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 Murphya and Mary Canalesb
aThe NewYork Presbyterian Hospital, NewYork, NY, and bSchool of Nursing University of
Vermont Burlington,VT, USA
Accepted for publication 24 April 2001
MURPHY N AND CANALES M. Nursing Inquiry 2001; 8: 173–181
In nursing the word compliance has competing meanings. In order to understand these meanings, nursing literature was
reviewed and a critical analysis of this concept was undertaken. This included an examination of how nursing was located in
relation to the historical controversy surrounding the term compliance. The philosophy that undergirds this analysis is critical
theory scholarship, which focuses on language as a vehicle for social control and domination. Literature was critically analyzed
according to how nurse authors define the term compliance and the historical context in which the term was used. Analysis
of the literature revealed three distinct categories: evaluative, rationalization, and acceptance. Each of these categories is
described 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 with
competing meanings. Although the negative connotations
of this term have been identified and discussed for decades
( Jonsen 1979; Trostle 1988; Hess 1996), compliance continues
to be used to describe patients and/or patient behavior. In
the last 20 years, healthcare literature related to compliance
has increased, while its usage pervades the vernacular of
healthcare providers. In 1973, a complete search of English
language literature on compliance revealed 246 articles
(Sackett and Haynes 1976). By 1977 the number of articles
hadtripled(Haynes,TaylorandSackett1979).TheCumulative
Index of Nursing and Allied Health Literature (CINHAL)
and MedLine databases list thousands of articles between
the years 1979 and 1999 that are compliance related. Although
the focus of this review is on nursing literature, compliance
research and anecdotal reports are also numerous in the
general health-related literature.
In an attempt to answer the question, ‘How does nursing
employ the term compliance?’, nursing literature was
reviewed 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 surrounding
the term compliance. The significance of this analysis
extends beyond semantics when we consider the implica-
tions of its application to patient care.
To answer the above question, a critique process was
developed that focused on two aspects of the compliance
literature. Initially, the literature was analyzed according to
how 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 distinct
categories emerged: evaluative, rationalization, and accept-
ance. This brief summary of the findings will be followed by
an in-depth discussion.
These three categories were chosen to reflect our inter-
pretation of the literature analyzed. The first category is
evaluative. This includes authors who approach the term
from an ethical, evaluatory and reflective perspective. They are
concerned 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 that
this 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: nancy.murphy@boomerangutang.com

N Murphy and M Canales
174 © 2001 Blackwell Science Ltd, Nursing Inquiry 8(3), 173–181
connotations. Despite their concerns, these authors
either continue to use the term or offer a different term
in its place.
The third and largest category is acceptance. Although
these authors focus on compliance, they rarely define the
term and never address the debate that surrounds compli-
ance in general. The process for categorizing the articles
reviewed and labeling the categories will be described in the
next section.
METHODS
The philosophy that undergirds this analysis is critical theory
scholarship, which focuses on language as a vehicle for social
control and domination (Thompson 1987). As put forward
in the seminal work by Thompson, ‘the process of critical
scholarship 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 was
read, reflected upon and reread for further insight.
While a master’s student, the first author initiated a critical
inquiry of the compliance literature. This review was con-
sidered ‘critical’ because of an ‘explicit attention to social
power and justice’ (Boutain 1999, 5). In order to conduct a
critical examination of the term compliance, the lead author
was provided with bibliographies of over 150 compliance-
related articles, representing many healthcare fields, from
members of a graduate nursing ‘compliance group’. From
these bibliographies, the first author chose 20 nursing
articles for review.
After reading these 20 articles, three themes began to
emerge. It was evident that some authors were opposed to
the term compliance, while other authors freely used the
term compliance without any critique and/or corresponding
definition. It was also evident that there were authors who
were between these two poles. The articles were initially
divided into three categories: opposed, free use and middle
ground.
Following this initial analysis and grouping process, the
authors expanded the literature search to include compliance-
related nursing articles from 1979 to 1999. The time frame
was selected based on the historical research that uncovered
the threefold increase in the general compliance literature
from 1973 to 1977 (Sackett and Haynes 1976; Haynes,
Taylor and Sackett 1979). Additional selection criteria for
inclusion in the literature review included a minimum of
two articles per year and representation of a wide range of
practice areas. In order to achieve these goals, a randomized
selection process was followed, based on the holdings of
the CINHAL database and access to the articles themselves.
The final total of compliance-related articles reviewed
was 60.
Interestingly, initial analysis of the additional 40 articles
indicated that there was consistency with the three categor-
ies that had originally emerged. Each article was reread to
confirm its place in the stated categories. It was not until all
of the articles were reread twice that the three categories
were named evaluative, rationalization and acceptance.
A CRITIQUE OF AN EARLY DEFINITION
OF COMPLIANCE
While analyzing the compliance literature in general and
the nursing literature specifically, the names and texts of
Sackett and Haynes (1976) and Haynes Taylor and Sackett
(1979) repeatedly appeared. In fact, 29 of the 60 papers
included in this critique referenced one or both of these
citations. Because Sackett and Haynes are treated with such
authority in the compliance literature, a brief review of the
term compliance, as presented by these authors, helps situ-
ate the debate within its historical context. This is important
for linking the current critique with previous analyses.
As put forth in the opening paragraph, the last 20 years
of healthcare literature has seen an explosion in the number
of articles that are compliance related. Sackett and Haynes
(both physicians) were interested in the issue of compliance
fromtheearly1970s.ThroughfundingfromSunLifeAssurance
Company of Canada they take credit for conducting extensive
methodological and administrative groundwork that preceded
the development of a series of research grant proposals for
randomized clinical trials (Sackett and Haynes 1976). They
also claim to have executed a complete search of the recent
English language literature on compliance and developed a
newsletter to disseminate compliance information.
Sackett and Haynes (1976) reported that the interest
generated by the newsletter led to an organized compliance
symposium, funded by National Health Grand of Health
and Welfare Canada, Merck Frost Laboratories Ltd, Ayerst
Laboritories Ltd, Hoechst Pharmaceuticals Ltd, and Pfizer
and Company Ltd. Entitled, ‘The workshop/symposium:
Compliance with therapeutic regimens’, it was held at
McMaster 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, ‘the
unfavorable connotation (of compliance) was discussed
at length’ (1). Sackett relayed that, although the altern-
ative terms of ‘adherence’ and ‘therapeutic alliance’ were
briefly considered, they were ultimately rejected. The term

© 2001 Blackwell Science Ltd, Nursing Inquiry 8(3), 173–181 175
‘compliance’, and its corresponding definition were accepted
by those attending the workshop. The accepted compliance
definition 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 which
the patient yields [authors’ emphasis] to health instructions
and advice, whether declared by an autocrat, authoritarian
clinician 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 and
Sackett (1979) revisited this issue. Haynes explained that the
definition is meant to be non-judgmental:
Western society is rapidly redefining the relationship
between health professionals and their clients and the con-
notation of compliance may seem to fly in the face of this
evolution. Nonetheless, the term is now thoroughly rooted
and we know of no acceptable alternative. Moreover, the
unhealthy connotations of the term keep ethical and social
issues in compliance research and management up front
where they belong, whereas a more neutral term might not.
Thus, whether you believe the term is obnoxious or, as we
do, merely utilitarian, we will use it with explanation but
without apology’ (1–2).
It is evident that Sackett and Haynes (1976) and Haynes,
Taylor and Sackett (1979) clearly understood and articulated
the controversy and difficulty surrounding the term compli-
ance. While they state that their purpose is utilitarian, their
acknowledgement that the term requires explanation
and/or apology seems to contradict its utility. In addition, the
process of analyzing compliance from the results of ran-
domized clinical trials raises further questions, which, due to
space limitations, will not be examined in this paper.
NURSING DEFINITIONS OF COMPLIANCE
In 1970, the nurse author Marston published a literature
review on compliance with medical regimens. At that time,
nearly all the compliance research to date was conducted
by physicians or behavioral scientists and Marston urged
nursing to enter the compliance arena: ‘There is much we
need to learn concerning the factors involved in helping
people to take care of their health when they are not under
the direct surveillance of professional caretakers, such as
physicians or nurses’ (Marston 1970, 312). She found it was
misleading to compare compliance rates from different studies
because of the wide variation in operational definitions and
the lack of objective measures of compliance.
Wuest (1993) raised similar issues in her critique of the
nursing compliance research literature. In her examination
of this literature, the definition of compliance was once
again central and the conundrum of competing definitions
was raised. In her conclusion, Wuest (1993) quoted Hard-
ing: ‘Whoever gets to define what counts as a scientific
problem gets a powerful role in shaping the picture of the
world from scientific research’ (217). This critique extends
Wuest’s examination beyond nursing research to include
nursing literature that is broad based, and encompasses
multiple nursing perspectives.
Of the 60 nursing articles included in this critique, only
25 articles define the term compliance (Hogue 1979; Linde
and Janz 1979; Yoos 1981; Dracup and Meleis 1982; Itano,
Tanabe and Lunn 1983; Connely 1984; Edel 1985; Hilbert
1985; Baer 1986; Burckhardt 1986; Lucas 1986; McCord
1986; Hussey and Gilliland 1989; Simmons 1992; Brown and
Grimes 1995; Parmee 1995; Cameron 1996; Crane, Kirby
and Kooperman 1996; Eaton, Buck and Catanzaro 1996;
Hentinen and Kyngas 1996; Hess 1996; Crespo-Fierro 1997;
Branden 1998; Lowry 1998; McGann 1999). Of these 25
definitions, the only consistency is among nine articles
whose authors use the definition originally set forth by
Sackett and Haynes (1976) (Hogue 1979; Yoos 1981;
McCord 1986; Hussey and Gilliland 1989; Simmons 1992;
Cameron 1996; Hentinen and Kyngas 1996; Crespo-Fierro
1997; McGann 1998).
However, not all authors who use Sackett and Haynes’
definition are pleased with it. McGann (1999) quotes it, but
follows it with this statement: ‘this definition disregards the
ways in which a prescribed regimen affects an individual’s
life and assigns the health care provider the role of “expert” ’
(45). Although Crespo-Fierro (1997) used Sackett and
Haynes’ definition of compliance, it is only one of several
definitions offered. Hentinen and Kyngas (1996) state that in
nursing, compliance is perceived as more than behavior or
coinciding with advice. Subsequently, they offer their own
definition of compliance: ‘An active, responsible process of
care, in which the individual works to maintain his/her
health in close collaboration with the health care personnel’
(326).
The other 17 articles that define the term compliance
use a variety of definitions. For example, Baer (1986) writes
that compliance is more than simply consenting to adhere to
a therapeutic regimen. Instead, it involves active participa-
tion of all members of society in health-care. Brown and
Grimes (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 between
those who have power and those over whom they exercise

power’. Dracup and Meleis (1982) used and defined the
term compliance as, ‘the extent to which an individual
chooses behaviors that coincide with a clinical prescription.
The regimen must be consensual, that is, achieved through
negotiations between the health professional and the
patient’ (31). Lowry (1998) sites a variety of definitions.
Nurse authors Burckhardt (1986) and Hess (1996) prefer
Webster’s definition, ‘the act or process of complying to
a desire, demand, proposal, or coercion ... adapt(ing) one’s
actions 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 does
this mean? While it could be said that this inconsistency
inhibits the development of a common definition of com-
pliance, we would argue that the variety of definitions put
forth by nursing, with explanations and apologies, expresses
a 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. But
this is only part of the story.
Thirty of the 60 articles reviewed offered no definition at
all of the term compliance. Often writing extensively and
passionately about compliance, these authors failed to pro-
vide an operational definition. This omission further com-
plicates the already complex and controversial use of the
term compliance.
ALTERNATIVE LANGUAGE
It is also important to point out that throughout the nursing
literature reviewed, it was not uncommon for the words
compliance 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 at
the First North American Nursing Diagnosis Association’s
(NANDA) national conference in 1973 (then known as the
National Conference Group for Classification of Nursing
Diagnosis). NANDA’s original 1973 definition was, ‘a per-
son’s informed decision not to adhere to a therapeutic
recommendation’ (Kim and Moritz 1982, 299). The pro-
ceedings of the third conference in 1978 (Kim and Moritz
1982), and the seventh conference in 1985 (McFarland and
Naschinski 1987; Myers and Spies 1987) revealed that
opposition to the term non-compliance existed among the
attendees, although it is an accepted diagnosis.
Despite continued opposition, non-compliance as a
nursing diagnosis has survived. The most current definition,
from the twelfth conference in 1996, is, ‘the extent to which
a person’s and/or caregiver’s behavior coincides with a
health promoting or therapeutic plan agreed upon by the
person (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 elimination
of the term non-compliance from the diagnosis taxonomy
(twelfth conference) (Bakker, Kastermans and Dassen
1997).
Similarly, the terms compliance and adherence are also
substituted for each other (Esposito 1995; Crespo-Fierro
1997). In a guest editorial Bradley-Springer (1998) calls for
the rejection of the term compliance, ‘a term denoting the
paternalistic 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 prescribed
regimen’ (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 adherence
are included in the search results. Consequently, as these
terms have been used so interchangeably, articles addressing
non-compliance and adherence were included in this liter-
ature review.
THREE CATEGORIES
The second focus of this critique analyzed the literature to
identify the historical context in which nurse authors used
the term compliance. Specifically, is the historical contro-
versy that surrounds the term compliance addressed by nurse
authors? As previously stated, three categories emerged
based 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 in
the 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. For
example, Burkhardt and Hess question the ethical compat-
ibility of compliance with nursing’s humanistic philosophy
and belief in self-determination. Edel and Wuest both call
for the elimination of the term from nursing language.
Wuest writes, ‘Our tacit acceptance of compliance as part of

our taxonomy is evidence of our complicity in disempower-
ment’ (219). She provides a feminist critique to uncover
ethnocentric and androcentric biases. Edel is also con-
cerned that using the term compliance may actually foster
power-based relationships. She evaluates compliance from
a sociologic and organizational management perspective,
where compliance is viewed as both a type of relationship
and an orientation, ‘a relationship in which power is used
by superiors to control or direct subordinates and the orien-
tation of the subordinates to this power’ (184). Parmee asks
the important question: Is patient education compliance or
emancipation?
Thorne (1990), Charonko (1992), Moore (1995) and
Lowry (1998) evaluate non-compliance. Moore writes that
the use of non-compliance results in the patient being
labeled ‘difficult’ or ‘troublesome’. She suggests that, ‘pro-
fessionals who label a patient as non-compliant are following
convenient paternalistic principles’ (72). Lowry points out
that little research has investigated the phenomena of non-
compliance in mental health and suggests that identifying
characteristics in that setting may be futile. She is concerned
with ‘the social prejudice of the healthcare professional,
their misuse of power to bring about compliance behaviors
and their inability to act as an effective advocate’ (280).
In summary, each author in this group has as their
central theme the evaluation of the term compliance/non-
compliance. They are cognizant of the historical context in
which the term has evolved, and address how its continued
use 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 to
use the term, however, because of its importance as a health-
care issue (Hogue 1979; Yoos 1981; Dracup and Meleis
1982; Connely 1984; Baer 1986; Lucas 1986; McCord 1986;
Simmons 1992; Price 1994; Cameron 1996; Crane, Kirby and
Kooperman 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, along
with McCord (1986), Crane, Kirby and Kooperman (1996)
and Eaton, Buck and Catanzaro (1996), interchange the
term compliance with the terms patient participation and
therapeutic alliance. These authors express their excite-
ment about the contribution that nursing can make to com-
pliance management. Yoos (1981) makes the point that
many providers consider the term compliance less and less
useful because of underlying authoritarian overtones, yet
she discusses how clinicians are ‘plagued’ and ‘frustrated’ by
non-compliant patients (27). Crespo-Fierro (1997) and
Simmons (1992) also offer a critique of compliance, and then,
similar to Yoos, discuss specific interventions and strategies
for improving compliance. While Connely (1984) and Baer
(1986) discuss the controversy surrounding the meaning of
the term compliance, their major concern is the negative
economic impact of non-compliance and its overall cost to
society.
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 continue
to use it as if they were disconnected from its underlying
assumptions, assumptions that they themselves identify.
After providing a critique of compliance, many of these
authors rationalize their continued use of the term with an
explanation for how they use it. Despite these explanations,
the term survives. Ultimately, the issue of compliance, in
whatever explained form, is more important for these
authors 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 offer
no form of critique. They forge ahead with interventions
and discuss the important role nurses play in improving
patient compliance (Linde and Janz 1979; Hoepfel-Harris
1980; White 1980; Brockway 1981; Rosenblum et al. 1981;
Kinnaird, Yoham and Kieval 1982; Gurnham 1983; Itano,
Tanabe and Lunn 1983; Schlenk and Hart 1984; Hilbert
1985; Ballard 1996; Davidson 1986; Padrick 1986; Westfall
1986; Bradshaw 1987; Wetherill, Kelly and Hore 1987; Kolton
and Piccolo 1988; Rutledge and Davis 1988; Hussey and
Gilliland 1989; Molzahn 1989; Zahr, Yazigi and Armenian
1989; Miller et al. 1990; Heyduk 1991; Lund and Frank
1991; 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; Hudacek
1995; Hentinen and Kyngas 1996; Witchowski and Kubsch
1997; Branden 1998; Pierce 1999).
Padrick (1986) discusses the myths and motivators of
compliance. Westfall (1986) addresses methods for assessing
compliance. 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 control
may assist the healthcare provider in identifying persons
less likely to comply. Forman (1993) discusses reasons and

interventions for non-compliance. This uncritical use of the
term compliance is not limited to generalist practice. It is
also visible in the articles/research about nurse practitioner
(NP) and midwifery practice. For example, Brown and
Grimes (1995), in their meta-analysis of nurse practitioners
and nurse midwives in primary care, identified that NP
patients scored higher on compliance than patients in
physician 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), mental
health (White 1980; Wetherill, Kelly and Hore 1987; Heyduk
1991; Lund and Frank 1991; Forman 1993), contraceptive
choice (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 Lunn
1983), asthma (Tettersell 1993; Price 1994), pediatrics (Zahr,
Yazigi and Armenian 1989) and adolescence (Gurnham
1983). For all the authors in this group, compliance is a
problem in need of a nursing solution and the identification
of the important roles nurses have in effecting compliance
is a common theme.
IMPLICATIONS FOR PATIENT CARE
What do these different relationships between nursing
and compliance mean for patient care? The first category
identified nurses who, through various evaluative formats,
are actively working against the issues of control and power,
some specifically recommending the elimination of the
term compliance from the nursing vernacular. The second
category identified nurses who are cognizant of the issues
surrounding compliance yet continue to use the term, albeit
in a different form, often with a corresponding rationaliza-
tion. It is the third category, the uncritical acceptance of
the term compliance and the reduction of it to a problem-
solving situation, that is cause for greatest concern. Hiraki’s
perspective can shed some light on the potential problems
inherent in such tacit acceptance:
The nursing process as a problem-solving method, when
inappropriately applied, has the power to decontextualize
the nurse–patient relationship, work as a tool of institu-
tional control, and perpetuate a technocratic ideology that
is patriarchal in nature (Hiraki 1993, 129).
We are not claiming that all papers that are uncritical are
malintended. In fact, some of the papers in the acceptance
group raised interesting and important questions. For
example, Heyduk (1991) discussed the importance of nurses
being informed by the patient, while the purpose of Lund
and Frank’s study was to explore patients’ perceptions of
medication 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 this
review are authored by nurses who are patient advocates.
Nurses who continue to apply only a problem-solving,
uncritical approach towards compliance, however, are likely to
perpetuateasystemofdominance.AsParmee(1995)suggests:
The concept of compliance in the nursing literature (man-
agement, changing behavior) reinforces the dominance
and paternalism of the medical model, thus keeping the
medical profession clearly in the position of power with
nurses party to the oppression of clients, thereby maintain-
ing their own oppressed position (15).
Such perpetuation of dominance reinforces the current
systems of oppression rather than advocating for and working
towards their dismantlement.
WHAT CAN NURSING DO?
The perspective that strongly informs the compliance liter-
ature to date is that of healthcare providers. There is almost
complete silence in the research literature as to what
‘compliance’ means for patients. Only a few authors have
addressed this issue (Thorne 1990; Lund and Frank 1991).
Thorne found that patients perceived non-compliance as
constructive and defined it as, ‘a conscious and reasoned
decision not to adhere to professional advice’ (63). The
findings of Lund and Frank suggest that possible differences
may exist between the perceptions of the patient and nurse
regarding the rationale for a patient’s ‘compliance’ with the
medical regimen.
The findings of this critical review indicate that nurses
will continue to study compliance and its application to prac-
tice. Rather than perpetuating a science of exclusion (Allen
1993), nurses can generate knowledge in new and innovative
ways. One possible direction for nurses who are interested
in ‘compliance research’ is the pursuit of methodologies
that 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). These
methodologies are increasingly discussed in nursing research
texts (Thorne and Hayes 1997; Streubert and Carpenter
1999), and have been actualized in nursing research projects
(Webb 1989; Thompson 1991; Henderson 1995; Rains and
Ray 1995; Cash et al. 1997; Campbell, Copeland and Tate

1998; Lindsey and Stajduhar 1998; Drevdahl 1999). While
Lather poses these methods, she is also critical of them,
demanding that we, ‘look closely at our own practice in
terms of how we contribute to dominance in spite of our
liberatory 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 and
agriculture (Whyte 1991), to its use as a tool in radical
political movements (Freire 1970), and even when there is
a critical intent, Campbell, Copeland and Tate (1998) are
sceptical of PAR’s goal of ‘equalizing power’. In working with
people with disabilities, they found:
As we worked together to uncover the relations of ruling in
health care, we began to understand them from our own
multiple locations. We came to understand that equalizing
research 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 hierarchical
divisions; power inequities do not simply disappear when
different methods are employed.
We believe that an understanding of patients’ perspect-
ives is crucial for nurses to provide care that honors the
voices of those previously excluded in nursing compliance
research. Nursing care that is informed, directed by, and
with patients, respects the rights of patients and values what
they contribute toward their care. We offer emancipatory
research models as one avenue for including patient voices.
We reinforce the need, however, for nurses to be continually
self-critical and to search for ways that dismantle existing
hierarchies between nurses and patients. Recognizing
and working to address power differentials can facilitate the
process of developing mutual partnerships.
ACKNOWLEDGEMENTS
Nancy Murphy wishes to acknowledge Joanne Singleton
for her advice and the ‘compliance group’ for their
contributions.
REFERENCES
Allen DG. 1993. Feminism, relativism, and the philosophy of
science: An overview. In Critique, resistance and action:
Working papers in the politics of nursing, eds JL Thompson,
D Allen and L Rodriques-Fisher, 1–9. New York: National
League for Nursing Press.
Baer CL. 1986. Compliance: The challenge for the future.
Topics in Clinical Nursing 7(4): 77–85.
Bakker RH, MC Kasterman and TWN Dassen. 1997. Non-
compliance and ineffective management of therapeutic
regimen: Use in practice and theoretical implications. In
Classification of nursing diagnoses: Proceedings of the twelfth
conference/North American Nursing Diagnoses Association,
eds MJ Rantz and P LeMone, 196–201. Glendale, CA:
CINHAL Information Systems.
Ballard N. 1986. Promoting compliance in rehabilitation of
a patient with a myocardial infarction. Topics in Clinical
Nursing 7(4): 57–64.
Boutain DM. 1999. Critical language and discourse study:
Their transformative relevance for critical nursing inquiry.
Advances in Nursing Science 21: 1–8.
Bradley-Springer. L. 1998. Prevention: The original adher-
ence issue. Journal of the Association of Nurses in AIDS Care,
9(3): 17–18.
Bradshaw S. 1987. Treating yourself: Improving compliance
in the elderly. Nursing Times 83(6): 40–1.
Branden PS. 1998. Contraceptive choice and patient compli-
ance: The health care providers’ challenge. Journal of Nurse
Midwifery 43(6): 471–82.
BrandtP,GNGroth,EHarman,CPhillipsandJDunbar-Jacobs.
1997. Noncompliance. In Classification of nursing diagnoses:
Proceedings of the twelfth conference/North American Nursing
Association, eds MJ Rantz and P LeMone, 434–6. Glendale,
CA: CINHAL Information Systems.
Brockway BF. 1981. Diabetic compliance: A biological tool.
Western Journal of Nursing Research 1(3): 113–15.
Brown S and D Grimes. 1995. A meta-analysis of nurse prac-
titioners and nurse-midwives in primary care. Nursing
Research 44(6): 332–9.
Burckhardt CS. 1986. Ethical issues in compliance. Topics in
Clinical Nursing 7(4): 9–16.
Cameron C. 1996. Patient compliance: Recognition of
factors involved and suggestions for promoting compliance
with therapeutic regimens. Journal of Advanced Nursing 24:
244–50.
Campbell M, B Copeland and B Tate. 1998. Taking the
standpoint of people with disabilities in research: Experi-
ences with participation. Canadian Journal of Rehabilitation
12(2): 95–104.
Cash P, P Brooker, W Penney, J Reinbold and L Strangio.
1997. Reflective inquiry in nursing practice or ‘revealing
images’. Nursing Inquiry 4: 246–56.
Charonko CV. 1992. Cultural influences in ‘noncompliant’
behavior and decision making. Holistic Nursing 6(3): 73–8.

Connely CS. 1984. Economics and ethical issues in patient
compliance. Nursing Economics 2: 342–7, 364.
Crane K, B Kirby and D Kooperman. 1996. Patient compli-
ance for psychotropic medications: A group model for an
expanding psychiatric inpatient unit. Journal of Psychosocial
Nursing and Mental Health Services 34(1): 8–15.
Crespo-Fierro M. 1997. Compliance/adherence and care
management in HIV disease. Journal of the Association of
Nurses in AIDS Care 8(4): 43–54.
Dale JJ and B Gibson. 1992. Information will enhance com-
pliance: Informing clients compression hosiery. Profes-
sional Nurse 8: 755–60.
Davidson SB. 1986. Using compliance research in clinical
practice. Topics in Clinical Nursing 7(4): 69–76.
Dracup KA and AI Meleis. 1982. Compliance: An interac-
tionist approach. Nursing Research 31(1): 31–6.
Drevdahl D. 1999. Meanings of community in a community
health center. Public Health Nursing 16(6): 417–25.
Eaton LE, EA Buck and JE Catanzaro. 1996. The nurse’s role
in facilitating compliance in clients with hypertension.
MEDSURG Nursing 5(5): 339–45, 359.
Edel MK. 1985. Noncompliance: An appropriate nursing
diagnosis? Nursing Outlook 33(4): 183–5.
Esposito L. 1995. The effects of medication education on
adherence to medication regimens in an elderly popula-
tion. Journal of Advanced Nursing 21: 935–43.
Fischera S and DI Frank. 1994. Attitudes, practices and role
of nursing in use of mamography. Cancer Nursing 17(3):
223–8.
Forman L. 1993. Medication: Reasons and interventions for
noncompliance. Journal of Psychosocial Nursing and Mental
Health Services 31(10): 23–5.
Freire P. 1970. The pedagogy of the oppressed. New York:
Continuum.
Gurnham RB. 1983. Adolescent compliance with spinal
bracewear. Orthopedic Nursing 2(6): 13–17.
Haynes RB, DW Taylor and DL Sackett. 1979. Compliance in
health care. Baltimore, Maryland: Johns Hopkins University
Press.
Henderson DL. 1995. Consciousness raising in participatory
research: Method and methodology for emancipatory
nursing inquiry. Advances in Nursing Science 17(3): 58–69.
Hentinen M and H Kyngas. 1996. Diabetic adolescents’ com-
pliance with health regimens and associated factors. Inter-
national Journal of Nursing Studies 33(3): 325–37.
Hess JD. 1996. The ethics of compliance: A dialectic.
Advances in Nursing Science 19(1): 18–27.
Heyduk L. 1991. Medication education: Increasing patient
compliance. Journal of Psychosocial Nursing and Mental
Hilbert GA. 1985. Accuracy of self reported measures of
compliance. Nursing Research 34(5): 319–20.
Hiraki A. 1992. Language and the reification of nursing
care. In Critique, resistance and action: Working papers in
the politics of nursing, eds JL Thompson, D Allen and
L Rodriques-Fisher, 129–36. New York: National League
for Nursing Press.
Hoepfel-Harris JA. 1980. Improving compliance with an
exercise program. American Journal of Nursing 80(3): 282–6.
Hogue CC. 1979. Nursing and compliance. In Compliance in
health care, eds RB Haynes, DW Taylor and DL Sackett,
247–59. Baltimore, Maryland: Johns Hopkins University
Press.
Hudacek S. 1995. Dietary compliance for patients with renal
disease. Nurse Practitioner 20(2): 75–7.
Hussey LC and K Gilliland. 1989. Compliance, low literacy,
and locus of control. Nursing Clinics of North America 24:
605–10.
Itano J, P Tanabe and JLJ Lunn. 1983. Compliance of cancer
patients to therapy. Western Journal of Nursing Research 5(1):
5–16.
Jonsen AR. 1979. Ethical issues in compliance. In Compliance
in health care, eds RB Haynes, DW Taylor and DL Sackett,
113–20. Baltimore, Maryland: Johns Hopkins University
Press.
Kim MJ and DA Moritz. 1982. Classification of nursing dia-
gnoses: Proceedings of the third and fourth national conferences.
New York: McGraw-Hill Co.
Kinnard LS, MAS Yohan and YM Kieval. 1982. Patient com-
pliance in rehabilitation programs: Case studies. Nursing
Clinics of North America 17(3): 523–32.
Kolton KA and P Piccolo. 1988. Patient compliance: A chal-
lenge in practice. Nurse Practitioner 13(12): 37, 40, 43, 44,
49–50.
Lather P. 1991. Getting smart. Feminist research and pedagogy
with/in the postmodern. New York: Routledge.
Linde BJ and NM Janz. 1979. Effect of a teaching program
on knowledge and compliance of cardiac patients. Nurs-
ing Research 28(5): 282–6.
Lindsey E and K Stajduhar. 1998. From rhetoric to action:
Establishing community participation in AIDS-related
research. Canadian Journal of Nursing Research 30(1): 137–52.
Lowry DA. 1998. Issues of non-compliance in mental health.
Journal of Advanced Nursing 28(2): 280–7.
Lucas CM. 1986. Compliance and illness responses. Topics in
Clinical Nursing 7(4): 47–56.
Lund VE and DI Frank. 1991. Helping the medicine go
down: Nurses’ and patients’ perceptions about medica-
tion compliance. Journal of Psychosocial Nursing and Mental

Marston MV. 1970. Compliance with medical regimens: A
review of the literature. Nursing Research 19(4): 312–23.
McCord MA. 1986. Compliance: Self-care or compromise?
Topics in Clinical Nursing 7(4): 1–8.
McFarland GE and CE Naschinski. 1987. Validation and
identification of nursing diagnoses labels for psychiatric
mental health nursing practice. In Clarification of nursing
diagnoses: Proceedings of the seventh conference, ed. AM McLane,
174–81. St Louis: Mosby Company.
McGann E. 1999. Medication compliance in adults with
asthma. American Journal of Nursing 99(3): 45–6.
Miller P, R Wikoff and A Hiatt. 1992. Fishbein’s model of
reasoned action and compliance behavior of hypertensive
patients. Nursing Research 41(2): 104–9.
Miller P, R Wikoff, MJ Garrett, M McMahon and T Smith.
1990. Regimen compliance two years after myocardial
infarction. Nursing Research 39(6): 333–6.
Molzahn AE. 1989. Primary nursing and patient compliance
in a hemodialysis unit. American Nephrology Nurses Associ-
ation Journal 16(4): 267–72.
Moore KN. 1995. Compliance or collaboration? The mean-
ing for the patient. Nursing Ethics 2(1): 71–7.
Myers JL and MA Spies. 1987. Nursing diagnostic skills: A
content analysis of spontaneously generated nursing
diagnoses. In Clarification of nursing diagnoses: Proceedings of
the seventh conference, ed. AM McLane, 324–31. St Louis:
Mosby Company.
Padrick KP. 1986. Compliance: Myths and motivators. Topics
in Clinical Nursing 7(4): 17–22.
Parmee R. 1995. Patient education: Compliance or eman-
cipation? Nursing Praxis in New Zealand 10(2): 13–23.
Pierce L. 1998. Your turn: Reader response handling non-
acceptance and non-compliance. Journal of Psychosocial
Nursing and Mental Health Services 37(1): 46.
Price B. 1994. The asthma experience: Altered body image
and non-compliance. Journal of Clinical Nursing 3(3): 139–
45.
Rains JW and DW Ray. 1995. Participatory action research
for community health promotion. Public Health Nursing
12(4): 256–61.
Rosenblum EH, Stone EJ and Skipper BE. 1981. Maternal
compliance in immunization of preschoolers as related
to health locus of control, health value, and perceived
vulnerability. Nursing Research 30(6): 337–42.
Rutledge DN and GT Davis. 1988. Breast self-exam: Com-
pliance and the health belief model. Oncology Nursing Forum
15(2): 175–9.
Sackett DL and RB Haynes. 1976. Compliance with therapeutic
regimens. Baltimore, Maryland: The Johns Hopkins Uni-
versity Press.
Schlenk EA and L. Hart. 1984. Relationship between health
locus of control, health value, and social support and
compliance of persons with diabetes mellitus. Diabetes Care
7(4): 566–73.
Shell R. 1995. Noncompliance in adolescent oral contra-
ceptive use. Nurse Practitioner 20(8): 7–10.
Simmons M. 1992. Interventions related to compliance.
Nursing Clinics of North America 27(2): 477–94.
Streubert HJ and DR Carpenter. 1999. Qualitative research in
nursing: Advancing the humanistic imperative, 2nd edn. Phil-
adelphia: Lippincott.
Tettersell MJ. 1993. Asthma patients’ knowledge in relation
to compliance with drug therapy. Journal of Advanced Nurs-
ing 18: 103–13.
Thompson JL. 1987. Critical scholarship: The critique of
domination in nursing. Advances in Nursing Science 10(1):
27–38.
Thompson JL. 1991. Exploring gender and culture with
Khmer refugee women: Reflections on participatory feminist
research. Advances in Nursing Science 13(3): 30–48.
Thorne SE. 1990. Constructive noncompliance in chronic
illness. Holistic Nursing Practice 5(1): 62–9.
Thorne S and E Hayes. 1997. Nursing praxis: Knowledge and
action. Thousand Oaks, CA: Sage.
Trostle J. 1988. Medical compliance as an ideology. Social
Science and Medicine 27(12): 1299–1308.
Webb C. 1989. Action research: Philosophy, methods and
personal experiences. Journal of Advanced Nursing 14:
403–10.
Westfall UE. 1986. Methods for assessing compliance. Topics
in Clinical Nursing 7(4): 23–30.
Wetherill J, T Kelly and B Hore. 1987. The role of the com-
munity psychiatric nurse in improving treatment compli-
ance in alcoholics. Journal of Advanced Nursing 12(6):
707–11.
White PH. 1980. Psychoactive medication noncompliance
in a geropsychiatric outpatient agency. Journal of Geron-
tological Nursing 6(12): 729–34.
Whyte WF. 1991. Participatory action research. Newbury Park,
California: Sage Publications.
Wichowski HC and SM Kubsch. 1997. The relationship
of self-perception with health care regimens. Journal of
Advanced Nursing 25: 548–53.
Wuest J. 1993. Feminist critique of noncompliance. Nursing
Outlook 41(5): 217–24.
Yoos L. 1981. Compliance: Philosophical and ethical consid-
erations. Nurse Practitioner 6(5): 28–30, 34.
Zahr LK, A Yazigi and H Armenian. 1989. The effects of
education and written material on compliance of pediatric
clients. International Journal of Nursing Studies 26(3): 213–20.

A Critical Analysis Of Compliance

Recommended

Recommended

More Related Content

Similar to A Critical Analysis Of Compliance

Similar to A Critical Analysis Of Compliance (18)

More from Kayla Smith

More from Kayla Smith (20)

Recently uploaded

Recently uploaded (20)

A Critical Analysis Of Compliance