Can tools used in marketing and business fit the nursing model?

By Michael C. LaFerney, APRN,BC

Mr. G, a 70-year-old white male recovering from a broken hip, has refused to go to therapy or eat with others in the community dining room. "I feel so frustrated," said Sally H, a nurse on a long-term care nursing unit. "I can't seem to communicate with Mr. G. He's so resistive to everything. And his behaviors set a negative tone for the unit. Other patients are starting to refuse also. I wish I knew what to do."

Have you ever felt like this? Motivating patients in a long-term care setting can be challenging. As nurses, we want patients to conform, adhere and comply. How can we help Mr. G be more cooperative and social so his rehabilitation can take place?

Borrowing Marketing Tools

Our nursing skills would have us first look at any medical or psychiatric reasons for Mr. G's refusal to participate in therapy. For example, is he depressed or in pain? In addition to these traditional nursing skills, we have many other tools at our disposal we can "borrow" to help in our patient care.

We often look to other disciplines to aid us in providing better care for our patients. But should nurses use tools employed in marketing or sales to help patients, or is this manipulation? Does the idea of patients being obedient and compliant go against nursing theory?

The Patients' Bill of Rights notes the patient has the right to refuse treatment and cannot be coerced.¹Can we actively use marketing tools without violating this?

To answer this question, we can turn to some basic principles of social psychology and apply them to our nursing setting. Social psychology is the scientific discipline that looks at how people behave, think and feel in social situations.²

Principles of Social Psychology

People prefer to be with people in circumstances similar to their own.² While protecting his privacy, introduce Mr. G to other patients with similar issues or rehabilitation exercises as his. The need to affiliate is based on the desire for approval, support, friendship and information. These patients can provide support and are a good source of information for what he can expect in therapy.

People's desire for self-evaluation motivates them to associate with others.²

Group membership fills needs for social comparison (comparing your own actions, feelings or abilities to others). Point out to Mr. G. that by attending the rehab group he will be able to assess his own progress by seeing how others with the same condition are doing.

People are more compliant to people with whom they have frequent contact.²

As his nurse, go into Mr. G's room frequently to check on him or ask if he needs anything. Engage in conversation about his life, family and interests. Once he knows you, it will be harder to say no. In contrast, a nurse who only comes to his room when called or goes infrequently will have little rapport needed to gain his compliance.

People like people who are competent.²Showing you are a caring, competent nurse will increase Mr. G's desire to be obedient. But studies suggest competence is not just knowledge or proficiency. Patients want a nurse who is "human," too, not perfect.

Moderate self-disclosure leads to reciprocity.² Self-disclosure can be tricky. We must retain our boundaries. However, hearing one of your own experiences or perhaps a story about a past patient in a similar position to Mr. G who did well may be helpful in getting him to discuss his own feelings.

There is an expectation of conformity and the influence of others can be helpful.²Talk to Mr. G about rehab along with other rehab patients. The larger the group, the more people are influenced. Three people are usually sufficient. By showing their conformity to therapy, it will be harder for him to refuse.

And we also know having one person in your corner can greatly reduce pressure to conform, so keep negative influences separated. Place him in a room with a compliant patient. We know people are more likely to like and model those in close proximity.

Use the "door in the face" technique, which is the tendency for a person who has refused a major request to subsequently be more likely to comply with a minor request.²For example, if your neighbor asked you to feed and walk his dog daily, cut his grass and clean his garage while he went on vacation for a month, you would refuse. If he then said, "OK, but could you pick up my mail for me?" chances are you'd say yes (even though you might have refused otherwise).

If you say to Mr. G, "I want you to go to both rehab sessions today and all meals," he will refuse. But if you follow it with "OK, but could you go to one group and one meal today?" chances are good he may comply. And if he goes to one, then you have momentum. Behaviorists and social psychologists believe if you can get someone who has been resistant to do one thing you have started the ball rolling.

Switch to the "foot in the door" technique(the tendency for a person who has first complied with a small request to be more likely to later fulfill a large request.²Now that he has completed and attended one group, you can ask him to now try two groups and more meals.

Cognitive dissonance can make people uncomfortable.²The theory of cognitive dissonance states contradictions or clashing thoughts cause discomfort. His not going to rehab clashes with his desire to be seen as a "good" patient. A way to reduce dissonance is to change your behavior. Suggesting the rehab staff might have to come to his room to provide his therapy might increase his thought that he is not being a "good patient" and motivate him to go, thus reducing his dissonance.

People will usually be obedient to authority.²Research suggests people will respond to those who have authority. If other initiatives aren't working, it may be necessary to call in "the big guns." If the patient perceives one as an authority figure, utilize this person to gain compliance. This could be done by saying, "I'll have the nurse manager speak to you." Or, if necessary, have the physician address the patient. And never forget the power of family members. They may be your best ally in obtaining compliance.

Patient Rights

Some nurse theorists object to the terms obedience, compliance and conformity as going against nursing theory and the Patients' Bill of Rights in that we want patients to be active participants in their care. However, in evidence-based practice we find, given the short stays on rehabilitation units and the fact insurance providers will not pay for a patient who does not participate, the nurse must have tools to harness the power of persuasion. Some might say this is manipulation, but is it really wrong to use successfully proven tools used in business, management and education to aid a patient in working toward his recovery?

In regard to patient rights, one must acknowledge persuasion is not coercion. Persuasion is the "act of inducing attitude changes and influencing a target market to action."³It is a leadership tool. We want the patients to have an attitude change and work in therapy to their benefit. Given there are critical times in a patient's recovery that must be addressed, a persuasive nurse may be the difference between a patient who has had a stroke regaining or losing a critical ability. Some may even feel it would be negligent not to use all available tools to get the patient's adherence to treatment.

The need for an effective method of obtaining compliance is clear. Noncompliance leads to 3.5 million hospital admissions annually, or 11percent of all admissions, and noncompliance is the greatest single cause for readmission to hospitals.⁴

Twenty percent of all prescriptions written are never filled and up to 60 percent of all medications prescribed are taken incorrectly or not at all. According to the World Health Organization, the noncompliance rate in long-term care averages 50 percent. This includes treatment for hypertension, high cholesterol, diabetes and asthma.⁵ est-practice approaches and motivational interviewing have not produced sufficient results.

Beyond Nursing

Nurses study other courses during their nursing programs, including those in psychology and business. Although we sometimes are fixated on nursing for the core of our training, much of what we learn in our corresponding studies is valuable in our treatment of patients. We should not be afraid to look outside of nursing for solutions to nursing problems. Given the high rate of patient noncompliance, the art of persuasion appears to be an essential skill in nursing practice. n

References for this article can be accessed at www.advanceweb.com/nurses. Click on Education, then References.

Michael C. LaFerney is a psychiatric clinical nurse specialist employed by Arbour SeniorCare, Rockland, MA.