Adherence: a concept analysisJanice M. BissonnetteJournal of Advanced Nursing 63(6), 634-643

Nursing 8440October 15, 2012Jennifer Bauman, RN, BA, PCCN

Background 2003 WHO initiative to improve rates of adherence

to therapies for chronic conditions Cost of non-adherence to medication therapy: $300

billion (Bowman, 2011)

“Despite agreement across health disciplines regarding the significance of the phenomenon of adherence, the definition of the concept of adherence is vague and ambiguous, and there is little agreement either within or among disciplines on a conceptual definition of adherence”(Bissonnette, 2008, p. 635).

Definition In literature, adherence used synonymously with

compliance, which has a paternalistic undertone Definitions of adherence are varied (p. 635)

“The extent to which patients follow instructions” (Haynes et al. 2005)

“Binding oneself to observance” (Webster’s 1995) “The extend to which a person’s actions or behaviour

coincides with advice or instruction” (Christensen 2004) “A collaboration to achieve mutually derived goals”

(Rose et al. 2000) “A voluntary collaborative relationship” (Chisholm

2000)

Approach Rodgers’ evolutionary method of concept analysis Synchronous, non-sequential, non-linear approach Six phases – see next slide Multiple databases, Publish dates 1970-2007 MeSH terms used: adherence, non-adherence,

treatment refusal 53 papers included, broad and representative

sample from each discipline Rodgers recommended 30 minimum items for

concept analysis

Phase IIdentification and

name of concept of interest: Adherence

Phase IIIdentificati

on of surrogate terms and relevant issues

Phase IIIAdherence

related systematic

data collectionPhase IV

Identification of attributes

associated with adherence

Phase VIdentificatio

n of the reference,

antecedents, and

consequences of

adherence

Phase VIIdentificati

on of related

concepts

Questions1. Is adherence conceptualized differently among the disciplines of nursing, medicine, psychology, and pharmacy?2. What attributes, antecedents, and consequences apply to the concept of adherence?3. What surrogate terms and related concepts are used?4. Is the use of adherence by health disciplines reflective of the language and definition identified in the literature?

Phase I: Name and Define• Adherence associated with compliance,

concordance, obedience, observance, conformity, acceptance, co-operation, mutuality, therapeutic alliance

• Health care definition from Haynes et al. (2005): “the extent to which patients follow the instructions they are given for prescribed treatments” (p. 636).

• NANDA diagnosis of non-compliance in 1973• Compliance Adherence Concordance

Phase II: Surrogate Terms Surrogate terms “serve as manifestations or

expressions of the concept, or similar terms used to express more than one concept” (p. 637). Differentiate the concept of interest from others For adherence: concordance, agreement,

cooperation, partnership

Phase III: Data Perspective and use of adherence from each

discipline Clarify concept, identify contextual variations Nursing: holistic, contextual, personal

characteristics; most use adherence Psychology: both adherence and compliance,

relationship between patient non-adherence and embarrassment, providers’ reluctance to address

Medicine: synonymous use of adherence and compliance, statistical, measurement tools, behavior of patients, predict/measure/intervene

Pharmacy: very much like medicine, focus on developing tools to measure, active and collaborative relationship

Phase IV: Attributes

Most common: decisional conflict, predictability, personal experience, power, agreement, pervasiveness

Can be used to develop a more reflective and realistic definition

Phase V: Reference, Antecedents, Consequences

Reference (Theme?): Healthcare professionals regarded by patients as knowledgeable sources of information about treatment, willingness of patient to accept all or part of prescription

Antecedent: prescribed medication regimen Consequences:

Patient-related Healthcare professional-related Healthcare system-related

Phase VI: Related Concepts

Therapeutic alliance, acceptance, and agreement (only one sentence in this analysis)

Result of Analysis No differentiation found between adherence

and compliance. “No definition of adherence was found that

reflects a patient-centered approach, the dynamic nature of adherence behavior, and the power imbalance implied by these terms” (p. 641).

Most research focuses on patients, few on healthcare providers’ perceptions and understandings of adherence, and none on nursing specifically.

Adequacy of Approach Multiple databases, disciplines, wide range of dates Excellent, especially for such an ill-defined, poorly

differentiated, ambiguous, confusing, and dynamic concept such as adherence.

Limitation: lack of (published) literature which clearly defines and differentiates adherence from compliance

Did the analysis serve to clarify, expand, or possibly obfuscate the meaning of the concept? Clarify the lack of definition, differentiation, data. More questions than answers!

Food for Thought Ethical dilemma

“If patients fully understand the consequences of non-adherence, do healthcare professionals have the right to make a judgment about their individual choices?” (p.640)

Is there really a single solution or approach, or is non-adherence part of human behavior?

Patients’ “obedience” to treatment regimens, blaming and accusatory approach to non-adherence

Use of the term “concordance” won’t help anything unless healthcare providers’ attitudes and perceptions change, understanding of patients’ contexts

RCT (randomized controlled trial) vs. qualitative and quasi-experimental

Concept analysis of “concordance” Need a definition of adherence using a “patient-centered

approach reflecting the dynamic nature of adherence behavior and avoiding the power imbalance implied by the term adherence” (p. 641).

Questions?

ReferencesBissonnette, J.M. (2008). Adherence: a concept analysis. Journal of Advanced Nursing, 63(6), 634-643.

Bowman, Dan. (27 May 2011). Patients not taking medications cost $300B. FierceHealthcare. Accessed October 14, 2012, from http://www.fiercehealthcare.com/story/patients-not-taking-medications-cost-300b/2011-05-27.

Walker, L.O. & Avant, K.C. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle, NJ: Pearson Prentice Hall.