Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions

Abstract

Kidney transplantation is considered the best therapeutic option and survival is dependent on adherence to the drug regimen. Adherence to the therapeutic regime thus becomes the key to success. However, the literature shows that not all patients are adherent, and readmission due to graft dysfunction is a reality. Although a direct relationship between adherence to the therapeutic regimen and graft dysfunction cannot be attributed, the issue of adherence is far from not deserving the attention of health professionals. This text aims to identify the importance of nursing interventions in promoting adherence to the therapeutic regimen. In an exploratory approach to the process of adherence, and reflecting on concordance and its relevance to adherence, given the heterogeneity of both definitions, we aimed to study the nurses’ role and the type of interventions to promote adherence to the therapeutic regimen in transplanted renal patients. We conclude that education and counselling are the predominant interventions and that concordance is part of this practice, where the expected outcome is kidney graft survival as a consequence of adherence to the therapeutic regimen.

1. Introduction

Kidney transplantation is recognised in the medical literature as the best therapeutic option in end-stage chronic kidney disease [1, 2].

There are both clinical and non-clinical reasons to believe that kidney transplantation is beneficial for the person with end-stage renal disease because it reduces cardiovascular risk from 9.0 to 3.5–5.0% per year for patients who remain on dialysis. Added to this are the numerous benefits associated with better quality of life, more freedom (not being dependent on dialysis), more time for daily activities (time gained from not being dependent on dialysis), reduced symptoms such as fatigue, sleep disturbances and, as hypothesised, more work activity [3, 4].

Adherence to the therapeutic regimen of transplanted kidney patients is fundamental in preventing kidney graft rejection, complications, and re-hospitalisations with increased costs for the person and the health system [5].

There is much evidence of the importance of adherence to the therapeutic regimen for kidney transplant patients, highlighting the consequences of non-adherence and giving depth to the benefits that adherence evokes, linking it to processes of well-being and good health.

The direct relationship between adherence and satisfactory health outcomes is perceived, and there are numerous references that report changing behaviours, modifying diet, managing medication, changing routines, and adopting healthy lifestyles, as a bridge to a long life with the kidney graft and better quality of life [6, 7, 8].

An indispensable component of kidney graft survival is adherence to the therapeutic regimen, which, although it extends beyond medication adherence to include dietary compliance and lifestyle changes, has mainly been studied on the pharmacological side [9, 10, 11, 12].

In one study the authors state that the probability of losing the kidney graft is seven times higher in the group of people not adherent to immunosuppressive medication, a reason in itself sufficient to capture the attention of the scientific community [3].

Some studies have tried to provide an empirical response to this problem, focusing on other aspects that are part of the therapeutic regimen. The results of the study by Gheih and colleagues reveal a clear preference of participants for the adherence to immunosuppressive medication (97.0%), but also show high values of adherence to low-fat diet (73.0%), infection prevention (89.0%), mouth care (brushing of teeth after meals) (37.0%), and physical exercise (walking) (23.0%). Lower adherence values were found in the activities related to monitoring water intake (12.0%), blood pressure (10.0%), temperature (6.0%), and urine output monitoring (2.0%) [7].

Adhikari and colleagues consider that lifestyle modifications have a high weighting in the success of kidney transplantation, however, the levels of adherence achieved by participants for all lifestyle dimensions assessed were low (64.1%), although with strong expression in some dimensions, particularly with regard to self-monitoring (89.54%), medical appointments (88.23%), infection prevention (93.46%), and dietary compliance (83.66%) [8].

These results seem to be in line with what we have previously said about the possible relationship between kidney graft survival and adherence to the therapeutic regimen in its broadest sense.

In this field of intervention, the multiplicity of factors associated with therapeutic adherence moves different actors and approaches. Innovative and pioneering, some projects evoke the individual and collective dimension of action [13, 14, 15, 16].

It is interesting to mention that the individual action of a health professional does not potentiate change, but the articulation between health professionals. Change occurs thanks to the action of the individual and groups, such as health professionals, family, network of friends, amongst others.

From time to time there are also great leaps due to social, economic, and political transformations, but it is necessary to invest at a personal level (of the individual and their families) since individual and collective investments are dimensions that coexist, interact, and complement each other, being essential for the success of adherence to the therapeutic regime.

Thus, we have a clear perception of the need for interdependence between all participants in the process. The awareness of the existence of multiple actors and interdependencies in changing behaviours and lifestyles and the respect for each one’s field of intervention is a common emphasis amongst nurses.

This professional group often assumes the pivotal position by managing the therapeutic plan with the patient and his/her family, which often involves the orientations of different professionals. All are the reason for success or failure, in a process whose dynamics is made of this interaction [17].

But the most important result with regard to practices promoting adherence to the therapeutic regimen is the empowerment of the patient and compliance with that regimen.

Adherence to the therapeutic regimen involves transitions and adaptations, which brings us to a great challenge if we consider that the trends verified in the literature consecrate a low adherence or non-adherence to the therapeutic regimen.

According to the World Health Organisation (WHO) about 50.0% of chronically ill patients do not adhere to the therapeutic regimen [18].

The literature gives us a clear idea of the prevalence of non-adherence amongst kidney transplant recipients (28.0%) and the implications of non-adherence to immunosuppressive therapy on health outcomes, episodes of graft rejection (20.0%) and organ loss (16.0%) [19].

A second point to be considered is the method used to measure adherence to therapy. The values vary between 2.0 and 67.0%, and the causes of conditioning adherence to the announced values are strongly linked to the operationalisation of the definitions and the measurement methods used. The indicators of adherence used vary between “taking compliance”, “dosing compliance”, “timing compliance”, amongst others.

The methods used include electronic monitoring, which also differ, such as the Medication Event Monitoring System (MEMS), the Short Message Service (SMS) and, more recently, technology based on digestible Integrated Circuits (ICs). Additionally, traditional methods such as patient reports and diaries, direct observation of therapy administration, pill counting, measurement of the concentration of the drug or its metabolite in the blood, and measurement of a biomarker in the blood are also used [20, 21, 22, 23].

These two aspects of therapeutic adherence, although distinct, are strongly interconnected. In fact, the traditional method and the more recent methods that employ technology play a primordial role in the context of promoting therapeutic adherence in individuals. Conversely, we could say that the variety of methods does not give us a single standard, the desired gold standard, central to a consensual explanation of therapeutic adherence by the scientific community.

Although international statistics are not very favourable in this area, the therapeutic alliance between the kidney transplant patient and the nurse, marked by their proximity, may intensify the relationship, translating into a greater capacity of the patient to manage his/her therapeutic regimen and annul the interferences and obstacles that contribute to non-adherence.

But what is meant by medication adherence and therapeutic adherence?

The concept has evolved over time, but there is no consensus amongst authors on its definition. The literature offers us different perspectives of therapeutic adherence, as we will see below.

2. Definition of adherence therapeutic

As previously stated, the definition of adherence to the therapeutic regimen is not consensual amongst authors and has evolved over time [24].

It has captured the interest of the scientific community, but although numerous studies from different disciplines have been developed to explain the phenomenon, it is still a worldwide problem.

For the nursing discipline, and based on the International Council of Nurses (ICN) definition, adherence to the therapeutic regimen is defined as adherence behaviour in a broader perspective, namely: “self-initiated action to promote well-being; recovery and rehabilitation; following guidelines without deviations; engaged in a set of actions or behaviours. Complies with treatment regimen; takes medicines as prescribed; changes behaviour for the better, signs of healing, seeks medicines on indicated date, internalises the value of a health behaviour, and obeys instructions regarding treatment. (Often associated with support from family and people who are important to the client, knowledge about medicines and disease process, client motivation, relationship between health professional and client)” ([25], p. 2).

However, the concept itself is somewhat paradoxical. If adherence is the expected outcome, it should prefigure a patient-centred approach, since one can hardly separate people from their circumstances. This means that the patient will have to be an actor and not just a spectator, to be a subject and not an object, to intervene and not just assist, in other words, the patient should not lose his autonomy in the treatment process. Thus, the importance of the patient’s action in his/her therapeutic process is equated. The perspective is dialectical between the actors and the various levels of contexts. The concept of adherence has demonstrated shortcomings by denying the patient this possibility. The awareness of the importance of the alliance and negotiation between health professionals and patients in managing the therapeutic regimen gives relevance to the concept of concordance, which aggregates all these attributes.

It is interesting to note that the concept of concordance is harmonised with the new paradigm of care provision, person-centred models, which see the individual as participants in their therapeutic process, according to their preferences, values, and expectations. Concordance implies working in partnership with the person [26].

Trust and negotiation are the foundations for building this partnership, where everyone feels involved, concentrating efforts towards a common goal that is possible to achieve due to the work that each one performs within the partnership. In other words, a relationship between equals with shared objectives, as opposed to a paternalistic approach [27].

A second point to be considered is the nurse-patient relationship, taking into account its importance in obtaining and sustaining agreement. The communication established based on trust, articulated with understanding, tolerance, and respect for the patient’s needs, makes that within this framework the care is negotiated and meets the common interests, in a situation of perfect balance [28].

Within the framework of concordance, the understanding between the parties involved in the therapeutic process about the responsibilities from the perspective of assigning the roles that each one will have to assume stands out. The aim is to eliminate the patient’s passivity and empower them to make informed decisions.

Imogene King’s theory of Goal attainment (1981) highlights, based on its process of interaction-transaction, the nurse’s role in helping patients achieve their goals. A key feature of this process is the participation of the nurse and the patient in defining the goals and exploring the resources to achieve them. This is in line with the principles and philosophy of the nursing profession itself, i.e., empowering the patient for self-care [29].

Returning to the issue of therapeutic regime management one can glimpse that skills and competencies are needed to manage the therapeutic regime and that often these skills have to be learned, being in fact a self-care activity. In a situation of interaction between nurse and patient, it is up to both to assess the patient’s ability to manage his/her therapeutic regimen. Concordance establishes the therapeutic alliance between the patient and the nurse, a relationship of equals, however, the patient is recognised as the expert of his/her own life. Defending this vision, the World Health Organisation (WHO), in the Ottawa Convention (1986), ratified the fundamental right of all people to be part of their own health care. From then on, the patient’s autonomy came to occupy a prominent place in nursing care [30].

For both, there are no longer margins or spaces where asymmetric power relations could emerge. In the last 30 years, the relationship between patients and health professionals has undergone important changes, with the patient assuming greater control in his/her health decisions. This relationship is also closely associated with the disease model that dominates each era [31].

The new model of care, centred on the patient and based on a holistic perspective, seeks to explore the patient’s perspectives and expectations, and understand them in their particular context. It implies sharing responsibility, involving the patient in decisions, and making him/her responsible for his/her health [32]. This model assumes great importance, especially at a time marked by the upsurge of chronic and lifestyle-related diseases [33].

We thus asked ourselves about the place of concordance in the practice of care in the promotion of behaviours of adherence to the therapeutic regime. Does the model have the effervescence and synergy that have permeated practices in recent decades? (I am only quoting the paternalistic model that still prevails in our health institutions) How have care practices been configured in the new model of care provision?

Authors such as Snowden [26], Gardner [34], point out that concordance is in simultaneity with the principles and values of the nursing profession when they “make the care of people your first concern, treating them as individuals and respecting their dignity^“ ([35], p. 2).

As a response to a care context marked by the holistic model as opposed to the previous approach, which proved to be an inefficient model, today we witness an interest in the centrality of the patient in the disease process and in meeting their needs. For Beresford [36], in order to optimise concordance, holism should be the goal of care provision and communication should be the heart of patient-centred care [37].

This new model of care is, however, a challenge in clinical settings, as patients move to other settings, whether to other healthcare institutions or to home. This increases the difficulty in negotiating the goals and the means to achieve them.

However, it is important to situate this positions between professionals and patients in a context of growing uncertainty which, from the point of view of care production, are increasing, such as new economic issues and new publics, in which in the same sociological profile of the public different ways of seeing may be inscribed.

However, it is public knowledge that health outcomes improve when patients are involved in their therapeutic process, working together with health professionals, as resources are used more effectively and efficiently. On the other hand, professionals feel more satisfied because their work has contributed to improving those outcomes. For the Health Department, the articulation of these two aspects shows that patients and health professionals are stakeholders in the success of concordance throughout nursing practice [38].

In line with a profession that values the uniqueness of the patient, which favours active listening, and advocates on behalf of the patient, we sought to analyse which nursing interventions are implemented by nurses to promote therapeutic adherence.

According to Giddens’ sociology, true shared decision-making results from the sharing of power. For the author, power is defined as the ability to “make it happen”, to “produce effects” in the societal world. If power is the ability to influence a course of events, in this particular case of the transition of the recently transplanted patient from hospital to home, resources are any strategies that increase this ability of the patient, that is, that provide the patient with the necessary tools to manage his therapeutic regimen [39].

Interestingly, despite advocating a patient-centred care model, in the concordance equation, the patients’ non-participation in their therapeutic process is in the numerator, i.e., the part of the number in which concordance is used by health professionals, in this case, nurses. According to the literature, one of the common complaints of patients is that their opinions, needs, and expectations are not considered in decisions about their health [40].

It thus seems plausible to argue that concordance-based care exponentially increases the chance of adherence, whilst the opposite may eventually contribute to non-adherence to the therapeutic regime.

There is a plethora of studies addressing this issue, showing the magnitude of its intensity on the patient and the health system.

Non-adherence behaviours lead to inadequate control of the disease, putting the patient at great risk due to the emergence of adverse effects.

Dew and colleagues studied the non-adherence rates of all types of organ transplantation, and, strangely, despite the high number of non-adherent transplant recipients across the various dimensions of the therapeutic regimen, the number of kidney transplant representative’s non-adherent to immunosuppressive medication rises relative to other recipients (36 cases per 100 patients per Year vs. 7 to 15 cases) [41].

Life expectancy also decreases four times more in the group of non-adherent transplant recipients [42]. We are thus elucidated about one of the striking features of the international reality in the field of adherence to the therapeutic regime, without exception. Added to this is the problem of growing discontinuity between healthcare services (although in recent years there are signs that this trend is being reversed, with a gradual increase in the articulation between healthcare institutions and patient follow-up).

Chronic illness, because it persists over time, requires continuous monitoring by health professionals in order to promote adherence to the therapeutic regime [43].

Two distinct but overlapping notions lead us to the concept of self-management and self-care. Indeed, we found that the term self-management is associated with the term self-care and, precisely in chronic diseases, aims to help patients maintain their well-being. It should be noted that chronic disease follows a trajectory marked by transitions and adaptations that involves a set of activities, such as medication management, adherence to a specific diet, changes in behaviours and lifestyles, which requires the action of the patient and the health professional to ensure an active life and a higher quality of life [44].

This would reinforce the proximity of adherence to the notions of self-management and self-care. We draw attention to the fact that both terms have the same purpose as adherence: to establish care partnerships and enable or empower the patient to take action.

Considering the transition as a medical and nursing phenomenon, nurses should analyse the present and predictable effects of the transition to transplantation. Transplant recipients have many tasks to perform: taking medication (according to medical prescription), changes in lifestyle, including diet, physical exercise, monitoring of signs and symptoms of organ rejection, monitoring of complications (infections), monitoring of fluid intake and elimination, monitoring of blood pressure and blood glucose, performance of complementary diagnostic tests, visits to consultations, smoking cessation, management of stress and emotions, and performance of other self-care activities essential to a good health status [6, 7, 8].

Briefly, after kidney transplantation, adaptation to the new condition creates the need for organ recipients, now in a newly acquired situation, to integrate the recommendations of the therapeutic regimen regarding immunosuppressive medication, lifestyles, routines, social roles, and emotional challenges [45].

Indeed, adherence becomes the major reason to ensure the survival of the kidney graft without the trade-off of losing the organ due to inadequate self-care. If patients can understand the importance of therapeutic compliance, they can also begin to understand its implications on their lives at various levels [46].

We cannot but agree with the statement of these authors regarding the relevance of adherence to the therapeutic regimen as a means to counteract the harmful consequences of non-adherence and to recognise the nurse’s intervention as vital, as it may contribute to the perception of the change that begins in the transition to the new condition, that is, when the person is admitted for transplantation.

In fact, according to their role in the health team, nurses play a central role in the management of the therapeutic regime, identifying difficulties and constraints, integrating the different aspects of the therapeutic regime, and constituting themselves as partners and resources [17].

According to the WHO, nurses are in a privileged position to diagnose, intervene, and assess results in aspects related to therapeutic adherence [18].

Evidently, the role of nurses is a key element in the framework of therapeutic adherence [47, 48], which calls for educational and behavioural strategies to promote adherence.

In addition to nurses, the presence of other health professionals, family, communities, and society are fundamental to promote adherence. Thus, a field of proposals is created in which the transplanted person will learn to manage his therapeutic regimen according to his needs [36].

Following the above, our objective is to identify the nursing interventions that promote therapeutic adherence amongst kidney transplant recipients, which leads us to the following research question: What are the nursing interventions that promote therapeutic adherence amongst kidney transplant recipients?

In the following section, we aim to answer this question.

3. Nursing interventions to promote adherence therapeutic

Therapeutic adherence is a current issue and is part of the “habitus” of nursing professionals’ actions, with terms such as “information”, “education”, “partnership”, “self-care”, and “empowerment” as frames of reference; in short, the essential components for therapeutic self-management.

Aiming to identify in the literature the nursing interventions promoting adherence to the therapeutic regimen, we used Bleser and colleagues’ classification for this purpose [49]:

1. Educational/cognitive interventions that communicate information related to kidney transplantation, by telephone, email, face-to-face, in written or verbal form.

2. Counselling/behavioural interventions, which aim to direct, adapt, and promote appropriate adherence behaviours.

3. Psycho-affective interventions, which include social support from significant others and health professionals.

We also determined the level of intervention according to the ecological model of McLeroy and colleagues [50]. For the authors, interventions can be classified into four levels, namely:

1. Patient level Interventions, directed only to the sick person, which include the above-mentioned categories of intervention (educational/cognitive, counselling/behaviour, and psychologic/affective Interventions).

2. Interventions at the micro level or interpersonal level, which refer to strategies focused on the patient/health care professional interaction, such as the perception of the quality of the relationship between them and the communication style practiced.

3. Interventions at the meso level, which are related to the characteristics of the health care organisation where care occurs, hospital or other health care institution, for example, how continuity of care is ensured or the articulation of skills amongst professionals.

4. Interventions at the macro level, which refer to interventions focused on the health system or the community where the patient lives, for example, health insurance, the patient’s expenditure on medication and, finally, the combination of the different levels reported interventions integrating more than one of the levels described.

Studies were found in the literature showing education as a resource to empower the patient and enable him/her to self-manage the therapeutic regime.

Several theories and theoretical models are at the basis of these educational programs. And, although adherence to the therapeutic regimen is a multidisciplinary work, in this case we only portray the nurse’s role in this process.

Table 1 shows the interventions developed by nursing professionals to promote adherence to the therapeutic regimen.

Interventions	Dimensions			Level
	Cognitive-INFORMATIONAL	Behaviour	Affective
Educational plan specific to each identified learning style (visual, aural, read/write, kinesthetic) and educational sessions [51].	Informative sessions; Video presentation; Orientation manual	Nurse couselling		Patient-individual
Transplant-TAVIE 3 interactive Web-based sessions.; Virtual nurse based on Social Learning Theory and Behaviour Changes Techniques [52]	Teaching, feedback; Role models (experiences of others’ patients)	Positive Reinforcement	Social interaction	Patient-individual
SystemCHANGE Interventions used the Deming’s Plan-Do-Check-Act to redesign personal environment system and daily health behaviour routines.; Educational Intervention. Using healthy living transplant brochures-Control Group; In-person visit; Telephone calls	Education; SystemCHANGE teaches patients to use person-level.; Quality improvement strategies to link adherence to established daily routines, environmental cues, and supportive people.; Attention Control (Patient Education) Transplant Health-Related Brochures.; Report	In-person visit; Small experiments of medical adherence solutions.	Nurse Orientation; Telephone calls to receive feedback (report) and discuss.; Telephone call to review transplant-related education materials.; Support of significant others.; Assess individual system and environment (SystemCHANGE).; Assess MA (EM); Feedback	Patient (individual) micro (immediate environmental setting of family, peers, health services, workplace).; Meso (interrelations between family, health care provider, employer)
The Disease Guidance Manual delivered on admission.; Health education; Nursing intervention based on Health Believe Model.; Sign behaviour agreement; Daily record; Follow-up: Phone, WeChat/SMS [15].	The Disease Guidance Manual; Report	HBM education; Feedback	Give encouragement about behaviour change.; Interaction: Telephone call WeChat SMS Family support	Patient, micro; Meso

Table 1.

Interventions developed by nursing professionals to promote adherence to the therapeutic regímen.

The data analysed show us that there are two types of interventions to improve therapeutic adherence: educational and behavioural interventions.

Education is the privileged intervention in most studies, but the way it is administered, and the contents taught show some different contours between the studies.

Information and communication technologies are essential tools for education and training, imposing greater autonomy to the patient.

This generates the need for nursing professionals to develop flexible education programs in which the internet and multimedia resources gain relevance. Video is one of the resources widely used by nursing professionals [51].

Educational interventions promote the knowledge of the person and/or caregiver about the disease and treatment, using a diversity of tools, whether paper-based, audiovisual, social media, or discussion.

On the other hand, behavioural interventions aim to help the person gain skills and/or competencies through training, counselling to manage their therapeutic regime.

Rocha and colleagues formulate an educational plan that was based on the learning styles of each participant. The methods used varied between subjects, and the privileged dimensions were cognitive and behavioural. The results showed an increase in medication adherence from the first to third meeting: 16.9% (in the first), 66.1% (in the second), and 79.9% (in the third). The construction of the educational plan was elaborated collaboratively, taking into account the subject’s own characteristics, and demonstrated health gains for the patient [51].

The same attitude was taken by Cotê and collegues. In this case, the authors used information technologies, creating an interactive website—Virtual Nurse. The expected results were achieved, namely medication adherence and self-efficacy. Participants found the individualised education interventions to be personalised, easy to understand and self-efficacy promoting. Medication adherence (11.4, range 1–12) and self-efficacy (81.3, range 0–100) scores were high. Perceived health status and quality of life similarly achieved high scores (8.3, in a range of 0–10) [52].

The study by Russell and colleagues implemented an innovative education system, SystemCHANGE, which included home visits and telephone calls. In this system one can observe negotiation as an essential strategy in goal setting and discussion as one of the means to define resources and solutions to identified problems. The results showed differences between the experimental group and the control group in medication adherence at 12 months (large differences in medians, 0.17, 95% CI, 0.06–0.33, p < .001). Program implementation lasted six months and follow-up was twelve months [15].

However, achieving adherence to therapy, patient involvement and ensuring the survival of the kidney graft requires knowledge and information. This involves informing, educating, and training the patient and/or caregiver to carry out this task. Precisely education and training are fundamental bases for any society.

We have found that listening to the sick person, respecting them, and having an attitude of trust are the bases for adherence. Telephone contact, email, or face-to-face contact are some strategies that facilitate this process. The active involvement of the person in his treatment is the best strategy for its success [53].

The sequence of such actions is reflected in patient autonomy, the elimination of barriers between health professionals and patients, the relationship between the two parties, and the facilitation of access by all citizens to the resources of the health system, the community and society in general.

Although adherence to the therapeutic regimen is an internationally recognised problem and the ways to solve it have already been studied, there are still problems whose impact is negative for the patient and for society.

4. Conclusion

It can be stated that the issue of adherence to the therapeutic regimen is one of the striking phenomena of kidney transplantation, transversal to all types of organ transplantation, which extends far beyond the simple management of medication, requiring an intervention of all health professionals along the trajectory of the disease in order to empower the patient and/or his family.

Although in recent years there are signs that this trend may be receding in some places, based on a plethora of studies which continue to show the existence of the problem at still high levels of non-adherence, we are generally witnessing the emergence of new models of care which, in themselves, facilitate adherence to the therapeutic regimen.

Within the emerging new models, studies show the importance of the nurses’ role in promoting adherence behaviours, which is an inherent characteristic of the profession itself. Nursing care is, by its essence, holistic care, based on communication and therapeutic alliance. Negotiation is a sine qua non condition of this process.

Nurses seek to know the response patterns of the ill person and/or caregiver to the disease or problem that affects them, because only in this way they can help them face that situation. The knowledge of the patients and/or caregivers’ needs and difficulties and their potential for autonomy allow for the development of a plan adjusted to these needs. Indeed, all clinical practices are guided by the needs of patients, and kidney transplantation is a real challenge for the patient and his or her family, involving many issues that are fundamental for success. Learning to deal with all these aspects requires knowledge acquisition, skills training, and coaching. The emotional needs connected with all the change must be emphasised, in addition to the stress that uncertainty and change provoke. The aim is to work out a plan with the patient and/or caregiver that allows him/her to make a healthy transition and ensure stability for the new role.

Education and counselling were the most commonly developed interventions by nurses after kidney transplantation. However, since most studies focused on medication adherence and the follow-up period did not exceed 12 months, it is important to develop longitudinal studies to measure the long-term effect of these programmes on kidney transplant survival. On the other hand, the heterogeneity of the instruments used does not ensure that a measurement standard is obtained, nor does it allow knowing the true effect of the interventions developed on adherence to the therapeutic regimen and their long-term impact.

5. Implications for practice

Working on the issue of therapeutic adherence within the new paradigm of health care is essential for the survival of the health system, taking into account the expenditure on health care with chronic diseases resulting from a population living longer and longer. Nurses, due to their characteristics, are equipped with the essential tools to work with patients in the search for the best solutions to their problems/health condition.

Some countries, such as the United Kingdom, are aware that the way forward is to educate, inform, and involve the patient and their family, preparing them to take care of themselves. The nurse, as an agent of change and educator, is in the right place and position to develop this role.

At the end of this reflective journey, we found that the issue of adherence to the therapeutic regimen in kidney transplantation leads to several disruptions, namely the change of perspective in the formulation of the care plan and the long-term follow-up of these patients.

The first rupture related to the care plan is to include the patient in the planning process and offer him/her the information and knowledge he/she needs to make a decision based on the best available evidence. The second rupture is to accompany the patient throughout this process, in favour of the idea of a transition process with an extended temporality. The aim is to ensure a transition whereby individuals emerge endowed with autonomy and are able to obtain the desired result: the success of the transplant.

Conflict of interest

The authors declare no conflict of interest.