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Impact on treatment recommendations Patient adherence with prescribed treatments has become an area of increasing interest and concern

over the last few decades. Studies have shown that non-adherence is a significant issue that causes serious problems for the health care system: Among the statistics:

Most studies show that between 25 and 50 percent of patients are non-adherent. Some studies show non-adherence rates as high as 93 percent. Most health care professionals underestimate the prevalence of non-adherence.

Alarmingly, despite significant advances in disease prevention and health care, many Americans continue to die of conditions that could have been prevented or treated. Although health risks for a number of serious diseases are known, millions of people continue to engage in unhealthy behaviors such as tobacco use, excessive alcohol consumption, a sedentary lifestyle, and poor dietary habits. Assuming that the patients condition has been accurately diagnosed and the appropriate treatment prescribed, the only way that recommended therapeutic or preventative regimens could be effective is for patients to follow advice given them. It is widely accepted that this does not occur in many instances. Non-adherence has a profound effect on the individual patients health status, on individual health care professionals, and also on the health care system. Huge amounts of health care dollars are wasted when medications are not taken correctly, when medical equipment is misused, when patients are re-admitted to hospital care for preventable problems, and when a large percent of the public continue to practice health habits that inevitably lead to serious disease. Patient non-adherence can take many forms, including missing health care appointments, not taking medications as directed, or not following recommended dietary or other lifestyle changes. A patients failure to keep an appointment is costly. It can have serious health consequences for the patient and contributes to increasing health care costs by wasting the time resources of health care professionals. Appointments for follow-up on a previously treated condition can also be a source of non-adherence, especially for patients who have no longer have troublesome symptoms. An example is the patient who seeks medical care, is prescribed antibiotics for a urinary tract infection, and is scheduled for a follow-up appointment for another urine culture to make sure her infection has been resolved. When the antibiotics are completed, the patient sees no reason to make the follow-up appointment and does not seek medical help until weeks later, when she experienced chills, fever, and flank pain-symptoms of a kidney infection, a much more serious problem than the original cystitis. Teaching patients about how to use their medications effectively is a significant challenge in our health care system. An estimated $100 billion is spent each year on problems caused by noncompliance with medication regimens. Table 18 outlines the basics of what patients must know in order to adhere to a medication prescription. Non-adherence involving medication use occurs in many ways. Patients may never have the prescription filled or may alter the prescribed dose-taking either too much or too little of the medication, or changing the time interval at which the medication is given. It is not uncommon for patients to save up drugs that should have been completely used,

increasing the possibility that they or others may use the drugs inappropriately later. In cases in which medication is a continual, ongoing part of controlling the disease itself, such as with hypertension or diabetes, failure to adhere can have life-threatening consequences. Patients who err on the side of excess run the risk of drug interactions, drug toxicity, and a variety of other impairments from misuse or overuse of prescribed, therapeutic medications. Non-adherence also affects dietary and other lifestyle changes suggested as part of treatment, sometimes with serious consequences. For example, a patient had circulatory problems in his lower extremities due to arteriosclerosis. When his foot became infected, he was instructed to soak it several times a day, followed by a heat lamp treatment. Unfortunately, the patient adhered only sporadically and eventually had a below-the-knee amputation. Problems with potential non-adherence are considered a major factor in developing new forms of medications and treatments. Many advertisements by drug companies claim that their produce will improve compliance. Various techniques have been used to assess adherence with treatments, especially drug therapy, including technical methods such as checking blood concentration and serum levels of drugs, and urine screening for drug metabolites or other biochemical markers. Other simpler methods are pill counts, checking whether prescriptions are dispensed, and direct questioning of patients. There are problems with all these methods. Blood and urine screening are affected by individual variations in metabolic and absorption rates. Pill counts may be unreliable, and direct questioning may impair the relationship between clinician and patient. In addition, none of these methods gives an indication of adherence to the treatment schedule. Patient non-adherence also has a negative impact on health professionals. We have the best of intentions in helping patients learn how to care for themselves and become discouraged and even angry when patients ignore our advice. Non-adherent behavior violates the professional beliefs, norms, and expectations we have about the relationship between patients and health care professionals. Not only do nurses and other health care professionals tend to underestimate the extent of non-adherence, but we may also have misconceptions about who is at risk for non-adherent behavior. We may assume that patients who are uneducated or from lower socioeconomic groups are less likely to follow recommendations; however, research has shown this not to be true. Amazingly, although it seems logical that patients with the most serious health care problems would be the most adherent, this has not been found to be true. One study found that patients with less severe medical problems were actually more likely to follow through with medical advice than those with a more severe illness. In addition, patients with asymptomatic disease conditions such as hypertension often have problems with adherence. It is thought that the level of perceived threat to health for asymptomatic patients is not enough to motivate a person to adhere to treatment recommendations, while very high levels of perceived threat cause such fear that the patient is unable to act. Table 18 What Patients Must Know About Their Medications

The name of the medication and what it is for The dosage, route of administration, and how long to take the drug Any special directions or precautions about how to prepare the drug or take the drug Common severe side effects or interactions that may occur with other drugs or food, how to avoid such interactions, and what to do if they occur When to call the physician about problems with the drug How to store the drugs Prescription refill information Actions to be taken if a dose is missed

SOURCE: Adapted from Kramer, E.J. (1999). Health promotion and disease prevention. In: Bateman, W.B., Kramer, E.J., & Glassman, K.S. (Eds.) Patient and Family Education in Managed Care and Beyond. New York: Springer Publishing Co., 100.

Causes of non-adherence
Reasons for patient non-adherence are complex. Researchers have found that the relationship between information given to the patient and the extent to which instructions are followed is not always strong. Information alone does not seem to affect the degree to which patients follow recommendations given by health professionals. Situational, personality, or socioeconomic factors often play a more important role in the extent to which patient follow recommendations than do the knowledge and understanding about what they are to do. Both internal and external factors seem to influence whether a patient follows health care advice. Internal factors include patient characteristics such as age, culture, social background, values, attitudes, and emotions caused by the disease. External factors include the relationship between the patient and the physician or the nurse; support from family, health care personnel, and friends; and the impact of health education. Studies have shown than men adhere less frequently than women. In addition, unemployed people or those who smoke or drink alcohol are also less adherent. Internal and external factors have a powerful influence on patient decision making and behavior change. Some studies have found that several features of the therapeutic regimen itself have been correlated with adherence. For example, the more the patient must change his or her lifestyle, the less likely the patient is to follow recommendations. In addition, the less complicated the treatment regimen, the higher the rate of adherence. These findings are consistent with the Health Belief Model. The Health Belief Model proposes that patients act on treatment recommendations when they believe that the benefits of treatment outweigh treatment barriers. They also believe that potential complications are severe and believe that they are at risk of developing complications. It is clear that the patient must have the knowledge he or she needs for health care management and must accept the recommendations of health care professionals as something they can accept and successfully achieve. Patients cannot carry out recommendations they do not understand and will not carry out recommendations they do not accept. Nurses and other health care professionals must do more than merely give the patient information. They must also be able to identify potential barriers to patient learning and the ability to follow treatment recommendations. They must act as learning facilitators and problem solvers, helping the patient to clarify issues and reach a decision or develop a plan that is compatible with his or her own priorities and lifestyle. Ultimately, patients control what they do with the recommendations they are given. The health care professionals responsibility is to enable patients to act on their own behalf by providing information, helping with the practical problems of carrying out recommendations, helping them be aware of alternatives, and supporting them in integrating new knowledge.

The patient as a passive recipient of care


The concept of compliance requires a dependent lay person and a dominant professional; one giving expert advice, suggestions, or orders, and the other carrying them out. Adherence to medical treatment is a concept based on professional beliefs about the appropriate roles of patients and health care professionals. The dominant professional view has been that the role of the professional is to diagnose, prescribe,and treat, and the role of the patient is to comply with what the health care professional believes is best. This view is an excellent example of the ethical principle of beneficence-attempting to do good. However, seen from this point of view, patient non-adherence is a behavior that challenges important beliefs, expectations, and norms. The non-adherent patient is viewed as interfering with, and in some instances, sabotaging the normal process and practice of health care. In some extreme instances in which patients continuously make choices that produce poor health care outcomes, their behavior is seen as deviant and irrational. In the case of people who are mentally ill, non-adherence is also seen as a symptom of illness, the nature of which makes patients incompetent to make informed, rational decisions about the need to adhere to treatment recommendations. Experts studying adherence point out that in the traditional patient-professional model the relationship is not an equal one. The physician is superior to the patient, and the patient is seen as a passive recipient of health care. This model has led to an inherent tendency to blame the patient and to view non-adherence as irrational and deviant.Such experts believe that the roles of patients and professionals need to be re-examined and that health care professionals need to see patients as individuals who construct and give meaning to their illness and who actively evaluate treatments prescribed and advice given. In addition, much of the research in this area has focused on health care professionals communication to the patient rather than communication between the two. Often health care professionals ask whether or not patients have adhered to treatment instructions, without asking why the patient found it difficult to comply or what the patient may have done instead. By using communication strategies that allow patients more equal participation in treatment decisions, nurses can help promote increased adherence. The terms compliance and/or adherence imply that we dictate to the patient what is to be done or changed and that the patient should obey us. We are often uncomfortable with the patients right to choose not to follow our advice or to change his or her mind. We should strive to enlist the patients partnership and view patient education as a process of influencing behavior in ways acceptable to the patient. Effective patient education requires an understanding of factors that influence the patient in decision making: values, beliefs, attitudes, current life stresses, religion, previous experiences with the health care system, and life goals. Patient education providers may begin with giving information and demonstrating skills, but if the patient is not included in deciding how learning will be applied and the goals of patient education are not mutually agreed on between the teacher and the learner, behavioral changes usually will not occur. The patients cooperation with the medical regimen involves choices every day. For example, the choice to follow a diabetic diet means making constant and sometimes inconvenient choices every day. We expect patients to do this every day for the rest of their lives even though we cannot guarantee that they will be free of serious diabetic complications. It is our role to offer guidance and support. We must be willing to respect patients right to choose although we may not agree with their choice.

Effect of interpersonal skills on adherence


Few interventions to increase adherence have been demonstrated through rigorous research to be consistently effective. Because human behavior is complex, there is no single or simple explanation for non-adherent behavior.However, there is growing consensus among researchers that the behavior of the health care provider has a significant influence on patient adherence. Specifically, the health care professionals ability to communicate and explain information while expressing warmth and concern for the patient appears to be associated with increasing patient adherence. Patient teaching in nursing is not simply repeating directions to patients or handing out printed materials. It is a process in which the nurse gathers data, individualizes instruction, provides support, and evaluates and follows up with the patients success in taking

responsibility for self-care. Studies show that a person-oriented approach is more helpful than handing out brochures or having patients view videos. One study showed that when asked what aspect of interactions had the most influence in increasing their adherence, most patients said that it was having someone take the time to talk to them, answer their questions, and consider their concerns. Sometimes when nurses view patient education as a relational process rather than a single intervention or program, they worry about finding the time to carry out such a process. However, many nurses find patient teaching that is incorporated as an organized part of each patient encounter actually saves time and greatly improves adherence. Teaching while doing is much more effective than doing a procedure and then planning to come back at some future time and do patient teaching. The way in which health care information is presented also has a major impact on the patients ability and willingness to follow treatment recommendations. For example, saying to a patient, If you quit smoking, you will live to be 100 is not useful. This statement is probably not true and it doesnt connect the need to stop smoking with anything important to the patient. On the other hand, if the nurse has established a personal relationship with the patient, understanding his or her goals and lifestyle, she might say instead: I know how important it is for you to see your grandchildren grow up. There is a lot of evidence that smoking will cause several diseases that will shorten your life. Stopping smoking is one of the best health decisions you can make for yourself in your entire life. Id like to help you do that. How can we work together on this? Nurses and other health care professionals can help improve adherence by evaluating what happens during follow-up visits. Does the content and process of the visit help or hinder the patients ability to follow his or her treatment plan? It is possible that the feeling of being well treated and given more responsibility and encouraged to take an active part in treatment may contribute to adherence. Increased attention should also be given to helping patients make lifestyle changes. Knowledge of a healthy lifestyle is necessary for good compliance, but it does not automatically lead to this outcome. Nurses should become familiar with each patients life and consider together with the patient how it would be feasible for the patient to change his or her lifestyle. Table 19 outlines guidelines for good provider-patient communication. A study of adolescents with diabetes provides an excellent model for learning about the impact of interpersonal relationships and patient adherence. The study looked at the relationship between the attitudes of physicians, nurses, parents, and peers and the ability of young diabetics to follow their treatment regimens. In the study, the actions of physicians were described as motivating, authoritarian, routine, or negligent. Patients described physicians as having a motivating style when they discussed treatment and self-care together. The most effective motivators demonstrated interest in how the young diabetics managed to fit diabetic self-care into their life. One patient, describing a motivating encounter, reported: The physician asks me if I have managed to care for myself at home and tries to help me organize my care so that it doesnt disturb my life. They always ask me what I think about a decision, and do I agree with it. Could I carry out this kind of self-care? Usually we decide together what we will do and how we will do it. In contrast, authoritarian physicians directed the patients care. Although they asked questions, the patients perceived that the physicians ignored the answers. The physicians pointed to mistakes the young diabetics made and told them what to do to avoid mistakes in the future. Here is a statement by a patient describing an encounter with an authoritarian physician: The physician talks like a boss, telling me how I should care for myself. They are not interested in how I have managed to care for myself. In fact the physician orders my care. They think they know whats best for me. Physicians who acted in the same way time after time were described as routine. Patients believe such physicians worked according to a predetermined model and the same model of action was followed for every patient, regardless of his or her needs. One patient said: The physicians always nag me in the same way and about the same matters. They always act in the same way. They have only one model, and their actions are based on it. They dont see me as an individual. Its the same whatever I do or say. I should tape what happens when I meet the physician and listen to the tape at home so I dont need to come to meet the physician and hear the same sentences every time. The physicians that the patients described as negligent did not appear interested. They paid attention to the medical record rather than to the patient, did not ask questions, and did not display any curiosity or interest about the life of adolescents and their problems. A young patient described an encounter with a negligent physician: They dont look at me. They hold discussions about me with my records-I could leave the consulting room and they would not realize that I was gone Its really useless and a waste of my time. I dont get anything for myself. Physicians who used a motivating style had a much greater positive impact on patient compliance than

those who were seen as authoritarian, routine, or negligent. Table 20 shows the characteristics that young patients in this study said motivated them to follow treatment recommendations. Nurses actions were described as motivating, routine, or acting on physicians instructions. Nurses who were motivators discussed issues with patients and used the discussion as a starting point for planning care. Patients also felt that motivating nurses listened to their opinions. The nurses who patients described as routine had an interpersonal style very similar to routine physicians-they asked questions but seemed to ignore the answers. A patient describing an encounter with a routine nurse said: Its the same whoever is the patient. Their action is always the same. Everything happens according to their own plans and the hospitals needs. The most important thing is that the hospitals timetable works well and everything that is important for the hospitals routine happens. If they change something and move away from routine, perhaps it would lead to enormous chaos. Nurses who were perceived as acting on physician instructions ignored the patients and their opinions and saw their role as reminding the patient to follow physician directions. A patient talking about a nurse he perceived to be acting as an agent of the physician stated: This is of no help to me, because the nurses do exactly what the physicians say. It is really difficult to discuss anything with them because they do not have any opinions of their own about my self-care and other matters concerning diabetes. Adherence was highest among patients who worked with nurses with a motivating style. Parents were described as motivating, accepting, or disciplinarian. Motivating parental actions included giving support and expressing interest in the young persons life in general. Such parents helped young diabetics to take care of themselves by helping them solve problems associated with self-care in everyday life. Motivating parents provided positive feedback and sometimes a reward if their child had coped with self-care particularly well. One patient, who described his parents as motivating, said: My mother and father help me to care for myself-they give me positive feedback when I have managed my self-care. Sometimes when I have cared for myself well, they give me rewards or money or something like that. I feel it supports me-then I have energy and will power to care myself. But its no good if my parents take part in my care too much. I have to have freedom too. Parents who patients described as accepting did not try to influence their children. Although they expressed interest and concern, the parents accepted that the young people would not necessarily care for themselves and did not try to force them to comply with selfcare. Parents who were described as disciplinarians tried to require the young diabetics to take better care of themselves. These parents consistently tried to take part in care. They reminded the patients often about the need for self-care and demanded that they carry out blood glucose levels frequently. Patients whose parents had a motivating style had the best compliance, followed by accepting parents. Adherence was lowest among adolescent patients whose parents were disciplinarians. Friends have a tremendous influence during adolescence. In this study, actions of friends were classified as dominant, providing silent support, or irrelevant. When friends dominated the lives of young diabetics, the patient adopted their friends lifestyle. Most often, diabetic self-care did not fit in with this lifestyle. In addition, dominating friends often tempted the patients to break from their desired health routines. Friends who provided silent support reminded the patients about the need for diabetic self-care and changed some of their own habits to support the patients lifestyle. For example, supportive friends did not buy sweets containing sugar when they were with young diabetics or tempt them to break their health regimens. The patients who saw their friends as irrelevant in relation to their diabetic self-care saw their responsibility for care as a natural part of their lives. They did not allow their friends lifestyles to influence their behaviors. The highest adherence was among adolescents who felt their friends were irrelevant or peripheral to their care, followed by adolescents who felt their friends provided silent support. Those who allowed their friends to dominate their actions had the lowest compliance. Results indicate that the nature of the relationship with physicians, nurses, parents and friends, influences adherence to diabetes self-care. The implications of this study for nurses are enormous. It is clear that adherence increases when the patient and health care staff negotiate, set, and agree on goals together. It is also important that patients feel their thoughts are important and their opinions valued. Nurses and other health care professionals must ensure that interactions with patients are not dominated by disease monitoring activities such as blood tests or paperwork. Although blood tests and paperwork are important, it is extremely helpful for the nurse to sit

down and devote a few minutes to discover what the patient is concerned about and what difficulties the patient is having with personal self-care management, followed by a discussion about how to integrate self-care into his or her unique situation. Although considerable time and effort have been spent studying patient adherence and variables that affect it, there is still little definitive information that enables nurses to ensure patient adherence. Major questions remain unanswered and warrant further research.6 Recent research, however, points to the relationship between the patient and the health care professional as extremely important in achieving adherence. By improving communication with patients, and by viewing them as partners in health care management rather than as passive recipients of information, better health care outcomes may be realized. Table 19

Guidelines for Good Provider-Patient Communication Staff respond to patients and take enough time to meet with them. Staff maintain eye contact, speak to the patient with respect, limit use of jargon, and speak in terms the patient can understand. Staff take time to listen to patient symptoms and concerns. Staff create an atmosphere that provides a level of comfort for patients to voice their questions about medical conditions and procedures and express their fears about the unknown. Staff demonstrate a nonjudgmental attitude toward patients who are different from themselves. An attitude of acceptance allows patients to honestly discuss sensitive issues such as sexual orientation and behavior, drug and alcohol behavior, and illegal activities or behaviors that differ from community norms. Staff respect concerns of all patients regardless of race or age and take all symptoms seriously instead of assigning labels to patients. Staff explain why tests are needed, when the results will be available, and how to get the results. Staff build partnerships that involve each patient in his or her health care, address barriers to behavioral change, and work with patients to identify alternative solutions. Staff are available for follow-up questions and return telephone calls promptly.

SOURCE: Adapted from: Bateman, W.B., Kramer, E.J., & Glassman, K.S. (1999). Patient and Family Education in Managed Care and Beyond. New York: Springer Publishing Co., 22.
Table 20

Characteristics of Nurses, Physicians

Described as Motivating Discussed treatment and self-care with patients Worked with patients to come up with treatment plan Demonstrated interest in how patients fit self-care needs into daily life Helped patients problem solve Discussed issues with patients and used the results to plan care Listened to patients opinions

SOURCE: Adapted from Kyngas, H., Hentinen, M., & Barlow, J.H. (1998). Adolescents perceptions of physicians, nurses, parents and friends help or hindrance in compliance with diabetes self-care. Journal of Advanced Nursing, 27(4), 760-769.

Interventions that can increase adherence


The nurse can use a variety of interventions to help the patient improve adherence. Here are some helpful strategies:

Ask the patient why he or she is not able to follow treatment recommendations. The patients view of why adherence is difficult Try to avoid proposing an immediate solution. Focusing your efforts on helping the patient learn problem-solving skills will be Determine whether the patient believes that adherence will help solve the health care problem. If the answer is no, find out Does the patient understand what to do? Its difficult for adults to admit they dont know how to do something. Often, if people

is the one that counts. of much greater benefit in the long run. patients beliefs about the problem. are not sure of what they are doing, they will often do nothing rather than risk doing something wrong. For example, to determine that a patient knows how to take medication, ask the patient to tell you exactly what he or she is going to do-take how many tablets, at what time, with/without food, and what side effects to look for.

Determine that the patient has the skills to adhere. Does the patient have limited hand function or visual problems that will Is adherence punishing? For example, some drugs have uncomfortable side effects or an exercise program may cause Is the new health care behavior too complex? Sometimes we ask patients to do many skills at the same time. Analyze Does the patient have a memory problem that interferes with compliance? Using memory aids to recall when to take Does the patient have the mental capacity to learn the required health care management skill? If not, locate a spouse, family

make adherence difficult? stiffness. everything you are asking the patient to do and simplify tasks if needed. medications or linking the new behavior with an already established activity can help. member, or neighbor to help the patient. Many older people who live alone are part of an informal helping network of friends and neighbors. Members of that network can be encouraged to call the patient regularly to remind the patient what he or she is to do.

Does the patient have the physical capacity to do the skill? If not, simplify the activity or provide assistance in the form of

assitive devices or support help. Adherence to health care recommendations is a major issue in health care today. Nurses and other health care professionals tend to believe that informing a patient about what to do will result in the patient following treatment recommendations. However, research shows that a large number of patients dont follow the treatment recommendations and health care instructions we give them. By

making patients more active partners in care and by forming closer interpersonal relationships with patients, nurses can help solve this significant problem.

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