You are on page 1of 7

learning zone

CONTINUING PROFESSIONAL DEVELOPMENT


Page 58 Medication adherence multiple choice questionnaire Page 59 Read Jessica Moorhouses practice profile on Ilizarov external fixation Page 60 Guidelines on how to write a practice profile

Strategies to improve patients adherence to medication


NS505 Kaufman G, Birks Y (2009) Strategies to improve patients adherence to medication. Nursing Standard. 23, 49, 51-57. Date of acceptance: June 24 2009.

Summary
This article explores issues surrounding adherence to medication. Terminology associated with the use of medication, most notably the terms compliance, concordance and adherence, are discussed. The article also explores factors that can influence the use of medication and discusses the role of nurses in supporting adherence to treatment.

Outline the role of nurses in improving adherence to medication.

Introduction
Prescribing medication is one of the most common interventions in health care and there is good evidence to suggest that taking medication in the doses recommended improves health outcomes (Horne et al 2005). However, there is a plethora of literature describing the extent to which patients are consistently found not to take their medications as directed (Snadden 2007). This phenomenon appears to affect patients with all conditions, including recent NHS priorities such as mental health, cancer, diabetes and respiratory illness (Horne et al 2005). Non-adherence to medication is believed to be responsible for considerable ill health and death (Dowell 2007a). It is often a hidden problem, undisclosed by patients and unrecognised by prescribers, but some estimates suggest as many as 80% of patients might be non-compliant in taking their medication (Dunbar-Jacob and Schlenk 2001). Recent advances in the design and presentation of medicines and the evolution of a more patient-centred approach in health service delivery have not, as yet, solved the problem of non-adherence. There is a pressing need to address non-adherence and develop effective strategies to make the delivery of health care more efficient and responsive to patients needs (Horne et al 2005).

Authors
Gerri Kaufman, lecturer, and Yvonne Birks, research fellow, Department of Health Sciences, University of York, York. Email: gk8@york.ac.uk

Keywords
Adherence, compliance, concordance, drug administration, patient-centred care These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

Aims and intended learning outcomes


This article aims to give nurses and other healthcare professionals an insight into the issues relating to adherence to medication. After reading this article you should be able to: Define the terms compliance, concordance and adherence. Identify factors that influence adherence to medication. Describe the concept of patient-centred care. List the steps involved in a medicines-use review. NURSING STANDARD

Terminology
The different terms associated with patients following or not following treatment regimens can august 12 :: vol 23 no 49 :: 2009 51

learning zone medicines management


feel unnecessarily complicated. The terms that have been used have changed rapidly in recent years and this has led to confusion about the correct or most appropriate term to use. Terms commonly used include compliance, concordance and adherence.

Time out 1
Reflect on the terms compliance, concordance and adherence. Provide your own definition of each term. Compliance Until relatively recently, the most common term for following treatment instructions was compliance. The term describes the extent to which the patients behaviour matches the health professionals recommendations (Haynes et al 1979). It has been criticised for its negative connotations, in that it implies a passive role for the patient and suggests an element of blame or recrimination for the individual who fails to comply with correct treatment instructions provided by an expert (Horne et al 2005). Adherence With the increased desire to emphasise the patients role in decision making, the term adherence replaced compliance, particularly in the literature on psychology and sociology. The emphasis in using the term adherence is on the patients freedom to decide whether or not to follow recommendations. Failure to adhere to treatment is not associated with blaming the patient for his or her decision. The terms adherence or non-adherence describe the extent to which the patients behaviour matches the agreed recommendations of the prescriber (Barofsky 1978). However, for some the notion of adherence does not place enough emphasis on the concept of patient choice. The term concordance, which describes a more patient-centred approach to prescribing and the taking of medicines, was therefore adopted. Concordance This term was originally defined as a new approach to the prescribing and taking of medicines (Medicines Partnership 2003). An agreement is reached after negotiation between a patient and a healthcare professional, which respects the beliefs and wishes of the patient when determining whether, when and how medicines are to be taken. In this alliance, the healthcare professional acknowledges the patients right to make choices about taking the recommended medications. The idea of concordance suggests the health professional has as much to learn as the patient, and that this can be achieved by a meaningful 52 august 12 :: vol 23 no 49 :: 2009

exchange about the patients experience of illness and the values and aspirations underpinning his or her preferences for treatment. It acknowledges that for many patients, non-compliance is a rational response to their personal perceptions of their illness and treatment (Horne 1993, McGavock 1996). Considering patients views and negotiating treatment options with them make a valuable contribution to the prescribing debate. Good prescribing practice should be a process of negotiation between the prescriber and the patient. However, concordance does not address the balance between individual rights, the responsibilities of prescribers and the reality that there are often three dimensions to prescribing decisions: the patient, the prescriber and the funder. There is also the assumption that by achieving concordance, adherence will improve. This may be the case, but there appears to be little evidence to support this (Horne et al 2005). As a term, concordance ignores some difficult dilemmas that practitioners face every day. For example, what happens if patients preferences conflict with the prevailing evidence? What happens if patients reject a treatment because they do not understand the risks or benefits correctly? What about situations where patients preferences could result in harm to themselves or others? (Horne and Weinman 1999). In 2005, an important scoping exercise examining concordance, adherence and compliance in taking medicine was completed (Horne et al 2005). The report concluded that the term concordance cannot be used to replace compliance or adherence (Horne et al 2005). While the terms compliance and adherence reflect the degree to which patient behaviour matches the prescribers advice, the term concordance is not related to behaviour. Concordance is actually a description of a more patient-centred consultation. However, achieving concordance in every clinical encounter is an unlikely prospect. Even the most articulate patients tend to behave in a relatively passive way, which will not threaten the relationship with the professional on whom they depend for future care. While some patients may wish to share decision making, many do not or are unable to within the current system, in which patient-centred practice and genuine patient involvement remain rare (Pollock 2005). So in reality, the term adherence is probably a better reflection of what happens in practice. Adherence emphasises the patients right to choose to follow a prescribers recommendations, but also tries to emphasise that failure to do so should not be a reason for blame. It does not reject the principles of respect for patients beliefs and is able to reflect the fact that taking medication may not always be a good thing as NURSING STANDARD

a prescription is not always appropriate or may not always reflect the patients changing circumstances (Horne et al 2005).

2005), perceptions of the necessity of medicines (Horne and Weinman 1999) and prescription charges (Mossialos and McKee 2003).

Time out 2
Go to the website www.healthtalkonline.org and listen to patients talking about their experiences of taking medication for a variety of conditions. Explore the disease specific areas of this site and look at the topics associated with taking medicines. Identify the key messages and how these will influence your discussions with patients about their medications.

Time out 3
Using the link www.sdo.nihr.ac.uk/files/project/ 76-final-report.pdf access the report on concordance, adherence and compliance in medicine taking (Horne et al 2005). Read section three, pages 52-60, which provides a summary of patients beliefs about their medicines. From the report, identify the key factors that shape patients views about their medications and decisions about adherence. How will this influence your approach to improving adherence to treatment? Make a list of things you can do in your area of practice.

Factors influencing adherence


There are many factors that influence whether patients do or do not adhere to a prescribed treatment. They tend to be examined from three main perspectives (Horne et al 2005). Epidemiology This perspective examines the incidence of non-adherence and explores sociodemographic factors such as age, socioeconomic status and education to explain non-adherence. One of the problems with this approach is that it tends to produce a large number of possible influences about adherence to medicines or other treatments, but is less useful in providing explanations that can allow healthcare professionals to tailor interventions to improve adherence (Horne et al 2005). Knowledge, comprehension and information giving A second approach looks at possible links between the lack of knowledge and poor comprehension as explanations for low adherence. However, current evidence for the associations between knowledge and adherence are limited (Haynes 1976). A certain level of knowledge about treatment is essential, but health professionals should not assume that all that is required to prevent non-adherence is to give more information. Patient behaviour The final approach tends to focus on adherence or non-adherence as a behaviour that varies between individuals. It tends to examine aspects such as motivation or the capacity to follow a treatment regimen. It attempts to understand whether the patient is motivated to take the treatment or whether he or she is capable of following a treatment regimen, and his or her beliefs about the illness and its treatment. Literature exploring the factors affecting adherence suggests that it is affected by poor memory recall (Incalzi et al 1997, Vedhara et al 2004), beliefs about the harmful effects of medicines, addiction and dependency (Pound et al NURSING STANDARD

Supporting adherence to treatment


Although the evidence base for effective strategies to improve adherence is limited, there are dividends if health professionals can improve adherence to effective treatments (Horne et al 2005). Nurses have a key role since the administration of medicines is an important part of their practice and nurses, as a result of prescriptive authority, increasingly prescribe medication. The following principles, which underpin patient-centred care, will be used as a framework to explore the knowledge and skills required by nurses to improve adherence to treatment (Cheesman 2006): Involving patients as partners in consultations. Sharing knowledge with patients. Supporting patients to take medicines. Involving patients as partners in consultations Patient-centred care that involves working in partnership with patients is increasingly seen as a means of delivering high quality, appropriate and cost-effective health care (Pollock 2005). While patient-centred care and genuine patient involvement remain rare, as a model or guide for professional practice, they continue to have value (Pollock 2005). Patient-centred care is characterised by open consultations where patients are encouraged to express their views and share decision making with the clinician. Open consultations demand good communication skills that foster an atmosphere of trust and focus on establishing a rapport with the patient. Exploring the patients illness and medical history is important, but this should be coupled with eliciting their ideas and concerns about the illness, and their expectations about treatment (National Institute for Health and Clinical Excellence (NICE) 2009). An empathic practitioner who welcomes information about the august 12 :: vol 23 no 49 :: 2009 53

learning zone medicines management


patients feelings and acknowledges the individual is important in empowering patients to communicate their views openly (Moulton 2007). Patients differ widely in their knowledge, ideas and attitudes about illness and treatment and they bring these to the consultation. Similarly, the practitioner brings knowledge and skills about the interpretation of illness and potential cures (Williams 2007). Achieving a common interpretation of the problem and agreeing a shared treatment plan relies on a knowledge and understanding of each others perspectives. Failure to discover the patients perspective and reach a shared understanding about illness and treatment can lead to discordance between the patients choice of treatment and the clinicians recommendations (Dowell 2007b).

Time out 4
Access the NICE guideline Medicines Adherence at www.nice.org.uk/CG76. Select the quick reference guide document and read the sections on increasing patient involvement (page 6) and understanding the patients perspective (page 7). Then read the scenarios below and consider how Jane and Johns health beliefs are likely to affect adherence to the prescribed treatment. How would you address their health beliefs during a consultation? Scenario 1 Jane is a 30-year-old woman who has a productive cough. Following a series of respiratory investigations, including spirometry and peak flow monitoring (British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) 2008), Jane was diagnosed with asthma and prescribed an inhaled bronchodilator. Her symptoms did not settle with the use of the bronchodilator so an inhaled corticosteroid was added to her treatment regimen (BTS/SIGN 2008). Jane disagrees with the diagnosis. She believes her symptoms are caused by a chest infection. Jane is reluctant to share her beliefs with the clinician who can be dismissive and always seems hurried. Jane was given information about asthma and the benefits of treatment, but she had difficulty understanding the information and did not take it all in. Friends have told her that it is easy to become over reliant on inhalers and that corticosteroids are particularly dangerous. Scenario 2 John is a 59-year-old man who recently attended a routine health check. He was diagnosed with hypertension and prescribed anti-hypertensive medication. John is not convinced about the diagnosis. He feels well and is not experiencing headaches, which he believes are a symptom of high blood pressure. John also believes that the prescribed medicine will cure his hypertension. 54 august 12 :: vol 23 no 49 :: 2009

Sharing knowledge Patients need a rationale for their diagnosis and treatment, and sharing information is important to formulate treatment plans that patients feel they have some control over and want to implement (Chafer 2003). Patients need to know how medicines work and how treatment will influence their problem in the immediate future as well as in the short and long term. Any negative consequences that are anticipated, such as side effects or response failure, need to be explained (Neighbour 2004). In consultations the benefits of therapy are discussed more often than the harms, precautions or risks although patients view these topics as essential. Failure to provide patients with the requisite information can generate concerns, misunderstandings and ambivalence about their diagnosis and prescribed medications (Elwyn et al 2003). Recall and understanding information Patients need to be able to remember and understand the information they are given. Both factors are considered important in improving adherence to treatment (Williams 2007). A number of techniques can be used to promote understanding and the efficient transfer of information. Finding out what patients already know and would like to know about their diagnosis and medicines is essential to provide the correct amount and type of information (Chafer 2003). In addition, delivering information in small amounts and checking the patients comprehension before moving on is an important skill in aiding understanding and assisting patients to remember information accurately. Sharing information should be coupled with checking the patients ability to follow a treatment plan, which is important in identifying any practical barriers to adherence (NICE 2009).

Time out 5
Access Medicines Adherence at www.nice.org.uk/CG76. Select the quick reference guide document and read the section on providing information (page 7). With reference to the scenarios described in Time out 4, answer the following: What kind of information do Jane and John need to help them adjust to the diagnosis and accept treatment? What strategies would you use when sharing information with Jane and John? How would you assess their understanding? Reasons for non-adherence to treatment Many patients find it difficult to discuss openly the ways in which they use or wish to use treatment. NURSING STANDARD

For example, a patient who is prescribed a diuretic may need to access the toilet frequently. The patient may choose not to take the diuretic or alter the timing of the dose if he or she is participating in activities where toilet facilities are not available. Patients may be reluctant to discuss the issues with a prescriber because of fear of criticism or jeopardising the clinical relationship with the prescriber (Dowell 2007a). Dowell (2007b) cites a variety of reasons why patients do not adhere to treatment. Patients with incorrect perceptions about the nature of their disease or who misunderstand prognosis and treatment are likely to manage their medicines inappropriately. For example, a patient with hypertension who believes that anti-hypertensive treatment will cure the illness may find it difficult to understand the need for lifelong medication. Patients who find it difficult to adjust to illness and who cope by ignoring the problem or playing it down can have difficulties accepting the need for treatment and adhering to medication. Some patients want to have control over their treatment, while others are content to adopt a passive role. Eliciting a patients role preference is not easy and an unmet desire for control can result in intentional non-adherence (Dowell 2007b). There are patients who want to control their illnesses and who are happy with the information they have received, but as a result of motivational difficulties they use their medicines inconsistently and cannot manage to achieve control. Blaming patients or issuing threats about the unpleasant consequences of non-adherence tend to be counterproductive. In situations where the use of treatment is a concern, the patient-centred technique of eliciting views and beliefs about illness and treatment can be informative. Unless conflicting beliefs and expectations can be discussed openly it is unlikely that adherence will be improved (Dowell 2007b).

Time out 6
With reference to scenario 1 in Time out 4, consider the reasons for Janes reluctance to share her health beliefs with the clinician. How would you feel if a patient elected not to follow prescribed treatment recommendations? Patients who elect not to follow treatment Some patients may choose not to follow established recommendations or may elect not to take the treatment at all. UK law states that an adult who is mentally competent has the right to refuse treatment (Crouch and Chapelhow 2008). In doing so, the patient does not have to provide a reason for his or her decision. However, the law NURSING STANDARD

insists that patients must be given enough information about the risks and benefits in a form that they can understand so that informed decisions can be made (Dowell 2007c). Making judgements about mental competence can be difficult since it is not always easy to distinguish between competence and incompetence (Dowell 2007c). Any healthcare professional unsure about a patients capacity to consent should seek an assessment from a specialist (Crouch and Chapelhow 2008). Patients who choose not to follow treatment recommendations or elect not to take a medicine can pose a dilemma for nurses involved in prescribing and administering medicines, particularly if the nurse believes that the patient is making a decision that is detrimental to his or her health. Accepting the patients decision might conflict with the ethical principles of beneficence (the duty to do good) and non-maleficence (the duty to do no harm) that underpin nursing practice. However, personal autonomy is a fundamental human right and the Mental Capacity Act 2005 states that a healthcare professional must respect the patients views even if they differ greatly from those of the clinician (Crouch and Chapelhow 2008). If a patient decides not to take or to stop taking a medicine that in the view of the professional could be harmful, the decision and the information given to the patient should be documented (NICE 2009). Supporting patients to take their medicines All nurses, whether they are involved in prescribing or the supply and administration of medicines, have a role in supporting patients to take their medicines. The Nursing and Midwifery Council (NMC) (2008) points out that the administration of medicines is not just a mechanistic task to be performed in strict compliance with the written prescription of an independent/supplementary prescriber, it requires thought and professional judgement (NMC 2008). It is well known that the power differential in many consultations favours the practitioner, which can result in patients not presenting their views or asking questions about medicines when they are prescribed (Dowell 2007a). Patients can be prompted and assisted to raise issues by nurses involved in the supply and administration of medicines since they may be perceived as more approachable than the prescribing practitioner (Dowell 2007a). According to NICE (2009) non-adherence should not be seen as the patients problem. It represents a fundamental limitation in the delivery of health care, often because of failure to fully agree the prescription in the first place or to identify and provide the support that patients need later on. If a patient decides to august 12 :: vol 23 no 49 :: 2009 55

learning zone medicines management


accept a prescription, the aim is to make appropriate adherence to the agreed recommendations easier (Horne et al 2005). It is important to recognise that non-adherence is common and that most patients are non-adherent at times (NICE 2009). Taking every opportunity to discuss medicines and medicine taking empowers patients (Cheesman 2006) and supports adherence. Although adherence can be improved, no specific intervention can be recommended for all patients. Interventions to increase adherence need to be tailored to the specific difficulties with adherence that the patient is experiencing (NICE 2009).

Medicines-use review
Nurses in any setting can use the principles of a medicines-use review to establish a patients use of his or her medicines with the aim of helping him or her to understand the therapy and identify any problems and possible solutions. The NO TEARS tool (Lewis 2004) for medication review provides a framework for exploring patients use of their medicines. It encompasses a number of steps. Need and indication When reviewing medicines it is important to explore the medicines that patients are actually taking and their experience of their medicines, including perceived efficacy. It is also important to explore when and how often treatment is taken and whether the medicines are actually needed.

Open questions Using open questions gives patients an opportunity to express their views and opinions so that any issues relating to adherence can be addressed. Tests and monitoring This involves checking whether the medicines are working, and whether patients are on the appropriate dose for optimal treatment of their condition. This can involve objective evidence of the effectiveness of the treatment, for example blood pressure monitoring. Evidence and guidelines It is important to consider the evidence base for the medicines the patient is taking and whether it has changed since the original prescription. This might involve making sure the medications reflect up-to-date guidelines for treating the patients condition. It is also important to consider whether the conditions for which the medicines were originally prescribed are still active or have resolved. Adverse events It is essential to explore whether there are side effects, interactions with other medicines or contraindications. The benefits of any medicine need to be considered in relation to the risks involved. Side effects may deter patients from taking their medication. If drugs are contraindicated patients may experience adverse effects which can jeopardise their health. Interactions with other medicines can be beneficial but can also be harmful. Risk reduction and prevention This is an opportunity to consider any risks that may be associated with the medicines the patient is taking. Some drugs need to be monitored closely because of the risk of adverse effects. Drugs that are newly licensed and denoted by a black triangle in the British National Formulary are examples of such drugs. The types and incidence of adverse

References
Barofsky I (1978) Compliance, adherence and therapeutic alliance: steps in the development of selfcare. Social Science and Medicine. 12, 5A, 369-376. British Thoracic Society, Scottish Intercollegiate Guidelines Network (2008) British Guideline on the Management of Asthma. BTS, London, SIGN, Edinburgh. Chafer A (2003) Communications Skills Manual. www.skillscascade .com/teaching/csManual.doc (Last accessed: July 20 2009.) Cheesman S (2006) Promoting concordance: the implications for prescribers. Nurse Prescribing. 4, 5, 205-208. Crouch S, Chapelhow C (2008) Medicines Management: A Nursing Perspective. Pearson Education, Harlow. Dowell J (2007a) Finding common ground. In Dowell J, Williams B, Snadden D (Eds) Patient-Centred Prescribing: Seeking Concordance in Practice. Radcliffe Publishing, Abingdon, 80-92. Dowell J (2007b) Finding common ground in special situations. In Dowell J, Williams B, Snadden D (Eds) Patient-Centred Prescribing: Seeking Concordance in Practice. Radcliffe Publishing, Abingdon, 93-120. Dowell J (2007c) Unresolved issues in patient-centred prescribing. In Dowell J, Williams B, Snadden D (Eds) Patient-Centred Prescribing: Seeking Concordance in Practice. Radcliffe Publishing, Abingdon, 121-136. Dunbar-Jacob J, Schlenk E (2001) Patient adherence to treatment regimens. In Baum A, Revenson TA, Singer JE (Eds) Handbook of Health Psychology. Mahwah, New Jersey NJ, 571580. Elwyn G, Edwards A, Britten N (2003) Doing prescribing: how might clinicians work differently for better, safer care. Quality and Safety in Health Care. 12, Suppl 1, i33-i36. Haynes RB (1976) A critical review of the determinants of patient compliance with therapeutic regimens. In Sackett DL, Haynes RB (Eds) Compliance with Therapeutic Regimens. The Johns Hopkins University Press, London 26-39. Haynes RB, Taylor DW, Sackett DL (1979) Compliance in Health Care. The Johns Hopkins University Press, Baltimore MD. Horne R (1993) One to be taken as directed: Reflections on non-adherence (non-compliance). Journal of Social and Administrative Pharmacy. 10, 4, 150-156. Horne R, Weinman J (1999) Patients beliefs about prescribed medicines and their role in adherence to treatment in chronic physical

56 august 12 :: vol 23 no 49 :: 2009

NURSING STANDARD

drug reactions are usually defined when the drug is used after licensing in the wider population. Close monitoring is important in providing additional safety data. Simplification and switches It is vital to consider whether treatment can be simplified. Negotiating any changes in medicines requires the patient and practitioner to work in partnership. Health beliefs need to be considered and any changes negotiated fully in the light of such changes. It is recognised that addressing each step of the medicines review framework (Lewis 2004) may not be relevant or appropriate for every encounter involving a discussion about the use of medicines. However, the framework is flexible and can be adapted by nurses to suit the setting and their needs. Medicine-use reviews have the potential to support adherence to treatment and maximise the effectiveness and safety of the medicines. Remember that patients may be seeing healthcare professionals from different specialties at the same time. Since medicine-use reviews can be carried out by nurses and healthcare professionals other than prescribers it is important that the prescriber is made aware of the outcomes of a review so that issues about medication use can be addressed.

Conclusion
Non-adherence to prescribed medicines is a significant problem that is associated with considerable morbidity and mortality. The factors affecting adherence are complex and no specific intervention can be recommended for all patients. A variety of terms are used to describe medicine use, which can be confusing. The term compliance with its authoritarian overtones and the implication that the patient should play a passive role has little place in current practice, which advocates patient-centred prescribing. However, the term concordance, which describes patient-professional partnerships and shared decision making about treatment, remains rare and is unlikely to be achieved in most consultations. Consequently, the term adherence, which emphasises the patients right to choose to follow treatment recommendations and does not reject the principles of respect for the patients beliefs is viewed as a more realistic term to describe medicine taking. That said, the concept of patient-centred care provides important principles to guide the practice of nurses and other health professionals who aspire to optimising adherence to treatment NS

Time out 7
Think about your role in medicines management and consider what elements of the NO TEARS tool (Lewis 2004) will help you to improve adherence to treatment. Practice using the tool, or a modified version in your area of practice, and reflect on the outcome.

Time out 8
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 60.

illness. Journal of Psychosomatic Research. 47, 6, 555-567. Horne R, Weinman J, Barber N, Elliott R, Morgan M (2005) Concordance, Adherence and Compliance in Medicine Taking. www.sdo.nihr.ac.uk/files/project/ 76-final-report.pdf (Last accessed: July 21 2009.) Incalzi RA, Gemma A, Marra C, Capparella O, Fuso L, Carbonin P (1997) Verbal memory impairment in COPD: its mechanisms and clinical relevance. Chest. 112, 6, 1506-1513. Lewis T (2004) Using the NO TEARS tool for medication review. British Medical Journal. 329, 7463, 434.

McGavock H (1996) A Review of the Literature on Drug Adherence. Royal Pharmaceutical Society of Great Britain and Merck Sharp and Dohme Ltd, London. Medicines Partnership (2003) Project Evaluation Toolkit. Medicines Partnership, London. Mossialos E, McKee M (2003) Rationing treatment on the NHS still a political issue. Journal of the Royal Society of Medicine. 96, 8, 372-373. Moulton L (2007) The Naked Consultation: A Practical Guide to Primary Care Consultation Skills. Radcliffe Publishing, Abingdon.

National Institute for Health and Clinical Excellence (2009) Medicines Adherence. Clinical Guideline 76. NICE, London. Neighbour R (2004) The Inner Consultation. Second edition. Radcliffe Publishing, Abingdon. Nursing and Midwifery Council (2008) Standards for Medicines Management. NMC, London. Pollock K (2005) Concordance in Medical Consultations. Radcliffe Publishing, Abingdon. Pound P, Britten N, Morgan M et al (2005) Resisting medicines: a synthesis of qualitative studies of medicine taking. Social Science and Medicine. 61, 1, 133-155.

Snadden D (2007) Taking medicines. In Dowell J, Williams B, Snadden D (Eds) Patient-Centred Prescribing. Radcliffe Publishing, Abingdon, 9-28. Vedhara K, Wadsworth E, Norman P et al (2004) Habitual prospective memory in elderly patients with type 2 diabetes: implications for medication adherence. Psychology, Health and Medicine. 9, 1, 17-27. Williams B (2007) Understanding medicine taking: models and explanations. In Dowell J, Williams B, Snadden D (Eds) Patient-Centred Prescribing. Radcliffe Publishing, Abingdon, 44-62.

NURSING STANDARD

august 12 :: vol 23 no 49 :: 2009 57

You might also like