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Janice M. . Bissonnette. Journal of Advanced Nursing. 63(6), 634-643. Nursing 8440. October 15, 2012. Jennifer Bauman, RN, BA, PCCN. Background. 2003 WHO initiative to improve rates of adherence to therapies for chronic conditions . ID: 720477

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Adherence: a concept analysis

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Adherence: a concept analysisJanice M. BissonnetteJournal of Advanced Nursing 63(6), 634-643
Nursing 8440October 15, 2012Jennifer Bauman, RN, BA, PCCN
Background2003 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 undertoneDefinitions 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)
ApproachRodgers’ evolutionary method of concept analysisSynchronous, non-sequential, non-linear approachSix phases – see next slide Multiple databases, Publish dates 1970-2007
MeSH terms used: adherence, non-adherence, treatment refusal53 papers included, broad and representative sample from each discipline Rodgers recommended 30 minimum items for concept analysis
Phase I
Identification and name of concept of interest: Adherence
Phase II
Identification of surrogate terms and relevant issues
Phase III
Adherence related systematic
data
collection
Phase IV
Identification of attributes associated with adherence
Phase V
Identification of the reference, antecedents, and consequences of adherence
Phase VI
Identification 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 DefineAdherence associated with compliance, concordance, obedience, observance, conformity, acceptance, co-operation, mutuality, therapeutic allianceHealth 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 1973Compliance  Adherence  Concordance
Phase II: Surrogate TermsSurrogate 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 othersFor adherence: concordance, agreement, cooperation, partnership
Phase III: DataPerspective and use of adherence from each disciplineClarify concept, identify contextual variationsNursing: holistic, contextual, personal characteristics; most use adherence
Psychology: both adherence and compliance, relationship between patient non-adherence and embarrassment, providers’ reluctance to addressMedicine: 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
0
Phase IV: AttributesMost common: decisional conflict, predictability, personal experience, power, agreement, pervasivenessCan be used to develop a more reflective and realistic definition
1
Phase V: Reference, Antecedents, ConsequencesReference (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-relatedHealthcare professional-relatedHealthcare system-related
2
Phase VI: Related ConceptsTherapeutic alliance, acceptance, and agreement (only one sentence in this analysis)
3
Result of AnalysisNo 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.
4
Adequacy of ApproachMultiple databases, disciplines, wide range of datesExcellent, 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!
5
Food for ThoughtEthical 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-adherenceUse 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).
6
Questions?
7
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
(5
th
ed.). Upper Saddle, NJ: Pearson Prentice Hall.