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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Noncompliance - Knowledge Deficit; Patient Education
Jeff Zurlinden, RN, MS
Meg Gulanick, PhD, RN

NANDA: A patient's informed decision not to adhere to a therapeutic recommendation; failure to follow prescribed treatment plan

The fact that a patient has attained knowledge regarding the treatment plan does not guarantee compliance. Failure to follow the prescribed plan may be related to a number of factors. Much research has been conducted in this area to identify key predictive factors. Several theoretical models, such as the Health Belief Model, serve to explain those factors that influence patient compliance. Patients are more likely to comply when they believe that they are susceptible to an illness or disease that could seriously affect their health, that certain behaviors will reduce the likelihood of contracting the disease, and that the prescribed actions are less threatening than the disease itself. Factors that may predict noncompliance include past history of noncompliance, stressful lifestyles, contrary cultural or religious beliefs and values, lack of social support, lack of financial resources, and compromised emotional state. People living in adverse social situations, such as battered women, homeless individuals, those living amid street violence, the unemployed, or those in poverty may purposefully defer following medical recommendations until their acute socioeconomic situation is improved. The rising costs of health care, and the growing number of uninsured and underinsured patients often forces patients with limited incomes to choose between food or medications. The problem is especially complex for elder patients living on fixed incomes but requiring complex and costly medical therapies.

Related Factors

Defining Characteristics

Expected Outcomes

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess patient's individual perceptions of health problems.
According to Health Belief Model, patient's perceived susceptibility to and perceived seriousness and threat of disease affect compliance with treatment plan.
(i) Assess beliefs about current illness.
Determining what patient thinks is causing his or her symptoms or disease, how likely it is that the symptoms may return, and any concerns about the diagnosis or symptoms will provide a basis for planning future care. Persons of other cultures and religious heritages may hold differing views regarding health and illness. For some cultures the causative agent may be a person, not a microbe.
(i) Assess religious beliefs or practices that affect health.
Many people view illness as a punishment from God that must be treated through spiritual healing practices (prayer, pilgrimage), not medications.
(i) Assess beliefs about the treatment plan.
Understanding any worries or misconceptions patient may have about the plan or side effects will guide future interventions.
(i) Determine reasons for noncompliance in the past.
Such reasons may include cognitive impairment, fear of actually experiencing medication side effects, failure to understand instructions regarding plan (e.g., difficulty understanding a low-sodium diet), impaired manual dexterity (e.g., not taking pills because unable to open container), sensory deficit (unable to read written instructions), disregard for nontraditional treatments (herbs, linamints, prayer, acupuncture).
(i) Determine cultural or spiritual influences on importance of health care.
Not all persons view maintenance of health the same. For example, some may place trust in God for treatment, and refuse pills, blood transfusions, or surgery. Others may only want to follow a "natural" or "health food" regimen.
(i) Compare actual therapeutic effect with expected effect.
Provides information on compliance. However, if therapy is ineffective or based on a faulty diagnosis, even perfect compliance will not result in the expected therapeutic effect.
(i) Plot pattern of hospitalizations and clinic appointments.
(i) Ask patient to bring prescription drugs to appointment; count remaining pills.
Provides some objective evidence of compliance. Technique is commonly used in drug research protocols.
(c) Assess serum or urine drug level.
Therapeutic blood levels will not be achieved without consistent ingestion of medication; overdosage or overtreatment can likewise be assessed.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Develop a therapeutic relationship with patient and family.
Compliance increases with a trusting relationship with a consistent caregiver. Use of a skilled interpreter is necessary for patients not speaking the dominant language.
(i) Include patient in planning the treatment regimen.
Patients who become co-managers of their care have a greater stake in achieving a positive outcome.
(i) Remove disincentives to compliance.
Actions such as decreasing waiting time in the clinic, recommending lower levels of activity, or suggesting medications that do not cause side effects that are unacceptable to patient can improve compliance.
(c) Simplify therapy. Suggest long-acting forms of medications and eliminate unnecessary medication. Eliminate unnecessary clinic visits.
Compliance increases when therapy is as short and includes as few treatments as possible. The physical demands and financial burdens of traveling must be considered.
(i) Tailor the therapy to patient's lifestyle (e.g., diuretics may be taken with the evening meal for patients who work outside the home) and culture (incorporate herbal medicinal massage or prayer, as appropriate).
(i) Increase the amount of supervision provided.
Home health nurses, telephone monitoring, and frequent return visits or appointments can provide increased supervision.
(i) As compliance improves, gradually reduce the amount of professional supervision and reinforcement.
(i) Develop a behavioral contract.
This helps patient understand and accept his or her role in the plan of care and clarifies what patient can expect from the health care worker or system.
(i) Develop with patient a system of rewards that follow successful compliance.
Rewards can be administered by the patient or family at home.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Provide specific instruction as indicated.
(i) Tailor the information in terms of what the patient feels is the cause of his or her health problem and his or her concerns about therapy.
(i) Teach significant others to eliminate disincentives and/or increase rewards to patient for compliance.
(i) Explore community resources.
Churches, social clubs, and community groups can play a dominant role in some cultures. Outreach workers from a given community may effectively serve as a bridge to the health care provider.
(i) Provide social support through patient's family and self-help groups.
Such groups may assist patient in gaining greater understanding of the benefits of treatment.

NIC

Behavior Modification; Decision-Making Support; Patient Contracting; Health Education

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