Empowering Patients – Recognising the Skills

1. Empowering Patients – Recognising the Skills Amanda J. Monsell Advanced Practitioner: North Cardiff Medical Centre Associate Lecturer: Non-medical Independent Prescribing Cardiff University Contact details: MonsellA@cardiff.ac.uk

2. Learning Outcomes • To be familiar with the key principle of concordance in non-medical independent prescribing. • To recognise the barriers to information-giving within a consultation • To highlight availability of patient decision making tools

3. Empowerment Patient empowerment is considered a paramount skill in the prescribing arena It can be defined as: 1. “To give power or authority to – to authorize” 2. “To give ability to; enable or permit” Sinclair et al 1999 pp. 468

4. Empowerment and Prescribing • Communication • Patient participation • Awareness of patients concerns • Shared-decision making • Concordance • Acceptance that sometimes the patient may want to decline treatment

5. Communication • Good communication and patient participation is the crux of the shared decision-making process1;2but how is this best achieved? • One needs to consider several factors • Patient’s capacity to retain and recollect information • Their understanding and assimilation of that information • The impact of consultation time on what are potentially life-long decisions

6. Capacity • Memory for recollection of information is poor and worsened by anxiety and age1 • Ability to remember information is small • 40-80% of information given in a consultation is forgotten immediately 2 • The more information given, the more is actually forgotten2

7. Understanding • To achieve patient understanding and true concordance requires time and the formation of a partnership between the clinician and the patient.3 • Equipoise is advocated from the clinician demonstrating no set opinion4 • This is highlighted as essential especially with the increase in poly-pharmacy2 • Consideration must be given as to how understanding can be best achieved

8. Time Implications • Within a consultation there must be recognition that the patient may need time to reflect upon the information given after all 10-15 minutes isn’t long! • Allowing a patient to go home and discuss the options with family and friends can help the process of informed decision making6 • Having easy access to patient information leaflets assists the process7

9. Barriers to Adherence • Anxiety • Poor relationship and using “medic speak”8 • Depression (use of PHQ-2 assessment for patients with chronic diseases in primary care)9 • Dictatorial or paternalistic approach to the consultation in some instances • Age and Gender10

10. Decision-making Aids • Media releases • Internet • Patient Information leaflets7; 11; 12 • Written • Pictorial11,12 • Videos / DVD13 • Verbal advice7; 14 • Expert patient groups

11. Patient Participation • How do we get patient’ “involved”? • Respect the patient’s opinion • Discuss their concerns • Continuity of care • Assess a patient’s literacy skills • Work as a team

12. Empowerment • Communication • Truthfulness • Back up verbal information with written leaflets • Build the relationship with the patient • Plan review appointment but allow open door access if problems arise

14. References • NICE (2009). Medicines adherence. Involving patients in decision about prescribed medicines and supporting adherence. NICE Clinical Guideline 76. London, National Institute for Health and Clinical Excellence. • Clyne, W., Granby, T., Picton, C. (2007). A competency framework for shared decision-making with patients: Achieving concordance for taking medicines. Retrieved from [last accessed 02/08/2011] • Hook, M. L. (2006) Partnering with patients – a concept ready for action Journal of Advanced Nursing56(2) pp. 133-143. • Kessels, R. P. C. (2003). “Patients’ memory for medical information.” J R Soc Med96(5): pp. 219-222. • McGuire, L. C. (1996). “Remembering what the doctor said: organization and adults’ memory for medical information.” Exp Aging Res 22(4): pp. 403-428. • Elwyn, G., Edwards, A. and Britten, N. (2003). ““Doing prescribing”: how doctors can be more effective.” BMJ327(7419): pp. 864-867.

15. References • Coulter, A. and Ellins, J. (2007). “Effectiveness of strategies for informing, educating and involving patients.” BMJ335(7609): pp.24-27. • LaRosa, J. H. and LaRosa, J. C. (2000) Enhancing drug compliance in lipid-lowering treatment. Arch Fam Med 9(10) pp. 1169-1175 • Li, C., Friedman, B., Conwell, Y. and Fiscella, K. (2007) Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depression in older people. J Am GeriatrSoc55(4) pp. 596-602 • Carter, S. Taylor, D. and Levenson, R. (2005) A question of choice – compliance in medicine taking – a preliminary review (3rd ed.) [Accessed: 06.09.2009: http://www.keele.ac.uk/schools/pharm/npcplus/medicinespartner/documents/research-qoc-compliance.pdf

16. References • Houts, P. S., Bachrach, R., Witmer, J. T., Tringali, C. A., Bucher, J. A. and Localio, R.A. (1998). “Using pictographs to enhance recall of spoken medical instructions.” Patient EducCouns35(2): pp. 83-88. • Edwards, A., Elwyn, G. and Mulley, A. (2002). “Explaining risks: turning numerical data into meaningful pictures.” BMJ 324(7341): pp. 827-30. • Barkhordar, A., Pollard, D. and Hobkirk, J. A. (2000) A comparison of written and multimedia material of informing patients about dental implants. Dent Update 27(2) pp. 80-84 • Hege, A. C. G. and Dodson, C. S. (2004). “Why Distinctive Information Reduces False Memories: Evidence for Both Impoverished Relational-Encoding and Distinctiveness of Heuristic Accounts.” Journal of Experimental Psychology: Learning, Memory& Cognition 30(4): pp. 787-795.