Nonadherence occurs when a patient (family, caregiver, or guardian) fails to adhere to a healthcare provider’s recommendations or prescribed treatment plan. This can include medications, procedures, follow-up appointments, and lifestyle modifications.
It is important to note that noncompliance has a negative connotation, as it refers more to a provider deciding on a suitable treatment with the expectation that the patient will comply. It is generally preferable to use the term ‘adherence’. The use of the word ‘adherence’ is a friendlier term and describes a process that has been agreed upon by both provider and patient. It is also important to note that a lack of adherence to treatment recommendations is often related to systemic barriers rather than a patient simply choosing not to adhere.
Poor adherence to healthcare recommendations, medications, and treatments is directly related to poorer outcomes, a lower quality of life, and higher healthcare costs. Nurses can play an important role in uncovering reasons for nonadherence and working with patients to meet goals that are important and relevant to them.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are common causes of nonadherence:
- Developmental abilities
- Lack of knowledge/understanding/motivation/skill
- Individual health beliefs, cultural and spiritual influences
- Cost/financial barriers
- Complexity of health regimen
- Denial
- Lack of health insurance coverage
- External barriers: lack of transportation or social support
- Poor patient-provider relationship (distrust in the health system)
- Lack of access to care
- Difficulty in behavior change (addiction)
- Depression or apathy
Signs and Symptoms (As evidenced by)
The following are common signs and symptoms of nonadherence. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Subjective: (Patient reports)
- Expression of disinterest, distrust, or denial
- Expression of frustration, barriers or hopelessness
Objective: (Nurse assesses)
- Failure to keep appointments
- Signs of poor adherence: worsening health, failure to make progress, worsening lab results, exacerbation of chronic conditions
- Frequent preventable hospitalizations
- Refusing medications or treatments
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for nonadherence:
- Patient will demonstrate a commitment to improving health status by implementing positive behaviors (not missing doses of medications, keeping appointments).
- Patient will verbalize an understanding of their health status and list changes required to improve their adherence.
- Patient will access resources in order to improve adherence.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to nonadherence.
1. Determine the patient’s or family’s perception of their condition.
Patients or family members who do not have a thorough understanding of their health and related outcomes may not be committed to the plan of care. They may not be aware of long-term effects or realize the severity of their disease. It is important that the nurse assesses the understanding of the disease.
2. Assess external caregivers.
Patients, especially older adults or small children may be dependent on another to coordinate their care.. Confer with the person in charge to prevent miscommunication or gaps in care.
3. Inquire about medications.
Nonadherence with medications is common and often leads to exacerbations or worsening of their health conditions. Obtain a thorough list of medications and ask specific questions about how many doses have been missed in a two-week timeframe. Inquire about reasons for nonadherence such as frequency, cost, or side effects.
4. Assess what the patient values most.
Cultural or religious values may not align with their healthcare treatment plan. It is important to have an open discussion about any potential barriers. Some hospitals may have religious or spiritual services that the nurse may be able to offer the patient.
5. Assess for a language barrier.
Patients who do not speak English may not comprehend instructions given to them but often will not request clarification. Poor communication is a preventable cause of nonadherence.
6. Assess for cost or resource limitations.
Some patients live in rural areas with limited access to specialists or transportation. The cost of care or medications is often also a significant barrier for patients, even if they have health insurance. Any time there is nonadherence, the nurse should assess for financial barriers.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with nonadherence.
1. Provide non-judgmental listening.
Healthcare professionals can often perceive nonadherence as the patient simply making a choice to not follow recommendations. Allow the patient time and space to discuss their reasons. A trusting and nonjudgmental relationship allows for the best possibility of improving adherence.
2. Ensure information is provided at their developmental level.
Inquire about the patient’s learning style and how they like to receive information. Give information in manageable amounts and limit the use of medical jargon.
3. Provide culturally sensitive and trauma-informed informed care.
Discrimination is a threat to adherence. Providing culturally sensitive and trauma-informed care when having conversations about adherence increases the likelihood of open and effective communication, builds trust, and minimizes the risk of re-traumatization.
4. Implement telehealth options.
Patients who frequently miss appointments or have other barriers to care may benefit from telehealth visits from their phone or computer.
5. Use interpreter services.
Whenever communicating healthcare information, it is expected to use an interpreter if the professional and patient do not speak the same language. Even so, studies show that healthcare professionals who use interpreters may not ask all necessary questions or ensure messages are delivered clearly, due to time constraints.
6. Direct to community resources.
If the cost of medications is a barrier, provide information on patient assistance programs. If located in the United States, local services such as the Area Agency on Aging assist with preventative healthcare services, insurance assistance, medical equipment and supplies, and transportation.
7. Involve the patient in their decisions.
Patients are more likely to follow through and remain committed if they are active participants in goals creation that are aligned with their priorities.
8. Ensure continuity of care.
Patients are more likely to complete follow-up appointments if they are scheduled prior to discharge. The use of inpatient pharmacies that deliver to the patient’s room before they are discharged home may prevent them from not picking up a new medication.
9. Simplify complex care.
Taking multiple medications several times per day, painful injections, or other time-consuming treatments increases the likelihood of nonadherence. Attempt to simplify regimens or involve a home health agency to administer care for better adherence.
10. Meet the patient where they are.
Any kind of behavior change is challenging. A patient will not be willing to make a change unless they can perceive a benefit. The nurse can be a supporter of small goals. For example, a patient who smokes may be unwilling to quit completely but may agree to reduce the number of cigarettes they smoke each day.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for ineffective health maintenance.
Care Plan #1
Diagnostic statement:
Noncompliance related to provider discontinuity as evidenced by exacerbation of symptoms.
Expected outcomes:
- Patient will report compliance with provider appointments and therapeutic regimens.
- Patient will control and prevent worsening symptoms of the current condition.
Assessment:
1. Assess the patient’s beliefs about their current illness and the importance of health care.
When there is discontinuity in care, the patient may feel lost in the health system, and there is an increased risk of inconsistent health information. It is important to assess the patient’s current understanding of their illness and trajectory of care.
2. Assess the patient’s motivation and willingness to follow the treatment plan.
Compliance with the treatment plan may depend on the patient’s perceived susceptibility to develop or acquire the illness, the severity of the condition, and the benefits of the care plan.
3. Assess the patient’s knowledge about the disease and its management.
Lack of knowledge about the disease and treatment also contributes to noncompliance with recommended treatment.
Interventions:
1. Establish a collaborative partnership with the patient to meet health-related goals.
Collaboration enhances patients’ trust. Having mutual health-related goals promotes motivation to adhere to treatment and improve health.
2. Assist the patient in enhancing self-efficacy or confidence in managing the illness.
Confidence fuels patient autonomy. Patients who believe in their capabilities are more likely to follow the treatment plan.
3. Increase the amount of supervision provided; gradually reduce the amount of professional care and reinforcement as compliance improves.
The nurse may enhance supervision through home visits, home health nurses, telephone monitoring, and frequent return visits or appointments can provide increased supervision that can be tapered as appropriate.
Care Plan #2
Diagnostic statement:
Noncompliance related to insufficient health insurance as evidenced by missed appointments.
Expected outcomes:
- Patient will attend appointments.
- Patient will utilize community social services to address health insurance concerns.
Assessment:
1. Identify resources that could help improve access to health resources.
Community centers and school-based clinics may serve as sources of free health services.
2. Assess the current gaps in care.
It is important to understand what potential barriers the patient has to following the treatment plan. Some potential barriers to care may include the cost of medications, office visits, hours of operation, and transportation. Once barriers are identified, then it becomes possible to create a plan.
3. Assess available social services for the patient.
Some social organizations have programs to help underserved populations. Assess for the patient’s knowledge of services that may be available to them.
Interventions:
1. Refer the patient to a social worker
Social workers are experts in helping patients navigate the health systems and different social programs.
2. Institute home visits or allow consults through phone calls.
The distance of the clinic from the patient’s house and the cost of transportation may be a barrier to patient care. In such cases, home visits or phone calls may make care more accessible.
3. Refer to community centers or social organizations.
Depending on availability, the nurse may recommend options to receive care or support such as community organizations. Healthcare providers may also collaborate with community outreach workers to improve care accessibility.
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.
- 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
