Transcript My Patient is Non-Compliant Because?

My Patient is
Non-Compliant Because?
Mary Rzeszut, MSW,LCSW
North 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 Categories
of 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-Adherence
Patient 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 Theory
Health 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 better
mental health, greater quality of life and improved health related
outcomes¹
¹Personality and Social Psychology Bulletin 1996
Self-Determination Theory Model of Health Behavior Change
Autonomy Supportive
vs.
Controlling Health
Care Climate
Mental Health
Autonomy
Personality
Differences
In
Autonomy
Higher Quality of Life
Competence
Relatedness
Intrinsic vs.
Extrinsic Life
Aspirations
Less Depression
Less Anxiety
Less Somatization
Physical Health
Adherence
Diet
Weight Less
Exercise
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 goals
What 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