Understanding and Responding to Noncompliance

This article was published in the Dutch journal for lymphedema therapists, Oedeminus, 10(3): 18-19, September 2007, and includes material from Dr. McMahon’s presentation “Challenges for the Lymphedema Therapist” given at the National Lymphedema Network’s 7th International Conference For Healthcare Professionals held in Nashville, Tennessee, USA.

Understanding Noncompliance

One of the most frustrating experiences in providing treatment is making recommendations that will help your patients and having your patients fail to implement them. You are unhappy. They are unhappy. Why does this happen?

Well, compliance with treatment recommendations requires change in patient behavior. So let’s begin by talking about behavior change. Recent research suggests that making and maintaining a behavior change has five separate steps or stages – three of which precede overt change in action. Noncompliance occurs during these earlier stages.

In other words, the process of change is a bit like an iceberg. Some of the most important work occurs before any actual change in behavior is visible!

Sometimes we move through these stages quickly. Sometimes, we move through them slowly. Sometimes we get stuck. Understanding the stages helps you better understand why and where patients are stuck. It also helps you tailor what you say and do to match their current stage and move them to the next, preventing or minimizing noncompliance.

What Are the Five Stages of Change?

Stage 1 is Precontemplation. I think of this as the “Problem? What problem? There’s no problem.” stage. Patients are uninformed, misinformed, or denying. They may think the swelling doesn’t matter. They may be uninterested or hopeless about doing anything about it. They are not even contemplating a change in their behavior.

Stage 2 is Contemplation. Here patients are dissatisfied with the present situation and contemplating a possible change but are still ambivalent or uncertain. They may say or think things like, “I don’t know.” “Maybe I do need to do something about this, but I’m not sure what.” “This isn’t a good time.” “I’m not quite ready.”

Stage 3 is Preparation. At this stage, patients are actively preparing to change in the upcoming few weeks or months – but haven’t yet begun the change itself. A patient in this stage may say things like, “I’m going to do something about this soon. What do I need?” and may begin gathering information, getting equipment, etc.

Stage 4 is Action. This is the stage most of us mean when we talk about change. Patients are adhering to treatment recommendations and changing their behavior.

Stage 5 is Maintenance. This is a final, essential, but often overlooked, stage in the change process. Changes in behavior need to be maintained over time and patients need to act to prevent, or quickly respond to, relapse.

How to Identify the Stage of Change

Because different actions are effective at different stages, you want to identify your patient’s stage of change. You can do this by asking four questions.

Two questions evaluate readiness to change:

On a scale of 0-10, how important is it for you to make this change right now?
What makes you choose that number rather than a lower one?

Two questions evaluate confidence in the ability to change:

On a scale of 0-10, how confident are you that you can make this change if you choose to?
What makes you choose that number rather than a lower one?

Answers of 3 or less are characteristic of the Precontemplation stage. Answers of 4-7 suggest the Contemplation stage. Answers of 7-10 indicate the Preparation or Action stage.

Increase Your Effectiveness

To motivate your patients more effectively and increase compliance, change what you do to match their stage of change. Here are suggestions and examples of different interventions for patients at different stages.

When patients are in Precontemplation, you want to create dissatisfaction with the status quo and give reasons to change. Try these approaches:

Present objective information. This can include facts about their condition and prognosis with and without adherence to treatment.
Then ask questions to help them explore the advantages or disadvantages of changing or not changing. Such questions might lead your patients to think about what are the best and worst possible outcomes if they change nothing vs. if they do change something. How do they feel about those outcomes?
Finally, repeat back to them any of their own statements that indicate reason to change, dissatisfaction with the present, and/or hope for a better future.

When patients are in the Contemplation stage, you want to increase their readiness to change and strengthen their confidence that they will be able to change successfully. Your strategy now is to focus on their feelings, their concerns, and their goals – as opposed to presentation of facts. Here are some techniques:

Instead of reiterating information you have already presented (or they already know), ask your patients questions that lead them to convince you of the advisability and possibility of change – as opposed to the other way around.
You might want to ask such questions as: “What would change do for you? What would be the benefits? What would that be like for you if those benefits were achieved? Why is that important to you?”
Feed back to them their statements that support change.

When patients are in the Preparation stage, your task is to help them both prepare to change and become committed to this health behavior change. Now you can begin to offer concrete assistance and to partner with them in problem-solving, planning, making a public commitment to the change, and gathering outside support and resources. You might do the following:

Shift your focus from feelings to plans. Encourage them to identify what they will need and how they will get it. Have them identify people who will support making a change. Plan when and how they will implement treatment recommendations.
Ask such questions as: “What worked for you when you successfully made a change in the past? What do you need? Who will support you?”
Encourage your patients to tell supportive others about their plan to change. Public commitment increases actual change.

When patients are in the Action stage, they are carrying out your treatment recommendations. You know what to do here. This is the stage for which you were trained. At this stage, you treat and you teach.

The final stage, Maintenance, can last indefinitely. The tasks of this stage are to maintain treatment gains and changed self-care behavior and to prevent, or minimize, relapse. As a lymphedema therapist, you play a powerful role by doing the following:

Plan ahead with your patients how they will handle any problems that may arise.
Encourage them to track their self-care behaviors and reward themselves for ongoing adherence to treatment recommendations.
Teach your patients how to monitor their lymphedema. If you can continue to see your patients over time, you will also track their lymphedema, ask about their compliance, praise continued adherence and problem-solve lapses.
Ask such questions as: “What problems could arise? What might interfere with maintaining your self-care indefinitely? How will you know if there’s a problem? How will you get back on track?”

If you notice that your patient has returned temporarily to an earlier stage for any treatment or self-care action, return to using the strategies for that stage.

Responding to Noncompliance

When noncompliance is a problem, try these four actions:

Reassess their stage of change for the actions involved. Explore readiness for and confidence in ability to change. Understand where they are.
Explore obstacles. Be respectfully, honestly curious about barriers to compliance or conflicts which interfere. Ask about the practical or emotional disadvantages or costs of your patients doing what you are recommending. Negotiate with them.
Find something you can honestly praise. Perhaps they are implementing some changes. Perhaps they are partially compliant. Perhaps they have made no changes, but may be able to move from one pre-action stage to the next. If they tell you what they are not doing, they are still in contact with you and are reporting honestly. All of these are worthy of praise.
Express caring, concern, and hope - regardless of the present level of success or compliance. Neither you nor they know what the future may bring. Plant seeds of hope for future change. Keep the door open for them to return for treatment.