Section 5. Strategies for Improving Adherence
Oncology nurses are in an ideal position to help patients identify their barriers to adherence and develop plans to deal with these barriers and improve adherence. Even when external barriers, such as access to medication, have been handled, patients may still face internal barriers such as lack of belief in the treatment or low motivation to stay on course through protracted or complicated medication regimens. Using appropriate interview techniques and helping patients recognize the need to change behavior are tools that oncology nurses can use to improve adherence.
5.1. Patient Interview Techniques
Basic nursing education provides instruction in the principles of patient communication. Listening, being open to discussion about sensitive topics, and using open-ended questions are some of the communication techniques used in everyday nursing practice. The attitude of the nurse toward the patient can affect how open and helpful patient communication will be. Traditional nurse counseling is often directive and focuses on the nurse’s assessment and resolution of the problem.
Open-ended questions can’t be answered with a “yes” or “no.” Rather, they invite patients to share their stories, thus resulting in less-biased data from patients. Open-ended questions allow patients to give spontaneous and unguided responses, which help build trust. Often, the responses to open-ended questions enable nurses to gain information they otherwise might not have considered. Open-ended questions usually begin with the phrase, “Tell me about . . . (how your exercise plan is going)?” or “To what extent . . . (have you been able to take your medication as we had discussed)?” versus closed-ended questions, which usually begin with “Did you . . . (take your medications as prescribed)?” Closed-ended questions focus on the practitioner’s agenda and thus place the patient in a passive and less-engaged role.
Motivational interviewing (MI) focuses on the patient’s perception of the problem and encourages the patient, not the nurse, to find the solution. MI is a method of counseling that is directive and client-centered. It encourages nurses to explore a patient’s understanding and concerns and determine his or her readiness for change (Calhoun & Admire, 2005; Levensky, Forcehimes, O’Donohue, & Beitz, 2007; Possidente, Bucci, & McClain, 2005).
MI was developed to counsel patients with addictive behaviors and has not been validated in oncology patient care, including adherence to oral therapies. However, the underlying principles of change and patient-centered approach to minimize resistance to change lend themselves to counseling patients with cancer who are unable to maintain optimal adherence to therapy.
5.3. Core Components of Motivational Interviewing
Empathy and reflective listening are core components of MI. Talking with patients in a supportive, reflective manner will show that the nurse understands the patient’s concerns and feelings without judging the patient’s actions or goals. Some questions that are concordant with the principles of MI and encourage nonadherent patients to think about the processes that are interfering with adherence include the following:
- “How can I help you?”
- “What do you need to know about _______?”
- “What does this choice mean for treatment of your disease?”
When counseling patients, nurses may feel resistance to their questions. Resistance comes in many forms and is viewed as a problem of communication between the patient and practitioner. Patients may argue with or ignore the nurses, or agree with everything they suggest. It is important to defuse resistance rather than fight it. When encountering resistance, the nurse should consider the following:
- Am I counseling at a level appropriate to the patient’s readiness to change?
- Am I pushing the patient to do more than he or she is ready for?
- Am I dismissing the patient’s feelings and concerns?
- Am I undermining the patient’s sense of personal autonomy?
- Am I acting as expert and telling the patient what to do?
MI can be utilized during procedures such as putting in an IV line or during routine patient education. Nurses do not need to exercise all of the MI techniques but rather should choose those that best fit their own style and their patients’ needs. Tools 8 and 9 contain tables and figures that explain the difference between traditional nurse counseling and MI and also suggest sample dialogue that can help nurses shift to an MI approach.
5.4. Helping Patients Change Behavior to Improve Adherence
Motivation is a fundamental process of change. Once patients are motivated to change behavior that affects adherence, the nurse is able to help them implement behavioral change. Some patients have sufficient internal motivation to recognize personal traits and situations that cause them to stray off course with medication adherence, for example, a busy work or family schedule, travel, forgetfulness, or lack of belief in the need for therapy.
Although motivation needs to come from within the patient—external motivation from the nurse or HCP is not very effective— it is possible to help patients recognize their own ambivalence about the need for change and to change behavior. One model that has been widely used in psychosocial interventions is the Transtheoretical Model of Change (TMC), which involves recognizing the stages of change (see Figure 1) and a person’s readiness to change behavior (see Tool 10) (Prochaska, Redding, & Evers, 2002; Prochaska & Velicer, 1997). Tools for evaluating and assessing the stages of change and readiness to learn are available in Tools 11 and 12.
A patient’s inability to adhere to oral therapies for cancer can negatively affect clinical benefit and can result in treatment resistance, disease progression, and death. Oral cancer therapies are most effective when patient adherence is optimized. An understanding of patient motivation to adhere to therapy, or to change nonadherent behaviors into behaviors that support adherence, can help patients achieve success in maintaining dosing as prescribed. Interview techniques and change models validated in other disciplines may be applicable to patients with cancer. Nurses, in collaboration with other healthcare professionals, play an important role in monitoring adherence. Identifying potential barriers and implementing intervention strategies will enhance adherence and thus improve clinical outcomes.