The impact of an intervention for nurse prescribers on consultations to promote patient medicine-taking in diabetes: a mixed methods study

Latter, Sue, Sibley, Andrew, Skinner, Timothy C., Cradock, Sue, Zinken, Katarzyna M., Lussier, Marie-Therese, Richard, Claude and Roberge, Denis (2010) The impact of an intervention for nurse prescribers on consultations to promote patient medicine-taking in diabetes: a mixed methods study. International Journal of Nursing Studies, 47 (9), 1126-1138. (doi:10.1016/j.ijnurstu.2010.02.004). (PMID:20211467)

Abstract

Background: 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.

Objectives: to evaluate a theory-based intervention designed to increase nurse prescribers' exploration of medicines' beliefs with people with diabetes.

Design: mixed methods concurrent triangulation design.

Settings: nurse prescribers were recruited from 7 Trusts in England.
Participants purposive sample of 14 nurse prescribers attended 4 one day workshops

Methods: 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.

Results: 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 practising new skills. Inhibiting factors included: patients' perceived lack of receptivity, time constraints, and concerns about opening a 'can of worms'. Six month 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.

Conclusions: 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.


What is already known about this topic:

• Medicines management plays an important part in the successful self-management of diabetes, but patient medicine-taking may not always be optimal for control of diabetes

• Evidence suggests that patients’ concerns and beliefs about the necessity of medicines are significant in influencing medicine-taking across a range of conditions

• Although nurse prescribers have an important opportunity to understand and influence patients’ beliefs about medicines, evidence from studies with patients with a range of conditions suggests they do not routinely explore these in their consultations

What this paper adds:

• The study highlights that an intervention designed to influence nurse prescribers’ exploration of medicines’ beliefs in diabetes was successful at increasing patient initiative in discussion of medicines, as well as discussion of concerns about medicines, consequences of non-adherence, attitudes to medication and patient opinions about medicines. Other ‘compliance-oriented’ discussion decreased following the intervention.

• The findings show that not all changes in nurses’ consultations were sustained at 6 month follow up and some key characteristics of their medication discussion showed no change from baseline

• Using a mixed methods design, the study identified factors that nurses perceived influenced the implementation of change in practice, including patient receptiveness to engage in discussion, time constraints, the support of colleagues and the importance of a nurse patient relationship

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Contributors

Author: Sue Latter

Author: Andrew Sibley

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