Nonadherence in healthcare arises when a patient, whether it be an individual, family member, caregiver, or guardian, does not follow the recommendations or prescribed treatment plan provided by their healthcare provider. This lack of adherence can manifest in various aspects of care, including medication regimens, scheduled procedures, follow-up appointments, and necessary lifestyle adjustments.
It’s crucial to understand that the term “noncompliance” carries a somewhat negative connotation. It implies a provider-centric approach where treatment decisions are made with the expectation of patient obedience. In contemporary healthcare, “adherence” or “ineffective adherence” are generally preferred terms. “Adherence” emphasizes a collaborative process, suggesting an agreement between the healthcare provider and the patient regarding the treatment plan. Furthermore, it’s essential to recognize that nonadherence often stems from systemic obstacles and barriers rather than a deliberate choice by the patient to disregard medical advice.
Poor adherence to healthcare recommendations, medication schedules, and treatment protocols is strongly linked to unfavorable health outcomes, diminished quality of life, and escalating healthcare costs. Nurses are uniquely positioned to play a vital role in identifying the underlying reasons for nonadherence and collaborating with patients to establish and achieve health goals that are meaningful and relevant to their individual circumstances.
Important Note: It is important to recognize that the nursing diagnosis “Noncompliance” has been retired by NANDA International. Initially, it was replaced by “Ineffective Adherence,” but in a subsequent update, this label was also retired. While the formal diagnosis is no longer in use, understanding the concept of nonadherence (now more accurately termed ineffective adherence) and its associated nursing care remains crucial for effective patient care. This article will discuss the concepts related to the retired diagnosis of “Noncompliance” as it is still a widely understood term and relevant to clinical practice when discussing patient adherence challenges.
Causes of Ineffective Adherence
Several factors can contribute to ineffective adherence. These can be broadly categorized as follows:
- Developmental Stage: Age and developmental abilities can influence a patient’s understanding and capacity to adhere to treatment.
- Knowledge Deficit: Lack of sufficient information, understanding of the treatment plan, or health literacy can significantly impede adherence.
- Motivational Issues: Insufficient motivation or lack of perceived benefit from the treatment can lead to nonadherence.
- Skill Deficiencies: Patients may lack the necessary skills to implement certain aspects of their treatment plan, such as administering injections or managing complex medication schedules.
- Health Beliefs and Cultural Influences: Individual health beliefs, cultural norms, and spiritual beliefs can sometimes conflict with recommended medical treatments, leading to nonadherence.
- Financial Constraints: The cost of medications, treatments, and healthcare services can be a significant barrier, especially for patients with limited financial resources or inadequate insurance coverage.
- Complexity of Treatment Regimen: Intricate treatment plans involving multiple medications, frequent appointments, or complex procedures are often challenging for patients to manage and adhere to.
- Denial: Denial of the illness or its severity can prevent patients from accepting and following necessary treatments.
- Lack of Health Insurance: Uninsured individuals may avoid seeking care or adhering to treatments due to financial concerns.
- External Barriers: Factors such as lack of transportation, inadequate social support, or geographical limitations in accessing healthcare services can hinder adherence.
- Poor Patient-Provider Relationship: Distrust in the healthcare system or a strained relationship with healthcare providers can negatively impact patient adherence.
- Limited Access to Care: Geographical inaccessibility to healthcare facilities or specialists can make it difficult for patients to receive and adhere to recommended care.
- Behavioral Change Challenges: Conditions like addiction or deeply ingrained habits are inherently difficult to change and can interfere with adherence to health-related recommendations.
- Mental Health Conditions: Depression, apathy, and other mental health conditions can significantly impair a patient’s motivation and ability to adhere to treatment plans.
Recognizing Nonadherence: Signs and Symptoms
Identifying nonadherence involves recognizing both subjective reports from the patient and objective observations made by the nurse or healthcare team.
Subjective Data (Patient Reports):
- Expressions of Disinterest, Distrust, or Denial: Patients may verbalize a lack of interest in their treatment, express distrust in healthcare providers or the system, or deny the need for treatment.
- Expressions of Frustration, Barriers, or Hopelessness: Patients might express frustration with their treatment plan, articulate barriers preventing adherence (e.g., “I can’t afford my medication”), or convey feelings of hopelessness regarding their health condition or the effectiveness of treatment.
Objective Data (Nurse Assessments):
- Missed Appointments: Failure to keep scheduled appointments, whether for follow-up care, therapy, or procedures, is a key indicator of potential nonadherence.
- Signs of Poor Adherence: This can manifest as a worsening of the patient’s health condition, failure to achieve expected progress in treatment, deteriorating laboratory results, or exacerbation of chronic conditions.
- Frequent Preventable Hospitalizations: Recurring hospital admissions, particularly for conditions that could be managed effectively with consistent outpatient care and adherence to treatment, may signal nonadherence.
- Refusal of Medications or Treatments: Directly refusing to take prescribed medications or participate in recommended treatments is a clear sign of nonadherence.
Expected Outcomes for Improved Adherence
Effective nursing care planning aims to establish clear goals and expected outcomes focused on enhancing patient adherence. These outcomes typically include:
- Commitment to Health Improvement: The patient will demonstrate a commitment to improving their health status by actively engaging in positive health behaviors, such as consistently taking medications as prescribed and attending scheduled appointments.
- Understanding of Health Status and Required Changes: The patient will verbalize a clear understanding of their current health status and articulate the specific changes necessary to improve their adherence to the treatment plan.
- Accessing Resources for Adherence Support: The patient will actively seek and utilize available resources designed to support and improve their adherence, such as patient assistance programs, transportation services, or community support groups.
Nursing Assessment Strategies for Nonadherence
A comprehensive nursing assessment is the cornerstone of addressing nonadherence. It involves gathering subjective and objective data to understand the patient’s situation fully. Key assessment areas include:
1. Understanding Patient Perception of Condition:
- Action: Determine the patient’s or family’s understanding of their health condition, its potential consequences, and the purpose of the recommended treatment plan.
- Rationale: Patients who lack a thorough understanding of their illness and its implications may not fully appreciate the importance of adherence. Assessing their knowledge base is crucial for targeted education and motivation.
2. Assessing External Caregivers:
- Action: For patients who rely on caregivers (e.g., older adults, children), assess the caregiver’s understanding of the treatment plan and their capacity to support the patient’s adherence.
- Rationale: Miscommunication or gaps in care coordination can arise when multiple individuals are involved. Involving and educating caregivers is essential for ensuring consistent support.
3. Medication Inquiry:
- Action: Obtain a detailed medication history, including prescription and over-the-counter medications. Specifically inquire about missed doses within a recent timeframe (e.g., the past two weeks) and the reasons behind any missed doses.
- Rationale: Medication nonadherence is prevalent and a frequent cause of health deterioration. Identifying patterns of missed doses and underlying reasons (frequency, cost, side effects) allows for tailored interventions.
4. Values and Beliefs Assessment:
- Action: Explore the patient’s cultural, religious, and spiritual values to identify any potential conflicts with the recommended treatment plan.
- Rationale: Respecting patient values and beliefs is paramount. Openly discussing potential conflicts and seeking culturally sensitive solutions can bridge gaps and improve adherence.
5. Language Barrier Evaluation:
- Action: Assess for potential language barriers. Determine if the patient fully understands instructions and offer interpreter services if needed.
- Rationale: Language barriers are a preventable cause of nonadherence. Effective communication is essential for ensuring patients comprehend their treatment plan.
6. Resource and Cost Limitations:
- Action: Assess for financial constraints, limited access to transportation, or other resource limitations that may impede adherence.
- Rationale: Financial and logistical barriers are significant contributors to nonadherence. Identifying these barriers allows nurses to connect patients with appropriate resources and support systems.
Nursing Interventions to Promote Adherence
Nursing interventions are crucial for addressing nonadherence and supporting patients in achieving their health goals. Effective interventions include:
1. Non-Judgmental Listening and Communication:
- Intervention: Create a safe and non-judgmental space for patients to openly discuss their reasons for nonadherence without feeling blamed or criticized.
- Rationale: Building trust and rapport is fundamental. Understanding the patient’s perspective and challenges is the first step toward collaborative problem-solving.
2. Developmentally Appropriate Information Delivery:
- Intervention: Tailor information to the patient’s developmental level, learning style, and health literacy. Provide information in manageable segments, avoiding complex medical jargon.
- Rationale: Ensuring patients understand information is critical. Using clear, simple language and appropriate teaching methods enhances comprehension and retention.
3. Culturally Sensitive and Trauma-Informed Care:
- Intervention: Provide care that is sensitive to the patient’s cultural background and acknowledges any past trauma experiences.
- Rationale: Discrimination and past trauma can create barriers to trust and communication. Culturally sensitive and trauma-informed approaches foster trust and improve communication about adherence.
4. Telehealth Integration:
- Intervention: Explore and implement telehealth options for patients who face barriers to in-person appointments, such as transportation difficulties or mobility limitations.
- Rationale: Telehealth can improve access to care and reduce appointment-related barriers, enhancing adherence to follow-up and monitoring.
5. Interpreter Services Utilization:
- Intervention: Utilize professional interpreter services whenever communication occurs across language barriers to ensure accurate and clear exchange of healthcare information.
- Rationale: Professional interpreters are essential for accurate communication and preventing misunderstandings that can lead to nonadherence.
6. Community Resource Referral:
- Intervention: Connect patients with relevant community resources, such as patient assistance programs for medication costs, transportation services, or social support organizations.
- Rationale: Addressing practical barriers like cost and transportation is crucial. Community resources can provide essential support to overcome these obstacles.
7. Patient Involvement in Decision-Making:
- Intervention: Actively involve patients in setting health goals and developing treatment plans that align with their priorities and values.
- Rationale: Patient autonomy and ownership are key motivators. When patients feel involved in decisions, they are more likely to be committed to the plan.
8. Continuity of Care Enhancement:
- Intervention: Schedule follow-up appointments before discharge, utilize inpatient pharmacies for medication delivery, and implement strategies to ensure smooth transitions between care settings.
- Rationale: Ensuring continuity reduces gaps in care. Proactive scheduling and medication access improve adherence to follow-up and medication regimens.
9. Treatment Regimen Simplification:
- Intervention: Collaborate with the healthcare team to simplify complex treatment regimens whenever possible, such as reducing medication frequency, combining medications, or exploring alternative routes of administration.
- Rationale: Complex regimens are burdensome. Simplification improves manageability and reduces the likelihood of errors and missed doses.
10. Meeting Patients Where They Are:
- Intervention: Acknowledge that behavior change is challenging and support patients in setting small, achievable goals. Celebrate small successes and focus on gradual progress.
- Rationale: Behavior change is a process. A supportive, patient-centered approach that acknowledges challenges and celebrates incremental progress is more effective than demanding immediate, drastic changes.
Nursing Care Plans for Addressing Nonadherence
While the “Noncompliance” diagnosis is retired, the principles of care planning for patients struggling with adherence remain highly relevant. Here are examples of care plan approaches, reframed to reflect current terminology and focus on addressing the causes of ineffective adherence.
Care Plan #1: Ineffective Adherence related to Discontinuity of Care
Diagnostic statement:
Ineffective Adherence related to provider discontinuity as evidenced by exacerbation of symptoms.
Expected outcomes:
- Patient will report consistent attendance at provider appointments and adherence to therapeutic regimens.
- Patient will demonstrate control and prevention of worsening symptoms of their condition.
Assessment:
1. Assess Beliefs about Illness and Healthcare Importance:
- Rationale: Discontinuity can lead to patient feelings of being lost in the system and receiving inconsistent information. Understanding their current understanding is vital.
2. Assess Motivation and Willingness to Adhere:
- Rationale: Adherence is influenced by perceived susceptibility to illness, condition severity, and perceived benefits of the care plan.
3. Assess Knowledge about Disease and Management:
- Rationale: Knowledge deficits directly contribute to ineffective adherence.
Interventions:
1. Establish Collaborative Partnership:
- Rationale: Collaboration builds trust and promotes shared goals, enhancing motivation for adherence.
2. Enhance Self-Efficacy and Confidence:
- Rationale: Confidence in managing illness empowers patients and increases adherence.
3. Increase and Gradually Reduce Supervision:
- Rationale: Increased supervision (home visits, phone monitoring) can be tapered as adherence improves, providing support during initial phases.
Care Plan #2: Ineffective Adherence related to Insufficient Health Insurance
Diagnostic statement:
Ineffective Adherence related to insufficient health insurance as evidenced by missed appointments.
Expected outcomes:
- Patient will attend scheduled appointments.
- Patient will utilize community social services to address health insurance concerns.
Assessment:
1. Identify Resources for Improved Access:
- Rationale: Community centers and school-based clinics may offer free or low-cost services.
2. Assess Current Gaps in Care:
- Rationale: Understanding specific barriers (cost, transportation, hours) allows for targeted planning.
3. Assess Available Social Services:
- Rationale: Many organizations offer programs for underserved populations; assessing patient knowledge of these is important.
Interventions:
1. Refer to Social Worker:
- Rationale: Social workers are experts in navigating healthcare systems and social programs.
2. Institute Home Visits or Phone Consults:
- Rationale: Addresses transportation and distance barriers, improving accessibility.
3. Refer to Community Centers/Organizations:
- Rationale: Community resources can provide accessible care and support.
Care Plan #3: Ineffective Adherence related to Insufficient Knowledge
Diagnostic statement:
Ineffective Adherence related to insufficient knowledge about the regimen as evidenced by nonadherence behavior.
Expected outcomes:
- Patient will verbalize increased knowledge about the therapeutic regimen.
- Patient will demonstrate adherence to the treatment plan (appointment attendance, reduced exacerbations, medication adherence).
Assessment:
1. Identify Current Knowledge and Adjust Teaching:
- Rationale: Baseline knowledge informs tailored teaching.
2. Assess Interest in Following Treatment Plan:
- Rationale: Unstable housing, beliefs, or finances can be root causes of nonadherence beyond knowledge deficits.
3. Assess Beliefs about Treatment Plan:
- Rationale: Understanding worries or misconceptions guides interventions.
Interventions:
1. Utilize Varied Educational Formats:
- Rationale: Different learning styles exist; diverse formats (group education, brochures, videos) enhance learning.
2. Tailor Information to the Individual Patient:
- Rationale: Patient-specific education empowers informed decisions and promotes behavior change.
3. Involve Family/Supportive People:
- Rationale: Support networks can motivate and assist with adherence.
4. Explain Material in Simple Terms and First Language:
- Rationale: Health literacy varies; simplified language and preferred language enhance understanding and adherence.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Chakrabarti S. (2014). What’s in a name? Compliance, adherence and concordance in chronic psychiatric disorders. World journal of psychiatry, 4(2), 30–36. https://doi.org/10.5498/wjp.v4.i2.30
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
- McQuaid, Elizabeth L, and Wendy Landier. “Cultural Issues in Medication Adherence: Disparities and Directions.” Journal of general internal medicine vol. 33,2 (2018): 200-206. doi:10.1007/s11606-017-4199-3
