A large number of people do not resume normal functioning during the early recovery period after an inpatient stay; in fact, they experience a decline in function. After a myocardial infarction, it has been found that most patients decline during the first month after discharge, which consequently increases the risk of one-year mortality and risk of readmission due to either further cardiac events, or secondary sequelae such as depression (Vibulchai, Thanasilp & Preechawong, 2015). There has been extensive literature that supports the benefits of rehabilitation, however the majority of it has focused on the physical rather than the psychological well-being of patients (Lavie et al., 2015). Furthermore, the literature commonly identifies benefits in the short term, with limited benefits shown in the long term. This all leads to the hypothesis that exercise programs currently do not achieve effective behavioural change in patients and that rehabilitation should take on a multidimensional approach which will account for psychosocial factors including self-efficacy, which has been shown to be important predictors of functional status (O’Neil et al., 2013).
Self-efficacy refers to the beliefs in one’s capabilities to execute an action. According to Bandura’s social cognitive theory, if people lack self-efficacy, they will likely perform an action ineffectively even if they know how to do it. One way to tackle this problem is to use skills mastery (Bandura, 1997); a method in which patients master fair and achievable goals. Bandura’s theory has proven to be successful in improving a patient’s psychological and functional status across multiple settings, including exercise rehabilitation (Vibulchai, Thanasilp & Preechawong, 2015) .
Failures are problematic, particularly if they happen early. This is important in terms of functional rehabilitation and goal setting; if we choose an overly ambitious goal and the patient fails, Bandura explains that this will negatively affect self-efficacy and thus, the patient may be deterred from returning to or completing rehabilitation. If we surveyed 100 practicing physiotherapists out there, I can almost say with confidence that 90 of you approach goal setting with a sole biomedical point of view; a goal that will aim to achieve what you as a therapist wants. However, what most of you do not realise is that compliance is a huge issue as these goals may not align with the patient’s needs. Health Leads Australia highlights the importance of collaboration when it comes to achieving outcomes (Health workforce Australia, 2016). This could simply be the case of integrating exercises into patient hobbies. Furthermore, a systems based thinking approach is required, and so involvement of all stakeholders is beneficial; for example, if the patient requiring rehabilitation is a professional golfer, involve their golf coach when designing their exercise program. This may be as easy as making a phone call to the coach to find out what exactly the patient does. Finally, it is important to consider the possibility of a patient regressing, therefore ensure goal setting is well paced and each goal is carefully thought out and achievable, as this will help patients build a sense of confidence in order to move on.
For any patients out there who are reading this blog, I encourage you to stand your ground and tell your therapist what you really think! Don’t be afraid to have your say, collaborate, rise to the top and achieve your outcomes!
Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman, 1997.
Health Workforce Australia (2013, July). Health LEADS Australia: the Australian Health Leadership Framework. Retrieved from https://www.aims.org.au/documents/item/352
Lavie, C. J., Arena, R., Swift, D. L., Johannsen, N. M., Sui, X., Lee, D., …& Blair, S. N. (2015). Exercise and the Cardiovascular System: Clinical Science and Cardiovascular Outcomes. Circulation Respiratory, 117(2): 207–219
O’Neil A, Berk M, Davis J, Stafford L. Cardiac-self efficacy predicts adverse outcomes in coronary artery disease (CAD) patients. Health Educ. Behav. 2013; 5: 6–14.
Vibulchai, N., Thanasilp, S., & Preechawong, S. (2015). Randomized controlled trial of a self‐efficacy enhancement program for the cardiac rehabilitation of Thai patients with myocardial infarction. Nursing & health sciences.