PPN201 - Week 8 Adherence

what is adherece?

The extent to which a persons behaviours (meds,diet,lifestyle changes) corresponds w HCPs reccomendation
Collaborative decision, the client doesnt not agree to the HCP decision

Article 1 - Bissonette 2008 evolution of terms

following directions from HCPs = compliance
-term used to describe pts obedience to recommendations with prescribed treatment
-later thought to be paternalistic and led to blaming the pt for not following
- linked to power of HCP over Pt

what is compliance

Undertone of paternalism
blame lies w pt

WHO definition of adherence

Based on assumption that pt agrees w plan and is actively participating
research has not show an improvment in adherence w shared decision making

what is concordance

Alliance between pt and HCP based on realistic expectation
-Pt and HCP mutually agree on regime thru a process of negotiation
-Attempt to equalize power imbalance

Adherence attributes (bisonnette,2008)

Decisional conflict
predictability
personal experience
power
agreement
pervasiveness

Antecedents of Adherence

Perscribed med regimen is the main one
- less frequently perscribe regimens: weight loss, smoking cessation, diet
- pt regard toward HCP as trusted and knowledgeable source of info
- willingness on part of pt to accept all/part of plan

3 categories of consequences to adherence

1. Patient related
2. HCP related
3. Healthcare system related

1. Patient related

Improved morbidity, reduced mortaility, conflict resoultion, attributional uncertatinty, empowerment and improvement in QoL

2.HCP related

Ambivalence towards a pt adherence behaviour, misinterpretation, disempowerment, acceptance or avoidance of the adherence behaviour

3. Healthcare system related

Decrease in cost and health care service use

Article 2 - Herrera et al., 2017 Theoretical models/frameworks of adherence

Social cognition theory
Health belief model
Theory of planned behaviour
Protection motivational model
Leventhals common-sense model

Health belief model

Explores pt attitudes and perception to adherence behaviours
Most used model in practice
tries to understand the reasons that pts dont adopt preventative behaviour

Health belief model - 4 elements

Pt follows regimen d/t understanding of
- percieved threat of a disease
- perceived benefits of health behavior
- perceived barriers to that behavior
- cue to action

Theory of planned behavior

looks at pt percieved behavioral control

Protection motivational theory -

non-adherence is a product of a pts maladaptive coping mech

Leventhal common sense model

Explores pt subjective experience of their illnes to understand the way the cope and adapt to illness
- Dynamic interaction among variables that influences health behaviors
- 4 dimensions of psychosocial adjustment; cause, consequences, identity, timeline

Understanding adherence from inside

Non-adherence/resistance is not irrational but expression of conflict of internal motivations or voices of Pt
- some pt voices are coherent w adherence other are not
- must use a pt focused apporach

Pro-adherence explantations

Self worth
Noticing benefits

Anti-adherence explanations

Self worth
QoL
Health of protecting from iatrogenic effects
Autonomy
Hopelessness

Article 3 - Russell et al. 2003 - Non compliance and Nursing Interventions

To ID non-compliant pts, objective measures are common
- pill counts, labs, and blood
This fails to take social context of pt lives
- choices may be constrained by social circumstance in which pt live their lives
- have to know social context to better understand pt actions

3 nursing interventions of Non-Compliance

Social model of health
Person centered model
Patient empowerment

Social model of health

Recognizes how social factors shape health behaviors
- holisitic approach, considers pt lives into decision making
- provide and in-depth understanding of how treatments affect their lives
- relationship building, relevant info, understand pt decision

Patient-centered approach

Examines power structure of ownership and control
- changes to this approach = resistance from HCP/Pt
- transfers some power to pt
- pt viewed as able to make treatment decision
- social context = shared meaning

Patient-empowerment

Encourages RNs to accept challenge and tensions that exist in trying to empower pts
- e.g. accepting pt health choices that may not align with plan
- rooted in acceptance not coercion/re-education
- social context
- listen to pt and share pt rationale

Article 4 - Whittaker, 2015 - Nursing Interventions

Negotiating non-compliance factors
- nursing views of non-compliance
- pt perception of health risk
- indivituals tolerance of risk
- lack of motivation

Pt education - whittaker, 2015

need a win-win situation for pt and nurse, this process mitigates nurse and pt factors
- incorporate a worldview based on interpretative paradigm
- self disclosure
- pt centered care

Nursing interventions

Role of nurse
-provide compassionate nursing care
-understand pt POV
-building therapeutic partnership
-building trust w client
- Pt centered care
- help pt understand risk of the disease

Article 5 - Paul & Sneed 2004 - transtheoretical model of change (TTM)

Approach that focuses on the clients understanding of their disease, illness experience, situation
- behaviour change is a process and occurs over time

3 dimensons of TTM

1. Various stages of change
2. Processes of change on which interventions are based
3. Action criteria for actual behavior (outcome)

6 Stages of Change in TTM

1. Pre-contemplation
2. contemplation
3. Prepartation
4. Action
5. Maintenance
6. Termination