Noncompliance and Non Adherence Behaviors of Patient In Nursing Education
What Is Noncompliance and Non Adherence Behavior
Noncompliance describes resistance of the individual to follow a predetermined regimen. It often results in blaming behavior when patient goals are not achieved (Yach, 2003) and condemns a patient’s behavior as flawed for the inability to conform to treatment (Ofri, 2012; Robinson et al., 2008). Ward Collins (1998) notes that noncompliance can be a highly subjective judgmental term sometimes used synonymous with the terms non cooperative and disobedient.
Helme and Harrington (2004) studied patients who were non compliant with their diabetes regimen and found that although most people admitted their failure to comply with their healthcare plan, many offered excuses or justifications, and some denied that noncompliance had occurred. Even though in this study participants had nothing to lose by admitting their noncompliance, many felt the need to explain or deny their failure to follow orders.
Noncompliance and Non Adherence Behavior In Health Care
Many studies on patient noncompliance have been conducted, and yet, the question of why patients are non compliant remains largely unanswered, primarily because of the complexity of the issue. Noncompliance can be related to patient issues such as knowledge or motivation, health illiteracy, treatment factors such as side effects, disease issues such as prognosis, lifestyle issues such as transportation, social demographic factors such as social and economic status, and psycho social variables such as depression and fear (Chesanow, 2014: Quan. 2016; Rosner, 2006).
The expectation of total compliance in all spheres of behavior and at the specified times prescribed is unrealistic. In some situations, non compliant behavior may be desirable and could be viewed as a necessary defensive response to stressful situations. The learner may use time outs as the intensity of the learning situation is maintained or escalates. This mechanism of temporary withdrawal from the learning situation may prove to be beneficial.
Following withdrawal, the learner could reengage. feeling renewed and ready to continue with an educational program or regimen. Viewed in this way, noncompliance is not always an obstacle to learning and does not always carry a negative connotation (Rosner, 2006). Nonadherence occurs when the patient does not follow treatment recommendations that are mutually agreed upon (Resnik, 2005).
It can be intentional or unintentional and, according to the World Health Organization, can be determined by the interplay of five sets of factors or dimensions socioeconomically related, patient related, condition related, therapy related, and healthcare team or system related (Sabaté, 2003).
Patient factors that contribute to non-adherence include stress, forgetfulness, substance abuse, having multiple medical conditions, uncertainty about health beliefs and practices, and real or perceived stigma associated with the conditions of being treated (Di Matteo, 2004; Pignone & Salazar, 2014). A patient’s non adherence to medical treatment recommendations can affect their health status as well as the healthcare system.
Noncompliance confers an unnecessary health risk and can result in increased medical expenditures (Heiby et al., 2005; Martin, Williams, Haskard, & DiMatteo, 2005). For example, a patient’s non adherence to medications for diabetes has been identified as contributory to health complications and preventable hospitalizations (Schwartz et al., 2017).
In many disease conditions, including diabetes, approximately 40% of patients were at high risk because of non adherence resulting from factors such as misunderstanding, forgetting, or ignoring recommended health regimens (Martin et al., 2005; Quan. 2016).
Specifically related to medication noncompliance or nonadherence, 50% of prescription drugs are taken incorrectly or not at all, 75% of patients do not always take their medications as directed, 125,000 deaths per year are attributed to poor medication compliance, and poor drug compliance is estimated to cost the healthcare system $290 billion per year through unnecessary hospitalizations, rehospitalizations, and premature death (Chesnow, 2014).
Research, as evidenced by the multidisciplinary healthcare literature, has focused on the compliance or adherence and noncompliance or nonadherence of healthcare consumers to their healthcare plans (Chesanow, 2014; Jin, Sklar, Min Sen Oh, & Chuen Li, 2008; Jimmy & Jose, 2011). The number of studies on the level of compliance reflects the importance of this concept to practice.
This phenomenon may result from an emphasis on cost-effective health care, as seen, for example, in shorter lengths of hospital stays when there is less time to teach. Also, related to the educator role is the fact that the successes of educational programs in a fiscally cost-conscious system ultimately are linked to measurement of patient compliance relative to outcomes.
Locus of Control for Nursing Educator for Noncompliance and Non Adherence
The authoritative aspect of compliance implies that the educator attempts to control, in some degree, decision making on the part of the learner. Some models of compliance have attempted to balance the issue of control by using terms such as mutual contracting (Steckel, 1982) or consensual regimen (Fink, 1976).
One way to view the issue of control in the learning situation is through the concept of locus of control (Rotter, 1954) or health locus of control (Wallston, Wallston, & DeVellis, 1978). Locus of control (LOC) refers to an individual’s sense of responsibility for his or her own behavior and the extent to which motivation to act originates from within the person (internal) or is influenced by others (external).
Health locus of control (HLOC) specifically relates LOC to health behaviors and describes an individual’s belief that health is dependent on internal and external factors. Through objective measurement, individuals can be categorized as internals, whose health behavior is self-directed, or externals, for whom others are viewed as more powerful in influencing health outcomes.
Externals believe that fate or some other powerful outside force(s) determines life’s course, whereas internals believe that they control their own destiny. For instance, an external might say, “Osteoporosis runs in my family, and it will catch up with me.” An internal might say. “Although there is a history of osteoporosis in my family, I will have necessary screenings, eat an appropriate diet, and do weight bearing exercise to prevent or control this problem.”
Dimensions of Noncompliance and Non Adherence
Recently, four dimensions to the concept of HLOC that expand on Rotter’s (1954) original concept of LOC have been identified by Combes and Feral (2011). The four dimensions are:
1. Internal: Power originates from within and is related to personal abilities
2. Chance external: Fate is a powerful outside influence
3. Others external: Others such as family, friends, and associates are powerful influences
4. Doctors external: Doctors have power to control outcomes.
As an example of the influence of HLOC, Brincks, Feaster, Burns, and Mitrani (2010) investigated how it affects the patient-provider relationship. They found that a powerful others HLOC (doctors external) resulted in HIV patients demonstrating a trusting positive relationship with physicians.
Janowski, Kurpas, Kusz, Mroczek, and Jedynak (2013) examined HLOC and acceptance of illness in patients with chronic diseases and found health related behaviors were significantly positively correlated with all categories (dimensions) of HLOC regardless of specific diagnosis, but they also found sociodemographic factors (age, gender, education, marital status) were crucial in determining frequency of health behaviors in these patients.
Many researchers in the health professions have studied the link between locus of control and compliance with therapeutic regimens. Given the complexity of the phenomenon of LOC characterized by the interplay of many factors that make up individuals cognitive and psychosocial behaviors, the results in this area have been somewhat mixed.
Some investigators have found a significant correlation and others an insignificant relationship between LOC and adherence to recommended treatments in patients with both acute and chronic conditions, such as orthopedic problems, hypertension, diabetes, obesity, and schizophrenia (Combes & Feral, 2011; Epstein, Kale, & Weisshaar, 2014; Indelicato et al., 2017; Lee, Ahn, & Kim, 2008; Morowatisharifabad, Mahmoodabad, Baghianimoghadam, & Tonekaboni, 2010; O’Hea et al., 2009; Omeje & Nebo, 2011; Porto, Machado, Martins, Galato, & Piovezan, 2014; Rosno, Steele, Johnston, & Aylward. 2008; Tahar et al., 2015).
Although the literature remains inconclusive as to the nature of the relationship between compliance in internal versus external LOC. Shillinger (1983) and Nguyen (2016) suggest that different teaching and coaching strategies are indicated for internals versus externals.
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