(2003; 211 pages)
The role of the nurse in improving adherence
By Tesfamicael Ghebrehiwet, Nursing and Health Policy Consultant, International Council of Nurses (ICN)
Nonadherence to treatment regimens is a persistent challenge to nurses and other health professionals. It is estimated that the percentage of patients who fail to adhere to prescribed regimens ranges from 20 to 80%1,2. Nurses are aware of the consequences of nonadherence and its high cost to the patient, the community and the health care system. In addition, nurses are all too familiar with the frustrations about treatment failures, poor health outcomes and patient dissatisfaction that accompany poor adherence.
1,2 Cramer JA et al. How often is medication taken as prescribed? A novel assessment technique. Journal of the American Medical Association, 1989, 261: 3273 - 3277 [erratum published in Journal of the American Medical Association, 1989, 262: 1472]. Wright EC. Non-compliance - or how many aunts has Matilda? Lancet, 1993, 342: 909 - 913.
The International Council of Nurses (ICN) estimates that there are about 12 million nurses worldwide. And with a proper understanding of the dynamics of adherence, and techniques in assessing and monitoring the problems of nonadherence, these millions of nurses represent a formidable force in improving adherence and care outcomes. Their presence in all health care settings, their closeness to people and their large numbers combine to position nurses for sustained strategies to improve adherence.
Nursing interventions to scale up adherence need to be based on innovative approaches that involve nurse-prescribing, patient participation in self-care, and continuous assessment and monitoring of treatment regimens. Such approaches should foster therapeutic partnerships between patients and nurses that are respectful of the beliefs and choices of the patient in determining when and how treatment regimens are to be followed. Because much of the treatment for chronic conditions takes place in the home and community setting, nurses can provide a link and support through home visits, telephone and other reminders that facilitate adherence. Through sustained contact, nurses can form a therapeutic alliance with patients and their families and provide ongoing support for taking the recommended medications. Some techniques of monitoring adherence include directly observed therapy (DOT), pill counting, thoughtful and non-judgemental interviews, and reviewing medication cabinets3.
3 Williams AB. Adherence to HIV regimens: 10 vital lessons. American Journal of Nursing, 2001, 101: 37 - 43.
Nursing strategies to improve adherence include:
- assessing the extent of adherence using non-threatening questions;
- asking about side-effects of medication and their effect on patient's quality of life;
- educating patients on their illness, the importance of adherence, how the treatment will help, possible side-effects and how deal with them;
- suggesting cues and reminders such as detailed schedules, integrating medication times with daily habits, using medication boxes and timers, alarms, beepers, etc;
- rewarding and reinforcing adherence behaviour, for example, through charts and graphics that show the impact of medication on clinical markers of disease: e.g. lower blood pressure, lower blood sugar, lower viral load, etc;
- encouraging the patient to cultivate therapeutic relationships with health professionals, and to talk with peer groups and family members.
Ensuring that treatment regimens are followed and administering medications and other treatments are some of the key roles in nursing. Nurses have diverse skills that must be tapped in improving adherence and care outcome. Continuing education programmes for nurses and other health professionals can improve their competence and awareness about the importance of adherence in health care.