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Non-compliance or client control?
Barb Fiveash
Lecturer, Faculty of Nursing, University of Newcastle, NSW
Article Text
Introduction
This paper questions whether it is that the client who is non-compliant with the health professional's treatment or whether it is the health professional who is non-compliant with the client's goals.
Client's compliance refers to the extent to which clients conform to the health professional's prescribed health care (Holm, 1993). Non-compliance is a term used in medical and nursing circles to describe a client who does not comply with the treatment program. Health care professionals have viewed non-compliance as the fault of the client: an error in their decision making. Non-compliance is also an approved diagnosis by the North American Nursing Diagnosis Association, although irregularly utilised in Australia (Carpenitio, 1991).
The nature of non-compliance
Non-compliance particularly with medical care such as prescriptions and surgical appliances is commonplace (Donovan & Blake, 1992). Such knowledge could suggest that non-compliance contributed to increasing medical costs. This view considers non-compliance as no more than delay in implementing the correct treatment and a delay in the treatment that results in deterioration of the person's health status and in all probability an increase in the care needed once a person represents.
Some authors (Stone, 1979; Donovan & Blake, 1992), estimate that non-compliance among health care clients rang e from on-third to one-half; while other authors (Bradley, 1989; Taylor, 1990; Simons, 1992), estimate that non-compliance ranges from ten to ninety percent. On the basis of this information, some researchers view non-compliance as a convention, a practice to be expected. From this perspective non-compliance is viewed as more a 'willingness by clients to participate in their own care' (Simons, 1992:477). Such comments raise questions about the nature of non-compliance as to whether or not non-compliance is client error or client control, choice and participation in health.
Donovan & Blake (1992) in their study in the United Kingdom questioned the concept of non-compliance. In a qualitative study of 54 outpatients with inflammatory arthropathy, they found that patients balanced the costs and risks against the benefits, taking into consideration an analysis of their personal, financial and social circumstances. Decisions were based on rational action rather than a wish not to comply with doctor's requests. Non-compliance is not necessarily a result of lack of knowledge in respect to the health condition, but on occasions a deliberate decision made by the client because they do not agree with the treatment prescribed, or for some other reasons they do not want to comply (Donovan & Blake, 1992) (a sound argument for clients to be given a clear, honest and full explanation of their situation rather than an abridged version) (Buchanan, 1995).
Non-compliant client or non-compliant nurse
When the goals of health care is determined by the client and the treatment is offered rather than ordered and the client has the power and the opportunity to re-negotiate a health care program more congruent with their own needs, then the client cannot be non-compliant because the service provided is the service that the client requested. The client cannot be non-compliant if the decisions about care and client goals of care have been decided by the client (Wright & Levac, 1992). Nor is the nurse in a position to give permission or allow the client to take certain actions because the client is in charge of their own care and the nurse should not have that degree of control, authority and power over clients. Rather than the notion of involving the client in care or participation or collaboration or therapeutic alliance, it is the client's health and undeniably belongs to the client.
It is the client who should have control and ownership of their body and health and only they should decide whether or not the health care meets their needs. It is inappropriate for the nurses to believe that they are the experts on the patient's health and that the client should comply with their world view (Wright & Levac, 1992). The underlying assumption here that needs challenging is that the nurse has the true view of the world (Holm, 1993). Non-compliance is parentalistic behaviour on the part of the nurse. Rather than blaming the client for being non-compliant, it is the nurse who is being non-compliant in respect to the client's goals (Holm, 1993).
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