The most recent draft NICE guidance on chronic primary pain has shone a light on the importance of communication in the management of this patient population. Alice Hopkins, MSK physiotherapist in NHS Lothian and PPA North Committee member, summarises a systematic review "The anatomy of positive messages in healthcare".
A recent systematic review  demonstrated that positive messages to patients can relieve pain, anxiety, improve lung function and minimise morphine use and length of hospital stay (across patients from various healthcare settings, including chronic pain services).
This systematic review did not explain the content or context of the messages or conversations between clinicians and patients, something which would be very valuable in order to know how to do this in day-to-day practice. The paper by Howick et al. (2019) , decided to do exactly that and define what kinds of positive messages were demonstrated to benefit patient outcomes.
The aim of this blog post is to summarise this research so physiotherapists have a better idea of how to convey positive messages to their patients and therefore improve the effectiveness of their interventions through personalising care for individuals.
The researchers included 22 papers in their systematic review and grouped the types of positive messages together. They themed these into different kinds of messages and these will be explored in more detail.
- specifying positive outcomes
- making the message personal
- drawing on association and meanings
- encouraging a supportive psychological context
- appealing to evidence or providing a rationale.
1. Specifying positive outcomes
Essentially, telling your patients the benefits (either specific benefits, or more general benefits) of your practice, i.e: “your pain will subside within a few minutes” (specific) vs simply “getting better” (general). Some studies also included general timeframes to their positive messages, “you will be better within a week or so”.
In short, letting your patient know the benefits of your treatment and explaining how much time that may take could lead to better patient outcomes.
2. Making the message personal and accessible
Most of the studies personalised the positive message by addressing the patient by their name or addressing it to them directly; “I think this will work for you” or by hand-writing their prescriptions or instructions. A few of the studies used analogies to make the information more relatable to patients.
In short, personalising any information put across to the patient is another way of conveying positive messages, and so should be considered when implementing person centred care.
3. Drawing on associations and meanings
A few studies included in the review tried to convey positive messages by associating positive thoughts to a treatment by increasing the patient’s attention to the treatment or by encouraging the patient to pay attention to the treatment (i.e. watching an injection being given) or by leading the patient to associate a treatment with a sensory perception like “[this] local anaesthetic [...] will numb the area and you will be comfortable during the procedure”.
In physiotherapy sessions, it may be possible to do this by asking a patient to notice their pain response to an exercise, for example.
4. Encouraging a supportive psychological context
The paper found that positive messages were also communicated by validating patient experiences, reassuring patients that their symptoms are explained, guiding patients throughout their journey to recovery and helping to normalise the side effects of an intervention.
In a pain service setting, this could be done by explaining that what they are experiencing may not be uncommon symptoms considering what they have been enduring.
Being supportive through empathy and respect, introducing yourself and shaking hands, understanding the patient’s perspective and emotional wellbeing were some of the simple tools to show a supportive and welcoming setting in the majority of these studies.
The papers within a rehabilitation setting reported that healthcare practitioners encouraged patients to be realistically optimistic about their capacity to reach a goal, using examples of previous success to draw on and to portray a healthcare system that believed patients were able to achieve their goals. This is all the more reason to encourage goal setting within physiotherapy.
5. Providing a rationale
Including an explanation of why an intervention will work in your positive message was linked to the positive patient outcomes. The clinician could have provided an explanation of the basic mechanism of how a treatment would work (i.e.: exercises increases strength and therefore function) or they could have justified why they felt the intervention would be effective through their experience, i.e. “most of my patients get better”, or even showcasing research evidence or an institutional authority such as NICE guidelines.
Throughout these 5 different ways of conveying positive messages, it was found that repetition was used regularly to reinforce messages to patients before or during the treatment. This illustrates that repetition of the message has a role to play in improving patient outcomes. On another note, most of the studies from the review put their positive message across before the intervention or treatment, however none conveyed it afterwards. It would be interesting to see if the positive message would work as well irrespective of timing.
All in all, positive messages seem to improve patient outcomes, however they are complex to craft and there are many ways to convey them. It seems that repeated suggestions about specific effects
of a treatment, explanations of how they work, delivered confidently and in a personalised way is the most common way to put across a positive message.
Food for thought during your next interaction with a patient: a small change in how you communicate could make a positive impact on your patients' results and physiotherapy experience.
1. Howick J, Moscrop A, Mebius A, Fanshawe TR, Lewith G, Bishop FL, et al. (2018) Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. J R Soc Med, Vol 111 (7), p 240-252.
2. Howick J, Lyness E, Albury C, Smith K, Dambha-Miller H, Ratnapalan M, et al. (2020) Anatomy of positive messages in healthcare consultations: component analysis of messages within 22 randomised trials. European Journal for Person Centered Healthcare, Vol 7 (4), p 656-664.