Noncompliance occurs when a patient (family, caregiver, guardian) fails to adhere to a healthcare provider’s recommendations or prescribed treatment plan. This can include medications, procedures, follow-up appointments, and lifestyle modifications.
It is important to note that noncompliance has a negative connotation as it refers more to a provider deciding on a suitable treatment with the expectation that the patient will comply.
The use of the word ‘adherence’ is a friendlier term and describes a process that has been agreed upon by both provider and patient. Noncompliance is more of a direct refusal while nonadherence can refer to external or more complicated barriers. Both phrases will be used interchangeably throughout this care plan.
Poor adherence to healthcare recommendations, medications, and treatments is directly related to poorer outcomes, lower quality of life, and higher healthcare costs. Nurses can play an important role in uncovering reasons for noncompliance and working with patients to meet goals that are important and relevant to them.
Causes of Noncompliance (Related to)
- Developmental abilities (lack of knowledge/understanding/motivation/skill)
- Individual health beliefs, cultural and spiritual influences
- Cost/financial barriers
- Complexity of health regimen
- Lack of health coverage
- External barriers: lack of transportation or social support
- Poor patient-provider relationship (distrust in the health system)
- Lack of access to care
- Difficulty in behavior change (addiction)
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Expression of disinterest, distrust, or denial
Objective: (Nurse assesses)
- Failure to keep appointments
- Signs of poor adherence: worsening health, failure to make progress, worsening lab results, exacerbation of chronic conditions
- Frequent preventable hospitalizations
- Refusing medications or treatments
- Patient will demonstrate a commitment to improving health status by implementing positive behaviors (not missing doses of medications, keeping appointments)
- Patient will verbalize an understanding of their health status and list changes required to improve their adherence
- Patient will access resources in order to improve compliance
Nursing Assessment for Noncompliance
1. Determine the patient’s/families perception of their condition.
Patients or family members who do not have a thorough understanding of their health and related outcomes may not be committed to the plan of care. They may not be aware of long-term effects or realize the severity of their disease.
2. Assess who is in charge of the patient’s care, if not them.
Patients, especially older adults may leave their healthcare up to their spouse or adult children. Confer with the person in charge to prevent miscommunication or gaps in care.
3. Inquire about medications.
Patients are often noncompliant with medications which in turn leads to exacerbations or worsening of their health conditions. Obtain a thorough list of medications and ask specific questions about how many doses have been missed in a two-week timeframe. Inquire about reasons why such as frequency, cost, or side effects.
4. Assess what the patient values most.
Cultural or religious values may not align with their healthcare treatment plan. Mexican-American patients may value alternative medicine over prescribed medications. African Americans often have a strong sense of spirituality and will seek religion for healing.
5. Assess for a language barrier.
Patients who are not native-English speakers may not comprehend instructions given to them but often will not request clarification. Poor communication is a preventable cause of noncompliance.
6. Assess for cost or resource limitations.
Some patients live in rural areas with limited access to specialists or transportation to get to care centers. The cost burden of medications and treatments may be too much for a disabled or elderly patient, even with insurance. These situations can be a source of shame and patients may not be forthcoming with these reasons for not adhering.
7. Evaluate compliance via lab work.
Compliance with medications can be evaluated by drawing serum drug levels or obtaining a urinalysis.
Nursing Interventions for Noncompliance
1. Provide non-judgmental listening.
Healthcare professionals can often perceive noncompliance as the patient simply making a choice to not follow recommendations. Allow the patient time and space to discuss their reasons. A trusting and nonjudgmental relationship allows for the best possibility of improving adherence.
2. Ensure information is provided at their developmental level.
Inquire about the patient’s learning style and how they like to receive information. Give information in manageable amounts and limit the use of medical jargon.
3. Be mindful of cultural competence.
Discrimination is a threat to adherence. Providers who receive training in cultural competence are shown to have better medication adherence among their low-income patients. Ensuring an understanding of racism, societal privilege, and disparities that affect patients allows for a greater sense of awareness.
4. Implement telehealth options.
Patients who frequently miss appointments or have other barriers to care may benefit from telehealth visits from their phone or computer.
5. Use interpreter services.
Whenever communicating healthcare information it is expected to use an interpreter if the professional and patient do not speak the same language. Even so, studies show that healthcare professionals that use interpreters may not ask all necessary questions or ensure messages are delivered clearly, due to time constraints.
6. Direct to community resources.
If the cost of medications is a barrier, provide information on patient assistance programs or Rx savings cards. Local services such as the Area Agency on Aging assist with preventative healthcare services, insurance assistance, medical equipment and supplies, and transportation.
7. Involve the patient in their decisions.
Patients are more likely to follow through and remain committed if they helped create their own goals in relation to their priorities.
8. Promote independence.
Do not perform tasks for the patient. Provide them with contact information, resources, and education and encourage them to take action. Enabling dependence prevents the patient from taking initiative and making progress towards their goals.
9. Ensure continuity of care.
Patients are more likely to complete follow-up appointments if they are scheduled prior to discharge. The use of inpatient pharmacies that deliver to the patient’s room before discharging home prevents them from not picking up a new medication at their own pharmacy.
10. Simplify complex care.
Taking multiple medications several times per day, painful injections, or other time-consuming treatments increases the likelihood of noncompliance. Attempt to simplify regimens or involve a home health agency to administer care for better adherence.
11. Meet the patient where they are.
Instances of addiction are difficult to overcome. A patient will not be willing to make a change unless they can perceive a benefit. The nurse can be a supporter of small goals. For example, a patient who smokes may be unwilling to quit completely but may agree to reduce the number of cigarettes they smoke each day.
12. Be firm.
Difficult patients with a habit of manipulation and refusal may require strict boundaries. The healthcare provider can provide no-nonsense options with some practices implementing a contract in order to continue treating a patient so as not to waste time and resources.
References and Sources
- Chakrabarti S. (2014). What’s in a name? Compliance, adherence and concordance in chronic psychiatric disorders. World journal of psychiatry, 4(2), 30–36. https://doi.org/10.5498/wjp.v4.i2.30
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- McQuaid, Elizabeth L, and Wendy Landier. “Cultural Issues in Medication Adherence: Disparities and Directions.” Journal of general internal medicine vol. 33,2 (2018): 200-206. doi:10.1007/s11606-017-4199-3