1. Nursing 8440 October 15, 2012 Jennifer Bauman, RN, BA, PCCN
Adherence: a concept analysis Janice M. Bissonnette Journal of Advanced Nursing 63(6),
Nursing 8440
October 15, 2012
Jennifer Bauman, RN, BA, PCCN

2. 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).

3. 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)

4. Approach Rodgers’ evolutionary method of concept analysis
Synchronous, non-sequential, non-linear approach
Six phases – see next slide
Multiple databases, Publish dates
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)

5. 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

6. 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?

7. 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

8. 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

9. 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

10. Phase IV: Attributes
Most common: decisional conflict, predictability, personal experience, power, agreement, pervasiveness
Can be used to develop a more reflective and realistic definition

11. 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

12. Phase VI: Related Concepts
Therapeutic alliance, acceptance, and agreement (only one sentence in this analysis)

13. 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.

14. 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).

15. 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).

16. Questions?

17. References
Bissonnette, J.M. (2008). Adherence: a concept analysis. Journal of Advanced Nursing, 63(6), Bowman, Dan. (27 May 2011). Patients not taking medications cost $300B. FierceHealthcare. Accessed October 14, 2012, from Walker, L.O. & Avant, K.C. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle, NJ: Pearson Prentice Hall.