By Debra Wood, RN, contributor
January 5, 2011 - Medications taken as prescribed can make a significant difference in people’s health, yet, time and again, nurses hear from patients that they have stopped taking a medication. The reasons often given are that: they felt better, so didn’t feel they needed the medicine anymore; they felt worse and blamed it on the drug; or they could not see the value in spending good money on something that seemingly offers little effect, even if it was controlling their blood pressure.
Louisa Travers, RN, CCRN, credits nurses’ therapeutic relationships with patients with improving medication adherence.
Adherence to medication regimens remains a challenge to improving outcomes. A recent article in The New England Journal of Medicine reported that as many as half of all patients do not take their medications as prescribed.
The New England Healthcare Institute, a nonprofit health policy organization, estimates non-adherence costs the health care system up to $290 billion a year in avoidable medical spending. Many hospitalizations would be unnecessary if people took prescriptions as providers direct.
Nurses can make a significant difference in patients’ understanding about their medications and their willingness to take the drugs as directed.
Louisa Travers, RN, CCRN, a clinical nursing educator at Long Island College Hospital in Brooklyn, N.Y., attributes that to the therapeutic relationship nurses develop with their patients.
“We teach the patients as soon as they reach the hospital,” Travers said. “Patients trust nurses to give them good advice.”
A recent review of prior studies from a team of researchers from Harvard University, Brigham and Women's Hospital and pharmacy health-care provider CVS Caremark, published in the Journal of Managed Care, found that nurses who instruct patients as they leave the hospital and pharmacists who speak to patients when they pick up their medicines are the most influential in encouraging patients to stay on their medications.
The team combed through more than 6,500 medical journal articles published between 1966 and 2008, and reviewed 168 articles in full. The study found that programs using mail, fax and brochure-type communications had relatively low impact on promoting patient adherence.
“We know that pharmacists and nurses are among the most trusted health care professionals,” said Troyen A. Brennan, M.D., MPH, executive vice president and chief medical officer of CVS Caremark and an author of the paper, in a written statement. “This study shows that trust translates into effective patient communications.”
Nurses and pharmacists offer a personal connection. Travers added that nurses continually teach. They inform patients as they administer medications about what they are taking and why, reinforcing it every day.
“By the time they are discharged, the patient is very knowledgeable about the actions of the medication and why they should continue the medication,” Travers said. “You need to have that one-to-one, and you need feedback.”
Carole Kenner, Ph.D., RNC-NIC, FAAN, suggested nurses follow up on their teaching after the patient returns home.
Carole Kenner, Ph.D., RNC-NIC, FAAN, dean of the School of Nursing at Northeastern University’s Bouve College of Health Sciences in Boston, added that patients also need reinforcement once at home, with home visits or a follow-up phone call.
Kenner recommends nurses distribute printed instructions with illustrations, when possible, to reinforce the discharge instructions and make a follow-up phone call the next day to make sure patients understand the medications and discharge instructions and ask if they are having any problems.
The meta-analysis, however, found that telephone calls independent of the nurse-patient therapeutic relationship had a low success rate. In-person interventions, either in the store with a pharmacist or at the hospital with a nurse, were most effective.
The authors suggest additional research is needed to determine the effect that life events, such as a hospital stay and associated psychological factors, have on adherence. In addition, they suggested that future studies explore new electronic approaches.
A pilot study reported in 2010 from the Center for Connected Health, a division of Partners HealthCare; Massachusetts General Hospital; and the Harvard Medical School Department of Dermatology suggests that text messaging reminder aids to patients age 14 to 30 years old with atopic dermatitis can be effective in improving medication adherence and self-care.
“Text messaging is a cost-effective way to deliver short, concise information to patients over a longer period of time, and because it is automated, requires no extra effort from the provider,” said Joseph C. Kvedar, M.D., director of the Center for Connected Health, in a statement. “Our study also indicates that patients are willing and ready to integrate technology, such as text messaging, into their care. It can also help to improve communication between patients and providers.”
Although concluding that text messaging can be used as an adjunct to conventional care, Kvedar and colleagues said more research is needed.
An unrelated pilot study, led by Cynthia Russell, Ph.D., RN, an associate professor of nursing at the University of Missouri Sinclair School of Nursing, and published in the journal Clinical Transplantation, found that transplant patients’ adherence to immunosuppressive medications improved with electronic monitoring followed my monthly feedback to the patient. However, the Missouri researchers concluded that a fully powered study is needed to confirm the results.
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