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Concept Analysis of Compliance Deborah Aderin Molloy College NUR 505.02 03/29/2011

Running Head: CONCEPT ANALYSIS OF COMPLIANCE Introduction The purpose of this paper is to analyze the concept of compliance as it is related to my everyday practice as a homecare nurse. The author will be using the Walker and Avant (1995) concept analysis to describe the attributes of compliance, antecedent that influences compliance, and the consequences of noncompliance. Concept analysis is the foundation for research studies or theory construction; it is useful for clarification of the relationship between the concepts. It is also necessary for evaluation of current tools and formation of new tools for research; it is as well necessary for theoretical application in the nursing diagnosis. Dictionaries Definitions of Compliance The word compliance is found to be in use in the medicine, nursing, behavioral and science fields. The Oxford English Dictionary (2009), defines compliance as (a) an act of conformity, acquiescing, or yielding, (b) a tendency to yield readily to others, especially in a weak and subservient way, (c) conformity, accordance, (d) cooperation or obedience .

The American Heritage Medical Dictionary (2007) defines compliance as

the degree of constancy and accuracy with which a patient follows a prescribed regimen, as distinguished from adherence or maintenance. The Merriam-Webster Dictionary of Law (1996) defines compliance as act or process of complying with a demand or recommendation. The Oxford English Dictionary (2009) defines compliance in other disciplines as: In physics, it is defined as a coefficient expressing the responsiveness of a mechanical system to a periodic force. In it is an act of favorable response to a request offered by others, and in physiology, it is defines as the tendency of a hollow organ to

Running Head: CONCEPT ANALYSIS OF COMPLIANCE resist recoil towards its original dimensions.

The Collins Thesaurus of the English Language (2002) identifies the synonyms of compliance as: agreement, obedience, assent, deference, observances, abidance, conformity, conformation, cooperation, complaisance, compliancy, obligingness, deference, docility, obedience, concession, concord, consent, civility and submission. Compliance is found to be a noun, which is a figure of speech that names a person, animal, place, thing and abstract idea. However, the definition of compliance was identified from1635 AD to 1645 AD. Defining Attributes of Compliance The defining attributes describe the characteristics of the concepts, and identify the contextual basis of the concept (Walker and Avant, 1995). The attributes of compliance include: (a) willingness to follow prescribed course of treatment; (b) act of steady devotion; (c) action in accord with prevailing practices, attitudes; and (d) acting together for a common purpose. Constructing a Model Case A model case includes all the critical attributes of the concept, and should be a paradigmatic example. This is a real case, that the author is absolutely sure is an instance of the concept (Walker and Avant, 1995). Ms. D is a 48 year old woman with the diagnosis of diabetes. She daily assess her blood glucose, documents the readings, incorporates an exercise regime into her schedule, administers her insulin, and follows the dietary instructions given. In this scenario, Ms.D demonstrated the attributes of compliance as in willingness to follow prescribed course of treatment, devotion to disease

Running Head: CONCEPT ANALYSIS OF COMPLIANCE and medication management, her action is in conjunction with health care providers towards common goal. Constructing a Borderline Case

The borderline case contains some of the critical attributes of the concept, but not all of them. It may contain some of the criteria, but differ substantially in one of them, and there are inconsistencies (Walker and Avant, 1995). Mr. Y was diagnosed with HIV/ AIDS, and started on antiviral medications. Most of his medications are twice daily, but he takes them once a day most of the time because he feels the medications are too much for him to handle. In this case scenario, Mr.Y was willing to follow the prescribed course of treatment, however due to improper timing and complex regimen, he was not devoted with the medication administration. Constructing a Contrary Case The contrary case is considered not to be related to the concept, whatever the concept is, that is certainly not an instance of it (Walker and Avant, 1995). It is opposite to the meaning of the concept. Mr. B, 16 year old with seizure disorder will not take his medications because he does not want his friends to know he is on any medications, he ended up having seizure activity in the school playground. In this case scenario, Mr. B is noncompliant with his medication.

Running Head: CONCEPT ANALYSIS OF COMPLIANCE Constructing an Illegitimate Case

The illegitimate case is considered to be improper use of the concept (Walker and Avant, 1995). Ms. H believes taking anti-anxiety medications before she leaves for work will prevent her from being stressed at work. Identifying Antecedents of Compliance Antecedents are the events or incidents that must occur prior to the occurrence of the concept (Walker and Avant, 1995). There are three antecedents that are interrelated to the concept of compliance namely: direct communication, indirect communication and structural organization (Gochman, 1997). The direct communication influences the personal beliefs of the patients by tailoring the instructions to meet individual needs and incorporating problem-solving skills. Indirect communication is done through family and health care providers. This will enhance the relationship between the patients and the providers. The structural organization is the removal of barriers that limits access to the treatments. Identifying Consequences of Compliance Consequences are the events or incidents that occur as a result of the occurrence of the concept (Walker and Avant, 1995). Compliance can be described as intentional or unintentional; however, the act of compliance has physical, psychological and social effects (Gochman, 1997). The psychological effects of compliance reinforce the feelings of satisfaction and eliminate guilt, shame and regrets. The physical effects of compliance includes improved health status, that leads to a productive life and improved

Running Head: CONCEPT ANALYSIS OF COMPLIANCE adherence; to reduce hospital admissions ,emergency room visits and sick days. The social effects of compliance include increased knowledge that promotes the patientparternership relationship and improvement in communication outcomes. Empirical Referents of Compliance Empirical referents are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself (Walker and Avant, 1995, p.46). Empirical referents explain how the concepts will be measured, observed, or verified to show accuracy and existence of the concept.

Burke and Ockene (2001) identified two major theories of planned behaviors: the health belief model and the theory of reasoned action versus self efficacy. The health belief model is a behavioral change and psychological model that was developed by Irwin M. Rosentock. This theory states that health behavior is determined by personal beliefs or perceptions. The theory of reasoned action versus self efficacy was formulated by Ajzen and Fishbein. This theory demonstrates the link between attitudes and behavior; it predicts that behavior can be deliberate and planned. Compliance in nursing is measured in five ways as: self report, behavioral counts, electronic monitors, biological indicators and direct observations. Self report includes interviews, questionnaires, and diaries; this is done during the initial assessment of the patient upon, during the course of care, and during discharge. The nurse will assess the patients knowledge about the medications, treatment, and disease management, to see what the patient has been doing to promote and maintain optimum health (Burke and Ockene, 2001).

Running Head: CONCEPT ANALYSIS OF COMPLIANCE Behavioral counts include pill counts and calorie counts. This strategy is useful when the nurse prepours the patients medications using the seven days medication box, or prefills the injectable medications such as insulin. The nurse can assess patient

compliance by counting the medication in the box, or medication bottles, or assessing the days of medications are taken. Electronic monitors as in blood glucose and blood pressure monitors, compliance is achieved by assessing the electronic monitors reading, since same cannot be altered. Patients are advised to record the readings in their log book, which the nurse can use as a comparison to the readings saved on the monitors. Biological indicators are the detection of treatment or outcome through blood work. Patients are sent to the laboratory for blood work to assess the therapeutic level of the medication or treatment they are receiving as in Coumadin for International Normalized Ratio and Prothrombin Tests (Burke and Ockene, 2001). Direct observation, is a direct observed therapy by The Department of Health as with patients on tuberculosis medications. The Department of Health is involved in cases where non-compliance is noted in patient diagnosed with communicable diseases such as tuberculosis. The patient will be observed taking their medication in the presence of the employees of the health department (Burke and Ockene, 2001). Self report and behavioral counts require patient willingness to disclose information to ensure accuracy of the behavior.


In the review of different literature and books concerning compliance, this author has come to realize the thin line between compliance and non-compliance. Noncompliance affects patient, society and the healthcare industry. In caring for patients as a homecare nurse in the community, patient compliance to disease, and medication and treatment plan, sometimes can be very difficult. Some of these patients are considered to be non compliant because of their reaction or attitudes towards their treatment regimes. This analysis is a learning tool for me in the sense that patient that are having difficulties with compliance sometimes have barriers holding them back. However, for a patient to be compliant, one needs to eliminate all the barriers that could lead to non-compliance. This can be achieved by performing comprehensive assessment on the patient during the initial visit, the course of their care and discharge. The nurse will want to assess the patient knowledge of his or hers disease, medication management, and treatment plan. Communication is the key element in patient teaching. Poor communication between patient and healthcare providers occurs when the patient levels of education, intelligence and language skills are not being considered. These patients may not comprehend the instructions or teachings, therefore may not ask any questions because they are too polite or too embarrassed. Cultural and religious assessment of the patient should be considered. The values and the concepts of the culture and religion of the patient should be considered. Nurses and other healthcare providers must be aware the many ways cultural and religious differences can impede health promotion and maintenance. I have patients that due to their cultural or religious beliefs, are not allowed to be involved in the management or

Running Head: CONCEPT ANALYSIS OF COMPLIANCE treatment plan of their loved ones. Psychological and psychosocial factors should be considered when caring for patients. Psychological issues, as being in denials are common among juveniles and young adults with chronic illnesses who get tired of compliance to diets and medication regime. Likewise, psychosocial stress occurs from poor living conditions, poverty, lack of inadequate support systems. These patients sometimes understand their disease and medication management, but have difficulty prioritizing their needs. The health care system sometimes creates a barrier in the patients ability to be compliant with their treatment. In homecare, most of the patients today have managed

care insurance, and the managed care company has a cap on the number of visits patients are eligible for. Patients are aware of these numbers, and some of these patients are being discharged without adequate knowledge. Conclusion In summary, the concept of compliance was selected for this analysis in reference to patient compliance to their medication, and disease management, treatment, and follow with their physicians. Patients have the tendency to deviate from compliance, and end up with inability to reach their optimal goal. In this analysis, the review of different theories and literature, the antecedents and consequences of compliance were examined. This authors main focus concerning concept of compliance is to relate to nurses and other health care providers, the appropriate strategies that can be implemented to promote compliance among our patient population.



References Avant, K., & Walker, L. (2009). Oxford Dictionary of Current English (4th ed.). Oxford : Oxford University Press. Brookes, I. (2002). Collins Writer's Thesaurus of the English Language (2nd ed.). Glasgow: HarperCollins. Burke, L. E., & Ockene, I. S. (2001). Compliance in Healthcare and Research . Armonk, NY: Futura Pub. Co.. Gochman, D. S. (1997). Handbook of Health Behavior Research . New York: Plenum Press. Merriam-Webster's Dictionary of Law . (1996). Springfield (Mass.): Merriam-Webster. The American Heritage Medical Dictionary (New updated ed.). (2007). Boston: Houghton Mifflin Co.. Walker, L. O., & Avant, K. C. (1995). Strategies for Theory Construction in Nursing (3rd ed.). Norwalk, CT: Appleton & Lange.