1. Narayan, Mary MSN, RN, HHCNS-BC, CTN

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Q: I am frequently assigned patients who are noncompliant. My supervisor says I should not use the terms "noncompliant" or "nonadherent" in my documentation. Why not?


Answer: The terms "noncompliant" and "nonadherent" have joined the ranks of "politically incorrect terms!" There are good reasons for this, and it has major implications for how we clinicians interact with our patients. The typical image associated with the terms "noncompliance" and "nonadherence" is one of stubborn patients who perversely refuse to do what they should do. Intrinsic to such a perception is that the patient was given all the information necessary to make good choices, understood that information, and just decided to make a negative choice, and there is nothing we can or should do to change that choice. And so, the thinking goes, because patients have an autonomous right to make bad decisions about their healthcare, they should be discharged from home care services as soon as possible. No use putting taxpayers' or insurers' money into a "lost cause." Thus, the terms "noncompliant" and "nonadherent" have developed negative nuances and connotations.


Instead of labeling patients with these terms, clinicians should explore why their patients are not adhering to a plan that would promote their health and well-being. This exploration, in turn, then creates a space for identifying creative and evidence-based strategies that enable patients to be more engaged in developing workable care plans that promote their health. There are probably as many reasons for not adhering to care plans as there are patients, and patients frequently have difficulty verbalizing, or even understanding, their own reasons. Undoubtedly, one reason is that the care plan was never the patient's care plan. Patients were given a list of things they must and must not do in order to successfully manage their chronic conditions, with little regard to how these plans would impact other parts of patients' lives, how they would make the changes they needed to make, and how they would overcome the barriers they would encounter. It was the provider's care plan for the patient-without taking into account the patient's unique values, circumstances, and needs related to the care plan.


Another reason for nonadherence is discouragement. Initially, when trying to follow the lifestyle changes required, patients may be unsuccessful. The actions they were expected to make involved too much expense, too much effort, too many side effects, too many hurdles, too many changes. Here is an analogy, which may help clinicians develop empathy to patients' predicaments. Giving patients an explanation of their disease process and then asking them to change their lifestyle is a little like telling a child that the way to be a good baseball player is to pick up a bat and hit a homerun. Obviously, the child is going to need a lot of coaching before he hits the ball out of the ballpark. No one comes to a new disease process as a skilled expert; learning to manage a disease process is a developmental skill! Most people require a lot of encouragement and support to develop new skills!


Thus, nonadherence isn't solely the patient's problem to fix. Rather, it is the clinician's responsibility, as part of the therapeutic relationship, to explore with the patient the reasons for the nonadherence and then to develop strategies for making the needed lifestyle changes. New research can help us to do this with evidence-based strategies, such as building the therapeutic relationship, motivational interviewing, and health coaching interventions.