Compliance and Adherence In Health Care and Nursing Educational Perspectives
Compliance and Adherence Concepts In Health Care Behaviors,Compliance and Adherence In Nursing Education,Nursing Educational Perspectives on Compliance Model.
Compliance and Adherence Concepts In Health Care Behaviors
The concepts of compliance, adherence, and motivation are used implicitly or explicitly in many health behavior models. This chapter discusses these concepts as they relate to health behaviors of the learner and presents an overview of selected theories and models for consideration in the teaching learning process. The nurse as educator needs to understand which factors promote or hinder the acquisition and application of knowledge and what drives the learner to learn.
Factors that determine health behaviors and outcomes are complex. Knowledge alone does not guarantee that the learner will engage in health promoting behaviors or that the desired outcomes will be achieved. The most well-thought-out educational program or plan of care cannot achieve the prescribed goals if the learner is not understood in the context of complex factors associated with compliance, adherence, and motivation.
Compliance and Adherence In Nursing Education
The terms compliance and adherence are often used interchangeably in the literature to refer to a patient’s effort to follow healthcare advice (Brown & Bussell, 2011; Robinson, Callister, Berry, & Dearing, 2008). However, these terms imply different views about the healthcare provider patient relationship.
Compliance is defined as the “extent to which the patient’s behavior (in terms of taking medications, following diets or executing other lifestyle changes) coincides with the clinical advice” (Sackett & Haynes, 1976, p. 11). According to the Merriam-Webster dictionary (2015b), compliance means “the act or process of complying to a desire, demand, proposal, or regimen or to coercion; a disposition to yield to others.
Defined as such, it has an authoritative undertone. Specifically, when applied to health care, it implies that the healthcare provider or educator is viewed as the authority, and the patient or learner is in a submissive role, passively following recommendations. Many nurses object to this hierarchical stance because they believe that patients have the right to make their own healthcare decisions and not necessarily follow predetermined courses of action set by health-care professionals.
Adherence, according to the World Health Organization, is “the extent to which a person’s behavior corresponds with agreed recommendations from a health care provider” (Sabaté, 2003, p. 3), such as taking medication, following a diet, and/or executing lifestyle changes.
Mihalko et al. (2004) define adherence as “level of participation achieved in a behavioral regimen once an individual has agreed to the regimen” (p. 448), and Hernshaw and Lidenmeyer (2006) describe adherence as the degree to which the patient follows the plan of care formulated in conjunction with the healthcare provider.
Furthermore, the Merriam Webster dictionary (2015a) defines adherence as “the act, action, or quality of adhering: steady or faithful attachment.” suggesting the need for the patient to attach and commit to the healthcare regimen.
These definitions address the need for patients to be involved in treatment decisions, which is quite different from passively following the healthcare providers’ prescriptions. The presumption with adherence is that the patient agrees with a recommendation put forth (Brown & Bussell, 2011).
During the 1990s, the terminology in the literature began to shift from compliance to adherence (Gardner, 2015), supporting a more inclusive and active patient role. The term adherence is considered more patient centered than compliance (Vlasnik, Aliotta, & DeLor, 2005) because it supports the patient’s right to choose whether to follow treatment recommendations.
Both compliance and adherence refer to the ability to maintain health promoting regimens, which are determined by the health care provider or in conjunction with the health-care provider, respectively. It is possible, though, for an individual to initially comply with a regimen but not necessarily be committed to it. For example, a patient who is experiencing sleep disturbances may comply for a short period of time with medication as directed.
The same patient, however, may not continue to adhere to the regimen for an extended time, even though his sleep disturbances continue. In this situation, there is temporary support of the plan but no commitment to follow through.
Because both compliance and adherence are terms commonly used in the measurement of health outcomes, they are often used synonymously in the literature despite the differences in social connotations between the terms (Gardner, 2015). In this chapter, these terms are used interchangeably.
Nursing Educational Perspectives on Compliance Model
Theories and models of compliance, as described by Eraker, Kirscht, and Becker (1984) and Leventhal and Cameron (1987), can be viewed from various perspectives and are useful in explaining or describing compliance from a multidisciplinary approach, including psychology and education. These theories and models are as follows:
1. Biomedical theory, which links compliance with patient characteristics such as demographics, severity of disease, and complexity of treatment regimen.
2. Behavioral/social learning theory, which focuses on external factors that influence the patient’s adherence, such as rewards, cues, contracts, and social supports.
3. Communication models, which attempt to explain compliance based on the communication between the patient and healthcare professional. These models address aspects such as the feedback loop of sending, receiving, comprehending, retaining, and accepting information.
4. Rational belief theory, which suggests that patients decide to comply or not comply by weighing the benefits of treatment and the risks of disease through cost-benefit logic.
5. Selfregulatory systems, in which patients are seen as problem solvers whose regulation of behavior is based on perception of illness, cognitive skills, and past experiences that affect their ability to plan and cope with illness.
Although these theories and models shed some light on the very complex issue of compliance, most sources agree that each of them has limitations and no one theory or model alone has proved to be superior to the others (Heiby, Lukens, & Frank, 2005; Munro, Lewin, Swart, & Volmink, 2007).
In recent years, researchers have attempted to use a multivariate approach to explaining compliance. For example. Heiby et al. (2005) have proposed the health compliance-II model, which incorporates variables from several theories and models. Further research is needed to identify a model that incorporates some of the multiple variables described subsequently.
Low compliance with making healthy life style changes is frequently seen in people who have chronic diseases. This is because positive outcomes resulting from behavioral change are not often immediate and, therefore, individuals become frustrated and non adherent to health plans that offer mainly long term benefits, not short term gratifications.
A web based behavior motivational tool, grounded in social cognitive theories, has been developed to help increase patient compliance. Entertaining gaming techniques are used to encourage change in behaviors by creating scenarios and “information interventions based on predefined rules to achieve effective compliance” (Lin, Ramakrishnan, Chang, Spraragen, & Zhu, 2013, p. 58).
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