Page 924 - Cardiac Nursing

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900 PA R T V / Health Promotion and Disease Prevention
self-efficacy). Research has produced several psychometrically tion of the treatment plan. Before closing the session, review with
sound instruments to measure the constructs that may influence the patient exactly what will be done: “Now let’s go over this plan
adherence across several behavioral domains. Because of their be- once more just to make sure I have given you all the information
havioral specificity, self-efficacy scales have been developed for you need. What is the medication you’re going to be taking?” Or,
several behavioral domains, including following a general cardiac to avoid putting the patient in an awkward position: “The name
diet and exercise program 162–164 for adhering to a cholesterol- of the drug is ... Now please tell me how many pills you plan to
lowering diet, 48,49 for following a weight-loss diet, 165–167 for take and when. Are there any symptoms you should report to us?”
smoking cessation, 168 and for medication taking. 169 Instruments In follow-up sessions, acknowledge each time how difficult it is to
have been developed that apply the processes of change to risk re- take medications or follow whatever treatment regimen has been
duction behavior, including an instrument that measures readiness recommended (e.g., smoking cessation, dietary change, or regular
for change to a low-fat diet 170 and one to measure future success exercise) and assess how the patient is doing. The nurse may say,
in smoking cessation. 171 These represent just a few of the self- “I know it can be difficult to remember to take your pills each
administered scales that can be used in the clinical or research set- time. Do you find that you forget to take your pills sometime?” or
ting. An extensive database of health behavior questionnaires is “Sometimes when patients feel better, they skip their medications.
available at Health and Psychosocial Instruments; access may vary Do you ever skip taking your pills when you feel good?” A general
by academic institutions. question may also be asked, such as “Tell me about your medi-
cines and how you are taking them.” Ask the patient to go
through each medication and describe how many pills are being
BUILDING A THERAPEUTIC taken and when. The same general questions can be applied to
RELATIONSHIP WITH THE other behaviors or activities. Regular follow-up on previously dis-
PATIENT cussed regimen plans conveys to the patient that the behavior is
important and so is adherence to it.
Working with a patient to ensure adequate adherence at the initia- An important part of follow-up is providing encouragement
tion of treatment, and over the long term either to enhance com- and reinforcement. The nurse needs to acknowledge the difficul-
pliance or remediate poor adherence, requires good rapport and ties the patient faces, but also must be firm regarding the impor-
clear communication lines between the patient and provider. Hav- tance of the treatment and continue to instill confidence in the
ing a good therapeutic relationship allows ongoing assessment of patient. Reinforcement should be given for the behavior change
the patient’s adherence and also provides an environment conducive made, not for the clinical outcome. Providing information on
to the patient confiding in the provider when barriers to adherence clinical outcomes (e.g., blood cholesterol levels) can be an addi-
arise. The patient needs to be queried regularly if he or she has any tional reinforcement to the patient, showing the progress he or
concerns about the condition or the treatment, and should be she has made in changing behavior and its positive effects on
commended for seeking and following through on the treatment health. However, focusing only on the clinical outcomes does not
process. acknowledge the behavioral efforts made by the patient, and
Listening reflectively to the patient and being supportive can fa- moreover, clinical outcomes such as serum cholesterol can be in-
cilitate communication. The provider should listen more than talk, fluenced by several intervening variables such as concomitant
and listen with interest. Encourage the patient to express problems medications or laboratory changes.
he or she anticipates having or has encountered in implementing The greatest challenge in adherence is to assist the patient to
the treatment. Acknowledge how difficult the new, possibly com- maintain the behavioral changes for the long term. As noted pre-
plex, treatment is and the demands it places on the patient, for ex- viously, there is a decline in adherence during the first year of
ample, “I am sure all of this is overwhelming to you. What concerns treatment, with continued erosion over time. This decline is usu-
you the most about your treatment?” Assist the patient to identify ally accelerated in the absence of any contact with the health care
barriers to implementing or following the treatment, such as no professional. Thus, adherence needs to be addressed at each visit
available time or place where he or she can exercise safely, or, for the with the previously suggested questions. Slips, lapses, or relapse
patient who needs to quit smoking, a spouse who smokes and has can be expected and should be prevented when possible. A slip is
no intentions of quitting. Determine what the patient’s view of the missing the treatment for a very brief period, for example, one or
treatment is, and clarify what the patient’s responsibilities will be in two doses of medication missed, a lapse is when the person does
carrying out the treatment. If possible, give priority to the patient’s not adhere for three to four days, and a relapse is usually when a
goal in the treatment plan. If ambivalence is present, try to help the person stops following the treatment regimen for at least a week.
patient resolve it, and use the strategies of motivational interview- If there is an indication the patient is lapsing, additional attention
ing that have been described previously in this chapter. needs to be provided. It may take the form of periodic telephone
When it is time to begin working on the treatment plan, the contacts and/or mail contact. This may include the patient re-
provider may begin by acknowledging the challenge, “I know how porting on progress made toward a goal, or the nurse assisting
difficult it is to make changes in long-established eating habits. with problem solving in difficult situations, correcting any further
We are asking you to make changes gradually over time and will problems, providing reinforcement for attempts and progress, and
work with you in making those changes. What may we do to as- helping the patient set new goals, if appropriate. It may help to
sist you with this?” and “What would you like to focus on first?” have the patient self-monitor behavior for a period and have these
Express confidence in the patient’s ability to implement the treat- records returned before each phone call, or have the patient bring
ment, and in the treatment having a beneficial effect if it is fol- them in at each visit. It is important that these diaries or records
lowed. Assist the patient gradually to assume responsibility for the be reviewed and used in pointing out positive behaviors and mak-
treatment. Involve the patient in development and implementa- ing suggestions for healthier behaviors.