Noncompliance

NANDA Definition
Behavior of person and/or caregiver that fails to coincide with a healthpromoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional.

Discussion of the Problem

In 1950s Rosenstock (1974) proposed a health belief model intended to predict which individual would or would not use preventive measures such as screening for early detection of cancer. Becker (1974) modified the health belief model to include these components: individual perceptions, modifying factors, and variables likely to affects initiating action. The health belief model is based on motivational theory. Rosenstock (1974) assumed that good health is an objective common to all people. Becker added positive health motivation as a consideration. Individual perceptions include the following: perceived susceptibility, perceived seriousness, and perceived threat. Factors that modify a persons perception include the following: demographic variables, sociopsychologic variables, structural variables, and cues to action. The likelihood of a persons taking recommended preventive health action depends on the perceived benefits of the action minus the perceived barriers to the action. Patients are more likely to comply when they believe that they are susceptible to an illness or disease that could seriously affect their health, that certain behaviors will reduce the likelihood of contracting the disease, and that the prescribed actions are less threatening than the disease itself. Factors that may predict noncompliance include past history of noncompliance, stressful lifestyles, contrary cultural or religious beliefs and values, lack of social support, lack of financial resources, compromised emotional state, battered women, homeless individuals, those living amid street violence, the unemployed, or those in poverty. Further, the rising costs of health care, and the growing number of uninsured and underinsured patients often forces patients with limited incomes to choose between food and medications. Geriatric patients living on fixed incomes but requiring complex and costly medical therapies. In dealing with such patients, the nurse should consider the factors influencing adherence. They are as follows: 1. Client motivation to become well 2. Degree of lifestyle change is necessary. 3. Perceived severity of the health care problem. 4. Value placed on reducing the threat of illness. 5. Difficulty in understanding and performing specific behaviors. 6. Degree of inconvenience of the illness itself or of the regimens. 7. Beliefs that the prescribed therapy or regimen will or will not help. 8. Complexity, side effects, and duration of the proposed therapy 9.Specific cultural heritage that may make adherence difficult. 10. Degree of satisfaction and quality and type of relationship with the health care providers, and 11, the overall cost of prescribed therapy.

Nursing Interventions Classification (NIC)

Behavior Modification Decision-Making Support Health Education Patient Contracting

Nursing Outcomes Classification (NOC)

Adherence Behavior Compliance Behavior Knowledge: Treatment Regimen Participation: Health Care Decisions

Goal and Objectives

Patient and/or significant other will report compliance with therapeutic plan. Patient will comply with therapeutic plan, as manifested by appropriate pill count, correct quantity of drug in blood or urine, verification of therapeutic effect, continued appointments, and/or fewer hospital admissions.

Subjective and Objective Data

"Revolving-door" hospital admissions Behavior indicative of failure to adhere Evidence of development of complications Evidence of exacerbation of symptoms Missed appointments Objective tests: improper pill counts or missed prescription refills; body fluid analysis inconsistent with compliance Therapeutic effect not achieved or maintained

Related Factors
Client-provider relationships Cultural beliefs Health beliefs Patients value system Spiritual values

Assessment (Dx)
Ask patient to bring prescription drugs to appointment; count remaining pills. This provides some objective evidence of compliance. Technique is commonly used in drug research protocols. Assess beliefs about current illness. Determining what patient thinks is causing his or her symptoms or disease, how likely it is that the symptoms may return, and any concerns about the diagnosis or symptoms will provide a basis for planning future care. Persons of other cultures and religious heritages may hold differing views regarding health and illness. For some cultures the causative agent may be a person, not a microbe. Assess beliefs about the treatment plan. Understanding any worries or misconceptions patient may have about the plan or side effects will guide future interventions.

Assess patients individual perceptions of health problems. According to the Health Belief Model, a patients perceived susceptibility to and perceived seriousness and threat of disease affect compliance with treatment plan. Assess religious beliefs or practices that affect health. Many people view illness as a punishment from God that must be treated through spiritual healing practices (e.g., prayer, pilgrimage), not medications. Assess serum or urine drug level. Therapeutic blood levels will not be achieved without consistent ingestion of medication; over dosage or over treatment can likewise be assessed. Compare actual therapeutic effect with expected effect. Provides information on compliance; however, if therapy is ineffective or based on a faulty diagnosis, even perfect compliance will not result in the expected therapeutic effect. Determine cultural or spiritual influences on importance of health care. Not all persons view maintenance of health the same. For example, some may place trust in God for treatment and refuse pills, blood transfusions, or surgery. Others may only want to follow a "natural" or "health food" regimen. Determine reasons for noncompliance in the past. Such reasons may include cognitive impairment, fear of actually experiencing medication side effects, failure to understand instructions regarding plan (e.g., difficulty understanding a low-sodium diet), impaired manual dexterity (e.g., not taking pills because unable to open container), sensory deficit (e.g., unable to read written instructions), and disregard for nontraditional treatments (e.g., herbs, liniments, prayer, acupuncture). Plot pattern of hospitalizations and clinic appointments.

Therapeutic Interventions (Tx)

Assist patient in developing a behavioral contract. This helps patient understand and accept his or her role in the plan of care and gives the patient an idea of what can be expected from the health care worker or system. Develop a therapeutic relationship with patient and family. Compliance increases when trust is built with a consistent caregiver. Develop with patient a system of rewards that serves as a means of recognizing and acknowledging successful compliance. Rewards promote positive reinforcement for compliant behavior. Involve patient in planning the treatment regimen. Patients who become partners of their care have a greater chance in achieving a positive outcome.

Simplify therapy. Avoid unnecessary clinic visits. Compliance is enhanced when therapy is as short and includes as few treatment regimen as possible. The physical demands and financial burdens of traveling must be taken into consideration. Tailor the therapy taking patients lifestyle into consideration (e.g., diuretics may be taken with the evening meal for patients who work outside the home) and culture (incorporate herbal medicinal massage or prayer, as appropriate).

Educative (Edx)
Encourage significant others to eliminate disincentives and/or increase rewards to patient for compliant behavior. Provide social support through patients family and self-help groups. Such groups may assist patient in gaining greater understanding of the benefits of complying to the treatment regimen. Provide specific and distinct instruction as indicated. Provide the information in terms of what the patient feels is the cause of his or her health problem and his or her concerns about therapy.