Nursing Profession and Adherence and Compliance
What Is Adherence Or Compliance
Adherence is defined as the degree to which behavior corresponds to a recommended therapeutic regimen (Haynes, Taylor, & Sackett, 1979). Numerous terms have been used to describe this behavior, including compliance, therapeutic alliance, and patient cooperation.
Although the literature is filled with
discussion of the acceptability of these terms and the differences between
them, most investigators view the terms as synonymous and independent of the
decision to engage in a particular therapeutic regimen. The most complete
literature can be obtained from structured databases with the term compliance.
Adherence Concept With Health Care And Nursing
Adherence to health care regimens has been discussed in the literature since the days of Plato. However, little systematic attention was given to this phenomenon until the 1970s, when there was a proliferation of research. One of the first reviews of the literature was published in Nursing Research (Marston, 1970).
Since that
time there has been a profusion of research from a variety of disciplines. The
majority of the research has been focused on patient adherence, although there
is a smaller body of literature on the adherence of research staff to clinical
protocols and a growing body of literature on provider adherence to treatment
guidelines.
Some Objections to Adherence
One of the issues that continues to arise in discussions of patient adherence is patient autonomy. Is nonadherence a patient right or is adherence a patient responsibility? This argument presumes that the patient is aware of his or her own behavior and has consciously decided not to follow a treatment regimen.
The literature suggests that fewer than 20% of patients with medication regimens consciously decide not to engage in a treatment program. Those patients who have decided to follow the regimen but do not carry it out are unaware of episodic lapses in behavior or have difficulty in integrating the health care regimen into their lives.
The most common reasons given by patients for lapses
in adherence are forgetting and being too busy. This group comprises on average
40% to 50% or more of patients in a treatment regimen.
In Case of Non-Adherence
The problem of nonadherence is costly in terms of dollars and lives. The national pharmacy council estimates that nonadherence to pharmacological therapies costs approximately $100 billion annually (Grahl, 1994). Although the cost of nonadherence to non-pharmacological therapies has not been estimated, the contribution to morbidity and mortality is high.
Failures to quit smoking, to lose and maintain weight, to exercise regularly, to engage in safe sex practices, to avoid excess alcohol, and to use seat belts contribute significantly to declines in functional abil ity as well as to early mortality.
Further data
suggest that nonadherence to pharmacological as well as nonpharmacological
therapies contributes to excess hospitalization and complication rates
(Dunbar-Jacob & Schlenk, 1996).
Poor Adherence
Poor adherence then is a significant problem of direct relevance to nursing. Nurse practitioners may prescribe or recommend therapies. Home health and community nurses provide education and assistance in carrying out health care advice.
Hospital, clinic, and office nurses provide education regarding treatment
plans. There is a need for intervention studies that will guide practice as
nurses prepare and support patients in the conduct of treatment regimens.
Why Study Adherence or Compliance
Research on adherence has been focused heavily on the determination of the extent of the problem and on predictors or contributing factors.
Recent reports by the Cochrane Collaboration suggested that just 36 randomized controlled studies have evaluated interventions to improve medication adherence and examine both adherence and clinical indicators as outcomes.
Few still have examined adherence to lifestyle behaviors. Most of these used general educational or behavioral counseling interventions. Just 1/3 of the interventions were found to have an effect on both adherence and outcome.
Strategies that showed
effectiveness were those that included components of self-management and/or
enhanced attention by health professionals.
Past Results
One problem in evaluating interventions and identifying relevant predictors is that of measurement. Most clinical studies have relied on self-report of adherence. There is a growing body of evidence indicating that individuals do not report accurately and those reports are biased toward an overestimate of performance.
Thus, alternative strategies are being used to obtain better information, such
as electronic monitors, PDAs and other technologies.
Coming Future
Future research on adherence should address strategies by which nurses can improve adherence to treatment regimens with attention directed toward various age groups, clinical populations, and regimen behaviors.
The research would benefit
from theoretical approaches to the problem of patient adherence and the design
of intervention strategies. Effective strategies delivered by nurses have
considerable promise of a favorable impact on health outcomes and costs
(Dunbar-Jacob & Schlenk, 1996).
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