Patients who do not adhere to their prescribed treatment plans are at risk for worse health outcomes, increased hospitalizations, diminished quality of life, and even death. Non-adherence may involve one or more components of the treatment plan, including medications, procedures, appointments, and lifestyle modifications such as dietary and exercise changes. Nurses are well-positioned to promote patient adherence to the patient’s treatment plan. Furthermore, they are expected to engage in behaviors that support adherence, such as providing education. Failure to do so can lead to professional liability.
By understanding the prevalence, types, and reasons for non-adherence, nurses can engage in activities that promote adherence, particularly effective communication, which is the focus of this article.
Overview of non-adherence
Unfortunately, nonadherence is a common problem, although statistics vary. Chapman and Chan note that adherence rates differ across patient groups, medications, and the methods used to measure non-adherence. For example, a McKinsey & Company report found that the 12-month median adherence to medications was 26% for patients with asthma, but 63% for patients with multiple sclerosis.
Common types of non-adherence include not filling medication prescriptions, not taking medication as prescribed, not following discharge instructions, and not making recommended lifestyle changes.
Various authors (e.g., Hichborn and colleagues, Religioni and colleagues) have categorized the reasons for non-adherence. Religioni and colleagues place the key factors influencing adherence into four groups.
Patient-related factors include the patient’s motivation, psychological factors, beliefs, knowledge, and the ability to manage their treatment. For example, low health literacy may explain why a patient does not follow surgical discharge instructions.
The American Medical Association provides several patient-related reasons for medication non-adherence: misunderstanding (for example, not understanding the purpose of a medication or how long it takes to see results); fear of potential side effects, particularly if they have experienced side effects before or know others who have; too many medications or a complicated dosing regimen; lack of symptoms (for example, once symptoms have gone, the patient may think they no longer need the medication); mistrust of medications in general; worry about dependency; and depression. Many of these, such as misunderstanding, depression, and fear, apply to non-medication aspects of the treatment plan as well.
Therapy-related factors include the complexity of the treatment regimen and side effects. Patients with multiple comorbidities often require more complex treatment plans, which can affect adherence.
Socioeconomic factors include low income (making it difficult to pay for insurance, out-of-pocket expenses, prescribed treatments, and provider care) and lack of social support to encourage adherence. For example, Ebeywa and colleagues cite evidence that rates of medication non-adherence are higher among minority, low income, urban communities.
Healthcare system-related factors include limited access to care, high out-of-pocket costs due to treatment and insurance coverage, and inadequate provider-patient communication.
Cummings also explores provider-patient communication as a factor for nonadherence, noting that the patient’s emotional state, their attitude towards the message, or an unclear message can inhibit communication, leading to non-adherence. Cummings also notes that a person’s culture influences their understanding and perceptions of the information provided by the nurse, and that those for whom English is a second language may have greater difficulty comprehending it. Furthermore, medical terminology can be difficult for patients to understand.
A nurse’s responsibility
A nurse is responsible for adhering to scope and standards of practice established by their state’s nurse practice act, legislation, the American Nurses Association, and employers. Failure to do so can result in litigation and even loss of nurse’s license.
Nurses must communicate through documentation to prevent later claims that the patient did not receive adequate information that enabled them to adhere to the treatment plan. Important topics to document include initial patient education and follow-up evaluations to assess non-adherence.
Assessment for non-adherence should include exploring the patient’s understanding of the treatment plan and identifying barriers such as language barriers, cultural values that conflict with the treatment, or a lack of transportation to keep clinic appointments. The nurse should clearly document the patient’s reasons for non-adherence and steps taken to address it. These include mutually agreed-upon action items (for example, connecting the patient with social services or providing additional education) and the patient’s understanding.
An example of documenting an interaction related to non-adherence is: “Patient states he stopped taking sertraline after a week because it ‘wasn’t doing any good.’ Discussed that it can take 4 to 6 weeks to experience the full effects of the medication. Patient states, ‘I forgot about that,’ and that he will start taking medication again. Will reassess medication adherence at next scheduled visit.”
Communication as a best practice
Best practices for avoiding and addressing non-adherence include helping to remove external barriers, such as cost constraints, by connecting patients with medication cost assistant resources. However, one of the most important best practices is effective communication when discussing treatment plans during initial and follow-up patient visits (sidebar #1). The foundation of effective communication is a collaborative nurse-patient partnership that is built on trust and nonjudgement on the part of the nurse.
Use of therapeutic communication techniques can help build that trust. Ernstmeyer and Chrisman provide a list of therapeutic communication techniques that is a helpful resource. These include clarification, exploration, paraphrasing, reflection, observation, acceptance, and silence. Examples are provided for each technique.
Kilgore and colleagues write that four factors underpin communication: the talker, the listener, the message, and the environment. Issues with one or more of these factors can lead to communication breakdowns, but strategies can be applied to each of the four factors to prevent them.
Examples from the article include:
- The talker: Use clear speech and face patients when speaking.
- The listener: Use the teach-back method (ask patients to repeat the information to you).
- The message: Keep messages concise and avoid medical jargon.
- The environment: Limit background noise and distractions.
Conversations about nonadherence can be difficult, so it is important for nurses to complete education on communication techniques and have the opportunity to practice them in a nonclinical setting. They should also be non-judgmental when discussing non-adherence with patients. Most importantly, nurses should remember that each interaction between the patient and provider contributes to the overall patient experience. Listening closely, asking thoughtful questions, and demonstrating empathy are key.
Communication tips
The following strategies promote effective communication between nurse and patient.
- Establish a goal for the conversation.
- Be aware of non-verbal behaviors on your part and the patient's. For example, a patient who is fidgeting and not making eye contact may be impatient with the length of your presentation.
- Keep the message clear, avoid medical jargon, and focus on the patient (for example, do not over-share personal information).
- Be sensitive to the patient’s cultural values and beliefs.
- Provide a translator as needed.
- Do not overload the patient with information. Focus on what the patient needs to know.
- Do not assume a patient understands the information the first time they hear it. Factors such as fear and a complicated regimen can impede comprehension. You may need to repeat information several times over subsequent encounters.
- Recognize themes in the conversation. For example, you may detect that the patient feels helpless about their situation.
- Avoid asking yes/no questions.
- Engage in active listening, which shows respect and facilitates understanding the patient’s perspective.
- Use visual aids as appropriate and provide printed or digital (depending on patient preferred format and language) educational information.
- Document education and key conversations in the patient’s health record.
When patients decline to comply
In some cases, the patient may choose not to comply with the treatment plan, despite the nurse’s best efforts. In this case, the nurse needs to assess patient’s capacity to make this decision. The nurse should also ensure that the patient has all the necessary information to make an informed choice, including the benefits of treatment, treatment options, and the consequences of forgoing treatment. If the patient continues to decline treatment, the nurse should document the reason for the refusal and the information provided to the patient.
Some hospitals use “Against Medical Advice” forms, however, the most crucial part from a liability protection perspective is the documentation in the patient’s health record. As long as the documentation showed that the nurse did not breach a duty (for example, by failing to provide information about the problems that may occur if the plan is not followed), the chance of a professional liability action being pursued is low.
Promoting adherence
Patient adherence to the treatment plan optimizes outcomes. Many factors, ranging from the individual patient to the healthcare system, can hinder adherence. Fortunately, nurses can and should use their communication skills to promote adherence and address reasons for non-adherence so that patients receive the full benefits from their treatment plan.
Lynn Pierce, FNP-C
Senior Risk Management Consultant with NSO
Sources:
- Cummings LM. Communication strategies for nurse-patient language barriers. ONS Voice. 2025. https://www.ons.org/publications-research/voice/news-views/05-2025/communication-strategies-nurse-patient-language; Ernstmeyer K, Chrisman E (eds.).
- Therapeutic communication and the nurse-client relationship. In: Nursing: Mental Health and Community Concepts. Open RN. 2022. https://www.ncbi.nlm.nih.gov/books/NBK590036/; Kilgore B, Harriger C, Gaita L, Sharpp TJ. Unmasking misunderstandings: Strategies for better communication with patients. Nursing. 2021;51(1):56-59.
REFERENCES
- American Medical Association. 8 reasons why patients don’t take their medications. 2023. https://www.ama-assn.org/practice-management/ama-steps-forward-program/8-reasons-patients-dont-take-their-medications
- Chapman CE, Chan HY. Medication nonadherence – definition, measurement, prevalence, and causes: Reflecting on the past 20 years and looking forwards. Front Pharmacol. 2025;16:1465059.
- Cummings LM. Communication strategies for nurse-patient language barriers. ONS Voice. 2025. https://www.ons.org/publications-research/voice/news-views/05-2025/communication-strategies-nurse-patient-language
- Ebeywa E, Gruss V, Koronkowski M. Promoting a shared medication adherence practice: a call to action. J Nurs Pract. 2021;17(10:1292-1296.
- Ernstmeyer K, Chrisman E (eds.) Legal considerations and ethics. In: Nursing Fundamentals. Open RN. n.d.
- Ernstmeyer K, Chrisman E (eds.). Therapeutic communication and the nurse-client relationship. In: Nursing: Mental Health and Community Concepts. Open RN. 2022. https://www.ncbi.nlm.nih.gov/books/NBK590036/
- Hichborn J, Kaganoff S, Subramanian N, Yaar Z. Improving patient driven adherence through data-driven insights. McKinsey & Company. 2018.
- Kilgore B, Harriger C, Gaita L, Sharpp TJ. Unmasking misunderstandings: Strategies for better communication with patients. Nursing. 2021;51(1):56-59.
- LegalClarity Team. What steps should you take if a patient refuses treatment. LegalClarity. 2025. https://legalclarity.org/what-steps-should-you-take-if-a-patient-refuses-treatment
- Pruitt SD, Khan R, Chaiyakunapruk N, et al. The silent epidemic of non-adherence – insights from the 2024a:care congress. BMC Proc. 2025;19(Suppl 10):13.
- Religioni U, Barrios-Rodriguez R, Requena P, et al. Enhancing therapy adherence: Impact on clinical outcomes, healthcare costs, and patient quality of life. Medicina. 2025;61(1):153.
- Thompson L, McCabe R. The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review. BMC Psychiatry. 2012;12:87.
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