My Patient is Non-Compliant Because?

Mary Rzeszut, MSW,LCSWNorth Shore University Hospital

Department of Nephrology

Objectives• Review definition of the terms non-compliance and non-adherence

in the hemodialysis unit

• Describe behaviors seen in non-adherence hemodialysis patients

• Identify root causes of non-adherence to hemodialysis treatment

• Describe techniques that can be applied to non-adherent patients to maintain positive outcomes

Adherence vs Compliance

•Compliance – conform, cooperate, or obey¹ •Adherence – steady devotion, support, allegiance¹

•Sense of something shared cooperatively by both parties rather than forced upon one by the other•Demonstrates patient centered care

¹ Dictionary.com

Patient Centered Care•Treating patients as partners• Involves them in planning their health

care •Encourages them to take responsibility for

their own health (self-management)

What’s Going On

• Estimated 50% of dialysis patients do not adhere to at least part of their treatment*

• Patients maintain adherence for approximately the first 6 weeks of treatment, after that adherence declines**

*Seminars in Dialysis, 2001**World of Irish Nursing, 2006

Two Categoriesof Non-Adherent Behavior• Intentional Non-Adherence - premeditated effort

to go against medical advice. An active decision driven by patient beliefs, treatment, disease and prognosis.

•Un-Intentional Non-Adherence – passive process of non-adherence through forgetfulness, carelessness, or circumstances out of their control.

Types of Non-Adherent Behavior

• Non-adherence to dialysis prescription•Missing sessions or signing off early• Non-adherence to renal diet and fluid restrictions• Non-adherence to medications• Improper care of dialysis access

Causes of Non-AdherencePatient Factors

•Limited understanding of the severity of medical condition•Psychosocial stress due to change in lifestyle

(financial, marital, employment issues, loss of control)•Limited cognitive ability•Limited transportation•Needle phobia

Patient Factors• Feel pressured or coerced• Lack of motivation due to low mood or anxiety•Chronic pain or other medical issues•Self blame/guilt if belief illness was self induced•Patient’s feelings of anxiety, shame and

vulnerability during every treatment whether expressed or not.

Health Care Team Related Factor’s

• Controlled motivation – use of authority, use of rewards• Introjections – manipulation of action by offering approval• Labels and judgments (difficult, angry, depressed, non-

compliant)• Poor communication • Lack of tools to provide interventions in adherence issues• Lack of awareness of patient’s learning/education ability

What Creates Adherence

• Improving patient adherence is a process that must include an evaluation of the patient’s level-of-readiness to follow health recommendations.

(World Health Organization, 2003)

•Collaboration vs. Confrontation

•Autonomy vs. Authority

•Evocation-drawing out, rather than imposing ideas

Self Determination TheoryHealth Behavior Model

• Assumes we are naturally motivated to improve our well being• Develop new behaviors when internalize reasons

for doing them rather than being forced to behave a certain way• Studies suggest that patients whose motivation for

health related behavior was more autonomous, showed greater adherence and better maintenance of health behavior change¹

¹Health Education Research, 2002

Psychological Needs• SDT suggests we move towards self-motivation when three

psychological needs are met.

• Autonomy- ability to choose a direction or behavior in life• Competence – ability to feel capable of producing a desired result• Relatedness – desire to feel connected and trusting of others

Meeting these three psychological needs has been associated with bettermental health, greater quality of life and improved health relatedoutcomes¹

¹Personality and Social Psychology Bulletin 1996

Self-Determination Theory Model of Health Behavior Change

Autonomy

Competence

Relatedness

Autonomy Supportive

vs.Controlling Health

Care Climate

Personality Differences

In Autonomy

Intrinsic vs.Extrinsic LifeAspirations

Mental Health

Less DepressionLess Anxiety

Less Somatization

Higher Quality of Life

Physical Health

AdherenceDiet

Weight LessExercise

Autonomous Supportive Environment

• Assess and respect the patient’s perception of illness• Describe their illness and treatment • Concerns or problems • What aspect of illness gives them the greatest worry or concerns

• Ensure patients have relevant information about health risks and the relation between behaviors and consequences associated with them• Support patient’s participation to decision making

“We advise that ………..whether you chose this is your decision and I will respect whatever decision you make”

Autonomous Supportive Environments

• Provide choices rather than ultimatums• Ask permission to have discussion• Encourage discussion by exploring resistances and barriers to

change• Help identify pathways to improve healthy outcomes

Competence• Enhancing a patient’s feelings of self efficacy builds

confidence to move ahead• Encourage participation in self care tasks• Provide education/skills and tools for change• Awareness of patient’s learning/education capability

and ability to absorb new information

• Assess patient’s confidence in performing behavior •Scale from 0 to 10 (zero not confident, 10 very confident)•Score higher than 7 indicates action plan will be successful

• Provide support when barriers emerge• Celebrate successes• Avoid demeaning evaluations of failures• Reinforce that change requires persistence and takes

several attempts

Competence alone does not create adherence, it must be accompanied by autonomy

Relatedness• Patients are more likely to adapt to self management

behaviors if they feel connected to health care providers• Convey sense of caring, concern, build trust• Supportive tone of voice• Avoid expressing criticism• Encourage family members to support patient’s

efforts toward self care

Strategies for Building Communication

• Have patient discuss problematic issue• Explore present coping strategies

What have you tried?

• Reflect on outcome and create awareness of behavior

Do you feel this strategy is working?Is it giving you the outcome you want in terms of your

health?Is there something you can do differently in this situation?

• Explore the negative feelings/thoughts associated with issue/problem Have you thought about how this problem makes you feel?

• Explore life goalsWhat type of life would you like to have?How do you know you are moving in the direction of obtaining goal?What’s getting in the way

•Ask open ended questions

“Alot of people find it difficult to have treatment three days a week. Tell me about your experience?”

“On a scale of 1 to 10, how important do you think it is for you to do the things we've been talking about?”

“On a scale of 1 to 10, how confident are you that you can adhere to this treatment regimen?”

A True Story…“So Mr. Johnson I understand your ESRD was caused by your IDDM and by the looks of your A1C levels you have not been controlled very well for awhile. I see your BP is high and based on your Hgb. I am wondering if that might not explain your fatigue and labile mood. In addition you have fluid around your lungs and heart which might be CHF and also might explain why you are so SOB”

What Did The Patient Hear?

“Mr. Johnson, Blah, Blah, Blah, Fluid, yada-yada, Lungs, yada-yada, Heart,SOB!”

“What do we live for if not to make life less difficult for each other?”

Roger Bannister, MD