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Keywords:

  • adherence;
  • compliance;
  • concept analysis;
  • concordance;
  • management;
  • medicine;
  • nursing;
  • partnership;
  • pharmacy;
  • psychiatry

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Aim

To report an analysis of the concept of concordance.

Background

Adherence-based medicines interventions are known to be of limited success. Concordance appears to offer an alternative approach consistent with person-centred approaches to decision-making. However, the application of the principle of concordance appears inconsistent. This article considers the extent to which any of this confusion may be a function of the different usage of the term concordance in the disciplines of nursing, general medicine, psychiatry and pharmacy.

Design

Rodger's evolutionary method of concept analysis.

Data sources

CINAHL, Medline, PsychINFO, Cochrane library, Psychology and Behavioural Sciences Collection were searched for publications between 2000 and 2012 with combinations of key words including concord*, adherence, compliance, medic*, psychiatr*, pharm*, nurs*.

Review methods

Rodgers' evolutionary analytic method was used to identify and explore the concept of concordance across healthcare disciplines. A representative sample of papers was identified from the source disciplines. Over 500 papers were identified. Exclusion criteria limited the final sample to 60 papers in total, entailing 15 per discipline. Each discipline's papers were analysed for references, antecedents, consequences, attributes and surrogates separately. The team then worked together to cross-check these interpretations.

Results

There was minimal agreement between the disciplines suggesting each discipline practised a different conceptualization of concordance. The main point of agreement was that better research is required to articulate the scope and value of partnership working.

Conclusion

The results clarified a distinct and currently missing research agenda.

Why is this research or review needed?

  • Concordance describes an ideal, patient-centred process of supported decision-making that appears to be difficult to operationalize in practise.
  • The terms adherence, compliance and concordance continue to be used interchangeably in the literature on medicine management.
  • Bissonnette suggested a concept analysis of concordance would broaden understanding of patient decision-making.

What are the three key findings?

  • Concordance is operationalized differently in the disciplines of nursing, pharmacy, medicine and psychiatry. This is new knowledge.
  • The different expressions of concordance can be explained as a function of the underpinning professional, political and philosophical drivers of the studied disciplines.
  • Shared decision-making is only possible in practice to the extent that these drivers are factored in to any model.

How should the findings be used to influence policy/practice/research/education?

  • The points of agreement and disagreement between the disciplines clarify the type of research required to empirically test partnership working in a systematic manner.
  • Research into the impact of concordance requires measurement of the clinician perspective, the patient perspective, a correlational judgement on the coherence between these two views, and an objective measure of care improvement agreed by both parties.
  • Without further research into concordance adherence-based interventions will continue to predominate.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

In 2008 Bissonnette conducted a concept analysis of adherence, differentiating the use of the term in various health disciplines. One of her main findings was that no definition of adherence incorporated the dynamic nature of medicine taking behaviour, nor the power issues underpinning it. She recommended that:

[a]concept analysis of concordance using Rodgers' method might broaden our understanding of how best to support patients' decisions about following recommended treatments. Bissonnette 2008, p. 641

This article addresses this recommendation and also follows Bissonnette in using her method of differentiating usage of the concept under study according to discipline. This ensures that the concept can be contextualized in the theory driving those disciplines (Paley 1996). The article addresses the following questions posed by Bissonnette:

  • Is concordance conceptualized differently among the disciplines of nursing, general medicine, psychiatry and pharmacy?
  • How might this understanding better support patient decision-making?

This article develops an evolutionary concept analysis (Rodgers 2000) of concordance, articulating the different usages of the concept in nursing, pharmacology, psychiatry and general medicine. It synthesizes these analyses to identify clinical consequences of coherence and incoherence between accounts.

Background

Bissonnette (2008) found there to be no differentiation between the terms adherence and compliance as used in the healthcare literature. She found no definition of adherence that reflected a patient-centred approach. This is of international relevance and of particular concern in UK because of the continuing association of the term adherence with patient-centred behaviour. For example in developing guidelines for medicine management National Institute for Health and Clinical Excellence (2009) had originally intended to use the term concordance to reflect current thinking on best practice in medicine management. This was based on the assumption that concordance best reflected the issues of dynamism, power and behaviour considered desirable in articulating person-centred medicine management. However, the guideline developers considered at the final draft stage that concordance was too difficult to articulate in a clinical guideline (Hemingway & Snowden 2012) and so the guideline was instead entitled:

Medicines Adherence: involving patients in decisions about prescribed medicines and supporting adherence.

The conceptual problems with conflating adherence and involvement have already been described by Bissonnette. According to Cribb (2011) the clinical consequences of this incoherence lead to what he refers to as a ‘deficit reading’ of health professionals. That is, because it is impossible to align genuine patient involvement with an adherence agenda, professionals are guaranteed to fail. It is much easier for people to recognize where patient involvement is not happening than to recognize the systemic reasons why. Professionals subsequently get blamed for not practising person-centred care (Cribb 2011). Concordance by contrast appears to offer a much clearer intention of genuine involvement in decision-making. Its focus is entirely patient-centred (De las Cuevas 2011). It describes agreement not behaviour (Barron & Snowden 2012) and therefore focuses on resolving patient-centred power issues to the end of mutual understanding.

However, NICE rejected the term concordance because it was too difficult for clinicians to operationalize. A complicating factor appears to be the differing usage of the term between professions. For example in genetics concordance refers to the presence of a given trait in both twins (Halfvarson 2011) and in literature it entails a list of all the words used in any particular body of work (Krishnamurthy 2006). Statisticians operationalize it as a numerical coefficient of agreement between raters (Chan et al. 2001). In a clinical context some use it to refer to a supportive discussion (De las Cuevas 2011) while others to following guidelines (Bauer et al. 2009). Many conflate it with adherence (Snowden 2008). Following Bissonnette's recommendation a concept analysis of concordance in relevant professions will help unpick these issues to establish if concordance is philosophically and clinically possible.

The purpose of a concept analysis is to clarify the meaning of a particular term to understand its function better. A better understanding of concordance may lead to better medicine management. It must be acknowledged that there is ongoing debate on the scope and purpose of concept analysis (Paley 1996, Risjord 2009). There is no space here to do justice to this here beyond a claim for clinical utility. That is, in the literature there is evidence that it is the use of the term concordance in practice that presents most confusion (Latter et al. 2007) given that it appears to be applied differently in different disciplines. Rodgers' (2000) evolutionary method of concept analysis offers a method of investigating the usage of the term. It also follows Bissonnette's method in her concept analysis of adherence and can therefore be seen as a consistent extension of her work.

Rodgers' method of concept analysis was chosen because it acknowledges that concepts are influenced by the contexts in which they are used (Tofthagen & Fagerstrøm 2010). It is these contextual differences that are of major interest here and so Rodgers' method is coherent with the aim of this article. Rodgers sees concepts as essentially cognitive in nature given that they are abstracted from reality but functional to the extent that they are used and understood by communities (Rodgers 2000). To structure her analysis Rodgers looked for discrete components of usage of the term under study. ‘Surrogates’ are those terms used interchangeably with the concept (e.g. adherence). ‘Antecedents’ precede the concept and ‘consequences’ follow. For example treating someone with dignity may be an antecedent to concordance and following advice may be a consequence in this case. ‘Attributes’ are characteristics of the concept. Partnership is often stated as a characteristic of concordance, as is discussion. These are therefore attributes of concordance. Finally ‘references’ describe the context of the concept, for instance where it occurs, such as a medicine round or a clinical consultation.

Surrogates, antecedents, consequences, attributes and references are obtained by a thorough reading of the selected papers. These components of the concept analysis combine to construct a picture of where and how a particular concept is used in a particular context. This essentially Wittgensteinian view of language (Wittgenstein 1953) therefore sees concepts not as context independent but entirely embedded in their usage. This dispositional approach to concept analysis is consistent with the purpose of the paper.

Data sources

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

According to Bissonnette the term concordance was first used in relation to medicine management in 1997. This history and the related history of the terms compliance and adherence from 1970–2008 are covered in her paper. The purpose of this concept analysis was to extend this analysis by studying a ‘credible sample’ (Tofthagen & Fagerstrøm 2010) of literature discussing concordance in each discipline. There are no hard and fast rules about what constitutes a credible sample except that it should be fit for purpose. Because of the relatively recent emergence of the concept of concordance in the health literature we focused mainly on recent (2000–2012) usage of the term and included discursive papers and research.

CINAHL, Medline, PsychINFO, Cochrane library, Psychology and Behavioural Sciences Collection were searched with various combinations of key words including concordance, adherence, compliance, concord*, medic*, psychiatr*, pharm*, nurs*, resulting in 524 papers. Papers were read in full where a definition or discussion entailing concordance appeared in the paper as a major theme and reference lists were checked to ensure no salient literature was missed. The quality of the included papers has significant impact on the credibility of any concept analysis (Tofthagen & Fagerstrøm 2010) and so quality was cross-checked among members of the team. Quality criteria for inclusion entailed the impact factor of the source journal and the number of subsequent citations of the paper. In the case of very recent papers the previous publication history of the author(s) pertinent to concordance, or the originality of the presented argument was considered to establish an indication of likely influence. A maximum inclusion of two papers per author was set so that each analysis would not be overly influenced by a particularly eloquent contributor.

Papers were deemed discipline specific if the lead author affiliated themselves with nursing, medicine, pharmacology or psychiatry, or where the lead organization specified a particular discipline. AS then reviewed the pharmacology literature, AD reviewed general medicine, CM reviewed psychiatry and BM reviewed nursing. Sixty papers were selected for final analysis; each discipline's concept analysis entailed review of 15 papers. Each discipline's papers were analysed for references, antecedents, consequences, attributes and surrogates by importing the papers into NVivo 9 (QSR, Victoria, Australia) and coding the relevant sections of the papers. In this way commonalities and differences between accounts could be easily tracked and interpreted. The team then worked together in NVivo9 to cross-check these interpretations. Final interpretations were agreed by all team members. Interpretations were excluded from final analysis where unanimous agreement was unattainable. The next section summarizes each discipline's concept analysis separately then synthesizes the whole to answer the stated aims of the paper.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Pharmacy

References

Pharmacists discussed the political backdrop for the move towards concordance (Cribb & Entwistle 2011) to contextualize the development in pharmacy and the wider healthcare system (Figure 1). The main practical application of concordance in action was the medicine review (Salter 2010). This meeting was described by Cribb (2011) as ‘patient professional dyad’, referring to the necessary interactional nature of the review.

image

Figure 1. Concept analysis of concordance in pharmacy.

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Surrogates

These included adherence and agreement following negotiation, also shared decision-making. The discussion of a ‘two-way’ process was mentioned frequently (De Almeida Neto & Aslani 2008, Knapp et al. 2009, Cribb 2011).

Antecedents

The pharmacy antecedents were grounded in recognition that people are not always rational (Tversky & Kahneman 1982) and so education targeted towards adherence can only ever hope to be partially successful. This generates a need for a better approach: concordance. There is a lot of discussion on the causes of irrationality to mitigate it (Volmer et al. 2008, Horne et al. 2010, Shi et al. 2010). For example De Almeida Neto and Aslani (2008) explanation for this apparently irrational behaviour is grounded in Brehm's psychological theory of reactance. Reactance suggests that people will do the opposite of what they are advised purely to reassert their right to choice, regardless of the impact of that decision. Recognition that people can react in this manner is therefore an essential antecedent to creating the right conditions for communication.

Consequences

De Almeida Neto and Aslani (2008) go on to claim that concordance mitigates reactance. However, at present the impact of this mitigation remains unproved to pharmacists. In fact scepticism persists in relation to the putative benefits of concordance in the pharmacy literature (Cribb & Owens 2010) and adherence thus continues to be touted as a desirable outcome of concordance (Chen et al. 2010). The political benefits of concordance are easier to articulate than the practical and Cribb (2011) points out that a consequence of this is that it is a lot easier to recognize when concordance is not happening than articulate how it should be operationalized. As such the concordance agenda has the potential to be seen as an impossible ideal, thereby creating a ‘deficit reading’ of professionals not practising it. Cribb goes on to define a research agenda compatible with this thesis. This will be returned to.

Attributes

The attributes of concordance as discussed by the pharmacists can best be analysed by reference to Knapp et al.'s (2009) factor analysis of the Leeds Attitudes to Concordance scale. They found the scale explainable by five components (Knapp et al. 2009, p. 182):

  1. Participation and involvement
  2. Paternalistic style
  3. The necessity to find common ground
  4. Perceived benefits of partnership
  5. Equality and shared control

Other major attributes of concordance can be viewed as subthemes of these components. For example, there was considerable discussion of authenticity as an essential attribute. In particular, much of the discussion of pharmacists' lack of skills in this regard (Salter 2010) is framed as function of ‘practical wisdom’, a significant Aristotelian concept discussed in depth by Cribb (2011). In a related paper the proximity of practical wisdom to friendship is discussed by Cribb and Entwistle (2011). Practical wisdom in this context facilitates equality and shared control through the skills of the practitioner. Failure of practical wisdom is associated with task-based approaches, continued paternalism and inability to find common ground.

However, there is evidence that pharmacists are not all comfortable with this facilitative role in conducting medicines reviews (Salter 2010). The pharmacy literature on attributes of concordance therefore reveals evidence of tension. Whilst there is an authentic concern with the conceptual limits of concordance (Cribb & Entwistle 2011) this is situated in recognition that patient autonomy is an increasingly important practical aspect of pharmacology (De Almeida Neto & Aslani 2008) that pharmacists feel unprepared to facilitate (Salter 2010).

Nursing

References

The routine day to day activity of medicines prescribing and administration was the principal reference for concordance in action in the nursing literature (Figure 2; Gray et al. 2002, Cashin et al. 2009, Courtenay et al. 2011). As with the pharmacists nurses also contextualized concordance according to its political, legal, professional and practical function. For example Latter et al. (2007) suggested that the expansion of nurse prescribing in UK at the turn of the century offered an opportunity to bring nursing values into the prescribing encounter through the act of concordance.

image

Figure 2. Concept analysis of concordance in nursing.

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Surrogates

Surrogates mainly entailed expressions of partnership and shared communication such as ‘participant partner’ (Barron & Snowden 2012). Equal understanding about medicine taking (Cashin et al. 2009), ‘two-way communication’ (Gray et al. 2002) and agreement were common surrogates for concordance, with (Courtenay et al. 2011) using adherence and concordance interchangeably.

Antecedents

In line with the referents, the antecedents depended on the political, legal, professional and practical context of the discussion in the papers. For example Barron and Snowden (2012) cited Scottish practice guidelines and legislation such as the Millan principles (Scottish Government 2005) as precursors to the principle of concordance, whilst in Australia the national strategy for the Quality Use of Medicines(Commonwealth of Australia 2002) was described as an antecedent (Cashin et al. 2009). More practical and professional antecedents focused on evidence that patients often failed to take medication consistently, hence the need for a new approach (Latter et al. 2007, Lehane & McCarthy 2009, Courtenay et al. 2011) grounded in the perceived need for more collaborative working (Gray et al. 2002).

Consequences

According to Barron and Snowden (2012) the consequences of concordance included improved prognosis and an enhanced nurse/patient relationship which resulted in better patient understanding of the therapeutic component of medication. This is a consequence also emphasized by Cashin et al. (2009). For Courtenay et al. (2011) concordance led to improved compliance/adherence to medication in the short term although they were unclear if this was sustained over a longer period. Lehane and McCarthy (2009) also observed that outcomes were not clear due to the paucity of evaluation studies of concordance to date.

Attributes

In defining the attributes of concordance most nursing authors emphasized partnership and autonomy underpinning individualized medicine management (Latter et al. 2007, Barron & Snowden 2012) and outlined the importance of practitioner and patient developing an equal understanding about medicine taking (Cashin et al. 2009). Gray et al. (2010) claimed that concordance emphasizes patients' rights. Wakefield (2012) suggested that compliance, adherence and concordance could be viewed as a sliding scale of medicine management responses to increasing capacity in mental health, with concordance representing the appropriate response to full ‘insight’ and cognitive capacity to engage in complex knowledge exchange.

In summary, concordance appears closely related to ideal nursing values. However, not all authors see concordance as a universal good. Lehane and McCarthy (2009) are concerned that concordance may be empowering but may also lead to lack of safety, presumably as the result of patients discontinuing their medicines.

General medicine

References

Most of the general medicine literature on concordance refers to the clinical consultation. These papers all take the position that concordance is another tool to enhance adherence (Figure 3). For example Street et al. (2008) use the term to explore the similarity between personal and ethnic dimensions of shared identity and conclude that adherence to medical advice is improved by shared cultural values and attributes. In a related paper (Street & Haidet 2011) the agreement between physicians understanding of their clients' health beliefs and their actual beliefs was explored as another dimension of concordance. Although most papers refer to agreement and shared decision-making as key concepts these are taken to mean agreement with expert opinion rather than shared decision-making between client and doctor (Charlin et al. 2006).

image

Figure 3. Concept analysis of concordance in general medicine.

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Surrogates

Most of the literature uses the term synonymously with shared decision-making and negotiation, but this is on a continuum from patient-centredness and negotiation between equals, through involvement and agreement between physician and patient to the concept of ‘informed adherence’.

Antecedents

Antecedents to concordance are discussed in terms of increasing patient rights (Penston 2007), the recognition that patients do not always follow recommendations (Bissell et al. 2004) and the general need to inform patients better (Jones 2003). They refer to issues around the doctor-patient relationship and the importance of good doctor-patient communication (Bertakis & Epstein 2009). For example issues of active participatory communication and its association with positive outcomes are highlighted by Gordon and Gerber (2011), but it is interesting to note that the positive outcome cited is adherence to and recall of the physician's recommendations.

Consequences

The suggested consequences of concordance in the medical literature point to the need for a more diverse workforce to enhance culturally sensitive interventions (Gordon & Gerber 2011) and to promote a shared understanding of values and health beliefs between physicians and patients (Street et al. 2008). This was seen as a predictor of patient satisfaction with the encounter and also of better adherence to the treatment regime. Jones (2003) suggests that concordance poses ethical and legal challenges and suggests that there is a potential conflict with the doctor's duty ‘to do no harm’. Penston (2007) provides a useful discussion of the ethical implications of concordance framed as a conflict between increasing patient autonomy and the rise of guidelines-based medicine. Penston (2007) states that ‘Instructing doctors to manage by central diktat…militates against patient participation’ (p. 158). He also makes the salient point that highly informed patients may see that the evidence for most interventions is actually fairly poor.

Attributes

To summarize, in line with the pharmacists and nurses the attributes of concordance in general medicine entail dynamic ideas of partnership, agreement and shared decision-making between the physician and patient (Butz et al. 2009). However, as Penston (2007) described above this exploration is compromised by professional guidelines. That is, agreement with the proposed medical intervention is generally seen as primarily important, thereby implicitly prioritizing adherence over genuine partnership. This is rarely discussed directly in this literature but more often discussed in the more abstract language of values and culture when discussing the barriers to partnership working.

Psychiatry

References

The concept of concordance was least developed in the psychiatric literature (Figure 4). The main referents entailed discussions of medicine interventions and diagnostic categorization. Consequently, reference material was orientated towards discrete domains of disease-management and poor adherence, particularly in relation to antipsychotic medication. Although there were notable exceptions, for example (De las Cuevas et al. 2011), references emphasized the problems inherent in managing a difficult-to-engage patient group requiring compliant medical management.

image

Figure 4. Concept analysis of concordance in psychiatry.

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Surrogates

These included key psychological dimensions such as self-efficacy (McCann et al. 2008). De las Cuevas et al. (2011) equated concordance with shared decision-making, although the bulk of this literature focused on adherence and interventions focused towards maximizing it (Horne et al. 2005).

Antecedents

The psychiatry concordance literature focused on medical intervention against a background of non-compliance. This was grounded in the recognition of suboptimal treatment and the need to improve outcomes (Bauer et al. 2009). A pre-occupation with the costs of health provision (Horne et al. 2005), bed use and alternatives to admission (Abas et al. 2003) confuses the agenda somewhat about the interests of clinicians, patients and health providers against the wider societal context.

Consequences

Consistent with the antecedents, the consequences focus on improvements in guideline concordance (Bauer et al. 2009), which in the context of several papers appears to be a metaphor for patient compliance. There were some contrasting observations, including emphasizing the importance and relevance of psychiatrists considering the patient's desire to participate in treatment and to consider the patients perspective of their medication and treatment (De las Cuevas et al. 2011). Aside from De las Cuevas, however, there was a general scepticism about the concept of concordance, given its inherent ambiguity in the absence of a study-specific operationalization of the term. In other words, evidence not currently available was required to support the claims being made for concordance.

Attributes

The attributional aspects of concordance entailed an underlying theme of relationships. The focus of agreement between the patient and the healthcare professional was especially salient, representing a dynamic process and an endpoint of negotiation (De las Cuevas et al. 2011). The notion that concordance represents a concept that challenges patient passivity and submissiveness (Gordon & Gerber 2011) is of particular relevance to those who may be disenfranchized by a psychiatric history or diagnosis.

However, the more traditional rhetoric of compliance, masquerading as concordance, is the main voice in the psychiatry literature. For example Horne et al. (2005) saw as positive the extent to which the patient's behaviour matches the prescriber's recommendations. Sewitch et al. (2007) simply saw concordance as a means to facilitate the following of guidelines. Neither of these positions attributes any sense of genuine partnership to the concept of concordance.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

Figure 5 represents the points of agreement between the disciplines. The references converge on the relationship between patient and clinician. This relationship varies according to the political, professional and legal position of the discipline, and the idiosyncratic traits of the patient. For example, some people want to follow prescribed courses of treatment without participating in the decision at all (Marland & Cash 2005). Some people want to be part of some of the consultation process but not make final decisions (De las Cuevas et al. 2011). As discussed by the pharmacists, people in general (including clinicians) are not as rational as they think they are (Kahneman 2011).

image

Figure 5. Composite view of concordance.

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The antecedents to concordance also entail a political and professional aspect in that they are driven by policy guidelines and again these differ between disciplines. So, although the need to educate and inform is a common antecedent the expression of this education and information also varies according to professional interpretation of these concepts. Partnership is a common attribute and surrogate across all, suggesting that partnership is strong common ground. Agreement is the other common attribute, suggesting that in terms of common understanding between the professions they all view concordance as about coming to an agreement in a partnership.

However, adherence is the other commonly cited surrogate. This suggests that the terms concordance and adherence are still being used interchangeably by authors in all professions. This in turn suggests that the distinction between adherence and concordance is unclear, a claim supported by the finding that all professions agreed that the consequences of concordance required further evidence. Whilst they all agreed that relationship building was a positive consequence of concordance the benefit of this remained unclear. In brief, there is currently insufficient agreement between disciplines on the concept of concordance to translate this into homogenous activity across the disciplines.

Practising concordance is therefore not only a very high level skill, it is also currently a different skill according to profession. For example in nursing and pharmacy it entails ‘comfort with uncertainty’ (Figure 1), a significant component of ‘practical wisdom’ (Cribb 2011). The problem with practical wisdom in general medicine and psychiatry is that it may not be enough to facilitate adherence and adherence rather than concordance remains the major goal of medicine and psychiatry (Charlin et al. 2006, Sewitch et al. 2007).

This concept analysis has therefore illuminated some clear points of tension between ethical rhetoric and professional accountability. This is useful because it offers a predictive model of attitudes and behaviour. For example Knapp et al. (2009) found nursing students statistically more favourable in their attitudes to concordance than either pharmacists or medical students. This could have been predicted and explained as a function of this concept analysis. The nurses were most active in integrating the principle of concordance as they interpret it and see concordance as coherent with their professional values. The pharmacists on the other hand are more philosophically advanced in their deconstruction of concordance but less confident about applying these principles in practice. The ‘courteous but not curious’ (Agledahl et al. 2011) medics do not see how genuine partnership can co-exist with medical accountability.

Concordance is therefore expressed differently in these different professions, as a function of their role in the spectrum of care interventions. Any attempt to operationalize it needs to take this into account.

Limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

The purpose of the literature search was to generate analysis from the highest quality sample. Whilst this process has been explicit, the pertinent literature necessarily included diverse methodologies. This means that there is no consensus on the best way of generating such samples. Despite every effort to generate representative samples it cannot be guaranteed that the literature studied here evokes all pertinent comment on concordance.

A related issue is that for the purpose of differentiating concept analyses the included disciplines were treated as homogenous. While situating concepts within their contexts is an essential aspect of Rodger's method, it must be recognized that this oversimplifies such contextualizations by treating professions as more consistent than they are. Nevertheless, the broad conclusions hold, and these are discussed below.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

The purpose of this project was to answer the following questions:

  1. Is concordance conceptualized differently among the disciplines of nursing, general medicine, psychiatry and pharmacy?

Concordance is conceptualized differently in the disciplines discussed here. This means that the disciplines are not referring to the same concept in interdisciplinary discussions. The points of agreement are in Figure 5 and have been discussed above. The points of disagreement are in the majority, however, and can all be seen as a function of the underpinning theory, policy and practice of the different professions. For example medics and psychiatrists are mainly interested in concordance as an end to compliance with instructions, or compliance with guidelines, thereby retaining the presumption that their opinion is the predominant factor in any relationship. They defend this position by reference to professional responsibility and accountability. This introduces provisos into the concept of concordance that diminish its authenticity.

The nursing literature is less sure about concordance, despite being the most enthusiastic and the language reflects this duality. Concordance is touted as a universal good in some instances, entirely coherent with nursing policy, principle and professional values. At the same time there is minimal evidence to support what this means in practice. Perhaps Wakefield's (2012) graded distinction between compliance, adherence and concordance best illuminates the pertinent issues for nurses. Despite the concept of insight being distinctly value laden, Wakefield nevertheless points to the clinical reality that part of the role of the mental health nurse is to make judgements about people's cognitive capacity and enforce mental health legislation. Concordance fits very uncomfortably as a universal principle in this environment and thus runs the risk of becoming meaningless here too.

Pharmacists are the most advanced in their deconstruction of concordance. They see the benefit and necessity of going beyond education and advice in the medicine review, yet at the same time remain uncomfortable in facilitating concordance-based approaches and sceptical as to the benefit. Cribb (2011) uses this position to generate several pertinent questions for further analysis, essentially questioning the credibility of either consumerist of paternalistic interpretations. It is concluded here that empirically testing these questions would be a theoretically sound method of articulating the strengths and limits of concordance in practice.

  1. How might this understanding better support patient decision-making?

The major problem with all four positions is that they are value laden and this obscures the most important question. The most useful and missing evidence is to establish if concordance works. This is the understanding that is required to better support patient decision-making.

To establish any benefit to concordance, coherent research questions must be answered. As discussed earlier Cribb (2011) has already asked many of these questions in his deconstruction of shared decision-making. In relation to concordance in particular studies would require a measure of the clinician opinion of a particular consultation, the patient's opinion of the same consultation, a measure of successful outcome as agreed by both parties and a measure of objective achievement of that outcome. Studies such as these are resource intensive and complex, but they are entirely possible and clinically very important. For example see Baile et al. (2011). If they show concordance has a positive impact then resources can be shifted to support it. If they show concordance has a null or negative impact then perhaps the patient opinion is less important that political, ethical and professional rhetoric would have us believe.

Without such evidence medics and psychiatrists will continue to assume they know best and nurses and pharmacists will have no evidence to counter these claims other than pointing to the limits of adherence discussed in this and many other papers. In other words an alternative method of medicine management needs to be systematically tested. Without such evidence the next iteration of the NICE medicine management guideline in UK will still be discussing adherence, with all the confusion and moral neglect that entails.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

  • substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;
  • drafting the article or revising it critically for important intellectual content.

Box 1: Summary definition of concordance

Concordance. The process of enlightened communication between the person and the healthcare professional leading to an agreed treatment and ongoing assessment of this as the optimal course.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Data sources
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Funding
  10. Conflict of interest
  11. Author contributions
  12. References
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