Non-Adherence to Therapy in Patients with Chronic Venous Insufficiency: A Concept Analysis

Introduction

The concept of adherence refers to the practice and maintenance of desired health behaviors (Cohen, 2009). Some health care providers use the terms compliance and adherence interchangeably (Martin, Williams, Haskard & DiMatteo, 2005). However, current researchers and theorists prefer the term adherence so as to avoid the negative connotations associated with the term compliance (Mudge, Holloway, Simmonds & Price, 2006). The word 'compliance' is suggestive of a passive and powerless role on the part of the patient (Cohen, 2009). The health care provider assumes a paternal role in this model and the patient obeys. In contrast the term 'adherence' suggests conformity rather than obedience. This concept is inclusive of the idea of concordance, which is a partner-like relationship between health care provider and patient (Mudge, Holloway, Simmonds & Price, 2006). A concordant relationship between health care provider and patient relies on an exchange of information between both parties and decision making is a collaborative effort encompassing both the health care expertise of the provider and the expectations and desires of the patient (Cohen, 2009). Adherence and concordance are indicative of the patient's agreement to the plan of care (VanHecke, Grypdonck & Defloor, 2009). As adherence to therapy implies that both the health care provider and the patient are following guidelines of treatment in order to promote positive outcomes this concept is self- explanatory. This analysis is more concerned with the concept of non-adherence as it applies to patients and their health care providers.

Health care as a whole, and nursing specifically, apply evidence based practice (EBP) in the real world to promote the best outcomes for the population being served (Chin, 2011). Only when EBP is effectively communicated to patients and a reasonable plan of care is developed concordantly between patient and health care provider can adherence be achieved (Martin, Williams, Haskard & DiMatteo, 2005).

More often than not, when non-adherence to treatment is discussed, it is in reference to the actions of the patient. Most of the literature reviewed for this analysis has reflected that point of view. It should be noted, however that there are circumstances where the lack of adherence is on the part of the health care provider. In such circumstances the health care provider is the one not adhering to basic protocols established by evidence. An example of this would be studies that report only 50% adherence to hand washing by physician when conducting patient encounters (Fife, Carter & Walker, 2010). This will be further explored in subsequent portions of this analysis.

Concerning patients with chronic venous stasis and edema, adherence on the part of both the client and the health care provider is paramount in effecting positive outcomes and long-term management of the disease. As venous stasis and chronic edema are lifelong and incurable conditions proper management and adherence to therapy are essential in order to avoid more critical conditions such as cellulitis and ulcerations (Fife, Carter & Walker, 2010).

Literature Review

There have been numerous studies examining the concept of non-adherence to treatment of patients with chronic venous stasis. Van Hecke, Grypdonck and Defloor have conducted several studies examining difficulty with adherence to treatment for venous stasis. The 2009 meta-analysis by the afore mentioned researchers is a review of thirty-one studies from 1995-2007 examining reasons for lack of adherence on the part of patients. By categorizing patient's responses to the current treatment modalities of compression, leg elevation and exercises, the researches identified instances of patient's inability to tolerate treatment as opposed to not adhering to treatment. This is an important distinction as some health care providers could fail to recognize that pain related to compression therapy is an indication of intolerance as opposed to non-adherence. A 2010 study by Van Hecke, et al, explores the development of nursing interventions aimed at promoting adherence to therapy for venous stasis patients. This qualitative study explores the failure of many randomized controlled trials of venous stasis therapy modalities to include patient perspectives. They further concluded that though it is a time consuming and lengthy process, the development of interventions that include patient perspective and input will ultimately yield better outcomes and positively impact future studies and applications to nursing practice.

A study in the British Journal of nursing utilizing focus groups sought to categorize patient's rationales for non-adherence. This study organized the reasons into four categories: frustration with the health care system (lack of specific expertise by general practitioners, wait times in health care provider's offices for treatment), functional limitations (properly fitted footwear while engaging in compression therapy, bathing issues with compression bandaging, pain related to compression therapy), Emotional reactions (unattractiveness of bandages, feeling unable to show legs or wear attractive shoes due to compression wrapping), and adopting avoidance strategies (avoiding crowded places such as public transportation for fear that being bumped by others would cause an ulceration, not going out in public to avoid reactions from people to the appearance of their legs). Once categorized the researchers sought to provide strategies for healthcare providers to implement in order to elicit adherent behavior in patients (Mudge, Holloway, Simmonds & Price, 2006).

Study published in Wound Healing and Regeneration explores non-adherence to clinical practice guidelines by health care providers. That study reveals that the issues of complexity of care, cognitive effort and reimbursement issues can have a negative impact on a health care provider's adherence to clinical practice guidelines. Of 2,139 patients represented in the study only 17% received adequate compression therapy for ulcers related to venous stasis. The barriers to providing adequate treatment were cited as lack of training to properly apply compression bandages, inadequate staffing to perform the time consuming process of proper bandaging and poor reimbursement for applying compression wraps by insurance payers (Fife, Carter & Walker, 2010).

The majority of the literature regarding non-adherence on the part of the patient offers that the solutions to overcoming non-adherence are improving communication and collaboration between health care provider and patient and improving education and information regarding the disease process and treatment modalities given to