information to give a patient; for example, which side effects to mention, where to obtain specialised information, as well as where the boundary of responsibility lies between the health professional and the patient. Chapter 3 of this book addresses some of the ethical and legal issues that are associated with medicines management and pharmacology.
Box 1.1 Reaching a shared decision
Work with the patient and, if appropriate, carer in partnership to make informed choices, agreeing a plan that respects patient preferences, including their right to refuse or limit their treatment.
Identify and respect the patient with regards to diversity, values, beliefs and expectations regarding their health and treatment with medicines.
Routinely assess adherence in a non‐judgmental way and understand the different reasons that non‐adherence may occur (this may be intentional or non‐intentional) and how best to offer support.
Build a therapeutic relationship with the patient that encourages two‐way effective communication.
With the patient and carer, explore satisfactory outcomes for the patient/carer.
Source: Adapted RPS (2016)
Concordance, adherence and compliance are terms that reflect fundamentally different approaches to care. When applied in its strict scientific definition, compliance is a useful term; however, it can also infer ‘nurse or doctor knows best’ and may be interpreted as condescending whereby patients do as they are told or advised. Compliance describes a patient's behaviour and concordance implies a process. It is appropriate, therefore, to refer to non‐compliant patients, but not to non‐concordant patients. The relationship between the patient and the health professional is non‐concordant, not the patient. NICE (2009) have determined that adherence presumes an agreement between the prescriber and patient about the prescriber's recommendations. Adherence to medicines is defined as the extent to which the patient's action matches the agreed recommendations. When there is non‐adherence, this has the potential to limit the benefits of medicines resulting in a lack of improvement, or a deterioration in health and wellbeing. The economic costs, suggest NICE (2009), are not only limited to wasted medicines but will also include the knock‐on costs that arise from increased demands for healthcare if the person's health deteriorates.
Honouring individual choices and beliefs are the hallmarks of professional healthcare providers (NMC, 2018a). Being aware of the individual's values, acceptance of these values and asking or seeking clarification are essential if the person is to be respected. This can also have a positive impact on medicine adherence.
Clinical considerations
Medicines management
In the UK, one in four adults experience mental health problems in their lifetime, with one in six experiencing a diagnosable mental health problem in any one year (Mental Health Foundation, 2016). People with mental health problems may die prematurely; the life expectancy of someone with bipolar disorder or schizophrenia is 15–20 years less than the general population (Hjorthø et al., 2017). Often this is because their physical health suffers due to the fact that they are unable to cope and deal with their long‐term condition in a regular and coherent way. The main risks that are specific to those with mental health conditions in terms of premature death include diabetes, obesity, hypertension, lack of exercise and smoking. It is estimated that one in three of the 100 000 people who die avoidably each year in England has a mental illness (Royal Pharmaceutical Society, 2018b).
Many of the medicines that are used to treat mental health problems are also associated with health risks. Pharmacists are experts in medicines and their use and can ensure that people get the best outcomes from their medicines, help to reduce adverse events, minimise any avoidable harm and unplanned admissions to hospital, while also ensuring that resources are used in an efficient way to deliver the standard and level of care that those with mental health conditions deserve. A multidisciplinary approach to medicines optimisation is advocated.
Discussing with patients their experiences of medicines use – for example, their views about what medicines mean to them, how medicines impact on their daily life, whether or not they are able to take their medicines – is a prerequisite that is demonstrated when promoting medicine optimisation.
Conclusion
Medicines are used more than any other intervention by patients as they strive to manage their medical conditions. The number of medicines prescribed, as well as the complexity of the medicines regimens that patients take, are and will continue to increase.
Nurses are involved in the management of medicines in almost every practice setting. Medicines management includes the safe and cost‐effective use of medicines in clinical practice, with greatest patient benefits, while at the same time minimising potential harm. It is essential that nurses have knowledge of the regulatory, professional, and legal and ethical frameworks that oversee the prescribing, storage, administration, and safe disposal of drugs and ensure they comply with them. The nurse must have a sound understanding of the wider field of therapeutic pharmacology, a key aspect of clinical practice aiming to provide safe and effective care through a sound understanding of how the use of drugs cause action and effect.
Glossary
Autonomy Is concerned with self‐determination and is a person's ability to make choices on the basis of that person's own preferences, beliefs and values.Capacity An ability to understand, deliberate and communicate a choice in relation to a specific healthcare decision at a particular time.Competence The achievement and application of knowledge, intellectual capacities, practice skills, integrity, and professional and ethical values needed for safe, accountable, compassionate, and effective practice as a registered practitioner.Compliance Medication compliance refers to the degree or extent of conformity to the recommendations about day‐to‐day treatment by the healthcare provider with regards to timing, dosage and frequency.Conduct A person's moral practices, actions, beliefs and standards of behaviour.Evidence‐based practice The conscious consideration and the application of the best available evidence along with the healthcare provider's expertise and a person's values and preferences in making healthcare decisions.Guidance A principle or criterion that guides or directs action. Guideline development emphasises using clear evidence from the existing literature, as opposed to expert opinion alone, as the basis for advisor materials.Health and wellbeing A state of complete physical, social and mental wellbeing; not just the absence of disease or infirmity. It is a positive concept that emphasises personal resources as well as physical capabilities.Regulations A rule or law designed to control or govern conduct.Standards Authoritative statements developed, monitored and enforced by, for example, healthcare regulators to describe the responsibilities and conduct expected of registrants. The standards are based on the principles and that underpin professional practice.Therapeutic Relating to therapeutics, the branch of medicine concerned specifically with the treatment of disease. The therapeutic dose of a drug is the amount needed to treat a disease.
References
1 Ballantyne, H. (2015). Developing nursing care plans. Nursing Standard 30 (26): 51–57.
2 Care Quality Commission (2018). Learning from safety incidents. https://www.cqc.org.uk/guidance‐providers/learning‐safety‐incidents
