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Advanced Nursing

2000, 32(1), 115-123

Issues and innovations in nursing practice

com pliance in w oun d care: discourse

E H a ll e tt PhD BNurs BAHons RGN HVCert DNCert PGDE

The University of Manchester

Fellow The University of Manchester

n n C a re s s PhD BNurs DNCert HVGert

A Luker PhD BNurs DNGert HVGert

The University of Manchester Manchester England

HALLETT G.E., AUSTIN L., GARESS A. LUKER K.A. (2000)

Journal

of

Advanced

Nursing 3 2 ( 1 ) , 1 1 5 - 1 2 3

Community nurses perceptions of patient comp liance in wound care:

a discourse analysis

As part of an interview study of com mun ity nurs es' percep tions of their work,

62 staff working within the district nursing service in one English National

Health Service Trust (grades

B—H]

were asked to recount occasions when they

had been involved in wo und care and to discuss the ways in which working

with patients who required such care could be either enhanced or made

difficult. A large number of respondents expressed the view that non-compli-

ance cou ld pose serious problems for the m anageme nt of wo und s. Data relating

to compliance are presented here and are interpreted in the light of discourse

analysis, an approach wh ich permits the researcher to focus on the m eanings

underlying the communications of research participants and to interpret those

meanings in the light of social and cultural m ores and influences. The authors

found that non-compliance could be explained by nurses in a num ber of

different ways. These ranged from passive resistance, which could be due to

ignorance or lack of motivation, through overt refusal, to deliberate interference

in order to prolong treatment. It also seeks to outline some of the factors tha t

appear to motivate the nurses' desire to achieve com pliance.

Keywords: compliance, wound care, discourse analysis, district nursing,

health services research, nursing policy, clinical guidelines, legal sanctions,

management

INTRODUCTION

ne Hallett School of Nursing Midwifery and

oupland III Building University of Man chester Oxford

D i s c o u r s e a n a l y s i s

is an

a p p r o a c h

to

S t u d y i n g b o t h

Manchester

M 3

9PL England. E-mail: karen.lukei®man.ac.uk patterns of meaning and modes of communication


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E

Hallett et al.

Through this approach it is possible to gain insights into

the perspectives of research participants, by interpreting

their use of language and their means of expressing

themselves. As an approach to the understanding of the

life-worlds of professional people, discourse analysis can

guide qualitative research by encouraging the researcher

to focus not only on the overt meanings conveyed by

participants, but also what is covert, implicit and taken-

for-granted in their modes of description, explanation and

interpretation.

Patient com pliance is an area of study wh ich len ds itself

well to discourse analysis. It is a concept which is so

deeply ingrained into the culture of nursing and of the

health professions more generally, that any discussion of

it is overlain with value judgements and assumptions of

which neither the participant nor the researcher may at

first be aware. It is only whe n one peels away these outer

layers that an insight into the meaning of this complex

concept can be obtained. Although the notion of patient

comp liance has recently been challenged, there has been a

general acceptance that patient compliance is a positive

and desirable feature of health care, and that wh en it is not

present the re is a need for some strategy to be put in place

to restore it. This pap er will examine this assum ption and

will offer an interpretation of it as presented through the

transcripts of 62 interviews conducted in one National

Health Service Community Trust in the United Kingdom

(UK) in 1998.

LITERATURE REVIEW

The nurse-patient relationship has long been an area of

interest to nurse researchers. It has been viewed as taking

potentially a number of different forms, ranging from one

in which the patient is entirely passive, to one in which

there is a genuine partnership between nurse and patient

(Cahill 1998). Few, if any, writers on the subject appear to

give any wholehearted support to the idea of a relation-

ship in which the patient is in control. Compliance is a

term that is often used when referring to relationships

between health professionals and their patients. It has

been defined in its simplest terms as 'a willingness to

follow or consent to the wishes of another person' (Buch-

mann 1997).

Much of the work that has been done on patient

compliance, in recent years, has focused on patients

suffering from chronic illnesses such as diabetes, asthma

and renal failure, in wh ich the success of treatment is seen

to be strongly dependent on the patient's behaviour

(Cameron

Cregor 1987, Hen tinen

Kyngas 1996, Kyngas

et al. 1996, Wainwright Gould 1997, Cochrane 1998).

The recognition that the patient will determine whether

they will com ply with treatment or not — the fact that the

professional does not ultimately have co ntrol over matters

of com pliance — has led to a num ber of studies attemp ting

to understand what 'factors' make patients more or

compliant (Jarvis 1998, Hyland 1998). Rand (1998 p.

suggested that non-compliance could be divided

'typologies' observing that:

The reasons for non-compliance are many and varied,

include erratic compliance, unwitting non-compliance,

intentional or 'intelligent' non-compliance.

Other authors have, however, focused more on the

to attempt to understand patients' perspectives on is

of compliance with treatment regimens (Caraher 1

Taylor 1996). Writers have suggested a number of way

which nurses might improve their relationships

patients and thereby secure better compliance with t

ment regimens. From the production of more effec

written patient information (Arthur 1995) through n

tiation (Trnobranski 1994) to teaching and counse

(Wilson-Barnett 1988), the literature advocates a num

of perspectives on this issue.

Nurses' consider the nurse-patient relationship

therapeu tic vehicle through w hich to influence the ca

patients. The role of the nurse has, thus, been viewe

least in part, as being to inform the patient and exp

treatment regimes, based on the assumption that if

patient understands he/she will comply. The abilit

make such modifications has been seen to be depen

on the quality of the nurse -patie nt relationship (Ashw

et al. 1992, Porter 1994, Webb Hope 1995).

Writers have variously advocated 'empowerm

(Elliot Turre ll 1996, Myers MacD onald 1996, H

1997),

'partn ersh ip' (Cahill 1998, Waterworth

1990,

Jewell 1994, Cahill 1996) and 'compliance' (S

1995,

Cameron 1996, Buchmann 1997). Holm (

observed that in an era in which health care is supp

to be conducted in such a way as to make patients

health professionals equal partners, there is no room

the language of 'compliance'. Decisions will be

patient's decisions, however much they may be based

the advice of health professionals; hence, non-compli

is not a possibility.

Most of the nursing literature on th e conce pt of com

ance takes the view that it is a positive feature of

nurse-patient relationship and hence one which sho

be fostered by the nurse. Cameron (1996) offers a lis

factors which may infiuence the likelihood of complia

and which may therefore be modified by the nurse.

suggests firstly that knowledge and understanding ma

related to compliance, though this relationship may

less direct than many would suppose because offerin

patient information will not necessarily increase mot

tion to comply. The quality of the interaction betw

patient and health professional is seen to have m

influence, as are the patient's pre-existing health be

and attitudes. Other influencing factors include the l

of social suppo rt available to the p atient an d the natur


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and innovations in nursing practice

Patient compliance in wound care

and

treatment (particularly their d uration

and

a useful analysis on the

of

compliance, although

she

does

not

attempt

to

on the vexed question of what value

Another author

who

takes

a

similar approach

to the

is

Buchmann (1997),

who,

like Cameron, focuses

the

subject from

the

implicit belief that com pliance —

in

this case 'adherence'

— is

inherently valuable

and

the terms 'compliance'

may be

used interchangeably bec ause

— the action of sticking to, supporting or

a

person

or an

idea' (Buchmann 1997

p.

132) —

the behaviour w hich will of necessity be attendant on

He

argues that

the

most effective

way of

is for the health professional to

ent po wer',

a

type

of

power which

is

viewed

and benevolent and which enables the

to be

viewed

as a

'frame

of

reference' (Buch-

p.

133).

He

also advocates

the

development

of

a number of ways in which adherence can

mak e specific enq uiries;

be benevolent;

encou rage self-disclosure

to

gain insight;

the patient's knowledge base;

the

patient 's commitment

to

taking appro-

priate actions;

an

attitude

of

positive regard;

a

sense

of

personal responsibility;

match client needs

and

wishes;

use selective positive feedback; and

to a

respected secondary

group.

A number

of

interpretations might

be

placed

on

such

a

At one end of a

scale,

it

could

be

seen

as a

valuable

for

ensuring appropriate

and

positive profes-

and patient outcomes; at the other, it might be

a

means

of

manipulating one's client

in

order

to

own professional status and power.

A number

of

authors have questioned

the use of the

it is paternalistic in tone

it

negates

the

partnership between patient

and

The term 'adherence' has already been

is

a perspective advocated by Esposito

in considering the effects of education on the self-

of

m edications

by

elderly patients. Moore

the

as an

equal partner

in the

patient-professional

ip, and M arinker (1998) advocates the use of the

One author

who

writes critically

of the

concept

of

is

Hess (1996

p.

18).

She

observes that

it is a

'construct that begs

for

consideration from

an

ethical

perspective'. She furtJier points out that at the opposite

en d

of

the scale from

the

paternalism

of

com pliance

is the

consumerism of 'isolated autonomy'. She advocates a

dialectic approach which draws these concepts together

into a mid dle ground w here there is a genu ine engagement

between

the

professional's desire

to do

what

is

right

and

the client's desire to fulfil his or her ovrai wishes. This

engagement

is

characterized

by

'defining

the

good that

is

mutually sought and identifying the means for achieving

that good' (Hess 1996

p. 24).

THE STU Y

Methods

Theoretical context

Discourse analysis

is an

approach

to

textual interpret-

ation.

In

adopting this approach,

the

researcher

is

searching

a

linguistic text

for

evidence

of the

social

and

ideological power structures that infiuenced

the

author.

The originator of the text is seen as unconsciously

directed

by

social norms

and

mores wh ich h ave their

basis in the structure of society. Denzin Lincoln (1998

p .

43)

observe that unlike

the

more straightforward

'content analysis' approach to the handling of q ualitative

data, approaches such

as

discourse analysis

aim to

'bring

out the hidden meanings in the text'.

The Speech

Act

Theory

of

John Aus tin (1962) w hich

was elaborated

by

Searle (1969),

was an

important early

approach

to

discourse analysis.

It saw the use of

language as a functional, purposeful action. Human

beings choose language

for

purposes which

are

driven

by social norms; these norms are likely to be culturally

determined. Later approaches have ranged from 'interac-

tional sociolinguistics' through the 'ethnography of

communication'

to

'pragmatics'

and

'variation analysis'

(Schiffrin 1994, Fiske 1998). For purposes of the inter-

pretation presented here,

the

approach taken coincided

most directly with the 'ethnography of communication' ,

in which

it is

recognized that language

is

used

to

'make

sense' of experience. In this approach it is recognized

that,

in

using certain linguistic forms,

the

author

or

originator of a text anticipates that these forms will have

a meaning

and

significance

for the

hearer which

are

similar to his or her own. Hence, this approach to

discourse analysis draws

on the

work

of

Alfred Sch utz

(1967) who wrote of the intersubjectivity inherent in

human societies.

ata collection and sample

In the present study, the texts under scrutiny w ere

interview transcripts.

As

part

of a

study

of

community

nurses' perceptions of quality, 62 nurses were interviewed

over

a

period

of 4

months

in

1998.

The

interviewing

was


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CE. Hallett et al.

undertaken by a team of four researcbers, and tbe partici-

pants were of grades B, D, E, F, G and H. Tbe nu mbers of

eacb grade of researcb p articipant are given in Table 1.

Tbe Director of Nursing Services for Community in one

National Healtb Service (NHS) Trust was approached and

she provided the researcbers witb tbe names and contact

numbers of locality managers wbo, in turn, put tbe

researcbers in contact witb a randomly selected sample

of commu nity nurses . A letter was sent to eacb com munity

nurse and once consent bad been obtained, eacb nurse

was interviewed. Tb e interviews lasted between 30 and 60

minutes and all but four were tape-recorded. All four of

tbe researcbers participated in interviewing, a process

wbicb was assisted by tbe use of a two-page interview

guide.

Tbe purpose of tbe study was to ascertain community

nurses perceptions of quality in tbeir work. A critical

incident type approacb was adopted in order to provide

participants witb an opportunity to discuss tbis issue in

ways tbat would be relevant and immediate to tbem. Tbe

interviewers asked tbe nurses to recall specific episodes of

patient care tbat bad been either particularly successful or

particularly difficult. Participants were asked to consider

examples tbat would fall into tbe broad categories of

palliative care, patients newly discbarged from bospital

and those witb cbronic wounds.

In discussing examples of wound care, participants

often mentioned compliance as an issue wbicb could bave

an impo rtant influence on tbe outcome of a patient co ntact

or series of contacts. Numerous cases were recounted in

wbicb non-compliance was seen by tbe nurse as a serious

obstacle to wound healing. In interpreting tbe data, it

became clear tbat these examples were so numerous that

they were of interest and importance in tbeir own rigbt.

Data analysis

Tbe tapes were kept in locked files tbat could only be

accessed by tbe researcbers and tbe secretaries under-

taking tbe transcription. All of tbe tapes were fully

transcribed and interpreted.

Table Number of respondents hy grade

Grade

Number of interviewees

Specialist

H

G

F

E

D

B

Total

2

7

11

4

9

20

9

In interpreting tbe narratives of tbe participants

autbors bave been guided by tbe approacbes to disco

analysis described earlier. Interview transcripts

viewed as texts for interpretation, and tbe interpreta

drawn from tbem are guided by tbe attempt not onl

understand tbe meanings wbicb certain events bold

participants bu t also to appreciate how these meaning

socially constructed in terms of professional-client

t ionships.

F I N D I N G S: D A TA PRESEN TA TI O N

The purpose of tbis paper is to offer insigbts into tbe

in wbich community nurses perceived and interpr

non-compliance, and to present the factors w

appeared to motivate nurses wben seeking to se

patieut compliance. Tbe data presented below take

form of descriptions of encou nters witb ind ividual cli

Tbey are divided uuder beadings representing ideas

the autbors viewed as salient.

Non compliant behaviour

Researcb participants had tbeir own explanations

wbat tbey saw as failure to comply witb treatm

regimens. Many of tbe descriptions offered by pa

pants often bad an air of resignation or even of fata

about tbem. There was a sense that a community n

sometimes felt that a situation would never improv

wound would never heal, because the patient was,

whatever reason, acting in a manner wbicb w

prevent bealing. Sucb situations were often associ

witb non-compliance, wbicb could take various fo

from deliberately damaging behaviour tbrougb pas

resistance, or inaction.

Flogging a dead horse

Tbe significance of tbese situations seems to lie, at lea

part, in tbe impac t tbey bad on tbe nu rses tbemse lves

community nurses, a si tuation in wbicb a wo

persisted wben tbey perceived tbat it ougbt to

possible to beal it, could be a profoundly disappo in

experience. One participant commented:

If the chronic wound gets better, you know that they ve comp

had the right diet... they ve put their legs up, had a lie dow

the afternoon, they ve not interfered with their dressing...

yes.

If they don t — I mean it s a two way thing isn t it really

they don t comply it s flog ging a dead horse isn t it r

hasically? (25D)

Her own doing

Tbe tbeme of tbe non-compliant patient being respons

for bis or ber own problems is continued in tbe follow

example:


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lt that every week they were deteriorating — partly from her own

think... the w ound s were certainly growing. think perhaps

a little bit under the ban dages ...

ed quite angry and infected on a couple of occasions,

pite antibiotics and all the rest of it. So did feel a little bit that it

d she has now been asse ssed by the

ulcer services and I don t know. She s in com pression and

her visits to once or twice a week. (08F)

The idea that this situation was a dead end for the

ed to the need to focus on the

nd does not heal, as there may be no other po sitive

just doesn t help himself

s part of me can unde rstand non-co mp liance... it s not a

ether you like it or not... We ve got

t d iet, says he doesn t eat m uch, b ut I mean if you go at

time, he s got fish, chips, double h elping of whatever, black

ing, steak pudding w hatever... he just doesn t help himself

for their ow n body, th at s, that s it.

The theme of a patient not helping himself whilst

pathetically by this nurse, recurred frequently

aling desp ite the nu rse s best efforts.

e refused

was a leg ulcer that she had . She had huge oedem atous legs. She

n t help her legs. She wou ldn t even p ut her feet up. She

lady, and we d idn t have a very good GP [general

anted looking at; we did n t know if she was taking

ng with h er and saying, If you do n t want to go into hospital,

s your c hoice. Nobody is going to force you . T he GP wa s

following me , wagging a finger at her and saying, You w ill go into

hospital. I will make you . (57F)

One interesting feature of this exemplar is the recogni-

tion that non-compliance may sometimes be the result of

fear. The nurse continues to discuss the patien t s w ishes

despite the GP seeking to impose his ow n view. The nu rse

goes on to describe a situation when, due to other

circumstances, the patient was admitted to hospital and

actually found her time in hospital a positive experience.

The nurs e con tinues he r narrative at a point following the

patient s discharge:

I sat and had a chat with her one day and said, you know, What

happened when you were in hospital? How did things go? and,

oh, everything was wonderful; everybody was marvellous and she

didn t know why she had been so frightened of hospital and... she

now will comply with everything. And because she s complying

with us we managed to get those healed, she has just come out of

compression and gone into stockings. (57F)

The story this nurse narrates is clearly a didactic one,

which fulfils the purpose of demonstrating that when a

patient fails to comply with treatment and advice there is

conflict. Wh en, how ever, she ha s an experience — of

whatever type — that enables her to comply, her wo und s

are healed.

He didn t believe

The following respondent recalled a patient who had

restricted his diet to the extent that it prohibited wound

healing:

We had a patient... who was into complimentary therapy, and he

didn t believe in modern m edical stuff and we ... had to get the

legal department in because all he wanted was these homeopathic

remedies which he made up

himself.

And he d got the most

awful... bilateral leg ulcers I d ever seen, which were just bright

green legs really with pseudomonas, and in a lot of pain... and

every day he made himself w alk a couple of miles... He was dying

but there was nothing we could do about it and in the end he did

die from malnutrition. It was the most horren dous leg ulcers. That

was hard for us because we knew things that might have helped

him... it was hard for us to watch him dying, and there was

nothing we could do about it. (19D)

This patient presents an almost archetypal example of

the isolated autonom y described by Hess (1996) in her

paper on the ethics of com pliance. His standpoin t was one

in which he did not comply with suggested treatment; he

overtly rejected treatment in favour of an alternative

regimen which he had devised for

himself.

The distress

felt by nurses in watching this patient die is transparent.

In the face of such autonomy, the nurses are seen to feel

utterly helpless and, given the patient s imp endin g d eath,

are forced into a position in which they need to get the

legal departm ent in in order to protect themselves.


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C.E. Hallett

et al.

Social ulcers

I n s o m e c a s e s n o n - c o m p l i a n c e was v i e w e d as a d e l ibera t e

a t t e m p t to d e la y w o u n d h e a l i n g in o r d e r to p r o l o n g

n u r s e s v i s i ts , w i t h s e v e r a l n u r s e s c o m m e n t i n g on s i m i l a r

s c e n a r i o s . W h i l e n u r s e s w e r e s y m p a t h e t i c t o w a r d s t h i s

t h e y w e r e not in a p o s i t i o n to me e t pa t i e n t s soc ia l ca re

n e e d s :

Sometimes patient compliance

is a

problem is n t it?...We have

patients that if they w ould follow w hat you re saying to them you

could heal

the

wounds,

but

they think

it is a

social visit really,

they don t want the wound to heal because while the wound s not

healed you re going

on a

weekly

or

2-weekly basis... We ac tually

call them social ulcers ... I have a lady that we almost healed the

leg ulcer

and she

didn t want

to

hear that because

it

would mean

that her friends weren t going to be going in twice a week and she

didn t like that. So she actually started

to

take the bandages

off...

Sh e did admit that, in the end, she would miss us when we

stopped going in.

(53G)

easons

or

seeking compliance

The statements made by nurses in relation to patient

compliance indicated that there were several factors

motivating them to secure compliance. This included

viewing patients as the passive recipients of care, endeav-

ouring to provide care consistent with good practice, and

working with the patient towards a mutually agreeable

outcome.

They just won t

do as

they re

told

The notion of patients having a passive role is exemplified

by the following extract:

You

are

still providing

a

good service

to

them even

if

they re

not

complying but, in that respect

think you get frustrated, I suppose,

with them. Cos they re not complying sometimes you think you

may as well talk to the wall because they just wo n t do as they re

told anyway. I mean it s fair enough if they re confused and it s

understandable that they might not comply, but just being down

right stubborn. (39E)

If we

can

educate them

While this viewpoint was present, a more common

assumption, which appeared to underpin the nurses

comments, was a perception that they were working

towards a shared goal with patients and this required

concordance of both belief and action. In this sense the

nurse was adopting the role of educator, informing the

patient regarding factors which contribute to wound

healing:

I think the education there, not only for the patient but for the

relatives as well, you know. I mean one example is Why have you

left the dressings

on so

long ... then you ve

got to

sort

of

explain

all about this wound healing and I think once they then sort of

think,

Yes,

well that contributes tow ards

my Mum or

healing p rocess b etter ... and I think if we can educate the

well as the patient

it

does make that little bit of a relationship

easier. (38E)

We

can try

different things

In this respect the nurse could be viewed as seekin

obtain informed consent when treating wounds. Non

less,

this did not preclude adopting alternative app

ches if patients were unhappy with treatment regime

It s not always down to they ve just removed them it s — th

either

not

comfortable, irrita tion, they feel sometimes w it

compression the bandages are too tight... I mean we ca

different things cos obviously that s one of the issues that

looking at as well. Patient comfort... some patients just

bandaging, say just around their ankle or just at the ca

whatever. So then you ve got to , you know, we can t do tha

we ve got to state that it s either better to leave it off or they

toe

to

knee compression

to

help

it to

heal.

(16D)

It s

not

within

the

wound care guidelines

Although some nurses did deviate from optimum pra

when seeking to meet patients needs, there was a

beyond which nurses felt unable to step, most notab

the treatment the patient wished to adopt was viewe

overtly harmful or it conflicted with practice guidel

In this respect nurses were wary of being seen to con

such action, even though it was recognized that pat

had the right to determine their own treatment:

We cannot prescribe paratulle,

it s not

within

the

wound

guidelines. So that s the only thing she insists on using, i

paratulle. I can t prescribe it... I m in a bit of a difficult situ

as to should I really be monitoring because she s not comp

an d I m even going against our guidelines just monitoring th

whether we then have to withdraw services because

non-compliant and we can t obviously recom mend what i

within the wound care guidelines. Then I need to take it fu

really with management

as to

where

we

go.

(37G)

Nurses concerns about legal, professional or manag

sanctions, as well as concern for patient well-b

appeared to underpin these type of comments.

It s

my

leg

and I

want

to be

responsible

for it

The notion of patients needing to take responsibilit

their own health was raised by others. Ultimately

could lead to the withdrawal of the service alth

nurses were reluctant to take this step:

Litigation... has crept in more and more. If you like, if y

going

to

somebody s house

and

they persistently interfere

the dressings that you put on, and persistently put somethin

on

in

between your visits,

and if you sit and you

talk

to

about

it and

they ll tell

you the

things they don t like abou

dressing yo u re using

and you try and

accommodate them


7/10


you have to say to people Look, we can t put w hat

re putting on and you put w hat you re putting on because if

d w e re not prepared to take that,

oard ... You ve got to accept it s my leg and I

else to put the care into that . And yes, we have

mean a couple of people have said, and they ve said

do it ourselves . (llE )

to respect that patient s request

ficult becaus e we have to respect that p atient s request. And we

t, you know, you feel that you can t leave them high

say,

Look, she s

... I mean we had a senior social worker, and this social

myself

so that s

essionals pu lled together to try and get one individua l to

type of care to keep her alive ... there are lots of moral

out here that w e re constantly faced w ith. So, some-

are because h e s overweight, hut the

doesn t ap pear to he interested heca use h e s over-

e wo n t do anjrthing ahout it and hecause there is n t

nsultant can do to make it right. And he s heen to

ust we ll, You ll have to get on as hest you can , and really the

t that interested hec ause h e s just a chronic long-term

prohlem and they look at it and think, Well, if you lost weight

and if you changed your lifestyle you might see an improve men t .

But we re the ones that are still going in three times a week and

dress his legs, or every day if they need... it s just very c onvenient

to say, Well, the district nurse w ill just go in and do it . (H E)

D I SCU SSI O N

Non-compliance, in the eyes of these research partici-

pants,

could take a number of different forms. It could

resemble a form of passivity in which the patient, for

whatever reason, was not helping him- or

herself.

There

could be a number of perceived reasons for this apparent

passivity. First, it could be due to ignorance, though the

implication was that this was rare, given that the commu-

nity nurses made a point of offering patients the informa-

tion they needed to modify their behaviour in ways which

wou ld prom ote healing. Second, it could be du e to lack of

motivation, as in the case of the patient who ate doub le

help ing of steak pie even though he w as obese. Third, it

could be the result of fear or some other strong emotion

which prevented the patient from taking positive action.

Not all non-compliance took the form of passive resist-

ance.

Some patients simply did not follow the advice

given. Once again, this behaviour w as often interpreted as

being due to fear. S ometimes, howeve r, it was seen as the

result of the patient believing he or she knew b est as in

the case of the treatment not fitting with lifestyle. Occa-

sionally non-compliance was presented as well-meaning

but m isguided interference. There w as a sense that if only

patients and their relatives would leave their wounds

alone leave them to the expe rts — everything would be

all right. Finally, some patients could be motivated to

interfere with their wounds from a deliberate desire to

prevent healing.

On a superficial level the term com pliance m ay suggest

a simple desire on the part of the nu rse to impose her w ill.

While the comments of some respondents appear to

illustrate this viewpoint it was also apparent that the

desire to seek compliance had a number of motivating

factors.

There was an implication that nurses were working with

patients tow ards the shared goal of a healed wo und , albeit

this was seldom stated explicitly. A predominant view

was that wound healing could only be successful if the

patient wished to adopt an active role. That is, patients

needed to take responsibility for their own health.

On the whole the nursing role was to impart advice,

based on the premise that they were most conversant with

the actions required to achieve wound healing. In this

respect the term compliance could be viewed more in the

light of informed consent. The idea of nurses as experts

does not, of course, preclude them from working in

partnership with patients and some nurses intimated that

a more equal relationship was desirable. However, it is


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Hallett

et al.

recognized that some patients may choose to relinquish

decision making to others (Beaver et al. 1996).

Nurses endeavoured to maintain services when others,

most notably doctors (physicians), had withdrawn theirs.

Many nurses recognized that patients had the right to

accept or reject advice. Situations in which patients did

not comply with 'ideal' practice often acted as a prompt

for reviewing treatment. On occasions this resulted in

some dissonance. The nurses sought to achieve the best

results for the patient in the prevailing circumstances,

whilst not appearing to condone the use of harmful

practice. It was at the stage where a mutually agreeable

compromise could not be reached that nurses felt

compelled to withdraw services. In some cases this was

prompted by an inability to meet the patient's needs

within the constraints of local guidelines aimed at

supporting evidence-based practice.

There was evident concern amongst some respondents

that failure to follow established guidelines might result in

punitive action, either managerial, professional or legal. In

some respects this tension crystallizes the dilemma

currently faced by community nurses. On the one hand

a considerable volume of current nursing literature (e.g.

Holm 1993, Hess 1996, Cahill 1998) advocates partnersh ip

with patients and patient autonomy; by contrast, there is

also a great deal of emphasis on guidelines, outcome

measurement and audit. As some of the incidents

recounted illustrate, there are times when respecting the

former can compromise the latter. This is problematic in

any circumstance. It may be particularly problematic for

community nurses who are often working in a one-to-one

relationship in a patient's home with a considerable

degree of autonomy.

Withdrawal of services was particularly difficult if

patients wishe d the nu rses to provide care, but a mu tually

agreeable compromise could not be reached. In some

ways,

there was less of a problem if patients overtly

refused treatment. None theless, this could be problematic

as it could be distressing for nurses if this refusal led to a

decline in the patient's physical condition, especially in

circumstances where death was the only foreseeable

outcome.

In many respects nurses were taking on a burden of

responsibility that could be ameliorated if they were

working as equal partners with patients. Resolution of

some of the conflicts presented might be attained if nurses

were able to achieve the 'genuine engagement' described

by Hess (1996). This would facilitate meeting the patient's

wishes w hilst working in accord with the nurse's desire to

achieve the best outcome for patients.

The perspectives offered by these research participants

sit comfortably with the ide as prese nted in the literatu re. In

the work of writers such as Cameron (1996) and Buch mann

(1997) it is taken for granted that compliance is positive,

non-com pliance negative, and the role of the nurse to secure

the former and implement strategies to overcome

damaging effects of the latter. Hess's (1996) observ

that a dialectic could exist between professional p

nalism and 'isolated autonomy' was borne out by at

one of the exemplars in the data and could be seen to

insights into the patterns presented by the others.

It could be argued that the term com pliance has no p

where partnerships with patients are seen as a desi

model. In fairness to the nurses in this study, the un

standing of the respondents' use of the term compli

was not explored and it is not safe to assume tha

nurses meant the same thing. Additionally, it is impo

to view the findings of this study within the contex

which they were sought. The use of a critical inc

approach inevitably led to respondents recounting

ations at two extremes — 'ideal practice' and

practice'. It may be that if an alternative approach

been used more data would have been available regar

'meeting in the middle ground' when ideal practice

perceived by the nurse, could not be achieved.

CONCLUSION

The nurses' contributions to our research were the m

valuable because they were h onest a nd open. The face

their remarks, which we have not commented on, inc

their perseverance, their diligence and their patie

Many will take the view that they were quite correc

believing that they knew best what was right for

patients and that in coping with episodes of non-com

ance they acted with forbearance and often with

kindness.

It would be unfair to assume that all nurses vie

patients as the passive recipients of care simply bec

they use the term compliance. Many appeared to

working towards what they viewed as mutually agree

goals. If there was a mechanism for making this exp

this could resolve some of the tensions and pres

placed on the nurses. It would acknowledge the righ

patients to determine the care they receive wit

compromising nurses.

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