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nonadherent refuse treatment nurse challenged challenge

From our readers…Nonadherent or compassion challenged?


Over the years nurses have labeled patients who choose (knowingly or unknowingly) to disregard instructions that could potentially alter their health condition toward a “better outcome” as noncompliant, reluctant, or recalcitrant. To soften the negative connotation the word noncompliant evokes, we have added descriptors such as “challenged.” Patients are compliance challenged or nonadherent and it is up to nurses to “un-challenge” these unruly types.

We are challenged to find a better sticky substance that will allow for adherence to the all-knowing healthcare plan. This expectation is a heavy burden for nurses to bear, as we have all met patients who have an intractable case of being uncooperative with their healthcare plan. It makes us sad, tired, angry, disrespectful, and disengaged. How many episodes of self-destruction can we witness without withdrawing our compassion? If we are the “glue” that facilitates adherence, we have a huge challenge before us. What do we do when the patient disregards our professional advice that is meant to promote wellness, recovery, and rehabilitation?

In 2001, Dossey wrote of contemporary health care’s penchant for nagging at patients to behave in a desired way. He describes the nagger as being “humor-challenged,” which begs one to consider what is going on with all these “challenges”? We have become a nation obsessed with making sure everyone is healthy, even when we disagree on how that outcome is accomplished or the definition of healthy. As Dossey so eloquently describes, we have become medical missionaries, serving up the word of health to an audience that has tuned most of us out. The more we “nag” about the principles of better health, the less likely we will have a receptive audience.

There is no doubt Americans have access to an over abundance of health information. Unless you live in a cave you probably know smoking is the greatest evil, overeating is next, and being a couch potato will more than likely land you in cardiovascular jail. As nurses we write care plans that many don’t follow, consequently we label those who are tired of our preaching and guilt mongering as “nonadherentv” and wonder why “they” just don’t listen. Having been a witness to the receiving end of this “teaching,” I would like to acquaint you with an example of a flawed process of instruction.

Imagine an 80-year-old man, about to undergo chemotherapy for the first time. His wife is at his side, but she has hearing aides in both ears. He is somewhat sedated from anti-nausea medications. She is highly anxious about not hearing because of the buzz created by the background noise at the busy clinic. Discharge instructions for the various procedures leading up to these chemo treatments have predominately been a list of possible side effects, things to worry about, who to call, next appointment, and so on — all delivered by reading the list, standing at the foot of the bed, with the nurse rarely looking at the patient. What have they learned? Don’t ask about a thing that has anything to do with other parts of one’s care, such as why is the colostomy not working so well today. You will be told to ask that particular physician. Of course he or she is not on call, so good luck. And when they ask to have the instructions repeated, they are told, “I have them all written down”. No one asked if the patient or his wife could read them.

When the couple arrives the first day of his chemo, the nurse tells them to “pick a chair” as she walks away. There is a room full of chairs, and they didn’t hear her because her back was turned to them. When the nurse returns the patient is still standing, (darn non-adherent patients!). The instructions are delivered again in just a bit more curt manner, “pick a chair”. Once they are settled in a chair that is far too big for the patient, the wife unfolds discharge orders from the day the implanted port device was inserted. A note written by the physician said the stitches are to be removed by the nurse when the patient reports for chemo. The nurse does not nag, she explodes. A tirade follows about whose job it is to remove stitches, and it certainly is not hers! The ability for any respectable relationship that fosters learning is now gone. What they have “learned” is not to ask anything. On another day an incident occurs that also reinforces no matter how worried you are, how distracted, DO NOT FORGET your med list. The ED nurse is too busy to look them up and she makes darn sure you know just how busy she is as she scolds the couple about their ineptitude. She mutters under her breath, can’t patients ever remember to bring their medication lists?! What a wonderful healing environment we create with this behavior.

We all know of stories such as this, we all know of patients who continue to consume alcohol or drugs when it is killing them. We all know of patients who are so deep in denial about their condition that they continue with harmful lifestyle activities. We know of patients with mental health diseases that prevent them from following care plans. We think bullying and nagging them into better behavior will fix the problem. And if we can’t fix it, it must be their fault. As we make these judgments and craft new labels that ease our guilt at having labeled someone “compliance challenged”, we need to remember all these patients must be treated with respect and dignity — even the ones who choose to disregard our advice. Yes, we can be angry that healthcare resources are “wasted” on them; yes, we can be totally frustrated by their choices. But we need to let it go.

As we pass through and touch their lives, and they touch ours, we can know we have done our best, when we do our best. When we withhold compassion from the next patient because we suspect he or she also may disregard our advice, we do not live up to our professional responsibilities. We need to embrace what teaching really means. And when we have truly done our best, we need to let it rest. When the glue doesn’t stick, it probably was not meant to adhere. I believe there is an old saying; you can catch more flies with honey…

If you find yourself continually “compassion challenged”, you may want to consider changing your adherent.

Becky Graner is a nurse consultant for North Dakota Nurses Association, Mandan.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

Selected references

Dossey L. The nag factor. Alternative Ther Health Med. 2001;7(1):12-18, 90-91.


  • Part of the problem so well described by Nurse Graner is the healthcare system expects learning to take place on a schedule convenient to the hospital, as required by accreditation or cost concerns. No one learns until they have basic rapport with their instructor and a NEED to KNOW. Use “teaching moments” from admission to discharge, when the patient and family are asking questions, voicing needs, or taking medications. Ask questions at the right moments: they will learn the answers over time.

  • Sounds like a control issue to me…for the nurse. The patient is the one ultimately in control and we have to remind ourselves of that. We also need to gently remind them of the consequences of some of their bad decisions and encourage them to make a different choice. The 80 year old man didn’t get their with my help…he got to be 80 years old without me there nagging at him.

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