Introduction

Health professionals' continuous and adequate training is fundamental for clinical practice quality, ensuring that patients benefit from adequate and updated interventions according to their specific clinical condition (^{Denniston et al., 2017}).

Therefore, the World Physiotherapy has developed a document entitled Physiotherapist Education Framework (^{World Physiotherapy, 2021}) that aims to guide and establish the prerequisites for the training of physiotherapists from pregraduate training to continuing professional education. The continuous and professional training of physiotherapists should be promoted throughout their professional career, from their pregraduate training, and constantly updated (^{World Physiotherapy, 2021}).

Throughout their career, physiotherapists must develop proficiency in patient assessment, activity/technique learning, in the technical application of procedures, as well as in the review and documentation/communication of interventions, both to the patients and to the other health professionals in the team, thus improving their knowledge and clinical reasoning (^{American Physical Therapy Association, 2013}, ²⁰¹⁵; ^{World Physiotherapy, 2021}). It is essential that the physiotherapist has and develops a wide range of knowledge, competencies, and skills appropriate to the role he/she plays in his/her professional clinical practice, health education, and commitment to the implementation of health practices and policies based on quality performance ((^{American Physical Therapy Association, 2013}, ²⁰¹⁵; ^{World Physiotherapy, 2021}). Within these competencies, we find specific technical components (assessment and specific technical interventions), general components that include communication, ethics and deontology, and management, leadership, and organizational skills (^{World Physiotherapy, 2021}). Finally, it is also crucial that they develop scientific competencies, specifically in research, development of evidence-based practice, and the professions' scientific development (^{World Physiotherapy, 2021}). This document also presents and develops the essential domains of professional practice for physiotherapists: assessment and intervention in physical therapy, ethical and professional components, communication, evidence-based practice, interprofessional teamwork, reflective practice and career-long learning, quality improvement, and management and leadership skills (^{World Physiotherapy, 2021}). Physiotherapists must possess and develop competencies in each domain, thus ensuring quality professional practice (^{American Physical Therapy Association, 2013}, ²⁰¹⁵; ^{Chartered Society of Physiotherapy, 2013}; ^{World Physiotherapy, 2021})

Regarding communication, it is essential that the physiotherapists can communicate precisely, with intelligible vocabulary and adequate to the context, providing an appropriate environment and the development of a relationship of trust, motivation, and empowerment of the patient, allowing for good therapeutic outcomes (^{European Commission, 2013}; ^{Health and Care Professions Council, 2013}; ^{World Physiotherapy, 2021}). It is also essential to have clinical records with the evaluation, decision making, intervention, and results obtained, updated, and made available to all health professionals who intervene with the patient; it is also essential to promote and coordinate communication according to legal and professional requirements (^{European Commission, 2013}; ^{Health and Care Professions Council, 2013}; ^{World Physiotherapy, 2021}) . They must also promote adequate and accurate information about physiotherapy to users, other social and health agents, and the community (^{European Commission, 2013}; ^{Health and Care Professions Council, 2013}; ^{World Physiotherapy, 2021}).

Finally, physiotherapists must demonstrate active listening and negotiation skills, based on patient-centered intervention, in order to develop trust and improve the therapeutic relationship with patients as well as the relationship between the multidisciplinary team, allowing for a more effective adaptation of objectives and intervention techniques to the specific situation (^{European Commission, 2013}; ^{Health and Care Professions Council, 2013}; ^{World Physiotherapy, 2021}).

Analyzing the situation of physiotherapy in Portugal, the Portuguese Association of Physiotherapists, in 2020, created the Profile of Competencies of the Physiotherapist (^{Associação Portuguesa de Fisioterapeutas, 2020}), within which communication also plays an important role. In this document, regarding communication, it was defined that the physiotherapists must develop and use effective communication strategies to inform clearly, transparently and efficiently the user/group, and promote a good therapeutic and professional relationship. The communication strategy should serve the purpose of clarifying, involving, and motivating the user/group in the process of physical therapy care, aiming at his/her satisfaction. Besides the beneficiaries of physical therapy services, the physiotherapist also communicates with other professionals, scientific, social and political communities (^{Associação Portuguesa de Fisioterapeutas, 2020}). Finally, it is essential to understand, within the training in clinical communication or communication skills, which are the syllabus involved, which concepts are essential to develop, and how the training of health professionals in general, mainly physiotherapists, is developed.

^{Miciak et al., (2018}), in a study that sought to identify the essential components to develop a therapeutic relationship between physiotherapists and users, identified three fundamental components: knowledge of the person and the construction of a relationship of support; support and effective ex-change of information; and the use of the body as a central point for communication development, in which the non-verbal communication, more specifically the touch and the body language, represent an essential component (Miciak et al., 2018).

Similarly, and more specifically in the context of aphasia, ^{van Rijssen et al., (2021}) developed a study that aimed to explore and describe experiences and communications needs of health professionals that intervene with aphasic patients. Results showed that health professionals' difficulties in communicating with these patients decreased their recovery potential, commitment, and motivation.

^{Wijma et al., (2017}), in a systematic literature review that aimed to assess physiotherapists' skills for patient-centered communication, through physiotherapists and patients perception, we're able to identify eight main themes that arise in the patient-centered approach such as individuality (knowing the patient and individualized treatment); communication (especially the non-verbal components); support (autonomy and empowerment); education (transmission of knowledge and continuous information) and the definition of therapeutic goals focused on the patient's goals.

Therefore, it is crucial to understand what training programs are available for healthcare professionals, specifically physiotherapists, to improve their knowledge about the fundamental concepts of clinical communication and improve their communication skills.

Thus, the objective of this study was to identify and analyze the courses/training programs in clinical communication or clinical communication skills that exist in Portugal (currently or in the past), aimed at physiotherapists, through a comparative documental analysis, namely of their objectives, typologies, program content and evaluation methods.

1. Methods

Online research was carried out in websites of professional training organizations for health professionals, in the official pages of different university and polytechnic teaching institutions of health courses, as well as in the training departments of different public and private health institutions, in the Portuguese Society of Clinical Communication and the Portuguese Association of Physiotherapists.

The keywords "Clinical Communication", "Training", "Communication Skills Training" and "Training in Health Communication" were used for the search, aimed at physiotherapists. The research was carried out between February and March, and September and October 2021, by searching online announcements and/or publications without specifying the time for the training. Data were analyzed regarding the name of the course, its regime, typology, recipients, place, date, training entity, trainer's qualifications, workload, objectives, syllabus, type of assessment, classification, and academic/professional degree granted (if applicable).

2. Results

Eight courses on clinical communication skills or health communication were identified from the search, including one postgraduate course, one master's course, one master's degree, and five professional training courses. All courses were aimed at health professionals from various areas, two online, one in synchronous mode and the other in asynchronous mode, with a slight synchronous component in one of the classes.

Except for one that a Brazilian organization organized; all courses were organized by Portuguese institutions. We identified three higher education institutions, one public vocational training institution, and one private vocational training company regarding the organizing institution. Three courses were organized by the same higher education institution, namely the Faculty of Medicine of the University of Porto. All the course typologies were organized in a theoretical-practical format with compulsory attendance. The course load ranged from eight to 100 curricular hours, plus one academic year of research/dissertation. Only three of the eight courses were postgraduate training, with degree and credit awarding.

Of the eight courses identified, only two did not provide the information on the syllabus, but those that did were somewhat homogenous, despite different levels in detail and description. The syllabus was aligned with the courses' objectives whenever the information was available. As far as assessment is concerned, the information about the methodology was not explicit in the courses where it was planned. To better visualize and analyze the results obtained, table 1 is presented below.

3. Discussion

Given the analysis of the results obtained, it is possible to verify that all courses were generally directed to health professionals, and no specific training for a particular health profession or clinical context was found. This finding differs in part from what is usually found in the literature, whose training of communication skills, despite being directed to several different health professionals, is often directed to a specific health situation or context, as identified for example in the studies ^{Miciak et al., (2018}), which aimed to assess the components of communication in rehabilitation; in the study by ^{van Rijssen et al., (2021}), which trained health professionals caring for patients with aphasia; and in the systematic review by ^{Wijma et al. (2017}), which looked specifically at the patient-centered communication skills of physiotherapists.

Through a more exhaustive search, it is also possible to verify that training in communication skills is more often addressed to physicians and nurses, in exclusive groups, and then in clusters of several health professions. The studies by ^{Tavakoly-Sany et al., (2020}), ^{Nakagawa et al., (2019}) and ^{Tanzi et al., (2020}) specifically addressed to physicians and the studies by ^{Keer et al., (2020)} and ^{Banerjee et al., (2017}) were addressed to nurses.

This is probably because training in communication skills has been integrated earlier in the curricular training of physicians and nurses than in the other health professions (^{Banerjee et al., 2017}; ^{Kerr et al., 2020}; ^{Nakagawa et al., 2019}; ^{Tanzi et al., 2020}; ^{Tavakoly et al., 2021}).

Concerning communication skills training, the most frequent intervention areas are oncology, working on delivering bad news (^{Banerjee et al., 2017}; ^{Tanzi et al., 2020}) ; in cardiovascular diseases to in-crease adherence to healthy behaviors and lifestyle habits (^{Backman et al., 2020}; ^{Nakagawa et al., 2019}), in obesity prevention and control, to increase motivation (^{Sease et al., 2021}) and physical ac-tivity (^{McCoy et al., 2017}), and in mental health diseases, on how to build trust with a patient in a therapeutic relationship (^{Papageorgiou et al., 2017}).

Regarding communication skills training for physiotherapists, it is usually organized with other pro-fessional groups and usually does not have a specific scope of intervention (^{Denniston et al., 2017}; ^{vanRijsen et al., 2021}).

This finding suggests that since the therapeutic intervention is more effective in a multidisciplinary team (^{Ellis & Sevdalis, 2019}), communication skills to be developed are comprehensive and should ideally involve the whole team considering that the therapeutic goals are more easily achieved through an interdisciplinary intervention (^{Abaraogu et al., 2019}; ^{Ellis & Sevdalis, 2019}).

The homogeneity of the syllabus was found, essentially directed to basic and advanced communication skills. It may be related to the fact that the courses are not specific to any particular pathology or condition but instead directed to health communication in general, addressing the essential topics inherent to clinical communication.

However, the technical specificity of the physiotherapist intervention, with an enormous range and variety of areas of intervention and specialization, suggests that the training of communication competencies should have a specific component for physiotherapy. The therapeutic relationship created with the users is very close and of trust. Motivation, positive reinforcement, support for autonomy, and even shared decision-making are essential to increasing the users' confidence and motivation levels (^{Norris et al., 2019}; ^{Wloszczak-Szuba & Jarosz, 2013}). Patient-centered communication plays an important role (^{Wijma et al., 2017}), thus increasing their collaboration and involvement in the rehabilitation process, components without which the results obtained are strongly compromised (^{Wijma et al., 2017}; ^{Wloszczak-Szuba & Jarosz, 2013}). This was not found in the syllabus of the courses identified in this comparative documentary analysis, probably because communication skills training is not yet consistently implemented in the professional training of physiotherapists. Hence, pregraduate training consists of basic communication concepts and skills on patient interviews and a light approach on advanced communication skills, but in general. It contradicts what is stated in the physiotherapist competencies profile and physiotherapists' training objectives worldwide, where communication training is considered essential and should be done throughout the whole career (^{World Physiotherapy, 2021}).

Therefore, there is a need to include training in shared decision-making, support for autonomy, and even coaching or motivational interviewing for physiotherapists to stimulate their clients' involvement, motivation, and autonomy (^{Akhbari et al., 2019}; ^{Miciak et al., 2018}; ^{Norris et al., 2019}; ^{Wijma et al., 2017})..

The fact that we did not find a large offer of training in clinical communication or training of communication skills for physiotherapists and other health professionals is in line with the majority of studies that suggest that training of communication skills is more frequent in the medical and nursing professions than in other health professions (^{Ajawi & Higgs, 2012}; ^{Doyle et al., 2013}; ^{Keer et al., 2020}; ^{Tanzi et al., 2020})..

The information found is not very descriptive; however, all courses have a theoretical-practical approach. Two of the courses (of professional training, not organized by higher education entities) do not refer to the teaching methodology.

In the courses that mention it, the theoretical part is expository, and the practical part includes watching videos, role-playing, and simulation of cases with standardized patients in one of the courses.

The fact that some courses do not provide all the information online could have been overcome thro-ugh direct contact with the organizing entity in order to request more detailed information, which could translate into a limitation of the present study. However, it was decided not to do so, because the intention was to understand what information was freely available, and easily accessible to possible interested parties who searched for the information.

This finding may suggest a better formative quality in postgraduate or higher education courses, which is easily understood because they are more complete courses, with more time load, and more specific and documented programmatic content. This finding is also justified because higher education institutions have to describe and make the description and syllabus of all their training offer on the institution's website, which is why the information is more accessible and detailed.

Conclusion

In addition to identifying the scarce formative offer in clinical communication and/or training of communication skills aimed at physiotherapists, the study allowed us to understand which methodologies were used, programmatic contents, and assessment methodologies. It was possible to conclude that despite having a different time load, the program contents were similar and adequate to the defined objectives in the situations where the information was available.

It was also possible to identify the predominant teaching methodology of theoretical expository and practical nature with the visualization of clinical vignettes and role-play activities and interviews with fictitious patients and their assessment methodology. However, the information provided on assessment methodology was not explicitly and clearly described. This is probably because the research was online, and not all the available information was available, constituting an explicit limitation to this study.

The study was also important to establish the formative needs in training and communication skills more directed to physiotherapists.