Patient Contracting and Nursing Care

Patient Contracting and Nursing Care Patient Contracting

Patient contracting is an intervention designed to enhance patient adherence to prescribed treatments and behaviors in both practice and research settings. The essence of patient contracting lies in creating a formalized agreement between the patient and the healthcare provider, which outlines specific behaviors the patient agrees to follow and the positive consequences they will receive upon successful adherence. This strategy enables patients to gain insights into their behavior and its relationship with their environment, leading to improved adherence to health-related behaviors such as medication intake, meal planning, and physical activity (Boehm, 1992).

Patient contracting is not only pertinent to nursing practice but also to research, as it provides a structured approach for patients to understand and commit to treatment regimens. By employing this method, nurses and healthcare professionals can help patients manage various aspects of their health, thereby improving their overall health outcomes.

Effectiveness of Patient Contracting

The effectiveness of patient contracting has been documented across various settings and health conditions. For instance:

  1. Dialysis Patients: In studies involving patients undergoing dialysis, patient contracting was used to control serum potassium and phosphorus levels. The approach led to significant improvements in managing these critical levels (Steckel, 1974; Laidlaw, Beeken, Whitney, & Reyes, 1999).
  2. Contraceptive Use: Among sexually active college women, patient contracting successfully increased knowledge and consistency in the use of contraceptive methods, demonstrating its effectiveness in educational and preventive health contexts (Van Dover, 1986).
  3. Hypertension Management: For hypertensive outpatients, patient contracting helped in increasing knowledge, ensuring appointment adherence, and reducing diastolic blood pressure (Steckel & Swain, 1977; Swain & Steckel, 1981).
  4. Chronic Conditions: In patients with chronic conditions such as arthritis, diabetes, and hypertension, patient contracting facilitated appointment adherence, weight loss, and blood pressure reduction (Steckel & Funnell, 1981).

However, patient contracting has had mixed results in some areas. For example, it did not significantly impact blood glucose and glycosylated hemoglobin levels in diabetic patients, indicating that while patient contracting can be effective, its impact may vary depending on the condition and context (Boehm, Schlenk, Raleigh, & Ronis, 1993; Morgan, BS, & Littell, 1988; Steckel & Funnell).

Patient Contract and Nursing

Patient contracting in nursing involves a collaborative process where the nurse and patient develop a written, signed agreement that details the behaviors the patient will engage in and the positive consequences that will follow successful adherence. This contract is a manifestation of the principle of positive reinforcement, which posits that behaviors followed by rewarding outcomes are more likely to be repeated (Boehm, 1992).

In practice, patient contracting requires the nurse to guide the patient in choosing both the behaviors to be modified and the rewards for achieving these behaviors. This collaborative approach ensures that the contract is tailored to the patient’s needs and preferences, enhancing its effectiveness.

Nursing Process and Patient Contract

The nursing process provides the framework for developing and implementing patient contracts. This process involves several stages:

  1. Assessment: The nurse assesses the patient’s current behaviors, health status, and needs. This assessment helps in identifying the adherence behaviors that need to be targeted and the steps required to achieve them.
  2. Planning: Based on the assessment, the nurse and patient collaborate to create a patient contract. The contract specifies the behaviors to be modified, the small steps involved, and the positive reinforcements that will be used.
  3. Implementation: The patient begins to follow the contract, and the nurse provides support and encouragement. This phase involves monitoring the patient’s progress and making adjustments to the contract as needed.
  4. Evaluation: The nurse evaluates the effectiveness of the patient contract by reviewing the patient’s adherence to the agreed behaviors and the impact on their health outcomes. This evaluation helps in refining the contract and improving future interventions.

The adherence behavior, which is often complex, is broken down into smaller, manageable steps. Through successive patient contracts, patients progressively learn and achieve the desired behavior. Initially, contracts may focus on self-monitoring to identify the steps and factors affecting adherence. Later contracts may involve strategies such as arranging antecedent events, practicing small steps, and ensuring positive consequences (Boehm, 1992).

Patient Contract and Behavioral Analysis

Behavioral analysis forms the foundation of patient contracting. It involves observing, recording, and analyzing the patient’s behavior to understand the patterns of adherence and the factors influencing it. The process includes:

  1. Self-Monitoring: Patients track their own behavior, providing baseline data that helps in understanding their current adherence levels and the factors affecting them.
  2. Behavioral Observation: The nurse uses the self-monitoring data to identify antecedent events (triggers for the behavior), the small steps involved in the behavior, and the consequences that follow.
  3. Behavioral Strategy Development: Based on the analysis, strategies are developed to help patients improve their adherence. This may involve modifying antecedent events, breaking down behaviors into smaller steps, and arranging positive consequences (Boehm, 1992).

Behavioral analysis helps in identifying the small steps that comprise the adherence behavior. By focusing on these small steps, patients can gradually achieve the overall behavior. For instance, a patient starting a walking program might begin with a short duration and gradually increase the time and frequency of walking as they progress.

Purposes of Behavioral Analysis

The primary purposes of behavioral analysis in patient contracting are:

  1. Identifying Small Steps: Behavioral analysis helps in breaking down complex behaviors into smaller, manageable steps. This gradual approach makes the behavior change process less overwhelming for patients.
  2. Guiding Behavior Change: By understanding the small steps and the factors influencing adherence, behavioral strategies can be developed to support patients in making and maintaining changes.
  3. Providing Feedback: Self-monitoring provides feedback on the effectiveness of the behavioral strategies, allowing for adjustments and improvements in the patient contract.

For example, sedentary patients may start by walking for a few minutes and gradually increase their walking duration. This step-by-step approach helps in building confidence and ensuring sustained adherence to the behavior.

Positive Reinforcement as a Behavioral Strategy

Positive reinforcement is a key strategy in patient contracting. It involves providing a rewarding consequence for performing the desired behavior, which increases the likelihood of the behavior being repeated. Positive reinforcement can take various forms:

  1. Pleasant Items and Activities: Rewards may include enjoyable items or activities that the patient values.
  2. Social Reinforcement: Praise and encouragement from others can reinforce positive behaviors.
  3. Cognitive Reinforcement: Feelings of pride and accomplishment can serve as cognitive rewards.

In contrast, eliminating positive reinforcement can be used to decrease or extinguish undesired behaviors. For example, if a patient is not adhering to a dietary plan, not receiving social reinforcement for eating healthy may help in modifying their behavior.

Changes in Strategies for Patient Contracting

Future research and developments in patient contracting may focus on several areas:

  1. Frequency of Contact: Studies are needed to determine the optimal frequency of contact with patients to effect progressive changes in adherence interventions.
  2. Maintenance Phase: Research should explore the use of patient contracting during the maintenance phase of adherence interventions to understand its long-term impact.
  3. Electronic Self-Monitoring: Utilizing modern technology, such as personal digital assistants or Internet websites, for electronic self-monitoring could enhance the patient contracting process.
  4. Objective Measures: Incorporating objective measures, such as electronic event monitors for medication adherence and accelerometers or pedometers for physical activity, could provide more accurate assessments of adherence behaviors.

In conclusion, patient contracting is a valuable intervention in nursing care that promotes adherence to treatment regimens. By using behavioral analysis and positive reinforcement, nurses can help patients achieve and maintain desired behaviors, ultimately improving their health outcomes. Future research and advancements in technology hold the potential to further enhance the effectiveness of patient contracting strategies.

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