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
- By Lunzeta Brackens
- Sep 01, 2012
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
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
- 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.