Today in the chart

See the Emotional Image Challenging Perceptions of Patient ‘Noncompliance’

It may even convince you to stop using the word “noncompliance” altogether.

You’ve seen this movie: A patient with a chronic health condition needs to make substantial lifestyle changes, but the individual just can’t stick with them. You offer advice and your emotional investment — but nothing.

In fact, noncompliance can be so frustrating for providers that they often forget to ask why a patient is struggling. That’s the powerful message behind a meme that went viral on LinkedIn last week.

Going Beneath the Surface

The image, shared by Maureen Dempsey, RN, BSN, shows an iceberg with about one-third of its mass above the ocean’s surface. Dempsey, a case manager from Baton Rouge, Louisiana, labeled the top portion “noncompliant patient.” Underneath the water, she wrote common reasons patients don’t follow recommendations, such as “doesn’t own a vehicle,” “doesn’t know how she’s going to pay rent,” and “doesn’t get paid time off to attend doctor’s appointments.”

Dempsey said that a recent experience at work inspired her to create the meme. It began with fellow nurses saying that a patient who didn’t take her medication as directed “had a bad attitude. When I went in to talk to the patient, I just asked a couple of open-ended questions. She poured out her life story,” Dempsey recalls.

“She wasn’t even a hard case! She just needed someone to stop talking at her and start listening to her,” Dempsey continues. The patient went on to tell another social worker that she felt everyone on the unit was against her. Dempsey notes that it was a valid perception, adding, “I see fellow clinicians misinterpret noncompliance every day.”

‘Noncompliant’ or Just Needing Help?

Through the image’s 127 comments, a rousing conversation emerged on the social determinants of health, costs of care, and insurance.

“We say that healthcare is available for everyone in this country, but how many of us would show up at 7:30 AM, take a number and then wait (sometimes hours) for a 15-minute OB appointment?” wrote one nurse educator. “Until we address all the issues that are barriers to health, we will continue to be a rich country that is sadly unable to promote health for all citizens.”

Added a patient advocate: “Nobody says ‘I’m not going to be compliant,’ but lots of people say ‘I’m not going to/can’t follow/accept that treatment,’ and there are so many of the latter who could and would follow the treatment if they had support. I see clients daily who sabotage their own healthcare for lack of that support which takes so many varied forms. Providers often see the noncompliance outcome and have no way of understanding the dynamics.”

Recalled another nurse: “So many times in my early nursing career, I just didn’t understand how anyone would not take care of their health or their child. So many patients labeled as noncompliant who just needed a helping hand.”

Tips for Providers Battling Patient ‘Noncompliance’

The reception to the meme on LinkedIn was overwhelmingly positive, but clinicians still misinterpret noncompliance daily, Dempsey says.

“I think it happens when clinicians … we can’t imagine what it would be like to not have a safe home, not to have a vehicle, to be insecure about food,” she explains. “Some clinicians seem to believe that poverty results from a person’s bad choices.”

As an expert in helping patients adhere to treatment plans, Dempsey offers some advice for nurses and advanced practice providers dealing with this challenge:

“Ask open-ended questions. Be respectful. Try treating every patient like a VIP,” she asserts. “I frequently tell my patients who live in poverty that I am here to serve them. It is every person’s choice whether or not they accept our treatment plan — honor that freedom of choice. And listen more than you talk.”

Another recommendation? Ditch the word “noncompliance” altogether.

“What we call noncompliance is really misunderstanding. We have providers prescribing meds and care plans for patients without a full understanding of the situation, so we frequently end up with plans that aren’t feasible,” Dempsey explains. “The more we treat this issue like it is a patient problem instead of a provider problem, the less our patients trust us.”

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