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Determinants of Patient Adherence


Patients’ poor knowledge about their health conditions is a health care issue that should not be underestimated. Inpatient care and services provided by medical staff constitute only a portion (albeit a large portion) of treatment and recovery, and the rest is comprised of patients’ self-care, adherence to treatment plans and prescriptions, and lifestyles.

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Patients who are insufficiently informed about their condition and treatment may unintentionally harm themselves by engaging in undesired practices or ignoring health care providers’ recommendations due to the lack of recognition of such recommendations’ importance. In this context, patient education is a crucial element of preventing negative health outcomes. The presented research discusses methods of increasing patient education retention and improving education delivery from the perspective of nursing practice at University of Miami Hospital (UMH).


Improving patient education has been chosen as the purpose of the Leadership and Management Practicum at UMH. This choice is justified by the current recognition of the importance of patient education among nursing theorists and practitioners. It is currently acknowledged in the nursing care providers’ community that patient education is not merely the delivery of knowledge to patients (Joseph-Williams, Elwyn, & Edwards, 2014), but should be regarded as a set of activities aimed at ensuring that patients not only know what their condition is and how it is treated but also understand how to prevent negative scenarios and complications and are willing to commit to recommended practices and behaviors.

The justification for the need has been shown by previous studies (see Review of Literature), and evidence has been provided for the positive effects of properly delivered patient education. However, there are barriers to successful education. Joseph-Williams et al. (2014) suggest that the main barriers are the lack of time and the “lack of agreement with the applicability of [shared decision making] to the patient…[and] to the clinical situation” (p. 307). Therefore, the effectiveness of education largely depends on the willingness and readiness of patients to actively engage in learning and cooperating with educators.

Unfortunately, this need for engagement, cooperation, and responsiveness is often overlooked in patient education initiatives. For example, Fenerty, West, Davis, Kaplan, and Feldman (2012) note that reminding patients about their treatment requirements can be a beneficial practice in terms of achieving better health outcomes. While it does not mean that patients tend to neglect their treatment and recovery guidelines, it suggests that patients tend to be less involved in the management of their health problems than necessary for the attainment of successful self-care practices. Patient education that is more patient-centered, promotes engagement, and takes into consideration patients’ willingness to commit to prescriptions and recommended lifestyles is, therefore, more likely to be successful.


Developing patient education strategies that comply with the description above is the main purpose of the presented research. First, it is important to increase patient education retention. Mackey, Doody, Werner, and Fullen (2016) reviewed 31 studies in the context of the role of health literacy in managing chronic diseases, and only one of the studies mentioned patient education retention as an important factor.

However, the background presented above shows that retention is a crucial factor because the effectiveness of patient education is not measured by the quality of educational materials or methods of delivery but by the level of patients’ understanding of the materials and their willingness to commit to the guidelines and recommendations provided by the medical staff. Therefore, ensuring that relevant information is properly retained and improving this retention are integral parts of delivering patient education.

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The second purpose is to define effective strategies for providing patient education. The researcher’s observations at UMH have shown that patients may be reluctant to adhere to their prescriptions and disease self-management guidelines not only because of a lack of knowledge but also certain attitudes toward their conditions and treatments that discourage their participation in self-care.

Based on the necessary characteristics of patient education, this reluctance can be attributed to poor education because education should be aimed at ensuring that patients understand the possible negative effects of noncompliance with their treatment plan (Fenerty et al., 2012). A patient education initiative that pursues these two goals can improve the overall understanding of how patient education can be provided to ensure better health outcomes for patients.

The first specific objective is to assess the current knowledge of patients about their condition and provide educational materials (approved by the health care facility) within the first eight hours of admission. The second objective is to measure patient education retention immediately after the educational session (the patient will be asked to repeat the information back to the provider). The third objective is to conduct repeat evaluation of patients’ understanding of their condition and treatment 24 hours after the session (or later, but before discharge). If the objectives are met, it will help the researcher achieve the two goals set for the presented research.

Review of Literature

In recent decades, a remarkable amount of academic attention has been paid to effective patient education; specifically, the issues of the successfulness of patient retention and understanding and the implementation of particular education delivery strategies have been addressed. For example, Fenerty et al. (2012) explore the concept of patient adherence and compare it to the previously approached concept of patient compliance. The latter implies that a patient should strictly follow any recommendations and guidelines provided by physicians and other medical staff members in the framework of the patient’s treatment and recovery plans.

It can be argued that this concept suggests passive behavior, or uncritical obedience to everything that is prescribed to a patient (Kardas, Lewek, & Matyjaszczyk, 2013). In contrast, patient adherence incorporates more active behaviors and implies that patients be more engaged in managing their conditions or health problems. From this perspective, patient education should be aimed at adherent behaviors as the desired outcomes of the instructional process as opposed to compliant behaviors.

Another important aspect of patient education that has been extensively studied is health literacy. Mackey et al. (2016) defined health literacy as the ability of individuals to access, understand, and use information about their health, such as how to maintain good health, prevent diseases, or manage current conditions. It is important that a significant part of contemporary patients’ self-care is associated with the increased access to information; virtually all patients can access online resources to learn something about their conditions and management methods.

Since this information can be unreliable, it is crucial that patients learn how to tell valid sources from invalid ones, how to verify facts, and how to use anything they learn from sources different from direct recommendations from a physician. The lack of health literacy is a major barrier to health education (Joseph-Williams et al., 2014), which is why educators should ensure that patients can properly apply the knowledge they receive during educational sessions or via written materials.

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Finally, many studies have confirmed that successful patient education is a predictor of better health outcomes. For example, Healy, Black, Harris, Lorenz, and Dungan (2013) state that, for diabetes patients, the delivery of inpatient education is a predictor of a lower readmission rate. Similarly, White, Garbez, Carroll, Brinker, and Howie-Esquivel (2013) demonstrate that patient education lowers the readmission rate among heart failure patients; moreover, the authors confirm that interactive methods, such as the method of assessing patients’ retention by asking them to repeat the information they receive via educational materials back to the educator (the method employed in the presented research), are effective in terms of ensuring better outcomes, including less frequent hospital readmission.

Research Methods

The method in the presented research was participant observation enabled by the Leadership and Management Practicum program at UMH, and the researcher was also the provider of patient education designed according to the goals described in the Aim/Purpose section. The methods were aligned with the research objectives and included structural evaluation of patient education retention. First, educational materials were provided to the patients within the first eight hours after their admission, including information on the pathophysiology of the patient’s condition, possible scenarios, and explanation of the current treatment plan (including prescribed medications). Additionally, information about non-pharmacological aspects of treatment, such as necessary lifestyle adjustments and dietary requirements. was delivered

Second, retention was measured, and the measurement was based on the initially provided materials, which had been structured for better understanding; e.g., several sections (such as medications, exercise, diet, contraindications, and so on) with several points in each. When testing the retention, the educator asked the patient to repeat relevant information and asked questions about it. The retention rate of 80 percent or more of the provided structured materials was considered a success.

Third, retention was assessed again approximately 24 hours later; for some patients, the period between the first and the second assessment was longer (but the second assessments needed to be conducted before the discharge in any case), and for other patients, the second assessment did not take place because they were discharged within 24 hours after the initial educational session. The difference of this assessment from discharge planning is that the patient had not only been supplied with guidelines, but also his or her knowledge and understanding were assessed against the structured materials as described above.

It can be argued that the combined role of an educator and a researcher undermines the reliability of research results. However, the delivery of the proposed patient education program should be regarded as not only implementation of patient education but also testing of the proposed instructional strategy. From this perspective, the researcher’s observations during educational and assessment sessions qualify for primary data that either confirm or disconfirm the effectiveness of the proposed pattern of patient education.

Implications for Nursing Practice

Medication Plans

Major implications for nursing practice derived from the presented research include reasons which cause patients to fail in adherence to their treatment and recovery plans and recommendations from health care providers despite the education that those patients received. First of all, it has been observed that many patients do not comply with health care guidelines provided to them once the symptoms of those patients’ conditions are alleviated. Even though they may be explicitly instructed to take medications regularly for a certain period, patients may discontinue the medication because they feel better and think they do not need drugs anymore. This shows that, in their patient education delivery, nurses should stress that medication plans do not depend on how a patient feels (unless specified otherwise by the physician), and these plans should be followed precisely.


Second, in every observed patient, the prescribed diet was a requirement of self-care and disease management that was not met. Patients were found to often think that they could indulge in foods that they had been explicitly recommended to avoid once they “feel better;” or no longer experience acute symptoms. In addition, patients may pay insufficient attention to their diet and unintentionally consume products that are harmful to them; for example, a patient who reduced the consumption of salt according to his physician’s recommendation still consumed soy sauce. In the framework of patient education, patients should be instructed that their diet can significantly affect their conditions, and the consumption of certain foods—which should be listed for the specific condition a patient has—can harm the patient and lead to hospital readmission or other complications.


Third, the observation has revealed that, even though some patients have appropriate knowledge about their conditions, they may be reluctant to adhere to self-care recommendations. The reason for this reluctance is an indifferent attitude toward disease management and a lack of understanding of possible negative outcomes. If this is the case, and patients refuse to comply with recommendations (or even refuse to receive education), a nurse practitioner should explain to the patients that their unwillingness to adhere to prescriptions (that may be challenging) is not something that will liberate them but rather something that will make them visit the hospital more frequently, develop complications, or undermine their future health, possibly to the extent of irreversibility.

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The findings also show that, while some patients are passive and do not want to engage in learning, other patients are very active and demand more from education than a nurse practitioner can deliver. For example, a patient asked about a medication that could be alternatively administered in a more convenient way (without lab testing), and the researcher asked the patient to address his questions to a physician. However, it may turn out that the patient is not eligible for receiving the medication, and the entire situation would simply create confusion and involve the patient in redundant activities. Nursing care providers should ensure that the education they provide is strictly relevant to a given situation and not so broad that it causes patients confusion.


In order to improve patient education strategies and retention, patients were provided with a three-step education: an instructional session regarding their conditions, treatment, prescriptions, disease management, and self-care; an evaluation of retention immediately after the session; and a repeat evaluation 24 hours later (if a patient is not discharged beforehand). Relevant literature confirms that ensuring better retention and better patient education is beneficial in terms of health care outcomes and recovery rates (such as low readmission frequency).

As a result, it is recommended that nursing care providers pay more attention to explaining treatment plans (in order to promote patient adherence as opposed to compliance), addressing the issue of the necessary diet and listing foods that should be avoided, describing possible negative effects of failure to comply with medical staff’s guidelines and recommendations, and ensuring that educational materials are tailored to specific patient cases instead of being too general and thus confusing for patients.


Fenerty, S. D., West, C., Davis, S. A., Kaplan, S. G., & Feldman, S. R. (2012). The effect of reminder systems on patients’ adherence to treatment. Patient Preference and Adherence, 6(1), 127-135.

Healy, S. J., Black, D., Harris, C., Lorenz, A., & Dungan, K. M. (2013). Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care, 36(10), 2960-2967.

Joseph-Williams, N., Elwyn, G., & Edwards, A. (2014). Knowledge is not power for patients: A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Education and Counseling, 94(3), 291-309.

Kardas, P., Lewek, P., & Matyjaszczyk, M. (2013). Determinants of patient adherence: A review of systematic reviews. Frontiers in Pharmacology, 4(91), 1-16.

Mackey, L. M., Doody, C., Werner, E. L., & Fullen, B. (2016). Self-management skills in chronic disease management: what role does health literacy have? Medical Decision Making, 36(6), 741-759.

White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? Journal of Cardiovascular Nursing, 28(2), 137-146.

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