Despite a nurse’s best efforts, some patients aren’t willing to follow instructions, but the impacts of patient noncompliance are too serious to ignore.

Prescription drugs provide an excellent example of the importance of adherence. It’s estimated that up to 30% of prescriptions go unfilled and as much as 50% of medications for chronic disease are not taken as directed according to a study published in Annals of Internal Medicine. The study’s authors go on to say that failure to follow prescriptions causes about 125,000 deaths per year and up to 10% of hospitalizations.

Nurses can enhance patient understanding of and adherence to their overall treatment plans by strengthening communication, rapport, and education.

It Starts with Communication

Asking the right questions and opening the lines of communication between patient and nurse can uncover critical barriers to treatment compliance.

  • Pose questions in a constructive, problem-solving manner. For example, “I see that you have not been completing your daily exercises. I wonder if they are causing you too much pain, or if there is some other reason?”
  • Try to relate personally to the patient to build a stronger therapeutic partnership. Get the patient to express what the nurse and care team can be doing to help them better meet their personal health goals.
  • Set and adhere to a discussion agenda for every encounter. Begin with a discussion of the patient’s personal goals and issues before moving on, such as “First, tell me what concerns you most, and then we’ll discuss test results.”

Encouraging Cooperation and Participation

Explain to patients that they must take some responsibility for the outcome of their care and treatment. Let them know that everyone caring for them wants them to be successful in regaining their health. If barriers to compliance persist, try asking the patient what he or she believes would be more effective. The goal should be to achieve a mutually acceptable care plan.

  • Clearly and explicitly convey the severity of the problem and the risks of not properly carrying out instructions. Give the patient an opportunity to ask questions and clarify the instructions.
  • Find out if there are any underlying factors affecting compliance. For example, “It sounds as though you may be concerned about the medication’s possible side effects. Is that why you have not taken it as prescribed?”
  • Identify any practical or logistical difficulties that may hinder compliance.
  • End each encounter by having the patient verbalize at least one self-management goal.

Enhancing Patient Education and Understanding

Key barriers to communication – such as low health literacy, cognitive impairment, or limited English – need to be assessed early on to help uncover the best solution for successful communication.

  • Have access to qualified and credentialed interpreters for use when necessary.
  • Ask patients if they have any questions about their medications and ask that they describe in their own words how to take them.
  • Consider involving a health coach, health navigator, and/or case manager for the patient.
  • Ask patients to repeat critical instructions and paraphrase in everyday words the medical information they have been given.

Helping Patients Manage Logistics

Sometimes a patient’s noncompliance issue is out of their hands due to a lack of personal support at home or financial restraints. Uncover where those patients are struggling:

  • Do health care information records note who can help your patient when they’re outside of the health care setting? Do they have the consistent help of a spouse, relative, friend, or paid caregiver to aid with their care?
  • Are patients asked whether they can get to appointments via car or public transportation, and are responses documented in the patient care record?
  • If a patient lacks the physical or mental capacity to perform such essential tasks as changing dressings or picking up prescriptions, has a relative or friend been asked to assist, with the permission of the patient or legal guardian?
  • Does the patient lack the financial resources to comply with their current care plan? Are they concerned about the out of pocket costs for treatment, or having to take time off of work?
  • Document these concerns in the patient care record, and work with the patient and their primary care provider (with the patient’s permission) to find solutions.

Supporting the Effort with Documentation

To help staff deal with hostile, manipulative, or uncooperative patients, written protocols should be in place to help all staff respond to and deal with difficult patients. This should include ways to document and procedures for such common concerns as:

  • Repeated prescription refill requests of questionable nature
  • Narcotic use and general pain management in drug-seeking patients
  • Appointment or procedure cancellations
  • Unacceptable behavior, such as belligerent voicemail messages or yelling or cursing at staff
  • After-hours patient calls
  • Refusal to consent to recommended treatment
  • Neglecting to take medications, do exercises, or make necessary lifestyle changes
  • Terminating the patient-provider relationship

Monitoring Compliance

Driving patient compliance often means health care teams need to repeat themselves again, and again, and again. Different tools and strategies can help nurses drive compliance.

  • Remind patients of upcoming appointments, including referrals and laboratory visits, via telephone and/or email.
  • Try electronic alerts to remind patients with a history of noncompliance about screening and monitoring requirements.
  • Inform blind or visually impaired patients of subscription services that use wireless devices to deliver reminders to take medications or perform vital self-care activities.
  • Schedule follow up and referral appointments before patients leave the facility.
  • Document no-shows and conduct telephone follow-up within 24 hours.

Know if there is a written policy for terminating the patient-provider relationship if the patient is chronically noncompliant and fails to respond to reminders and other messages.

Keep at It

Patient noncompliance is a deep issue with no easy answers or simple solutions. Nurses in almost any setting will encounter noncompliant patients, but with consistent communication and a persistent, but cooperative, spirit nurses can work to overcome the risk of noncompliance one patient at a time. Nurses also can explore Nurses Service Organization’s patient self-assessment checklist to help facilitate open communications.


Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.

Jennifer Flynn

Jennifer Flynn

Jennifer Flynn, CPHRM, is Risk Manager for Nurses Service Organization in the health care division of Affinity Insurance Services, Inc. specializing in risk management. With more than 16 years’ experience in the health care insurance business, Jennifer is dedicated to educating health care professionals on professional liability risks and offering strategies to mitigate those risks. For more information, please visit www.nso.com.
Jennifer Flynn

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