Managing Disruptive Patients _ ________________________________________________________________
The correct answer is D. Rationale : As much teaching as possible is needed for the patient and his family. It would not be unusual for a patient to try to hide the nonadherence to medications prescribed from his family.
BOX 1. CYCLE OF NONADHERENCE BETWEEN PATIENTS AND HEALTHCARE PROFESSIONALS Depending on the reasons for nonadherence, the patient may be quite happy to be left alone or to be overly dependent on the healthcare professional. More likely, however, the patient will feel that their real healthcare needs are going undetected. This behavior may become a cycle. Nonadherence Cycle • Patient is nonadherent • Healthcare professional feels angry, powerless, and so forth • Healthcare professional withdraws or overreacts • Patient’s needs go unmet Healthcare Professional Strategies to Stop This Cycle • Becoming aware of feelings • Performing a healthcare professional assessment • Using care planning as a mutual process INTERVENTIONS Healthcare professionals can be key players in enhancing adherence on the part of their patients. By establishing rapport and creating trust, they present themselves to their patients as informed and knowledgeable persons who can answer questions and offer ways to adhere to plans of care. Health- care professionals can reassure patients that it is not always easy to change long-term behaviors and gently reinforce why some changes may be necessary. Providing their patients with education as to the reason for certain treatment regimens is something healthcare professionals are well equipped to do. Often patients are more likely to follow through on their treat- ment requirements when they fully understand the reason and importance of what they are doing. Patients benefit from the help of family and friends; healthcare professionals can assist their patients in obtaining support from these individuals. If there is a particular part of the treatment that goes against the patient’s belief system in some way, the healthcare professional can help explain this to the healthcare team and together they (including the patient) can try to come up with an alternative intervention. Healthcare professionals implement their role as a patient advocate when they assist in these situations. In addition to being professionals with a job to do, healthcare professionals are also individuals with their own belief systems. When patients are nonadherent, healthcare professionals can take it personally and react poorly in the situation. It is helpful for healthcare professionals to examine their reactions and why the patient may be acting in this way. Table 3 provides some suggested healthcare professional interventions along with their rationale for working with patients who are nonadherent.
NONADHERENCE Healthcare professionals’ willingness to examine their attitudes and feelings toward the patient is of primary importance in working with patients who are nonadherent. The identity of a healthcare professional is closely tied to the concepts of helping, caring, and service. When a patient appears to reject a healthcare professional’s expertise in promoting wellness, the healthcare professional must deal with many intense and conflicting emotions. Many healthcare professionals state that they would prefer to spend their time with motivated patients who want to get well rather than with patients who do not comply with their treatment plan. They express anger that the patients are “wasting” a bed, precious resources, or the healthcare profes- sionals’ time. It is important to understand that many patients who are nonadherent are not deliberately working against the treatment team. Sometimes anger can lead to withdrawal of services. A health- care professional may avoid going into the patient’s room or omit teaching the patient because “the patient isn’t going to do it anyway.” The healthcare professional should deal with these feelings in another way because it is obviously not help- ful to punish the patient with these behaviors. Discussing the patient’s case with the healthcare team and getting sug- gestions for new approaches to handling the patient can be helpful. Discussions may need to focus on the degree to which care is patient-centered, so that patients feel they are active, respected partners in healthcare decisions. Patients will resist interventions if they feel that their needs are not being heard or respected. When they do resist and appear to be nonadherent, this may be a signal to the healthcare team that an internal assessment of the system’s approaches to patient care should be conducted (see Box 1). At times, healthcare professionals may feel unable to “allow” a patient to be nonadherent. This situation might occur when the healthcare professional has some commonality with the patient, such as being the same age as the patient or having a parent who died of the disease the patient has. Healthcare professionals who feel powerless in the face of a patient’s nonadherence may push the patient to adhere while assuming decision-making responsibilities that belong to the patient.
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