Download Adherence or compliance?

Dialysis-MHigginsTH/AM
18/10/2006
16:05
Page 1
Renal Disease
Adherence or
compliance?
It is vital that haemodialysis patients adhere to a strict diet, fluid and
medication regimen – which is no mean feat, writes Margaret Higgins
ADHERENCE behaviour is a clinical concern in the care of haemodialysis patients.
Adherence is necessary for optimal health
and wellbeing.1 Non-adherence leads to
individual suffering for patients and their
families and an economic expense for
society. If non-adherence is undetected
the human cost is considerable. It can contribute to unnecessary diagnostic testing
and result in potentially harmful regimen
changes.1
From a review of the literature in relation to adherence to diet, fluid and
medication regimes by haemodialysis
patients, it was found that there is no gold
standard for measuring adherence in
haemodialysis patients.3
Is it adherence or compliance? There is
lack of a generally accepted definition.
Compliance is where the patient is merely
told what to do with regard to treatment
and expected to follow the recommendations unquestionably. On the other hand,
adherence assumes a collaboration
between the patient and the treatment
provider.4
Two major themes were identified
which formed the structure of the review:
• Barriers to adherence
• Factors facilitating adherence.
The review indicated that non-adherence with medical treatment is estimated
to occur in more than 50% of patients.5
Barriers to adherence include: perceptions
of chronic illness, depression, health beliefs
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WIN November 2006
and locus of control, and situational factors.
Confronted with a ‘new way of being’ in
the world, patients are cognisant of an
uncertain future, continuous dependence
on life-sustaining technology and on
healthcare providers.6 Disease status even
occupied dreams.7 Patients feel deprived
of ‘normal life’.8
Evidence suggests that an individual’s
perception of their situation will determine whether they will adhere to medical
regimens.7,9-11 This highlights the need for
nurses to help patients to articulate the
meaning that they ascribe to their illness.
An unrealistic negative evaluation of
themselves causes loss of self worth and
an embittered outlook.12 Incidence of
depression varies from 2% to 60%. 13 Incidence of suicides are reported to range
between four to 400 times that of the general population.14 Early psychological
assessment by nurses is important so that
patients can be supported appropriately.
The Health Belief Model identifies four
main beliefs that can influence adherence
to regimens. Perceived benefits, barriers,
susceptibility to illness, severity of the outcome of non-adherence.15 Some 19 studies
using meta-analysis engaged the Health
Belief Model to predict adherence. The
best predictions were perceived benefits
of treatment and perceived seriousness of
the disease. Beliefs about the side effects
of medication is a barrier to adherence.15
In the Health Belief Model an assessment
of the risks versus the benefits of a course
of action takes place. Patients may have little incentive to take phosphate-binding
medication if they do not perceive the link
between phosphate and a tangible outcome such as worsening symptoms. It is
important for nurses to acknowledge and
discuss medication side effects with
patients.
Locus of control (LOC) is the way a person perceives their ability to control their
lives.16 Internally-orientated patients are
more likely to take responsibility for and
place a higher value on health.17,18 Patients
with external LOC generally display poor
adherence.19 Being male, young and having external LOC are associated with poor
adherence to fluid restriction.20 It is important that nurses are aware of such
personality characteristics as LOC to help
patients at risk of maladaptive behaviour.
Patients will need more advice.
Situational factors include:
• Inability to accept limitation of diet21
• Consumption of food in private or public22
• Consumption of food or fluids by others
at home, in restaurants and entertaining
guests23
• Multiple prescriptions, under-dosing,
over-dosing, missing medications.21-24
Nurses are in a position to analyse environmental factors likely to interfere with
adherence and to facilitate desired behaviour. Factors facilitating adherence include:
family support, knowledge of the benefits
Dialysis-MHigginsTH/AM
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Renal Disease
Improving adherence in
haemodialysis patients
of diet and fluid restriction, patient
medication education, and professional
support.
With regard to family support, high levels of satisfaction with support provided
by family determines better fluid adherence.25 Patients holding perceptions of a
more supportive family environment significantly adhere more favourably to fluid
restriction.26 Lower phosphate levels are
associated with greater amounts of family
support.27 Patients without family support
have a three times greater mortality risk
than those with support.28 Positive supportive relationships facilitate good health
behaviours.29
Patients must be made aware of the
benefits of diet and fluid restrictions.
Nurses need to know that patients move
through a series of stages when adopting
a health-related behaviour: precontemplation, contemplation, action, maintenance.30
Targeting patients in the precontemplation stage is an important first step in
moving towards fluid adherence.31 Gentle
guidance and knowledge over a number
of months achieves the best results in
fluid adherence.32 Patients need to hear
that limiting fluids will keep leg swelling
down, blood pressure under control or
make breathing easier between treatments.
Knowledge of phosphate control has
increased significantly and calcium levels
have improved significantly following one
to one education by nephrology nurses.33
Patients have identified tangible health
benefits from improved adherence
through the knowledge of benefits. They
have reported decreased joint pains and
pruritis and increased activity.34
Mutually agreed upon goals between
nurses and patients, signed by patient’s
known as ‘contracts’, have been successful
in dietary adherence.4,34-36 The contracting
process involves the patient in a therapeutic decision – making process of a specific
behaviour.
Continuous patient medication education is vital for adherence. Patients must
have clearly labelled containers, physical
appliances to open them and simplified
regimens.37 Education has improved
adherence.38-41 Only 4% of patients knew
the dosage of all medications, 50% knew
nothing of the consequences of exceeding dosage in one study.42
Verbal information should always be fol-
• Non-adherence has been found to be
commonplace and problematic
• Family support and education are key factors
in adherence success
• Education and counselling should begin predialysis to help patients identify existing
coping strategies and to develop new ones
• There is concrete evidence that patients
maintain adherence for approximately six
weeks but after that adherence declines. Thus
ongoing education should be an integral part
of patient’s treatment after maintenance
haemodialysis has been established
• Primary nursing is the preferred method of
work organisation as it takes an individualised
and realistic approach by involving patients
and family members
• Primary nursing’s main focus fosters the
development of a therapeutic nurse-patient
relationship
• Haemodialysis nursing is a very specialised
and empowering method of nursing.
Therefore, nurses must have the knowledge
and skills to develop a realistic understanding
of patients’ unique needs to ensure quality care
• Ensuring patients have family and
professional support and implementing
patient teaching programmes to improve
adherence with diet, fluid and medications
into routine treatment is essential. Such
measures will facilitate adherence to
treatment regimens and contribute to optimal
health status and quality of life
lowed up by written information.40,43 Cognitive function decreases during dialysis
and is not always a suitable teaching
time.44 The importance of continuous reinforcement of information cannot be
overemphasised as education outside the
dialysis setting is not always possible due
to lack of resources.
Professional support must always be
available for nephrology patients. Cognitive interventions such as counselling has
shown an immediate drop in interdialytic
weight gain and behaviour interventions
such as video-taped advice to reinforce
adherence have proved successful.45 Frequent interventions are more likely to be
effective.46 For patients with a high risk of
ineffective self-management the use of
the Dungan Model47 is designed to
promote personal growth and selfresponsibility.This model involves eight to
10 therapeutic sessions over five weeks
taking into account cultural, material and
emotional environments including the
family.47 It appears patients adhere initially
and then there is a decrease in adherence
over time. Therefore, it is important that
interventions are staged and managed to
ensure patients are followed up.
Nurses are ideally placed to influence
patients. They can reinforce and evaluate
patients’ understanding of treatment regimens due to their sustained contact with
patients. Nurses can become familiar with
individual lifestyles and plan the feasibility
of making changes contributing to adherence to treatment.48 The need for nurses to
understand difficulties associated with
adherence cannot be over-emphasised as
lack of adherence affects delivery of care,
morbidity and mortality.
All patients with renal disease are
required to adhere to diet fluid and medications regimens. Although technology
today is increasingly efficient, the dialysis
treatment does not perfectly reproduce
normal kidney function. Thus the need for
dialysis patients requiring diet therapy to
avoid complications of high potassium,
itching, weight loss, fluid overload and
bone disease.
Excess fluid, which includes all beverages
that become liquid at room temperature,
can cause oedema, hypertension, shortness of breath and in some cases cardiac
failure.
The haemodialysis patient has to take a
minimum of seven prescribed medications
daily,49 including:adrenergic blocking agents,
analgesics, antacids and phosphate binding agents, anti-anaemics, anti-emetics,
antidiarrheals, stool softeners, antihypertensives, cardiotonics, cation exchange
resins, diuretics, dopamine receptor agonists, electrolyte replacements, heavy
metal chelating agents, vitamins and due
to susceptibility to infections these
patients frequently require antimicrobial
agents to combat infections.29
Not only are patients required to take
several types of medications at varying
times throughout the day, they must only
ingest the approved amounts and types of
fluids and foods, and adhere to a preset
dialysis schedule. Such activities require an
inordinate amount of attention and selfdiscipline in order to adhere. As a
consequence, patients’ lives become
restructured based on the interference of
externally imposed obligations.
Margaret Higgins is a CNM 2 at the Haemodialysis
Unit, Merlin Park Regional Hospital, Galway
References on request from [email protected] (quote:
Higgins,M.WIN 2006; 14(10): 28-29)
WIN November 2006
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