NON-COMPLIANCE IN THE TREATMENT OF CHRONIC DISEASE
Robert W. Stein, III, RN, MSHA, CHE, LNC
Compliance has been defined by Sackett and Haynes (cited in Minnick, 1982) as the extent
that a patients behavior coincides with the clinical prescription. The literature is rampant with discussion over
the appropriateness of using the terms compliance and noncompliance. Many suggest that they imply that the client
is passive, lacking autonomy, and that the health care professional is coercive, brainwashing, paternalistic, and
controls society. The alternate terms of adherence and nonadherence, which have a less negative connotation, are
used interchangeably. Other terms for compliance that have gained less popularity include Fink1s (cited in Baer, 1986) consensual regimen, Steckel1s (cited in Baer, 1986) mutual contracting, and Weintraub's (cited
in Baer, 1986) intelligent noncompliance (Baer, 1986).
Interestingly, one study uses these terms differently. Barofsky, Sugarbaker, and Mills (1979)
describe a continuum of self-care ranging from compliance (associated with coercion), to adherence (associated
with conformity), to self care (a therapeutic alliance with the health care provider).
For the purposes of this paper, compliance and noncompliance will be used according to their
traditional definitions, and without the implication of coercion.
The U.S. Department of Commerce (cited in Lubkin, 1986) reports that 24% of tile population
aged 45-64, 7% of the population younger than 45, and nearly 50% of those older than 64 are afflicted with a chronic
disease. The most common chronic diseases are those related to the cardiovascular system. Largely control of these
diseases depends on the client complying with a prescribed diet, activity, and/or medication therapy (Minnick,
1982). However, the National Council on Patient Information and Education report that there are 125,000 deaths
and 300,000 hospital admissions annually because of noncompliance to cardiovascular active prescriptions.
Clark (cited in Redman, 1984) reports that in general, approximately one-third of patients
are compliant. Another one-third of patients are noncompliant because they misunderstood the treatment plan for
them. The final one-third of patients are noncompliant as an informed, conscious choice to be noncompliant. Rates
of noncompliancy are reported even higher, up to 60%', in low income groups (Redman, 1984).
The 20 million lost workdays resulting from this noncompliance costs the United States 1.5
billion dollars yearly. Additionally, the National Council on Patient Information and Education reports that up
to 90% of outpatients overall, make errors in taking their medications, and up to 50% of prescriptions written
will not produce the intended result because they are not taken as directed.
The reasons that noncompliance occurs is not completely clear. It is found across all demographic,
personality, and social types. Noncompliant patients tend to have a poor understanding of their disease and treatment,
but special education sessions only transiently increase compliancy (Becker, 1979). Patients without an understanding
of their disease and its treatment cannot be compliant; however, knowledgeable patients may or may not be compliant.
Family, friends, and supporters may increase or decrease compliance and should be included whenever an educational
plan is used (Padrick, 1986).
Noncompliancy may result from differing interests or expectations of the patient and health
care provider (Woldum, 1985). Anderson (cited in Lubkin, 1986) offers as an example, the diabetic more concerned
about preventing hypoglycemia than controlling hyperglycemia. Whereas the health care provider, aware of the complications
of prolonged hyperglycemia, may be more interested in maintaining a blood sugar near normal. A stated intent to
be compliant with a treatment plan may or may not actually correlate with compliance (Padrick, 1986).
Misperceptions or dissatisfaction with the patient-health care provider relationship may
also be a cause of noncompliance. Feelings of helplessness or a lack of autonomy may result in noncompliance. Previous
failures of therapy (possibly also related to noncompliance) may discourage patients into giving up on present
or future treatment plans (Woldum, 1985).
The treatment plan itself may even be a cause of noncompliance. Expensive, long term therapy
with severe or annoying side effects, or therapies requiring a great deal of behavioral change may encourage noncompliance
(Becker, 1979).
Noncompliant patients may be labeled as apathetic, uninterested, or unmotivated to being
healthy. This may be a result of denial or what Hoover (cited in Padrick, 1986) calls patient burnout. It is difficult
for some patients with chronic, asymptomatic diseases to accept that they are ill, especially if the disease requires
an alteration in their life-style. Patients in this state of denial have no motivation towards compliance with
health care behaviors because they do not feel that they are ill (Padrick, 1986).
Hoover (cited in Padrick, 1986) describes another situation where the patient may be labeled
apathetic. She describes patient burnout as patients with chronic disease, living with unrelinquishing stress,
becoming listless, indifferent, forgetful, careless, or bored. The source of stress may be a constant fear of the
unknown, fear of the long-term complications, or fear of the treatment plan. These patients in denial or burnout
are both noncompliant, but will require different strategies to increase their compliance (Padrick, 1986).
The implications of noncompliance to the client are many. Most obviously, noncompliance interferes
with the therapeutic efforts of the health care provider and negates the benefits of preventative health care measures.
Noncompliance may result in additional, often costly, and unnecessary tests or diagnostic procedures. Exposure
to additional work-ups will increase the clients risk of developing an iatrogenic complication. Noncompliance may
result in acute exacerbation of chronic illnesses requiring longer, more extensive treatments and increased lost
workdays (Woldum, Ryan-Morrell, Towson, Bower, & Zander, 1985). Noncompliance may even be responsible for the
emergence of resistant strains of organisms (Baer, 1986).
On a broader scope, the impact of noncompliance on society and the health care industry is
equally as impressive. Noncompliance results in negative perceptions and general dissatisfaction with health care
services. It also interferes with meaningful quality assurance evaluations for the health care facility (Baer,
1986).
The exact cost of noncompliance cannot be determined accurately. As described earlier, however,
it certainly does result in additional health care costs (Woldum et al., 1985). In 1982, 317 billion dollars was
spent in the United States on health care. Of that, 40% or 127 billion dollars was spent at hospitals. Private
health insurance companies paid for 26.6% of health care expenses, while individual health care consumers paid
for 32.496. The remaining, and the largest portion, 39.7% is paid for by various state and federal agencies using
public tax monies (Sheridan, 1985). Connelly (cited in Baer, 1986) states that patient compliance with recommended
health care behaviors could reduce the need and demand for costly, highly technical health care services, shorten
or eliminate hospital stays, and lower overall health care costs.
The problem of noncompliance is one that the nursing profession is in a unique position to
be able to help the patient and society. The size, focus, process, and accountability of nursing make it the most
qualified of all the health care professions for assisting society with the problem (Baer, 1986).
Nursing is in a position to contribute to compliant behaviors based, if nothing else, purely
on its size and amount of patient contact. Nursing is the single largest group of health care providers in the
United States (Baer, 1986). Marston (cited in Baer, 1986) states that nursing has the greatest potential of all
the health care providers for affecting the patients health care behaviors as a result of its size and amount of
patient contact.
The focus of nursing traditionally has been a holistic approach in promoting, maintaining,
and restoring the patient’s wellness. Nursing also has functions in patient education, promotion of support systems,
and the facilitation of rehabilitative life-style changes. Noncompliance is a response that affects all of these
areas of wellness. The result being that nursing is in a position to offer patients, and society, much in terms
of noncompliance (Baer, 1986).
Health care compliance requires active participation of the patient with complete disclosure
of information and mutually established goals. Nursing incorporates this in conjunction with the patient and appropriate
significant others into assessing, diagnosing, planning, implementing, and evaluating of the nursing process. Therefore,
nursing is in an excellent position to intervene in noncompliance (Baer, 1986).
The health care consumer demands accountability and commitment from its providers. Nursing
demonstrated this commitment in the first Patient Bill of Rights drafted by the National League for Nursing in
1959, and it continues to be of great importance today. Dealing with the issue of noncompliance requires the high
level of accountability and commitment to the patient that nursing can provide (Baer, 1986).
Nursing should attack the noncompliance problem because of its far-reaching effects on the
individual patient and society. The problem is congruent with traditional nursing methods. Many feel that nursing,
of all the health care professions, is best qualified to address the issue of noncompliance (Baer, 1986). Steckel
(cited in Baer, 1986) states that the issue of improving patient compliance provides nursing the opportunity to
demonstrate nursing1s unique and essential contribution
to health care.
Generally, in order to increase compliance rates, Woldum et al. (1985) suggests that we first
evaluate the treatment plan to insure its effectiveness if the patient is compliant. The complexity, convenience,
and required duration of the treatment should also be considered. Short, simple easy to follow regimens have a
higher compliancy rate. Next, the cost and side effects must be considered. Treatments of modest cost and without
severe or annoying side effects will receive greater compliance. When developing a treatment plan for an individual,
consideration must be given to the patient’s perceptions, the degree of support/supervision required and available,
and to the degree of behavior change requested.
Specific strategies for increasing compliance can be grouped into the three broad categories
of organizational strategies, educational strategies, and behavioral strategies (Young, 1986).
In organizational strategies related to the system, the system is adjusted for the convenience
and accommodation of the patient by arranging for appointments at other than traditional times (Young, 1986). Increased
attention and supervision by the health care provider, by increasing the frequency of appointments, will increase
compliancy -especially at the beginning of a new treatment plan. The health care provider may enlist the help of
office staff, pharmacists, public health or employee health care providers in increasing support and supervision
of the noncompliant patients additionally (Sackett, 1979).
Flow through the system can be evaluated to limit the period patients must wait in the waiting
room. Decreasing waiting time will increase the probability that the patient will keep, and will be on time for,
their appointments (Young, 1986).
In organizational strategies related to the treatment plan, the patient must be asked to
be an active partner in the designing of a therapeutic regimen. Involvement of the patient will ensure similar
expectations, goals, and the development of the least disruptive regimen possible (Young, 1986).
The treatment plan may need modification by the use of injectables, simplification, tailoring,
and calendar dispensing. Treating a patient with long acting injectables may be one way to ensure compliance. Simplification
is the streamlining of the number and frequency with which health care behaviors must be performed. Often a patient
can remember to take their medication twice a day, but not four times a day. Through the use of simplification,
dosages and schedules can be adjusted to create a treatment plan that is more easily remembered (Sackett, 1979).
Tailoring is the matching of health care behaviors with ritualistic activities of daily living.
Few patients would forget to brush their teeth9
eat, go to bed, etc., and by pairing the health care behavior with a ritualistic behavior the compliance with the
health care behavior will be improved (Sackett, 1979). An example of tailoring would be the keeping of a medicine
next to the toothpaste in the medicine cabinet. Scheduling the medicine due at the usual time the patient brushes
their teeth will increase the likelihood that it will not be forgotten.
Calendar dispensing increases the compliance of patients that are forgetful by providing
a calendar or chart individualized to the patient’s regimen. When a therapy is done or medication taken, the patient
marks a check on the chart for that time period. When in doubt if a therapy was done or medication taken, referral
to the chart will provide the answer (Sackett, 1979).
The literature is divided over the importance of educational strategies to noncompliance.
It is generally agreed however, that while knowledge is a requirement for compliance, it will not create compliance
by itself (Young, 1986).
Education can take many forms from group discussion / demonstration to video and written
presentations. Six general principles of education are brevity, organization, primacy, readability, repetition,
and specificity. Green (cited in Young, 1986) has shown that patients cannot remember 50% of what the health care
provider instructed them only five minutes earlier. Written material increases the retention, but must be clearly
written on a fourth grade level. A specific, mutually agreed upon learning goal must be established. The last stage
in any learning program is a final evaluation of what was learned (Young, 1986).
Behavioral strategies for treatment of noncompliance include contracting and self-monitoring.
In contracting, a realistic goal is set to allow the patient some success and personal control. When the patient
has mastered the contracted task, a second or more contracts can be added until compliance, and self-control are
reached (Young, 1986).
Self-monitoring is the observation and recording of health care behaviors. A high level of
involvement is achieved by the patient first observing their behavior, then evaluating it, and finally, regulating
it. The effect of self-monitoring is even greater when the spouse is interested and reminds (not nags) the patient
of the health care behavior (Young, 1986).
A critical aspect of behavioral strategies is that they require a satisfactory patient -
health care provider relationship. Similar expectations of the relationship, a mutual sharing of feedback, and
a balance of direction and evaluation is necessary for successful behavioral intervention (Young, 1986).
The incidence and effects of noncompliance are widespread and far -reaching (Baer, 1986;
National Council on Patient Information and Education; Redman, 1984; Woldum et al., 1985). The problem is one that
the nursing profession is uniquely prepared to address using the tools of the profession (Baer, 1986). Nursing
has an obligation to its clients and society to focus its energies on the problem of noncompliance (Baer, 1986).
Noncompliance is a treatable problem.
REFERENCES
- Baer, C. (1986). Compliance: The Challenge for the Future. Topics
in Clinical Nursing, 7(4),
77-85.
- Barofsky, I., Sugarbaker, P., & Mills, M. (1979). Compliance and Quality of Life Assessment.
In S. Cohen (Ed.) New Directions in Patient Compliance
(pp.59-74). Lexington: Lexington Books.
- Becker, M. (1979). Understanding Patient Compliance: The Contributions of Attitudes and
Other Psychosocial Factors. In S. Cohen (Ed.) New Directions in Patient Compliance (1-31). Lexington: Lexington Books.
- Lubkin, I. (1986). Chronic Illness: Impact and Interventions. Boston: Jones and Bartlett
Publishers.
- Minnick, A (1982). The Study Problem. In P. Kalisch and B. Kalisch (Eds.) Studies in Nursing Management: Vol.9 Patient Teaching by Registered Nurses.
Ann Arbor: UMI Research Press.
- National Council on Patient Information and Education (1987). Statistical Report. Washington,
D.C.
- Padrick, K. (1986). Compliance: Myths and Motivators. Topics
in Clinical Nursing, 7(4),
17-22.
- Redman, B. (1984). The Process of Patient Education 5th Ed. St. Louis: C.V. Mosby Co.
- Sackett, D. (1979). Future Applications and Hypothesis From Old Research. In S. Cohen (Ed.)
New Directions in Patient Compliance (pp.33-59). Lexington:
Lexington Books.
- Sheridan, D. (1985) The Health Care Industry in the Marketplace:	Implications for
Nursing. The Journal of Nursing Administration, 13(9),
36-40.
- Woldum, K., Ryan-Morrell, V., Towson, M., Bower, K., & Zander, K. (1985). Patient Education: Foundations of Practice. Rockville: Aspen Systems.
- Young, M. (1986). Strategies for Improving Compliance. Topics
in Clinical Nursing, 7(4), 31-38.
