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.
- Patient's value system
- Health beliefs
- Cultural beliefs
- Spiritual values
- Client-provider relationships
- Behavior indicative of failure to adhere
- Objective tests: improper pill counts or missed prescription
refills; body fluid analysis inconsistent with compliance
- Evidence of development of complications
- Evidence of exacerbation of symptoms
- "Revolving-door" hospital admissions
- Missed appointments
- Therapeutic effect not achieved or maintained
- Patient and/or significant other report compliance with
- Patient complies with therapeutic plan, as evidenced by
appropriate pill count, appropriate amount of drug in blood or urine, evidence
of therapeutic effect, maintained appointments, and/or fewer hospital
- (i) independent
- (i) Assess patient's individual perceptions of
- 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
- Many people view illness as a punishment from God that must
be treated through spiritual healing practices (prayer, pilgrimage), not
- (i) Assess beliefs about the treatment
- 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
- 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,
- (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
- (i) Compare actual therapeutic effect with
- 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
- (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
- (i) independent
- (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
- 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
- (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,
- (i) Increase the amount of supervision
- 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
Education/Continuity of Care
- (i) independent
- (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.
Behavior Modification; Decision-Making Support; Patient
Contracting; Health Education
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