Patient Contracting and Nursing Care

Nursing Care and Patient Contracting 

Patient Contracting,Effectiveness of Patient Contracting,Patient Contract and Nursing,Nursing Process and Patient Contract,Patient Contract and Behavioral Analysis,Purposes of Behavioral Analysis,Positive Reinforcement as a Behavioral Strategy,Changes in Strategies for Patient Contracting.

Patient Contracting

     Patient contracting is an intervention for promoting patient adherence in practice or research settings. Patient contracting provides an opportunity for patients to learn to analyze their behavior relative to their environment and to select behavioral strategies that will promote learning, changing, or maintaining adherence behaviors (Boehm, 1992). 

    Patient contracting is relevant to nursing practice and research because it can assist patients to adhere to treatment regimens, such as medication taking, meal planning, and physical activity.

Effectiveness of Patient Contracting 

    Research on the effectiveness of patient contracting in nursing has been reported for a variety of behaviors across settings and disorders. For example, patient contracting has been used to control serum potassium levels (Steckel, 1974) and serum phosphorus levels (Laidlaw, Beeken, Whitney, & Reyes, 1999) in patients on dialysis

To increase knowledge and consistency in use of contraceptive methods by sexually active college women from a student gynecology clinic (Van Dover, 1986)

To increase knowledge, keep appointments, and reduce diastolic blood pressure in hypertensive outpatients (Steckel & Swain, 1977; Swain & Steckel, 1981)

To keep appointments, lose weight, and reduce blood pressure among outpatients with arthritis, diabetes, and hypertension (Steckel & Funnell, 1981). 

    Patient contracting did not reduce blood glucose and glycosylated hemoglobin in patients with diabetes (Boehm, Schlenk, Raleigh, & Ronis, 1993; Morgan, BS, & Littell, 1988; Steckel & Funnell).

Patient Contract and Nursing 

    Patient contracting is the process in which the nurse and patient negotiate an individualized, written, and signed agreement that clearly specifies the behavior and identifies in advance the positive consequences to be given when the patient has successfully performed the behavior (Steckel, 1982). 

    The patient chooses the behavior and reinforcer in the contract with direction by the nurse. Patient contracting is based on the principle of positive reinforcement, which states that when a behavior is followed by a reinforcing consequence, there is an increased likelihood of the behavior being performed again (Boehm, 1992).

Nursing Process and Patient Contract

    The nursing process provides the context within which to develop the patient contract. The nursing process provides the clinical data that can be jointly used by nurses and patients to establish priorities for adherence behaviors (Steckel, 1982). The adherence behavior is the ultimate complex behavior to be learned or changed. 

    The adhesion behavior is broken down into successive approximations or small steps. By performing small steps of the behavior, the patient gradually achieves performance of the adherence behavior. 

    Over a series of patient contracts, the patient will specify a variety of behaviors, which include such behavioral strategies as self-monitoring, arranging and rearranging antecedent events, practicing small steps of the adherence behavior, and arranging positive consequences (Boehm, 1992) . 

    The first several patient contracts are usually for self-monitoring to identify the successive approximations of the adherence behavior and the antecedents and consequences of the behavior. 

    In later patient contracts, patients specify behavioral strategies related to arranging antecedent events, practicing a small step of the behavior, or arranging positive consequences. 

    Self-monitoring is ongoing throughout the behavior change process to provide data about the effectiveness of the new antecedents, the performance of the small steps of the behavior, and the new positive consequences.

Patient Contract ad Behavioral Analysis

    Behavioral analysis is the foundation of the patient contracting intervention. Behavioral analysis is the process by which the patient's behavior is observed, recorded, and analyzed in order to describe the successive approximations of the adherence behavior, the antecedent events that precede the behavior, and the consequences that follow the behavior. 

    The behavioral data used in the analysis are obtained by the patient through self monitoring (Boehm, 1992). Behavioral analysis begins with the patient self-monitoring the adherence behavior. 

    Self-monitoring provides baseline data that can be used to determine the effectiveness of the behavioral strategies implemented later in the behavior change process. 

    By using the patient's self-monitoring records, the nurse can teach the patient to identify antecedent events that precede the behavior, small steps that comprise the behavior, and consequences that follow the behavior. Based on the behavioral analysis, behavioral strategies are specified that will assist in the behavior change.

Purposes of Behavioral Analysis

    Behavioral analysis can identify the multiple small steps that comprise the adherence behavior. When the small steps are identified, the behavioral strategy is to perform a small step of the adherence behavior for a designated period of time. When that small step is being successfully performed, the patient moves onto the next small step. 

    Eventually, patients gradually achieve performance of the adherence behavior (Steckel, 1982). This be behavioral strategy is effective because patients are often overwhelmed by expectations of a treatment regimen, which can lead to nonadherence. 

    For example, sedentary patients who are beginning a walking program might start by walking 5 minutes three times per week. Each week the walking goal is gradually in- creased until they achieve their goal of accumulating 30 minutes of moderate-intensity walking 5 days per week.

Positive Reinforcement as a Behavioral Strategy

    Positive reinforcement is the behavioral strategy in which a positive consequence is provided contingent upon performance of the desired behavior, which results in an increase in performance of the behavior.     

    Behavioral analysis can identify positive consequences for behaviors and provide ideas for new consequences (Boehm, 1992). The behavioral strategy is to arrange positive reinforcement to acquire or maintain a desired behavior. For example, adopting a walking program will be strengthened if a positive consequence follows each walking goal that is met. 

    Positive consequences can be pleasant items and activities; social reinforcement, such as praise; and cognitive reinforcement, such as feelings of pride. Conversely, eliminating positive reinforcement can be used to decrease or extinguish an undesired behavior. For example, eating with selected companions may eliminate positive consequences for inappropriate food item selections.

Changes in Strategies for Patient Contracting

    There are several directions for future research. First, studies are needed to determine the frequency of contact needed with subjects to produce progressive changes in adherence interventions using patient contracting. 

    Second, patient contracting during the maintenance phase of adhesion interventions has not been studied. Third, electronic self-monitoring by personal digital assistants or Internet web sites could be used during studies. 

    Fourth, studies could include objective measures of adherence behaviors, such as, electronic event monitors to assess medication adherence and accelerometers or pedometers to assess physical activity.