Lecture 5: Patient Education and Facilitating Behavior Change

Non-Compliance in PT

Not doing what is prescribed

Doing too much of what is prescribed

Never starting

Quitting Prematurely

More info does NOT = behavioral change

What is necessary for compliance

Choosing to participate

Knowing what/how plan will occur

Having the cognitive skills to do it

Motivation

Factors related to non-compliance

Lack of understanding

Health belief conflicts

Dissatisfaction with HCP

SES

Chronicity of S&S

Treatment setting, long waits, non-continuity of care, expense

Inadequate communication, poor rapport

Elements contributing to instruction

Specific impairments

Current situation

Need for health & wellness services

Transition to different roles

Plan of care

Specific disabilities

What consistutes good patient-centered instruction

Assess patient needs

Consider individual differences

Have a written plan to address needs

Provide info and skills needed

Have a variety of educational tools

Engage patient

Evaluate the learning achieved

Intrinsic motivation

Connectedness

Self-Efficacy

Autonomy

Explanatory Models for Patient Readiness

Cause of injury

Reaction to injury

What will cure injury

Personal preference

Valued activities

Expectation as a patient

Expectation as YOU as a PT

Their expectation of recovery

Questions to elicit explanatory models

Ask them what THEY thing

What has this caused you

Will it last a while

How severe do you think it is

Negotiating Shared Meaning via Explanatory Models

Engage in dialogue —> understand pts Explanatory model —> develop shared understanding —> recognize psychological and contextual factors —> consider the illness experience -> consider pt, community, etc

Motivational Interviewing

Collaborative conversation that strengthens a person's commitment to change

Used to strengthen personal motivation for and commitment to a goal by eliciting reasons for change

- Patient-centered

- supportive, yet direct

- Designed to enhance intrinsic motivation and reduce patient ambivalence about change

- recognize and support autonomy

OARS for motivation interviewing

Open-ended questions

Affirmations

Reflective Learning

Summaries

Goals of motivational interviewing

Express empathy

Develop discrepancy

Avoid arguments

Facilitate self-efficacy and positive outlook

5 R's of motivational interviewing

Relevance —> why is it important to them

Risks —> risks of non-adherence for them

Rewards —> pt ID potential rewards

Roadblocks —> ID what might get in the way

Repetition —> repeat this every time they are non adherent

Use variety in active learning, reflecting, and summarizing

It sounds like you're saying...

From your point of view...

I would imagine you....

The thing that bothers you is...

I can see why you are so angry and frustrated

I can hear how upsetting this has been for you

It must be really hard for you right now to...

Health Belief Model

Understanding how your patient is experiencing their illness

To facilitate change, we must TALK to our patients about their beliefs and how it is influencing their health behaviors

Modifying factors

-Demographic variables

- psychosocial variables

Threat Perceptions

Perceived Susceptibility —> I do/dont think it will happen to me

Perceived Severity —> it wont/will be bad

5 A's of the Health Belief Model

Address the issue —> what do you think is the problem

Assess the patient —> what have you done recently, what is motivating you

Advise the patient —> Completing your HEP will get you back to doing what you want to do

Assist the patient —> negotiating a POC, educating

Arrange f/u —> when you come back lets see how youre doing

Transtheoretical Model and Stages of Change

Non-linear model of change

May enter at any stage, relapse at any stage

Apply appropriate educational strategies based on the stage the client is in

Steps

- Pre-contemplative

- Contemplative

- Preparation

- Action

- Maintenance

- Termination/Habit

Pre-contemplation stage

No intent to change over next 6 months

Build awareness!

Contemplation Stage

Considering change over next 6 months, weighing pros/cons

Educate them: motivational interviewing

Preparation Stage

Intending to act in Next 30 days

- make small steps

Commitment, planning, small goals

Action Stage

Making change (0-6 months in to it)

Education = supportive coaching

HIGH risk of relapse

Maintenance Stage

Behavior is changed > 6 months

Integrated into life style

Relapse prevention

Independence

Termination Stage

100% self-efficacy

Confirming identity

Optimal Theory

Conditions that enhance expectancies, provide autonomy, support, and promote external focus, resulting in virtuous cycle of enhanced motor learning

Goals: improve motor performance and motor learning

Contributions to Optimal Theory

Motivation

- Autonomy - social environment, internal thoughts, values

- enhanced expectancies - belief that there WILL be positive outcomes

Attention

- External focus

Conditions that ENHANCE the learner performance EXPECTATIONS or support their need to feel AUTONOMOUS facilitates motor learning Goals

Optimal Theory: Enhancing Expectations

Initially allow more successful attempt and then add more challenges

Emphasize successful trials with DETAILED DB

- less FB on errors

Make them believe about their ability

Optimal Theory: Autonomy

Give choices/control to learner

- choose color of ball, type and timing of feedback, degree of challenge

- boost intrinsic motivation

Rate the preferences for each activity, choose what activities want to play, choose the challenge

Optimal Theory: External Focus

The way the patient monitors the task using physical and other cues to control concentration

- may influence or help differentiate between capacity, capability, and performance

Internal vs External Focus

Internal = focused on body movement, conscious feedback

- keep your feet wide and bend your knees to keep from spilling cup of water when you walk

External = direct attention away from body and TOWARD the intended movement

- unconscious, fast, reflexive feedback

- keep the tray level to avoid spilling water, reach to the target with your hand.

- ENHANCES MOTOR LEARNING

Optimal Theory example and summary

Autonomy = what would you like to do first?

Enhanced expectancies = last time you walked 100 ft, how far will you get this time?

External focus = hit the target with your hand, weight shift more

Cognitive

If I asked you about this exercise and why we do it, what would you say

Psychomotor

If I asked you to show me and demonstrate this exercise, could you?

Affective

Can you tell me why it is important for you to do this exercise