The Relationship Between Adherence and Perceived Self-Efficacy: How To Improve Functional Outcomes By Motivating Your Clients

Editor’s note: This text-based course is a transcript of the webinar, The Relationship Between Adherence and Perceived Self-Efficacy: How To Improve Functional Outcomes By Motivating Your Clients, presented by Caryn Shore-Genack, MS, OTR/L.

Introduction and Overview

Thank you for participating in today's session. To begin, I'd like to share a bit about my background. I returned to school later in life and graduated in 2011 with my Master's of Science and began practicing almost immediately after receiving my board credentials the next year. I began in geriatrics with a strong focus on sub-acute care. I also worked for a PACE program, which a program for the All-inclusive Care of the Elderly, which was an outpatient setting that helped facilitate elderly people remaining at home independently and safe for as long as possible. I have worked in home care, both Medicare Part A, Medicare Part B, managed care. I do outpatient upper extremity orthopedics. In the last year and a half, I made the transition to pediatrics. I do school-based assessments, early intervention, and school-based care. I enjoy teaching very much. In fact, am teaching a course in Touro College this semester and recently gave a lecture on this subject. I presented these slides (which have been edited for the purposes of this one-hour presentation) at the end of last year at the state-level conference. I have previously given other webinars for OccupationalTherapy.com that I hope you'll take a look at. I'm pleased to be sharing this information with you today.

As a way of introduction, in the ever-changing climate of medical reimbursement, it remains more relevant than ever to focus on generating improved functional outcomes for our patients. It is well-documented that therapeutic interventions will be ineffectual if clients are unsuccessful in generalizing them into their daily routine. The field of occupational therapy believes that through therapeutic use of self, the skilled practitioner can select the just-right challenge, and in the process, have a positive impact on the self-efficacy of their clients. The current evidence-based literature indicates a direct correlation between perceived efficacy and adherence. Nonetheless, why is it that adherence is such an uncommon phenomenon?

I want you to think about your current practice setting, and ask yourself the following questions:

1) What is the current rate of compliance to attend sessions in your current practice setting? 

• 25-50%
• 50-75%
• 75-100%

2) Is this comparable to similar settings (yes or no)?

3) Which outcomes appear to be most likely associated with higher follow-up appointment rates (select all that apply)?

• Increased independence for (I)ADLs
• Decreased pain
• Increased range of motion
• Increased strength
• Other

4) Are there common client characteristics that are associated with the likelihood for returning to follow-up appointments (select all that apply)? 

• Strong desire to return to paid work or family role
• High level of respect for authority or advanced education
• Low tolerance for pain or discomfort (seek relief)
• Understand the benefits and purpose of selected activities
• Belief in the efficacy of selected activities

5) Are there common provider characteristics (select all that apply)?

• Level of education
• Empathetic
• Good listener
• "Drill sergeant"
• Provides clear instructions and explanation of activities

One client characteristic that is associated with the likelihood of returning to follow up appointments is whether or not they understand the benefits and purpose of our prescribed activities. They need to have "buy-in" in order to want to return to see us. Another common motivating factor for keeping follow-up appointments is the client's desire to go back to work or resume their role within the family. Additionally, and understandably, clients come back and see us because they want to seek relief from their pain, and they also believe in the efficacy of these activities to relieve their pain and enable them to engage in their regular routine.

With regard to the characteristics of occupational therapy providers, having empathy and being a good listener is important in the field of OT to understand the client and help them to achieve their desired goals. We also need to provide clear instructions and explain activities in order to guide the client to properly perform different exercises and tasks. With regard to being a "drill sergeant", there are patients who need that cold, direct, medical model approach. Each patient needs something different from us in order to produce positive results. It's important for us to implement a therapeutic use of self and be able to manipulate our personality and communication style, depending on what motivates the patient. 

Operational Definitions: Adherence and Compliance

In some of the literature I've read, the terms adherence and compliance have been used interchangeably. However, in an article by Redomski (2011), he clarifies the difference between these two terms:

Adherence is the degree to which patients and research participants act in accordance with the advice of their clinician or researcher.

Compliance connotes patient passivity and obedience and suggests behavioral change without internal acceptance.

Adherence has more positive connotations than compliance. The literature indicates that for patients who adhere to their programs (e.g., home exercise programs, home modifications, keeping appointments, medication management), in the long run, you may document that patient as compliant. Conversely, if the patient is not compliant, that denotes a power struggle. The patient that is adherent is the patient that's going to make a lifestyle change and implement these recommendations as habits, which is our ultimate goal.

Barriers

It's important to keep in mind that barriers are not excuses. These are real obstacles in the road for our patients. We need to be sensitive. We need to problem-solve with our patients which barriers they can anticipate, which barriers they're already experiencing, and perhaps even match them with supports in the community.

As we discuss barriers across different populations (e.g., athletes, geriatrics, people with mental health issues), there is some repetition, as different populations may experience the same barriers. For example, the mental health patient is not necessarily going to have a physical disability as a barrier but may share other characteristics with the geriatric population and the athlete.

Physical Dysfunction: Athletes/Physical Activity

With the athlete, this is not necessarily physical dysfunction, but perhaps we're mediating an injury. The barriers may be related to cognitive issues, emotional issues, and behavioral issues.

With regard to the cognitive, this does not necessarily relate to having a cognitive impairment, but it involves the thought process and understanding the nature of the injury, the goals of the prescribed treatment, and the prognosis for recovery. When we get to models, we are going to discuss the fact that patients perceive injuries and disabilities in different ways. They can either believe that it's worse than it truly is, or they may not acknowledge the severity. Does the patient have an accurate understanding of the injury? They may have a good understanding of the injury and be aware of how their body feels, but do they understand why you've selected these particular exercises or activities, either in the clinic or for their home exercise program? How do they feel about their prognosis? What has the doctor said? What is the timeline? Do they believe that recovery is possible?

Emotional issues that may cause barriers to therapy include (but are not limited to) anxiety, blame, guilt, and anger. With regard to behavioral issues, action is required by the patient. In the psychological literature, behavior is not a positive or negative behavior, it's not a professional behavior. Behavior is the outcome. It's a measurable action. In some cases, as the saying goes, you can bring a horse to water, but you can't make it drink. We can give our patients the tools, but are they going to participate in the session when they're present? Are they going to carry it over into their personal lives? If so, for how long (Christakou and Lavalle, 2009)?

Physical Dysfunction: Geriatrics/Physical Activity

Within the geriatric population, one of the barriers to compliance may be ill health and change in health status. One of the components of this includes pain. Pain may or may not be a factor in terms of compliance. The literature indicates that pain can be a huge barrier and that we should encourage our patients to communicate their pain experience. If they're skipping a session because they overdid their home exercise program and now they're in too much pain, or they discontinued their home exercise program because it hurt too much, we want that information. Likewise, we want to use the time in the session to decrease the patient's pain and give them strategies for managing their pain.

Another barrier to compliance with home exercises may be that the person lives in an unsatisfactory physical environment, such as a neighborhood that has poor sidewalks or has a high crime rate. A patient may not be able to get to the clinic or to a recreational facility because of those same environmental reasons, or due to lack of transportation. They may have a lack of social support and not have family living nearby who can give them a lift or help them.

If a lack of time becomes a barrier, we want to ask the patient when are they available to come to sessions, how frequently during the day, and at what time can they do their exercise program. How can we help them break it down so that they're more successful at performing it? Additionally, the patient may exhibit a lack of interest in performing their exercises or increasing their activity. 

Money often is a key factor for many populations. It may be a motivator, where a person wants to go back to work and they diligently perform their exercises and adhere to their program. Or, money can become a barrier, where they don't want to take time off work in order to come to an appointment. It may be that they can't afford the transportation, the medication, or the copay.

Fear of can either be a motivator or a barrier. Understandably, the patient doesn't want to be re-injured. Perhaps the patient is fearful of being injured in your care. They may have a lack of knowledge and understanding regarding the need for increased activity. Sometimes we have pain and stiffness, and initially, it hurts. We have to educate our patients that motion is lotion, and they are not going to feel better if they don't move. Select exercises with your patient that will help them move throughout the day. All of these are opportunities for intervention (Adams-Fryatt, 2010).