Managing Disruptive Patients _ ________________________________________________________________
of bacteria (U.S. Food and Drug Administration, 2020). Population health is affected by medication nonadherence; an example of this is persons with tuberculosis who did not adhere to treatment protocols, creating the antibiotic-resistant tuberculosis strain now evident (Centers for Disease Control and Prevention, 2017). Patients fail to take medications as prescribed approximately 30%-50% of the time, which often leads to hospitalization and emergency room visits (Poonawalla, 2024). One of the recom- mended means of improving adherence is to involve the patient in the development of the treatment plan (Poonawalla, 2024). Patients with mental health disorders are frequently nonadher- ent with medications. Some psychiatric medications do have intrusive side effects that may seem to the patient more difficult to bear than the illness itself. Patients who are nonadherent with medications may also be nonadherent with interventions such as rehabilitation, relaxation, counseling therapy, quitting smoking, or losing weight. HEALTH BELIEF MODEL Many attempts have been made to create a conceptual model of adherence that will enable healthcare providers to predict and understand patients’ behavior. The Health Belief Model offers some understanding of the phenomenon of adherence. In a systematic review, Abdallah et al. (2024) found that individu- als’ beliefs about their susceptibility, perceived benefits, and sense of self-efficacy are strongly linked to their adoption and use of preventative measures for common treatable diseases. The significance of this model is that it suggests that patients’ choices depend on their beliefs, not necessarily on the medical evaluation of the situation. The Health Belief Model proposes that changes in beliefs about the severity of and susceptibility to a health outcome and its consequences are associated with the motivation to take action. Once an individual feels threatened, a decision is made from among alternative actions based on a cost-benefit analysis. This model also emphasizes the concept of self-efficacy. Patients must feel capable of mastering their environment and behavior to risk trying to make behavioral changes. If they do not feel capable, assistance may be offered by healthcare providers through skill practice and positive reinforcement so that the patients come to see that they are capable of change. The model postulates that people choose healthcare actions when they are faced with a threat to their health. The actions they choose depend on their perceptions of the situation. They decide how much of their personal goals they might be risking and compare it with how severe the threat is to their health. Then a further determination is made as to whether the costs to their lifestyle are worth the potential benefits. Unfortunately, a lot of this “balance sheet” is based on personal viewpoints and not on medical facts. Even when patients decide on a course of action that is adherent, they struggle with long-term habits that must be overcome. Lifelong habits are difficult to change, and the ease of continuing a previous
pattern of behavior works against making healthy lifestyle changes (Alyafei and Easton-Carr, 2024). For many patients, nonadherence may be the perception that the illness is less of a problem than the treatment. Some changes are much more difficult than others as well. LEGAL AND ETHICAL ISSUES Healthcare professionals face increasingly complex situations in which the patient’s wishes may deviate from the treatment recommendations. Some ethical guidelines can help healthcare professionals choose a response to a patient who is nonad- herent. In addition, to practice within the law, healthcare professionals must be aware of legal guidelines. This area of healthcare is changing quickly. Healthcare professionals need to be clear about their obligations to patients and be knowl- edgeable about patients’ rights. RIGHTS OF THE PATIENT Inviolability is the fundamental right of every individual to be left alone. The U.S. Constitution and Bill of Rights are based on this principle. The individual has authority over what happens to their body. In practice, however, the situation is not always so clear. In some instances, individual rights may interfere with the rights of others. In addition, fluctuations in public sentiment may affect the decisions made by practitioners and institutions. Ethicists differ in their perceptions about the dilemmas that healthcare professionals face. The concept of personal free- dom becomes unclear when the perspective is one of social responsibility. Some ethicists believe that people can have both individual autonomy and responsibilities to one another. The issue of mandatory testing for communicable diseases illustrates the dilemma of conflicting principles. Inviolability would guarantee the individual the right to refuse such testing. The principle of social responsibility would support mandatory testing because the individual has the obligation to participate to protect others. LEGAL CONCERNS One legal issue that affects a Healthcare Professional when discussing patient adherence to treatment is the issue of com- petence. A patient is considered competent if they are able to participate in making decisions, which means the patient has the ability to comprehend information, understand choices, and communicate their decision verbally or nonverbally to the healthcare team. For example, patients must be able to understand the nature of their illness and the available treat- ment alternatives. Equally important is an understanding of the consequences of any decision the patient might make about these alternatives. Patients are presumed to be competent. This assumption means that the burden of proving incompetence belongs to parties other than the patient. Unless otherwise indicated, patients are assumed to be making competent choices about their healthcare.
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