Medication non-compliance causes nearly 125,000 deaths in the United States and costs an estimated $290 billion annually. In fact, the number of patients who are non-compliant has reached epidemic proportions and is increasingly considered to be one of the most pressing issues in healthcare today. Research from the National Council for Patient Information and Education suggests that roughly 50% of patient prescriptions are taken incorrectly or not at all.
One survey found that a third of patients discharged, did not understand the purpose of their medications when they went home, and 86% of patients did not know their medications side effects. Consequently, there has been a breakdown between the communication of medication instructions and what patients are comprehending.
Patient adherence to a medication regimen is critical to good patient outcomes. Effective provider/patient communication is also critical to positive outcomes, patient satisfaction, health status, and adherence. According to the Agency for Healthcare Research and Quality, educating patients before they leave the hospital can decrease readmissions, reduce unnecessary visits to the ER, and lower costs.
Although medication adherence is a complex issue, research suggests that simple interventions are the most effective in fostering medication adherence. The American College of Preventative Medicine recommends using the mnemonic SIMPLE, to help improve patient adherence.
- S imple regimen
- I mpart knowledge
- M odify patient beliefs and human behavior
- P rovide communication and trust
- L eave the bias
- E valuate adherence
S – Simple regimen. A complex treatment can affect patient compliance. Which is why providers should consider trying a simple regimen whenever possible. Medications taken once-a-day, or at the same time of day are usually preferred. However, the regimen should also coincide with the patient’s daily activities. Encourage the use of aids such as medication organizers and alarms.
I – Impart knowledge. Adherence is increased when patients are knowledgeable about their conditions and the benefits of treatment. A few best practices include:
- Focus on shared decision-making.
- Provide clear, written, and verbal instructions for all prescriptions.
- Speak in common terms and try not to use medical jargon.
- Include the use of written information or materials.
- Include family and friends when appropriate.
- Offer quality online references for patients that wish to seek health information from the web.
M – Modify patient beliefs and human behavior. Patient education alone is not enough to improve patient adherence. Engaging patients in an open dialogue about their expectations is also necessary. Address any fears or concerns the patient may have about taking the medication. Empower patients to self-manage their condition and ensure they are clear about the risks of non-compliance.
P – Provide communication and trust. A physician’s communication style is one of the key factors to winning patients trust. Best practices for enhancing communication include:
- Improve interviewing skills
- Practice active listening skills
- Provide emotional support
- Provide clear, direct, and thorough information
- Encourage the patient’s input in treatment decision-making
- Allow time for patients to ask questions ‘
- Build trust
L – Leave the bias. Physician interventions that increase patient/physician partnership are important strategies to overcome disparities. For example:
- Encourage practice to learn more about low health literacy and how it affects patient outcomes
- Review communication style to see if it is patient-centered
- Understand the demographics of a patient population
- Ensure patient communication and education is tailored to the patient’s level of understanding
E – Evaluating adherence. The problem of nonadherence is often underestimated. However, if it isn’t suspected, it cannot be corrected. Measuring adherence can lead to better patient compliance and can be implemented through self-reports and simply asking patients directly if they are following their drug regimen.
In March, my wife and I were thrilled to welcome our second child to the world. Our baby boy was born healthy and we could not be more thankful. I did catch myself taking notes, however, as I’ve been working closely with Always Culture and learning about best practices for providing an optimal patient experience. Our overall experience was good, but there were some areas of opportunities that, if addressed, could have made it great.
Our son was a big boy – over 9 pounds, and my wife is very petite, so a few days before the due date her doctor advised that we schedule a cesarean. We gratefully accepted. My wife’s water broke with our first child, and it was like one of those movie scenes where you rush to the hospital, so it was weird just showing up at a certain time to have the baby. Weird, but nice. We stayed for two nights.
We didn’t have any really bad interactions with nurses, but we could tell a difference between the providers that were just going through the motions, trying to get through their shift, and the ones that were actually engaging with us. Right off the bat, they were asking some intake questions and mixed in with medical history, medications, and the like, was this one: “Have you ever thought of hurting yourself or anyone else?” The nurse asked it in the same casual tone that she asked about cigarette smoking. I couldn’t help but think that if the answer was “yes”, would anyone feel comfortable saying so? What would the follow-up be? It just seemed like a very personal and intimate detail that should have been approached with a bit more care.
After the baby came, we were like many parents with newborns; exhausted, delirious, and looking for the staff to assure us that our son was doing well. We may actually be a bit more sensitive than many parents. I know I tend to look for things to worry about when it comes to my kids. That’s why I replayed every word I heard from the care team over and over in my mind.
There is no “routine” for patients and their families
I remember at one point the pediatrician came in and asked us how the baby’s blood sugar was. I was thinking “I don’t know… let me ask the doctor!” The question was completely out of left field. I felt like there was something going on that we didn’t know about. I pestered the next few people who came in the room about “have you heard anything about his blood sugar?” They hadn’t. It was fine. I don’t know why the doctor asked the question, but I learned that routine communication is not routine for patients and caregivers.
Empathy goes a long way
We had a couple of nurses that I wish I could give a million dollars each. They were truly caring toward my wife. They listened, asked questions to discover what was important to her, and had empathetic responses that made us feel like we were in good hands. Breastfeeding was something that we were especially focused on because we had struggled with our first child. We knew we wanted to get as much advice as we could while we were in the hospital. Even though the nurses and lactation consultants didn’t have all the answers, the time spent with us “in the trenches” meant the world to us.
The last thing I would say about communication is that I wish that all of the staff had utilized the communication boards. Some did, but most didn’t. Time doesn’t seem to exist those first few days, so it’s helpful to know what meds you can have when, remember who your nurse is now, and how she can be reached if needed.
There were only a couple of times during our stay when I got upset. They both had to do with responsiveness. After my wife’s catheter was removed, it took a while before she could go to the restroom on her own. While she waited, her pain (and anxiety) continued to build until it became unbearable. She had been told not to try and use the restroom on her own, but she really wanted to try so she could relieve the pain. We were unable to get help to the restroom. Multiple calls using the call light didn’t work. The staff that answered the call seemed indifferent and a little put off that they had been bothered.
Eventually, I helped her to the toilet and she was able to relieve her pain (and bladder). The nurse arrived while she was in the restroom, and I was a little surprised that she didn’t stay to help her back to bed. In general, the call lights seemed to be completely ineffective. There were several occasions when she needed pain meds that I eventually went out to the nurse’s station because it was the only way we could get help. I don’t know what she would have done had she been alone.
Shift Reports and Rounding set the tone for attentive care
We never experienced a bedside shift report or regular rounding. We often found ourselves just hoping someone would show up soon, and often expecting to have to track someone down. Several hours after one shift change I went to the nurse’s station asking if we could get some medication and they asked who my nurse was. I had to respond, “I don’t know, we never met her.” Despite having some sub-par experiences, it’s amazing how one person can turn it around. It was the nurse at the station who asked me who my nurse was. She understood that the ball had been dropped and she picked it up. She got my wife’s medication and set clear expectations for when we could expect to see her again. After finding the nurse assigned to us, she had taken over our care personally. Each shift change we had been hoping that we would get a nurse who was paying attention. She was a breath of fresh air.
Any inpatient stay is a vulnerable time for patients and their families, even on joyous occasions like childbirth. Having a caregiver who is truly paying attention makes all the difference in the world. Implementing best practices like bedside shift reports, regular rounding and communication boards can help make a patient feel like they are being cared for and make a good experience an exceptional one.
Consistency is the hallmark of a culture focused on safety and quality, but it should also come as no surprise that consistency is one of the most difficult qualities of care to maintain. It is all too easy for organizations to be distracted by a new method or metric in trying to accomplish quality or satisfaction goals, and what gets overlooked are the basics of patient care: the basics of clear explanations, the basics of listening, the basics of responding to call lights, and the basics of effective pain management (just to name a few).
When it comes to pain management, nothing could be more basic than the process of administering medications to our patients. The essentials of this process are telling the patient four things: the medication’s name, the dosage, the medication’s purpose, and any side effects they might experience. The idea here is that these four pieces of information should be repeated EVERY TIME for EVERY PATIENT. Now if that sounds repetitive…it is…and it is for a reason.
It’s all about patient education, and repetition is a great tool for learning—especially for patients whose main job in the hospital is to learn: learning about their diagnosis, learning how to manage pain, learning about their medications and side effects. Don’t forget that all of this information can be new and scary to patients. Not to mention that most of it is effectively in a foreign language. Repetition is key to make sure a patient’s medication information is heard and remembered, and this won’t all happen on the first telling. The first time they got their meds, maybe they caught the name; at the third administration, maybe they heard the side effects and made a connection with how they had felt earlier.
Repetition in the medication administration process is also helpful to family members. Not only can they hear, remember and remind the patient about their medications, but family members can frequently change over the course of a stay. Repeating these same four items for each medication can help different family members pick up and reinforce different parts of a patient’s medication education.
As soon as you start talking about processes and “scripting” there is usually a very vocal group of frontline staff that balk at the idea. I have read and heard comments saying that it relegates them to “robots” and takes away their relationship with their patients. Of course, no one wants nurses to have their own individuality and style of care controlled from on high, but comments like these are an oversimplification of scripting—focusing too much on the letter of the law and not the spirit of the law. The idea behind this process is so that the patient hears what they need to hear every time, so that they might be educated by the time they leave your care.
Let’s not forget to approach our patient interactions and medication administration experiences with a sense of empathy. We must remember that while this is the 40th time we’ve explained the name, dosage, purpose and side effects of Lortab today, it’s the first time your patient has heard it—or maybe it’s the third time you’ve told them, but it will be the first time they truly hear you.
We don’t need to look at scripting or a process as something that removes or replaces our personal interactions with our patients—rather, the process is there to make sure we communicate with our patients effectively and educate them correctly.
So, if we can agree that a process doesn’t kill our individuality as care providers, and that it can be extremely beneficial to patient education and safety, then we should lay out that process. Fortunately, it’s simple.
Our patients want to be educated. They want to know what they are taking and why, and there is no better time to educate them than when you are administering their medications. Our patients expect to be partners in their own care, and they deserve to be educated on precisely why they are taking their medications.
For every medication, at every administration, there are four main subjects that should be covered: the medications name, the dosage, the purpose of the medication, and the possible side effects.
When telling your patient the name of a medication, use the name as ordered to avoid any confusion later.
Tell the patient dosage amount that they might hear their providers use or read on their bottle at home.
Use a brief, clear explanation of why their doctor is ordering the medication or how it will help.
Keep the terminology on their level, and begin by describing the more common side effects and then the more serious side effects. Let them know that these side effects can be managed to put them at ease, and most importantly, make sure they know to contact you or their nurse if they need the side effects addressed.
The basic statement might look like this: “Mr. Cumberbatch, here is your Lortab for your pain, it’s ten milligrams and you might feel some drowsiness or light-headedness.”
If you’re struggling with this process because you feel forced in communicating with your patients, try leaning into the repetition. Try saying, “I know I say this every time but…” or “Here it is again…” before you give them the four points for their medications. While the repetition might initially feel cumbersome or annoying to you, the winning result will be when your patient can tell you the name, dosage, purpose, and side effects of each of their medications. When it comes to patient education and patient safety, there is no substitute for a simple process consistently delivered to every patient.
Communication with patients on medications is important for both patient experience, HCAHPS scores, AND patient safety.
Listen to the podcast to learn tactics for improving communication on medications or checkout the full video and article: Communication on Medications Effects HCAHPS Scores and Patient Safety
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