Practice Tip of the Week | Choosing Collaboration Over Obedience

By Kanaka Sathasivan, MPH

On its surface, compliance simply refers to whether a patient is following their care plan, for example taking their prescriptions, exercising or making dietary changes as recommended. However, the connotations of being labeled non-compliant extend far beyond that, implying that patients are stubborn, unmotivated, deliberately contrarian or maybe even lazy.

While patients may never see the note on their chart that marks them as non-compliant, it can frame future interactions with providers and can pass stigma from one provider to another. The word also has implications beyond any individual patient, from the way provider-patient relationships are structured to hindering agency in patients and perpetuating the social determinants of health and health disparities.

Person-centered Communications

Striking out the words compliant and non-compliant starts with reframing the conversation, understanding patient perceptions and empowering patients. Patients are the experts on their own bodies and unique circumstances, but they are often hesitant to advocate for themselves. A common phrase among advocates for shared decision-making is “no decision about me without me.”

Though it has many proposed definitions, person-centered care ultimately means the patient and provider are working together on the patient’s health. More than just being respectful or considering patient preferences, person-centered care must also establish mutual trust, support patient education, further patient autonomy and be considerate of each person’s subjective experiences and their life situation.

Person-centered communications builds on this concept by also including emotional interactions. By providing space for emotional disclosures, nurses can better glean and address issues that may affect adherence to care plans. Person-centered communications also means incorporating a trauma-informed approach, which builds trust and leads to patient empowerment.

Person-centered communications must start from a place of understanding, good faith and empathy, which are antithetical to expecting or requiring compliance from patients. In addition, compliance is a paternalistic concept that implies a need for obedience, suggesting that providers dole out instructions that patients follow, rather than patient and provider working together.

Similarly, expecting compliance can ― whether deliberately or subconsciously ― lead to providers dismissing patients or discounting their experiences. Studies show that people with chronic illness, Black people and other racial and ethnic groups, and even younger people are often dismissed by providers who refuse to conduct tests or order treatment due to bias or perceptions about compliance. (A common suggestion among these groups is to request that the refusal be documented in their medical records, at which point the provider may change course and reconsider their decision. Interestingly, this flips the script wherein a note about the provider may influence the care plan more than a note about patient "compliance.”)

Circumstance and Ability

In your practice, as we do at certain times in this article, you may use the word “adherence” instead of “compliance.” However, even this word puts the onus on the patient and consequently the blame for not following through with a care plan. Subsequently, providers may be missing the opportunity to address circumstances beyond the patient’s control.

Nurses know health disparities exist and that social determinants of health can affect people in profound ways; however, applying this to practice can be difficult. With limited time, providers cannot always inquire about patients’ financial situations, family situations, environmental challenges or other issues that can affect the ability to adhere to care plans. Addressing such issues may also be beyond the scope of a health care provider, besides connecting patients to external resources.

Accessibility can also complicate adherence to care plans. Was the plan communicated in a way that the patient understood it? Did the patient even agree to follow the plan? Even patients without diagnosed disabilities may struggle with certain tasks, such as opening pill bottles with safety caps, following prescription schedules, or overcoming pain to exercise. In these situations, labeling a patient “non-compliant” only serves to blame or shame.

It is time to move beyond both compliance and adherence to the concept of “concordance,” with provider and patient working together toward a shared goal.

From Principle to Practice

Supporting patient autonomy and building agency in patients is not easy and will not happen just by removing “compliance” and “adherence” from your vocabulary. Addressing a patient’s ability to follow a health behavior starts with understanding the goal of “health.”

One model is the Capability Approach, which proposes that the patient’s own subjective experiences or definition of well-being should guide any health care provided. This approach means nurses should look at many dimensions that influence health and have conversations about personal goals for functioning and visions for care. Providing person-centered care under this model also means that treatment cannot be prescribed by following a formula and providing instructions, but that it must be decided jointly through a respectful conversation.

Nurses may find Choosing Wisely useful; this tool offers five questions that patients should ask their providers before getting a test, treatment or procedure. Another approach is by building a supportive social-emotional environment to ensure patients feel safe, feel heard and feel that they are in control. What this environment looks like will vary from hospital care to out-patient care to long-term care to hospice care.

While changing your practice will be challenging, it will ultimately benefit both you and your patients.

Additional Reading

Behaviour Change, Social Practice Theory, and Learned Helplessness

Patient Angst: When You Just Have To Say 'No' To The Doctor