The Dirtiest Word in Chronic Health Care

Did that title get your attention? I hope so, because what I'm about to share here could change the way you relate to difficult patients with chronic health issues, especially those with type 2 diabetes. Nurses Announcements Archive Article

You are reading page 2 of The Dirtiest Word in Chronic Health Care

noc4senuf

683 Posts

Specializes in Geriatrics, WCC.

Coming from a LTC perspective, we gave up the term non-compliant several years ago. We now use "choices" or "chooses". since we have orders, care plans and a multitude of other things in place to care for our resident and then they turn around even after the education and don't follow it. They choose.

talaxandra

3,037 Posts

Specializes in Medical.
It seems to me that the confusion here in many post is letting the pt determine what should be done in their care which defeat the purpose of science and medicine[/quote']

That's certainly the traditional view of medicine - we know best and the patient should follow along. However, our goal now is collaborative care - working out, with the patient, a plan that s/he can follow long-term, Ideally that's going to include all the things best practice recommends, and exclude all the things that are likely to be deleterious, but the point is that we advise and the patient decides. ""We know best" is a distressingly patriarchal concept.

The definition of compliant (acquiescent, obeying the rules, esp. to an excessive degree) is passive and objective. What we want is patients who are active participants in their care, and a plan of care that's subjective and tailored tot he needs of that individual patient.

rn/writer, RN

9 Articles; 4,168 Posts

i see nothing wrong with using "non-compliant " or "compliant" these are terms chosen to help communicate among care provider . would it make a difference if a different term was used instead?
yes, i believe it often would make a difference. far too often, noncompliant is medical-speak for someone who is being difficult and that can really set up a negative expectation for a practitioner who has never met the patient. it also reveals the strong possibility that someone (or many someones) have been engaging in a power struggle with the patient--a contest in which everyone stands to lose.

i understand that at time the provider may jump to quick conclusion labeling of "non-compliant" a pt who wakes up on a random day and don't feel like taking her/his morning pill
a morning pill? this indicates a poor understanding of the kinds of measures many diabetics are expected to take in their lives. a typical plan (i refuse to call it a regimen--another impositional word) can include half a dozen lancet sticks, many pills, a complex diet, exercise, possibly insulin and other tasks and expectations. if the diabetic has co-morbidities, there are likely to be more meds and other restrictions. and some of these "helpers" bring side effects along with them. this isn't a whimsical feeling of not wanting to take a pill or two.

when the pt come to seek treatment to you ( hospital , dr , nurse ect...)they are saying clearly --i trust you to care and guide me with my health -therefore we have the duty to help them understand and follow the regimen which will help ,
a newly diagnosed diabetic is probably not saying, "i trust you to care and guide me with my health." they are probably saying, "what the heck? how can this be happening to me? i don't like this one bit." if we don't give them some time to work through the emotions, if we rush to treat them while they're still reeling, chances are any help we can offer is going to be lumped in with the bad news. after all, who thinks it's good news that you have to change so many things about your life. if we wait at least a little while and give the person time to get over the shock, then we can give them information about what might lie ahead if their disease goes untreated. only then will they see the tools we have to offer them as helpful and not just more intrusions into their already upended life.
i personally see it fit to communicate"compliant " or " non compliant " in charting in a way that will be clear and precise for others providers to realize how they should approach each pt base on that
as i said, this is often shorthand for "difficult patient" and prepares other medical people to dig in and do battle. not a good start for new relationships.

yes the pt should be responsible for their care but when they come seeking help that means it is time for us to implement what we know and have learned to work for specific conditions and the disease .
if someone comes to us with a complaint of having to go to the bathroom all the time and we hit him with the news that he has a lifelong systemic disease that may kill him, we need to give him enough time to actually start seeking our help. with a great many people, that isn't going to happen the very day they get the diagnosis. but if we respect the need for a little time and space to process the information, that seeking can occur. that's if we, in our rush to rescue, haven't already shut it down.

remember the only time there is a charting about compliance there was an agreement to the plan of care on bothe side pt& provider right?
i would amend that to say the we chart about compliance when we came up with a plan of care and the patient didn't say no. that doesn't mean they were on board with it. we too often assume that an absence of visible resistance is the same as agreement. how many patients tell the doc or the nurse what they want to hear and then do their own thing. respectful care asks the patient to truly share their reaction. can they see themselves adhering to such a stringent protocol? would it be better to start exercising now and add some dietary changes next month? checking bg five times a day is a lot. how about twice a day. you can do more once you've got the hang of it. this is not the ideal, but it's better than the "nothing" that many patients do when it all seems too overwhelming.

so if all of the sudden the pt starting to back up why not wanting to use the "dirty word"? . the pt coming to us asking for our professional advice and care , we give it and if the choose to back up after they have agreed that being non compliant hun???????????
if a patient truly seems to be on board or they've been doing certain things and now they've backed off, i'd ask them what happened. and i'd listen to the answer. maybe they've been ill. maybe their spouse was laid off and they can't afford their meds. maybe they just needed a break. often, there are solutions when patients feel they can be honest. but if we just scold them and label them non-compliant, we could be adding to their reluctance to deal with their disease instead of being their allies in the fight.

i like the idea of choices and choosing. i also like participating/not participating.

beachmom

220 Posts

My brother-in-law chose not to do his insulin for the past few months. Showed up on our doorstep 6 weeks ago with a foot infection for me to "fix" since I'm a nurse. 12 days in the hospital, 2 surgeries to remove all his toes, and then he moved in with us for awhile. He can't go home until he can go up stairs and take care of himself. At first I was emptying his urinal and waking up at 8:00 each morning (after working swing shift) to fix his breakfast. When I didn't get up, he fixed his own breakfast, slipped, bonked his foot and bled all over my floor. He's slowly healing and now sort of walking, but I've spent countless hours helping him over the past few weeks. All because of his noncompliance... oh, excuse me, his choices.

He is now checking his blood sugar and taking his insulin and mostly making good food choices. Thank goodness for that. Please excuse my grumpiness. I need a bit of rest.

talaxandra

3,037 Posts

Specializes in Medical.

RN/writer, I wish I could kudos your post twice - you beautifully articulated all the things I thought in response to that post. Thank you.

Nurse&

31 Posts

Specializes in Nursing.
OK...I see your points. We don't want to come off in a demeaning or patriarchal way towards our clients/patients. Also nurses acutely recognize that life-style changes are never easy. But, can you please tell me what you call it when a client/patient does not do what is at least minimally necessary for their well-being? If that behavior is not to be described as "non-compliant", what other word-smithing shall we use? It seems to me that politically correct wording doesn't help anyone get better.

I agree that nurses should strive to try any angle of teaching that will successfully escort clients/patients to wellness. But when all else fails, what do you call it..... Failure to Effectively Motivate?

Thank you . you at least see things the way i do

Nurse&

31 Posts

Specializes in Nursing.

A morning pill? This indicates a poor understanding of the kinds of measures many diabetics are expected to take in their lives. A typical plan (I refuse to call it a regimen--another impositional word) can include half a dozen lancet sticks, many pills, a complex diet, exercise, possibly insulin and other tasks and expectations. If the diabetic has co-morbidities, there are likely to be more meds and other restrictions. And some of these "helpers" bring side effects along with them. This isn't a whimsical feeling of not wanting to take a pill or two.

Yes a morning pill ... i worked as Nurse in charge in a NH few years ago and i had some of the patients on Dr's order for 1 pill every day at 6 am . sticks , diet , insulin and all others being observed troughtout the day but I gave that 1PILL at 6 am per DR Order !

I read the rest of your post your have your Views , i have mine . we can't think alike and some of the words you used i wouldn't .With that being said i found someone who think like i do below is her post

"yrmajesty3 Re: The Dirtiest Word in Chronic Health Care

OK...I see your points. We don't want to come off in a demeaning or patriarchal way towards our clients/patients. Also nurses acutely recognize that life-style changes are never easy. But, can you please tell me what you call it when a client/patient does not do what is at least minimally necessary for their well-being? If that behavior is not to be described as "non-compliant", what other word-smithing shall we use? It seems to me that politically correct wording doesn't help anyone get better.

I agree that nurses should strive to try any angle of teaching that will successfully escort clients/patients to wellness. But when all else fails, what do you call it..... Failure to Effectively Motivate?"

Nurse&

31 Posts

Specializes in Nursing.

"Failure to Effectively Motivate?" i like this lol......

i wish i could kudo your post 5 times.

rn/writer, RN

9 Articles; 4,168 Posts

My brother-in-law chose not to do his insulin for the past few months. Showed up on our doorstep 6 weeks ago with a foot infection for me to "fix" since I'm a nurse. 12 days in the hospital, 2 surgeries to remove all his toes, and then he moved in with us for awhile. He can't go home until he can go up stairs and take care of himself. At first I was emptying his urinal and waking up at 8:00 each morning (after working swing shift) to fix his breakfast. When I didn't get up, he fixed his own breakfast, slipped, bonked his foot and bled all over my floor. He's slowly healing and now sort of walking, but I've spent countless hours helping him over the past few weeks. All because of his noncompliance... oh, excuse me, his choices.

He is now checking his blood sugar and taking his insulin and mostly making good food choices. Thank goodness for that. Please excuse my grumpiness. I need a bit of rest.

I'm so sorry you're going through this. My article was talking about newly diagnosed diabetics who are at a fork in the road. They can either perceive healthcare workers as the enemy and meds and diet and the rest as intrusions to be avoided or they can see us as allies and the meds and diet and the rest as tools to fight the disease. My point was that we have a lot to do with which view the patient takes.

If we jump in and start rescuing before the patient sees the need for and the importance of the measures that can help him, we stand a good chance of "vaccinating" the patient against ever taking us seriously. Then it takes something like losing part of a foot to cut through the denial. I don't know that this happened with your bil, but the immediate imposition of a bunch of rules and restrictions is so common that it may well have been a part of his experience.

Yes a morning pill ... i worked as Nurse in charge in a NH few years ago and i had some of the patients on Dr's order for 1 pill every day at 6 am . sticks , diet , insulin and all others being observed troughtout the day but I gave that 1PILL at 6 am per DR Order !
Maybe it wasn't the med itself, but the fact that it was ordered for 0600. Nursing homes are just that--the patient's home. The fact that the doc ordered the pill for 0600 may work for him and for you, but it may feel intrusive and rude to a sleeping patient. That's when you talk to them and find out why they're resisting. Maybe that same pill would be welcomed at 0800.

talaxandra

3,037 Posts

Specializes in Medical.
OK...I see your points. We don't want to come off in a demeaning or patriarchal way towards our clients/patients. what other word-smithing shall we use? It seems to me that politically correct wording doesn't help anyone get better.

The reason I don't use 'compliant' and 'non-compliant' isn't because I "don't want to come off in a demeaning or patriarchal" or because I think it's politically correct, or as a form of word smithing. I believe the words we use often carry a potent, and unexplored, load of information. As rn/writer wrote, "non-compliant" reveals subtext about an adversarial relationship rather than a partnership, opposing goals (getting the patient to 'comply' rather than working out to incorporate techniques of diabetes management into the patient's life), and predicts failure.

Rather than using 'non-compliant' in my notes I document the conversation I've had with the patient about what aspects of their management plan didn't work and why, what might be more effective next time, support techniques (referral to the dietician, for example) etc. And if the admission's still acute I'll document that this is not the most appropriate or effective time for this discussion, but that I'll reassess the next day - and ask in the interim that other staff refrain from chiding the patient or attempting discussions about management plans unless initiated by the patient.

talaxandra - endocrine CNS

rn/writer, RN

9 Articles; 4,168 Posts

Thank you so much for you insights, Talaxandra. This is a population that is routinely disrespected and diminished by the medical community. But if a non-diabetic were one day told that they had to change their diet and many other aspects of their lives--right now!--they might find themselves balking.

Diabetic self care is not an all or nothing proposition. Something is better than nothing. And if that "something" goes well and proves doable, something else might be added. The patient will demonstrate a ramping up rather than the ramping down that frequently takes place as one thing after another is decreased or let go entirely.

The "ally vs. adversary" comparison is one that a lot of healthcare workers don't get. We say we're fighting the disease, but we end up fighting the patients. And they fight back. It makes such a difference to come in as an ally and say, "Here's the problem. Here are the remedies. How can I help you be successful in your fight?"

talaxandra

3,037 Posts

Specializes in Medical.
My brother-in-law chose not to do his insulin for the past few months He's slowly healing and now sort of walking, but I've spent countless hours helping him over the past few weeks. All because of his noncompliance... oh, excuse me, his choices.

He is now checking his blood sugar and taking his insulin and mostly making good food choices. Thank goodness for that. Please excuse my grumpiness. I need a bit of rest.

Hi beachmom - one of the most unfair things about poorly-managed diabetes is the toll is takes on people around the patient. If it were my BIL I'm sure that as well as being tired I've be angry that I was being inconvenienced as a result of his poor long-term decision making.

Obviously I don't know your BIL, and he may be an inconsiderate PITA in many respects. But if he's anything like most people with diabetes, particularly if he was diagnosed some time ago, his diabetes education consisted predominantly of rules, threats, one way communication and an expectation that he modify virtually every aspect of his life.

We all know that diabetic complications are the result of long-term glycemic imbalance, and that the only uncertainty is which system will be affected first, and how badly: impotence or gastopares, diminished vision or blindness, lose renal function or lose a toe? But these are long term - many of my patients feel fine. They may eat a chocolate bar, and find that though their blood sugar shoots up, they feel okay - maybe they need more insulin, but big whoop. Or they skip a pill and nothing happens. And over time the compromises of effective diabetes management give way to short term preferences.

We all do it - I want to lose weight, but I have a slice of cake. I want to improve my cardiovascular fitness but right now I'd rather surf AN than go outside. I should... but I want...

Making lasting change is really difficult. It's hard enough when the person's motivated - by a desire to be thinner, or fitter, or not have symptoms of IBS. I'm thinking of a friend transitioning to a FODMAP diet with mixed success, even though the consequences of eating the wrong foods are rapid and painful. How much harder when the results are distant and the intervening time's unaffected.

Any movement toward good glycemic control is better than none. Any exercise is better than none, any medication, any monitoring... And small changes are not only more sustainable, they lead to further change. SO working on a collaborative plan and reviewing it regularly has significantly more success in the long term. And that's what we care about.