Unanticipated Roles In The Drama Of Patient Compliance
Geena describes “encouraging my post-op patient to cough and deep breathe all shift” and her frustration and disappointment when, at the end of the shift, it is apparent that, despite her provision of pain medication, proper instruction, and empathic persuasion, the treatment goal was not reached.
The post’s title, It’s what you signed up for, is derived from the point made by another nurse during a discussion about this all too common situation:
The appropriateness and effectiveness of various tactics (e.g., good cop/bad cop) are also considered. It was another standard strategy, however, dissolved the reluctance of Geena’s exemplar patient to participate fully in treatment:
In oversimplified terms, patient noncompliance, even if transient, brings the nurse’s (or any healthcare professional’s) philosophical commitment to patient autonomy into conflict with the importance of successfully executing the treatment plan.
The clinician’s role is also, however, influenced by multiple other factors, including but not limited to the following:
- Practical matters, such as limited time, staff, and other resources
- Professional and regulatory requirements
- Personal and professional expectations
- Local and cultural mores
- Environmental modes (nursing is typically expected to intervene more directly and forcefully, for example, in the case of a noncompliant ICU inpatient than with an resistant outpatient)
- The severity of the patient’s disorder
- The patient’s age, personality, attitude, and intelligence
My modification of the title of Geena’s post from It’s what you signed up for to Who Signs Up For What in the title of this post has two referents:
1. I understand the use of It’s what you signed up for as shorthand for “the patient has the final responsibility for following or not following the treatment plan,” but it is not a trivial point that much of the time patients don’t know what they’re signing up for. Some patients, for example, are unconscious, delirious, demented, intoxicated, too young, unable to communicate, or otherwise incapable of understanding or legitimately consenting to necessary treatment. Even intelligent, educated, attentive adults, however, cannot anticipate every requirement of treatment. I’ve been present at more than a few discussions of impending operations that would require some type of postoperative chest physiotherapy similar to that described in the Codeblog post to decrease the risk of pulmonary complications; in none of those discussions was the patient told, “The day after your chest is ripped open and then sewn back together, we’ll expect you to perform some respiratory calisthenics that will result in excruciating pain – for
your own good.” And, even if a patient signs an informed consent documents with such information in the fine print, how many operative candidates who know that the proposed surgery is necessary for a cure or palliation of their disorder, who are overwhelmed by an avalanche of data, and who may be worried about survival can be said to understand the details of what they are signing up for?
2. Who Signs Up For What also makes explicit the underlying theme of Geena’s post. It’s what you signed up for applies not only to patients but also to nurses, doctors, respiratory therapists, and all healthcare professionals. Garnering patient compliance is, as the cliche has it, part of the job description. My contention is that, like the postoperative patient facing a deep breathing exercise, we healthcare professionals may not have known exactly what we were signing up for.
In any case, It’s what you signed up for offers a useful perspective on patient compliance and raises some fundamental questions every healthcare professional would do well to address.