Nursing theories 4: adherence and concordance

Introduction

The underpinning theory that guides nursing practice can sometimes be forgotten in busy clinical environments. This article, the fourth in a six-part series providing a snapshot of nursing theories and their implications for practice, discusses adherence, compliance and concordance.

Adherence

Adherence is the extent to which someone follows an agreed set of actions. It assumes an equal relationship between two people and is a voluntary process. In healthcare, it usually relates to:

• Making lifestyle changes;
• Taking prescribed medication (National Institute for Health and Care Excellence, 2009);
• Seeking help if symptoms change;
• Attending consultations.

Non-adherence to medication means either not taking prescribed treatments or taking them incorrectly. It may be due to:

• Lack of understanding;
• Lack of trust in the health professional;
• Dislike of taking medication;
• Experience or fear of side-effects;
• Lack of motivation;
• Forgetfulness.

Non-adherence is generally higher for lifestyle changes. Adherence can be complex where people do not have mental capacity or insight, but informed choice is a right.

Compliance

Compliance relates to a more paternalistic or even autocratic relationship, in which someone is seen as either following instructions (compliant) or disregarding them (non-compliant). Being labelled ‘non-compliant’ by health professionals becomes a barrier to empathising with a patient’s perspective. It prevents understanding of why the patient is unable or unwilling to adhere to lifestyle changes, medication regimens or advice. It places responsibility for a perceived failure to optimise health outcomes on the patient, and assumes that health professionals know best. This terminology is not helpful in practice, but is still found in research papers as it is used in international research databases.

Concordance

Concordance is an indicator of the quality of decision-making in healthcare. It depends on patients being well-informed about the evidence supporting their choices and on finding the best fit with their own goals (Winn et al, 2015). A concordant relationship promotes self-management of health; it is based on trust, enabling patients to discuss with the health professionals providing care how other aspects of their life influence, and are influenced by, health and health interventions. It is a partnership to achieve the best health and wellbeing outcomes.

Why are adherence and concordance important?

Adherence is an important outcome measure for healthcare because non-adherence increases morbidity and mortality and health service costs, as well as clinical issues, such as the risk of resistant strains of disease developing due to antimicrobial resistance (Arbuthnott and Sharpe, 2009).

Cognitive factors (such as dementia or learning disabilities); interpersonal factors (particularly trust in the physician), patient involvement and participatory decision-making, and patients’ attitudes towards their health, cultural variations and depression are all significant factors in their ability to adhere to lifestyle changes and medication.

Trust is the most important factor in patient satisfaction and adherence to care; health professionals need to develop a concordant relationship with their patients so that they can understand them and work together to optimise health interventions and outcomes (Box 1).