NURS 8250 Week 5 Concept Analysis Paper Example

Where Adherence Ends: A Concept Analysis Separating Adherence From Compliance and Concordance in the Management of High Blood Pressure

Student Name

College of Nursing, Walden University

NURS 8250: Advanced Theoretical and Scientific Perspectives in Nursing

Instructor Name

Month Day, Year

Where Adherence Ends: A Concept Analysis Separating Adherence From Compliance and Concordance in the Management of High Blood Pressure

Aim and Method

Every concept runs into its neighbors, and a concept analysis exists to find the line between them. This paper analyzes adherence as it is used in the management of high blood pressure at a composite primary care practice, where the nurse-led hypertension clinic records whether patients are adherent at each visit, and separates it from two neighboring concepts, compliance and concordance. It follows the steps Walker and Avant (2019) describe: identifying uses of the concept, determining defining attributes, building model, borderline, related and contrary cases, then naming what precedes the concept, what follows it and how it can be observed.

The aim is practical. In the clinic, adherent is written in notes to mean anything from taking every pill to showing up at the appointment. A clearer definition would let the clinic know what it is counting and what to do when adherence is low.

How the Word Is Used

In everyday language, to adhere means to stick to something, a surface, a rule or a belief. In health care, the word came into wide use as an alternative to compliance. A widely cited definition from the World Health Organization (2003) describes adherence as the extent to which a person's behavior, such as taking medication, following a diet or changing lifestyle, corresponds with recommendations agreed with a health care provider. The word agreed is central to that definition and to this analysis.

In pharmacology, adherence has been broken into phases. A proposed taxonomy separates initiation, when the first dose is taken, implementation, how closely actual dosing matches the prescribed regimen, and discontinuation, when treatment ends; persistence is the time between initiation and discontinuation (Vrijens et al., 2012). In hypertension research, adherence is often treated as a leading cause of uncontrolled blood pressure, and poor adherence is common (Burnier & Egan, 2019).

Defining Attributes

Three defining attributes emerge from the uses. First, a recommendation the person has agreed to. Adherence presupposes that the person accepted the plan, not merely that it was prescribed. Second, a correspondence between behavior and that plan over time. Adherence is a matter of degree across days and months, not a single act. Third, active participation by the person. The person carries out the behavior, and adherence can change as circumstances change.

These attributes distinguish adherence from its neighbors. Compliance shares the second attribute but not the first and third: it describes a patient following instructions given by an authority, with the implication that failure is the patient's fault. Concordance shares the first and third attributes but places its emphasis elsewhere: it describes the process of agreement between clinician and patient, including the patient's beliefs and preferences, rather than the behavior that follows.

Cases

Model case. Mr. A., 58, has high blood pressure. At his clinic visit, the nurse and he discuss his readings, his concerns about side effects and his work schedule. They agree on a once-daily tablet taken with breakfast and home blood pressure checks three times a week. Over the next three months, his pharmacy refills are on time, his home log is complete and he misses two doses, both while traveling. All three attributes are present.

Borderline case. Ms. B., 64, agreed to the same plan but, after reading about side effects, began taking her tablet every other day to make it last longer, because the copay rose. Her behavior corresponds only partly to the plan, and she changed it without telling the clinic. The first and third attributes are present, but the second is weakened, which places her at the edge of adherence.

Related case: compliance. Mr. C., 70, was told by a physician to take two tablets daily and did so without discussion, because he believes doctors should not be questioned. His behavior matches the plan, but he did not agree to it in any meaningful sense and does not participate beyond following orders. This is compliance.

Related case: concordance. Ms. D., 45, and the nurse spend a visit exploring her wish to try lifestyle changes before medication, reach an agreement to review in six weeks and document her preferences. No behavior has yet followed. This is concordance, the agreement itself.

Contrary case. Mr. E., 52, never filled his prescription and did not discuss it. He shares no attribute with the concept.

What Comes Before and After

Antecedents are what must happen before adherence can occur. They include a plan that the person understands, an agreement reached with the clinician, access to the medication, including cost, and the capacity to carry out the plan, such as memory and routine. For the clinic, the most important antecedent is the agreement: without it, what looks like adherence may be compliance, and what looks like nonadherence may be a disagreement that was never voiced.

Consequences include the intended effect of treatment, here blood pressure control, and effects on the relationship with the clinic. Osterberg and Blaschke (2005) note that poor adherence to medication is common across chronic conditions and contributes to worse outcomes, which is one reason clinics monitor it.

Empirical Referents

Empirical referents show how the concept can be observed. Pharmacy refill records measure initiation and persistence. Pill counts and electronic pill bottles measure implementation. Patient self-report measures behavior but is subject to recall and the wish to please. None of these measures the first attribute, agreement. For the clinic, that means a patient could look adherent on refill data while having never agreed to the plan, which is compliance. A referent for agreement would need to come from the visit itself, such as a documented shared decision.

Implications for the Clinic

The analysis suggests two changes. First, the clinic should stop recording adherent as a single yes or no and instead record the phase, initiation, implementation or persistence, so that a patient who never filled a prescription is distinguished from one who takes it inconsistently. Second, the clinic should document the agreement: what the patient and nurse agreed and any concerns the patient raised. With those changes, the clinic's data would describe adherence rather than a mixture of adherence, compliance and silence, and a patient like Ms. B., whose cost concern was never heard, would be easier to identify.

References

Burnier, M., & Egan, B. M. (2019). Adherence in hypertension. Circulation Research, 124(7), 1124-1140. https://doi.org/10.1161/CIRCRESAHA.118.313220

Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353(5), 487-497. https://doi.org/10.1056/NEJMra050100

Vrijens, B., De Geest, S., Hughes, D. A., Kardas, P., Demonceau, J., Ruppar, T., Dobbels, F., Fargher, E., Morrison, V., Lewek, P., Matyjaszczyk, M., Mshelia, C., Clyne, W., Aronson, J. K., & Urquhart, J. (2012). A new taxonomy for describing and defining adherence to medications. British Journal of Clinical Pharmacology, 73(5), 691-705. https://doi.org/10.1111/j.1365-2125.2012.04167.x

Walker, L. O., & Avant, K. C. (2019). Strategies for theory construction in nursing (6th ed.). Pearson.

World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. World Health Organization.