Self-Efficacy: The Key to Motivating Patients in Physical Therapy

Ever wonder why some patients are motivated to fully engage with their treatment plan, adhere to their home exercise program, and do what it takes to reach their goals while others are not?

You wouldn’t be the only one. Clinicians are often frustrated when patients fail to “buy into” their treatment plans. It’s also quite common that we judge those patients as not interested in getting better or even lazy. After all, they should want to get better right? So, why don’t they just do it?

Before labeling them as such, though, let’s review a key psychosocial driver of patient motivation that’s often overlooked: self-efficacy.

What is self-efficacy?

Self-efficacy was originated by Albert Bandura, a Canadian American psychologist and professor at Stanford University. He described self-efficacy as one’s assessment of their own ability to execute a course of action necessary to deal with a situation (Bandura, 1977*).  

It’s hard to get motivated to do something if we don’t believe we can do it. Nearly all successful performance requires some degree of self-efficacy (a.k.a. a belief that it’s doable). While much of the focus on self-efficacy is directed toward school student performance, recent insights into patient self-efficacy have exposed a key variable in the treatment encounter that may have been overlooked.

Patients who don’t believe that they can do what is necessary to succeed may already feel like it's not worth trying, particularly those who don’t already lead the most active lifestyles. In fact, according to a recent survey commissioned by WebPT and Clinicient that examines the PT experience from the patient’s perspective, most PT patients (53%) either only do light, infrequent exercise or don’t bother to exercise at all. This same report also notes that your least active patients are more likely to experience motivation challenges, and as such, require extra encouragement. Therefore, understanding the structure of self-efficacy can be a powerful strategy to helping all patients succeed, regardless of their activity levels. 

Bandura described self-efficacy developing from four primary sources: 

• Performance accomplishments
• Vicarious experiences
• Social persuasion
• Emotional and physiological states

Let’s break these down.

Performance Mastery

Performance mastery is the degree to which we believe we can achieve a meaningful goal and is conditioned on whether we have accomplished the same or similar goal in the past. A person will approach a task by referencing a previous experience that was perceived as success or failure. 

For example, a patient who was an athlete in high school may recall the success of setting a schedule to train. This past experience of success may enhance their belief in their ability to successfully engage in an exercise prescription for low back pain.   

Vicarious Experiences

A person can develop high or low self-efficacy by observing another person perform a task—or, in other words, through vicarious experiences. “Seeing people similar to oneself succeed by sustained effort raises observers’ beliefs that they too possess the capabilities to master comparable activities to succeed” (Bandura, 1977).  

In our heads it sounds like, “If they can do it, I suppose I can too.” We often see this in marketing videos where normal people are sharing how they succeeded with this program. However, this is only effective if we see people similar to ourselves succeed. Imagine a supermodel demonstrating a core stability exercise program. While your rare supermodel patients may get it, most patients may not identify with that individual and say to themselves, “well yeah, that’s not me, though.”

Connecting with others who have experienced the challenge and overcome it is a powerful motivator, and can trigger a sense of unity and resolve among your patients. This is also why having greater representation among the individuals you or your software vendors choose for home exercise program imagery and videos is so incredibly important.  

Social Persuasion 

Social persuasion pertains to the words we hear directly from others. Positive verbal feedback while performing a task creates a sense of confidence as long as the feedback is authentic and from a credible source. It may sound like a pep talk from a coach encouraging a player. In the clinic it might sound like: “Nice, I really like how you are learning this movement so quickly. Great job.”

This influence is often imprinted at an early age and lays the foundation for our beliefs later in life.  Many heard from parents or caregivers that they were not good at math or sports or whatever. This can often leave an indelible mark and influence their motivation to attempt similar endeavors as they get older. 

What’s more, it’s been proven that regular check-ins are essential to optimal patient outcomes. Per The PT Patient Experience Report, between visit check-ins doubled patient-perceived PT success. What’s more, patients who reported that their PT checked in on their progress in between appointments experienced a 94% HEP success rate. And of those who didn’t receive regular provider communications, only 67% achieved successful HEP outcomes.

This points to the importance of a well-oiled patient engagement process and system. With engagement technology, such as Keet and WebPT Reach, it has never been easier to connect with your patient with a positive and encouraging message. 

Emotional and Physiological States

When engaging in a meaningful task there is an element of physiological arousal. Emotions play a significant role in any performance. Too much or too little adrenaline can result in a poor result.  Patients are often anxious and fearful about their experience and their outcome. Fear avoidance is a well understood example of how a patient’s fear can dissuade them from participating in an activity. When we can help a patient regulate their emotion with relationship skills, we can help them gain the confidence necessary to succeed in a task. 

How can you promote self-efficacy among your patients?

Understanding self-efficacy and the potential impact it can have on your patients’ success can have a tremendous impact on patient adherence, retention, and outcomes. So, how can you nurture self-efficacy among your patients?

The first step is to gain an understanding of your patient's level of self-efficacy during the interview. After establishing rapport, you can ask some questions to get a sense of any barriers related to their belief in their ability to play their role. Here’s an example of a good question to open with:

“Now that we have gone over the treatment options, I’m wondering what might get in the way of you reaching your goals?”

Perhaps they respond that they’ve always struggled to do stuff at home because they have young kids and it’s too hard to carve out time for themselves—a clear sign that home exercise program adherence could be problematic. This is a great opportunity to dive a little deeper. Here’s an example scenario:

PT: “I hear ya, there is a lot going on at home, and these exercises will require some focus. It sounds like you agree the exercises will help, but you are not sure if you can create the time and space to make it work at home.”

Patient: “Yeah, that’s about right.”

PT: “Can you remember a time in the past when you really had to focus to get something you really wanted?”

Patient: “Actually, I had to pass a test for my certification a few years ago. My kids were a little younger, but I worked with a neighbor to help with the kids while I studied.”

PT: “Cool, it sounds like you have successfully done this before, then! What options can you think of this time?”

This is a great example of eliciting performance mastery—helping the patient recall a past success with a similar endeavor and building a bridge to the current situation. This almost always gets the patient more confident in their ability to problem solve the current situation. 

Building Confidence with Clarity and Collaboration

The key to this breakthrough is to connect with the patient in a way that inspires their confidence.  Also, to outline mutual expectations from the start. In fact, per the aforementioned WebPT and Clincient report, “patients who feel their therapist outlined clear expectations are more likely to report a high level of perceived satisfaction.”

Patients are more likely to believe in their own abilities when they are treated as equal partners in care, and as such, should be united on any and all decisions made regarding their treatment throughout their entire care journey. Aligning expectations helps:

• Patients to better understand their role in the process and feel valued as a contributor; 
• Providers make more collaborative decisions about the patient’s treatment and inspire self-efficacy with psychologically informed power skills; and
• Both patients and providers feel confident in navigating any logistical or financial issues regarding their plan of care.

A patient’s success depends upon many factors, self-efficacy being a main player in this lineup. Most patients struggle to stay engaged because they simply believe that they cannot succeed.  By recognizing this early in the treatment encounter, you can use psychologically informed skills to guide the patient toward a new belief that helps them succeed.  

*Bandura, A. (1977). Social learning theory. Prentice-Hall.