Effect of interpersonal skills on adherence

Few interventions to increase adherence have been demonstrated through rigorous research to be consistently effective. Because human behavior is complex, there is no single or simple explanation for non-adherent behavior.However, there is growing consensus among researchers that the behavior of the health care provider has a significant influence on patient adherence. Specifically, the health care professional’s ability to communicate and explain information while expressing warmth and concern for the patient appears to be associated with increasing patient adherence.

Patient teaching in nursing is not simply repeating directions to patients or handing out printed materials. It is a process in which the nurse gathers data, individualizes instruction, provides support, and evaluates and follows up with the patient’s success in taking responsibility for self-care. Studies show that a person-oriented approach is more helpful than handing out brochures or having patients view videos. One study showed that when asked what aspect of interactions had the most influence in increasing their adherence, most patients said that it was having someone take the time to talk to them, answer their questions, and consider their concerns.

Sometimes when nurses view patient education as a relational process rather than a single intervention or program, they worry about finding the time to carry out such a process. However, many nurses find patient teaching that is incorporated as an organized part of each patient encounter actually saves time and greatly improves adherence. Teaching while doing is much more effective than doing a procedure and then planning to come back at some future time and „do patient teaching.“ The way in which health care information is presented also has a major impact on the patient’s ability and willingness to follow treatment recommendations. For example, saying to a patient, „If you quit smoking, you will live to be 100“ is not useful. This statement is probably not true and it doesn’t connect the need to stop smoking with anything important to the patient. On the other hand, if the nurse has established a personal relationship with the patient, understanding his or her goals and lifestyle, she might say instead: „I know how important it is for you to see your grandchildren grow up. There is a lot of evidence that smoking will cause several diseases that will shorten your life. Stopping smoking is one of the best health decisions you can make for yourself in your entire life. I’d like to help you do that. How can we work together on this?“

Nurses and other health care professionals can help improve adherence by evaluating what happens during follow-up visits. Does the content and process of the visit help or hinder the patient’s ability to follow his or her treatment plan? It is possible that the feeling of being well treated and given more responsibility and encouraged to take an active part in treatment may contribute to adherence. Increased attention should also be given to helping patients make lifestyle changes. Knowledge of a healthy lifestyle is necessary for good compliance, but it does not automatically lead to this outcome. Nurses should become familiar with each patient’s life and consider together with the patient how it would be feasible for the patient to change his or her lifestyle. Table 19 outlines guidelines for good provider-patient communication.

A study of adolescents with diabetes provides an excellent model for learning about the impact of interpersonal relationships and patient adherence. The study looked at the relationship between the attitudes of physicians, nurses, parents, and peers and the ability of young diabetics to follow their treatment regimens. In the study, the actions of physicians were described as motivating, authoritarian, routine, or negligent. Patients described physicians as having a motivating style when they discussed treatment and self-care together. The most effective motivators demonstrated interest in how the young diabetics managed to fit diabetic self-care into their life. One patient, describing a motivating encounter, reported: “ The physician asks me if I have managed to care for myself at home and tries to help me organize my care so that it doesn’t disturb my life. They always ask me what I think about a decision, and do I agree with it. Could I carry out this kind of self-care? Usually we decide together what we will do and how we will do it.“ In contrast, authoritarian physicians directed the patient’s care. Although they asked questions, the patients perceived that the physicians ignored the answers. The physicians pointed to mistakes the young diabetics made and told them what to do to avoid mistakes in the future. Here is a statement by a patient describing an encounter with an authoritarian physician: „The physician talks like a boss, telling me how I should care for myself. They are not interested in how I have managed to care for myself. In fact the physician orders my care. They think they know what’s best for me.“ Physicians who acted in the same way time after time were described as routine. Patients believe such physicians worked according to a predetermined model and the same model of action was followed for every patient, regardless of his or her needs. One patient said: „The physicians always nag me in the same way and about the same matters. They always act in the same way. They have only one model, and their actions are based on it. They don’t see me as an individual. It’s the same whatever I do or say. I should tape what happens when I meet the physician and listen to the tape at home so I don’t need to come to meet the physician and hear the same sentences every time.“

The physicians that the patients described as negligent did not appear interested. They paid attention to the medical record rather than to the patient, did not ask questions, and did not display any curiosity or interest about the life of adolescents and their problems. A young patient described an encounter with a negligent physician: „They don’t look at me. They hold discussions about me with my records-I could leave the consulting room and they would not realize that I was gone … It’s really useless and a waste of my time. I don’t get anything for myself.“ Physicians who used a motivating style had a much greater positive impact on patient compliance than those who were seen as authoritarian, routine, or negligent. Table 20 shows the characteristics that young patients in this study said motivated them to follow treatment recommendations.

Nurses‘ actions were described as motivating, routine, or acting on physician’s instructions. Nurses who were motivators discussed issues with patients and used the discussion as a starting point for planning care. Patients also felt that motivating nurses listened to their opinions. The nurses who patients described as routine had an interpersonal style very similar to routine physicians-they asked questions but seemed to ignore the answers. A patient describing an encounter with a routine nurse said: „It’s the same whoever is the patient. Their action is always the same. Everything happens according to their own plans and the hospital’s needs. The most important thing is that the hospital’s timetable works well and everything that is important for the hospital’s routine happens. If they change something and move away from routine, perhaps it would lead to enormous chaos.“ Nurses who were perceived as acting on physician instructions ignored the patients and their opinions and saw their role as reminding the patient to follow physician directions. A patient talking about a nurse he perceived to be acting as an agent of the physician stated: „This is of no help to me, because the nurses do exactly what the physicians say. It is really difficult to discuss anything with them because they do not have any opinions of their own about my self-care and other matters concerning diabetes.“ Adherence was highest among patients who worked with nurses with a motivating style.

Parents were described as motivating, accepting, or disciplinarian. Motivating parental actions included giving support and expressing interest in the young person’s life in general. Such parents helped young diabetics to take care of themselves by helping them solve problems associated with self-care in everyday life. Motivating parents provided positive feedback and sometimes a reward if their child had coped with self-care particularly well. One patient, who described his parents as motivating, said: „My mother and father help me to care for myself-they give me positive feedback when I have managed my self-care. Sometimes when I have cared for myself well, they give me rewards or money or something like that. I feel it supports me-then I have energy and will power to care myself. But it’s no good if my parents take part in my care too much. I have to have freedom too.“

Parents who patients described as accepting did not try to influence their children. Although they expressed interest and concern, the parents accepted that the young people would not necessarily care for themselves and did not try to force them to comply with self-care. Parents who were described as disciplinarians tried to require the young diabetics to take better care of themselves. These parents consistently tried to take part in care. They reminded the patients often about the need for self-care and demanded that they carry out blood glucose levels frequently. Patients whose parents had a motivating style had the best compliance, followed by accepting parents. Adherence was lowest among adolescent patients whose parents were disciplinarians.

Friends have a tremendous influence during adolescence. In this study, actions of friends were classified as dominant, providing silent support, or irrelevant. When friends dominated the lives of young diabetics, the patient adopted their friends‘ lifestyle. Most often, diabetic self-care did not fit in with this lifestyle. In addition, dominating friends often tempted the patients to break from their desired health routines. Friends who provided silent support reminded the patients about the need for diabetic self-care and changed some of their own habits to support the patient’s lifestyle. For example, supportive friends did not buy sweets containing sugar when they were with young diabetics or tempt them to break their health regimens. The patients who saw their friends as irrelevant in relation to their diabetic self-care saw their responsibility for care as a natural part of their lives. They did not allow their friends‘ lifestyles to influence their behaviors. The highest adherence was among adolescents who felt their friends were irrelevant or peripheral to their care, followed by adolescents who felt their friends provided silent support. Those who allowed their friends to dominate their actions had the lowest compliance. Results indicate that the nature of the relationship with physicians, nurses, parents and friends, influences adherence to diabetes self-care.

The implications of this study for nurses are enormous. It is clear that adherence increases when the patient and health care staff negotiate, set, and agree on goals together. It is also important that patients feel their thoughts are important and their opinions valued. Nurses and other health care professionals must ensure that interactions with patients are not dominated by disease monitoring activities such as blood tests or paperwork. Although blood tests and paperwork are important, it is extremely helpful for the nurse to sit down and devote a few minutes to discover what the patient is concerned about and what difficulties the patient is having with personal self-care management, followed by a discussion about how to integrate self-care into his or her unique situation.

Although considerable time and effort have been spent studying patient adherence and variables that affect it, there is still little definitive information that enables nurses to ensure patient adherence. Major questions remain unanswered and warrant further research.6 Recent research, however, points to the relationship between the patient and the health care professional as extremely important in achieving adherence. By improving communication with patients, and by viewing them as partners in health care management rather than as passive recipients of information, better health care outcomes may be realized.

Table 19

Guidelines for Good Provider-Patient Communication

  • Staff respond to patients and take enough time to meet with them.
  • Staff maintain eye contact, speak to the patient with respect, limit use of jargon, and speak in terms the patient can understand.
  • Staff take time to listen to patient symptoms and concerns.
  • Staff create an atmosphere that provides a level of comfort for patients to voice their questions about medical conditions and procedures and express their fears about the unknown.
  • Staff demonstrate a nonjudgmental attitude toward patients who are different from themselves. An attitude of acceptance allows patients to honestly discuss sensitive issues such as sexual orientation and behavior, drug and alcohol behavior, and illegal activities or behaviors that differ from community norms.
  • Staff respect concerns of all patients regardless of race or age and take all symptoms seriously instead of assigning labels to patients.
  • Staff explain why tests are needed, when the results will be available, and how to get the results.
  • Staff build partnerships that involve each patient in his or her health care, address barriers to behavioral change, and work with patients to identify alternative solutions.
  • Staff are available for follow-up questions and return telephone calls promptly.
SOURCE: Adapted from: Bateman, W.B., Kramer, E.J., & Glassman, K.S. (1999). Patient and Family Education in Managed Care and Beyond. New York: Springer Publishing Co., 22.

 Table 20

Characteristics of Nurses, Physicians

Described as ‚Motivating‘

  • Discussed treatment and self-care with patients
  • Worked with patients to come up with treatment plan
  • Demonstrated interest in how patients fit self-care needs into daily life
  • Helped patients problem solve
  • Discussed issues with patients and used the results to plan care
  • Listened to patients‘ opinions
SOURCE: Adapted from Kyngas, H., Hentinen, M., & Barlow, J.H. (1998). „Adolescent’s perceptions of physicians‘, nurses‘, parents‘ and friends‘ help or hindrance in compliance with diabetes self-care.“ Journal of Advanced Nursing, 27(4), 760-769.

Interventions that can increase adherence