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

Patient engagement is an integral part of the physical therapy process. The traditional view of engagement has been that it’s 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 it’s 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 patients take a genuine interest in their own health and become able and willing to participate in interventions that promote their own wellbeing.

This is not a state of being that a patient either “is” or “isn’t” when you first meet them. Patient engagement is a skill that 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 in your ability to help them. 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 can’t 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 you’re 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, you’ll 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 this…with 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 this with them, 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.”

Communication Strategies for the 3 Phases of Engagement

In considering our approach to patient communication, it is helpful to think “with” and “in”: we want to ensure that we are engaged “with” our patient and that our patient is engaged “in” the process. Given that this is a rather broad concept, here are some specific strategies to apply during each of these three phases—and a few to avoid.

Dependance Phase Communication

DO:

• Build trust by demonstrating empathy and validating the patient’s experience.
  • “I’m sorry you’ve had to deal with this.”
  • “I would feel _____ in your situation, too.”
• Find the positive through the use of Motivational 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 didn’t 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 it’s 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 provoke the 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 didn’t 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, you’ll 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, you’ll 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 isn’t to enact immediate change, but to get the patient thinking about it.

DON’T:

• Indulge the patient’s inclination to rely on you. Instead, encourage any attempts toward independence. Less “doing to” and more “doing with.”
• Highlight what didn’t work. Even if a patient tries something on their own and doesn’t get the desired outcome, stay positive!
  • Point out that the patient just discovered a way that doesn’t work for them. You could say something like “Everyone has a unique nervous system, and now we know what does and doesn’t feel good for yours. That’s important data that you helped us collect!”

Self-Determined Phase Communication

DO:

• • Ask the hard questions to prepare for what’s 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 that’s not enough, you’re 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 isn’t always top of mind when someone is experiencing pain or another challenge, but your patient’s 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 one’s life.

  DON’T:

• Get upset when the patient doesn’t do everything you ask. Instead, step back and remember that this is a natural part of the process and it’s 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 a comprehensive course that explores these three phases in-depth, as well as team strategies to consider when communicating with the patient’s family and other members of their healthcare team.