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Helping Patients Manage Therapeutic Regimens
-Communication with special patients
& Ethical Principles
Week 8 Lecture
Hiwa K. Saaed PhD
School of Pharmacy
University of Sulaimani
False Assumptions about Patient Understanding and Medication
Techniques to Improve Patient Understanding
Techniques to Establish New Behaviors
Techniques to Facilitate Behavior Change
Theoretical Foundations Supporting Behavior Change
“Keep watch also on the fault of patients which often makes them lie
about taking of things prescribed.” Hippocrates
Hippocrates made this remark over 2,000 years ago!
Unfortunately, concern about how patients actually use their
prescribed medications continues to this day.
the extent to which a person’s behavior coincides with the medical advice
given. i.e., The extent to which the patient’s follow doctors’ prescriptions
about medicine taking. Traditional patient–provider relationship in which
providers told patients what to do and patients presumably did it
the extent to which the patients behavior matches agreed
recommendations from the prescriber.
The term “adherence” (emphasizing the need for agreement) has largely
replaced “compliance” and was intended to move away from the
paternalistic view of patients as individuals who simply did as they
Concordance: “an agreement reached after negotiation between a patient and
health care professional that respects the beliefs and wishes of the patient in
determining whether, when and how medicines are to be taken.”
Concordance obligates providers and patients to reach mutual decisions. This
joint decision making requires a meaningful dialogue between patients and
providers on medical options and patient preferences.
Rate of Adherence
The exact rate of adherence to medication regimens varies from study to
study since researchers in this area define and measure adherence
However, regardless of definition and measurement, adherence rates are
well below 100%. The consensus is that adherence rates for long-term
therapies tend to be about 50%.
Some researchers use:
indirect methods of measuring adherence (interview patients and
family members, have patients keep diaries)
direct methods (assessing blood or urine levels of medication).
Cost of Nonadherence
Most nonadherences have negative effects on patient health which, in
turn, can result in increased :
emergency room and physician visits,
and decreased productivity in the work place.
Reasons exist for poor- or nonadherence
Numerous reasons exist, some reasons are related to
patient perception of medications “the positive outcomes”.
Many patients are afraid of taking medications,
while some may rely too heavily on medications and take more than prescribed.
Health care providers,
Others evolve from the health care delivery system.
lack of insurance coverage,
access to medications,
and other economic concerns.
Nonadherence can be divided into two broad
1. Unintentional (inadvertent): forgetting
2. Intentional, involves decisions a patient has made to alter a medication
regimen or to discontinue drug therapy (permanently or temporarily).
an uncomfortable side effect
or skip doses of a medication that should not be taken with alcohol before
going to a party.
about Patient Understanding and Medication Adherence
Do not assume that:
1. Physicians have already discussed the medications.
2. Patients understand all information provided.
3. If patients understand what is required, they will be able to take the
4. When patients do not take their medications correctly that they: “don’t
care” “aren’t motivated” “lack intelligence "or “can’t remember.”
5. Once patients start taking their medications correctly, they will continue to
take them correctly in the future.
6. Physicians routinely monitor patient medication use.
7. If patients are having problems, they will ask direct questions or volunteer
+ Techniques to Improve Patient Understanding
1. Emphasize key points. “This is very important” helps them remember
2. Give reasons for key advice, e.g., with an antibiotic prescription, tell
why it is necessary to continue medication use even though symptoms
3. Give definite, concrete, explicit instructions. Any information that
patients can mentally picture is more easily remembered. Use visual
aids, photographs, or demonstrations.
4. Provide key information at the beginning and end of the interaction.
5. Supplement and reinforce spoken words with written instructions.
6. Assessment of a patient’s ability to read and understand key written
instructions is required.
7. End the encounter by taking feedback .
+ Techniques to Establish New Behaviors
1. Tailoring of regimens: New behaviors should tied to an existing habits.
2. Provide appropriate adherence aids.
Individualized medication packaging for daily or weekly doses.
Alarms on cell phones and other devices can be programmed to signal when
medication doses are to be taken.
3. Suggest ways to self-monitor.
use a medication diary or calendar on which to record their medication use.
Other monitoring can involve treatment effects: blood pressure or testing their blood
4. Monitor medication use.
5. Make proper referrals; refer patients to appropriate social service agencies,
such as government programs for low-income patients.
+ Techniques to Facilitate Behavior Change
Establish a new habit (beginning a medication regimen)
Change old habits (overeating).
Stop existing habits (smoking).
For chronic diseases such as diabetes, the changes involve
-establishing new behaviors (drug therapy and daily blood glucose
-changing old habits (diet and exercise),
-ceasing other behaviors (drinking alcohol).
+ Theoretical Foundations Supporting Behavior Change
Three components of motivation to change:
a. Willingness, which is indicated by the amount of discrepancy
patients perceive between current health status and goals they have
b. Perceived ability or the amount of self-confidence patients feel in
their ability to initiate and maintain behavioral change (also known
c. Readiness, which is related to how high a priority is given to these
+ Theoretical Foundations Supporting Behavior Change
empathic understanding is a core,
it facilitates the patient’s own problem-solving ability.
frees patients from the fear that they are being judged because of
Rogers’ theory is said to be client- or patient-centered because the
crucial decision to change is seen to reside in the patient. Providers
can only assist a patient in making informed decisions that are
consistent with the patient’s own goals.
Stages of Change
Precontemplation: unwillingness to change, lack recognition of
problem, deny seriousness of risks.
Contemplation: acknowledging that there is a problem but no ready
or sure of wanting to make a change.
Preparation/determination (getting ready to change)
Action/willpower (change is initiated)
Maintenance (change is established and incorporated to lifestyle,
focus is on avoiding relapse)
Relapse (returning to older behavior)
STAGE 1: PRECONTEMPLATION
persons are not thinking seriously about changing.
Defend their current bad habit(s) and don’t feel it is a problem
Interventions must focus on getting them to think about changing
habits, to begin to consider the pros and cons of behavior change.
Raise awareness of problem
Encourage thinking about
Express willingness to help
STAGE 2: CONTEMPLATION
The contemplation stage “thinking about” changing their behavior—
not immediately but within the next 6 months or so.
They believe in the benefits of change but also see the personal costs
or challenges involved. They feel ambivalent.
People are on a teeter-totter, weighing the pros and cons of quitting
or modifying their bad behavior.
Interventions at this stage can best be focused on getting patients to
describe the “pros”.
STAGE 3: PREPARATION
the individual is ready to implement a change program or initiate a
new regimen almost immediately(< 1 month). These individuals
have reached a decision in favor of change.
STAGE 4: ACTION/ Willpower
The action stage is the initial period in changing a behavior.
During this initial period of change, the desire to go back to old
habits makes the potential to relapse of concern.
STAGE 5: MAINTENANCE
In the maintenance stage, relapse can continue to be of concern but
persons can often continue with the new habits without constant
vigilance against relapse.
The new behaviors have become more integrated into lifestyles and
routines. Patients gain more confidence in their abilities to maintain
However, for certain changes, such as abstinence from addictive
substances, dangers of relapse continue indefinitely.
+ Motivating patients to change
Roll with resistance
Elicit and reinforce “change talk”
+Communication with special patients
In certain individuals, the aging process affects the learning process, but
not the ability to learn. Some older adults learn at a slower rate than
The elderly might also have problems such as poor vision, speech or
Therefore, it is very important to set reasonable short-term goals, and
break down learning tasks into smaller components.
It is also important to encourage feedback as to whether they understand
the intended message.
+ Communication with special patients
Terminally Ill patients are usually intimidating to work with because people
do not want to say the “wrong” things that would upset them.
Before interacting with them, be aware of your own feelings about death.
Simply being honest with them can improve their interaction with them. It
will also open them up to voice out their concerns as well.
Many terminally ill patients know that they can make others feel
uncomfortable. You should not avoid talking to them unless you sense that
they do not want to talk.
Not interacting with them only contributes further to their isolation and
may reaffirm that talking about death is uncomfortable.
+ Communication with special patients
Patients who are mentally ill can be difficult to
Open-ended questions would be more effective as they
can be used to determine the patient’s cognitive abilities.
Ethical considerations include whether they require
consent from the patient for treatment.
Mentally Ill Patients might not always understand their
treatments or medication purposes.
Communication with Children
Attempt to communicate at the child’s developmental level
Ask open-ended questions rather than questions requiring only a yes or no
Use simple declarative sentences for all children
Ask the child whether he or she has questions for you
Augment verbal communication with written communication
Nonverbal communication is very important with children therefore be aware of
your facial expressions, tone of voice, gestures, and so on.
Children want to know. Healthcare professionals should communicate directly
with children about medicines and treatment.
When an error occurs, you must make sure that the patient is not harmed or
does not continue to be at risk.
The first general response to find an error might be…
1. Avoidance ‘’I didn’t make the error’’
2. Blaming someone or something else ‘’the physician’s poor handwriting was
3. Rationalizing that the error was not important ’’ it is no big deal that I gave
tablets rather than capsules’’
4. Rationalizing that the patient will call the pharmacy if there is a problem.
When Errors Occur
What do you do When an Error Occurs? How do you handle
the embarrassing situation of telling someone that you made
Initial contact with patient
The first few moments of contact with patients are critical in determining
how the situation will be resolved. If patient is in the pharmacy, go with
him/her to quit area where other people can’t overhear.
When Errors Occur
+ During the initial contact pharmacist should…
1. Make a simple, but clear statement that he/she is extremely sorry for the
2. Not place the blame on technology, other people or the fact that he/she
was too busy.
3. Not minimize the importance of the error.
4. Convey that fact to the patient so that he/she feels that the pharmacist is
still concerned and are working toward a resolution and didn’t just
forget about it.
5. Thank the patient for bringing the error to your attention.
+ Further contact
Once the patient has a clear idea that an error has occurred and how it is being
resolved. To some patients, a lengthy explanation may seem like you are
making excuses…for example. You should …
Be honest and upfront with the patient about the long term consequences of
Make sure that you don’t rush through the experience and allow patient time
to ask questions and express their feeling.
Encourage patient expressions about what they are thinking and feeling about
Contact them later to know if they have additional questions and update them
with relevant information.
+ Contacting other health care providers
Pharmacist should alert physicians or other health care providers if
they were involved with the original error.
Wrong drug prescribed
Prescribing two interacting medications,…
Revealing errors to other providers is helpful for their quality assurance efforts
as well. They need to know how they may have personally contributed to the
error and how communication and other elements of the system need to be
improved to minimize future errors.
Beneficence: act in the best interest of the patient.
Autonomy is the principle that establishes patient rights to
self-determination- to choose what will be done to them.
Honesty principle states that patients have the right to the
truth about their medical condition, the course of disease,
the treatments recommended and the alternative
Informed Consent: treatment can be implemented if all
relevant information is provided.
Confidentiality serves to assure patients that information about their
medical conditions and treatments will not be given to individuals
without their permission.
Fidelity is the right of patients to have health professional provide
services that promote patients’ interests rather than their own.
Ethically, the responsibilities of physicians should be directed towards
the patients rather than directed at the financial well-being of the clinic.