Although, as already mentioned in Chapter 8, one may discuss the responsibility of the health professional for initiating and maintaining a working relationship, it does take two and establishing an alliance with the patient may be easy or challenging. Not all patients are good communicators and some may be difficult to get on with. However, whatever the patient’s personal qualities are, it is important to think about how one approaches interactions with patients and what one’s own motivations and goals are. These are factors the health professional has control of and is responsible for.

Compliance adherence or partnership?

There are a variety of reasons why at least 50% of patients do not carry through with treatment prescribed for them. In an editorial surveying the problem, Hill (1999) raises many important issues, pointing out that a high percentage of patients do not follow medication regimens. She described issues that influenced patients such as: side

BOX 9.1 CASE STUDY: JUDY

Judy has been depressed for many years, even though she is only 18. She can’t remember a time when she has really felt happy for more than a few minutes. She doesn’t get on with her parents and has left home and works in a supermarket to support herself. She shares a house with other people of similar age to her. Sometimes, however, there are times when she feels so bad and helpless to change her life that she takes it out on herself by physically injuring her own body. Sometimes this is because she just doesn’t want to put up with her life anymore, sometimes it is because she just wants to punish herself for being such a ‘loser’. When this happens, she may be admitted to her local hospital’s emergency department. All the clinical staff there know her quite well. Some are quite supportive and caring; others will make her wait longer until they have dealt with ‘more important’ patients with ‘genuine’ injuries; it is almost, she feels, as if they are are punishing her for being such a nuisance and wasting their time. Depending on who is working in the department at the time, she never quite knows how people will behave towards her.

effects and costs; treatment difficulties; fatalism or resistance to control; forgetting to take medication; and little external support. When the symptoms begin to subside they may see no need to complete their medication; they cease because there may be no sign of improvement. They may decide that if a little works then a lot will be even better. If suffering from a chronic illness, a patient may tire of taking medication or other treatment. Sometimes a treating health professional, such as doctor or midwife, may tell a patient they are not required to do something, such as provide a urine sample, whereas other staff may insist they do. When the patient refuses, the staff may see him or her as a problem patient (Caltabiano & Sarafino 2002), that is, someone who does not passively accept treatment, is uncooperative, complaining, displays emotions and is dependent. A minority of patients may receive secondary gain, that is, rewards from the role of being sick (Ogden 2004). But there is a danger of health professionals who see that an individual does not appear to follow the usual illness phase or suffers more pain than seems reasonable to them, perceiving the patient negatively without attempting to understand why it is happening.

Hill (1999) discussed other issues coming from the health professionals’ perspective, including assuming that the patient is responsible for compliance, inadequate communication with the patient, concentration on symptomatology rather than prevention, limitations of time and not following up the patient. There is no doubt that the issue of patients and their part in the treatment process is of concern to many health professionals. It has been said that much of the literature to do with health professional–patient communication issues has to do with getting the patient to cooperate with the health professional’s treatment goals or compliance (Crossley 2000). The word compliance seems to be used without consideration of how it might shape their and other health professionals’ attitudes to relationships with patients. If an individual is not willing or able to do what is requested of them at a particular time, they may be described, both verbally and in their patient records, as noncompliant. The problem with this is that this descriptor can frequently be taken up by other health team workers, often without any thought or questioning of its origins.

But the danger is the strong possibility that a patient may then be perceived as such for the rest of their treatment history. It then can become a self-fulfilling prophecy: other health professionals expect a person to have a particular attitude to treatment and relate to them in such a way that leads the patient to demonstrate that attitude. From your clinical experience so far, consider if you have observed any of these relationships occurring between health professionals and patients.

Possibly, some health professionals describe a patient as noncompliant because they present a challenge of some sort, usually to do with not wishing to accept a particular form of treatment that has been prescribed for them. Sometimes it might be as straightforward as the patient having very little English and not understanding what the health professional is expecting of them; it may be a well-educated person who simply questions what is being done to them; or it might also be a patient who refuses to accept any kind of treatment.

The term compliance itself has been criticised because of its paternalistic or even coercive implication (Happell et al 2002). The writers suggest the alternative term adherence, believing it has a stronger implication of choice by a patient. In fact, that term now seems to be widely used in the literature (Crossley 2000, Happell et al 2002, Lyons & Chamberlain 2006, Taylor 2006) but it is debatable whether this is an improvement because adherence in the community also has the implication of following rules or direction. It would be better that neither of these labels was used and the patient’s behaviour was simply described.

Making decisions about one’s own health

Becker and Rosenstock’s (1984) work that resulted in their health belief model (HBM) (see Fig 7.6 in Chapter 7) was concerned with how people make decisions about their health. They concluded that a person’s motivation to engage in healthy behaviours depended on how severe they saw their problem and how susceptible they perceived themselves. Over time it was developed and extended by these social psychologists seeking to promote better preventive health (Janz & Becker 1984, Rosenstock 1974). It is still one of the most commonly used models of health behaviour change and has been used in measuring individuals’ likelihood of changing their health behaviours (Caltabiano & Sarafino 2002). Its basis is that preventive health behaviour in an individual is influenced by five factors: (1) any barriers they perceive to carrying out a particular response; (2) perceived benefits of performing the recommended response; (3) their perceived susceptibility to a health threat; (4) perceived severity of a health threat; and (5) cues to the person taking action in response. So it follows that it is what the patient thinks is important in influencing her decision.

The HBM raises the important question of how much should health professionals honestly and carefully explain to patients about their health status. It also implies the importance of having to consider the individual’s capacity and ability to cope with these facts, understand them and to then act on them. This can often be an issue. This is why it is important for the health professional to attempt to engage the patient in a working partnership, or alliance, while also recognising that this may at times be a challenge, due to the patient having a variety of reasons for not wishing, or being able, to cooperate. Shelton (1998) listed some of these factors: not experiencing a significant degree of distress from the illness, not accepting the fact of being ill, having poor communication skills, the regimen of treatment being too complex, feeling embarrassed about the treatment, possible side effects and the possible gains from being seen as ill. All of this reinforces the need for good communication skills, easy-to-comprehend treatment plans with clear instructions emphasising the positive gains from following treatment and, following from this, the patient experiencing treatment successes. However, there will be times when this may not be successful. For example, even given the best health professional communicator, the patient may not possess adequate communication skills her/himself.

In spite of the above challenges, it still behoves the health professional to aim at working successfully with their patients. Treatment should be seen as a partnership, rather than a battle of wills or a procedure to be done. It should be seen as entering into interactions with patients with the goal of seeking to form a working alliance. While bearing in mind an individual’s diagnosis and treatment plan, what are their needs here and now and how may they be assisted in making informed decisions about their treatment? How could their needs be incorporated into a treatment plan? However, many health professionals still do not follow this approach. Unfortunately, the health service industry is still largely based on medical diagnosis and treatment of disorders, rather than the patient (Lyons & Chamberlain 2006). In spite of this case-based model still being common, research now seems quite conclusive that, where health professionals use a patient-based approach to care, rather than a case basis, patients are more likely to cooperate in their care (Caltabiano & Sarafino 2002). These authors also make the interesting point that the role of being a patient is usually only an occasional one, which makes it feel novel and strange when one is in it and not one which is desirable, whereas the health professional has a full-time role that is part of their personal identity and also seen as desirable. These differences in roles might not be considered by the health professional. Caltabiano and Sarafino (2002) also believe there is a danger in making the health professional totally responsible for the interaction, in that it may make the patient seem to occupy the passive role and not able to be responsible. However, it is true that how the health professional responds to the patient can influence the interaction, even though all patients should be treated equally, whether liked or not (Lyons & Chamberlain 2006).

CRITICAL THINKING