No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Concordance in action: towards systematic individualized care
Abstract
This article describes the construction and impact of an education module designed to improve medicine management in mental health nursing. In particular, it justifies the need for such education and illustrates the impact that it can have on knowledge and understanding. It examines a specific example of translating theory into practice by presenting a case study where person-centred medicine management was put into action in a busy acute ward. By analysing the process issues surrounding this case it is argued that future attempts to articulate concordance can be supported better.
This article describes the construction of a tool to measure concordance in clinical practice. The second of two parts, it details the strategic background underpinning concordance and expands the rationale as this relates to the construction of individual items within the evaluation tool used and described. Cribb (2011) considers that while policy drivers extol the rhetoric of shared decision-making and person-centred care, the application of this is complex. Cribb's thesis is summarised to show that the evaluation tool is grounded in the right type of evidence to support the facilitation of concordance in clinical practice.
Medical terminology is at continuous process of change since the language of medicine needs the rapid incorporation of new terms or changing the existing ones to be in touch with new ideas, concepts and practices. The evolution of the terms "compliance", "adherence" and "concordance" in the field of medicine-taking represents a good example of this. Although these three terms are frequently used interchangeably generating some confusion, compliance, adherence and concordance mean different things and must be used in different ways. Compliance refers to the extent to which patients follow doctors' prescription about medicine taking; adherence refers to the extent to which patients follow through decisions about medicine taking; and concordance refers to the extent to which patients are successfully supported both in decision making partnerships about medicines and in their medicines taking. This terminology evolution may actually be more important than mere semantics since better adherence to a treatment regimen could be achieved through open-ended physician-patient communication, incorporating the beliefs and preferences of the patient in the decision-making process. At present time, concordance could be useful as a normative or aspirational term while compliance and adherence must be the terms used for scientific measurement in medicine-taking field.
Nurses on registration are expected to have sufficient knowledge and skills in medicine management to practice safely and competently. This article reports on research involving midwifery and nursing students, who were asked to complete a questionnaire related to their experiences of medicines-related training and education, and how it prepared them for practice. The results showed an overall satisfaction with the pre-registration delivery, but differences emerged in the perceived efficacy of different educational strategies. Clinically-based and simulated aspects of the programme delivery were highly rated, with theoretical delivery scoring poorly in contrast. A stepped approach is suggested, with medicine course delivery needing to be strongly highlighted as a lead up to safe and competent nursing interventions when administering medication and all other related interventions. A grant from the innovation fund at the University of Huddersfield funded an evaluation of students' experiences of medicines management education and training using a self-administered questionnaire.
This paper describes the development of an adherence therapy intervention in schizophrenia and synthesizes the results to date of a collaborative international programme of research. Sticking to treatment is essential to control symptoms and prevent relapse, but as with other long-term conditions, medication adherence is poor. Adherence therapy seeks to facilitate a process of shared decision making, where both parties work towards agreed goals. Central is the theory that when patients make shared choices with a professional they are more likely to stick with them because they are personally owned and meaningful. The results of adherence therapy trials that seek to test this theory are mixed. Outcomes of trials might have been be affected by the point in the patient's illness cycle when therapy was delivered and by sampling bias. Authors of trials of medication management and alliance training packages that aim to equip mental health workers with adherence therapy competencies show considerable promise in improving clinical outcomes. Helping patients manage their medication is central to the work of mental health nurses. We argue that the potential benefits to patients are such that there is sufficient evidence to recommend that all mental health nurses receive medication management training.
People are typically overly optimistic when evaluating the quality of their performance on social and intellectual tasks. In particular, poor performers grossly overestimate their performances because their incompetence deprives them of the skills needed to recognize their deficits. Five studies demonstrated that poor performers lack insight into their shortcomings even in real world settings and when given incentives to be accurate. An additional meta-analysis showed that it was lack of insight into their own errors (and not mistaken assessments of their peers) that led to overly optimistic estimates among poor performers. Along the way, these studies ruled out recent alternative accounts that have been proposed to explain why poor performers hold such positive impressions of their performance.
In Scotland, between 25 and 30% of all GP consultations involve depression, stress or anxiety. The incidence of depression is high and rising, with mental health problems in old age being very common. Depression can be reliably diagnosed and treated in primary care, and a range of treatments are available; however, the effectiveness of all treatments is limited by non-concordance with the treatment plan. There are many reasons why medicines may not be taken as prescribed, including adverse effects, poor communication between health professional and patient, the effects of the illness, including cognitive impairment and patients' disagreement with the need for treatment. A case study on a patient with depression is presented, using the Situation, Background, Assessment, Recommendation (SBAR) format. The case study demonstrates a critical understanding of how issues of role, concordance and psychopharmacology impacted on the recovery of the patient.
This article provides evidence to suggest that mental health nurses may not be as competent in medicines management as they believe themselves to be. A psychological model of skills awareness is used throughout the article to offer a theoretical explanation of this putative deficit and provide discussion of the possible causes. Training directed towards improving medicines management skills will be introduced. Training such as this is essential if mental health nurses are to offer the best care to those in receipt of their services and make best use of the opportunities provided by prescribing legislation.
Accessible summary
Prescribing medication used to be the role of the doctor, but in recent years nurses have begun to prescribe following training and supervision.
In this single case study from one NHS Trust, we conducted interviews to look at the views of a practising and non‐practising prescriber to understand and compare their experiences of prescribing in mental health, and also the views of service users receiving this care in the community.
Service users reported that receiving their medication from a nurse was more convenient and less stressful, an issue of particular importance for helping their mental health. The practising nurse prescriber described her experiences and felt she had a good structure of supervision and support from the team. Reasons why trained nurse prescribers may not be practising are discussed, with suggestions for future developments and guidance given.
Nurse prescribing appears to work well in a specialist mental health setting when carried out in a supported and structured way. Offering choice was important; however, for some service users, information about why medication may be helpful was still needed.
Abstract
Non‐medical prescribing is a relatively new competency that appears to benefit both service users and health professionals alike. However, little is known about its use in mental health settings. This single case study in one UK National Health Service (NHS) Trust aimed to look at these views and consider how the role can be developed further in light of this. Six service users and two nurses trained in nurse prescribing were individually interviewed. One trained nurse had been prescribing for the last 3 years; the other was trained but had never practised. Service users reported that nurse prescribing was more convenient and less anxiety provoking, an issue of particular importance for optimizing mental health services. Offering choice was deemed important; however, for some service users, information about why medication may be beneficial was highlighted as an unmet need in the prescribing process. The practising nurse prescriber described her experiences and credited a good structure of supervision and support from the team. Reasons why trained nurse prescribers may not be practising are discussed, with suggestions for future developments and guidance. This competence appears to work well in a mental health setting when conducted in a supported and structured way.
The implementation of Mental Health Nurse (MHN) prescribing in the UK remains disappointing. A much cited critique of MHNs prescribing is that it would be unsafe, as MHN would not have the appropriate knowledge of pharmacology to practise mental health prescribing. The knowledge of pharmacology of MHNs with the prescribing qualification has not been assessed in the UK. In addition, the views of MHNs with the prescribing qualification who have undertaken a psychopharmacology course have not been explored. The aims of this study are to measure the efficacy of a 10-day advanced training programme on psychopharmacology on the knowledge levels of MHNs with the prescribing qualification; and to explore the positive and negative experiences of individual participants of the training in psychopharmacology and how it supported their prescribing practice. A repeated measures design was used in which participants acted as their own controls. Participants were assessed 10 weeks before the training programme and again on day one of the training programme using a Multiple Choice Questionnaire. In addition, a series of focus groups were conducted to explore the helpful and unhelpful aspects of the course in sustaining the MHNs' prescribing practice. Following the training period there were significant increases in the MHNs' knowledge of psychopharmacology in comparison with the two base line means. Participants when interviewed 18 months after completing the training described the training as a helpful though they described it had not resulted in large increases in prescribing practice, citing systemic barriers to its implementation. Short and focussed training for MHNs who prescribe may increase their knowledge of psychopharmacology. The development of such programmes may well be part of the solution to support MHNs with the prescribing qualification to prescribe, supported by the views of the MHNs who participated in the focus groups. However, further work is required to remove organizational barriers. The data raise questions both about the current suitability of nurse prescribing preparation programmes in the UK and the suitability of NHS settings to support MHN to prescribe.
This paper develops an interpretation of the impact of mental health nurse prescribing in the UK. A constructivist-grounded theory methodology was applied to 13 semi-structured interviews with mental health clinicians and service users. The same interpretivist methodology was applied to the literature. Thirty-two practising UK mental health nurse prescribers gave structured feedback on the coherence of the emergent theory. It was found that the theory describes the process of becoming competent in mental health nurse prescribing. This process highlights possible deficits in non-prescribing mental health nurses. It is recommended that if this is corroborated then structured education in medicines management be introduced into pre- and postregistration mental health nursing in UK. The findings of this research offer a framework. That is, the categories emerging within this research translate easily into learning outcomes which can underpin delivery of a consistent medicine management strategy across all levels of nurse education.
Nurse prescribers are in a key position to promote medicine-taking in diabetes. Although patients' beliefs about medicines are important predictors of medicine-taking, evidence suggests nurses do not routinely explore these.
To evaluate a theory-based intervention designed to increase nurse prescribers' exploration of medicines' beliefs with people with diabetes.
Mixed methods concurrent triangulation design.
Nurse prescribers were recruited from 7 Trusts in England.
A purposive sample of 14 nurse prescribers attended four 1 day workshops.
Audio-recordings of each nurse prescribers' consultations with diabetes patients were collected at baseline, 1 week, 3 months and 6 months after the intervention. Nurse prescribers were interviewed at 1 month and 6 months post-intervention. Changes in medicines' discussion and participation in consultations were analysed using MEDICODE. Interview data were analysed using Framework Analysis.
MEDICODE themes of 'attitudes towards medication' showed a significant rise at 1 week (p<0.01) and 3 months (p<0.05). 'Asks patient opinion about medication' significantly increased at 1 week (p<0.01). Discussion on 'concerns about medication' rose significantly at 1 week (p<0.001) and 6 months (p<0.01). Discussion on 'expected effects of medication', 'action of medication' and 'reasons for medication' showed no change. There were no significant changes in Dialogue Ratio. However, the Preponderance of Initiative moved towards more patient initiative at 1 week (p<0.0001), 3 months (p<0.0001), and 6 months (p<0.0001). In interviews, nurses reported increased attention to patients' medication beliefs and adoption of patient-centred skills. Contextual factors that positively influenced ability to explore medicines beliefs in practice settings were: support of colleagues and practicing new skills. Inhibiting factors included: patients' perceived lack of receptivity, time constraints, and concerns about opening a 'can of worms'. Six months interviews revealed using skills in practice enhanced nurses' confidence and sustainability of skills requires a nurse-patient relationship. Method triangulation illuminated how the intervention was implemented in practice contexts.
The intervention was effective at changing some key dimensions of prescribing consultations. The use of a self-efficacy framework in the intervention, to promote nurses' confidence in working in a different way, may have been instrumental in effecting the changes found. Contextual factors influencing beliefs exploration in medicine-taking consultations were identified.
Registered nurses undertaking programmes of study to become non-medical prescribers appear to have limited biological science knowledge. A case study was undertaken to determine whether the nurses entering Prescriber programmes considered studies in bioscience in their pre-registration nursing courses had been sufficient, linked to practice, and had prepared them for their roles as registered nurses. The literature identifies a continuing trend amongst nursing students describing a lack of sufficient bioscience in initial nurse education; there is limited literature on the views of experienced registered nurses. The participants in this study were 42 registered nurses from adult and mental health nursing, community and inpatient services. The results obtained from questionnaires and interviews are described. Questionnaire analysis identified that 57.1% of participants indicated bioscience in their pre-registration nursing programme had been limited and 40.5% stated the bioscience content had not prepared them for their roles on registration. Those reporting extensive coverage of bioscience were all aged over 41 years and had qualified before 1995. Greatest coverage of bioscience in pre-registration programmes was reported in relation to anatomy and physiology, with relatively limited coverage of microbiology, pharmacology or biochemistry. Respondents considered all five topics to be important. Interviews supported the questionnaire findings.