Introduction

Dealing with patients who either can’t or won’t participate in their care can be a challenge for health care providers across all settings. In wound care, this lack of participation can result in greater financial costs, diminished quality of life, and suboptimal clinical outcomes. This is part one of a two-part series on noncompliance in wound care patients. Part one addresses possible reasons for noncompliance. In part two, strategies to address these issues and increase patient participation are discussed.

Why Are Patients Noncompliant?

Nonadherence to or noncompliance with care places a large burden on the nation’s economy. In the United States, nonadherence is responsible for an estimated 125,000 deaths and between $100 billion and $300 billion in medical costs annually. Noncompliance with treatment has been an issue health care providers have faced for many years, and it has both economic and morbidity or mortality implications. In wound care, this means poor wound healing outcomes, impaired quality of life issues, and frustration for both patients and clinicians. This issue is indeed a major cause of treatment failure. The Oxford Lexico dictionary defines noncompliance as “the failure to act in accordance with a wish or command.”²

This connotes an intentional refusal by the patient to comply with recommendations or instructions for care. More recently, the term nonadherence has been used to describe patients who do not comply for unintentional reasons. The World Health Organization defines adherence as the extent to which a person’s behavior (i.e., taking a medication, following a diet or activity restriction, making lifestyle changes) corresponds to the agreed recommendations of a health care provider.³ If we examine the concept of patient adherence or noncompliance, we need to consider that this is not a binary term and that there may be degrees to which a patient follows or does not follow health care provider recommendations. We also need to consider the idea of voluntary and involuntary nonadherence.

Voluntary nonadherence refers to an intentional effort to go against or not adhere to medical advice. Nonintentional or involuntary nonadherence refers to unwillingly going against the advice of health care professionals. The descriptions and labels placed by health care providers on a patient can significantly impact the quality and availability of the care they receive. It is important, whenever possible, to distinguish between patients who are unable to comply and patients who are unwilling to do so.⁴ So what are the issues surrounding “nonadherence,” and why is this a problem in wound care? Some of these issues include knowledge gaps, limited interactions with or recommendations from health care providers, perceived disadvantages, and social or psychological factors. ^5,6,7

Gaps in Knowledge

In some cases, patients may not understand the severity or implications of having a chronic wound. A small ulcer on the toe of a person with diabetes may not seem serious to a patient who might feel that a few days of over-the-counter antibiotic ointment will do the trick. The patient may not appreciate the fact that such a wound can become difficult to heal or infected or potentially could pose a threat to limb or life. In other cases, a patient may not understand the purpose or outcomes of a particular treatment or therapy and may be reticent to use it.

If a treatment or modality is not perceived as effective, a patient is likely to discontinue it. This can be a challenge in treating patients with chronic lower extremity wounds who might be frustrated with the slow healing progress of such a wound. If there are unrealistic expectations about clinical outcomes, a patient may become frustrated and seek other care or simply stop treatment. Some patients are likely to seek information about their condition or wound on the Internet.

Although there are some excellent patient resources available on the Internet, there are also many sites that offer inaccurate, inadequate, or incorrect information. This issue can potentially lead patients to self-treat or delay care. Furthermore, when a patient seeks professional care, if this online information does not accord with health care providers’ recommendations, this can also lead to issues with compliance. ^5,6,7,8

Limited Recommendations or Education

Patients who do not understand a particular treatment or how to use a specific device or dressing are less likely to be successful with treatment or with device or dressing use. In this case, if there is a lack of engagement with the patient or a lack of appropriate education or instruction, the patient is less likely to be compliant with treatment.

The patient who goes home with a negative pressure wound therapy device may become very frustrated when it alarms and they do not know how to troubleshoot the device. Similarly, the patient who does not know how to apply a topical product appropriately to a wound bed may be discouraged by issues with dressing function, leakage, or wound complications caused by inappropriate use of the dressing. This, in turn, leads to disappointment and potentially a lack of faith in the clinician’s recommendation and treatment. Patients who may not understand the rationale behind pressure injury preventive measures may not consistently apply these principles. This noncompliance can lead to the development or worsening of a pressure injury. ^6,7,8

Disadvantages of Treatment

Many of the recommendations made in wound care to patients often involve activities that can be perceived as too difficult, uncomfortable, or even inconvenient. For example, donning compression stockings for a patient with limited range of motion or arthritis can be daunting. Similarly, having to routinely change a complex dressing or pack a deep surgical wound may prove overwhelming for a patient or family member. Use of an offloading device such as a controlled ankle movement (CAM) walker or specialty shoe may be uncomfortable and affect gait, thus potentially exacerbating a chronic pain issue. Compliance over a long period can become a true challenge for wound care patients. As result, over time the patient may become discouraged, tired, or frustrated. ^5,6,7,8

Psychological Factors

Psychological factors that impact patient compliance in wound care can be attributed to the stigma or implications of treatment. Compression “stockings” may be perceived by some patients as a garment that only women wear, and these patients may refuse such a treatment option. The stigma of a total contact cast or a bulky or strange dressing may make some patients self-conscious and therefore less likely to participate in their care. In some cases, psychiatric issues can play a role as well. Patients with factitious disorders have been known to sabotage their wounds. This may be apparent when a patient’s wound has been making progress only to start regressing without an obvious clinical reason. Although rare, this is a factor to consider.

The benefits of the sick role and the attention that a patient receives may provide a strong motivation for this patient. Behaviors seen in factitious disorders may include the following: a dramatic but inconsistent medical history; unclear symptoms that are not controllable and become more severe or change once treatment has begun; unpredictable relapses following improvement in the condition; the presence of multiple surgical scars; the appearance of new or additional symptoms following negative test results; a history of seeking treatment at numerous hospitals, clinics, and doctors’ offices, possibly even in different cities; and reluctance by the patient to allow doctors to meet with or talk to family, friends, or previous doctors. Also of note, a wound that suddenly deteriorates without a logical clinical explanation may be a clue to a factitious disorder. ^5,6,7

Social Factors

Some wound management options may involve treatments or products that are not covered by insurance or that may require an out-of-pocket cost. If the cost of a product, medication, or piece of equipment is too great, the patient is likely to decline use. Social issues can also be a barrier to proper care. For example, patients of a lower socioeconomic status are less likely to own a car and are more likely to have inadequate means of transportation, to lack schedule flexibility for appointments or to have restrictions resulting from family responsibilities (child or elder care).

When a patient is labeled noncompliant or nonadherent, this designation can become an insidious roadblock to providing appropriate care. This label also brings an unhealthy stigma that can be unfairly attributed to the patient. This gives the impression that a patient may be intentionally acting against medical advice. A patient with these labels may be perceived as a “lost cause,” “not worth the time,” or a “waste of resources.” Getting to the reasons behind a patient’s not following recommendations for care is imperative so that strategies can be developed to address these issues. ^6,7

Examples of Patient’s Perceptions Related to Nonadherence

Conclusion

There are a number of potential factors that can lead to a patient being unable and, in some cases, unwilling to follow a recommended plan of care. As a health care provider, it is imperative to understand these factors so that potential strategies and solutions can be developed to meet the specific care needs of each patient.

References

1. Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open. 2018;8(1):e016982. doi:10.1136/bmjopen-2017-016982
2. Non-compliant. Lexico Dictionaries | English. Accessed January 21, 2022. https://www.lexico.com/definition/non-compliant
3. Sabate E. Sabate E.WHO Adherence Meeting Report. Geneva,World Health Organization, 2001.; 2001.
4. Pferdehirt R. Voluntary and involuntary nonadherence: Terminology for labeling patient participation. J Healthc Ethics Adm. 2021;7(3):1-7. doi:10.22461/jhea.1.71629
5. Malik M, Kumari S, Manalai P. Treatment nonadherence: An epidemic hidden in plain sight. Psychiatric Times. Published March 27, 2020. Accessed January 14, 2022. https://www.psychiatrictimes.com/view/treatment-nonadherence-epidemic-h…
6. Dawson AJ, Akaberi A, Galanaud JP, Morrison DR, Kahn SR, SOX Trial investigators. Patient-reported reasons for and predictors of noncompliance with compression stockings in a randomized trial of stockings to prevent postthrombotic syndrome. Res Pract Thromb Haemost. 2020;4(2):269-277. doi:10.1002/rth2.12296
7. Gong JM, Du JS, Han DM, Wang XY, Qi SL. Reasons for patient non-compliance with compression stockings as a treatment for varicose veins in the lower limbs: A qualitative study. PLoS One. 2020;15(4):e0231218. doi:10.1371/journal.pone.0231218
8. invisalert. Tips on how to treat non-compliant patients. InvisALERT. Published July 21, 2020. Accessed December 27, 2021. https://www.observsmart.com/tips-on-how-to-treat-non-compliant-patients/
9. Moffatt C, Murray S, Keeley V, Aubeeluck A. Non-adherence to treatment of chronic wounds: patient versus professional perspectives. Int Wound J. 2017;14(6):1305-1312. doi:10.1111/iwj.12804
10. Working with non-compliant clients: A stages of change approach for engaging clients in treatment – journal of global engagement and transformation. Everypiecematters.com. Accessed December 27, 2021. https://everypiecematters.com/jget/volume01-issue02/working-with-non-co…
11. Palmer WJ. 10 Reasons why patients are not compliant. Dermatology Times. Published July 28, 2018. Accessed December 27, 2021. https://www.dermatologytimes.com/view/10-reasons-why-patients-are-not-c…
12. Ledger L, Worsley P, Hope J, Schoonhoven L. Patient involvement in pressure ulcer prevention and adherence to prevention strategies: An integrative review. Int J Nurs Stud. 2020;101(103449):103449. doi:10.1016/j.ijnurstu.2019.103449
13. Someshwara Rao PN, Vincent AV. A study on non-healing plantar diabetic foot ulcers to assess the effect of compliance of using customised footwear in wound healing. Int Surg J. 2020;7(6):1938. doi:10.18203/2349-2902.isj20202409
14. Hubli M, Zemp R, Albisser U, et al. Feedback improves compliance of pressure relief activities in wheelchair users with spinal cord injury. Spinal Cord. 2021;59(2):175-184. doi:10.1038/s41393-020-0522-7

About the Author

Dr. Dianne Rudolph, DNP, APRN, GNP-BC, CWOCN is a nurse practitioner board-certified in Gerontological advanced practice nursing and as a wound, ostomy and continence nurse. She has been a nurse for more than 30 years with experience in trauma care, acute care, home care, hospice, long term care, rehab and wound care. She is very passionate about caring for adults and older adults with complex medical and wound needs. She has been a faculty member for several schools of nursing and is currently adjunct faculty at the University of Texas Health Science Center in Houston. She has presented multiple lectures and has published articles and book chapters on a variety of topics. She is currently working for South Texas Wound Associates, a practice which provides complex wound care for patients in the clinic, acute care and long term care settings.