Page 414 - Encyclopedia of Nursing Research

PATIeNT CONTRACTING n 381

physical activity, and monitoring airflow and patient chooses the behavior and reinforcer
blood glucose levels. in the contract with direction by the nurse.
Research on the effectiveness of patient Patient contracting is based on the principle P
contracting in nursing has been reported for of positive reinforcement, which states that
a variety of behaviors across age groups, set- when a behavior is followed by a reinforc-
tings, and disorders. For example, patient ing consequence, there is an increased likeli-
contracting has been used to control levels of hood of the behavior being performed again
serum potassium (Steckel, 1974) and serum (Boehm, 1992).
phosphorus (laidlaw, Beeken, Whitney, & The nursing process provides the context
Reyes, 1999) in patients on dialysis, to pro- within which to develop the patient contract.
mote adherence to daily peak expiratory The nursing process provides the clinical
flow monitoring in children with asthma data that can be jointly used by nurses and
from pediatric practices (Burkhart, Rayens, patients to establish priorities for adherence
Oakley, Abshire, & Zhang, 2007), to pro- behaviors (Steckel, 1982). The adherence
mote adherence to self-monitoring of blood behavior is the ultimate complex behavior to
glucose in adolescents with diabetes treated be learned or changed. The adherence behav-
at a children’s hospital clinic (Wysocki, ior is broken down into successive approxi-
Green, & Huxtable, 1989), to achieve rehabil- mations or small steps. By performing small
itation goals in adolescents with tetraplegia steps of the behavior, the patient gradu-
who received multidisciplinary care in an ally achieves performance of the adherence
inpatient rehabilitation unit (Gorski, Slifer, behavior. Over a series of patient contracts,
Townsend, Kelly-Suttka, & Amari, 2005), the patient will specify a variety of behav-
to increase knowledge and consistency in iors, which include such behavioral strategies
use of contraceptive methods by sexually as self-monitoring, arranging and rearrang-
active college women from a student gyne- ing antecedent events, practicing small steps
cology clinic (van Dover, 1986), to improve of the adherence behavior, and arranging
self-foot-care behaviors and reduce serious positive consequences (Boehm, 1992). The
foot lesions in patients with type 2 diabetes first several patient contracts are usually for
in primary care (litzelman et al., 1993), to self-monitoring to identify the successive
increase knowledge, keep appointments, and approximations of the adherence behav-
reduce diastolic blood pressure in hyperten- ior and the antecedents and consequences
sive outpatients (Steckel & Swain, 1977; Swain of the behavior. In later patient contracts,
& Steckel, 1981), to and keep appointments, patients specify behavioral strategies related
lose weight, and reduce blood pressure to arranging antecedent events, practicing a
among outpatients with arthritis, diabetes, small step of the behavior, or arranging pos-
and hypertension (Steckel & Funnell, 1981). itive consequences. Self-monitoring is ongo-
Patient contracting did not reduce blood glu- ing throughout the behavior change process
cose and glycosylated hemoglobin in patients to provide data about the performance of the
with diabetes (Boehm, Schlenk, Raleigh, & small steps of the behavior and the effec-
Ronis, 1993; Morgan & littell, 1988; Steckel & tiveness of the new antecedents and positive
Funnell, 1981; Wysocki et al., 1989). consequences.
Patient contracting is the process in which The reinforcer in the contract is chosen
the nurse and the patient negotiate an indi- by the patient and provided by the nurse in
vidualized, written, and signed agreement return for evidence that the behavior was
that clearly specifies the behavior and identi- successfully performed, such as the self-
fies in advance the positive consequences to monitoring records. Reinforcers are unique
be given when the patient has successfully to patients. The availability of reinforcers
performed the behavior (Steckel, 1982). The varies greatly by the practice or research