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Compliance with Hand Rehabilitation
Compliance with Hand Rehabilitation: Health Beliefs and Strategies Gail N. Groth, OTR/C, CHT Mary Beth Wulf, OTR/C, CHT Milliken Hand Rehabilitation Center, Barnes Hospital, St. Louis, Missouri
C controllable variable in medical intervention. It can strongly sway the outcome of any treatment.
ompliance is the most unpredictable, least
Yet, too often we confidently provide treatment without making the issue of compliance a priority. Three years ago we retrospectively examined the clinical outcomes of patients who had had mallet finger injuries. Much to our surprise, we found compliance to be the critical factor in the final outcome.! This finding has led us to examine the issue of compliance more closely. The Clinton administration has unwittingly forced the issue of compliance into the foreground. The degree to which health care will undergo reform is unclear, but the percentage of people enrolled in managed care plans will undoubtedly increase. Managed care plans, which currently pay for an average of 6.7 treatment visits per referral,2 will not accommodate noncompliant patients. Similarly, the framework for the impending reform will be health promotion and disease prevention. 3 This will place the responsibility of compliance on patients. For the purposes of this article, compliance is defined as active engagement in the rehabilitation process. As therapists, our role in ensuring compliance is to assist our patients in their engagements, enabling them to make informed and affirmative choices. To do this, we must be aware of the external and internal factors that influence compliance and the strategies to improve compliance. Accordingly, this article broadens the therapist's awareness of the issue of compliance through exploration of external and internal factors, identification of methods of measurement, and discussion of improvement strategies that relate to specialized treatment of the hand.
SCOPE OF NONCOMPLIANCE Poor compliance with the medical regimen is a major problem in the healing/recovery process. Fedder states a simple rule of thumb: one-third of patients Presented at the Sixteenth Annual Meeting of the American Society of Hand Therapists, Kansas City, Missouri, October 1993. Correspondence and reprint requests to Gail N. Groth, OTR/C CHT, Milliken Hand Rehabilitation Center, Barnes Hospital, One Barnes Hospital Plaza, Suite 17430, St. Louis, MO 63110.
18
JOURNAL OF HAND THERAPY
always comply, one-third never comply, and onethird sometimes comply. Rates of compliance with splint usage vary from 23% to 65%.5,6 Estimates vary greatly depending on the method of measurement, the patient's age, and the definition of compliance. Rates of compliance with exercise regimens range from 40% to 55%.7 Compounding the problem is the difficulty in predicting compliance. Sackett states, "Every time the ability of clinicians to predict the future compliance of their patients has been put to a rigorous test, clinicians have failed to outperform the toss of a coin." 8 TABLE 1.
External Factors Influencing Patient Compliance with Hand Rehabilitation
• The longer the elapsed time between the referral and the actual appointment, the lower the likelihood that the appointment will be kept. 21 . 22 • A long stay in the waiting room negatively affects compliance. 23 • Referring physicians can positively affect compliance through communicating to the patient how critical our intervention is. • If there is a good working relationship between the referring physician and the therapist, the patient will more likely receive consistent information, which will enhance compliance.
• A patient will more likely comply if he or she is told to make an appointment with a specific therapist, rather than with a clinicY • Compliance decreases as the duration of the treatment increases. 25 • The more treatment sessions scheduled, the lower the compliance. 2h • There is a negative correlation between age and the ability to recall information 27 • With a local and stable family, compliance may well be enhanced. 2H • The patient's health insurance, general financial situation, and work schedule may affect compliance with attendance (if not exercises) . • Inconveniences associated with clinic accessibility. • Fifteen percent of patients have identified lack of transportation to the C/illic as the reason for failing to take their medicines'at IlOlIIe!2" • Low literacy and illiteracy limit problem-solving ability and reading comprehension. 2H • Ability to remember instructions.'"
FACTORS INFLUENCING COMPLIANCE
INDIVIDUAL PERCEPTIONS
MODIFYING FACTORS
LIKELIHOOD OF ACTION
[~DemQQra~hiC v~-(oge, sex, I
In a comprehensive review of the literature, Haynes identified over 200 factors that correlate with compliance.') We have chosen to categorize these into external and internal factors. External factors are those that have an impact on the patient through his or her environment (Table 1). Many of these factors are easily recognized by clinicians. Moreover, if all of the external factors working to improve compliance were stripped away, noncompliance still would not improve unless the internal factors were addressed. Therefore, we have decided to focus on internal factors. Internal factors relate to the patient's health belief system and have a significant impact on compliance. There are several theoretical models directed at health beliefs and their influence on patient behavior. The Health Belief Model (HBM) (Fig. 1) was proposed by Becker lO in 1974 to examine the interrelationship of factors that relate to compliant behavior. We have adapted components of this model, applying them to hand rehabilitation (Fig. 2). Each component is described as follows.
!---,----~ SociQosycbologjcgl variables
;
of
minul
I
and reference group pressure, etc.)
.
i P~rceiv~d,Susceptibiljty to
I Diseas.e X
~
preventive action
I(personality, social closs, peer
i y
I
Perceived
I
I race, elhnlcity, elc.)
.
I, Percer,ved Senousness
~
I
I
I
I
Y
,
~II i s e o s e ' x '
: (seventy) of Disease "X" ...-J! L-_________
I
Perceived Threat of
..
r-
J
.....-
Actk;~~
--------1
oMas,s medio campaigns ·Advlce from others
I
I-
----Cu •• to
l ·Reminder postcard from
physician or dentist ·lIlness of family member or friend .Newspaper or magazine article
I
FIGURE 1. The Health Belief Model. This model examines the interrelationship of factors that relate to compliant behavior. Reproduced with permission from Becker et at. I()
absolute immobilization will not comply with the rehabilitation program.
Perceived Efficacy of Rehabilitation
Perceived Susceptibility to Loss of Hand Function
The patients's perception of the effectiveness of treatment plays a role in the patient's compliance. For example, if a patient believes that wearing a protective splint following a flexor tendon repair will not prevent tendon rupture, he or she will be less likely to do so. If a patient feels he or she has no control over the outcome of the disease or injury, he or she will be less likely to invest time in the home exercise program.
A patient who undergoes ray amputation of the index finger will be more likely to comply with his or her home strengthening program if he or she believes that weakness will interfere with performing valued functional tasks.
Perceived Severity of Injury
Perceived Relationship between Costs and Benefits of Rehabilitation
It is not the actual seriousness of the injury that determines compliance, but rather the patient's perceptioll of the disease or injury. This perception can vary from patient to patient. For example, a patient who has a nonarticular hairline fracture of the index metacarpal and believes that every fracture warrants
The benefits of rehabilitation can be thought of as the rewards of rehabilitation. Increased hand function, return to work, and reengagement in activities
Perceived efficacy of rehabilitation
Perceived of Injury
FIGURE 2. The Health Belief Model as adapted for hand rehabilitation.
severity
Perc.lved susceptibility to loss of hand function
Self-Efficacy
Pa t lent-Pra ctlt loner RelatIonship
/-----<.
t Socioeconomic Environment Medical History & Environment
January-March 1995
19
of daily living (ADL) are typical rewards. The costs of rehabilitation might be pain and loss of personal time. For example, if a patient is to perform home exercises following a flexor tenolysis, the benefits of increased range of motion must outweigh the costs of frequent dressing changes and pain during exercise. Self-efficacy Self-efficacy is a concept proposed by Albert Bandura, a social learning psychologist. II This concept refers to a patient's perception of being competent in performing the recommended treatment. Bandura would say that a patient will not exhibit a specific behavior (compliance) unless he or she feels competent in doing so. Patient-Practitioner Relationship Good communication skills and a warm, empathetic manner are the basic ingredients for success. 12 A positive tone increases satisfaction. 7 Compliance is frustrated by faulty communication, ignoring or overlooking the patient's concerns, medical jargon, and unclear instructions. Patient satisfaction improves compliance. Patients are most satisfied by physicians who are knowledgeable, trustworthy, confident, and enthusiastic. They are influenced by physicians who expect positive results! 4 How the physician communicates this conviction also affects compliance. 13 Feinberg showed that 61 % of the patients complied when the physician was personable; when the physician was business-like, only 35% of the patients complied. 7 The patient's active participation in the relationship improves compliance. An example is the process of setting and achieving goals. The goals must be mutually agreeable, explicitly defined, and potentially achievable. 12 Danielson and Wanzel found that exercisers who failed to attain their own exercise goals dropped out roughly twice as fast as did those who did attain their goals. 14
therapists may be uncomfortable relying on subjective measures. However, clinical judgment is a rich source of information that should not be dismissed. Multiple methods of measurement should be used to most accurately assess compliance. Ideally, both an objective method and a subjective method are included. For example, Codori et a1. report that if a patient is able to perform prescribed exercises at a follow-up visit, he or she will most likely report compliance with the exercise program as well. 19 They conclude that proficiency evaluations, along with selfreports, may be used to assess compliance.
IMPROVEMENT STRATEGIES There are specific strategies to improve compliance (Table 2). We emphasize that the use of a combination of strategies will be most effective. 12 In adTABLE 2.
Strategies to Improve Patient Compliance with Hand Rehabilitation
• Address sources of patient and/or family dissatisfaction. • Strive to integrate the home program into a patient's ADL * regimen. no • Emphasize ADL patients should or should not do. • Provide information about expected treatment response times (e.g., 10-12 weeks for full tensile strength of flexor tendon repairs). • Reduce the complexity of regimens (e.g., reduce the number of exercises) . • Demonstrate, and have the patient rehearse, complex exercise/ splint regimens. • Reeducate periodically when the duration of treatment is long. • Distinguish between different types and purposes of exercises and splints. • Make the first appointment within one or two days of the referral. • Provide either telephone or postcard reminders. • Immediately follow up on broken appointments. • Pleasant atmosphere of the patient treatment area: good lighting, coffee, music.
METHODS TO MEASURE COMPLIANCE
• When possible, one-on-one conversation in addition to supervised treatment.
A number of objective and subjective methods are available to therapists to measure compliance. The most objective measures of compliance include mechanical counters,15 attendance records,1 direct observation in therapy,16 exercise proficiency evaluations,19 and wear of splints. 31 The advantage of objective methods is that bias is minimized. A disadvantage is that compliance with home exercise programs (which typically constitute the bulk of treatment) will not be evaluated with these methods. Subjective measures of compliance include selfreports,6 family reports, 5 and clinician judgment. 17 Self-report is the most commonly used method. Selfreports identify 50% of noncompliers. 18 " ... when [patients 1 admit that they have a compliance problem, they are virtually always telling the truth"!8 Some
• Apply principles of learningO?: brevity, organization, primacy, readability, repetition, specificity.
20
JOURNAL OF HAND THERAPY
• Start with the simple and move to the complex. • Nonverbal behavior affects the amount of information our patients receive." • The manner of communication may be as important as the content of the communication. • Behavioral tools'": shaping, behavioral contracts • Self-management: the process of recording, interpreting, and responding to behavior." • Encourage the patient to recognize self-defeating thoughts whi1e exercising. Replace these with positive coping statements.'" • Establish meaningful, positive reinforcement.'" *ADL
=
activities of daily living.
dition, Southam and Dunbar 20 have established guidelines to assist therapists in facilitating compliance. These guidelines have been adapted to the field of hand rehabilitation. 1. Assess the whole person and not simply the hand condition. Information regarding the patient's perceptions, beliefs, goals, and self-efficacy needs to be gathered through the use of interviews or questionnaires. Also, learning limitations and external factors that may serve as barriers to compliance need to be identified. 2. Consider the prescribed regimen from the patient's perspective. It is conceivable that the patient may have other life demands more salient than his or her hand condition. It is important to consider the patient's lifestyle, priorities, and resources. 3. Establish a collaborative relationship based on negotiation. Determine where patients can execute some control in the treatment program. Allowing patients to be actively involved in the decision-making process will help to nurture a collaborative relationship, which will enhance compliance. A treatment program that is acceptable and carried out accurately is better than an ideal program that is ignored. 4. Be patient-oriented. Written and verbal treatment recommendations need to be delivered in a clear and specific manner. Patients also need positive reinforcement for their efforts and achievements. This reinforcement will have a greater effect than threats and negative reinforcement. 5. Customize treatment. Individualized patient education is as important as individualized treatment protocols. Treatment intervention should require the least amount of change in established habits of lifestyle. Give specific suggestions about how patients may integrate their home exercise programs into their ADL. 6. Incorporate family support. When appropriate, family members and friends can be helpful allies by reminding patients of their home programs, precautions, and goals. 7. Provide continuity of care and accessibility. Patients should view the therapist as sincere, respectful, accessible, knowledgeable, and competent. Patients need to feel comfortable asking questions and verbalizing concerns. 8. Utilize other health care providers and community resources. Facilitating compliance should be viewed as a cooperative goal of the entire health care team. Inform the patient, when necessary, of the various community resources for dealing with psychological and emotional problems. 9. Repeat everything. The level of compliance may fluctuate throughout the treatment process, requiring ongoing evaluation and ongoing instructions. Therefore, educational and motivational interventions require repetition. 10. Don't give up. Far too often, noncompliant patients are viewed as uncooperative and undeserving of good clinical outcomes. Just as the patient should not give up on the exercises, the therapist should not give up on the patient.
CONCLUSION Compliance has a profound impact on the clinical outcome of hand injuries or diseases and demands the therapist's attention. Compliance is also becoming pivotal as the U.S. government considers health care reform. Though compliance is an elusive variable in clinical treatment, it is a variable that can be defined, measured, and fostered. Acknowledgments The authors thank Dorothy Edwards, PhD, for her help in organizing and editing the manuscript, Kathy Mantz for the manuscript graphics, and the patients of the Milliken Hand Rehabilitation Center for stimulating our interest in this topic.
REFERENCES 1. Groth GN, Wilder DM, Young VL: The impact of compliance on the rehabilitation of patients with mallet finger injuries. J Hand Ther 7:21-24, 1994. 2. Englehardt D. Personal communication, 1993. 3. U.S. Department of Health and Human Services, Public Health Service: Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Publication No. (PHS) 91-50212. Washington, DC, Superintendent of Documents, U.s. Government Printing Office, 1991. 4. Fedder DO: Managing medication and compliance: physicianpharmacist-patient interactions. J Am Geriatr Soc 30(11):5113117, 1982. 5. Oakes TW, Ward JR, Gray RM, Klauber MR, Moody PM: Family expectations and arthritis patient compliance to a hand resting splint regimen. J Chronic Dis 22:757-764, 1970. 6. Feinberg J, Brandt KD: Use of resting splints by patients with rheumatoid arthritis. Am J Occup Ther 35:173-178,1981. 7. Feinberg J: The effect of patient-practitioner interaction on compliance: a review of the literature and application in rheumatoid arthritis. Patient Educ Couns 11:171-187,1988. 8. Sackett DL: A compliance practicum for the busy practitioner. 111 Haynes RB, Taylor DW, Sackett DL (eds): Compliance in Health Care. Baltimore, The Johns Hopkins University Press, 1979, p 288. 9. Haynes RB: Strategies for improving compliance: a methodological analysiS and review. hz Sackett DL, Haynes RB (eds): Compliance with Therapeutic Regimens. Baltimore, The Johns Hopkins University Press, 1976. 10. Becker MH, Maiman LA, Kirscht JP, Haefner DP, Drachman RH, Taylor DW: Patient perceptions and compliance: recent studies of the health belief model. In Haynes RB, Taylor DW, Sackett DL (eds): Compliance in Health Care. Baltimore, The Johns Hopkins University Press, 1979. 11. Bandura A: Self-efficacy: toward a unifying theory of behavior change. Psycho I Rev 84:191-215, 1977. 12. Meichenbaum D, Turk DC: Facilitating Treatment Adherence. New York, Plenum, 1987. 13. Hulka BS: Patient-clinician interactions and compliance. 111 Haynes RB, Taylor DW, Sackett DL (eds): Compliance in Health Care. Baltimore, The Johns Hopkins University Press, 1979. 14. Danielson RR, Wanzel RS: Exercise objectives of fitness program dropouts. 111 Landers DM, Christina RW (eds): Psychology of Motor Behavior and Sport. Champaign, IL, Human Kinetics Publishers, 1971. 15. Carpenter JO, David LJ: Medical recommendations: followed or ignored? Factors influencing compliance in arthritis. Arch Phys Med Rehabil 57:241-246, 1976. 16. Dunbar J, Dunning EJ, Dwyer K: Compliance measurement with arthritis regimen. Arthritis Care Res 2(3):8-16, 1989. 17. Moon MH, Moon BA, Black WAM: Compliance in splintwearing behavior of patients with rheumatoid arthritis. N Z Med J 83(564):360-364, 1976. 18. Haynes RB, Sackett DL, Gibson ED, et al: Improvement of medication compliance in uncontrolled hypertension. Lancet 1:1265-1268, 1976. 19. Codori AM, Nannis ED, Pack AD: The development of a
January-March 1995
21
20. 21. 22. 23. 24. 25. 26. 27. 28.
22
clinical measure of compliance with hand rehabilitation. J Hand Ther 5(1):29-33, 1992. Southam MA, Dunbar JM: Integration of adherence problems. ill Meichenbaum 0, Turk DC (eds): Facilitating Treatment Adherence. New York, Plenum, 1987. Finnerty FA, Shaw LW, Himmelsbach CK: Hypertension in the inner city: detection follow-up. Circulation 47:76-78,1973. Glogow PH: Noncompliance: a dilemma. Sight Save Rev 2934, 1973. Alpert JJ: Broken appointments. Pediatrics 34:127-132, 1964. Rockart JF, Hofmann PB: Physician and patient behavior under different schedule systems in a hospital outpatient department. Med Care 7:463-470, 1969. Bergman AM, Werner RJ: Failure of children to receive penicillin by mouth. N Engl J Med 268:1334-1338, 1963. Brand F, Smith R, Brand P: Effect of economic barriers to medical care on patient's noncompliance. Public Health Rep 92:72-78, 1977. Ley P: Primacy, rated importance, and the recall of medical statements. J Health Soc Behav 13:331-337, 1972. Hussey LC, Gilliland K: Compliance, low literacy, and locus
JOURNAL OF HAND THERAPY
of contro!' Nurs Clin North Am 24(3):605-611, 1989. 29. Shulka R, Singh G, Jain SK, et al: Impact of extra motivation among tuberculosis patients on the duration of their unknown drug continuity: a multivariate approach. Indian J Med Sci 37:23-28, 1983. 30. Ley P: Psychological studies of doctor-patient communication. 111 Rachman S (ed): Contributions to Medical Psychology. Oxford, England, Pergamon, 1977. 31. Nicholas JJ, Gruen H, Weiner G, Crawshaw C, Taylor F. Splinting in rheumatoid arthritis. l. Factors affecting patient compliance. Arch Phys Med Rehabil 63:92-94, 1982. 32. Ice R: Long term compliance. Phys Ther 65(12):1832-1839, 1985. 33. Knapp ML: Nonverbal Communication in Human Interaction, 2nd ed. New York, Holt, Rinehart and Winston, 1978. 34. Martin JE, Dubbert PM: Behavioral management strategies for improving health and fitness. J Card Rehabil 4:200-208, 1984. 35. Fisher CA: Adherence to sports-injury rehabilitation programmes. Sports Med 9(3):151-158, 1990. 36. Cuneo YO, Snider DE: Enhancing patient compliance with tuberculosis therapy. Clin Chest Med 10(3):375-380, 1989.
C controllable variable in medical intervention. It can strongly sway the outcome of any treatment.
ompliance is the most unpredictable, least
Yet, too often we confidently provide treatment without making the issue of compliance a priority. Three years ago we retrospectively examined the clinical outcomes of patients who had had mallet finger injuries. Much to our surprise, we found compliance to be the critical factor in the final outcome.! This finding has led us to examine the issue of compliance more closely. The Clinton administration has unwittingly forced the issue of compliance into the foreground. The degree to which health care will undergo reform is unclear, but the percentage of people enrolled in managed care plans will undoubtedly increase. Managed care plans, which currently pay for an average of 6.7 treatment visits per referral,2 will not accommodate noncompliant patients. Similarly, the framework for the impending reform will be health promotion and disease prevention. 3 This will place the responsibility of compliance on patients. For the purposes of this article, compliance is defined as active engagement in the rehabilitation process. As therapists, our role in ensuring compliance is to assist our patients in their engagements, enabling them to make informed and affirmative choices. To do this, we must be aware of the external and internal factors that influence compliance and the strategies to improve compliance. Accordingly, this article broadens the therapist's awareness of the issue of compliance through exploration of external and internal factors, identification of methods of measurement, and discussion of improvement strategies that relate to specialized treatment of the hand.
SCOPE OF NONCOMPLIANCE Poor compliance with the medical regimen is a major problem in the healing/recovery process. Fedder states a simple rule of thumb: one-third of patients Presented at the Sixteenth Annual Meeting of the American Society of Hand Therapists, Kansas City, Missouri, October 1993. Correspondence and reprint requests to Gail N. Groth, OTR/C CHT, Milliken Hand Rehabilitation Center, Barnes Hospital, One Barnes Hospital Plaza, Suite 17430, St. Louis, MO 63110.
18
JOURNAL OF HAND THERAPY
always comply, one-third never comply, and onethird sometimes comply. Rates of compliance with splint usage vary from 23% to 65%.5,6 Estimates vary greatly depending on the method of measurement, the patient's age, and the definition of compliance. Rates of compliance with exercise regimens range from 40% to 55%.7 Compounding the problem is the difficulty in predicting compliance. Sackett states, "Every time the ability of clinicians to predict the future compliance of their patients has been put to a rigorous test, clinicians have failed to outperform the toss of a coin." 8 TABLE 1.
External Factors Influencing Patient Compliance with Hand Rehabilitation
• The longer the elapsed time between the referral and the actual appointment, the lower the likelihood that the appointment will be kept. 21 . 22 • A long stay in the waiting room negatively affects compliance. 23 • Referring physicians can positively affect compliance through communicating to the patient how critical our intervention is. • If there is a good working relationship between the referring physician and the therapist, the patient will more likely receive consistent information, which will enhance compliance.
• A patient will more likely comply if he or she is told to make an appointment with a specific therapist, rather than with a clinicY • Compliance decreases as the duration of the treatment increases. 25 • The more treatment sessions scheduled, the lower the compliance. 2h • There is a negative correlation between age and the ability to recall information 27 • With a local and stable family, compliance may well be enhanced. 2H • The patient's health insurance, general financial situation, and work schedule may affect compliance with attendance (if not exercises) . • Inconveniences associated with clinic accessibility. • Fifteen percent of patients have identified lack of transportation to the C/illic as the reason for failing to take their medicines'at IlOlIIe!2" • Low literacy and illiteracy limit problem-solving ability and reading comprehension. 2H • Ability to remember instructions.'"
FACTORS INFLUENCING COMPLIANCE
INDIVIDUAL PERCEPTIONS
MODIFYING FACTORS
LIKELIHOOD OF ACTION
[~DemQQra~hiC v~-(oge, sex, I
In a comprehensive review of the literature, Haynes identified over 200 factors that correlate with compliance.') We have chosen to categorize these into external and internal factors. External factors are those that have an impact on the patient through his or her environment (Table 1). Many of these factors are easily recognized by clinicians. Moreover, if all of the external factors working to improve compliance were stripped away, noncompliance still would not improve unless the internal factors were addressed. Therefore, we have decided to focus on internal factors. Internal factors relate to the patient's health belief system and have a significant impact on compliance. There are several theoretical models directed at health beliefs and their influence on patient behavior. The Health Belief Model (HBM) (Fig. 1) was proposed by Becker lO in 1974 to examine the interrelationship of factors that relate to compliant behavior. We have adapted components of this model, applying them to hand rehabilitation (Fig. 2). Each component is described as follows.
!---,----~ SociQosycbologjcgl variables
;
of
minul
I
and reference group pressure, etc.)
.
i P~rceiv~d,Susceptibiljty to
I Diseas.e X
~
preventive action
I(personality, social closs, peer
i y
I
Perceived
I
I race, elhnlcity, elc.)
.
I, Percer,ved Senousness
~
I
I
I
I
Y
,
~II i s e o s e ' x '
: (seventy) of Disease "X" ...-J! L-_________
I
Perceived Threat of
..
r-
J
.....-
Actk;~~
--------1
oMas,s medio campaigns ·Advlce from others
I
I-
----Cu •• to
l ·Reminder postcard from
physician or dentist ·lIlness of family member or friend .Newspaper or magazine article
I
FIGURE 1. The Health Belief Model. This model examines the interrelationship of factors that relate to compliant behavior. Reproduced with permission from Becker et at. I()
absolute immobilization will not comply with the rehabilitation program.
Perceived Efficacy of Rehabilitation
Perceived Susceptibility to Loss of Hand Function
The patients's perception of the effectiveness of treatment plays a role in the patient's compliance. For example, if a patient believes that wearing a protective splint following a flexor tendon repair will not prevent tendon rupture, he or she will be less likely to do so. If a patient feels he or she has no control over the outcome of the disease or injury, he or she will be less likely to invest time in the home exercise program.
A patient who undergoes ray amputation of the index finger will be more likely to comply with his or her home strengthening program if he or she believes that weakness will interfere with performing valued functional tasks.
Perceived Severity of Injury
Perceived Relationship between Costs and Benefits of Rehabilitation
It is not the actual seriousness of the injury that determines compliance, but rather the patient's perceptioll of the disease or injury. This perception can vary from patient to patient. For example, a patient who has a nonarticular hairline fracture of the index metacarpal and believes that every fracture warrants
The benefits of rehabilitation can be thought of as the rewards of rehabilitation. Increased hand function, return to work, and reengagement in activities
Perceived efficacy of rehabilitation
Perceived of Injury
FIGURE 2. The Health Belief Model as adapted for hand rehabilitation.
severity
Perc.lved susceptibility to loss of hand function
Self-Efficacy
Pa t lent-Pra ctlt loner RelatIonship
/-----<.
t Socioeconomic Environment Medical History & Environment
January-March 1995
19
of daily living (ADL) are typical rewards. The costs of rehabilitation might be pain and loss of personal time. For example, if a patient is to perform home exercises following a flexor tenolysis, the benefits of increased range of motion must outweigh the costs of frequent dressing changes and pain during exercise. Self-efficacy Self-efficacy is a concept proposed by Albert Bandura, a social learning psychologist. II This concept refers to a patient's perception of being competent in performing the recommended treatment. Bandura would say that a patient will not exhibit a specific behavior (compliance) unless he or she feels competent in doing so. Patient-Practitioner Relationship Good communication skills and a warm, empathetic manner are the basic ingredients for success. 12 A positive tone increases satisfaction. 7 Compliance is frustrated by faulty communication, ignoring or overlooking the patient's concerns, medical jargon, and unclear instructions. Patient satisfaction improves compliance. Patients are most satisfied by physicians who are knowledgeable, trustworthy, confident, and enthusiastic. They are influenced by physicians who expect positive results! 4 How the physician communicates this conviction also affects compliance. 13 Feinberg showed that 61 % of the patients complied when the physician was personable; when the physician was business-like, only 35% of the patients complied. 7 The patient's active participation in the relationship improves compliance. An example is the process of setting and achieving goals. The goals must be mutually agreeable, explicitly defined, and potentially achievable. 12 Danielson and Wanzel found that exercisers who failed to attain their own exercise goals dropped out roughly twice as fast as did those who did attain their goals. 14
therapists may be uncomfortable relying on subjective measures. However, clinical judgment is a rich source of information that should not be dismissed. Multiple methods of measurement should be used to most accurately assess compliance. Ideally, both an objective method and a subjective method are included. For example, Codori et a1. report that if a patient is able to perform prescribed exercises at a follow-up visit, he or she will most likely report compliance with the exercise program as well. 19 They conclude that proficiency evaluations, along with selfreports, may be used to assess compliance.
IMPROVEMENT STRATEGIES There are specific strategies to improve compliance (Table 2). We emphasize that the use of a combination of strategies will be most effective. 12 In adTABLE 2.
Strategies to Improve Patient Compliance with Hand Rehabilitation
• Address sources of patient and/or family dissatisfaction. • Strive to integrate the home program into a patient's ADL * regimen. no • Emphasize ADL patients should or should not do. • Provide information about expected treatment response times (e.g., 10-12 weeks for full tensile strength of flexor tendon repairs). • Reduce the complexity of regimens (e.g., reduce the number of exercises) . • Demonstrate, and have the patient rehearse, complex exercise/ splint regimens. • Reeducate periodically when the duration of treatment is long. • Distinguish between different types and purposes of exercises and splints. • Make the first appointment within one or two days of the referral. • Provide either telephone or postcard reminders. • Immediately follow up on broken appointments. • Pleasant atmosphere of the patient treatment area: good lighting, coffee, music.
METHODS TO MEASURE COMPLIANCE
• When possible, one-on-one conversation in addition to supervised treatment.
A number of objective and subjective methods are available to therapists to measure compliance. The most objective measures of compliance include mechanical counters,15 attendance records,1 direct observation in therapy,16 exercise proficiency evaluations,19 and wear of splints. 31 The advantage of objective methods is that bias is minimized. A disadvantage is that compliance with home exercise programs (which typically constitute the bulk of treatment) will not be evaluated with these methods. Subjective measures of compliance include selfreports,6 family reports, 5 and clinician judgment. 17 Self-report is the most commonly used method. Selfreports identify 50% of noncompliers. 18 " ... when [patients 1 admit that they have a compliance problem, they are virtually always telling the truth"!8 Some
• Apply principles of learningO?: brevity, organization, primacy, readability, repetition, specificity.
20
JOURNAL OF HAND THERAPY
• Start with the simple and move to the complex. • Nonverbal behavior affects the amount of information our patients receive." • The manner of communication may be as important as the content of the communication. • Behavioral tools'": shaping, behavioral contracts • Self-management: the process of recording, interpreting, and responding to behavior." • Encourage the patient to recognize self-defeating thoughts whi1e exercising. Replace these with positive coping statements.'" • Establish meaningful, positive reinforcement.'" *ADL
=
activities of daily living.
dition, Southam and Dunbar 20 have established guidelines to assist therapists in facilitating compliance. These guidelines have been adapted to the field of hand rehabilitation. 1. Assess the whole person and not simply the hand condition. Information regarding the patient's perceptions, beliefs, goals, and self-efficacy needs to be gathered through the use of interviews or questionnaires. Also, learning limitations and external factors that may serve as barriers to compliance need to be identified. 2. Consider the prescribed regimen from the patient's perspective. It is conceivable that the patient may have other life demands more salient than his or her hand condition. It is important to consider the patient's lifestyle, priorities, and resources. 3. Establish a collaborative relationship based on negotiation. Determine where patients can execute some control in the treatment program. Allowing patients to be actively involved in the decision-making process will help to nurture a collaborative relationship, which will enhance compliance. A treatment program that is acceptable and carried out accurately is better than an ideal program that is ignored. 4. Be patient-oriented. Written and verbal treatment recommendations need to be delivered in a clear and specific manner. Patients also need positive reinforcement for their efforts and achievements. This reinforcement will have a greater effect than threats and negative reinforcement. 5. Customize treatment. Individualized patient education is as important as individualized treatment protocols. Treatment intervention should require the least amount of change in established habits of lifestyle. Give specific suggestions about how patients may integrate their home exercise programs into their ADL. 6. Incorporate family support. When appropriate, family members and friends can be helpful allies by reminding patients of their home programs, precautions, and goals. 7. Provide continuity of care and accessibility. Patients should view the therapist as sincere, respectful, accessible, knowledgeable, and competent. Patients need to feel comfortable asking questions and verbalizing concerns. 8. Utilize other health care providers and community resources. Facilitating compliance should be viewed as a cooperative goal of the entire health care team. Inform the patient, when necessary, of the various community resources for dealing with psychological and emotional problems. 9. Repeat everything. The level of compliance may fluctuate throughout the treatment process, requiring ongoing evaluation and ongoing instructions. Therefore, educational and motivational interventions require repetition. 10. Don't give up. Far too often, noncompliant patients are viewed as uncooperative and undeserving of good clinical outcomes. Just as the patient should not give up on the exercises, the therapist should not give up on the patient.
CONCLUSION Compliance has a profound impact on the clinical outcome of hand injuries or diseases and demands the therapist's attention. Compliance is also becoming pivotal as the U.S. government considers health care reform. Though compliance is an elusive variable in clinical treatment, it is a variable that can be defined, measured, and fostered. Acknowledgments The authors thank Dorothy Edwards, PhD, for her help in organizing and editing the manuscript, Kathy Mantz for the manuscript graphics, and the patients of the Milliken Hand Rehabilitation Center for stimulating our interest in this topic.
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