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

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

A purposive sample of 14 nurse prescribers attended four 1 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 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.

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.

Introduction

Managing medicines effectively is a key strategy in patient self-management of many long term conditions, including diabetes (ADA, 2008a, ADA, 2008b). Many people with diabetes need to take medicines to control their condition: Type 1 diabetes requires self-management of insulin, Type 2 diabetes often necessitates use of oral medications and insulin, and associated conditions such as cardiovascular disease often require medication use over many years in order to successfully maintain health status, minimise symptoms and prevent long term complications. However, medicine-taking remains a significant problem: up to 50% of people with long term conditions do not take their medicines as prescribed (WHO, 2003) and in diabetes, reports indicate that between 36–93% of doses are not taken as prescribed (Cramer, 2004).

In the UK, a series of legislative changes over the last decade have led to an increasing number of qualified nurses able to independently prescribe medicines. Independent prescribing includes responsibility for clinical assessment of patients, as well as establishing a diagnosis and the clinical management required (Department of Health, 2004). From May 2006, appropriately qualified nurses in England have been able to independently prescribe all medicines from the national formulary, with the exception of some controlled drugs. Increasingly, nurse prescribers are able to manage complete episodes of on-going patient care for people with diabetes and therefore play a key role in helping them manage their medicines.