Nursing 8440 October 15, 2012 Jennifer Bauman, RN, BA, PCCN Adherence: a concept analysis 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 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). Adherence rates average 50% Little evidence to support various adherence methods Difficult to objectively measure adherence “Some authors suggest that optimizing adherence rates could lead to an increase in the rate of adverse mediation side effects as patients avoid recognizing serious side effects in an effort to follow recommendations as prescribed” (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 Beginning 242 papers, narrowed down to 114 based on relevance to the term adherence and its application in health care (27 nursing/39 psychology/33 medicine/15 pharmacology) Sampling was by choosing every second paper appearing on the search list  53 papers included (15 from mental health, medicine and nursing; 8 from pharmacy)

Identification and name of concept of interest: Adherence Phase I Identification and name of concept of interest: Adherence Phase II Identification of surrogate terms and relevant issues Phase VI Identification of related concepts Phase V Identification of the reference, antecedents, and consequences of adherence Phase III Adherence related systematic data collection Phases of Rodgers’ evolutionary approach, representing the dynamic and inter-relational phases of the concept analysis of adherence Recreated from Bissonnette, 2008, p. 637 Phase IV Identification of attributes associated with adherence

Questions 1. 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 Patient-related: improved morbidity and reduced mortality, conflict resolution, attributional uncertainty, empowerment, improvements in quality of life … also possibly increased morbidity and mortality due to increased side effects Healthcare professional-related: ambivalence towards a patient’s adherence behavior, misinterpretation, disempowerment, acceptance, avoidance of the adherence behavior. Healthcare system-related: decrease in cost and health care service use

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! “However, this [lack of published literature] re-enforces how a concept analysis can identify whether the current definition truly reflects the context of use and meaning adopted by patients and healthcare professionals. The purpose of concept analysis to determine the state of the science surrounding a concept of interest and it is limited in its ability to provide researchers with more than just a perspective based on inconsistencies found in the literature” (Bissonnette, 2008, p. 640).

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?

References Bissonnette, 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.