Post on 17-Dec-2015
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.