OT/PT Special

Fostering Compliance in a World of Resistance

Why Clients Resist Doing What's Best for Their Health & Advice on Getting Them to Do the Right Thing

It’s human nature to resist. We resist our temptations, what’s right, what’s wrong, and if we get it into our heads that we aren’t going to do something, then we probably won’t.

This resistance is even more evident in patients who are given a list of orders that they choose not to follow. Why is there such strong opposition when it comes to doing what’s good for our health? It’s a question that therapists and clinicians have struggled with for some time.

“Do you use sunscreen every time you walk out the door?” asks Stefanie Laurence, OT, education manager for Motion Specialties in Toronto. “None of us do. It may be good for us, but if it doesn’t fit my lifestyle or what my values are, I don’t do it.”

Susan Cwiertnia, PT, MS, clinical education specialist with VARILITE, shared the same sentiments. “All of us are guilty of not doing what is right for our health at times. Chalk some of it up to human nature, but there are many reasons that people don’t always do what is best for them. A good clinician or supplier will communicate effectively with the consumer to find out their lifestyle needs and try to find equipment that matches.”

Issues of Abandonment

In a study conducted by the Australian Institute of Health and Welfare (AIHW), 227 adults living with long-term disabilities in the United States were surveyed concerning equipment abandonment. The study revealed that a third of the devices reported by the survey group was completely abandoned. These items included crutches, walkers, canes, wheelchairs and scooters. It was noted that users continuously changed equipment until they found something that they were more comfortable with in social settings. The highest rate of abandonment usually takes place in the first year. The second peak typically refl ects a change in needs and occurs around five years after the initial use of the device.

Laurence says people are buying aids such as walkers, canes and wheelchairs from drug stores without ensuring that they fit their specific needs. Not only patients, but caregivers also purchase equipment that goes unused, especially if it is viewed as cumbersome.

Laurence notes that a mother might have the equipment to lift her 120-lb. child from his bed to transfer him to his chair, but because it’s difficult, Mom picks up the child herself without using the help of the lift .

“So the lift gets stuck in the corner, kind of like the treadmill that becomes a clothes hanger,” Laurence adds.

According to the study conducted by the AIHW, reasons that contributed to abandonment included improvement or deterioration in functional ability; performance of the equipment; and receiving equipment too easily from suppliers, which fostered the belief that it could be replaced whenever needed. However, when consumers participated in the selection of a device, it was retained more often than not.

In one study, Laurence says, equipment abandonment was at 37 percent when an assessment was made by one person, but that number dropped to 9 percent when a team approach was instituted, which signifies the effectiveness of an interdisciplinary approach. She pointed to communication among therapists, clients and sales reps as playing a key role in compliance. She says she teaches her therapists that there should be roles specifically for each member of a team.

And clients, she says, need to be experts on themselves. “I, as a therapist, can’t see every place that you’re going to use the equipment... I don’t go to school or to work or to grandmother’s house with them, so I’m relying on them to be an expert on themselves, and as a therapist I need to encourage the person to be realistic about themselves, and what their expectations and needs are for the piece of equipment.”

The therapist has to be the translator, and the salesperson has to take those parameters and look at what can be off ered. “They should be able to say, ‘We have five chairs that meet these parameters, and here’s the unique difference in each one of them.’” And the client can say, ‘Oh, I never thought about that,’ or “Is this the only one that comes in hot pink? Because hot pink is one of my goals.’ So if we give them the lime green one, they’re not going to be seen out in public with it because they wanted the pink one.”

Practicing Due Diligence

Sometimes noncompliance is a result of poor education. “Some things can be presented in a manner that is too technical or clinical for some clients, and they can feel overwhelmed or confused,” Cwiertnia says. She suggests finding out how clients best learn new information. Are they tactile, visual or auditory learners, or all three? For example, Cwiertnia found that using a pressure mapping system to teach patients how to weight shift for pressure relief is a valuable tool.

“The visual of being able to see what happens when they weight shift and how far they need to lean gets them excited and helps them to understand better,” she says.

If a client isn’t using all the functions of a chair and isn’t caring for it, Laurence has to ask whether or not all the relevant information has been provided to that client. “Have you looked with them to see why it’s important to do something, or did the equipment just get dropped off by a driver?” she asks.

If the equipment is just getting dropped off, it should at least come with a tip sheet, Laurence suggests. Clinicians can help their clients be more compliant by developing a tip/cheat sheet of how to respond when things go awry: “If you have redness, call this number. If the brake breaks, here’s who you’re going to call. It should just be a page or two of written information, not a 200-page owner’s manual.” Of course, there will always be that one person who reads the owner’s manual from cover to cover, but since most people won’t, a cheat sheet listing the top 10 things to look for and numbers to call would be helpful.

But even after clinicians simplify things, some people still can’t seem to find enough time in the day to use the equipment. “If you had a choice between doing laundry to have clean (clothes) and getting in a standing frame, which would you choose?” asks Cwiertnia. Not having enough time is often another reason given for not properly maintaining equipment, along with not having the physical ability to do so.

When equipment is prescribed incorrectly, this negatively impacts the end user. “Sometimes small changes in equipment such as a wheelchair can mean big changes for the user that aren’t realized at the time of evaluation,” Cwiertnia says. “For example, if the seat-to-floor height is increased slightly, it might make a difference in being able to use a desk at work or school because they don’t fit underneath anymore.”

In addition to prescribing equipment correctly, clinicians should also warn their clients about the risk of ordering online. “They get into trouble with this because everybody is different, and what worked for their friend might not work for them,” Cwiertnia comments. “People do this because they can purchase it cheaper, but when equipment is purchased online, you don’t have the advice of professionals or service after the purchase.” These clients need to know that they can’t just use their measurements from one wheelchair to purchase another one made by another manufacturer — it might not fit, and the chair ends up going unused or not being used for very long.

When clients don’t get what they want, it isn’t unusual for them to try to create it. Clinicians see all sorts of “MacGyvering” come through the door of the clinic, says Cwiertnia. But sometimes what they see is driven by necessity. Although it might not be textbook or ideal, it works for them. “Working in the cushion business,” Cwiertnia says, “I’ve seen people roll up towels and place them underneath their cushion to keep them from leaning to the side.”

Some clients are content with what they have or with not using what they have. In this instance, Laurence says she can’t force them to take equipment; she can only tell them they’ll be safer using it.

Getting patients and caregivers to understand the importance of using equipment for their own safety and preservation of their health or their loved one’s health is paramount. But this task can sometimes be arduous.

Many times some of the factors that contributed to the original body structure or function that has been impaired also contribute to the inability to deal with the current condition, says Ginny Paleg, DScPT, MPT, PT.

Some of the factors listed by Paleg were poor nutrition, poor access to medical care, drug abuse and poor social support, which are all risk factors for cerebral palsy and developmental delay.

“And yet these same mothers are now expected to organize multiple medical appointments and machines,” Paleg points out. “We need to re-organize our expectations.”

To make matters worse, many parents are still grieving and have not yet accepted their child’s disability. Laurence agrees. “Families either fall in one of two camps: ‘Oh my God, I don’t want anyone to know my child has a disability’ or ‘Yes, I want them to know that my child has a disability, and that he’s not just being lazy.’”

Sometimes listing out the pros and cons of using different types of equipment will help to foster compliance. Be prepared to show them evidence, Paleg says. “‘Your child cannot participate unless he’s active, and here are five studies that show using the stander and gait trainer will maintain range of motion and help your child’s hip form better. Here’s the study that says if your child doesn’t stand for three weeks, (he) will be harder to dress, wash and toilet.’”

Embarrassment is often another reason for noncompliance. Both Laurence and Cwiertnia say that sometimes families will ask for a stroller instead of a wheelchair. The stroller “isn’t so medical looking and it makes their kids look like others,” Cwiertnia says. You might have an adult who needs a wheelchair, but requests a scooter because it doesn’t look disabling. If the client uses a walker, he won’t want to use it in public, fearing that he might not have a place to store it or be able to get past tables in a restaurant.

Help Your Clients Help Themselves

Whether it’s embarrassment, lack of time, support or physical ability, figuring out the real problem in order to enact a solution entails doing some detective work, Laurence says.

“Use your phone to record the conversation,” Paleg adds. “Use a structured interview with validated standardized questions.” This is definitely the time to use your observation and assessment skills. You’ll also want to have input from each person providing therapies. “There has to be a consistent message and honesty across the board,” Laurence says, “and yes, you have to be a bit of a detective to figure out what they really want and really need.”

Let your clients know that the downside of not using equipment properly or at all is injury. The injury could have a slow onset such as overuse syndrome of the shoulder, or it could be sudden if the equipment failed because of a lack of maintenance, Cwiertnia says.

Communicate constantly. Even after having done an assessment, clarifying questions still have to be asked, Laurence says. “Someone has to sit down and say OK let’s just clarify: We’re looking for something that’s going to do this and this and that. And the client might say, ‘Wait a minute, I didn’t mean that.’ So you have to set your goals to communicate back and then revise what the goals are.”

Everyone must be on the same page. When talking to a client who’s getting a new wheelchair, Laurence says she finds out what he liked about his existing wheelchair and what he didn’t like. “Their expectation is that the new one will have all of the good features of the current one and none of the bad ones. But if you don’t know what they like about their current equipment, you’re taking a shot in the dark without doing your homework.”

It’s OK to use humor and personal stories to build relationships with your clients. But remember: Timing and delivery are important. Laurence recalls a situation where a clinician was concerned that her client might fall, so she told him that he should not be walking. As the client headed for the door, he looked back and said ‘I’ve been walking this way for 60 years, why stop now?”’ Laurence followed the client and asked if he would take the clinician’s advice, and he said no. She believes a better approach would have been to say, ‘I know that walking is important to you and that you have walked for a very long time. Let’s do some brainstorming about what we can do to make it safer for you.’” The difference between the two approaches? The first method didn’t involve the patient in the process, whereas the second one did.

Linking people who have the same equipment needs allows them to share tips, frustrations or suggestions, and is an overall good idea. Laurence says one could even serve as a mentor for the other: “You don’t feel like you’re alone and that you’re the only person that feels this way or that is using this equipment.”

Encourage clients to borrow or rent equipment before making a purchase. Laurence believes this is especially helpful when trying to prescribe equipment for those with new injuries. Renting the equipment before making a purchase is the best route to go when they don’t fully understand what their new routine will be like, she says.

As with anything else, there has to be buy-in from clients, and they must understand why the equipment is being used and must have goals. But Laurence realizes that no matter how much education and support is given, there will always be a select few who will resist. She referred to the study where compliance decreased from 37 percent to 9. “There’s always that 9 percent, so if you think that every piece of equipment will be used every time, let’s be honest. I have shoes in my closet that I don’t wear and vitamins that I don’t take, and it doesn’t matter how much I know. People are always going to have a residual amount of resistance because there’s no perfect piece of equipment for everybody.”

Clinician’s Orders: Tips to Help Your Clients Comply

  • Create a cheat sheet. Develop a tip sheet with answers to some of the most common problems along with numbers to call when those problems occur.
  • Determine how the client learns best. Education is the key to success for both clinicians and clients.
  • Exposure is crucial. Take clients to shows and expose them to the
    equipment that they will use.
  • Make a list. List the pros and cons to reiterate the effects of compliance and noncompliance.
  • Get them to try something borrowed before getting something new. Encourage clients to borrow or rent equipment for as long as they need to before making a purchase.
  • Link up. Link people with similar injuries or families who have children with the same condition.
  • Take a team approach. Do your due diligence by talking to everyone involved in the client’s therapy.
  • Practice total involvement. Never leave the client out of the decision-making process.
  • Don’t take it personally. There will always be a percentage of clients who won’t comply for whatever reason, and there’s nothing you can do about it.

This article originally appeared in the September 2012 issue of Mobility Management.

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