a critical analysis of compliance

© 2001 Blackwell Science Ltd

Nursing Inquiry

2001;

8

(3): 173–181

F e a t u r e

Blackwell Science, Ltd

A critical analysis of compliance

Nancy Murphy

a

and Mary Canales

b

a

The New York Presbyterian Hospital, New York, NY, and

b

School of Nursing University o f Vermont Burlington, VT, USA

Accepted for publication 24 April 2001

MURPHY N AND CANALES M.

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In nursing the word compliance has competing meanings. In order to understand these meanings, nursing literature wasreviewed and a critical analysis of this concept was undertaken. This included an examination of how nursing was located inrelation to the historical controversy surrounding the term compliance. The philosophy that undergirds this analysis is criticaltheory scholarship, which focuses on language as a vehicle for social control and domination. Literature was critically analyzedaccording to how nurse authors

define

the term compliance and the historical

context

in which the term was used. Analysisof the literature revealed three distinct categories: evaluative, rationalization, and acceptance. Each of these categories isdescribed and the selection criteria identified. We recommend that, nurses intent on conducting future compliance research,consider emancipatory models for their investigations.

Key words:

compliance, critique, participatory models.

Among healthcare providers, ‘compliance’ is a word withcompeting meanings. Although the negative connotationsof this term have been identified and discussed for decades( Jonsen 1979; Trostle 1988; Hess 1996), compliance continuesto be used to describe patients and/or patient behavior. Inthe last 20 years, healthcare literature related to compliancehas increased, while its usage pervades the vernacular ofhealthcare providers. In 1973, a complete search of Englishlanguage literature on compliance revealed 246 articles(Sackett and Haynes 1976). By 1977 the number of articleshad tripled (Haynes, Taylor and Sackett 1979). The CumulativeIndex of Nursing and Allied Health Literature (CINHAL)and MedLine databases list thousands of articles betweenthe years 1979 and 1999 that are compliance related. Althoughthe focus of this review is on nursing literature, complianceresearch and anecdotal reports are also numerous in thegeneral health-related literature.

In an attempt to answer the question, ‘How does nursingemploy the term compliance?’, nursing literature wasreviewed and a critical analysis of this concept was under-taken. This included an examination of how nursing was

located in relation to the historical controversy surroundingthe term compliance. The significance of this analysisextends beyond semantics when we consider the implica-tions of its application to patient care.

To answer the above question, a critique process wasdeveloped that focused on two aspects of the complianceliterature. Initially, the literature was analyzed according tohow nurse authors

define

the term compliance. A second,focused analysis was conducted to examine the historical

context

in which the term was used by the authors. By analyz-ing the literature with these particular foci, three distinctcategories emerged: evaluative, rationalization, and accept-ance. This brief summary of the findings will be followed byan in-depth discussion.

These three categories were chosen to reflect our inter-pretation of the literature analyzed. The first category isevaluative. This includes authors who approach the termfrom an ethical, evaluatory and reflective perspective. They areconcerned with issues of paternalism, coercion, and acquies-cence that arise when the term compliance is employed.These authors find the concept of compliance to be incon-gruent with goals of the nursing profession.

The second category is rationalization. These are nurses,who, in writing about compliance, raise the issue thatthis term has, or could be perceived to have, negative

Correspondence: Nancy Murphy, 85-25 109 Street, Richmond Hill, New York,11418-1234 NY, USA. E-mail: [email protected]

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connotations. Despite their concerns, these authorseither continue to use the term or offer a different termin its place.

The third and largest category is acceptance. Althoughthese authors focus on compliance, they rarely define theterm and never address the debate that surrounds compli-ance in general. The process for categorizing the articlesreviewed and labeling the categories will be described in thenext section.

METHODS

The philosophy that undergirds this analysis is critical theoryscholarship, which focuses on language as a vehicle for socialcontrol and domination (Thompson 1987). As put forwardin the seminal work by Thompson, ‘the process of criticalscholarship is one that rests on reflection and insight’ (33).This analysis involved a ‘progressive experience that un-raveled layers and layers of unquestioned premises’ (34).Using critical scholarship as the framework, each article wasread, reflected upon and reread for further insight.

While a master’s student, the first author initiated a criticalinquiry of the compliance literature. This review was con-sidered ‘critical’ because of an ‘explicit attention to socialpower and justice’ (Boutain 1999, 5). In order to conduct acritical examination of the term compliance, the lead authorwas provided with bibliographies of over 150 compliance-related articles, representing many healthcare fields, frommembers of a graduate nursing ‘compliance group’. Fromthese bibliographies, the first author chose 20 nursingarticles for review.

After reading these 20 articles, three themes began toemerge. It was evident that some authors were opposed tothe term compliance, while other authors freely used theterm compliance without any critique and/or correspondingdefinition. It was also evident that there were authors whowere between these two poles. The articles were initiallydivided into three categories: opposed, free use and middleground.

Following this initial analysis and grouping process, theauthors expanded the literature search to include compliance-related nursing articles from 1979 to 1999. The time framewas selected based on the historical research that uncoveredthe threefold increase in the general compliance literaturefrom 1973 to 1977 (Sackett and Haynes 1976; Haynes,Taylor and Sackett 1979). Additional selection criteria forinclusion in the literature review included a minimum oftwo articles per year and representation of a wide range ofpractice areas. In order to achieve these goals, a randomizedselection process was followed, based on the holdings of

the CINHAL database and access to the articles themselves.The final total of compliance-related articles reviewedwas 60.

Interestingly, initial analysis of the additional 40 articlesindicated that there was consistency with the three categor-ies that had originally emerged. Each article was reread toconfirm its place in the stated categories. It was not until allof the articles were reread twice that the three categorieswere named evaluative, rationalization and acceptance.

A CRITIQUE OF AN EARLY DEFINITION OF COMPLIANCE

While analyzing the compliance literature in general andthe nursing literature specifically, the names and texts ofSackett and Haynes (1976) and Haynes Taylor and Sackett(1979) repeatedly appeared. In fact, 29 of the 60 papersincluded in this critique referenced one or both of thesecitations. Because Sackett and Haynes are treated with suchauthority in the compliance literature, a brief review of theterm compliance, as presented by these authors, helps situ-ate the debate within its historical context. This is importantfor linking the current critique with previous analyses.

As put forth in the opening paragraph, the last 20 yearsof healthcare literature has seen an explosion in the numberof articles that are compliance related. Sackett and Haynes(both physicians) were interested in the issue of compliancefrom the early 1970s. Through funding from Sun Life AssuranceCompany of Canada they take credit for conducting extensivemethodological and administrative groundwork that precededthe development of a series of research grant proposals forrandomized clinical trials (Sackett and Haynes 1976). Theyalso claim to have executed a complete search of the recentEnglish language literature on compliance and developed anewsletter to disseminate compliance information.

Sackett and Haynes (1976) reported that the interestgenerated by the newsletter led to an organized compliancesymposium, funded by National Health Grand of Healthand Welfare Canada, Merck Frost Laboratories Ltd, AyerstLaboritories Ltd, Hoechst Pharmaceuticals Ltd, and Pfizerand Company Ltd. Entitled, ‘The workshop/symposium:Compliance with therapeutic regimens’, it was held atMcMaster University Medical Center in Hamilton, Ontario,in May 1974 (Sackett and Haynes 1976).

The issue of inconsistency with the definition of compli-ance was a central theme of the symposium. In addition, ‘theunfavorable connotation (of compliance) was discussedat length’ (1). Sackett relayed that, although the altern-ative terms of ‘adherence’ and ‘therapeutic alliance’ werebriefly considered, they were ultimately rejected. The term

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‘compliance’, and its corresponding definition were acceptedby those attending the workshop. The accepted compliancedefinition was, ‘the extent to which the patient’s behavior(in terms of taking medications, following diets, or execut-ing other lifestyle changes) coincides with medical advice’(1). As Sackett explained:

Yet the term fits and it amply describes the extent to whichthe patient

yields

[authors’ emphasis] to health instructionsand advice, whether declared by an autocrat, authoritarianclinician or developed as a consensual regimen through nego-tiation between a health professional and a citizen (1–2).

After the second symposium in 1977, Haynes, Taylor andSackett (1979) revisited this issue. Haynes explained that thedefinition is meant to be non-judgmental:

Western society is rapidly redefining the relationshipbetween health professionals and their clients and the con-notation of compliance may seem to fly in the face of thisevolution. Nonetheless, the term is now thoroughly rootedand we know of no acceptable alternative. Moreover, theunhealthy connotations of the term keep ethical and socialissues in compliance research and management up frontwhere they belong, whereas a more neutral term might not.Thus, whether you believe the term is obnoxious or, as wedo, merely utilitarian, we will use it with explanation butwithout apology’ (1–2).

It is evident that Sackett and Haynes (1976) and Haynes,Taylor and Sackett (1979) clearly understood and articulatedthe controversy and difficulty surrounding the term compli-ance. While they state that their purpose is utilitarian, theiracknowledgement that the term requires explanationand/or apology seems to contradict its utility. In addition, theprocess of analyzing compliance from the results of ran-domized clinical trials raises further questions, which, due tospace limitations, will not be examined in this paper.

NURSING DEFINITIONS OF COMPLIANCE

In 1970, the nurse author Marston published a literaturereview on compliance with medical regimens. At that time,nearly all the compliance research to date was conductedby physicians or behavioral scientists and Marston urgednursing to enter the compliance arena: ‘There is much weneed to learn concerning the factors involved in helpingpeople to take care of their health when they are not underthe direct surveillance of professional caretakers, such asphysicians or nurses’ (Marston 1970, 312). She found it wasmisleading to compare compliance rates from different studiesbecause of the wide variation in operational definitions andthe lack of objective measures of compliance.

Wuest (1993) raised similar issues in her critique of thenursing compliance research literature. In her examination

of this literature, the definition of compliance was onceagain central and the conundrum of competing definitionswas raised. In her conclusion, Wuest (1993) quoted Hard-ing: ‘Whoever gets to define what counts as a scientificproblem gets a powerful role in shaping the picture of theworld from scientific research’ (217). This critique extendsWuest’s examination beyond nursing research to includenursing literature that is broad based, and encompassesmultiple nursing perspectives.

Of the 60 nursing articles included in this critique, only25 articles define the term compliance (Hogue 1979; Lindeand Janz 1979; Yoos 1981; Dracup and Meleis 1982; Itano,Tanabe and Lunn 1983; Connely 1984; Edel 1985; Hilbert1985; Baer 1986; Burckhardt 1986; Lucas 1986; McCord1986; Hussey and Gilliland 1989; Simmons 1992; Brown andGrimes 1995; Parmee 1995; Cameron 1996; Crane, Kirbyand Kooperman 1996; Eaton, Buck and Catanzaro 1996;Hentinen and Kyngas 1996; Hess 1996; Crespo-Fierro 1997;Branden 1998; Lowry 1998; McGann 1999). Of these 25definitions, the only consistency is among nine articleswhose authors use the definition originally set forth bySackett and Haynes (1976) (Hogue 1979; Yoos 1981;McCord 1986; Hussey and Gilliland 1989; Simmons 1992;Cameron 1996; Hentinen and Kyngas 1996; Crespo-Fierro1997; McGann 1998).

However, not all authors who use Sackett and Haynes’definition are pleased with it. McGann (1999) quotes it, butfollows it with this statement: ‘this definition disregards theways in which a prescribed regimen affects an individual’slife and assigns the health care provider the role of “expert” ’(45). Although Crespo-Fierro (1997) used Sackett andHaynes’ definition of compliance, it is only one of severaldefinitions offered. Hentinen and Kyngas (1996) state that innursing, compliance is perceived as more than behavior orcoinciding with advice. Subsequently, they offer their owndefinition of compliance: ‘An active, responsible process ofcare, in which the individual works to maintain his/herhealth in close collaboration with the health care personnel’(326).

The other 17 articles that define the term complianceuse a variety of definitions. For example, Baer (1986) writesthat compliance is more than simply consenting to adhere toa therapeutic regimen. Instead, it involves active participa-tion of all members of society in health-care. Brown andGrimes (1995) define compliance according to a set of vari-ables that include taking medications, keeping appoint-ments, and following recommended behavior changes. Edel(1985) uses the sociologist Simmel’s understanding of com-pliance, ‘as the major element of the relationship betweenthose who have power and those over whom they exercise



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power’. Dracup and Meleis (1982) used and defined theterm compliance as, ‘the extent to which an individualchooses behaviors that coincide with a clinical prescription.The regimen must be consensual, that is, achieved throughnegotiations between the health professional and thepatient’ (31). Lowry (1998) sites a variety of definitions.Nurse authors Burckhardt (1986) and Hess (1996) preferWebster’s definition, ‘the act or process of complying toa desire, demand, proposal, or coercion ... adapt(ing) one’sactions to another’s wishes, to a rule, or to a necessity’ (18).

So, almost 30 years after Marston’s (1970) initial con-cern, a wide variation in the operational definition of com-pliance continues within the nursing literature. What doesthis mean? While it could be said that this inconsistencyinhibits the development of a common definition of com-pliance, we would argue that the variety of definitions putforth by nursing, with explanations and apologies, expressesa discomfort with the term. In addition, we see these vari-ations as part of a struggle to articulate a nursing phenom-enon and resist the reductionism of patient labeling. Butthis is only part of the story.

Thirty of the 60 articles reviewed offered no definition atall of the term compliance. Often writing extensively andpassionately about compliance, these authors failed to pro-vide an operational definition. This omission further com-plicates the already complex and controversial use of theterm compliance.

ALTERNATIVE LANGUAGE

It is also important to point out that throughout the nursingliterature reviewed, it was not uncommon for the wordscompliance and non-compliance to be used interchange-ably. Similar to compliance, a variety of definitions for non-compliance have been used (Thorne 1990; Charonko 1992;Wuest 1993; Moore 1995).

Non-compliance was accepted as a nursing diagnosis atthe First North American Nursing Diagnosis Association’s(NANDA) national conference in 1973 (then known as theNational Conference Group for Classification of NursingDiagnosis). NANDA’s original 1973 definition was, ‘a per-son’s informed decision not to adhere to a therapeuticrecommendation’ (Kim and Moritz 1982, 299). The pro-ceedings of the third conference in 1978 (Kim and Moritz1982), and the seventh conference in 1985 (McFarland andNaschinski 1987; Myers and Spies 1987) revealed thatopposition to the term non-compliance existed among theattendees, although it is an accepted diagnosis.

Despite continued opposition, non-compliance as anursing diagnosis has survived. The most current definition,

from the twelfth conference in 1996, is, ‘the extent to whicha person’s and/or caregiver’s behavior coincides with ahealth promoting or therapeutic plan agreed upon by theperson (and or family or community) and health care pro-fessionals’ (Brandt et al. 1997, 434). However, some mem-bers of NANDA continue to actively call for the eliminationof the term non-compliance from the diagnosis taxonomy(twelfth conference) (Bakker, Kastermans and Dassen1997).

Similarly, the terms compliance and adherence are alsosubstituted for each other (Esposito 1995; Crespo-Fierro1997). In a guest editorial Bradley-Springer (1998) calls forthe rejection of the term compliance, ‘a term denoting thepaternalistic requirement to yield to the will of a provider’,and offers adherence as the currently more acceptable term,‘which implies a steady propensity to stick to a prescribedregimen’ (17). She fails to articulate, however, how adher-ence avoids the same pitfalls as compliance.

When searching CINHAL and MEDLINE for compli-ance literature, articles with non-compliance and adherenceare included in the search results. Consequently, as theseterms have been used so interchangeably, articles addressingnon-compliance and adherence were included in this liter-ature review.

THREE CATEGORIES

The second focus of this critique analyzed the literature toidentify the historical context in which nurse authors usedthe term compliance. Specifically, is the historical contro-versy that surrounds the term compliance addressed by nurseauthors? As previously stated, three categories emergedbased on our analysis of the literature: evaluative, rational-ization, and acceptance. Each of these categories will be indi-vidually presented and the specific criteria for inclusion inthe category identified.

Evaluative

The first group of authors relate compliance with evaluation:Edel (1985); Burckhardt (1986); Thorne (1990); Charonko(1992); Wuest (1993); Moore (1995); Parmee (1995); Hess(1996); and Lowry (1998). All of these authors are uncom-fortable with the nursing profession’s use of the term com-pliance, and they evaluate it from various perspectives. Forexample, Burkhardt and Hess question the ethical compat-ibility of compliance with nursing’s humanistic philosophyand belief in self-determination. Edel and Wuest both callfor the elimination of the term from nursing language.Wuest writes, ‘Our tacit acceptance of compliance as part of




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our taxonomy is evidence of our complicity in disempower-ment’ (219). She provides a feminist critique to uncoverethnocentric and androcentric biases. Edel is also con-cerned that using the term compliance may actually fosterpower-based relationships. She evaluates compliance froma sociologic and organizational management perspective,where compliance is viewed as both a type of relationshipand an orientation, ‘a relationship in which power is usedby superiors to control or direct subordinates and the orien-tation of the subordinates to this power’ (184). Parmee asksthe important question: Is patient education compliance oremancipation?

Thorne (1990), Charonko (1992), Moore (1995) andLowry (1998) evaluate non-compliance. Moore writes thatthe use of non-compliance results in the patient beinglabeled ‘difficult’ or ‘troublesome’. She suggests that, ‘pro-fessionals who label a patient as non-compliant are followingconvenient paternalistic principles’ (72). Lowry points outthat little research has investigated the phenomena of non-compliance in mental health and suggests that identifyingcharacteristics in that setting may be futile. She is concernedwith ‘the social prejudice of the healthcare professional,their misuse of power to bring about compliance behaviorsand their inability to act as an effective advocate’ (280).

In summary, each author in this group has as theircentral theme the evaluation of the term compliance/non-compliance. They are cognizant of the historical context inwhich the term has evolved, and address how its continueduse problematizes the nurse–patient relationship.

Rationalization

The second group of articles is categorized as rationaliza-tion. These nurse authors have critiqued the term compli-ance, specifically its negative connotations. They continue touse the term, however, because of its importance as a health-care issue (Hogue 1979; Yoos 1981; Dracup and Meleis1982; Connely 1984; Baer 1986; Lucas 1986; McCord 1986;Simmons 1992; Price 1994; Cameron 1996; Crane, Kirby andKooperman 1996; Eaton, Buck and Catanzaro 1996; Crespo-Fierro 1997; McGann 1999).

Hogue’s (1979) analysis suggests that nurses view compli-ance as a means to an end, not as an end in itself. She, alongwith McCord (1986), Crane, Kirby and Kooperman (1996)and Eaton, Buck and Catanzaro (1996), interchange theterm compliance with the terms patient participation andtherapeutic alliance. These authors express their excite-ment about the contribution that nursing can make to com-pliance management. Yoos (1981) makes the point thatmany providers consider the term compliance less and less

useful because of underlying authoritarian overtones, yetshe discusses how clinicians are ‘plagued’ and ‘frustrated’ bynon-compliant patients (27). Crespo-Fierro (1997) andSimmons (1992) also offer a critique of compliance, and then,similar to Yoos, discuss specific interventions and strategiesfor improving compliance. While Connely (1984) and Baer(1986) discuss the controversy surrounding the meaning ofthe term compliance, their major concern is the negativeeconomic impact of non-compliance and its overall cost tosociety.

The theme connecting these authors is somewhat ironic.While they are all aware of the problems and historical con-troversies surrounding the term compliance, they continueto use it as if they were disconnected from its underlyingassumptions, assumptions that they themselves identify.After providing a critique of compliance, many of theseauthors rationalize their continued use of the term with anexplanation for

how

they use it. Despite these explanations,the term survives. Ultimately, the issue of compliance, inwhatever explained form, is more important for theseauthors than the problems the term presents.

Acceptance

This third group of articles is categorized as acceptance.These nurse authors are completely silent about the histor-ical controversy surrounding the term compliance and offerno form of critique. They forge ahead with interventionsand discuss the important role nurses play in improvingpatient compliance (Linde and Janz 1979; Hoepfel-Harris1980; White 1980; Brockway 1981; Rosenblum et al. 1981;Kinnaird, Yoham and Kieval 1982; Gurnham 1983; Itano,Tanabe and Lunn 1983; Schlenk and Hart 1984; Hilbert1985; Ballard 1996; Davidson 1986; Padrick 1986; Westfall1986; Bradshaw 1987; Wetherill, Kelly and Hore 1987; Koltonand Piccolo 1988; Rutledge and Davis 1988; Hussey andGilliland 1989; Molzahn 1989; Zahr, Yazigi and Armenian1989; Miller et al. 1990; Heyduk 1991; Lund and Frank1991; Dale and Gibson 1992; Miller, Wikoff and Hiatt 1992;Forman 1993; Tettersell 1993; Fischera and Frank 1994;Price 1994; Brown and Grimes 1995; Esposito 1995; Hudacek1995; Hentinen and Kyngas 1996; Witchowski and Kubsch1997; Branden 1998; Pierce 1999).

Padrick (1986) discusses the myths and motivators ofcompliance. Westfall (1986) addresses methods for assessingcompliance. Davidson (1986) guides readers in the use of com-pliance research in clinical practice. Hussey and Gilliland(1989) suggest that assessing literacy and locus of controlmay assist the healthcare provider in identifying personsless likely to comply. Forman (1993) discusses reasons and



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interventions for non-compliance. This uncritical use of theterm compliance is not limited to generalist practice. It isalso visible in the articles/research about nurse practitioner(NP) and midwifery practice. For example, Brown andGrimes (1995), in their meta-analysis of nurse practitionersand nurse midwives in primary care, identified that NPpatients scored higher on compliance than patients inphysician groups. Hudacek (1995), Shell (1995) Branden(1998) and Kolton and Piccolo (1988) all use the term com-pliance when discussing advanced practice nursing.

A variety of practice areas are represented in this group:adult elders (Bradshaw 1987; Esposito 1995), mammo-graphy (Fischera and Frank 1994), diabetes (Brockway 1981;Hentinen and Kyngas 1996; Schlenk and Hart 1984), mentalhealth (White 1980; Wetherill, Kelly and Hore 1987; Heyduk1991; Lund and Frank 1991; Forman 1993), contraceptivechoice (Branden 1998), cardiology (Linde and Janz 1979;Hoepfel-Harris 1980; Ballard 1986; Miller et al. 1990; Miller,Wikoff and Hiatt 1992), oncology (Itano, Tanabe and Lunn1983), asthma (Tettersell 1993; Price 1994), pediatrics (Zahr,Yazigi and Armenian 1989) and adolescence (Gurnham1983). For all the authors in this group, compliance is aproblem in need of a nursing solution and the identificationof the important roles nurses have in effecting complianceis a common theme.

IMPLICATIONS FOR PATIENT CARE

What do these different relationships between nursingand compliance mean for patient care? The first categoryidentified nurses who, through various evaluative formats,are actively working against the issues of control and power,some specifically recommending the elimination of theterm compliance from the nursing vernacular. The secondcategory identified nurses who are cognizant of the issuessurrounding compliance yet continue to use the term, albeitin a different form, often with a corresponding rationaliza-tion. It is the third category, the uncritical acceptance ofthe term compliance and the reduction of it to a problem-solving situation, that is cause for greatest concern. Hiraki’sperspective can shed some light on the potential problemsinherent in such tacit acceptance:

The nursing process as a problem-solving method, wheninappropriately applied, has the power to decontextualizethe nurse–patient relationship, work as a tool of institu-tional control, and perpetuate a technocratic ideology thatis patriarchal in nature (Hiraki 1993, 129).

We are not claiming that all papers that are uncritical aremalintended. In fact, some of the papers in the acceptancegroup raised interesting and important questions. For

example, Heyduk (1991) discussed the importance of nursesbeing informed by the patient, while the purpose of Lundand Frank’s study was to explore patients’ perceptions ofmedication compliance in comparison to nurses’ pers-pectives of patients’ non-compliance (Lund and Frank 1991).It is our opinion that the majority of papers included in thisreview are authored by nurses who are patient advocates.

Nurses who continue to apply only a problem-solving,uncritical approach towards compliance, however, are likely toperpetuate a system of dominance. As Parmee (1995) suggests:

The concept of compliance in the nursing literature (man-agement, changing behavior) reinforces the dominanceand paternalism of the medical model, thus keeping themedical profession clearly in the position of power withnurses party to the oppression of clients, thereby maintain-ing their own oppressed position (15).

Such perpetuation of dominance reinforces the currentsystems of oppression rather than advocating for and workingtowards their dismantlement.

WHAT CAN NURSING DO?

The perspective that strongly informs the compliance liter-ature to date is that of healthcare providers. There is almostcomplete silence in the research literature as to what‘compliance’ means for patients. Only a few authors haveaddressed this issue (Thorne 1990; Lund and Frank 1991).Thorne found that patients perceived non-compliance asconstructive and defined it as, ‘a conscious and reasoneddecision not to adhere to professional advice’ (63). Thefindings of Lund and Frank suggest that possible differencesmay exist between the perceptions of the patient and nurseregarding the rationale for a patient’s ‘compliance’ with themedical regimen.

The findings of this critical review indicate that nurseswill continue to study compliance and its application to prac-tice. Rather than perpetuating a science of exclusion (Allen1993), nurses can generate knowledge in new and innovativeways. One possible direction for nurses who are interestedin ‘compliance research’ is the pursuit of methodologiesthat are committed to a more just social order.

Lather (1991) identifies three postpositivist, praxis-oriented research programs

—

feminist research, critical ethno-graphy and Freirean ‘empowering’ or participatory research

—

as having an openly emancipatory intent (51). Thesemethodologies are increasingly discussed in nursing researchtexts (Thorne and Hayes 1997; Streubert and Carpenter1999), and have been actualized in nursing research projects(Webb 1989; Thompson 1991; Henderson 1995; Rains andRay 1995; Cash et al. 1997; Campbell, Copeland and Tate




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1998; Lindsey and Stajduhar 1998; Drevdahl 1999). WhileLather poses these methods, she is also critical of them,demanding that we, ‘look closely at our own practice interms of how we contribute to dominance in spite of ourliberatory intentions’ (15).

In addition, the use of participatory action research(PAR) is extremely varied. Its application spans the spec-trum from organizational management in industry andagriculture (Whyte 1991), to its use as a tool in radicalpolitical movements (Freire 1970), and even when there isa critical intent, Campbell, Copeland and Tate (1998) aresceptical of PAR’s goal of ‘equalizing power’. In working withpeople with disabilities, they found:

As we worked together to uncover the relations of ruling inhealth care, we began to understand them from our ownmultiple locations. We came to understand that equalizingresearch relations through participation may be an ideolog-ical construct and not an achievable goal (Campbell, Cope-land and Tate 1998, 100).

Hence, the concept of ‘empowerment’ itself is not uncon-tested. Lather notes, ‘empowerment is a process one under-takes for oneself; it is not something done “to” or “for”someone’ (4). This kind of work is complex and these meth-odologies are not a panacea for dismantling hierarchicaldivisions; power inequities do not simply disappear whendifferent methods are employed.

We believe that an understanding of patients’ perspect-ives is crucial for nurses to provide care that honors thevoices of those previously excluded in nursing complianceresearch. Nursing care that is informed, directed by, andwith patients, respects the rights of patients and values whatthey contribute toward their care. We offer emancipatoryresearch models as one avenue for including patient voices.We reinforce the need, however, for nurses to be continuallyself-critical and to search for ways that dismantle existinghierarchies between nurses and patients. Recognizingand working to address power differentials can facilitate theprocess of developing mutual partnerships.

ACKNOWLEDGEMENTS

Nancy Murphy wishes to acknowledge Joanne Singletonfor her advice and the ‘compliance group’ for theircontributions.

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a critical analysis of compliance

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