Patient Adherence: Pearls and Pitfalls
Adherence is a term that is meant to denote a patient’s choice in taking an active part in their treatment by following suggested guidelines. Patient adherence is crucial in wound care to achieve wound healing and closure. As clinicians, it is up to us to figure out why some patients become nonadherent and decide what to do about it.
Factors that influence adherence may be divided into three categories: patient, task and clinician characteristics.
There are several patient characteristics that may influence adherence:
- Prior experiences of the patient
- Patient support systems
- Lack of understanding of their role or task(s)
To counter these characteristics, the clinician should take care to emphasize that the past is the past- what has happened before will not necessarily happen again. The clinician should help the patient realize that they are in control, and that adherence is a personal choice that will affect the outcome. Patients who have inadequate support may be less adherent than patients with a lot of support; in this case, caregiver involvement should definitely be encouraged. In terms of lifestyle, clinicians should inform patients of the risks and benefits associated with adherence and should jointly decide upon measures to combat lifestyle risks. Clinicians can also improve patient adherence by ensuring that the patient is fully aware of any actions that they should be performing, as well as how to perform them. A patient who is well informed is far more likely to follow all instructions given.
Task characteristics that may influence adherence include:
- Task is too complex
- Unable to perform procedure (patient perception)
- Task aversion (i.e. task causes pain or discomfort)
- Task coincides with a past behavior or lifestyle
There are several things that clinicians (and patients) can do to counter these negative task characteristics. When a task is deemed to be too complex, the clinician should provide clear written instructions and communicate the behaviour expected of the patient. If the patient feels that he/she is unable to perform a certain procedure, the clinician can encourage them to demonstrate the procedure during a clinic visit until they are confident they can perform the procedure correctly. When a procedure is likely to cause pain or is aversive to the patient in some way, the clinician should develop a plan to counter this effect; for example, if the patient experiences pain during dressing changes, he/she should be counselled to take pain medication one half hour prior to the procedure. Ensuring patient comfort will improve adherence. In terms of behaviour and lifestyle, patients may be nonadherent when a task is tied to certain long-standing behaviours, such as those associated with diet or exercise. It is important for the clinician to be able to determine what the barrier to adherence is and come up with a way to get around the barrier to improve adherence.
Are there clinician characteristics that can influence adherence? Of course there are, and these may have a potent effect on adherence. The following clinician characteristics should be avoided:
- Poor relationship with the patient
- Do not allow patients to voice their concerns
- Do not provide encouragement/reinforce “good” behaviours
- Failure to act when patient adherence or a worsening of patient condition occurs
- Poor continuity of care
Clinicians should strive to avoid the above by showing interest in, and concern for, the patient. Clinicians should also allow patients to speak freely regarding their concerns and provide positive feedback when it is warranted. Avoiding judgement is directly related to the status of the clinician/patient relationship. The clinician should be alert to changes in condition or signs that the patient has been nonadherent and should provide the patient with objective evidence, as well as stating what will likely happen if the behaviour does not change. It is also important to provide encouragement when the patient performs appropriately, providing concrete examples. Continuity of care is of utmost importance to building a relationship with a patient, thus clinicians should try to avoid inconsistent and uncoordinated care.
Although it seems difficult, promoting adherence really boils down to caring for and about the patient. Patients who believe that you are truly interested and really care about them are much more likely to be adherent in the care of their wounds.
If you enjoy learning about wound care, consider becoming certified in wound management. Wound Educators is the foremost online wound education forum, offering wound certification courses for healthcare professionals.
Meyers, B (2008). Wound Management: Principles and Practice. 2nd edition. Pearson Prentice Hall. Upper Saddle River, New Jersey. pg. 205-207.