Patient Engagement Strategies

Editor's Note: This text-based course is a transcript of the webinar, Patient Engagement Strategies, presented by Tania Sofia Nogueira, MSc, HCPC – UK, COT – UK, ACSS – PT.

Learning Outcomes

• After this course, participants will be able to identify the meaning of patient engagement.
• After this course, participants will be able to recognize factors influencing patient engagement.
• After this course, participants will be able to list strategies to promote patient engagement.

Introduction

Hello, everyone. Thank you for joining me in this session called Patient Engagement Strategies. My name is Tania, and I am an OT who graduated in 2005. I have been working in mental health and welfare to work systems in different roles, including as an OT, care coordinator, clinical support manager, and safeguarding officer. Currently, I am working in a mental health service for young people.

Regarding this session, health professionals strive to provide care to people when they are unwell and assist them in staying well. Patient engagement is recognized to be an integral part of healthcare and a critical component of healthcare service.

In addition, resources may be better used if they are aligned with patients' priorities. It is expected that we, as OTs, engage patients in the decision-making process and in therapy, although we know that individual patients may vary in their preference for such involvement.

On the other hand, health practitioners have multiple competing priorities, which may sometimes appear to conflict with patient engagement. Having that in mind, I encourage you to use this session as an opportunity to reflect on your experience as an OT and to think critically about your practice, including those principles and strategies we may assume as basic. I hope that this session will add even more value to our role.

Polls

1. What does an engaged patient look like?
2. How can we provide services that matter to patients?
3. How would you describe a ‘challenging’ or a ‘difficult’ patient?
4. On a scale of 1-10 (1 – not at all; 10 - constantly), to what extent are you, as an occupational therapist, actively practicing the core value of patient-centeredness?

We have organized four questions that I would invite you to answer. Answers are anonymous. There are no right or wrong answers, so please be honest as much as possible.

What Does an Engaged Patient Look Like?

Here are some of your answers: eye contact, participation, alert, smiling, attentive, asking questions, agreeing with the action plan, motivated, happy, smiling, following instructions, involved, talking, engaging, showing interest, facial expressions, tone of voice, and sense of humor. I like this one. I also like the element of non-verbal communication that you are mentioning, like alert, active, cooperative, body language, and interest. 

How Can We Provide Services That Matter to Patients?

From the service side, what ideas cross your mind in terms of providing service that patients value? The answers coming in are using a client-centered approach, meaningful activities, asking open-ended questions, asking about their interests, and discussing goals. Patient-centered care is something that we are going to cover today. Meaningful activities are linked with our core values as OTs. We also use an individualized and prioritized plan. We want to use good assessment techniques and set up a rapport.

How Would You Describe a Challenging or a Difficult Patient?

When you think about a challenging or difficult patient, what are the first words that cross your mind? Some of your answers include non-compliance, no motivation, behaviors, impulsivity, and resistance to accepting help. They may have negative attitudes, are apathetic, argumentative, and hostile. Other words mentioned are combative, dismissive, and agitation. They may have a flat affect and are withdrawn.

On a Scale of 1-10 (1 – not at all; 10 - constantly), to What Extent Are You, as an Occupational Therapist, Actively Practicing the Core Value of Patient-centeredness?

Again, we are not here to judge. Please use this space as a protective time and space to reflect on yourself, about your practice as an OT, and think in terms of the patient center care. To what extent are you delivering that? We have 39% at level 8 and 21% at level 10, which are Impressive. I can also tell that there is nothing below five, which is great. 

Why Are There Patients Not Fully Engaging in Therapy?

Reviews have instigated the factors that support or prevent patients from being willing to participate actively in therapy. Before we start exploring those specific factors, I would like to share with you some insights.

Insights

• Engaged patients have better outcomes and lower acute care use, and low levels of engagement are associated with more adverse events (1, 10).
• A patient’s level of engagement can be influenced by a therapist’s level of engagement (3, 13).

Studies have demonstrated that engaged patients have better outcomes and lower acute care use and that low levels of engagement are associated with more adverse events. For example, the study suggests that chronically ill patients who are engaged in their care live longer than an unengaged peer who otherwise received similar treatment.

A recent study found that poorly engaged clients who struggle, did not understand, or hated therapy were influenced to become more engaged by OTs who showed a passion for the job, personalized treatments to meet individual client needs, and had positive non-verbal communication. On the other hand, clients reported that their motivation to participate in therapy was affected by disengaged OTs described as focusing on service requirements, seeming disconnected or disengaged, and doing only the legal obligations of the job title.

In this same study, disengaged OTs often put the responsibility on the poor engagement levels of the client. They did not take any responsibility.

• Past researchers found that occupational therapists lacked the skills and understanding of using a patient-centered approach (13)
• Patient-centered care is conceptualized differently among different stakeholders, impacting effective implementation in care settings (16)
• Human behaviors and decision-making are complex and driven by cognitive, social, and environmental factors (6)

Another finding of this study was that OTs lack the confidence or knowledge to make a difference in these regards. An OT engagement level can affect a client's engagement. Think about your daily level of engagement as an OT in your practice. Past researchers found that OTs lack the skills and understanding of using a patient-centered approach.

Despite the importance of the client-centered principle being reflected in the professional standards established by the American Occupational Therapy Association, there are different barriers to implementing this approach. In a study comparing clients' and the OTs' perceptions of the process of client-centered care, barriers to applying these principles included things like clients that are not able to verbalize their concerns, clients expecting therapists to set the goals for them, and practice settings in which the client's individual goals were not appropriate for the service agenda.

Patient-centered care refers to healthcare that first respects and, second, responds to the preference, needs, and values of the individual patients throughout all healthcare decisions. Based on research, patient-centered care is conceptualized differently among stakeholders, impacting effective implementation in care settings.

Based on that, perhaps it may be helpful in your specific practice to think about the quality indicators of patient-centered care because, at this stage, there is nothing set up, and therefore, we have almost to look individually service by service.

The last insight that I would like to share with you relates to the fact that human behaviors and decision-making are complex and driven by cognitive, social, and environmental factors. Behavioral science helps us to understand how people behave and why. In this session, I am going to present some practical ideas to promote patient engagement based on behavioral science.

Let's now move into the factors affecting patient engagement.

Patient-related Factors (5, 10, 13, 18)

• Demographic characteristics
• Health conditions (e.g., illness severity)
• Lack of confidence
• Low self-awareness about their preferences and what they value in life
• Low level of health literacy
• Low self-awareness about what resources/options are available
• Lack of belief in support
• Patient’s perception of their role and status as subordinate to clinicians

One patient-related factor is demographic characteristics. For example, older female clients who have had a stroke have negative prognostic factors for patient engagement.

Health conditions like cognitive impairments, increased comorbidities, depressive symptoms, or higher fatigue are correlated with poor participation.

There are also factors related to a lack of self-confidence and low self-awareness, and we are going to understand later how this is important.

A low level of health literacy affects a person's ability to recognize and prevent illness and use effective self-help strategies.

Other factors relate to what resources and options are available. They may also have a lack of belief in support and believe they are subordinate to clinicians.

Staff-related Factors (5, 7, 10, 18)

• Negative attitudes
• Lack of effective communication
• Lack of knowledge
• Lack of empathy
• Workload and limited time (perceived time pressure)
• Disengaged professionals or burnout
• Uncertainty about diagnosis or treatment/care

Staff-related factors include negative attitudes and staff perceptions of patients. For example, more patient-centered consultations occur with those patients who are perceived to be better communicators.

There can also be a lack of effective communication. Evidence suggests that healthcare professionals can exercise power in the consultations through the use of professional or expert language or technical terms, which may act as a barrier to communication and engagement.

Other factors include a lack of knowledge, lack of empathy, increased workload, and limited time. Professionals can be disengaged, burned out, or unsure about diagnoses and treatments. Quite often, we may feel stuck in certain cases. We can use these factors as a starting point to reflect on our impact on patients' levels of engagement.

Other Factors (7, 10)

• System-related factors
• Not everyone has the same opportunity to be fully engaged
• Different social determinants of health can affect how engaged patients may be
• (Book – ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,' 2003; Report – ‘A Framework for Educating Health Professionals to Address the Social Determinants of Health, 2016’)

There can be system-related factors, like the high costs of resources and services or a lack of time due to commitments or priorities.

We also have to bear in mind that not everyone has the same opportunity to engage fully, and there are different social determinants of health that can affect how engaged patients are related to economic stability or education access.

For those who are interested in knowing more about these, here are two references. Multiple researchers have argued that the benefits of a rehabilitation program are limited if a patient is not completely engaged in the therapeutic process.

What is Patient Engagement? (3, 10, 13)

• Ability to obtain, process, and communicate health information
• Active commitment and contribution to the decision-making
• High level of interest invested in therapy and active participation in therapy tasks
• Development of a mutually trusting relationship or connection between two parties

Patient engagement is the ability to obtain, process, and communicate health information, which relates to the active commitment and contribution to decision-making, the high level of interest invested in therapy and active participation in therapy tasks, and the development of a mutually trusting relationship or connection between two parties.

This was one of the questions in the poll. In practical terms, engaged patients are those who understand their healthcare needs, ask questions, monitor and discuss their symptoms, believe that they play an important role, and think there is value in setting goals and action plans.

Engagement Strategy

• How do you connect with your patients in a way that’s valuable to them?
• Who are your patients?
• What do they need?
• Thinking about how you can provide services that matter to them
• What technology solutions can you use to communicate with them regularly?
  • (Report – ‘Patient Perspectives on Patient Engagement Technology’ 2022)

We have covered what patient engagement is and the factors affecting it. Now, we are going to progress toward strategies to promote that engagement.

When we think about developing an engagement strategy within our practice, the next step is how to connect with patients in a way that they value. To do that, we need to understand who our patients are, what they need, and how we can provide services that matter to them. For that, we need to listen to them and also think about what technology solutions we can use to communicate with them regularly.

In terms of technology and digital tools, a US report was published last year called Patient Perspectives on Patient Engagement Technology. It found that four in five Americans want the ability to use technology when managing their healthcare experience. Another finding was that organizations are not aligned with patients for things like self-scheduling and prescription refill requests, which are two things that they value. It is important to keep in mind that patients value convenience more than anything else when seeking care.

For today's session, I organized patient engagement strategies into three domains, as they are all connected and interrelated. These three domains are how to instill positive attitudes, how to increase a sense of control, and how to improve motivation. For each of these domains, we will cover different areas and explore practical applications. The strategies can be used in a flexible way and included in a handout almost as a guide or a reference when you are looking to address a specific challenge with a patient.

How to Instill Positive Attitudes?

• Deciding to change
• Building resilience

Let's start with how to instill positive attitudes, including deciding to change and building resilience. 

Deciding to Change (9, 10, 12)

• Readiness to Change
  • How ready are your patients to recover?
  • Are they willing to put in the effort to do so?
• Develop readiness to change
• Demonstrate the value of what the therapy has to offer and how it can help them to reach their personal goals
• Connect with the “Why” for each patient

Deciding to change relates to readiness to change. How ready are the patients to recover, and how much are they willing to put some effort into doing so? We may have patients in different stages. We can have patients who are not ready and do not want to change their circumstances and thus do not want to engage in therapy. We may have patients who recognize the value of the therapy, but they are not yet ready to commit to doing the work. We may have patients who wish to do what is required, but they need to start with small and manageable steps, while others are fully engaged in all aspects of therapy. 

When we are working with a patient, it is important to explore their readiness to change. In a therapeutic setting, while some people might express an external desire to recover, internally, they may be afraid or comfortable to a certain extent with their circumstances. As such, they are likely to engage superficially with therapy. For example, in a mental health setting, we may have patients using the sessions just to offload and not putting any effort into applying the strategies that we are covering.

When there is evidence that a patient is not ready to engage fully or there are elements of superficial engagement in the therapy, our approach needs to focus on developing their readiness to change. This is designed to empower a person to believe that they can improve their life. Developing readiness to change is about helping patients to improve their awareness about themselves, their potential to recover, and the support available to make the change happen.

The other relevant thing to help patients decide to change is to connect therapy to the "why" of each person. By clearly helping them to understand the value of what the therapy has to offer and how it can help them to reach their personal goals, not therapeutic goals. We can increase the chance they will be ready and willing to do the work required and achieve a successful outcome.

Practical Applications for Their Readiness to Change

• Increase their knowledge -> Provide information
• Promote change in their attitude about the future -> Share good examples
• Increase in their participation -> Make contact personal and meaningful
• Involve them in activities designed to help them become more aware of possibilities and their own potential

We can increase their knowledge, provide information about their condition, and discuss what professional support/resources are available.

We also need to promote change in their attitude about the future by sharing success stories. This will help them to increase positive expectations of change and show them that it is possible to make it better.

We can increase their participation by making every contact personal and meaningful. This relates to the fact that at the start of the therapy, we may have different paperwork, assessments, and questionnaires to complete as part of the service process. These activities make the first contact less personal. We need to keep this in mind to find a balance and be flexible.

It is important that we involve them in activities designed to help them become more aware of possibilities and their own potential. It can be activities that increase their awareness about their interests and values. We can also develop activities that increase their awareness and insight into their own support needs. I find this particularly helpful in the mental health setting. We are helping them to increase their insight into their health condition and the need for treatment. Activities can help them to increase their acceptance that it is okay to use support and almost normalizes access to specialist support.

• Spend time at the beginning of therapy discussing their “why”
• Identify their reasons and motivations
• Communicate the value/benefits of the therapy
• Connect their goals with specific elements of the therapy to clearly demonstrate the value
• Revisit this conversation to make sure their why is still the same if patients are losing momentum during the recovery

We need to spend time at the beginning of the therapy to discuss their "why." What are their motivations and reasons that can support the value and the benefits of therapy?

We want to connect their goals with specific elements of the therapy to demonstrate the value clearly. For example, if a client tells us that they want to live independently or get married, we can explore with them. For instance, we can tell them that therapy can help them to develop their communication and interaction skills which will help them to feel more confident in meeting new people or developing motor skills, an essential element for them to be more autonomous in their community mobility.

Finally, it is important that we revisit this conversation throughout the time to make sure that their why is still the same if patients are losing momentum during the recovery.

Building Resilience (9, 12)

• Dealing with setbacks
• Awareness of current mindset » work towards growth mindset » Power of "Not Yet"
• Make the therapy feel more manageable by chunking the journey into smaller bite-sized steps
• Track personal and professional victories and goals

In terms of building resilience, an important part of therapy is dealing with setbacks. We know that patients will need to be able to bounce back from a relapse or complication and keep their confidence and motivation to continue to work to achieve their goals. This can be facilitated through resilience. Resilience has been found to be associated with lower stress and higher motivation.

How we feel is often a consequence of how we think. Those with a growth mindset tend to keep working despite setbacks and hold the belief that setbacks are an opportunity for growth. Based on that, it is important to use approaches that promote positive thought patterns and positive self-talk and to apply the power of the "not yet." A failure puts a person nowhere, while a "not yet" puts a person on a trajectory toward success. It tells the person that they have made progress and they can keep growing their skills.

To make the therapy feel more manageable, we can chunk the journey into smaller bite-sized steps and track the personal and professional victories and goals.

Practical Applications for Building Resilience

• Establish what feels achievable for them within a defined timeframe (e.g., consider their other responsibilities)
• Encourage patients to view progress, both big and small, and to look back on past months

How do we do that? We can establish with them what feels achievable. For that, we have to think about their other responsibilities. For young people, their studies take the majority of their time and energy, and this is something that we need to bear in mind when we are setting up goals with them. We can encourage patients to view progress, both big and small, and to look back on the past months. I think in terms of reflection, there is lots of room to improve in our practice.

Other ways to promote resilience are related to helping patients to create a balanced routine, doing things that they enjoy, socializing, resting/sleeping, and eating well. This will help them to become more resilient to stress, be more mindful, and be aware of thoughts, feelings, and body sensations to improve stress reactions. We can help them to build their skills and communication skills as a way to develop sustained relationships, as it will be a good way to develop resilience as well.

In our approach, we use what we call a strengths-based approach with a focus on the positives and strengths of the person because this will be a good way to foster individual resilience.

How to Increase a Sense of Control?

• Maintaining autonomy
• Increasing self-efficacy
• Providing support

Now, let's move to the second domain and talk about how to increase a sense of control. We are going to explore maintaining autonomy, increasing self-efficacy, and providing support.

Maintaining Autonomy (9, 10, 15)

• Self-determination
• Informed decision-making
• Self-regulatory activities
  • Goal Setting
  • Planning
  • Reflection

Generally speaking, autonomy is the ability of the person to make their own decisions without outside pressure, and this relates to self-determination. When patients feel they are in the driver's seat, they are more likely to feel motivated and fully engaged.

Informed decision-making is a big piece of our work. When we talk about this, there are a few elements to consider. The first is the patient's role in decision-making. Discuss with them what the clinical issue is and any alternatives. What are the pros and cons of each alternative? Clarify any doubts and any questions they may have, assess their understanding, and then explore what decision they want to make. We want also to reflect if we have covered all of these elements when we are helping patients to make informed decisions. 

Self-regulatory activities of goal setting and planning can promote autonomy. We know that patients are more likely to engage in progress when they set goals, create their own action plans, and reflect. They feel more accomplished and are more likely to learn from the past when they think back to their past goals and plans.

Practical Applications for Maintaining Autonomy

• When selecting the next steps, listen to what your patient wants rather than just telling them what to do
• Integrate decision aids into care
• If they are reluctant to make their own suggestions, present different options and allow them to choose
• Devote time to allow patients to reflect on what they’ve done
• Use language that highlights their commitment

When selecting the next steps, listen to what patients want rather than telling them what to do. Sometimes we are in a rush and do not allow them to make a decision by themselves. We can integrate decision aids into care. There are some things online available already, but we can go through simple things like visual aids.

If they are reluctant to make their own decisions, we can present different options and allow them to choose.

Devote time to allow patients to reflect on what they have done. It is important that we pay particular attention to those achievements that were a result of specific choices that the patient has made.

Use language that highlights their commitment. We can use words like "could", "may", or "if you like" instead of saying things like "must", "should", or "have to". Developing materials in alternative formats is another way to promote autonomy.

Increasing Self-efficacy (9, 13, 15)

• Refers to our beliefs about our own capabilities and how strongly we believe that we can achieve an outcome if we put our minds to it
• Sources of self-efficacy
• Experiencing success
• Testimonials or social models
• Encouragement

In terms of increasing self-efficacy. Self-efficacy refers to our beliefs in our own capabilities and how strongly we believe that we can achieve an outcome if we put our minds to it. Self-efficacy is one of the most reliable predictors of successful behavior. In fact, when asking patients about their level of confidence in their own ability to engage in therapy to achieve something, anything below a 7 on a 1 to 10 scale is likely to result in failure.

There are three main sources of self-efficacy. The most effective way to improve self-efficacy is to experiment with success or overcome challenges in other areas of life. Testimonials or social models are seeing someone similar to ourselves achieving a goal that can boost our belief in our own personal ability to succeed. Encouragement and support from a trusted source can also increase self-efficacy.

Please note that if we are encouraging patients to do something that there is a chance that they will not succeed, the encouragement may have a negative impact.

Practical Applications for Increasing Self-efficacy

• Ask your patients to define their personal values:
  • What motivates them?
  • What do they like about themselves?
  • Understand what they value and what their priorities are
• Give examples of success from other patients – it is more motivating when they can clearly picture themselves accomplishing their goal
• Encourage patients to invest time tracking their progress and noting down their success

We want to know what the patient's personal values are. For example, we can write words like family, responsibility, health, and money, and we can ask them to organize these from the most important to the least important and start a conversation about this. We can also give examples of success from other patients. It is more motivating when they have practical examples where they can clearly picture themselves accomplishing their goal.

We should encourage patients to invest time in tracking their progress and noting their success. Through that process, we can give them praise for sticking with their goals. This is enough to activate a reward area in our brain.

Human beings are social animals. We thrive when we are part of groups and communities, and we do not like being disconnected or feeling like we do not belong. Our social identity is based on our membership in different groups, which is an important source of pride and self-esteem. Based on that, it is important that we think about what happens when our patients identify themselves as a patient. What is the impact of that on their engagement and consequent recovery? We want to provide alternative social models that demonstrate successful recovery stories and offer a new point of reference.

It is also important to maintain therapy engagement by providing new social models for our patients to follow by again sharing success stories from other patients who have been going through therapy. We should try to find people with the most similar circumstances. For example, older people may get more value by hearing success stories from other older people because they will be able to relate more easily. We can even create group sessions to hear testimonials directly in the first person.

It is important that we reassure patients that being ill or a patient of a health service is not representative of who they are. We need to talk with them about other roles in their life. Sometimes they may present with reduced roles, but bear in mind that we all have at least one role of being a citizen so we can explore that further. We can create support groups where patients can support each other and swap stories. 

How to Improve Motivation?

• Introducing novelty
• Motivational interviewing
• Prompting action
• Driving accountability

The third domain is how to improve motivation, including four main areas: introducing novelty, motivational interviewing, prompting action, and driving accountability.

Introducing Novelty (12, 15)

• Motivation is the process that regulates and governs our goal-oriented behavior » We tend to have natural ebbs and flows in our motivation
• Introducing novelty increases motivation
• Fresh start effect
• Clean slates
• Quick wins

Motivation regulates our behavior and we know it has ups and downs. Motivation can also fluctuate our levels of engagement within our role as an OT. We tend to have higher motivation at the beginning of a new chapter, and it is what we call the fresh start effect.

If we have a new beginning, we take that as an opportunity to achieve something that our past selves did not. In fact, people are more likely to start new goals on a Monday, their birthday, or when something out of the ordinary creates the feeling of a new season. It creates a new cycle that makes us feel more motivated and optimistic to accomplish our goals. This can also be considered a clean slate.

Quick wins are that we feel more confident and will achieve something big after we have accomplished something small. If we start with a small task or goal, then we can progress from that. It can be great for motivation.

Practical Applications for Introducing Novelty.

• Keep resources for later in the patient journey
• As the recovery progresses, incorporate new things (e.g., group sessions, a one-off session with a different therapist)
• Have a 3-month check-in with your patient and try to create the feeling of a fresh start » past self vs. future self

Keep resources for later in the patient journey to introduce novelty. This works in two ways. We do not want to overwhelm patients at the start of treatment with too many options. Sometimes, in the beginning, we are excited to help the patient, and we bombard them with lots of things. Instead, we can provide resources in a gradual way.

By keeping resources back, it will allow also us to save some new material for later in the program. As their recovery progresses, we can incorporate new things, like a new group session or a one-off session with a different therapist. For example, if a patient presents with social anxiety, we can ask a colleague to conduct a role-play with them.

It is also imperative that we do a three-month check-in with our patients. We can create a feeling of a blank slate by having the patient talk and think about their past self and their future self. This will help them to visualize that they are now at a new point with more knowledge and experience than they had three months ago.

Motivational Interviewing (10, 12)

• Patients are responsible for creating their own change
  • Therapist enhance their intrinsic motivation and promote their commitment
• Key aspects:
  • Empathy – build rapport and show you understand
  • Dualities – explore both sides of a choice
  • Resistance  - ensure that the patient is the driver
  • Build confidence and celebrate victories
• Praise and Reward
  • Pygmalion effect

Motivational interviewing is a useful approach to help to motivate and establish responsibility for patients. It is based on the underlying assumptions that the patient is responsible for creating their own change, and our responsibility as OTs lies in enhancing their intrinsic motivation and prompting their commitment.

Motivational interviewing tends to work best in situations when a patient is ambivalent and lacks motivation. They are stuck with mixed feelings about engaging or not in therapy. A great way to increase motivation is by using positive reinforcement. When a behavior is met with a reward, it is more likely to be repeated in the future. As we are rewarded, our brains release dopamine which increases happiness, and the more we are rewarded, the more dopamine is released, creating a positive feedback loop. When I talk about rewards, I am talking about simple things. If a child works well during a session, we can allow them at the end five minutes to play their favorite game.

I also like to highlight the Pygmalion effect, the psychological phenomenon whereby high expectations lead to improved performance in a given area. For example, if a health professional does not expect much from a patient, they may give them very basic work that does not challenge them or require much thinking or effort. This will have an impact on the motivation and then, consequently, on the result.

Practical Applications for Motivational Interviewing.

• Ask open-ended questions
• Use metaphors while communicating
• Look for opportunities to engage in ‘double-sided’ reflections
• Using warm & friendly statements fosters a feeling of being cared about
• Use every opportunity to provide positive reinforcement
• Rewards such as digital badges or completion acknowledgments have a great impact

The key skills of motivational interviewing are asking open-ended questions to explore individual experiences, perspectives, and ideas. If patients are uncertain about whether or not they want to make a change, we can use metaphors while communicating. Instead of saying, "Let's start a new group session." We can use terms like a new path or changing a journey to make the change feel less effortful or more positive. With young people, I like to relate their recovery journey with video game levels.

We can look for opportunities to engage in double-sided reflections. It is about reflecting on both positives and negatives of each choice. We need to warm and friendly statements to foster a feeling of being cared about, and it can be simple things like, "I am here if you need me."

Use every opportunity to provide positive reinforcement. Say things like "Well done," "That's impressive," and "Nice work" to promote motivation.

We can also use rewards such as digital badges or completion acknowledgments.

Prompting Action (10, 12, 15)

• Make an action as easy as possible to build patient’s ability to understand what they need to do and increase their likeliness to act
• Communicate value from their perspective in tasks. For example: “I think you will find this fun / you’ll learn about yourself/you’ll improve wellbeing/relationships/confidence/gain more control over your life”. Or “This activity matches your interests/ strengths …”

When talking about prompting action, we refer to environmental triggers or external factors that prompt and cue our actions. They are important in bridging the gap between our intentions and our actual behavior.

The key component of any trigger is to ensure that we make a connection as easy as possible so that there are no barriers in the way of performing the action. This also relates to how the action, tasks, and activities are presented. Therefore, it is important that we communicate the value of the task from the patient's perspective, and second, we promote and prompt the action by keeping things simple because we know that if humans feel a little incompetent, we simply disengage, especially in times of distress.

Practical Applications for Prompting Action.

• Chunking information
• Focus on 1-2 tasks/actions at a time
• Reduce ambiguity version
  • Use simple and clear language; visual aids
  • Outline exactly what they need to do + lay out how long it should take
• Start with tasks that are easy (progressive goal setting)
• Choice overload
  • Too many choices - impede decision-making

Chunking information into smaller and more relevant bits is easier to process and understand.

We should focus on one or two tasks/actions at a time and reduce what we call ambiguity aversion by using simple and clear language. Visual aids are also helpful. We can also outline exactly what they need to do. There are articles now that include how many minutes it takes to read it. This helps to manage our expectations about it effectively. In the same way, in our sessions, it is important that we show people what is going to happen by giving them a clear structure.

Start with tasks that are easy within the logic of progressive goal setting. Regarding choice overload, it is important to bear in mind that when presented with too many choices, too many materials, or too many simulations at the same time, we often struggle to make decisions. A simple example of this is when we go to an ice cream shop, and there are more than 20 flavors; it is much more difficult to make a decision as compared to having only four or six options. The same principle applies to therapy.

Driving Accountability (12, 15)

• Make patients accountable for their personal efforts
• Better life outcomes
• Willing to accept responsibility for actions and follow through on commitments
• Intention-Action gap

When we are responsible for our efforts, we have better life outcomes in different areas of life. Also, when we are accountable, we are willing to accept responsibility for our actions and follow through on commitments to ourselves and others. However, we know that, as humans, we have an intention-action gap. Thus, our intentions are not always the same as what we actually do.

Practical Applications for Driving Accountability.

• Precommitment
  • Encourage patient to share their goals with someone else
  • Writing their goals down and signing them
• Commitment
  • Use sms messages by getting patients to confirm they will be attending your session 24 hours before they take place (highlight the consequences of not attending)
• Let patients know what expectations you have for them

Accountability can be difficult for our patients but there are some strategies to promote this. One of the strategies is to encourage patients to share their goals, write them down, and sign them. When we declare our behavioral intentions and sign our names, we are more likely to follow through with our actions.

A commitment device is meant to make it harder for us to not do our desired action. We can use SMS messages to get patients to confirm they will be attending our session 24 hours before they take place, for example.

It is crucial that we let patients know what our expectations are. We expect them to attend the session. Let's personalize correspondence using their first name. Effective patient communication and engagement require multiple touchpoints throughout your patient's journey with us.

We also want to use a communication strategy that considers what is important to them before, during, and after their clinic visit. Their sessions can help us to deliver more personalized engagement tactics that motivate patients to take active roles in their care. We can consider sending them emails or text messages about how they are feeling because this will create a sense of urgency for patients who recognize the symptoms that they experience, which can lead them to take action. This can give you information about what their support needs are. You can then create frequently asked questions or a video to help them to address their issues. Even for those who do not have any symptoms, this can help them to build trust and confidence in the service provider.

Other Engagement Strategies (1, 7, 10, 18)

• Educating/empowering patients to recognize their health needs and to seek health care.
• Encouraging patients to ask questions or speak about their concerns.
• Engaging patients in the design and development of tools helps to enhance their understanding of health issues and encourages them to make use of the relevant tools.

Another engagement strategy is educating and empowering patients to recognize their health needs through leaflets, videos, and other educational material. We also want to encourage patients to ask questions and involve them in the design of these tools because that will enhance their use of them.

• Targeted education around professionals’ attitudes and behaviors to support shared decision-making and the relationship between patient-service.
• Patient-led education of health professionals has been proposed as a strategy to engage patients in developing safer services (current evidence is limited about its impact).
• Patient and family engagement in policy development has also gained increasing recognition.

We can target education around attitudes and behaviors as a way to promote the relationship between professionals and the patient. Patient-led education of health professionals has been proposed as a strategy to engage patients in developing safer services, and policy development has also gained increasing recognition. There are even services that involve patients in the recruitment process as part of the interview panel, for example.

• Giving feedback to patients on follow-up actions taken about the issues they raised.
• Actively promoting patient-feedback systems.
• Providing patients with appropriate, accurate, and up-to-date information about treatment and safety issues in a user-friendly language and format.
• Use care conference.

Other strategies are giving them feedback when they raise concerns, promoting their feedback about the service provided, and providing them with updated information. Some developed countries have begun to give patients access to their own electronic health records.

Another practical strategy to help increase the client's engagement is a care conference where we get all stakeholders involved and have a direct conversation with the client.

How to Deal With Challenging Patients?

How to deal with challenging patients is what we are going to cover briefly. 

Based on the research, people who do not assume the patient role expected by health professionals may have different values, beliefs, and personal characteristics and can be defined as difficult patients. Difficult patients are defined as those who elicit negative emotions, like fear, anger, and frustration, from health professionals. According to the literature, 20% of patients are perceived and stigmatized as difficult by healthcare professionals.

Factors Influencing Challenging Behavior (2, 4, 8, 11)

• Person is more challenging ‘in nature’
• Previous challenging behavior in similar circumstances has resulted in reward/success
• Person believes that goals will be best achieved through an aggressive response
• Frustration (e.g., from an inability to communicate effectively)
• Person feels threatened
• Person feels powerless

What are the factors influencing challenging behavior? People can be more challenging in their nature or previous challenging behavior resulted in a reward. They believe that their goals will be best achieved with that approach. They may have frustration, for example, because of their difficulties communicating. The person may also feel threatened or powerless.

• Person is in pain
• Pressure from friends to behave aggressively
• Person feels justified by being angry
• Person expects to be confronted/treated with hostility
• Person has been in conflict with the individual in the past
• State of physiological arousal (e.g., anxious)
• Others are behaving aggressively around

They can be in pain or receive pressure from friends to behave in a challenging way. They feel justified by being angry and expect to be confronted and treated with hostility. The person may be in conflict with a particular service or with a specific individual. They may have increased states of psychological arousal if others are behaving in an aggressive way around them.

Behaviors That Encourage Challenging Behavior (2, 4, 11)

• Adopting a patronizing attitude
• Humiliating or talking down to patients
• Using wrong names or inappropriate forms of address
• Using jargon and overfamiliarity
• Telling patients how they feel
• Trivializing a patient’s problems
• Telling patients they are wrong to feel/behave as they do

There are also behaviors that can encourage challenging behavior from our side, like adopting a patronizing attitude, humiliating or talking down to patients, using wrong names or inappropriate forms of address, using overfamiliarity, telling patients how they feel, trivializing their problems, and telling patients that they are wrong to feel and behave as they do. We may do these things when we are exhausted or have back-to-back appointments.

Get Ready!

• Be familiar with the following policies:
  • Safeguarding, health and safety, lone working
• Review notes
• Get to know your patients (e.g., baseline behavior, history, triggers, and coping strategies related to negative feelings and interests)
• Be aware and recognize your limits -> know when to seek additional help

Let's get ready because those situations can happen. How we can get ready? We can get familiar with our internal policies around safeguarding, health, and safety policies, and review the notes before we start working with the patient. We need to get to know their baseline behavior and interests because that will help us to de-escalate situations.

Coping strategies related to negative feelings include recognizing our own limits and knowing when to seek additional help. Sometimes, seeking help is the most professional decision we can make.

Elements of De-escalation

• Ensure the safety of everyone
• Recognize patient is doing the best they can under the circumstances
• Be aware of your own emotions
• Be aware of your own body language
• Be aware of personal space, yours and theirs
• Keep safe distance
• Side on to the patient
• Avoid directly facing
• Always be at the same eye level
• Listen and be non-judgemental
• Use a calming tone of voice (do not patronize)
• Do not use frantic gestures, slow everything down
• Paraphrase (to evidence you are listening)
• Keep them talking
• Use short sentences, simple vocabulary
• Speak slowly and calmly
• Give time to process and respond
• Repeat the message whenever you make requests
• Ask open questions
• Repeat back and clarify their statements
• Assume that what they are saying is the truth
• Agree or agree to disagree
• Inform about the acceptable behaviors and consequences of behaviors (List consequences of inappropriate behavior without threats or anger)
• Offer things that will be perceived as acts of kindness (e.g., drink, access to a phone)
• Define the problem (break it down)
• Search for and consider alternatives
• Structure expectations
• Set timeframes and responsibilities
• Stick to agreements – no false promises

The first elements are related to our self-awareness. We have to bear in mind our emotions, our body language, everyone's safety, and also that the patient is doing their best.

Elements of de-escalation are associated with things related to our interaction, our verbal and non-verbal communication skills, our purpose when engaging with them in that specific moment, what it is important to achieve, and how we are going to achieve it. For that, we need to acknowledge how we are interacting with them verbally and non-verbally.

Finally, it is important to effectively manage and solve the problem at that specific moment. I would like to highlight two or three things for this. One relates with "agree or agree to disagree." Another is to inform patients about what is acceptable behavior and what is not acceptable and the consequences of that. Ask them to take ownership and responsibility for their own actions and then offer things that will be perceived as acts of kindness. Simple things that can make all the difference.

What-If Scenarios

Now that we covered the theory part, I would like to think about scenarios we may face during our daily practice. 

What Would You Do If...

1. A patient thinks ‘someone like me can’t get better'
2. A patient is sitting with an unrealistic expectation
3. A patient is scared of change
4. A patient lacks confidence in their ability

Let's look at these scenarios. Please share your views and give examples.

What would you do if a patient thinks, 'someone like me can't get better?'

• Help them be successful
• Start simple
• Encouragement
• Give examples/case studies
• Provide reassurance
• Start with small steps
• Peer assurance
• Positive self-affirmation
• Validation
• Advocate for them
• Good communication
• Be mindful of why they are feeling like that

Again, it is very important that we use examples of people like them going through the recovery and what they have gained so we establish a norm. We can arrange to have people meet in person to hear testimonials directly. This can be really impactful. And even perhaps, for example, a group session where previous patients return to share their stories about what would work well.

What would you do if a patient is setting unrealistic expectations?

• Breakdown steps/small steps
• Small wins
• Instigate shorter-term reassurance
• Chunking
• Discuss with them what to do next

The process will be about working on a plan towards manageable steps and not dismissing their unrealistic expectations. It is moving them from their dream goal into more manageable steps and asking them to set some short-term steps. We are grading activities and simplifying them so they can be achievable. Help them to build momentum to ensure that that is possible from the start. Also, ask about their perception of the current level. It is about working around your insight about where they are at the moment in a realistic way. Help them to build their insight and progress from that.

What to do if a patient is scared of change?

• Take time for that
• Acknowledge their fear
• Provide validation
• Listen in an empathic way
• Reassure
• Find out what they are afraid of
• Understanding/validating
• Provide reassurance that it is okay to feel scared of something when we are not sure what is going to happen

This relates to motivational interviewing. We can use what we call the decisional balance to work through the possibilities. The decisional balance is about weighing the pros and cons of doing something and not doing something, like engaging or not engaging in therapy. This will help them to make a decision.

What would you do if a patient lacks confidence in their ability?

• Encouragement
• Praise
• Past accomplishments
• Small wins
• Realistic goals
• Set up tasks so there is a high probability of success
• Build their sense of autonomy

It is good to share a timeline of their life and past achievements using a strengths-based approach. 

Questions and Answers

Can you give an example of how you use a video game level with a young person?

It is about trying to see the therapy almost as a video game. "Therapy will be like a video game with different levels and challenges." Use the analogy of video games and relate it to therapy. "We are going to overcome challenges step by step, and the complexity is going to progress over time."

How exactly can we explain to the patient how realistic their goals must be to avoid being discouraged?

This relates to taking your time to understand their journey, their level of insight about their difficulties, and their level of insight into where they are now and where they want to go. They are often unaware of what is required to achieve a specific goal. We have to work with them around their awareness of their strengths and difficulties and show how difficulties can impact their ability to achieve a goal. I believe this can be linked with providing information in alternative formats, like visual aids.

We can also check with the patient if they want to engage other people that are meaningful for them to give them more support in a systematic way if that makes sense. If there are other people available to help, they need to have a good understanding of their life journey, and we can use their past experiences in terms of self-efficacy. For example, what have they achieved in the past to have a good understanding of who they are as an individual and use those strengths in therapy?

If a teenager does not want to hear examples, what should we do?

Young people tend to attend therapy because their parents tell them to do it. Based on my experience, we need to understand their level of readiness. We also need to help them to develop an awareness of themselves and their difficulties and provide lots of information.

I like to give lots of information in different formats so they can find, in their own way and at their own pace, what is relevant. This will catch their attention. I also like not to make a big deal about that. I want to give them ownership and accountability by helping them to develop the readiness to change, providing lots of information, and trying to develop their insight. 

You mentioned the number of patients who wanted technology in treatment based on a study. Can you please repeat those results?

Based on that report, four in five Americans want to have access to technology for simple things like scheduling appointments. Additionally, what they value most is convenience, but most organizations are not aligned with that.

Summary

As we come to an end, I want to emphasize that we can help our patients to make the best of therapy. We all have the potential to improve our practice. Being here today is a great sign of your motivation to progress on that.

I would like to finish by saying that in terms of patient engagement, we cannot please all people all the time. Often, we may be too hard on ourselves as health professionals. We may overthink how a session went and beat ourselves up for not saying the perfect thing. We can even blame ourselves for our clients' progress.

Let's do our best with the resources that we have available and remember that we are humans and do not have all answers. And in this process, let's give ourselves the grace and the kindness we deserve. 

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