The concept of compliance requires a dependent lay person and a dominant professional; one giving expert advice, suggestions, or orders, and the other carrying them out. Adherence to medical treatment is a concept based on professional beliefs about the appropriate roles of patients and health care professionals. The dominant professional view has been that the role of the professional is to diagnose, prescribe,and treat, and the role of the patient is to comply with what the health care professional believes is best. This view is an excellent example of the ethical principle of beneficence-attempting to do good. However, seen from this point of view, patient non-adherence is a behavior that challenges important beliefs, expectations, and norms. The non-adherent patient is viewed as interfering with, and in some instances, sabotaging the normal process and practice of health care. In some extreme instances in which patients continuously make choices that produce poor health care outcomes, their behavior is seen as deviant and irrational. In the case of people who are mentally ill, non-adherence is also seen as a symptom of illness, the nature of which makes patients incompetent to make informed, rational decisions about the need to adhere to treatment recommendations.
Experts studying adherence point out that in the traditional patient-professional model the relationship is not an equal one. The physician is superior to the patient, and the patient is seen as a passive recipient of health care. This model has led to an inherent tendency to blame the patient and to view non-adherence as irrational and deviant.Such experts believe that the roles of patients and professionals need to be re-examined and that health care professionals need to see patients as individuals who construct and give meaning to their illness and who actively evaluate treatments prescribed and advice given. In addition, much of the research in this area has focused on health care professionals‘ communication to the patient rather than communication between the two. Often health care professionals ask whether or not patients have adhered to treatment instructions, without asking why the patient found it difficult to comply or what the patient may have done instead. By using communication strategies that allow patients more equal participation in treatment decisions, nurses can help promote increased adherence.
The terms compliance and/or adherence imply that we dictate to the patient what is to be done or changed and that the patient should obey us. We are often uncomfortable with the patient’s right to choose not to follow our advice or to change his or her mind. We should strive to enlist the patient’s partnership and view patient education as a process of influencing behavior in ways acceptable to the patient. Effective patient education requires an understanding of factors that influence the patient in decision making: values, beliefs, attitudes, current life stresses, religion, previous experiences with the health care system, and life goals. Patient education providers may begin with giving information and demonstrating skills, but if the patient is not included in deciding how learning will be applied and the goals of patient education are not mutually agreed on between the teacher and the learner, behavioral changes usually will not occur.
The patient’s cooperation with the medical regimen involves choices every day. For example, the choice to follow a diabetic diet means making constant and sometimes inconvenient choices every day. We expect patients to do this every day for the rest of their lives even though we cannot guarantee that they will be free of serious diabetic complications. It is our role to offer guidance and support. We must be willing to respect patients‘ right to choose although we may not agree with their choice.