CHAPTER 29 Noncompliance, nonadherence, or barriers to a sustainable plan?

1. List potential barriers to achieving a sustainable wound management plan.

2. Describe interventions to prevent or minimize barriers.

3. Provide examples of factors associated with impaired activity that may be mistaken for patient noncompliance.

4. Summarize The Joint Commission standards related to patient education.

5. Identify strategies to improve education materials and methods.

Historically, the term noncompliant has been used to describe the patient who, for whatever reason, does not adapt to interventions deemed necessary by health care providers. Nurses’ descriptions of behaviors from noncompliant patients have ranged from passive resistance and lack of motivation to overt refusal and deliberate interference with care (Hallett et al, 2000). However, patients who have been labeled noncompliant report a lack of understanding of why or what they were supposed to do, or an inability to perform prescribed interventions (Edwards et al, 2002).

This gap in perception leads to obvious questions about the noncompliance label, which has been described as an arrogant term suggesting that the patient’s job is to do what he or she is told to do by the health care provider (Rappl, 2004; van Rijswijk, 2004). In recent years, the term noncompliance has been replaced with the more politically correct term nonadherence or inability to perform self-care (Seley, 2009). Regardless of terminology, however, misperceptions remain; the patient did not comply with the plan. The wound specialist’s role is to critique the plan of care (rather than the patient). This chapter presents important factors to address in order to formulate a sustainable wound management plan designed to achieve mutually agreed upon goals.

Significance

In the United States in 2005, 133 million Americans had at least one chronic disease (Ogden et al, 2007). Medical care of chronic diseases accounts for more than 75% of the nation’s $1.4 trillion in medical care costs (National Center for Chronic Disease Prevention and Health Promotion, 2009). Economic costs related to medication noncompliance are as high as $100 billion annually in health care and lost productivity and up to $8.5 billion annually in preventable clinic visits and hospitalizations (Durso, 2001). The Wound, Ostomy and Continence Nurses (WOCN) Society (2003) estimated that $2.2 to $3.6 billion was spent annually for the care of pressure ulcers and cited noncompliance as one of the causes of the 13% to 56% recurrence rate. Recurrence rates for venous leg ulcers are reported to be as high as 70% (Robson et al, 2006). The most important intervention to prevent recurrence, graduated compression, is associated with noncompliance (Furlong, 2001; Phillips, 2001; Wipke-Tevis and Sae-Sia, 2004). Similarly, a 59% recurrence rate is reported with diabetic foot ulcers (Steed et al, 2006), and the offloading and footwear options critical to prevention are associated with noncompliance (Armstrong et al, 2005; Wu et al, 2008).

Barriers to a sustainable wound management plan

When planned interventions are not completed and goals are not met, the best question is not, “What’s wrong with the patient?” Rather, we should be asking, “What’s wrong with the plan?” The patient and care team together must reevaluate the goals to determine if they are patient centered and realistic and then identify actual or potential barriers to achieving a sustainable plan. Ideally, this process should occur while the initial plan of care is being developed so that barriers can be minimized or eliminated at the onset. This section discusses potential and actual barriers. Possible interventions to prevent or minimize each barrier are listed in Table 29-1.

TABLE 29-1 Interventions to Prevent or Minimize Barriers to a Sustainable Wound Management Plan

Barrier	Intervention
Inappropriate goals	Collaborate with patient; make sure goals are mutual Set goals based on best evidence Ensure goals are clearly written and understood Explain interventions needed to accomplish goals before patient commits to the goal Provide guidance by breaking goals into intermediate steps Adjust goals as needed for changes in assessment parameters
Depression, pain, anxiety	Be aware that many patients with depression will not ask for help Appropriate pain assessment and management (see Chapters 25 and 26) Address aspects of wound management that trigger or exacerbate depression, pain, or anxiety Collaborate with social services and physician for appropriate referrals
Cognitive impairment, complicated regimens, impaired dexterity	Simplify procedures Divide procedures into easier intermediate steps Choose dressings that require fewer changes Choose products that are easy to use Use combination products to minimize steps Encourage use of memory aids and assistive devices when indicated Clearly label supplies Dispense appropriate number of supplies Collaborate with occupational therapy
Impaired activity and mobility	Prescribe compression that is compatible with appropriate shoe wear Prescribe offloading devices compatible with wheelchair and home environment Adapt clinical environment to accommodate patients with mobility impairment (low examination tables, closer parking) Be aware of wound management recommendations that may hinder mobility Prescribe sitting program compatible with employment and parenting needs Facilitate home care when appropriate
Financial barriers, lack of social/environmental resources	Collaborate with social services Identify payer and reimbursement sources Learn prices of products and less expensive alternatives Learn resources and available funds available to patients with low income Financial guidance for prioritizing
Skepticism	Address concerns immediately Be honest about risk versus benefits of recommended interventions Respect and incorporate life experiences Do not minimize concerns Recommend a second opinion Provide alternative interventions (and goals as needed)
Knowledge deficit	Develop education plan that matches developmental phase, cognitive and physical abilities, and educational and cultural background (see Boxes 29-2 and 29-3) Use multiple methods of educational methods and tools (see Table 29-3)

Inappropriate goals

Outcomes improve when patients are involved in setting the goals that affect their lives (Masspro, 2008). In order to facilitate a sustainable plan of care, health care professionals need a paradigm shift from a directive, paternalistic style to a more collaborative interactive style in which problems, treatment goals, and management stratagems are defined together (Heisler et al, 2002). Identification and consideration of patient preferences and actions are central to evidence-based decision making (DiCenso et al, 2005).

The goal of wound healing as a standard for all patients is unrealistic and often is inappropriate (Whitney et al, 2006). For example, a patient who is malnourished and does not care to receive enteral or elemental feedings will not achieve the goal of wound healing. Once the patient understands that wound healing is unrealistic, he or she may decide to reconsider supplemental feedings or may aim for a goal that keeps him or her at home, avoid hospital admission, control symptoms (e.g., odor, exudate), and enhance quality of life as defined by the patient. In other cases, the treatment may produce added discomfort or risk for the patient (Whitney et al, 2006). For example, bed rest for a patient with an ischial tuberosity wound may put the patient at risk for pneumonia due to prolonged immobility. The resulting deconditioning may lead to falls during transfers, causing a vicious cycle with broken bones and more immobility.

Wound healing potential must be based on the most current evidence and communicated in such a way that the patient and family understand (e.g., a patient with peripheral vascular disease with an ankle–brachial index <0.5 requires revascularization for healing to occur; venous insufficiency requires compression for wound healing to occur; pressure ulcer healing is not realistic without pressure relief, nutrition support, and management of urinary or fecal incontinence). When healing is no longer realistic, the plan of care should be revised to focus on goals that support the patient’s comfort and his or her need and desire for socialization.

Goals are prioritized into short- and long-term goals. Short-term goals focus on the most pressing issues, such as pain control, infection prevention, and dressing changes. Long-term goals focus on disease management and fostering independence. Discharge goals vary by practice setting. Crucial decisions, such as the patient being able to return to home and live alone, rest on the outcome of learning. The minimum performance necessary for the patient to function must be identified, and progress toward this level must be communicated.

In order to integrate interventions needed for optimal healing, the patient must face multiple adaptations to accommodate the wound as well as the underlying disease. To understand the range of adaptations facing the patient, the wound specialist must know the impact of the wound on the patient’s life. The National Family Caregivers Association estimates that family caregivers provide approximately 75% of the home care in the United States (Turnbull, 1999). Hence, to achieve a sustainable plan of care, education and goal setting must include families and caregivers. The wound specialist must help the patient and family determine their goals based on what the patient and family are able and willing to do to achieve those goals. This can be accomplished only if decisions are based on full disclosure and an understanding of relevant information.

Depression, pain, and anxiety

A systemic review of the impact of wounds and of quality of life underscored the number of problems, such as pain, sleeplessness, social isolation, loneliness, and job loss, that can lead to anxiety and depression (Herber et al, 2007). The National Institute of Mental Health estimates that 14.8 million adults in the United States suffer from depression. This constitutes 6.7% of the population at any given time. Up to 80% of patients with depression are untreated or undiagnosed. Many patients with depression will not ask for help, have difficulty performing activities of daily living, and may be unable to follow through with agreed upon interventions (Kessler et al, 2005). A quality-of-life survey conducted by Hyland et al (1994) reported that patients spent an average of 1.5 to 2 hours thinking about their wounds. Whether a patient experiences depression prior to developing a wound or becomes depressed because of the profound challenges the wound presents, the patient’s perception related to quality of life should be assessed.

Cognitive impairment

Cognitive impairment may be an obvious barrier to achieving a sustainable treatment plan; however, the presence of cognitive impairment can be subtle. It is important to review past medical records and speak with family members so that cognitive deficits can be identified and the plan of care adjusted accordingly. In many settings, occupational therapy and speech therapy can assist in identifying cognitive deficits and can assist the wound specialist in developing a plan of care that incorporates the unique learning needs of the patient. Memory aids and reminders have shown effectiveness in medication compliance studies (Durso, 2001).

Complicated regimens

Complicated regimens present considerable room for error and confusion, especially in the presence of impaired cognition, mobility, or dexterity. Interventions must be described in as few steps as possible. If multiple steps are required, combination products can simplify the process (Nix and Ermer-Seltun, 2004). Dispensing appropriate amounts of supplies and clearly labeling them simplifies the procedure for the patient. Combining interventions with routines already established (e.g., meal times) will increase the likelihood of success.

Impaired dexterity

The wound specialist must have the expertise and resources available to design a plan of care that accommodates the individual with impaired dexterity. For example, many combination dressings and products eliminate the need for cutting tape. Practice and return demonstrations are critical for the patient with impaired dexterity. Often the patient has learned to compensate for impaired dexterity and just needs an easy-to-apply product or an assistive device (Phillips, 2001). Because impaired dexterity can significantly affect procedure time, selecting dressings that require fewer changes may be more realistic and sustainable.

Impaired activity and mobility

Impaired activity and mobility affect the patient’s ability to accomplish many important activities needed for disease management and wound healing. Unfortunately, these challenges are not always understood by the health care system and lead to inaccurate assumptions about noncompliance (Box 29-1). The extent to which impaired activity and mobility affect a patient’s life must be explored thoroughly before realistic goals and interventions can be put in place. For example, the wound specialist must be aware of the many interventions (e.g., sitting restrictions) and devices (e.g., bulky compression and high-profile support surfaces) that actually can create an activity or mobility deficit for the patient (Armstrong et al, 2001, 2003; Furlong, 2001; Phillips, 2001; Rappl, 2004; Wipke-Tevis and Sae-Sia, 2004). Patients have reported losing their jobs or retiring early because of immobility secondary to a wound or treatment for a wound (Ashford et al, 2000; Brod, 1998; Herber et al, 2007; Phillips et al, 1994).