It can be the difference between full recovery or lifelong disability.
Mary Jones, a patient who has had a knee replacement, has not gotten up for physical therapy (PT) since her arrival in the rehab unit following surgery. “I’m too tired,” she says, “maybe tomorrow.” Because of her lack of movement, nurses are concerned she might develop post-surgery complications, such as pneumonia. Physical therapists note her sad affect and lack of motivation, concluding that they may indicate depression.
The nurse manager brainstorms with others to determine how to get Mary up and moving because her case manager is thinking about stopping payment for skilled care, given her perceived noncompliance. Some nurses resist pressuring Mary to go to PT, feeling that a patient should be a partner in his or her treatment plan. A psychiatric evaluation is suggested, but they recognize that if depression is the diagnosis, an antidepressant will be prescribed and may take several weeks to start working. What can the team do to gain Mary’s compliance and obedience?
Coercion not acceptable
Sometimes people need to be prompted into action, and influencing a person to perform a desired action, especially without his or her awareness, requires techniques that are subtle, indirect, and difficult to detect (Forsyth, 2014). Some techniques, known as hard tactics, cannot be used in nursing for ethical and legal reasons. We cannot bully, punish, or withhold items to gain compliance, because that would be coercion. We can, however, effectively use softer tactics that help gain patients’ cooperation and compliance in meeting their goals. The benefit is for the patient. Letting Mary stay in bed—not moving, developing complications, and not progressing—is not acceptable, and the negative consequences of using compliance tactics to achieve desired results outweigh the negative results of not using them.
First, make it an expectation that rehab will be done. Rule out reasons for noncompliance. Is the patient in pain? Is the patient cognitively able to understand the implications of his or her actions? If the patient has pain, we can medicate an hour or two before rehab to ward off pain prior to its occurrence rather than treating it after therapy. If a patient doesn’t understand the implications, we can activate the healthcare proxy to get permission to more actively engage the patient. Coming in the room and announcing, “It’s time to go to therapy!” as a way of expressing expectation of treatment is more effective than asking, “Do you want to go to therapy?” In many cases, the latter approach will be answered with a no.
Tactics to consider
If the patient is cognitively intact, tools are available to help elicit his or her consent. Appraisal is pointing out what the patient will gain. “If you go to rehab, your pain will decrease each day.” Collaboration is letting the patient know that, however difficult the therapy, you are there to help and provide assistance. “I know you have difficulty getting up, so we are going to assist you.” Claiming expertise can be helpful. “I've worked with knee replacements for 10 years and am certified in this area of nursing. I know I can help you.”
Once the patient agrees with going to rehabilitation, ingratiate. For example, flatter Mary—tell her how much better she looks up and out of bed, and praise her efforts. Instructing is important. Identify steps needed to perform what you are asking her to do, and be willing to negotiate if she has a different way to achieve the task. Socializing while providing hands-on care can be effective for developing trust needed for the patient to join forces with you. Humor can be helpful (Forsyth, 2014).
There are many ways to get a patient to comply. The foot-in-the-door technique is when the nurse makes a small request the patient agrees to, after which a larger request is made. “We need you to sit up on the side of the bed to change your dressing, Mary.” Once Mary has complied with this less-stressful request and is sitting up, the nurse may say, “Since you’re already up, you can now ambulate with your therapist.”
Another tactic is the “door-in-the-face” technique. A large request is made, and when the patient refuses, a much smaller request is made. When Mary refuses to go down to rehab, the nurse will suggest, “OK, if you won’t go downstairs to rehab, can they come up here and do some bedside exercises with you?” Mary agrees.
The nurse as persuader
Nurses can use tactics that are persistent and persuasive. While this can make a patient uncomfortable, such approaches may raise cognitive dissonance between the patient’s desire to be a “good patient” and his or her desire to stay in bed. When a patient holds two conflicting cognitions, he or she will often comply because of the emotional discomfort. Or the patient may rebel and get angry. If so, another approach should be considered.
Using an authority figure can be helpful because people are taught to obey authority. For example, the nurse manager or physician may meet with the patient to emphasize the importance of going to rehab. We prefer that patients be collaborative partners in their care, and that is the desired goal. There are times, however, when nurses must step up and put aside this partnership model for the patient’s benefit. Nursing is a powerful position, and we must not be afraid to use our power of persuasion for our patients’ welfare.
Remember, persuasion is not coercion. With persuasion, the nurse is utilizing approved resources and techniques to get the patient to do something that will benefit him or her. After some medical situations, such as a stroke, there is a critical time when rehab must be done or vital functions may not recover. We cannot wait two weeks for an antidepressant to work. A persuasive nursing staff may be the difference between a full recovery or lifelong disability.
Michael C. LaFerney, PhD, RN, PMHCNS-BC, psychiatric clinical nurse specialist at Arbour SeniorCare in Haverhill, Massachusetts, USA, is adjunct professor of psychology at Quincy College in Quincy, Massachusetts.
Forsyth, D. R. (2014). Group dynamics (6th ed.). Belmont, CA: Wadsworth Cengage Learning.