Project

Nursesroleinpromotingmedicationadherence-2.pdf

www.Nursing2023.com January l Nursing2023 l 39

Abstract: A patient’s willingness and desire to adhere to their medication plan are af- fected by their beliefs about taking medica- tions, their self-efficacy, health literacy level, ability to afford prescription drug costs, and relationship with their clinicians. This article details strategies for creating a collaborative relationship with the patient, developing trust, and nurturing medication adherence.

Keywords: health beliefs, health literacy, medication adherence, medication complex- ity, medication costs, pharmacotherapy, self- efficacy

BY LORRAINE M. ZOROMSKI, EdD, MSN, RN AND SHARON FRAZIER, MSN, RN

Nurses’ role in promoting medication adherence

SH U

TT ER

ST O

C K /R

U SL

A N H

U ZA

Case study Thomas, an RN, works in a rural hospi- tal’s ED. One of his patients, DG, was familiar to him. DG was a 62-year-old male, a delivery truck driver with a his- tory of hypertension, type 2 diabetes, and heart failure. He was in the ED for the second time in 6 months. This time, he had 4+ pitting edema in the lower extremities and shortness of breath (SOB). He was treated with an I.V. di- uretic and supplemental oxygen, and lab tests were ordered. When asked about taking his medications at home, DG stated that he was “doing pretty good.”

After treatment, DG demonstrated reduced SOB and peripheral edema. Thomas suspected medication adherence may be an issue and asked DG about barriers to taking medications at home. Thomas has built trust with DG by nor- malizing barriers to taking medications and said, “Most people find it hard to take diuretics consistently as prescribed. Tell me the difficulties you have with taking your diuretic.” DG responded that he often did not take his diuretic because it interfered with his driving routine. Thomas discussed this finding with his healthcare provider, who agreed

NSG0123_Features_MedicationAdherence_Deepak.indd 39 07/12/22 11:55 AM

40 l Nursing2023 l Volume 53, Number 1 www.Nursing2023.com

promote medication adherence: med- ication complexity, health literacy, patient-clinician communication, health beliefs, and self-efficacy.7

Another critical factor in medica- tion adherence is medication cost.3,8

Assessing and addressing these six variables will provide nurses with a framework for increasing patients’ medication adherence. This article discusses nursing strategies to create a collaborative relationship with pa- tients, develop trust, and nurture medication adherence.

Medication complexity Complexity includes both the num- ber of medications and the frequency of administration. For example, pa- tients with chronic diseases often take five or more daily medications.9 Thuy et al.7 found that regardless of other factors, such as education, health lit- eracy, and cognitive ability, the com- plexity of the medication regime can affect adherence. Nurses can work with healthcare providers (HCPs) and pharmacists to simplify the medica- tion plan by reducing the number of medications and their frequency.

Consider the patient’s lifestyle and adjust times for administration when possible. Medication assistive tech- nologies and reminders, such as elec- tronic applications (apps), weekly pill organizers, phone alarms, and situational and meal cues, can help patients manage complex regimens. Alarms, in particular, have been shown to improve adherence sub- stantially.10,11

Other strategies that have im- proved medication adherence include restructuring the patient’s interpersonal system and physical environment.10 Strategically placing medications in the physical environment can provide vi- sual triggers for patients to take their medications. For instance, placing medications next to a toothbrush can cue patients to take their medications at bedtime.

To increase medication adherence for a complex medication regimen, assess the patient’s understanding of the medications and provide educa- tion where knowledge gaps exist.

Finally, consider social support. Having one or two people to remind patients that may be forgetful may be more successful at promoting medi- cation adherence.10

Health literacy Health literacy–the summation of a patient’s ability to competently access health information and comprehend, analyze, and use it to make their own health decisions or important health judgments–significantly influences medication adherence.5 Studies have shown that patients with low health literacy have low medication adher- ence rates.7

Health literacy is associated with a patient’s education level.12 Pa- tients with a higher education level tend to comprehend health infor- mation and apply it to their daily life easier than someone with a low- er education level.12

It is important to begin a collab- orative conversation by asking the

that DG could take his diuretic in the afternoon to allow him to complete his route without excessive diuresis. Thom- as discussed this proposed change with DG, who said he would like to try this new schedule for his diuretic. Thomas documented in the medical record for the clinic staff to follow up during DG’s next clinic visit in 1 month and assess the revised medication schedule.

Introduction Nurses are frequently engaged in administering and educating their patients about prescribed medica- tions. However, nurses often feel frustrated when they discover pa- tients are not taking medications as prescribed. This barrier to effective healthcare delivery has been a global and national focus for decades.1 The World Health Organization (WHO) has found that, on average, 50% of patients do not take their medica- tions as prescribed.1 The CDC esti- mates that the US has spent $3,453 billion on healthcare in 2019, which is 30% higher than healthcare spend- ing in 2009.1,2 The national report card on medication adherence data by the National Community Pharma- cists Association correlates with the WHO data: 51% of survey respon- dents were nonadherent to their medication regime, resulting in an overall C+ national score.3 Recently, a report by Piña et al.4 found that 62% of over 24,000 adults with chronic illness, including hyperten- sion, diabetes, and dyslipidemia, for- got to take their medications, with 37% admitting that it was because they ran out of medications.

Patients adhering to the prescribed medication regime have reduced morbidity and mortality and im- proved outcomes.5 Conversely, non- adherence results in higher readmis- sion rates and higher healthcare costs.6

Nurses need to understand why patients may not take their medications as prescribed. Thuy et al.7 highlighted five factors that

To increase medication adherence for a complex

medication regimen, assess the patient’s

understanding of the medications and provide

education where knowledge gaps exist.

NSG0123_Features_MedicationAdherence_Deepak.indd 40 07/12/22 11:55 AM

www.Nursing2023.com January l Nursing2023 l 41

follow-up, and ensuring a connec- tion between the HCP and the pa- tient.14 Effective communication skills determine the patient’s level of engagement in their care and adher- ence to their medication plan.7,15

Health beliefs Nonadherence may be intentional. Patients may choose not to take medications as prescribed because of their attitude toward or presump- tions about medications. A patient’s personal beliefs about their disease and their treatment plan may perplex nurses. Still, they are rooted in the patient’s lifestyle patterns, cultural beliefs, experiences, and perceptions of their condition. Patients who don’t understand the disease or illness trajectory may not be compelled to adhere to their medication plan or other treatments. These patients are especially concerned about how the medications will affect their bodies, how many adverse reactions they may experience, and if the medica- tions will result in long-term effects outside their disease.16

Bhattarai et al.13 report that if a person views the prescribed medica- tion as helpful for their condition, they will be more likely to take it as prescribed. Suppose a person consid- ers the medication harmful or be- lieves it is hurting them. In that case, they will be more apt to skip doses, reduce the dosage, or stop taking the medication altogether.1 Also, if a pa- tient believes their condition will adversely affect their life to a great extent, they will be adherent.17 Thus, a belief in the necessity of medica- tion in treating or curing a condition can be balanced or offset by one’s concerns about the medication’s po- tential adverse reactions or the im- pact of medications. In other words, patients constantly engage in a risk- benefit analysis of their medications. This analysis determines whether patients will take their medica- tions as prescribed. The risk-benefit

analysis repeats when a new medica- tion or treatment is added to the reg- imen.18 Nurses need to be engaged in this risk-benefit analysis with the patient as a part of the collaborative approach.

Sometimes beliefs cannot be changed or modified, but nurses can address them through education and effective communication.16 Nurses must actively encourage medication adherence by learning about their patients’ perceptions of medications and dispelling myths.

Probing questions can elucidate how patients view their condition and treatment plan (see Communica- tion strategies to assess and promote medication adherence). Begin by ask- ing the patient about their general beliefs regarding their medications. Follow-up with questions regarding their beliefs about the necessity of the medications, barriers to taking them, and their motivation for adherence.19

Clarifying the patient’s under- standing of their diagnosis, its trajec- tory, and how the medications work helps identify applicable education that may change beliefs. Nurses must also consider patients’ diverse per- spectives and beliefs about taking medications that may impact their adherence.

Self-efficacy Self-efficacy is a belief in one’s capa- bility to control their outcomes in life. The father of self-efficacy, Albert Bandura, described self-efficacy as “the beliefs that determine the goals people set for themselves, how much effort they expend, how long they persevere, and how resilient they are in the face of failures and setbacks.”20 People with low self- efficacy avoid what they perceive as difficult tasks, have a weak commit- ment to goals, and are led by self- doubts.20 Chronic diseases, and the management needed, can take a toll on one’s self-efficacy. As one experi- ences barriers, adverse reactions,

patient what they know about the medication and how it treats their condition. This assesses the patient’s knowledge, engages the patient, clar- ifies assumptions, and creates a start- ing point for further education.

Provide education in simple terms. Focusing education on essen- tial information in small chunks is most helpful. Start with the patient’s medication list. Having patients identify what each medication is for and when it is taken informs the nurse where education is need- ed. If short on time, focus on the most critical medications. Expand education and communication to include a support person.

Patient-clinician communication A patient’s trust and interaction with their healthcare team influence med- ication adherence. The level of satis- faction with one’s healthcare team is correlated to one’s level of adher- ence: low satisfaction results in low levels of patient adherence, whereas high satisfaction results in high lev- els of adherence. The frequency of patient-clinician interaction partially influences satisfaction. Limited in- teraction can result in low satisfac- tion, increasing the likelihood of nonadherence.13

The nurse plays an integral role in developing and supporting the pa- tient and HCP relationship. Those with chronic diseases require more frequent interactions through follow- up on diagnostic study results, treat- ment plans, and care after discharge. The nurse usually provides this fol- low-up.

The communication and support provided in nurse-patient interac- tions factor in the patient’s satisfac- tion with their HCP. For example, in a narrative systematic review of 34 articles, nurses promoted a significant improvement in medica- tion adherence in ethnically di- verse populations through education,

NSG0123_Features_MedicationAdherence_Deepak.indd 41 07/12/22 11:55 AM

42 l Nursing2023 l Volume 53, Number 1 www.Nursing2023.com

Communication strategies to assess and promote medication adherence

Barrier to adherence Probing question Rationale

Medication complexity How often do you miss taking medication? What do you think is the cause of missing your medication?

What barriers or problems have you had with regularly taking your medications?

Nurses often make assumptions instead of directly asking the patient for input. Direct questioning engages the patient, focuses nurses’ efforts, and saves time.7

Health literacy What do you know about how [insert medication name] works?

What is your understanding of your diagnosis?

Exploring what a patient knows is important in building motivation. Asking and acknowl- edging what the patient knows increases their engagement and the likelihood of follow-up actions.22

Assessing any gaps in the patient’s understand- ing of their diagnosis is important. Sometimes a patient may not believe the diagnosis, so it is important to share the patient’s diagnostic study results to reinforce understanding.7

Patient-clinician relationship

Describe your relationship with your clinician.

How comfortable are you discussing your medication concerns with your clinician? Please explain.

Concerns with sharing adherence behaviors with the clinician need to be explored with the patient.15

Encouraging patients to be active participants in their healthcare decisions is important.15

Health beliefs What kind of worries do you have regarding taking your medications?

Often, patients have beliefs that make them feel uncomfortable taking medications. Tell me about any beliefs or concerns that have kept you from taking your medications.

Starting with a statement that helps the patient realize they are not alone, normalizing their experience and encouraging them to be more open.15

Self-efficacy What is the one thing you think you could do to help you consistently take your medica- tions?

What would be most helpful to you to im- prove your medication adherence?

Ask what the patient feels they can do. Using this information in the plan increases the likelihood of adopting it. Focusing on one thing at a time increases the probability of success, supporting an increase in self-efficacy.20

Supporting the patient with low self-efficacy by providing something tangible to support change encourages them to act.20

Cost of medications The cost of medications is usually a concern for patients. How has the cost affected you in getting the medications you need?

Have you changed how often or how much you take your medications due to the cost of the medication? If the answer is “yes,” follow up with, “Tell me about the changes you have made in taking your medications to lower the cost?”

Showing cost as a widespread problem allows the patient to discuss affordability; this is em- barrassing or uncomfortable for many.22

When affordability is an issue, patients who want to maintain adherence often reduce their dosage, thinking this will be an effective solution.22

NSG0123_Features_MedicationAdherence_Deepak.indd 42 07/12/22 11:55 AM

www.Nursing2023.com January l Nursing2023 l 43

changes, and challenges in managing their medication regimen, they can lose a sense of control. This loss of control can ultimately lead to apa- thy and depression.18 A study by Al-Ganmi et al.21 reported that self- efficacy was significantly correlated with one’s adherence to their medi- cation regimen and pointed to the need for clinical nurses to engage in assessing and promoting a patient’s self-efficacy. In addition, depression further limits one’s engagement in self-management by negatively im- pacting medication adherence. A large systematic review by Bhatta- rai et al.13 not only showed that de- pression resulted in higher rates of medication non-adherence but also worsening health status.13 The nursing goal is to increase medica- tion adherence by increasing a pa- tient’s self-efficacy.

Self-efficacy can be improved by increasing patient success and per- suading them to believe in themselves. Generating a short-term measurable goal that the patient acknowledges is attainable sets the patient up for suc- cess. The goal needs to be short-term because the patient will quickly expe- rience success. The goal should be measurable, with specific criteria to meet it. For example, a patient’s goal to take their medication daily is not specific enough. Refine the goal by instructing the patient to take their medication when they have morning coffee. Success can be measured by counting the number of medications at the goal’s start and then a week later to affirm success. The goal should be generated by the patient and acknowl- edged as something the patient will work to obtain.

Following up with patients work- ing on improving their self-efficacy provides a check on goal attainment and allows for celebration and en- couragement, further increasing self- efficacy. Success begets success; a met goal generates interest in tack- ling the next one.

Cost of medications Cost is a major factor in determining one’s ability to access and adhere to a medication regimen. The US healthcare system is complex, with varying levels of prescription drug coverage. As a result, some patients experience restric- tions on their drug coverage (generic versus brand name) and high out-of- pocket costs or copayments. Accord- ing to Neiman et al.22 and confirmed by the Agency for Healthcare Research and Quality (AHRQ),8 reducing the economic burden of prescription drugs for patients will improve medi- cation adherence rates.

The AHRQ performed a compre- hensive literature review to under- stand the drivers behind medication nonadherence. Amplifying prescrip- tion drug coverage and access to Medicare Part D had a moderate im- pact on medication adherence. When corporations eliminated or re- duced employee copayments for pre- scription drugs, the AHRQ found a modest improvement in adherence.8

Asking the patient about their ability to afford their medications is an important first step in promoting adherence. Nurses can begin this discussion by first asking about barriers related to the cost of medi- cations. Next, nurses can encourage adherence when the price is an is- sue by seeking generic equivalents to replace more costly trade names; using assistive websites, such as RxAssist.org; and gathering infor- mation on pharmaceutical programs that finance medications from phar- macists, nurses, and HCPs.22 The FDA is also advocating for improving access to generic medications by streamlining pathways for generic drug companies to acquire approval faster than normal.23 Lastly, most drug companies offer coupons, dis- counts, or financial assistance to help pay for the prescriptions on their home website. One example is the Medicine Assistance Tool, an online tool to help people pay for

their prescription drugs.24 Linking the patient to these financial resourc- es will improve medication access and adherence.

Conclusion Medication adherence is a com- plex public health problem. Research shows that a patient’s perceptions and beliefs significantly influence their adherence. Additionally, other factors such as medication complexity, cost, health literacy, self-efficacy, and per- sonal factors are important consider- ations. Therefore, nurses are pivotal in exploring medication perceptions, facilitators, barriers to adherence, and building a long-term trusting rela- tionship with the patient. ■

REFERENCES 1. Kisa A, Sabaté E, Nuño-Solinís S. Adherence to long-term therapies: evidence for action. World Health Organization. 2003. www.researchgate. net/publication/318679616_ADHERENCE_TO_ LONG-TERM_THERAPIES_Evidence_for_action.

2. National Center for Health Statistics. National health expenditures, average annual percent change, and percent distribution, by type of expenditure: United States, selected years 1960- 2019. Centers for Disease Control and Prevention. 2019. www.cdc.gov/nchs/data/hus/2020-2021/ HExpType.pdf.

3. Phelan J, Ergun D, Langer G, Holyk G. Medication adherence in America: a national report card. 2013.

4. Piña IL, Di Palo KE, Brown MT, et al. Medication adherence: importance, issues and policy: a policy statement from the American Heart Association. Prog Cardiovasc Dis. 2021;64:111-120. doi:10.1016/j. pcad.2020.08.003.

5. Centers for Disease Control and Prevention. Health literacy basics. 2021. www.cdc.gov/ healthliteracy/basics.html. Accessed 2022.

6. Vrijens B, De Geest S, Hughes DA, et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol. 2012;73(5):691- 705. doi:10.1111/j.1365-2125.2012.04167.x.

7. Thuy LT, Monkong S, Pookboonmee R, Leelacharas S, Viwatwongkasem C. Factors explaining medication adherence of older adults with hypertension: a cross-sectional study. Pac Rim Int J Nurs Res. 2020;24(3):306-320.

8. Agency for Healthcare Research and Quality (AHRQ). Medication adherence interventions: comparative effectiveness. Closing the quality gap: revisiting the state of the science executive summary. AHRQ publication. 2012. No. 12-E010- EF. Rockville, MD. www.effectivehealthcare.ahrq. gov/reports/final.efm.

9. National Center for Health Care Statistics (NCHS). Prescription drug use among adults aged 40-79 in the United States and Canada. Centers for Disease Control and Prevention. www.cdc. gov/nchc/data/databriefs/db347_tables-508. pdf#page=4.

NSG0123_Features_MedicationAdherence_Deepak.indd 43 07/12/22 11:55 AM

44 l Nursing2023 l Volume 53, Number 1 www.Nursing2023.com

10. Andrews AM, Cheng A-L, Bartlett Ellis RJ, Emerson AM, O’Brien T, Russell CL. SystemCHANGE solutions to improve medication adherence in kidney transplant recipients: a secondary data analysis. Nephrol Nurs J. 2021;48(4):389-417.

11. Mohammadi Torkabad S, Negahban Bonabi T, Heidari S. Effectiveness of smartphone-based medication reminder application on medication adherence of patients with essential hypertension: a clinical trial study. J Nurs Midwifery Sci. 2020;7(4):219-225. doi:10.4103/jnms. jnms_16_20.

12. Kilic HF, Dag S. The relationship between health literacy and medication adherence in a hypertensive patient population. Int J Caring Sci. 2020;13(1):101-107.

13. Bhattarai B, Walpola R, Mey A, Anoopkumar- Dukie S, Khan S. Barriers and strategies for improving medication adherence among people living with COPD: a systematic review. Respir Care. 2020;65(11):1738-1750. doi:10.4187/ respcare.07355.

14. Singh P, LeBlanc P, King-Shier K. Interventions to improve medication adherence in ethnically diverse patients: a narrative systematic review. J Transcult Nurs. 2021;32(5):600-613. doi:10.1177/10436596211017971.

15. Slyer JT. Shared decision-making to improve medication adherence. Nurse Pract. 2022;47(8):41-47.

16. Cinar FI, Mumcu Ü, Kiliç B, Polat Ü, Özkaptan BB. Assessment of medication adherence and related factors in hypertensive patients: the role

of beliefs about medicines. Clin Nurs Res. 2021;30(7):985-993. doi:10.1177/1054773820981381.

17. da Graça Pereira M, Ferreira G, Machado JC, Pedras S. Beliefs about medicines as mediators in medication adherence in type 2 diabetes. Int J Nurs Pract. 2019;25(5):e12768. doi:10.1111/ ijn.12768.

18. Maffoni M, Traversoni S, Costa E, et al. Medication adherence in the older adults with chronic multimorbidity: a

systematic review of qualitative studies on patient’s experience. Eur Geriatr Med. 2020;11(3):369-381. doi:10.1007/s41999-020-00313-2.

19. While A. Medication adherence: understanding the issues and finding solutions. Br J Community Nurs. 2020;25(10):474-479. doi:10.12968/ bjcn.2020.25.10.474.

20. Bandura A. Self-efficacy. Harv Ment Health Lett. 1997;13(9):4-6.

21. Al-Ganmi AHA, Alotaibi A, Gholizadeh L, Perry L. Medication adherence and predictive

factors in patients with cardiovascular disease: a cross-sectional study. Nurs Health Sci. 2020;22(2):454-463. doi:10.1111/nhs.12681.

22. Neiman AB, Ruppar T, Ho M, et al. CDC Grand Rounds: improving medication adherence for chronic disease management – innovations and opportunities. MMWR Morb Mortal Wkly Rep. 2017;66(45):1248-1251. doi:10.15585/mmwr. mm6645a2.

23. Food and Drug Administration. The generic drug approval process. 2022. www.fda.gov/drugs/ news-events-human-drugs/generic-drug-approval- process.

24. Pharmaceutical Research and Manufacturers of America (PhRMA). Medication assistance tool. www.mat.org.

Lorraine Zoromski is a nursing instructor and program director of the RN-to-BSN program at the University of Wisconsin Stevens Point. Sharon Frazier is retired from the University of Wisconsin Stevens Point after 6 years as a nursing academic staff member.

The authors have disclosed no financial relationships related to this article.

DOI-10.1097/01.NURSE.0000902956.76232.93

NSG0123_Features_MedicationAdherence_Deepak.indd 44 07/12/22 11:55 AM