A total of 50% of prescribed medications are not taken properly (Stoate et al, 2000; World Health Organization (WHO), 2003; Brown and Bussell, 2011). Some estimate this figure could be as high as 75%, as most patients will discontinue their medication without informing their prescriber (Walker and MacAulay, 2005). Therefore, it is recommended that good prescribing practice should address the issue of concordance (National Institute for Health and Care Excellence (NICE), 2009). When reviewing the literature on concordance, the term non-compliance is frequently found (Schulz, 2020); the dictionary definition for this is given as ‘a failure to act in accordance with a wish or command or with a formal requirement’ (Concise Oxford Dictionary, 2015). What this definition lacks is any acknowledgement of the person behind the patient or the health professional trying to manage a complex prescribing consultation. Interestingly, whilst there is little consensus within the literature as to the causes of non-compliance, there is, however, significant consensus as to what might mitigate it, and these coalesce around making consultations more patient centred. This paper will consider what the evidence tells prescribers about patient-centred approaches within prescribing and why they need to form the basis of the prescriber's practice if the challenge of concordance is hoped to be met.
Background: psychological adaptation to change
Non-compliance is not a new thing within the world of prescribing but a census on its causes is still hard to find and views on its origins vary from the psychological, social or cultural (Broekmans et al, 2010; Lee et al, 2016; Lee and Khan, 2016; Low et al, 2017). However, there is consensus on what helps concordance and these all focus on consultation techniques that allow practitioners to prescribe in a patient-centred way (NICE, 2009; Coulter and Collins, 2011; Hart et al, 2016; Wei et al, 2016). Therefore this consensus does offer some clues as to what is happening to patients that makes non-compliance more likely, and it points to the need for a better understanding as to what prescribing medication means to an individual patient (Schwabe et al, 2012; Kekale et al, 2016; Chou P-L et al, 2018).
A person seeking help or advice from a prescriber is often trying to adapt to a change in their life, which means they come to the prescribing consultation with hopes and concerns related to what that change means to them and to those people most important to them (Weaver et al, 2016; Verbrugghe et al, 2017; Huyard et al, 2017). The literature points to the fact that these underlying thoughts and feelings can often mean the patient is not fully present within the consultation, leading to an increased likelihood that communication between patient and prescriber is less than effective (Kurtz et al, 2005; Jin et al, 2008). A number of papers and reports show that a patient's recollection of their past medical history contains significant omissions, with some patients unable to recall up to 80% of it accurately (Stoate et al, 2000; WHO, 2003). Other sources show that the information given to patients about a prescription regarding administration and side effects is poorly retained, with some patients only remembering 10% of what they were told (Malbasa et al, 2007; NICE, 2009; Huyard, 2017). The fact that something significant happens to patients' ability to recall information in the context of many prescribing consultations is undeniable, but the exact nature of what is occurring is somewhat less clear (Verbrugghe et al, 2017).
It is clear emotions significantly impact on an individual's ability to take in and process information (Abercrombie et al, 2008). It is also known that during health-related consultations, anxieties are often present, perhaps related to past and current experiences or related to fears about future vulnerabilities (Low et al, 2017). The literature looking at the psychological adjustment to change offers some insight into what takes place when patients recall experiences related to illness or life changing events; these experiences are similar to those of loss and bereavement, including fear, anger and intrusive thoughts about future vulnerabilities for oneself and significant others (Table 1) (Stroebe and Schut, 2010; Verbrugghe et al, 2017). Similarly, a discussion around drug treatment regimens and side-effects can induce strong emotions as they reconfirm the patient's diagnosis and that life has now changed, perhaps forever. Psychologically such adjustment does not happen quickly and often involves a process of non-acceptance and acceptance with periods of avoiding thoughts about the change altogether (Figure 1) (Miller and Rollnick, 2012). As a result, the process of prescribing medication can involve the patient in a complex internal interaction between wanting help and wishing it was not needed, meaning the patient's ability to engage effectively in prescribing consultations fluctuates over time. It is this process of psychological adaption that is now thought to be a significant factor in concordance (Hart et al, 2016). This paper will consider the assessment and management of this process.
Table 1. Dual process of loss and adjustment (Stroebe and Schute, 2010)
| Physical | Behavioural | Emotional | Cognitive |
|---|---|---|---|
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Figure 1. The change curve
Assessment
Prescribers commonly adopt a consultation structure such as the Calgary Cambridge, Pendleton or Neighbour model, which better enable gathering information and make it less likely that vital information is missed (Hart et al, 2016). This systematic linear framework also tries to ensure principles of partnership working and a patient-centred approach are adopted; however, it does tend to promote a problem-solving approach and place the health professional in the role of problem solver; they also lack any emphasis on an assessment of what meaning the current situation has for the patient, how they might be adjusting to it, and what medication might mean to them going forward (Weaver et al, 2016). It does allow flexibility within the opening, gathering, problem recognition, formation or explanatory planning stages of the consultation process for a more patient-centred approach. However, the health professional needs the ability and confidence to elicit the patient's thoughts and feelings and know how to respond to them, especially non-verbal cues that indicate the patient is emotionally or cognitively distracted by experiences linked with adaptation (Table 1) (Kurtz et al, 2005). The research shows that health professionals block or avoid addressing such cues to avoid conversations where difficult emotions may be encountered, often feeling they lack the skills to manage them or failing to see their significance when it comes to prescribing successfully, believing the physical not emotional experience of the patient needs to be their priority (Jansen et al, 2010). The literature shows that concordance is improved in the presence of prescribers who are able to acknowledge and empathise with the patient's subjective experiences and this is dependent on an ability to pick up and acknowledge cues that a patient has concerns or is experiencing an emotional response at any point within a consultation (NICE, 2009; Jansen et al, 2010; Hart et al, 2016). It needs to include the ability to elicit what these concerns might be and to acknowledge, regardless of their objective reality, the importance and significance of them for the patient (Rollnick et al, 2008). In recent studies, it has been shown that this empathic acknowledgement of the patient's subjective reality enhances adaptation to change and increases the patient's ability to take in and process information, as well as forming the basis of the rapport and therapeutic alliance that positively impacts on concordance across a number of specialties (Finset et al, 2011; Kekale et al, 2016). Within this also sits the patient's sense of efficacy, how able they feel to adapt to the current situation and there are clear links between empathy, efficacy and concordance within the prescribing literature (Miller and Rollnick, 2012; Hart et al, 2016).
Assessment models such as the Calgary Cambridge, Pendleton or Neighbour are useful frameworks but a greater emphasis needs to be placed within them on the importance of ongoing assessment and validation of the patient's experience, which, in turn, creates the environment in which greater concordance can be achieved (Schulz, 2020). This paper will explore the skills to do this for the remainder of the discussion.
Improving concordance
Listen to the patient and let them do the majority of the talking
Any prescribing consultation must start with listening to the patient and this includes both verbal and non-verbal forms of communication. As prescribers listen to what the patient says, they must also listen to how they speak and how they present themselves physically. This might be termed ‘total listening’, where what is said is as important as the cues communicated by the patients as to how it feels to say it. Open-ended questions are important and allow the prescriber to have a better understanding of the patient and to begin the process of building rapport, where the patient begins to feel part of a collaborative process, where their thoughts are valued and listened to and where they can begin to feel safe to express any concerns they have (Jansen et al, 2010). Questions then may probe into discrepancies, as well as fears, perceptions and beliefs (Kurtz et al, 2005). For example, a consultation may begin by inviting the patient to tell us what brings them to the consultation:
Prescriber:
‘Hello how are you today?’…‘What do you hope for from seeing me today?’… ‘How does this make you feel?’
This might be developed further in more established consultations, as when discussing analgesia with a patient who chooses not to take medication, despite pain. Asking open questions will help the prescriber explore the patient's concerns and motivations:
Prescriber:
‘What concerns you about taking the Oramorph when you first get pain?’….‘How do you feel at that time?’… ‘What do you feel you might gain if you did take the Oramorph, when you get the pain?’
A common trap the prescriber can fall into is telling the patient what they need to do. This will often inhibit the patient from disclosing further concerns and may increase feelings of isolation and anxiety and act as a block to self-efficacy and adaptation (Miller and Rollnick, 2012). This ‘telling mode’ can be prevented by the following rules:
- Pause after each question, give the patient time to answer and you time to listen
- Try to ensure the patient is doing the majority of the talking
- Ask only one open question at a time
- Acknowledge what the patient tells you
- Paraphrase and/or summarise
- Always ask the patient's permission to give advice.
The prescriber should focus on weaving between asking open-ended questions, acknowledging what has been said and reflecting back to the patient an appreciation of their concerns, hopes, challenges, successes and efforts to manage the currentsituation (Hart et al, 2016). It is this patient-centred interaction that promotes adaptation, builds rapport and empathy and ultimately lays the foundation for improved concordance.
Prescriber (open-ended question):
‘Since we last met, tell me how things have been going with regards to taking your metformin tablets?’
Patient:
‘It has been terrible. I have had diarrhoea every day with these tablets. I cannot carry on taking them, because I cannot even leave the house. I want my life back.’
Prescriber (empathic acknowledgement):
‘Things sound very difficult and a real struggle at the moment. The metformin is severely affecting your daily life. It sounds like something needs to be done urgently.’
Patient:
‘Yes… Something needs to be done. I am not sure what you can do, but anything is worth a try?’ Here, the patient's emotional state is visibly reduced.
Prescriber (affirms, summarises and asks an open-ended question that requests permission to give advice):
‘Despite the difficulties the medication is causing, it sounds as if you want to tackle the problem. There are things that we can do together to explore and resolve the problem; would you like to think about them with me?’
Empathy and resistance to change
To be able to convey a non-judgmental, empathetic approach, it is important that the prescriber understands the nature of resistance to change and how it is linked to behaviour changes (Figure 1) (Rollnick et al, 2008). This is because when resistance is evident, the patient may display resistant behaviours, such as anger, inadequacy, frustration or even a laissez-faire attitude (Table 1). These negative feelings can easily be projected onto the prescriber, whereby the prescriber begins to feel angry, frustrated or perhaps inadequate as well. Therefore, it is important to recognise that it is normal for patients to have times of resistance, ‘what is the point’ moments or ‘I wish they would stop telling me to do things’ thoughts. It is important to remember that resistance is a way of managing change, and the anxiety that comes with life being very different. The prescriber's focus should be on acknowledging these and being empathetic and curious about the patient's perceptions, beliefs and values.
Patient:
‘It's ok people saying take these tablets and the diarrhoea should get better, but I wasn't like this before the radiotherapy, I can't even go out for a walk with my dog.’
Prescriber:
‘It sounds like life has changed significantly since the radiotherapy, and people don't get that….its not just a case of taking a tablet and things will be better.’
It is these types of interactions that prescribers often report as difficult and frustrating, being left with uncertainty as to know what to do next, not realising that it is the act of empathising with a patient's experience and resisting the temptation to suggest solutions that in itself acts as the intervention (Sep et al, 2014). It is this empathic response that supports adaptation within the patient, reduces the sense of isolation and fear and supports cognition towards being able to process and adjust to the changing circumstances. This ultimately supports prescribing and concordance (Jin et al, 2008; Jansen et al, 2010; Kekale et al, 2016; Bluethmann et al, 2017).
Resist the temptation to adopt the role of fixer
Many prescribers are familiar with Prochaska and DiClemente (1982) trans-theoretical stage of change model (Figure 2). It recognises that the change process is cyclical, and individuals typically move back and forth between the stages of change, and cycle through the stages at different rates (Miller and Rollnick, 2012). This is important because a prescriber's response to a patient's statement should consider the patient's stage of change. If a patient responds with a pre-contemplative statement, such as ‘I am not sure what all the bother is about me taking these hypertensive tablets', the prescriber should respond by being curious. This type of approach looks to promote catharsis and raise the patient's consciousness of the concordance issue. In response to a contemplative statement, such as ‘I know I should take my hypertensive tablets, but I am not keen on taking medication.’ The prescriber should amplify the patient's wish to change, but also explore the patient's ambivalence, thus encouraging a degree of self-evaluation.
Figure 2. Transtheoretical model stages of change Prescriber:
‘You see taking the medication is important but something is making you not keen on taking it, what is that?’ Pause and give the patient time to think and respond.
Box 1.Top tips
- Resist the temptation to adopt the fixer role within prescribing consultations
- Use open ended questions and pauses when listening to the patient's understanding, ideas, beliefs, hopes and concerns
- Acknowledge you have heard what has been said before rushing to provide solutions
- Look out for and acknowledge any cues regarding patients struggle with their current situation
- Empathise - this can literally change brain chemistry and promotes adaptation
- Reflect and affirm the patients desire to change
- Aligned your prescribing approach with the patient's ability and readiness to consider management options
- End the session by summarising what the patient's priorities are and how the action plan aims to meet them
- Acknowledge at the end of the session that it would be normal for additional concerns to arise and that these can be talked about.
Therefore, it is important not to jump ahead of the patient's stage of change. If a patient responds with a pre-contemplative statement and the prescriber responds as if they are in preparation or action stage by giving advice, the patient is likely to disengage. This is because the prescriber has jumped ahead of the patient's stage of change, created a situation where the patient is likely to feel anxiety and increased the likelihood that resistance will then follow. The case scenario below describes the detrimental impact of this.
A nurse prescriber working in the community was very eager that the patient begin to self-administer their post-operation anticoagulant medication. In their eagerness, the nurse jumped ahead of the patient's stage of change, by not exploring the patient's reluctance to self-administer their medication. The patient's fear and anxiety was not considered, and the patient refused to self-administer. On reflection, the prescriber felt if time had been spent exploring the patient's issues, it was likely that the patient would have accepted the support they needed to self-administer and this would have ensured the district nurse's time was used more effectively (Hart et al, 2016).
Reflect or affirm the patient's desire to change
The rule is not to miss an opportunity to reflect back or affirm the patient's desire, ability, reason, need or commitment to change. This allows reflection of the patient's positive values, behaviours and attitudes and can promote confidence and self-efficacy (Miller and Rollnick, 2012; Van Camp et al, 2013).
Patient:
‘I will try and self-administer the blood thinning medication. I want to get well as soon as I can.’
Prescriber (affirming and reflecting back the desire and need to change):
‘That's really good that you want to take more control of your health and in doing so, you will have better control of your blood levels.’
Conclusion
This paper has considered what the evidence tells prescribers about concordance and non-compliance in prescribing. A high a proportion of prescribed medication is either not taken or discontinued by patients. Patient-centered approaches within prescribing can significantly improve this situation by addressing some of obstacles that exist for prescribers and patients when it comes to adjusting to changes in people's lives.