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Adherence: A Concept Analysis Carrie Lee Gardner, DNP, FNP-BC Carrie Lee Gardner, DNP, FNP-BC, is Assistant Professor at the Troy University School of Nursing, Troy, Alabama.

Search terms: adherence, compliance, concept analysis Author contact: [email protected], with a copy to the Editor: [email protected] Financial disclosure: The author has not received any type of compensation for the production of this manuscript.

PURPOSE: To utilize a Wilsonian method of concept analysis to define and describe the concept of adherence. DATA SOURCES: Published research articles, nursing literature, published books, and national and international advisory reports. DATA SYNTHESIS: The concept of adherence was analyzed using the Wilson method. Results, applications, and practice implications in regards to the concept of adherence were then derived from the analysis. CONCLUSIONS: Adherence is a complex, multifaceted concept that can greatly impact patient behaviors and nursing practice. Further clarification of adherence is needed to help delineate this concept from other related terms. IMPLICATIONS: Healthcare providers should have an understanding of the concept of adherence in the context of patient care in order to guide patient self-care behaviors.

Approach to the Concept Analysis The purpose of this paper is to analyze the concept of adherence using Wilson’s methodological approach to concept analysis. This paper will also provide examples of the utilization of the concept in the literature and present a subsequent discussion of adherence and the related terms of compliance and concordance in a social context. Wilson’s method has been criticized for being ontologically reductionist/positivist, possibly limiting nurses’ ability to analyze more abstract nonobservable concepts, lacking in rigor, and introducing subjectivity into the process (Beckwith, Dickinson, & Kendall, 2008; Cronin, Ryan, & Coughlan, 2010; Duncan, Cloutier, & Bailey, 2007). However, Wilson’s method has been influential in the development of multiple nursing-specific concept analysis frameworks that are widely used in research, most specifically Walker and Avant’s method of concept analysis and Roger’s evolutionary approach method (Cronin et al., 2010; Rodgers & Knafl, 2000). Wilson devised his method of concept analysis in 1963 to provide a framework for the development and clarification of ambiguous concepts and to assist students with the organization of knowledge for a school entrance examination. He proposed that concepts must be analyzed, developed, and refined in order to provide a framework and clarify meaning during knowledge development (Cronin et al., 2010; Rodgers & Knafl, 2000). During the process of Wilson’s method of concept analysis, questions of the concept are isolated, cases are presented, social contexts and anxieties are addressed, and results are discussed. One of the methodological strengths of Wilson’s method is the lack of complexity, making it easy to use for even a novice researcher. Despite criticisms,

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Wilson’s method provides a user-friendly framework with its focus on clarification of concepts and works well for the clarification of concepts impacting patient outcomes and nursing practice. Significance of the Concept Adherence is a key concept in nursing practice and impacts the care of patients throughout the healthcare system. Only 50% of patients, in developing countries, suffering from chronic diseases adhere to recommended treatment regimens (Sabate, 2003). Poor adherence can lead to suboptimal effectiveness of treatment regimens, threats to patient safety, and increasing healthcare costs for disease management. Medication nonadherence has been estimated to cost approximately $177 billion dollars annually because of direct and indirect healthcare costs (National Council on Patient Information and Education, 2007). Patient self-management of medications, lifestyle changes, and monitoring is the cornerstone of treatment for chronic health conditions. Adverse effects such as intense relapses, exacerbations of symptoms, and increased risk of dependence, toxicity, and resistance can occur in response to poor patient adherence (National Council on Patient Information and Education, 2007; Sabate, 2003). Through improving patient adherence, healthcare providers can treat disease processes more effectively, decrease costs, and enhance patient safety. The importance of the concept of adherence has been widely studied and reported in healthcare literature. However, there is a lack of clarity in the definition and use of the term in the literature. The National Council on Patient Information and Education (2007) outlines several common terms utilized in the literature to describe the 1

Adherence: A Concept Analysis self-administration of treatment regimens by patients in response to provider recommendations. Compliance, adherence, and concordance are often used interchangeably in the literature and in practice. The term compliance has been utilized since the 1950s and gained much popularity in the 1970s. During the 1990s, terminology in the literature began to shift to adherence rather than compliance. Negative connotations were linked to the term compliance because of the association of lack of autonomy and passiveness of the patient in the treatment process (National Council on Patient Information and Education, 2007; Robinson, Callister, Berry, & Dearing, 2008). More recently, the term concordance has also been cited in the literature. Concordance tends to convey an active partnership in the treatment plan between the patient and the provider, and has gained popularity in usage especially in the European medical community (National Council on Patient Information and Education, 2007). However, adherence and compliance are more widely cited in the literature and will be the terms utilized for this concept analysis. Lack of consistency and standardization of terminology has limited progress in defining and measuring patient adherence, and there needs to be further refinement of the concept of adherence. Data Collection A search of the following databases and published literature was utilized to analyze the concept of adherence: Cumulative Index to Nursing and Allied Health Literature, PsychINFO, ABI/INFORM Complete, and PubMed. The key medical subject headings used were adherence, nonadherence, compliance, and concordance. The search was then narrowed to full-text articles published in English. Additional articles were identified and reviewed after examining the reference list of selected articles. Articles included focused on the definition, examination, and measurement of the concepts of adherence, nonadherence, compliance, noncompliance, and concordance. Exclusion criteria included non-English articles, and articles focused on interventions to improve patient adherence rather than the definition and measurement of the terms. Articles from the 1990s to present were included in the literature search. To account for the evolutionary process and the historical impact of the derivation of the concept of adherence, year of publication was not utilized as an exclusion criteria for this literature review. This search strategy was not intended to be an inclusive search to include all possible relevant publications. Instead, articles were reviewed and chosen to include relevant literature that provides a diverse representation of definitions for the concept of adherence. Analysis The concept of adherence and the differences in adherence and compliance have been widely discussed in the 2

C. L. Gardner literature by many disciplines. Wilson’s method of concept analysis will be utilized for the following analysis of the concept of adherence in the context of health care and patient care. Based on its systematic approach, Wilson’s method is appropriate for analysis and further clarification of the concept of adherence. Case models illustrating the concept will be presented with a discussion of major components and attributes of the concept following each case. Social contexts and anxieties regarding adherence and the related terms of compliance and concordance will also be discussed during the analysis of the concept. Isolating Questions of Concept The need for clarification of the concept of adherence has been widely reported in the literature. The Wilson method utilizes questions in the categories of facts, values, and concepts to begin analysis of the concept at hand (Rodgers & Knafl, 2000). Because of the lack of clarity, questions arise regarding the definition of adherence as a concept. These questions include: What is adherence? Does adherence differ from compliance? What attributes and values of the patient and provider impact the concept of adherence? The first question is a mixed question of fact and value. In order to answer this question, a working definition of adherence should be proposed and an in-depth analysis of values related to the definition must also be explored. The second question is a question of concept and seeks to delineate the differences and highlight the similarities in the concepts of adherence and compliance. In order to form a concept definition of adherence within the context of nursing, an analysis of the term compliance must also be performed. The third question is a question of value and calls for an analysis of the values that can impact how adherence is perceived as a concept in a social context. Finding Right Answers As outlined by Wilson, definitions of concepts must be derived and analyzed based on the context in which they are used (Rodgers & Knafl, 2000). Adherence and compliance have been used interchangeably in the literature contributing to the lack of clarity and ambiguity of the concepts. Merriam-Webster’s online dictionary defines Adherence (2013a) as “to stick to something; to attach firmly to something.” The same dictionary defines compliance as “the act or process of doing what you have been asked or ordered to do; the act or process of complying to a desire, demand, proposal, regimen or to coercion” (Adherence, 2013a). Taber’s cyclopedic medical dictionary defines Adherence (2013b) as “stickiness; the extent to which a patient’s behavior coincides with medical advice” (p. 51). Of note, compliance is defined as “adherence” (p. 537), indicating the ambiguity of the terms in medical language. Therefore, in order to adequately define adherence, the definition of compliance must also be analyzed.

C. L. Gardner Historically, the term compliance was utilized when discussing the extent to which a patient acted on medical advice. Early research of the concept of compliance formulated a definition that is very similar to definitions for adherence that arise in the literature. However, because of the negative connotations with the concept of compliance and the perceived lack of patient autonomy associated with the concept, considerable controversy over the definition of the concept began to arise. The terminology in the research began to shift to adherence during the 1990s (Vrijens et al., 2012). Adherence can be described as a multidimensional concept encompassing the following wide-ranging factors: health system, social/economic, condition-related, patientrelated, and therapy-related factors (Sabate, 2003). As reported by Sabate (2003), the World Health Organization Adherence Project adopted the following working definition of adherence: “the extent which a person’s behavior-taking medications, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” (p. 3). In the literature, adherence is also defined and studied in the contexts of patient independence, self-efficacy, and self-determination (Buchmann, 1997; Lutfey & Wishner, 1999). In light of these autonomous contexts, adherence can also be conceptualized as the degree to which the patient follows the plan of care formulated in conjunction with the healthcare provider (Hernshaw & Lidenmeyer, 2006). The underlying context of active patient involvement during the planning and treatment process helps to differentiate adherence from other terms in the literature. Model Case A. M. is a 63-year-old patient recently diagnosed with hypertension. She is being seen in the clinic today because of high blood pressure readings on multiple occasions over the last several weeks. During her clinic visit her, blood pressure is 172/94. Her physical exam, electrocardiogram, and lab work are unremarkable for any abnormal findings. The patient meets with her primary healthcare provider and discusses options. The patient and the healthcare provider agree that the patient should begin a blood pressure medication and begin lifestyle changes (including exercise and dietary changes) to treat her hypertension. The patient is to return to the clinic in 2 weeks and again in 1 month for follow-up measurement of her blood pressure. At the 2-week visit, the patient reports that she has been taking her medication as ordered and has implemented an exercise program into her lifestyle. She also has been eating a low-sodium diet. During her visit, her blood pressure is 152/ 80, and she has lost 1.82 kg. At the 1-month follow-up appointment, the patient reports that she is still taking her medication and continues with her exercise regimen and dietary changes. During the visit, her blood pressure is 134/ 76, and she has lost 2.73 kg. The patient is encouraged, and reports she is going to continue with her medications and lifestyle changes in order to control her blood pressure.

Adherence: A Concept Analysis In this case, the patient has an alteration in health status. Her actions during the planning and treatment process reflect common elements of the concept of adherence. As a team, the primary healthcare provider and the patient discuss treatment options and arrive at a treatment plan for the health alteration. The patient then follows the plan of treatment and recommendations of the healthcare provider with a positive resolution of the alteration in health (Sabate, 2003). The patient in this case is actively involved in the planning process with the healthcare provider, which emphasizes the importance of self-determination and autonomy in the definition of the concept of adherence (Buchmann, 1997; Lutfey & Wishner, 1999).

Contrary Case S. D. is 56-year-old patient with a long-term history of hypertension. During the visit to the clinic today, his blood pressure is 182/96. He has been prescribed blood pressure medication in the past and failed to have the prescription filled. The patient and the primary healthcare provider discuss treatment options for the patient’s hypertension. The healthcare provider outlines the detrimental effects of uncontrolled hypertension, and the patient indicates verbally his understanding. The cost of prescribed medications has been a problem in the past. Therefore, the healthcare provider checks the costs of medications at the pharmacy and finds a low-cost generic option. The patient is very pleased with the choice of medication and the cost of the medication, and agrees to begin taking it that day. He is to return to the clinic in 1 week for follow-up measurement of his blood pressure. The patient returns at the 1-week interval, and he reports he has been taking his medication as prescribed. His blood pressure is 170/86. The healthcare provider increases the dosage of the prescribed medication, and the patient is to return to the clinic in 2 weeks. The patient does not return to the clinic until 3 months later to be seen for an upper respiratory infection. His blood pressure is 178/88, and he is no longer taking any blood pressure medication. When asked why he has stopped the medication, he tells the healthcare provider that he would rather not take any medications and does not like how the medication makes him feel. This case illustrates an example of nonadherence. The patient formulated a plan of care in conjunction with the healthcare provider and accepted the treatment recommendations from the healthcare provider. The patient then chose not to continue with the treatment plan as agreed upon by both parties (Resnik, 2005). Nonadherence can be further categorized as intentional or unintentional. This case would be an example of intentional nonadherence where the patient knowingly decides to deviate from the recommended plan of care. Unintentional nonadherence occurs when factors beyond the patient’s control such as cognitive deficits, poor comprehension, and physical limitations inhibit following the plan of care (Horne, 2006). 3

Adherence: A Concept Analysis Related Case L. M. is a 52-year-old patient who is in the clinic today for a scheduled annual check-up. His blood pressure is 146/78. The primary healthcare provider discusses the blood pressure reading with the patient and outlines the potential adverse effects that accompany elevated blood pressure. The provider recommends lifestyle changes and frequent home monitoring of blood pressure readings to evaluate for persistently elevated blood pressure readings. The patient does not want to begin any lifestyle changes at this time, but does consent to return to the office for another evaluation in a week. He would like to monitor his blood pressure for several weeks before beginning to alter his diet or other lifestyle choices. This case illustrates a related concept to the concept of adherence. In health care, providers must remember that patients always have the right to self-determination and the right to refuse treatment. Treatment refusal differs from nonadherence in that the patient is not accepting the plan of treatment from the beginning (Resnik, 2005). In analyzing adherence, the patient is involved in the planning phase and follows provider recommendations for treatment. Nonadherence constitutes the patient being actively involved in devising a treatment plan, agreeing to the plan, and failing to actually follow the plan. Treatment refusal is a related concept because the patient is still actively involved in planning the treatment course. However, the patient chooses to refuse and not accept the recommended plan of care, thereby differing from nonadherence (Resnik, 2005; Sabate, 2003). Borderline Case A. D. is a 46-year-old patient who over the last 10 months has been under a considerable amount of stress with his job and has gained 15 lbs. At a health fair at work, he was noted to have a blood pressure reading of 152/76. He bought a home blood pressure monitor and has been monitoring his blood pressure at home very closely. He reports that his blood pressure reading has ranged from 148–170/72–96 at home. He is very concerned with his blood pressure and would like to also discuss lifestyle changes, including stress reduction techniques, exercise recommendations, and dietary changes to treat his blood pressure. The primary healthcare provider and the patient discuss options and together arrive at a combination treatment plan. The patient will start taking blood pressure medication and will also begin lifestyle changes. He is joining a gym and is going to adopt a low-cholesterol, low-sodium diet. He is going to monitor his blood pressure very closely at home. The patient is to return to the clinic in 2 weeks and 1 month for follow-up. At the follow-up appointment, the patient’s blood pressure is improving but is still elevated at 148/82. One month after beginning medications and lifestyle changes, the patient’s blood pressure is 132/72, and the patient has lost 2.73 kg. The patient returns in 3 months for a follow up. 4

C. L. Gardner He has lost a total of 5.45 kg since his first visit and has been participating in a regular exercise program. He reports that he has quit taking his medication 2 weeks ago because his blood pressure readings at home were beginning to be in the range of low normal. At the clinic today, the patient’s blood pressure reading is 124/76. This is an example of a borderline case of adherence. The patient followed the recommended plan for treatment of the disease alteration; therefore, many components of a model case for adherence are present (Sabate, 2003). However, there are also some underlying criteria for nonadherence in this case as well. The patient has deviated from the recommended plan of care, but still reached the treatment goal of blood pressure control (Horne, 2006). Social Context and Underlying Anxiety Concepts can develop different meanings based on the social context in which they are perceived and analyzed (Rodgers & Knafl, 2000). The concept of adherence is multidimensional and can be analyzed, defined, and evaluated in many different social and disciplinary contexts. In the context of a business model, adherence is viewed as the ability to make a commitment to a plan and proceed without deviation. Adherence to strategic business plans is often viewed as an organizational outcome and defines firm characteristics. Concepts such as hostility and technological sophistication are utilized in defining the ability of an organization to adhere to a business plan and stay focused on a particular objective (Covin & Slevin, 1998). Likewise in the medical field, adherence can be conceptualized through a completely different view and in the context of financial implications. Rather than analyzing and evaluating adherence as the commitment to a treatment plan, outcomes of adherence can be measured through the identification of healthcare costs related to lack of adherence or nonadherence (Roebuck, Liberman, Gemmill-Toyoma, & Brennan, 2011). Underlying anxieties play a major role in the social context and subsequent concept development of adherence and compliance. The evolution of terminology usage moving from compliance to adherence began in response to underlying anxieties regarding negative social connotations. As mentioned above, adherence and compliance are often used interchangeably in the literature of health disciplines and in everyday patient care (Robinson et al., 2008). However, outside the medical field, compliance has a connotation of loss of autonomy, lack of self-determination, and is conceptualized as how well someone is following the rules of an authoritative figure (Horne, 2006; Lutfey & Wishner, 1999; Robinson et al., 2008). In response to social contexts and anxieties, a new term, concordance, is developing in the literature. The concept of concordance focuses on the importance of communication between the healthcare provider and the patient, and identifies them as equal partners in the creation of the treatment plan. Concordance allows for the exploration of patient beliefs and active

C. L. Gardner participation of the client in the treatment process (Bissell, May, & Noyce, 2004; Horne, 2006). Regardless of the terminology, it is apparent that social contexts and underlying anxieties greatly impact the development of terminology and concepts that define the commitment of patients and providers to a plan of care. Practical Results Concepts must be analyzed and defined in order to lead to practical results and delineation in terminology. Concept analysis should result in a more thorough understanding of the structure and usage of a concept in order to facilitate the generation of theoretical and empirical knowledge (Rodgers & Knafl, 2000; Walker & Avant, 1995). In terms of adherence, much debate has occurred in the literature regarding definition of this concept and differentiation between the terms compliance, adherence, and concordance. This analysis has identified from the literature that the concept of adherence refers to the degree in which patient behaviors coincide with provider recommendations and mutually agreed upon plans of care (Lutfey & Wishner, 1999; Sabate, 2003; Vrijens et al., 2012). Conceptual, Theoretical, and Empirical Applications Conceptual definitions and the underlying concepts are the building blocks of theoretical knowledge. There are many theories and conceptual models utilized in research that seek to define participation in health behaviors and the factors that influence adoption of new health behaviors. Theories and models that provide frameworks to predict patient participation in behavior change help to better define and operationalize the concept of adherence. Patient self-determination and perceived patient benefits are underlying themes in many of the theories and models cited in research studies evaluating adherence and behavior change. The Health Belief Model proposes that a person’s readiness to act on a proposed behavioral change depends on the perceived risk, severity, and benefit of the health behavior change (Olsen, Smith, Oei, & Douglas, 2008). The Transtheoretical Model of Change helps to define the stages of health change with the final steps being maintenance and termination. Patients in the earlier stages of change such as precontemplation, contemplation, and planning tend to have lower adherence rates than those in the later stages of maintenance and termination (Genberg, Lee, Rogers, Willey, & Wilson, 2013; Prochaska & DiClemente, 1983). The Theory of Planned Behavior proposes that a patient’s behavioral intention to change is a predictor of actual behavioral change. This model has been successfully utilized to predict the adherence of patients to health behavior change (Gipson & King, 2012; Manning & Bettencourt, 2011). Health behavior models and theories seek to provide a framework to describe constructs related to individual beliefs, attitudes, intentions, and motivation (Gipson & King, 2012). These same constructs are also

Adherence: A Concept Analysis evident in the concept of adherence as derived from concept analysis. Utilization of health behavior theories that predict behavior change can help predict treatment adherence in patient populations. Adherence can be measured empirically using multiple measurement tools and typically requires a multifaceted approach. Self-report questionnaires and patient selfreport are common measurements of adherence to treatment recommendations. This method is easy to administer; however, it can introduce potential participant bias into the process of measurement (Clark, Farrington, & Chilcot, 2014; Rolley et al., 2008). An example of a valid self-report tool is the Medication Adherence Report Scale, which assesses a patient’s report of nonadherent behavior to recommended medication treatment regimens (Ohm & Aaronson, 2006). Electronic monitoring devices and pill or dosage counts can be utilized when monitoring medication adherence. There are also external surveillance devices such as the Medication Event Monitoring System, which measures the access of containers through electronic sensors on the lid of the container (Rolley et al., 2008). Improvement of patient outcomes as measured through physiological parameters can also be an evaluation of adherence to treatment recommendations in conjunction with self-report (Clark et al., 2014). For example, if the treatment recommendation is weight loss and the patient adheres to the plan of treatment, then the patient should begin to lose weight during the subsequent visits to the clinic. Likewise, intake of a low-carbohydrate diet should positively impact serum blood glucose levels. Adherence may also be measured and evaluated through evaluation of behaviors in the area of treatment regimens and follow-up care (Clark et al., 2014). With the evolution of the concept of adherence, the validity and reliability of measurement tools must continually be reevaluated and new tools that reflect the social context of the concept should be developed. Results in Language Adherence is a complex, multidimensional concept impacted by essential elements such as autonomy, self-determination, self-efficacy, and communication. Adherence and compliance were found to be used interchangeably and synonymously in healthcare research despite the differences in social connotations between the two terms. This concept analysis identifies the need to emphasize in the literature the differences in adherence and compliance. If the term concordance continues to be utilized in the literature and gains popularity in usage, further research and analysis should be conducted to delineate this concept from the concept of adherence. Implications of Findings Adherence to treatment recommendations is a major consideration in the treatment of disease processes that enhance patient safety. Nonadherence to treatment plans 5

Adherence: A Concept Analysis can lead to ineffectiveness of treatments with increased suffering of patients and increased healthcare costs (Sabate, 2003). Healthcare providers should place importance on the understanding of the concept of adherence in the context of patient treatment protocols. Further clarification of adherence should occur in order to propose better working definitions of the concept and continue to delineate differences in the related terms of compliance and concordance. Better definition and improved operational definitions of the concept of adherence can provide a better basis for theory derivation and measurement development. References Adherence. (2013a). In Merriam-Webster’s online dictionary. Retrieved from http://www.merriam-webster.com/ Adherence. (2013b). In Taber’s cyclopedic medical dictionary (22nd ed.). Philadelphia: F. A. Davis Company. Beckwith, S., Dickinson, A., & Kendall, S. (2008). The “con” of concept analysis: A discussion paper which explores and critiques the ontological focus, reliability, and antecedents of concept analysis frameworks. International Journal of Nursing Studies, 45(12), 1831–1841. doi:10.1016/ j.ijnurstu.2008.06.11 Bissell, P., May, C. R., & Noyce, P. R. (2004). From compliance to concordance: Barriers to accomplishing a re-framed model of health care interactions. Social Science & Medicine, 58, 851–862. doi:10.1016/S02779536(03)00259-4 Buchmann, W. F. (1997). Adherence: A matter of self-efficacy and power. Journal of Advanced Nursing, 26(1), 132–137. doi:10.1046/j.13652648.1997.1997026132.x Clark, S., Farrington, K., & Chilcot, J. (2014). Nonadherence in dialysis patients: Prevalence, measurement, outcome, and psychological determinants. Seminars in Dialysis, 27(1), 42–49. doi:10.1111/sdi.121159. Covin, J. G., & Slevin, D. P. (1998). Adherence to plans, risk taking, and environment as predictors of firm growth. Journal of High Technology Management Research, 9(2), 207–237. Cronin, P., Ryan, F., & Coughlan, M. (2010). Concept analysis in healthcare research. International Journal of Therapy & Rehabilitation, 17(2), 62–68. Duncan, C., Cloutier, J. D., & Bailey, P. H. (2007). Concept analysis: The importance of differentiating ontological focus. Journal of Advanced Nursing, 58(3), 293–300. doi:10.1111/j.1365-2648.2007.04277.x Genberg, B. L., Lee, Y., Rogers, W. H., Willey, C., & Wilson, I. B. (2013). Stages of change for adherence to antiretroviral medications. AIDS Patient Care and STDs, 27(10), 567–572. doi:10.1089/apc.2013.0126 Gipson, P., & King, C. (2012). Health behavior theories and research: Implications for suicidal individuals’ treatment linkage and adherence. Cognitive and Behavioral Practice, 19(2), 209–217. doi:10.1016/j.cbpra.2010.11.005

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C. L. Gardner Hernshaw, H., & Lidenmeyer, A. (2006). What do we mean by adherence to treatment and advice for living with diabetes? A review of the literature on definitions and measurements. Diabetic Medicine, 23(7), 720–728. doi:10.1111/j.1464-5491.2005.01783.x Horne, R. (2006). Compliance, adherence, and concordance: Implications for asthma treatment. [Supplemental material]. Chest, 130, 65S–72S. doi:10.1378/chest.130.1_suppl.65S Lutfey, K. E., & Wishner, W. J. (1999). Beyond “compliance” is “adherence.” Diabetes Care, 22(4), 635–639. Manning, M., & Bettencourt, B. A. (2011). Depression and medication adherence among breast cancer survivors: Bridging the gap with the theory of planned behavior. Psychology and Health, 26(9), 1173–1187. doi:10.1080/ 08870446.2010.542815 National Council on Patient Information and Education. (2007, August). Enhancing prescription medicine adherence: A national action plan. Retrieved from http://www.talkaboutrx.org/documents/enhancing _prescription_medicine_adherence.pdf Ohm, R., & Aaronson, L. S. (2006). Symptom perception and adherence to asthma controller medications. Journal of Nursing Scholarship, 38(3), 292–297. Olsen, S., Smith, S., Oei, T., & Douglas, J. (2008). Health belief model predicts adherence to CPAP before experience with CPAP. European Respiratory Journal, 32(3), 710–717. doi:10.1183/09031936.00127507 Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of selfchange of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. doi:10.1037/0022006X.51.3.390 Resnik, D. B. (2005). The patient’s duty to adhere to prescribed treatment: An ethical analysis. Journal of Medicine and Philosophy, 30, 167–188. doi:10.1080/03605310590926849 Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. A. (2008). Patientcentered care and adherence: Definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners, 20(12), 600–607. doi:10.1111/j.1745-7599.2008.00360.x Rodgers, B. L., & Knafl, K. A. (2000). Concept development in nursing. Philadelphia: Saunders. Roebuck, M. C., Liberman, J. N., Gemmill-Toyoma, M., & Brennan, T. A. (2011). Medication adherence leads to lower healthcare use and costs despite drug spending. Health Affairs, 30(1), 91–99. doi:10.1377/hlthff.2009.1087 Rolley, J. X., Davidson, P. M., Dennison, C. R., Ong, A., Everett, B., & Salamonson, Y. (2008). Medication adherence self-report instruments: Implications for practice and research. Journal of Cardiovascular Nursing, 23(6), 497–505. Sabate, E. (2003). Adherence to long-term therapies: Evidence for action. Retrieved from http://www.who.int/chp/knowledge/publications/ adherence_full_report.pdf Vrijens, B., DeGeest, S., Hughes, D. A., Przernyslaw, K., Demonceau, J., Ruppar, T., . . . Urquhart, J. (2012). A new taxonomy for describing and defining adherence to medications. British Journal of Clinical Pharmacology, 73(5), 691–705. doi:10.1111/j.1365-2125.2012.04167.x Walker, L. O., & Avant, K. C. (1995). Strategies for theory construction in nursing. East Norwalk, CT: Appleton & Lange.

Adherence: a concept analysis.

To utilize a Wilsonian method of concept analysis to define and describe the concept of adherence...
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