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.
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC), which has made it a topic of dinner conversation as well as a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients. But it’s also important for nurses to be well aware of steps they can take to help protect themselves from possible legal action stemming from opioids.
Scope of the Problem
The depth and breadth of prescription opioid abuse is far reaching. In 2014, almost 2 million people in the United States abused or were dependent on prescription opioids. At least half of all opioid overdose deaths involve a prescription opioid. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people aged 25 to 54.
Role of the Nurse
A 2016 study published in the Journal of the American Medical Association (JAMA) by Baker and colleagues notes that there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78%), followed by oxycodone (15.4%). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7%), perhaps indicating that more health care providers are becoming aware of the addiction issue.
Screen Patients
Nurses are well positioned to detect patients with substance misuse. One simple screening tool is the National Institute on Drug Abuse (NIDA) Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT) from the Substance Abuse and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the Patient Carefully
Pain medication should be matched to the individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status.
A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply Evidence-Based Pain Management
To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication.
NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
Nurses should complete continuing education courses in pain management, and document they did so, which can provide evidence of their knowledge in event of legal action.
Educate Patients
Nurses have an opportunity to educate patients about the role of pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61%) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. Patients can search for places that collect controlled substance drugs through the Drug Enforcement Administration at www.deadiversion.usdoj.gov.
The same survey found that about 20% shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer Patients as Indicated
Nurses need to closely monitor patient use of controlled drugs to avoid overdependence or potential addiction, and refer chronic pain patients to a pain management center or specialist. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain Medications Cautions
Below are some considerations for the use of pain medication in patients:
Use non-steroidal anti-inflammatory drugs (NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
Provide patient education.
Document patient communications, education, and referrals in the health record.
Protecting Patients and Nurses
Nurses who assess and monitor patients for treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so helps protect patients from harm and nurses from potential liability.
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.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500.
