Amanda J. Monsell
Advanced Practitioner: North Cardiff Medical Centre
Associate Lecturer: Non-medical Independent Prescribing
Cardiff University
Contact details: MonsellA@cardiff.ac.uk
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
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
Empowerment and Prescribing
 Communication
 Patient participation
 Awareness of patients concerns
 Shared-decision making
 Concordance
 Acceptance that sometimes the patient may want to
decline treatment
Communication
 Good communication and patient participation is the
crux of the shared decision-making process1;2 but 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
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
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
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
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
Decision-making Aids
 Media releases
 Internet
 Patient Information leaflets7; 11; 12
 Written
 Pictorial11, 12
 Videos / DVD13
 Verbal advice7; 14
 Expert patient groups
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
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
References
1.
2.
3.
4.
5.
6.
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 Nursing 56(2) pp. 133-143.
Kessels, R. P. C. (2003). “Patients’ memory for medical information.”
J R Soc Med 96(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.” BMJ 327(7419): pp. 864-867.
References
Coulter, A. and Ellins, J. (2007). “Effectiveness of strategies for
informing, educating and involving patients.” BMJ 335(7609):
pp.24-27.
8. LaRosa, J. H. and LaRosa, J. C. (2000) Enhancing drug
compliance in lipid-lowering treatment. Arch Fam Med 9(10)
pp. 1169-1175
9. 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 Geriatr Soc 55(4) pp.
596-602
10. 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/medicinespar
tner/documents/research-qoc-compliance.pdf
7.
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 Educ Couns 35(2): pp. 83-88.
12. Edwards, A., Elwyn, G. and Mulley, A. (2002). “Explaining risks:
turning numerical data into meaningful pictures.” BMJ 324(7341): pp.
827-30.
13. 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
14. 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.
11.