Introduction

Dealing with patients who 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 great financial costs, diminished quality of life, and suboptimal clinical outcomes. This is part 2 of a 2-part series on noncompliance in wound care patients. Part 1 addressed possible reasons for noncompliance. In part 2, strategies to address these issues and increase patient participation are discussed.

Part 1 of this blog discussed factors that impact a patient’s ability to adhere to clinician recommendations for care. Consequently, the most appropriate term to use when dealing with patients facing these obstacles is nonadherence. This term tends to be less value laden and more objective than noncompliance. Some of the reasons for nonadherence are voluntary and some are involuntary, or beyond the patient’s control. To review briefly, these reasons may include gaps in knowledge about the implications or severity of a chronic wound, limited recommendations or education by clinicians, perceived disadvantages to treatment, psychological factors, cultural factors, and social or financial constraints.

Additionally, in some cases, alcohol or drug dependence can impact the patient’s ability to participate fully in their care. So how does a clinician overcome these potential challenges? This is not an easy topic, as many readers will agree. There is a paucity of information in the available literature that is specific to dealing with wound care patients.

Differential Diagnosis: Important Questions

One helpful suggestion is to come up with a “differential diagnosis” for the nonadherence. Is the issue the result of a lack of knowledge, a lack of perceived benefits of treatment, or cultural, psychosocial, or other factors? Drilling down to identify the reason(s) can help guide the clinician to develop a successful approach.

Nonadherence within a wound care program can be frustrating and exhausting for the wound care clinician. It can provide a tremendous challenge and requires the clinician to figure out why a patient is not adhering to a carefully thought-out plan. Rather than giving up on these patients, take a step back and reflect. And don’t be afraid to ask yourself, are you missing something?^1,2 The following sections provide some tips for clinicians to use in dealing with these patients.

Patient-Focused Care

It is important to shift health care delivery to focus more directly on the diverse needs of each patient. This approach to patient-centered care increases the patient’s willingness to share ideas with the provider and opens opportunities to collect important patient-specific information. Providers can use this patient-specific information to guide the unique challenges to that particular patient’s wound care process.

This requires an empathetic approach in which clinicians put themselves in the patient’s shoes, thus recognizing the challenges that the patient may be dealing with and understanding what is being asked of the patient. Expanding clinician participation in care can make the patient feel that the challenges are shared with the clinician as part of a team approach and shared decision making. Recognizing not only the severity of the chronic wound but also the physical, social, and psychological factors affecting that patient is critical.^3,4

Patient Education

Clinicians should provide education on lifestyle modifications, diet and nutrition, medication use, the effect of comorbidities on healing, and the importance of adherence to the plan of care either at home or in the facility, if applicable. It may be necessary to review and reinforce education at each visit.

• Ask the patient to describe how they understand their medical disorder in their own words. What do they understand about the wound and what caused it?
• Ask whether the patient understands the purpose of treatment and the consequences of ineffective treatment. For example, not wearing compression consistently or changing a dressing as ordered can significantly thwart the wound healing process. This is intuitive to us as clinicians but may not be as obvious to the patient.
• Have the patient explain the specific treatment recommendations agreed on in detail. Do they understand what a negative pressure dressing involves? Are they willing to wear a total noncontact cast for a certain length of time or commit to offloading?
• Use open-ended questions. Ask whether the patient feels confident in following the treatment recommendations and whether the patient sees any problems. Ask whether the patient feels they can commit to the plan of care, including any restrictions required. Do they understand that there is usually a period of weeks or even months for some treatments to be successful?
• Work together to find solutions to any problems with compliance that are identified. Again, is there a lack of knowledge or understanding, or is there a psychosocial issue at stake? Are there financial or social constraints? Are there any cultural issues to consider? In this case, a team or interdisciplinary approach can be helpful in identifying potential solutions or resources for a potential challenge.^3-5

Document Everything

Although documentation is a critical part of patient care, it’s particularly important to maintain meticulous records when dealing with noncompliant patients. Documenting all patient discussions, all diagnosis and treatment plans, and any questions or concerns the patient or the family may have will serve as a verified record to reference in the event of noncompliance. This documentation serves 2 purposes. First, it provides a record of what strategies or treatments have been attempted and their outcome. Second, it helps protect the clinician from a risk management perspective. Although most cases will never result in litigation, it is always essential to document defensively. This serves as a record of care long after the patient interactions are completed.^4,5

Set Boundaries and Enforce Them

Sometimes a patient exhibits noncompliant behavior because of potential control issues or psychological issues. It can be easy sometimes to have a patient get under one’s skin. Don’t let personality characteristics such as passive-aggressive or defensive behaviors become a source of frustration or irritation. Imposing basic limits and enforcing them in earnest will help the patient consider the very real consequences of their noncompliance. Always be prepared to follow through with limits that are set; this is in the best interests of both the clinician and the patient.

It is also important to avoid ultimatums. Don’t threaten a nonadherent patient with empty ultimatums, but rather, be objective when explaining their options to them, and try to focus on the positive outcomes of being compliant. Actively avoid a power struggle, Explain the potential scenarios and consequences, but always give the patient their rightful choice. In some cases, it may be necessary to discharge a patient from care and have them find an alternative wound clinician.^4-6

Case Study Analysis: Joan

Joan is a 78-year-old woman with a history of diabetes, chronic obstructive pulmonary disease, hypertension, and obesity. She was seen initially in the wound clinic after an extended hospitalization and a stay in a rehabilitation facility for COVID-19 pneumonia and severe debility. Before her illness, she lived with her spouse in a small home in the community. She was discharged home with home health care and was referred to the wound clinic for a pressure injury on the left buttock, an injury she acquired as an inpatient. She was seen in the wound clinic and diagnosed with an unstageable pressure injury of the left ischial area.

She had a Foley catheter in place. A plan of care was discussed, to include daily application of a wound dressing, home health care to assist with dressing changes, and some physical therapy at home. Orders were also written for a hospital bed with a pressure redistribution surface, a wheelchair, and a wheelchair cushion. She was also given samples of a nutritional supplement and a coupon to purchase more as needed. Joan and her husband were in total agreement with the plan of care. Joan returned to the clinic 14 days later after rescheduling her appointment, and her wound was significantly worse. There were no signs of infection, but after careful discussion, offloading appeared to be a significant problem for her. She stated she could not sleep in the bed and was using a recliner. She stated that the wheelchair and cushion were too uncomfortable, and she was instead using a rollator with a seat for locomotion. She stated that physical therapy was not helping, and she was becoming more debilitated. She was not taking any supplements. She stated that none of the dressings were staying in place and that her buttocks were constantly sore and painful. It was suggested that a different dressing could be used that could adhere better. She stated that nothing was working, and she was clearly frustrated. The home health agency was contacted for new wound care orders and a specific request for physical therapy to work with transfer training in and out of the hospital bed. The company supplying the wheelchair was contacted to see about modifications to the chair to make it more comfortable. Joan returned to the clinic 1 week later without any improvement in her wound. She seemed very distraught and frustrated.

A social work consultation was requested, and a home visit was made. After discussion with the social worker, it was learned that before her hospitalization, Joan was responsible for all of the housework, cooking, and cleaning in the home. After discussion with Joan, it became apparent that having a chronic wound and debility prevented her from bearing the household responsibilities. For Joan, there was a secondary gain by being “ill.” It took some trial and error to come to the differential diagnosis for her noncompliance, but once this was identified, she could be referred for appropriate counseling for herself and her spouse. Ultimately, her spouse began to assume more responsibility in the household, and within 2 months, Joan’s pressure injury was almost completely resolved.

In Joan’s case, it was critical to engage the patient and try to empathize with her situation. She was clearly tired and overwhelmed with the issues related to her hospitalization and pressure injury, and the idea of assuming her normal responsibilities was also overwhelming. Educating her and her spouse about the nature of her wound and caring for it were well received in clinic but not acted on in the home. This discrepancy created a barrier to her care. The care provided to Joan, as well as notation of her nonadherence, was thoroughly documented. Even though Joan was nonadherent to her plan of care, the wound team did not consider discharging her but rather continued efforts to work with her. Once the underlying factors were identified that impacted her care, it became possible to help her work through them. Ultimately, this care was successful.^7-10

Conclusion

Managing a patient with a complex or chronic wound is a challenge in itself and can be made more complicated when there are issues of noncompliance or nonadherence at stake. A comprehensive, patient-centered approach to care is vital. In this way, one can take into account the multiple factors that can adversely affect outcomes and address them with the patient. This shared decision-making approach is essential for successful treatment of the wound care patient. Educating the patient, setting boundaries when appropriate, and documenting thoroughly are critical elements.

References

1. Cahill R. Nonadherent and noncompliant patients: overcoming barriers. The Doctors Company. 2020. Accessed June 20, 2022. https://www.thedoctors.com/articles/nonadherent-and-noncompliant-patien…
2. Hurlow J, Hensley L. Achieving patient adherence in the wound clinic. Todays Wound Clinic. 2015. Accessed June 20, 2022. https://www.hmpgloballearningnetwork.com/site/twc/articles/achieving-pa…
3. 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
4. Kleinsinger F. Understanding noncompliant behavior: definitions and causes. Perm J. 2003;7(4):18.
5. Invisalert. Tips on how to treat non-compliant patients. ObservSMART. 2022. Accessed June 20, 2022. https://www.observsmart.com/tips-on-how-to-treat-non-compliant-patients…
6. Managing the noncompliant person. Crisis Prevention Institute. 2021. Accessed June 20, 2022. https://www.crisisprevention.com/Blog/Managing-the-Noncompliant-Person
7. 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
8. 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
9. Malik M, Kumari S, Manalai P. Treatment nonadherence: an epidemic hidden in plain sight. Psychiatric Times. 2020;37(3). Accessed January 14, 2022. https://www.psychiatrictimes.com/view/treatment-nonadherence-epidemic-h…
10. Sinkfield-Morey T. How using the term “non-compliant” keeps providers from partnering with patients. Creat Nurs. 2018;24(3):178-185. Accessed June 20, 2022. https://connect.springerpub.com/content/sgrcn/24/3/178.full.pdf

Suggested Reading

1. 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
2. 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
3. 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
4. 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

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.