Developing and Maintaining Therapeutic Compliance
Melinda O. Trimble
LEARNING OBJECTIVES
On completion of this chapter, the reader should be able to:
1. Explain the importance of education before and after a sleep study is performed.
2. Identify educational opportunities in patient care.
3. Develop a process for patient education within the sleep center.
4. Identify written materials to reinforce compliance.
5. Identify support mechanisms for questions/concerns about positive airway pressure (PAP).
6. Communicate with the patient’s family about the importance of PAP compliance.
7. Explain the techniques to help bed partners adjust to PAP.
8. Reinforce the importance of cleaning procedures.
9. Identify potential problems and setbacks to successful therapy.
10. Describe various techniques to increase compliance.
11. Identify community education resources.
12. Assess patient outcomes.
KEY TERMS
Assessment
Compliance
Education
Intervention
Obstructive sleep apnea (OSA)
Outcomes
Positive airway pressure (PAP)
In an era in which there is increasing knowledge, sophistication, and technologic advances to prevent and/or control many diseases, it is alarming that large numbers of individuals continue to be incapacitated, debilitated by, or succumb to, conditions for which effective treatments or measures of prevention are available (1). Sleep disorders are no exception. Although few would disagree that education is an important component of patient care, the majority of health professionals have received no formal training to prepare them for conducting patient education. Often, it is assumed that anyone with a health care background is qualified to educate a patient.
Sleep health education is an essential component to overall patient care. The provision of education for all sleep disorder patients is critically important. In 2014, the Board of Registered Polysomnographic Technologists created a new certification examination for sleep health professionals as a benchmark to assure that minimum competency levels for patient education are achieved. The Certification in Clinical Sleep Health is offered to health care professionals seeking a nontechnical sleep certification. Certification is not required but is an important component of the evolving field of sleep health.
In the sleep center setting, patient education can be one of the most rewarding and gratifying things a sleep technologist experiences. Unfortunately, this is not true for many sleep technologists. A lack of time to educate patients properly and/or a lack of tools to educate patients can be especially frustrating. In this chapter, we will provide you with tools and methodologies that are useful to teaching regardless of the setting (i.e., hospital, home, or in daily lives).
Establishing a standard of care for positive airway pressure (PAP) therapy and education is essential to enhance therapeutic compliance. Managing sleep apnea patients with consistent, standardized instruction and information about sleep-disordered breathing is an achievable goal. This involves educating patients during the initial contact with a sleep technologist at the time of the sleep study, as well as during subsequent treatment and follow-up.
Patient education is best defined as the process that evolves from an exchange between health professionals and patients. As a sleep technologist, one has many opportunities to provide patient education.
Education may occur on the phone, during a chance encounter, after an office visit, or at the time of a procedure; it may even occur in a more public setting such as a support group or an outreach effort. Although recognizing opportunities for education is important, effective education requires establishing a rapport with the patient and acquiring trust.
Education may occur on the phone, during a chance encounter, after an office visit, or at the time of a procedure; it may even occur in a more public setting such as a support group or an outreach effort. Although recognizing opportunities for education is important, effective education requires establishing a rapport with the patient and acquiring trust.
Consider the individual who is unable to tolerate daytime sleepiness, who has a nagging worry over near-miss auto accidents, or who is worried about the distress that snoring causes to the family. The patient decides to see a physician and is referred to a sleep center for a consultation with a sleep specialist. The opportunity to build a rapport begins the moment the patient calls to make the appointment. The rapport that is established between the patient and the sleep center staff will establish a foundation of trust and contribute to the successful resolution of the patient’s sleep issues. If patients have confidence in the staff and the physician, they are more likely to listen, ask questions, and follow instruction. Likewise, when the patient is referred to the sleep center, that initial contact with the scheduling staff will have an impact on how the patient perceives the entire sleep study process. In addition, if the patient is approached with a genuine concern for his or her well-being, he or she is more likely to become engaged in the efforts to successfully resolve sleep problems.
One of the most common diagnoses established in a sleep center is obstructive sleep apnea (OSA). Although there are no cures for this disorder, there are treatments, and one of the most effective forms of treatment available to date is PAP. There are many reasons why an individual may have trouble acclimating to the PAP device, and understanding the patient’s concerns will be key to a successful titration. Consider the pretitration situation where the patient declares, “I will not be able to sleep with that mask on my face or use that machine.” The sleep technologist should understand from the patient’s perspective the fundamental reason(s) why the patient believes the device would not be tolerated and work to address the issues. As an example, if the patient is claustrophobic, consideration may be given to acclimation sessions. If PAP has been determined to be the primary therapeutic intervention for the patient, all efforts should be exhausted before alternative therapeutic options (if any) are considered. Knowing how well the patient tolerates the device during the titration is imperative, especially if the patient is resistant to using the device at home. Review the titration detail carefully. Look for positive as well as negative responses throughout the titration segment of the polysomnogram. The information gleaned from a titration is critical to establishing the starting point, as well as goals for the patient’s adherence to therapy.
PATIENT EVALUATION
Setting Goals
Patient education is an effective approach to improving PAP adherence. The plan for education should include specific goals and outcomes (Fig. 56-1), as these will determine the focus for the patient’s adherence. Work with the patient to establish these goals; ensure that they are realistic and appropriate for the patient’s unique situation. The sleep technologist’s role is to enable the patient to act on his or her own behalf by providing information, assisting with the practical problems of carrying out recommendations, increasing awareness of alternatives, and supporting the patient in the general acceptance and integration of new knowledge (1).
To begin, the sleep professional must get to know the patient. It will be necessary to consider the patient’s emotions, his or her personal and professional environments, and beliefs and values. A thorough review of the patient’s chart should provide fundamental information about the patient; however, information beyond this
source will need to be obtained. Talking with the patient will be necessary to identify any concerns the patient has about his or her own health condition as well as determine the value the patient places on personal health. With this basic understanding, the sleep technologist can begin to develop an appropriate patient-centered therapy adherence plan.
source will need to be obtained. Talking with the patient will be necessary to identify any concerns the patient has about his or her own health condition as well as determine the value the patient places on personal health. With this basic understanding, the sleep technologist can begin to develop an appropriate patient-centered therapy adherence plan.
 Figure 56-1 Worksheet for setting patient goals. |
An assessment of resources and a determination of professional and personal support available to the patient will be necessary for plan development. Coordination of educational efforts will minimize the risk of redundancy and contradictions and prevent components of the plan from being overlooked. It is necessary to determine who from the sleep center will be involved in the adherence plan and identify specific responsibilities for each person. Every staff member has the opportunity to be involved in the patient’s compliance. If not involved directly, the staff member should at least be familiar with the structure of the adherence plan.
Family and friends can influence the success or failure of a patient’s medical outcome. As the sleep technologist becomes involved with the patient’s therapy, the role of the family becomes increasingly apparent. The sleep technologist will need to understand the family’s general lifestyle. A series of questions such as “Who talks to whom?” and “How does the family interact with each other?” will be important to assess the dynamics and the appropriateness of the family’s involvement. If there are family or friends available for support and if it is appropriate that they be involved in the patient’s therapy, permission to involve them will need to be obtained from the patient. The impact of OSA extends beyond the individual and may have significant effects on the family. As such, the family should be included in the education process whenever possible to ensure the best outcome for the patient.
More than 70 sleep disorders have been classified in the International Classification of Sleep Disorders—Third Edition (ICSD-3), with varying options for treatment. Whether the therapy is behavioral, psychological, pharmacologic, or surgical, education is a key component to the patient’s success for improving the quality of life. For some, it may be a fairly expeditious process with relatively few steps; for others, it will be a lengthy process and the steps will be minute and numerous. Understanding the patient, coordinating resources, and assessing his or her response to the prescribed therapy will be vital to structuring realistic achievable goals toward adherence to therapy.
Learning Needs
No matter how dire the situation, patient compliance is always a choice. It is a very important concept for the sleep technologist to understand the process of patient education, and it is critical to recognize what is necessary for patients to learn and understand about their sleep disorder and the prescribed therapy to achieve long-term adherence.
Learning begins when the patient starts to ask questions and, conversely, when the patient does not have answers for the questions being asked by the health care professional. Initially, the patient will need to be made aware of the sleep disorder, its prognosis, possible treatment options, and consequences of noncompliance. Also, it will be helpful for the patient to understand who participates in the education plan and the roles and responsibilities of each individual. It should be clearly communicated that the health care professionals involved in this treatment compliance plan work on behalf of the patient and want to establish a partnership to ensure adherence and improve the patient’s quality of life.
Participants for such a plan may include, but are not limited to, the
patient
durable medical equipment (DME) company staff
sleep technologist
clinical sleep specialist
family
primary care physician (PCP)
payer (insurance company)
sleep disorders center staff
support group
Establishing a coordinated partnership with the patient is a group effort. Effective communication needs to be developed collectively among the participants as well as individually with the patient. The patient should realize that even with complete adherence there might be circumstances that necessitate assistance or direction. A change in health status, a trip out of the country, or equipment problems will be issues that can be readily addressed by the respective sleep professional(s).
Learning Priorities
With most medical conditions, the prognosis generally dictates the path and the priorities for learning. The spectrum of sleep disorders is extremely broad, and consequences range from the merely troublesome day or two of mild jet lag to the tragic loss of life when someone falls asleep at the wheel of an automobile (2).
Health and safety risks associated with the patient’s condition will be a priority in the learning process. For the sleep patient, this may involve the PCP in the assessment of health and the sleep specialist to evaluate the patient’s complaints and symptoms. If an individual does not understand or comprehend the significance of the health condition, it will be difficult to convince that individual to proceed with diagnostic testing or to
comply with treatment recommendations. Therefore, it is important that the patient understands why a PAP machine has been prescribed and what the therapy will involve.
comply with treatment recommendations. Therefore, it is important that the patient understands why a PAP machine has been prescribed and what the therapy will involve.
Sleep professionals need to determine what type of information is appropriate for the patient, as well as what type of changes the patient will need to make in everyday life. The goal of the adherence plan should be to assist the patient in learning the skills and knowledge necessary to develop behaviors that will maximize a positive health outcome.
Learning Assessment
Although an adherence plan involves many sleep professionals, one of the most influential roles is that of the sleep technologist responsible for the PAP titration. The sleep technologist has a very narrow window of opportunity to introduce the patient to PAP, titrate to an optimum therapeutic pressure, and influence the patient’s willingness to consider PAP as a treatment option. This time constraint makes the interaction between the sleep technologist and the patient all the more essential to achieving long-term compliance.
Acquiring specific information as part of an assessment will maximize the opportunity for a successful titration and increase the probability of compliance. An appropriate assessment will provide the sleep technologist with insight to the patient’s motivation, which is necessary before he or she can effectively communicate with the patient (Table 56-1). There are certain factors that influence a patient’s motivation and how the patient responds to sleep testing and treatment; these factors may be classified as individual, social, and environmental.
Table 56-1 Assessment Questions for PAP as a Therapeutic Intervention: Potentially Helpful Questions When Assessing the Patient with Sleep Apnea | ||||||||||||||||||
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Individual Factors: Determine the Patient’s Learning Potential
Determining the knowledge level of the patient is part of the patient assessment and critical to education and the learning process. Generally, a sleep technologist can identify an individual’s level of knowledge through observation and conversation. If the patient’s level of knowledge is unknown, it will be difficult for the sleep technologist to know if the patient understands the health condition, has sufficient knowledge to assume responsibility for treatment, or understands the consequences of not following the treatment recommendations. In addition to knowledge, skill level and attitude contribute to an individual’s ability to learn. The sleep technologist needs to ascertain whether or not the patient has the appropriate skill level to adhere to the treatment regimen. If not, the sleep technologist may need to adjust or modify the teaching techniques used, so that the patient is able to understand the concepts needed to use the treatment device.
Social and Environmental Factors: Determine if These Factors Facilitate or Hinder Medical Care
Social factors such as family, religious beliefs, cultural values, and employers have the potential of facilitating
or hindering patients from reaching their desired goals. As an example, a patient returned for a follow-up to the sleep center and during the appointment was asked if he had been using his continuous positive airway pressure (CPAP) machine. He stated that he had not and upon further questioning, it was discovered that the reason he was not using it was that the noise bothered his wife. With this knowledge, the sleep technologist can start helping the patient by determining if the noise issue involves the mask or the device and suggest changing to a different mask or moving the device further away from the bed.
or hindering patients from reaching their desired goals. As an example, a patient returned for a follow-up to the sleep center and during the appointment was asked if he had been using his continuous positive airway pressure (CPAP) machine. He stated that he had not and upon further questioning, it was discovered that the reason he was not using it was that the noise bothered his wife. With this knowledge, the sleep technologist can start helping the patient by determining if the noise issue involves the mask or the device and suggest changing to a different mask or moving the device further away from the bed.
It is vital for the sleep technologist to understand the reaction of family members to the patient’s condition and treatment. If family members appear hesitant or apprehensive about learning the skills needed to assist with care of the patient at home, then the success of the treatment may be compromised. Some family members may not be responsive or may not wish to take an active role.
Issues such as these can be identified only after the sleep technologist has had the opportunity to observe and communicate with the family. If issues are identified, support and guidance should be provided to assist the family in creating solutions. The sleep technologist must understand the significant impact that social factors (e.g., family) may have on the desired goals and create an educational plan according to the patient’s priorities.
The impact of environmental factors such as geographic location, employer and job requirements, work and social schedule, and living arrangements should also be considered. The sleep technologist will need to understand the availability of resources to the patient. Does the patient’s work schedule hinder his ability to arrange follow-up appointments? Is transportation available to allow for participation with a support group? Considerations such as these will need to be made because the sleep technologist works with the patient to look at solutions for these issues in order to establish and meet treatment goals.
Understanding the patient’s priorities will allow the sleep technologist to determine which factors may facilitate the patient’s progress and which factors may hinder it.
EDUCATIONAL OPPORTUNITIES
Education should start at the initial visit. The sleep technologist and the board-certified sleep specialist should codevelop the educational process used within the sleep center. This will ensure a consistent educational process. Patient education should be a multitiered process consisting of pretest, test, posttest, and PAP setup instruction and information.
Pretest
When possible, the patient should have the opportunity to visit the sleep center before the sleep study. This offers the patient the opportunity to become familiar with the facility and the test process and minimizes any apprehension about sleeping in an unfamiliar environment. Written instructions should be provided before the study to ensure that the patient is appropriately prepared and the information being recorded will be valid. Basic instructions are listed in Table 56-2.
The admission process as well as the testing process should be fully explained to the patient. While the patient is at the sleep center, there is an opportunity for him or her to experience the PAP device. This helps acclimate the patient to the device in case it is necessary to apply PAP during the study. The patient can also be introduced to a PAP interface to assure proper fit before titration, and notes can be made in the patient’s chart to notify the night sleep technologist of any potential problems the patient may have acclimating to the device. If problems arise, the sleep technologist should make every effort to work through the issues before the test. Potential issues may include hard-to-fit faces, claustrophobia, nasal obstruction, and edentulous mouths.
This is the patient’s opportunity to ask any questions before testing and the sleep technologist’s opportunity to address any concerns. The sleep technologist should make the most of this time to ensure that the patient is comfortable with the facility and the procedure.
Test Night
When the patient arrives on the night of the study, the sleep technologist should orient and/or reorient the patient to the facility, the procedure, the hookup, and the PAP titration if applicable. In many instances, the patient will not have had a pretest visit to the sleep center and the sleep technologist will be the sole educator for the patient before testing. The sleep technologist should always ensure that the patient understands the
procedure(s) being performed. The patient should have ample opportunity to ask questions or express concerns. It is particularly important to fit the patient with a mask and acclimate him or her to PAP therapy pretest if there is a possibility for a split-night study.
procedure(s) being performed. The patient should have ample opportunity to ask questions or express concerns. It is particularly important to fit the patient with a mask and acclimate him or her to PAP therapy pretest if there is a possibility for a split-night study.
Table 56-2 Pretest Instructions | |||||||||
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