Patient noncompliance and termination in advanced practice nursing

Patient Noncompliance

Noncompliance in Patients

Advanced Practice Nursing represents a partnership between the patient and service provider. Many times the success of the treatment plan depends on the patient taking responsibility for compliance with certain prescribed actions. Examples of these actions include taking prescribed medication as directed, following a certain diet, or following an exercise regimen. If a patient does not follow the treatment plan, it can jeopardize the outcome of the treatment. Many physicians and other medical practitioners now view patient noncompliance as a breach of the relationship.

The practice of "firing" patients that do not follow recommended advice is becoming more common. This research will explore the practice of terminating patients for lack of compliance to prescribed medical treatments. It will explore the ramifications of this practice for the patient and for the medical practice. It will explore alternatives to firing a patient and steps that can be taken by the nurse practitioner to help avoid this unfortunate event.

Factors Affecting Patient Noncompliance

The American Medical Association supports the practice of firing a patient for failure to follow prescribed medical procedures. The American Academy of Nurse Practitioners defines the relationship as that of helping clients to make wise health and lifestyle choices. They recognize the relationship as a partnership, rather than a service. This research explores the ethics involved in terminating the patient/client relationship when the patient fails to follow sound medical advice.

When a patient chooses not to follow prescribed treatment regimens, it can have serious affects on their health. It may reduce their quality of life, or may lead to increased morbidity or death in some cases (Rosner, 2006). These issues make the topic of patient noncompliance an important issue for medical professionals. Noncompliance with treatment plans can lead to increased costs due to worsening conditions, or the development of new conditions or complications. Noncompliance has medical and financial implications.

Often nurse practitioners and other medical personnel are at a loss to understand the reasons for patient noncompliance. However, there are often reasons for a patients actions or lack of action during the treatment plan. Understanding these reasons will help nurse practitioners to be able to predict those patients that are at risk for noncompliance and develop ways to help them follow their treatment regime. Recently, a considerable amount of academic research concerning the prevalence and reasons for patient noncompliance has been produced. The following summarizes the latest findings regarding patient noncompliance among various health disciplines. Many of these studies are targeted towards doctors, but they still apply to nurse practitioners, or any other health professional that must interact with patients on a regular basis.

Often information regarding medication history relies on self-reporting by the patient. Among heart patients, compliance with the treatment regime can be important to preventing future heart related incidents. In a recent study, blood samples were taken from patients upon admission to the hospital. The purpose of the study was to determine if information regarding medication use by patients matched medication levels found in the blood system (Glintborg, Hillestrom, & Olsen et al., 2007). Results indicated that only 2% of the patients reported use of drugs that were not found in their system. However, six percent of the patients had drugs in their system that was not reported prior to the blood draw (Glintborg, Hillestrom, & Olsen et al., 2007). The study concluded that a majority of the patients provided accurate information to health care professionals and that only a small percentage misrepresented their medication history. However, those patients that did not report other medications that they were taking are of particular concern due to the possibility of a harmful drug interaction.

In a similar study, noncompliance with heart medication regimes was defined as failure to comply at least 75% of the time (Gehi, Ali, & Na et al., 2007). Noncompliance was found to lead to a significant increase in coronary events as compared to patients that complied with the prescribed regime (Gehi, Ali, & Na et al., 2007). The reasons for patient noncompliance are not well understood and a number of factors contribute to noncompliance in patients.

Ho, Spertus, Masoudi & associates (2006) found several demographic factors that correlated with patient discontinuation of medication after myocardial infarction. Those that did not graduate from high school were more likely to discontinue at least one of three medications prescribed. Increasing age was also associated with medicine discontinuation. Females were more likely than males to discontinue at least one medication (Ho, Spertus, & Masoudi et al., 2006). This study also corresponded with Gehi, Ali & Na et al. (2007) in that patients who discontinued their medication had a significantly lower one-year survival than patients that followed the prescribed medication regime. Therefore, it is important to stress the need to follow prescribed treatments.

Patients prescribed thienopyridine therapy after placement of a heart stent were likely to discontinue treatment after only 30 days or less (Spertus, Kettelkamp, & Vance et al., 2006). Discontinuation of this therapy was associated with death within 11 months, due to complications (Spertus, Kettelkamp, & Vance et al., 2006). This study found similar demographic risk factors to Spertus, Kettelkamp, & Vance et al., (2006) in noncompliant patients. They found that those with lower educational levels, older patients, and married patients were less likely to comply with prescribed medication regimes. Another fact found in this study was that cost, preexisting cardiovascular disease, and anemia were factors in noncompliant patients. One of the key concerns raised in this study was that many patients that discontinued their medication had not received discharge instructions prior to leaving the hospital. They also had not received referral for cardiovascular rehabilitation (Spertus, Kettelkamp, & Vance et al., 2006).

Many studies address rates of noncompliance, but little attention has been directed towards discovering the reasons for noncompliance. Chatterjee, (2006) found that the quality of the doctor/patient relationship plays a significant role in outcomes regarding noncompliance. In the past, the doctor may have viewed the patient as less knowledgeable and therefore, the less knowledgeable of the two in terms of treatment decisions. Patients felt as if they were being dictated or given orders by the doctor.

It is now recognized that the patient has the right to make decisions about their own health and treatment. This developed into the idea of "concordance" (Chatterjee, 2006). Under this relationship model, the patient is viewed as an equal and has the right to make informed decisions. Patients with concordance in the doctor/patient relationship were more likely to follow prescribed diabetes management routines than those that lacked concordance in their doctor/patient relationships (Chatterjee, 2006).

In asthma patients, low rates of adherence to asthma self-management regimes were linked to the patient feeling that treatment was unnecessary (Horne, 2006). Asthma patients were also concerned about the long-term adverse affects of corticosteroids (Horne, 2006). Local symptoms that were considered intolerable also affected patient noncompliance with asthmas self-maintenance regimes (Horne, 2006). These reasons for noncompliance represent legitimate concerns and remind us that the noncompliance issue is not one-sided. Medical professionals need to address legitimate concerns such as these in order to increase patient compliance with prescribed medication regimes.

Depression was found to be a factor in discontinuation of medication adherence in patients with coronary heart disease (Gehi, Haas, & Pipkin et al., 2005). Renal transplant patients were found to comply with immunosuppressant therapy after transplant surgery (Chisholm, Lance, & Mulloy, 2005). Sex of the patient was not found to be a factor in noncompliance within this group. However, patient age, income, and time since the implant procedure were found to affect compliance rates in this group of patients (Chisholm, Lance, & Mulloy, 2005).

Pharmacist instruction did not increase patient compliance in patients with uncontrolled diabetes (Odegard, Goo, & Hummel et al., 2005). A significant number of patients beginning medication for a number chronic conditions including stroke, coronary heart disease, asthma, diabetes, and rheumatoid arthritis, quickly became noncompliant with their medication regimes (Barber, Parsons, & Clifford et al., 2004). Noncompliance in this group occurred in as little as ten days after prescription. Patients cited medication problems and a lack of information as key factors in their decision to discontinue medication as prescribed (Barber, Parsons, & Clifford et al., 2004). Some of the patients that reported no problems and were compliant in the beginning later developed problems and had discontinued medication by the four-week mark. These studies highlight the need for support for patients beginning a new medication regime.

Noncompliance in women with fibromyalgia was predicted by several factors. Those not under a rheumatologist's care were less likely to continue therapy, as were those with less disease activity (Sewitch, Dobkin, & Bernatsky et al., 2004). Instrumental coping mechanisms increased the likelihood of compliance in patients (Sewitch, Dobkin, & Bernatsky et al., 2004). Problems with the doctor/patient relationship were found to be at the heart of many noncompliant women in the study. These patients were divided into compliant, intentionally noncompliant, and unintentionally noncompliant. Those that were unintentionally noncompliant often cited costs or inability to access the treatment as reasons for noncompliance.

These studies demonstrate that there are several factors associated with patient noncompliance, regardless of the disease being treated. Medication side effects represent only one of these issues. Nurse practitioners could help to resolve many of these issues by being proactive and asking questions about side effects in patients at risk for becoming noncompliant. They may also be able to predict noncompliance in patients that are prescribed medications with known side effects. By informing the patient of the side effects and giving them practical ways to cope with them, the nurse practitioner can play an active role in helping to eliminate patient noncompliance.

Education was found to play an important role in patient noncompliance. The overall educational level of the patient was found to be important. The nurse practitioner can take positive action by being aware of the patient's overall educational background. Extra care must be taken with those of low educational status. The nurse practitioner must make certain that these patients understand the medication, any side effects, and the importance of taking their medication or following other treatment regimes. The nurse practitioner must make certain that the patient has all of the information that they need and that they understand this information.

This group of studies highlights the role that the nurse practitioner can take in preventing noncompliance in patients. Being sensitive to those patients that fall into risk categories for noncompliance will help the nurse practitioner in taking appropriate action to make certain that the most common reasons for noncompliance are eliminated, or at least lessened in at-risk patient populations. The nurse practitioner must be willing to educate the patient in all aspects of the treatment plan. They must also be willing to listen to patient concerns and to help them devise ways to alleviate fears and problems with their medication regime. Academic research supports the idea that the nurse practitioner can have a positive impact on the willingness and ability of the patient to follow their treatment program.

Conclusion

Patient noncompliance can have a negative impact on the patient in terms of future reoccurrence of the condition or possibly even death. In the time that a physician spends with a noncompliant patient, they could have been helping a patient that was willing to comply with the treatment plan. The noncompliant patient is not acting in their own best interest and are preventing others from receiving medical treatment. The noncompliant patient is not likely to resolve their medical issues, particularly when they are severe or life threatening. To dismiss a patient without having first made every effort to resolve the issues of noncompliance could be seen as a violation of medical ethics. The physician or nurse practitioner knows that to abandon the patient may pose a threat to their health and life. Therefore, in the best interest of the patient it is better to attempt to continue treatment. However, this can be difficult when the patient is uncooperative.

The research revealed that many factors are associated with noncompliance in patients. In some cases, the patient had perfectly logical reasons for noncompliance, such as side effects, or lack of access due to cost. The topic of patient noncompliance is not black and white. In many cases patients would be compliant if they had access to needed medication or transportation to pick it up. In other cases, issues regarding information or side effects need to be addressed. Rather than simply dropping the patient for noncompliance, doctors, and nurse practitioners must open the channels of communication and find out the reasons for patient noncompliance.

It is doubtful that patients are noncompliant without reason. They are the ones that sought medical attention in the first place. It would be safe to say that patients do not wish further illness or the risks associated with noncompliance. If the reasons for noncompliance can be addressed, many of these patients will be compliant, leading to a better outcome for everyone. In some cases, follow up calls may be needed to help provide patient support.

It is true that when a patient is noncompliant, they have breached the partnership between the medical provider and the patient. However, recent trends that move towards firing the patient for noncompliance do not attack the root of the problem and resolve the issues for anyone. The problem may be in the doctor/patient relationship. It may be a lack of information or failure to provide proper instructions. To simply fire a patient for noncompliance without attempting to first listen to them and try to resolve the issues of noncompliance equates failure to provide adequate information to the patient. In this case, it is the health care provider that is in breach of the relationship, not the patient.

Instead of simply telling the patient to "take these pills or else I will drop you as a patient," perhaps the medical provider needs to take extra time to make certain that patients understand the risks of noncompliance and that they understand exactly what is needed from them to stay healthy and avoid future problems. The nurse practitioner can take a proactive, rather than a reactive stance in helping to prevent noncompliance in patients. They need to open the lines of communication and help the patient to resolve any fears, issues with side effects, or other problems that they may have in complying with the prescribed medication regime. They need to make certain that they treat every patient as a human being that is capable of making a rational decision.

Taking an authoritarian stance towards the patient demeans them and makes them a recipient, rather than a partner in the treatment plan. Learning to listen to patients and address their needs is more of an art than a science. Practice makes perfect and the nurse practitioner needs to practice listening to patients, as much as they need to learn to educate patients properly on their treatment. They need to learn to approach the patient with respect and view them as a partner and equal in the relationship. This is the first step to developing a true partnership that will benefit both the patient and the practitioner.

The Nurse Practitioner can learn from previous studies and learn to spot those patients that are at particular risk of noncompliance and then take positive measures to help prevent noncompliance. This is a positive approach that is more likely to lead to improved relationships between medical patients and the patient, than the authoritarian approach of firing the patient and treating them like a bad child. In this approach the doctor is "punishing" the patient and treating them like a spoiled child, rather than promoting and fostering a lifelong relationship of care and compassion. Attempting to improve and foster positive relationships is much more likely to lead to compliance in the patient than then fear that they will be punished and lose access to medical care if they do not comply.

In some cases, the patient may be truly noncompliant and obstinate. In this case, the nurse practitioner should establish the real reason why the person sought help in the first place. Understanding a patient's motives and objectives in seeking treatment will help to promote a better relationship in the future. More often than not, the patient has a perfectly good reason for noncompliance. Addressing these issues is the best approach for the patient and the medical professional. A patient that has been fired for noncompliance is not likely to make positive referrals to their friends and relatives with similar problems.

However, a professional that goes the extra mile to foster communication and positive relations is likely to build lifelong dedication and will benefit from the positive image that they portray. This will help foster a positive, rather than a negative image within the community. Relationships are a two way street and require work from all parties involved. Keeping this in mind is the first step to building positive relationships that build lifelong trust and a true partnership between medical personnel and their patients.

This study revealed many components of the relationship between the patient and the nurse practitioner. These components form the basis of actions that can be taken by the nurse practitioner to help improve patient relations and help to reduce the possibility of patient noncompliance. When a patient must be terminated for noncompliance, it harms the patient and has a damaging affect on the practice. The nurse practitioner can have a positive influence on reducing the need to release patients for noncompliance. The nurse practitioner needs to be aware of the potential for patient noncompliance and must be willing to take the necessary actions to prevent it.