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Commitment Over Compliance: Communication Strategies for the 3 Stages of Patient Engagement

Patient engagement is an integral part of physical therapy. Most patients do not begin physical therapy with the same outlook with which they will leave it. As rehabilitation professionals, our approach to communication is the foundation upon which this transformation will take place, and it is a skill that we can all improve.

October 26, 2021

8 min. read

Patient engagement is an integral part of the physical therapy process. The traditional view of engagement has been that its either something patients do or do not do, but this is an incomplete way of looking at a very complex issue, and it omits our role in their recovery.

As rehabilitation professionals, we are uniquely positioned to foster higher levels of patient engagement. It can be very rewarding to watch patients become actively engaged in their health as you work with them. Our approach to communication is the foundation upon which this kind of transition takes place, and its a skill that we can all improve upon.

What Is Patient Engagement?

True patient engagement goes beyond adherence and compliance. We would be better served to view patient engagement as a broader concept in which patientstake a genuine interestin their own health andbecome able and willingto participate in interventions that promote their own wellbeing.

This is not a state of being that a patient either is or isnt when you first meet them. Patient engagement is askillthat can be learned,and to get there, we must meet patients where they are.

The 3 Phases of Patient Engagement

Most patients do not begin the rehabilitation process with the same outlook with which they will leave it. Patient engagement is a journey, and it can be divided into three phases: dependence, empowerment, and self-determination.

Phase One: Dependence

In this initial phase, patients are typically in a great deal of fear. They may also be feeling unsure, helpless, overwhelmed, and discouraged. This is largely where patients will require the most help and will look to their care provider for a lot of instruction and tactile cues.

Because they lack confidence in themself, patients will seek that confidence inyourability to helpthem. Patients in this phase will require extra positive reinforcement and are more likely to turn over all decision making to you to avoid feeling additional overwhelm.

  • Dependent patient thinking: I cant do this.

Phase Two: Empowerment

This secondary phase is where patients will build confidence in their ability to help themself recover. They will feel more curious and more empowered (given that youre still there.) They may show an active interest in how their body works by asking questions about not only what they should be doing but why they should be doing it.

In this phase, patients will begin to think of you as someone helping them learn how to do this on their own. Their mentality is more productive as they begin to view themself less as someone broken and more as a patient in need of treatment.

Though they will usually still prefer to do exercises in your presence, youll notice that this is where patients are more likely to adhere to a home exercise program and/or begin addressing certain problematic lifestyle behaviors. Your patient will show visible interest in becoming involved in decision making, so they are able to make self-informed adjustments, although the therapist is still guiding the discussion.

  • Empowered patient thinking: I can do thiswith your help.

Phase Three: Self-Determination

In this final phase, patients feel positive, confident, and in control of their own health, possibly for the first time they can remember. Their engagement in home exercise programs stems from a desire to help themself, rather than because they ought to.

Your intervention is needed occasionally rather than regularly and pertains to a specific question, the goal of which is to be even more informed and better able to help themself. Your patient will begin to see you as someone who is in thiswiththem, available for help when needed, but believes in their ability to help themself. Here, patients want to take charge of their health and to be able to make their own decisions on demand.

  • Self-determined patient thinking: I can do this, and if I get stuck, I know what to do.

Phifer - Patient Engagement

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Phifer - Patient Engagement

Communication Strategies for the 3 Phases of Engagement

In considering our approach to patient communication, it is helpful tothink with and in:we want to ensure that we areengaged withour patient and that our patient isengaged inthe process. Given that this is a rather broad concept, here are some specific strategies to apply during each of these three phasesand a few to avoid.

Dependance Phase Communication

DO:

  • Build trust by demonstrating empathy and validating the patients experience.

    • Im sorry youve had to deal with this.

    • I would feel _____ in your situation, too.

  • Find the positive through the use ofMotivational Interviewing. For example:

    • On a scale of 1 to 10, with 1 meaning not the least bit ready and 10 meaning totally ready, how ready are you to ________?

    • When the patient responds, ask why they didnt provide a lower number. This helps them (not you) identify what it is in their own life that motivates them to make this change. The more they can think about their personal motivations, the more inclined they will be to follow through.

  • Demonstrate your commitment

    • Follow up with your patient. Call them the next day just to check in and see how the first day of their exercise or new behavior went.

    • Encourage them to contact you by providing your business card, email address, or even your cell phone number. Most are unlikely to use this, but knowing its there might give them the support they need to make a start.

DON'T:

  • Give them too much to focus on. Instead, minimize the physical and mental load. Keep things simple to avoid overwhelm. This might look like an HEP that has one exercise on it.

  • Use controlling language when asking questions and/or giving commands. Instead, avoid setting negative expectations about the treatment, which may provokethe nocebo effect.

  • Double up or rush their sessions. Allowing for plenty of time and 1:1 focus instead will help build the relationship of trust and ultimately lead to better engagement.

 

Empowerment Phase Communication

DO:

  • Bring the patient into the process.

    • Ask questions such as: What questions do you have? and How does that work for you?

  • Highlight care that didnt require your involvement.

    • For example, if a patient with a thoracic rotation limitation previously required manual manipulation to their thoracic spine to provide relief, and is now able to create that relief by performing an exercise on their own, youll want to highlight that not only is their condition improving (which gives them hope for recovery) but also that they were able to create that result themself by following your guidance (which gives them added motivation to adhere to their HEP.)

    • Here, youll also want to phase out the manual therapy and phase in more home exercises.

  • Introduce discussions about behavioral change.

    • What role do you think smoking plays in how you were feeling? The goal of this conversation isnt to enact immediate change, but to get the patient thinking about it.

DON'T:

  • Indulge the patients inclination to rely on you. Instead, encourage any attempts toward independence. Less doing to and more doing with.

  • Highlight what didnt work. Even if a patient tries something on their own and doesnt get the desired outcome, stay positive!

    • Point out that the patient just discovered a way that doesnt work for them. You could say something like Everyone has a unique nervous system, and now we know what does and doesnt feel good for yours. Thats important data that you helped us collect!

 

Self-Determined Phase Communication

DO:

    • Ask the hard questions to prepare for whats next.

      • Where do you want to be? What do we need to do to help get you there? What do you think the next step is?

    • Complete their care by reviewing where they started and where they are now. Remind them they have everything they need to stay in control of their own health. Prepare them for the eventuality of future pain by reminding them of what they learned. If at any point thats not enough, youre still there and you can get them in any time.

    • Remind them that their story is powerful. They now have the ability to help others by spreading the word about their journey.

      • Ask the patient if they would be willing to share their experience with those who are in situations like theirs before they sought your help. Rehabilitative care isnt always top of mind when someone is experiencing pain or another challenge, but your patients experience shows firsthand how powerful the results of treatment can be not only to treat the initial concern, but also to improve the quality of ones life.

    DON'T:

  • Get upset when the patient doesnt do everything you ask. Instead, step back and remember that this is a natural part of the process and its healthy for them to explore boundaries. We must help patients explore the vision for their health and what they can do beyond this process.

To further develop your understanding of patient engagement and expand your communication skills in this area, I offer acomprehensive coursethat explores these three phases in-depth, as well as team strategies to consider when communicating with the patients family and other members of their healthcare team.


Below, watch Craig Phifer discuss the swimming analogy for the 3 phases of patient engagement in this short clip from his MedBridge course, "Enhancing Patient Engagement Throughout the Course of Care."

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