutions in Croatia that perform physiotherapy, and the research involved 502 physiotherapists and 2902 patients. The analysis of the results obtained from the questionnaire on the communication competencies of physiotherapists shows that an assertive style of communication adopted by physiotherapists significantly increases the effectiveness of their cooperation with patients. However, it was established that physiotherapists that are older or somewhat older both in terms of age (the group between the ages of 35-49 and the group above the age of 50) and in terms of length of service (group with 15-29 years of service and group with more than 30 years of service) have lower indicators of assertiveness in communication than their younger colleagues (group with less than 15 years of service). Empathy also ranked highly as a desirable trait in working and communicating with patients. Furthermore, in this part of the research, an assessment of attitudes towards disagreements in communication at the workplace was also performed, in which it was observed that physiotherapists perceived disagreements, i.e. conflicts as ˝undesirable˝, in the sense that they were inclined towards avoiding open conflict at the workplace. They were more inclined towards switching conversation to another topic, or avoiding communication with conflictive persons. The research of physiotherapy patients’ views on the effectiveness of communication with their physiotherapists was based on a questionnaire that assessed patient’s views of and satisfaction with the communication competencies of their physiotherapists. This questionnaire implemented among patient tested their own assessment of their health status, assessment of fear of communicating with their physiotherapist, assessment of the effectiveness of their communication with their physiotherapist, assessment of physiotherapy patients’ views on interpersonal communication with their physiotherapist, assessment of the behaviour of physiotherapists in communication, assessment of the manner of speech of physiotherapists. The results show that the majority of respondents (85.5%) reported having a moderate fear of their physiotherapist, a smaller part of the respondents reported a high degree of fear (14.5%), while none of the respondents reported not having a fear of physiotherapists. Furthermore, patients’ views on the effectiveness of their communication with their physiotherapist was assessed. The effectiveness of communication was tested according to the following parameters: (1) thoroughness of the physiotherapist’s questions on the patient’s health status and symptoms; (2) attentiveness of the physiotherapist in communication with the patient; (3) elaborations of the medical problems of the patient or the procedures planned for the patient; (4) the physiotherapist’s responses to the questions asked by the patient; (5) length of conversation and time dedicated by the physiotherapist to talking with the patient; and (7) the physiotherapist’s level of intimacy with the patient. The analysis of the data concerning effectiveness of communication with the physiotherapist showed that patients valued the traits of patience and attentiveness the most in conversation with their physiotherapist. The analysis of the results pertaining to physiotherapy patients’ views on their interpersonal communication with their physiotherapist also shows what patients find important during physiotherapy: they want to be heard, to be able to openly express their problems without feeling criticised, for the physiotherapist to express a sincere interest in their health concerns and to show initiative in explaining the further course of treatment – through advice, support and instructions. As for the behaviour of physiotherapists towards patients in communication, users of physiotherapy highly value having enough time to consult with the physiotherapist during physiotherapy, being attentively listened to by the physiotherapist while they were talking about their health concerns; having their physiotherapists help them feel well enough to perform their everyday life activities; receiving explanations on the purpose of the planned tests and procedures from their physiotherapist at the beginning of therapy; receiving help from their physiotherapist in understanding the advice that they received during therapy; being warned of the consequences of not performing the recommended therapeutic exercises as recommended and instructed. The research results also show that the respondents, as an error in communication, most commonly stressed that physiotherapists talked too fast in conversation with them. The average values obtained also show that they used incomprehensible speech, that they were confused in communication and neglected them in communication. The analysis of courses that are part of the formal education of physiotherapists established that, within the syllabi of courses that are part of the formal education of physiotherapists, there exist courses where communication is taught. The research encompassed syllabi at 2 polytechnics and 5 universities in Croatia, on the undergraduate and graduate level. On the territory of Croatia, the formal education of physiotherapists is performed through university and professional study programmes. The analysis set apart the following 5 compulsory courses on the undergraduate level with content and objectives related to the communication competencies of future physiotherapists: 1. Ethics of Healthcare, 2. Physiotherapy Assessment, 3. Clinical Propaedeutics, 4. Communication Skills, 5. Foreign Language; together with 3 elective courses: 1. Palliative Care, 2. Psychology of Sports, 3. Gerontology. At the level of graduate study programmes of physiotherapy, 3 compulsory courses related to improving the communication competencies of future physiotherapists were found: 1. Management in Healthcare, 2. Working with the Disabled, 3. The Skill of Medical Teaching; together with 3 elective courses: 1. Teamwork, 2. Working with a Group, 3. Business Communication. Educational programmes have recognised the need for teaching communication skills as soon as at the undergraduate level, and the course ˝Communication Skills˝ was introduced at all 7 institutions for training physiotherapists, with content and objectives encompassing the knowledge that future physiotherapists will need in their work with patients, their families and work colleagues. However, the results of this analysis did not prove conclusive as to whether the students are familiarised with this content only informatively, or whether they are trained to resolve concrete communication problems. CONCLUSION Further research and guidelines within the profession should take into consideration the educational framework of communication competencies and include it in the legal framework of the profession, for example including it in the ethical code of physiotherapy, standards in physiotherapy and similar. The legal and educational framework within the profession should certainly be in harmony, so that results in the field of communication competencies may both gain importance and be systematically implemented and monitored in practice. On the basis of the questionnaires, both those given to patients and those given to physiotherapists, important new knowledge on the work processes of physiotherapists concerning communication and the necessary competencies was obtained. Above all, one needs to spend time in rehabilitation in order for rehabilitation to be as effective as possible, and this also applies to communication as an integral part of rehabilitation. Elderly patients demand extra attention not only in the rehabilitation process, but also when it comes to the manner of communication itself. Likewise, patients with a lower level of education need extra care for their fears to be assuaged, as do elderly patients. Within all systems (forms) of treatment, it is necessary to implement training on the manner, methods and procedures of communication, as well as to insist on good and effective communication within the healthcare team itself.