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    10 barriers to compliance—and how to overcome them

    CE Center

    RN/AHC Media Home Study Program

    CE credit is no longer available for this article. (Expired March 2009)


    Originally posted March 2007


    PAM BURLEY is nurse manager of the transplant unit at Methodist Specialty and Transplant Hospital in San Antonio. The author has no financial relationships to disclose.

    Caring for a patient who refuses to comply with instructions can be frustrating, but our strategies for improving compliance among transplant patients can help you keep your patients healthy.

    Because you've cared for countless patients who haven't followed their prescribed treatment, the following stats should come as no surprise: More than half of patients with asthma, diabetes, and other chronic diseases don't take their medications or make recommended lifestyle changes.1 In fact, prescription noncompliance accounts for 10% of all hospital admissions, with an average stay of four days, and numerous doctor visits and diagnostic tests.1,2 Even more sobering: An estimated 125,000 people die each year because they don't take their medications correctly.3

    As a nurse on a transplant unit for nine years, I've encountered many noncompliant patients. Awaiting a new kidney, pancreas, liver, or heart, many of these patients are too sick to do much of anything. In addition, many have a history of poor eating habits and lack of exercise that contributes to postop noncompliance.

    Despite receiving education from our nurses about controlling blood glucose, cholesterol, and blood pressure, maintaining a proper diet, and exercising regularly, they were often readmitted for problems that could have been prevented if they'd followed our directions. They typically admitted cheating on their diet, missing office appointments, and other noncompliant behaviors described in the box on page 00.

    We realized that scolding or labeling patients as recalcitrant wasn't the answer. Instead, we decided to assess patients for barriers to compliance soon after admission and find ways to address them, thus improving outcomes. We've found that our approach has left patients better prepared to manage their health at discharge.

    Whatever types of patients are under your care, you can use our approach. Here's a list of common barriers?in no particular order?and strategies you can use to help patients overcome them:

    1. Inadequate health literacy. Health literacy is the degree to which patients can understand basic health information needed to make appropriate health decisions.4 According to a U.S. Department of Education survey, 36% of Americans have Basic or Below Basic health literacy. This means they can't read and understand health information written above a basic level,4 and have trouble finding the hospital or physician's office, keeping appointments, completing hospital registration and insurance forms, and understanding discharge instructions and prescriptions.5 Their decreased comprehension can result in poor health, reduced access to medical care, and hospitalizations.5

    Strategy: We make sure our instructions are written at a sixth-grade reading level. By using short words, simple sentences, and clear illustrations, we verbally reinforce written instructions.5

    Suspect a literacy problem if your patient makes excuses when you attempt to review written material. He may say that he forgot his reading glasses or would rather read the material when he gets home. Confirm your suspicions by handing him written material upside down or asking him to read a prescription label.5 In these cases, ask a family member or friend to join you and take extra time to verbally review the material.

    2. Financial constraints. More than 14 million American adults with chronic conditions can't afford to fill their prescriptions.6 And this barrier isn't limited to patients who are indigent--in 2003, 40% of adults with chronic conditions who were working and privately insured had trouble paying for their meds.6 Although financial arrangements for transplant patients are usually worked out in advance, we've had patients whose insurance companies dropped them or who had policies that paid for only some of the many medications needed to prevent organ rejection.

    Strategy: We approach a patient with a potential financial problem tactfully and respectfully, asking such questions as "Are there circumstances that make it difficult to fill your prescriptions?" or "Are you testing blood glucose less often because you're trying to conserve supplies?" In addition, we call in a social worker or transplant coordinator, who talks to the physician about generic drugs or contacts pharmaceutical companies about programs that offer prescriptions at reduced prices. And we explain that our patients with diabetes can save money by using generic testing supplies.7

    If the patient is readmitted, we assess his financial status again. Additional financial burdens or a change in insurance might make it more difficult for him to pay for meds.7

    3. Cultural differences. At our hospital, we encounter many patients whose native language isn't English. While our instructions are basic in tone and direction, language barriers often still exist. Additionally, we've found that Hispanic male patients are very stoic, in general, and don't readily admit to feeling pain. And some patients from certain cultures, including Native American, don't understand the need for medical care until they feel sick.8 As a result, they may postpone care until they have a physical ailment that actually indicates long-term complications of chronic disease such as diabetes.9 Furthermore, some groups, including Hispanic and Native American women, often think that money for their healthcare would be better spent on their families.9,10

    Strategy: When language barriers exist, we ask nurses or social workers to act as go-betweens. To improve communication, our hospital is considering hiring professional interpreters. If you care for several patient populations that don't speak English, use discharge instructions written in multiple languages to ensure improved compliance.

    With our Hispanic male patients, we look for nonverbal cues that indicate pain, such as wincing, and try to make them more comfortable. For patients who are reluctant to spend money on healthcare, we emphasize that delayed treatment can adversely affect their families in the long run, resulting in increased costs, reduced function, and hospitalizations.10

    4. Religious beliefs. We also found that some patients aren't able to follow their prescribed diets due to religious practices. For example, Muslims required to fast during Ramadan may feel torn about taking their meds or eating and opt to refuse medication. We've also cared for patients who won't accept blood due to their beliefs as practicing Jehovah's Witnesses.

    Strategy: Whatever the scenario, we approach patients and their families respectfully. We emphasize the necessity of following diet and medications as prescribed.

    Whenever possible, we try to tailor our care to the patient's individual beliefs. For example, while caring for a Muslim patient who often refused medication, we learned that the left hand is considered unclean in the Muslim culture. So we used the right hand to give him medication, and he was more cooperative. And, since patients who are Jehovah's Witnesses accept non-blood replacement fluids, they can be treated with bloodless medicine.

    5. Family dynamics. In some cases, patients have had a family member whose quality of life didn't improve after a transplant, so they thought they, too, wouldn't be successful. For others, family members don't understand the extent of the patient's illness. In both cases, individuals may be reluctant to comply or may receive little familial support with postop instructions and lifestyle changes.

    Strategy: While acknowledging patients' fears, we stress the importance of following the prescribed postop regimen and explain that regardless of a family member's experience, many transplant patients are able to lead healthy lifestyles. We also sit down with family members and ask them to describe their loved one's illness. If necessary, we review and reinforce the seriousness of the patient's condition.

    6. Emotional concerns. The daily grind of dealing with a chronic condition?and a transplant?can leave patients feeling hopeless, which hinders their ability to retain instructions about caring for themselves. If your patient has recently been diagnosed with a serious disease, he may be too overwhelmed or distraught to fully understand how the illness will change his life.

    Strategy: At our hospital, transplant patients undergo a psychological evaluation before and after surgery. We also encourage patients to discuss their feelings with us and their loved ones. Even patients with a support system, however, may benefit from talking to others with the same condition. The box on page 00 describes how groups offer emotional comfort.

    7. Lack of motivation. Most transplant patients are so ill before surgery, they become accustomed to being sick, and their physical condition leaves them reluctant to exercise. They're not alone, though; few individuals have the motivation to exercise routinely.

    Strategy: When our patients complain that they're too tired or don't have time to exercise, we advise them to start slowly. For example, we may instruct them to walk for five minutes a day, eventually reaching a goal of one hour. We also encourage them to do activities they enjoy?such as yard work, dancing, swimming, biking, or, with their physician's approval, even something more strenuous like skating?and ask them to keep a written record of their physical activity. For patients with diabetes, we stress the importance of checking blood glucose before and after exercise, and logging the results.

    8. Inadequate teaching time. In some cases, we found that we contributed to patients' noncompliance by not spending enough time educating them.

    Strategy: We conduct two 15-minute teaching sessions in the morning, and return later in the day to review the material. Encouraging questions, we offer reassurance that we'll help them stabilize their disease before discharge.

    9. Poor communication. A lack of interdisciplinary collaboration left patients vulnerable to post-discharge complications. For instance, a patient may develop acute rejection if a nephrologist regulates anti-rejection medication without consulting the transplant team.

    We also realized that we were lecturing patients during educational sessions instead of engaging them in a discussion and we weren't providing some necessary tools to help them manage their disease.

    Strategy: To make sure patients get consistent care across the board, we now share information on medications and treatments with other disciplines and emphasize the importance of monitoring creatinine levels in transplant patients. We encourage other nurses to serve as liaisons and urge physicians in their departments to contact the transplant team with questions.

    Because patients who are involved in making treatment decisions are more likely to comply,2 we now talk to patients and not at them. We teach them to manage their health, focusing on adhering to their recommended medication, diet, and exercise regimens.

    To help patients with proper dosing, we explain that they can associate taking meds with a specific task, such as eating breakfast, or be prompted by reminder cards or a pre-set beep on a watch. Other memory aids include stickers on bottle caps that match the color of the medication, pill boxes with sections for each day of the week, or computerized caps that flash at dosing time and record the elapsed time since the bottle was opened.2 We also emphasize the importance of reporting side effects instead of stopping or adjusting the dose.

    Our transplant patients with diabetes must maintain tight control of their blood glucose, especially because they typically take insulin to counter the hyperglycemic effects of prednisone, which prevents transplant rejection. We review the importance of keeping blood glucose logs. If patients have been hospitalized before, we review the logs they've kept at home. By praising their efforts when they've been diligent, we motivate them to continue. If entries are sporadic, we ask if they ran out of strips, forgot to keep up their log, or didn't think it was necessary.

    We also emphasize the importance of tracking food and exercise, especially for patients with diabetes, so they can see how diet and exercise affect blood glucose. After surgery, transplant patients are finally free of many preop dietary restrictions and tend to overeat.

    To help them, we recommend the American Diabetes Association's Rate the Plate Web site (www.diabetes.org/ all-about-diabetes/chan_eng/i3/i3p4.htm ). This tool illustrates a balanced meal, consisting of a plate half filled with vegetables and the other half split evenly between protein and starch. It helps patients become familiar with food portions, and shows them how to make better choices.

    10. Logistics. A lack of transportation, family members' work schedules, and even the cost of gas can prevent people from keeping appointments after discharge. Some of our patients, for example, live eight hours from the hospital, which makes traveling to monthly follow-ups costly and time-consuming.

    Strategy. Before discharge, we make sure a family member or friend can drive patients to follow-up appointments. If they can't, we ask a social worker to look into other transportation possibilities.

    The End Result

    By recognizing the need for change and implementing these strategies, we have created an environment where our patients are better informed and more proactive about their care. In turn, they're more likely to comply with treatment, which makes them healthier in the long run.


    1. American Heart Association. "Statistics you need to know." 2006. www.americanheart.org/ presenter.jhtml?identifier=107 (8 Dec. 2006).

    2. The Merck Manuals: Online Medical Library. "Improving compliance." 2003. www.merck.com/mmhe/sec02/ch016/ch016e.html (7 Dec. 2006).

    3. Walker, T. (2001). Understanding patients' needs is key to medication compliance. Managed Healthcare Executive, 11(1), 34.

    4. National Center for Education Statistics. "The health literacy of America's adults. Results from the 2003 national assessment of adult literacy." 2006. http://nces.ed.gov/pubs2006/2006483_1.pdf (8 Dec. 2006).

    5. Andrus, M. R., & Roth, M. T. (2002). Health literacy: A review. Pharmacotherapy, 22(3), 282.

    6. Reed, M. C. "An update on Americans' access to prescription drugs." 2005. www.hschange.com/CONTENT/738/ (8 Dec. 2006).

    7. Pavlovich-Danis, S. J. "Differentiating between inability to afford prescription medications and 'noncompliance.'" 2004. www.geriatrictimes.com/g040611.html (8 Dec. 2006).

    8. O'Fallon, A. "Culture within a culture: U.S. immigrants confront a health system that many citizens can't manage." www.ama-assn.org/ama/pub/category/15228.html (8 Dec. 2006).

    9. Taylor, C., Keim, K. S., et al. (2004). Social and cultural barriers to diabetes prevention in Oklahoma American Indian women. www.cdc.gov/pcd/issues/2004/apr/03_0017.htm (8 Dec. 2006).

    10. American Diabetes Association. "Case study: Mrs. Gomez & gestational diabetes." .www.diabetes.org/ for-health-professionals-and-scientists/ gomez-case-study-4.jsp (11 Dec. 2006).

    Spotting the red flags of noncompliance

    Look for these behaviors that clue you into a patient's lack of compliance:

    • Frequently missing follow-up appointments.
    • Forgetting" to have lab work done.
    • Resisting the use of reminders to take medications.
    • Failing to follow lifestyle changes, including diet and smoking cessation.

    Clinical signs

    • Inability to achieve target goals of BP, weight, or cholesterol levels.
    • For patients with diabetes, incomplete logs of blood glucose levels, diet, and exercise?and persistent elevation in hemoglobin A1C levels.

    Source: Leichter, S. B. (2005). The business of diabetes. Making outpatient care of diabetes more efficient: Analyzing noncompliance. Clinical Diabetes, 23(4), 187.

    Strength in numbers

    You can help patients, especially those discouraged or overwhelmed by their diseases, decide if support groups are right for them. Explain that these groups often reduce anxiety, depression, and feelings of isolation. Members can teach coping skills, provide a safe place to share concerns, and offer information about community resources and treatment.

    Patients need to find a group that matches their needs and personalities. Those led by a professional facilitator, such as a nurse, are generally educational in nature, while member-led groups tend to focus on emotional support. Cyber-savvy patients, or those with a physical disability that makes attending groups in person difficult, may find help through online communities, including virtual bulletin boards, electronic mailing lists, and chat rooms.

    Direct patients to hospital-based groups or national organizations dedicated to their diseases. They can also search the Internet and check the local telephone directory. Chances are, they'll need to attend a few meetings to determine if the fit is a good one. Caution them to be wary of any group that charges high fees (most are free) or encourages them to stop medical treatment.

    Sources: 1. Mayo Foundation for Medical Education and Research. "Support groups: Find information, encouragement and camaraderie." 2005. www.mayoclinic.com/health/support-groups/MH00002 (12 Dec. 2006). 2. Lindemalm, C., Strang, P., & Lekander, M. (2005). Support group for cancer patients. Does it improve their physical and psychological wellbeing? A pilot study. Support Care Cancer, 13(8), 652.