Growing in Clinical Confidence and Patient Adherence

Written By: Annique Bekker, OT, CHT

Virtual Hand Therapy Fellow '25/'26

I started working as an occupational therapist in 2019 in a government setting in South Africa. For about five years, including two years in primary health care, I was exposed to complex hand injuries in challenging clinical environments.

Many of my patients came from rural areas. They often presented with severe hand injuries, limited access to follow-up care, and significant social and economic barriers. Hand therapy resources were restricted, appointment times were short, and patients could often only be seen once a month, or sometimes once every eight weeks.

I often felt overwhelmed by the responsibility of managing these cases with limited mentorship and specialist knowledge. At the time, I relied heavily on textbooks and protocols. They gave me structure, but I did not always feel confident in my clinical reasoning. When a patient did not progress as expected, I questioned whether I had missed something. When outcomes were poor, it was difficult to know whether the main challenge was my own knowledge, the patient’s adherence, or the limitations of the health system.

Building Clinical Confidence

In September 2024, I started the Virtual Hand to Shoulder Fellowship. This became an important turning point in my growth as a hand therapist. The program helped me understand anatomy, tissue healing, biomechanics, and clinical reasoning in a more structured way. I began to look at each patient more individually: what structure was injured, what stage of healing they were in, what movement was limited, what function was affected, and what intervention was most appropriate at that point.

As my knowledge improved, my confidence also improved. I became less anxious and more able to make decisions based on what I observed clinically, rather than relying only on a protocol.

In 2025, with the support of my primary health care facilities, I started a dedicated hand clinic. This allowed me to organize my time better and see patients with hand injuries more regularly, often weekly. The improved structure helped me prepare more thoroughly, follow patients’ progress more closely, and reinforce education and home programs more consistently. For the first time, I could apply my learning in a more sustained way and begin to see how improved clinical reasoning influenced treatment planning and patient engagement.

Recognizing the Role of Patient Adherence

As I grew in confidence, I also realized that knowledge is only one part of effective hand therapy.

Even when I understood the injury better and created a more appropriate treatment plan, the patient still had to carry that plan into daily life. They had to wear the orthosis, perform exercises, protect healing structures, attend follow-up appointments, and continue with daily responsibilities.

This is where the concept of adherence became important to me. O’Brien (2012) explains that “adherence” is a more client-centered term than “compliance,” because it reflects active and voluntary collaboration between the patient and therapist. This distinction changed the way I thought about poor follow-through. Instead of viewing it only as a patient not listening, or as me not providing the correct therapy, I began to see adherence as something influenced by many factors.

O’Brien describes adherence using the World Health Organization’s multidimensional model, which includes socioeconomic factors, health-system factors, condition-related factors, treatment-related factors, and patient-related factors. In my own setting, this made practical sense. A patient may understand the importance of therapy but still struggle because of transport costs, long travel distances, pain, work demands, family responsibilities, limited health literacy, or long gaps between appointments.

Linking Confidence and Adherence

This helped me connect two important parts of my growth as a hand therapist: my own clinical competence and my patients’ adherence.

When I lacked confidence, it was harder to explain treatment clearly, simplify a plan, adapt a protocol, or identify what mattered most. As my competence improved, I became better equipped to educate patients, design realistic home programs, explain the purpose of orthoses, and adjust treatment to the patient’s context.

Improved clinical reasoning did not only help me choose better interventions. It helped me communicate those interventions more meaningfully.

At the same time, patient adherence reminded me that good treatment is not only technically correct. It also needs to be understandable, realistic, comfortable where possible, and relevant to the patient’s daily life. Education alone is often not enough. Patients may be overwhelmed, in pain, anxious, or unable to remember all instructions. Treatment plans need to consider the person, the injury, and the system around them.

Moving Forward

My journey in hand therapy has not only been about gaining knowledge, but about becoming more clinically grounded and confident in my reasoning.

Through many hours of reading, working through the fellowship content, engaging in mentorship, and reasoning through case studies, I slowly became more competent in treating complex hand injuries. I learned that confidence does not mean always knowing the answer immediately. It means being able to slow down, observe carefully, understand what I am seeing, and make thoughtful clinical decisions.

This growth helped me shift my focus. Instead of being overwhelmed by my own insecurities, I became more able to focus on the actual problem in front of me: the injury, the stage of healing, the patient’s function, and the factors influencing recovery.

As I became more secure in my clinical reasoning, I also felt more free to consider the patient factors that affect adherence. Understanding both my role as the therapist and the patient’s role in the rehabilitation process has made my work more meaningful and satisfying, especially when patients reach their goals and regain function.

To other young therapists who may feel overwhelmed or uncertain: you are not alone. Growth takes time. Keep asking questions, keep reading, seek guidance, and keep reasoning through what you see. Listen to your patients, try to understand their context, trust the knowledge you are building, and never stop learning.

Reference

O’Brien, L. (2012). The evidence on ways to improve patient’s adherence in hand therapy. Journal of Hand Therapy, 25(3), 247–250. https://doi.org/10.1016/j.jht.2012.03.006