Nurse practitioners' communication styles and their impact on patient outcomes: an integrated literature review

Purpose: The purpose of this review was to examine the published research from 1999 to 2005 describing nurse practitioner (NP)–patient interactions and to determine the best practice to enhance patient outcomes.
Data sources: Databases searched included Academic Search Elite, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source Consumer Edition, Health Source Nursing/Academic Edition, Medline, and PsychInfo.
Conclusions: Two communication styles described in the literature and determined by authors were (a) biomedical and (b) biopsychosocial. The biopsychosocial style is identified as patient-centered communication. Seven studies were then analyzed for NPs' communication styles and the impact that they had on patient outcomes. The studies analyzed demonstrated that biopsychosocial (patient-centered) communication style positively influences patient outcomes as evidenced by (a) improved patient satisfaction, (b) increased adherence to treatment plans, and (c) improved patient health.
Implications for practice: The results of this review indicate that patient-centered communication incorporated into the NPs' practice is associated with improving patient outcomes such as (a) improved patient satisfaction, (b) increased adherence to treatment plans, and (c) improved patient health. Future research needs to be performed in order to fully study the relationship between NPs using patient-centered communication style and its impact on patient outcomes. Clinical recommendations are made based on findings of the integrated literature review.     

Strategies to promote medication adherence in children with asthma.

Asthma, the most common chronic disease in childhood, continues to be associated with high rates of morbidity and mortality, despite improved treatment protocols. Lack of adherence to individual treatment plans has been implicated in these poor outcomes. The purpose of this article is to assist the nurse in identifying obstacles that might limit adherence to treatment, and offer practical suggestions for promoting adherence in pediatric patients. The reasons that children and children's families fail to adhere to individual treatment plans include financial barriers, misconceptions about asthma, cultural influences, and mistaken health beliefs. In addition, family education about asthma management can be inadequate. An efficiently run asthma program, which includes family education, easy telephone access to the provider, prompt attention during exacerbations, and frequent follow-up, can improve adherence. By eliminating barriers to adherence and maintaining open communication and consistent positive support, nurses can help children with asthma attain and maintain the highest quality of life.     

Medical specialists' patient-centered communication and patient-reported outcomes

BACKGROUND: Physicians' patient-centered communication in the medical consultation is generally expected to improve patient outcomes. However, empirical evidence is contradictory so far, and most studies were done in primary care. OBJECTIVE: We sought to determine the association of specialists' patient-centered communication with patient satisfaction, adherence, and health status. METHODS: Residents and specialists in internal medicine (n = 30) and their patients (n = 323) completed a questionnaire before a (videotaped) follow-up encounter. Patients' satisfaction was assessed immediately after the consultation and their self-reported treatment adherence, symptoms, and distress 2 weeks later. Specialists' patient-centered communication was assessed by coding behaviors that facilitate or rather inhibit patients to express their perspective. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior. Outcomes were assessed using standard questionnaires. Analyses accounted for relevant patient, visit and physician characteristics. RESULTS AND CONCLUSIONS: Medical specialists' facilitating behavior was associated with greater satisfaction in patients who were less confident in communicating with their doctor. Patient-centered communication was not associated with patients' health status or adherence in general, but facilitating behavior was positively related to the adherence of patients with a foreign primary language. In general, patients appeared to be more satisfied after an encounter with a more-facilitating and a less-inhibiting physician, but these associations diminished when controlling for background characteristics. We conclude that the absence of strong associations between patient-centered communication and patient-reported outcomes may be explained by medical specialists being responsive to patients' characteristics.     

"RAPID" team triage: one hospital's approach to patient-centered team triage

Patients who present to the emergency department want definitive care by a health care provider who can perform an initial assessment, initiate treatment, and implement a disposition plan. The traditional "nurse triage" model often creates barriers to the process of rapidly evaluating patients. Therefore, innovative strategies must be explored to improve the time of patient arrival to the time seen by a qualified provider in order to complete a thorough medical screening examination. One such approach is a rapid team triage system that provides a patient-centered process. This article describes the implementation of a rapid team triage model in an urban community hospital.     

Medication adherence and persistence: A comprehensive review

Estimates of adherence to long-term medication regimens range from 17% to 80%, and nonadherence (or nonpersistence) can lead to increased morbidity, mortality, and healthcare costs. Multifaceted interventions that target specific barriers to adherence are most effective, because they address the problems and reinforce positive behaviors. Providers must assess their patients’ understanding of the illness and its treatment, communicate the benefits of the treatment, assess their patients’ readiness to carry out the treatment plan, and discuss any barriers or obstacles to adherence that patients may have. A positive, supporting, and trusting relationship between patient and provider improves adherence. Individual patient factors also affect adherence. For example, conditions that impair cognition have a negative impact on adherence. Other factors—such as the lack of a support network, limited English proficiency, inability to obtain and pay for medications, or severe adverse effects or the fear of such effects—are all barriers to adherence. There are multiple reasons for nonadherence or nonpersistence; the solution needs to be tailored to the individual patient’s needs. To have an impact on adherence, healthcare providers must understand the barriers to adherence and the methods or tools needed to overcome them. This report describes the barriers to medication adherence and persistence and interventions that have been used to address them; it also identifies interventions and compliance aids that practitioners and organizations can implement.     

Adherence in patients on dialysis: strategies for success.

Adherence is a major problem in patients with chronic kidney disease. Patients can be nonadherent with different aspects of their treatment, which includes medications, treatment regimens, and dietary and fluid restrictions. Although many lessons have been learned from adherence research, the evidence of how to modify adherence is somewhat mixed. To minimize nonadherence, interventions need to focus on both patient factors and the extent to which relationships and system problems compromise the patient's ability to adhere to medication and treatment plans. There continues to be a tendency to focus on the patient as the reason for problems with adherence, ignoring other factors such as the patient-health care provider relationships and the health care system that surrounds the patient. These latter factors can have a considerable effect on adherence. The nurse can develop a strong relationship of support with the patient, identify barriers, and offer strategies to help patients improve adherence.     

Dyslipidemia: Current Therapies and Strategies to Overcome Barriers for Use

Dyslipidemia continues to be a major predictor of adverse cardiovascular outcomes in patients with risk factors as well as diagnosed atherosclerotic cardiovascular disease. Recent clinical trials and national guidelines from the US Preventive Services Task Force, American College of Cardiology, and American Heart Association have reinforced a paradigm shift from quantitative reduction of low-density lipoprotein cholesterol targets to prevention and risk factor reduction. Optimized medical therapies have become more inclusive of patients in both the primary and secondary care settings. Although statins continue to be a cornerstone of all recommended therapeutic options, many barriers to patient adherence with medical therapy exist. As medical options change to include the newer lipid-lowering treatments, patient adherence and provider practice challenges can diminish the benefits these medications offer. Although the phenomenon of adherence is complex, multidisciplinary teams, technology, improved communication, prior authorization, step-wise approaches, and the streamlining of the appeal process have shown benefit to mitigate cardiovascular disease-related sequelae. A current overview of practitioner barriers such as organizational restrictions, as well as patient challenges such as poor health literacy and poverty, are examined. Collaborative, multidisciplinary planning and interventions are reviewed with suggestions to increase patient adherence and optimize treatment regimens. This article reinforces existing knowledge while providing new insights to these issues.     

Physician process and patient outcome measures for diabetes care: relationships to organizational characteristics

BACKGROUND: Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes. PURPOSE: To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes. DESIGN: Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers. SAMPLE: We sampled 109 Veterans Affairs medical centers (VAMCs). RESULTS: Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients. CONCLUSIONS: Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.     

Patient-related barriers to cancer pain management: a systematic exploratory review

The aim of this review was to systemically explore the current evidence regarding patient-related barriers to cancer pain management to find new areas that might be important for better understanding of patient barriers' phenomenon. The method used in this study was a computerised literature search, carried out in Cochrane Library, Medline (through PubMed), Web of Science and EMBASE databases for the period 1994–2005. Thirty-seven studies, dealing with cognitive, sensory and affective patient-related barriers, as well as studies, describing patients' pain communication and their adherence to analgesic regimen were included and analysed. The dominant part of articles studied cognitive patient-related barriers to cancer pain management, while affective, sensory barriers, as well as pain communication and pain medication adherence were studied in much less extend. However, the findings from different studies regarding relationships between cognitive barriers and pain intensity were not consistent. On the contrary, the quality of pain communication was consistently found to be not satisfactory in some key areas. The associations between more expressed attitudinal as well as sensory barriers and less optimal adherence were also consistent. In conclusions suggestion for the new research areas on patient-related barriers to cancer pain management are made. Firstly, further research is needed to differentiate the role of cognitive, affective and sensory factors with respect to their impact on pain relief, pain communication and medication adherence. Besides that, validated instruments to assess patients' pain communication and adherence to analgesic regimen are lacking.     

Dealing with the obstacles in adhering to highly active antiretroviral therapy.

Improving patient adherence to highly active antiretroviral therapy (HAART) is essential to effective treatment and represents a major challenge confronting healthcare providers. Because of their holistic perspective, nurses are uniquely qualified to identify the psychosocial and practical obstacles to full adherence and help patients deal with these problems. Studies have shown that many factors related to the disease, the patient, the provider, and the treatment regimen all play important roles in adopting and maintaining adherent behavior. Therefore, any attempt toward improving adherence should include adherence assessment and an approach that targets the patient, the provider, and the regimen. The availability of antiretroviral agents that are administered once daily and/or are associated with lower toxicity can help to simplify treatment regimens and avoid certain side effects, thereby facilitating greater adherence to highly active antiretroviral therapy.     

Rationale and design of the ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus (ENGAGE-DM) pragmatic trial

BackgroundPoor glycemic control among patients with diabetes may stem from poor medication and lifestyle adherence or a failure to appropriately intensify therapy. A patient-centered approach could discern the most likely possibility and would then, as appropriate, address patient barriers to non-adherence (using behavioral interviewing methods such as motivational interviewing) or help facilitate choices among treatment augmentation options (using methods such as shared decision-making).ObjectiveTo test the impact of a novel telephone-based patient-centered intervention on glycemic control for patients with poorly-controlled diabetes.Methods/designENGAGE-DM (ENhancing outcomes through Goal Assessment and Generating Engagement in Diabetes Mellitus) is a pragmatic trial of patients with poorly-controlled diabetes receiving treatment with an oral hypoglycemic agent. We randomized 1400 patients in a large health insurer to intervention or usual care. The intervention is delivered over the telephone by a pharmacist and consists of a 2-step process that integrates brief negotiated interviewing and shared decision-making to identify patient-concordant goals and options for enhancing patients' diabetes management. The trial's primary outcome is disease control, assessed using glycosylated hemoglobin values. Secondary outcomes include medication adherence measures, assessed using pharmacy claims data.ConclusionsThis trial will determine whether a novel highly-scalable patient engagement strategy improves disease control and adherence to medications among individuals with poorly-controlled diabetes.     

Development of Dual Language Information Cards as a Tool for Communication Between Radiation Therapists and Cantonese-Speaking Patients Undergoing Radiation Treatments for Head-and-Neck Cancer

The establishment of an effective relationship between patient and provider is dependent upon effective communication. However, this can be difficult to achieve with patients who do not speak English as their first language. Language barriers are associated with adverse effects on quality of care, treatment outcomes, and patient and provider satisfaction. These patients are more likely to experience acute side effects and more likely to use emergency room services for problems that are treatable in primary care settings. Interpreter services and dual language providers are often used to overcome these barriers, but they are often limited by their cost and availability. The radiation therapy environment provides further challenges to overcoming these barriers by virtue of the outpatient setting and high volume of appointments. As part of their efforts to improve patient care, the British Columbia Cancer Agency (BCCA)–Vancouver Centre radiation therapy department introduced dual language cards as a tool to facilitate communication between Cantonese-speaking patients and radiation therapists. This paper outlines the method of devising and evaluating a dual language tool.     

Provider-perceived barriers and facilitators for ischaemic heart disease (IHD) guideline adherence

RATIONALE, AIMS AND OBJECTIVES: Clinical practice guidelines have become a standard way of implementing evidence-based practice, yet research has shown that clinicians do not always follow guidelines. METHOD: As part of a larger study to test the effects of an intervention on provider adherence to ischaemic heart disease (IHD) guidelines, we conducted five focus groups at three Veterans Administration Medical Centers with 32 primary care providers, cardiologists, and internists to identify key barriers and facilitators to adherence of the guidelines. Using content analysis, responses were grouped into categories. RESULTS: The main perceived advantages of using the IHD guidelines were improvements in quality and the cost of care. Perceived barriers were the lack of ability of guidelines to manage the care of any one individual patient, the difficulty of accessing guidelines, and high workloads with many complex patients. While providers agreed on the benefits of aspirin, beta-blockers and angiotensin converting enzyme inhibitors, barriers for use of these medications were lack of consensus about contraindications, difficulty in providing follow-up during medication titration, and lack of patient adherence. Sources of influence for guideline use were: professional cardiology organizations, colleagues, mainly cardiologists, and key cardiology journals. However, most providers acknowledged that following guidelines was a personal practice decision. CONCLUSIONS: While results validated the influences of using clinical practice guidelines, our results highlight the importance of ascertaining guideline-specific barriers for building effective interventions to improve provider adherence. An advisory panel reviewed results and, using a modified nominal group process, chose implementation strategies targeting key barriers.     

Multilevel factors affecting tuberculosis diagnosis and initial treatment

Objectives The study aims to assess provider adherence to national tuberculosis programme guidelines on diagnosis, initial regimens and dosages, and to examine independent effects of factors at patient, staff and hospital levels influencing adherence. Methods A review of 383 medical records of new tuberculosis (TB) patients and interviews with related staff were carried out. The study was conducted in 16 public hospitals of seven provinces of southern Thailand. The outcome variables were provider adherence to the guidelines on diagnostic procedure, initial regimen and dosage. Independent variables consisted of patient, staff and hospital factors. Multilevel logistic regression was used to identify factors associated with adherence. Results The proportions of adherence to the diagnostic procedure, initial regimen and initial dosage prescribed were 70.0%, 100.0% and 57.1%, respectively. Most of diagnosis non‐adherence was anti‐TB drugs being prescribed for smear‐negative patients without prior antibiotic trial (12.5%). The anti‐TB drug with the highest percentages of patients receiving non‐adhered dosage was ethambutol (33.6%). In contrast to single‐level analysis, which showed significant influence of up to five factors, multilevel analysis confirmed only strong effect of male patients receiving better adhered diagnosis and of non‐doctors and TB clinics providing better dosage adherence. Conclusions Adherence to TB diagnostic procedures was not good, and adherence to initial dosage, especially for ethambutol, was poor. TB clinics, the key factor of adherence, should be expanded. Female patients should be reviewed more carefully because they tend to receive poorer diagnosis adherence.     

Eliciting accurate reports of adherence in a clinical interview: development of the Medical Adherence Measure

Nonadherence is a major public health concern but reliable assessment methods are limited. The Medical Adherence Measure (MAM) was designed as a semi-structured clinical interview to elicit comprehensive and accurate responses from patients regarding adherence during the course of standard clinical care. The measure was developed in three phases and administered to 219 pediatric patients (ages 1.3-23) and/or their parents to assess the content, clinical utility, and ease of use. The MAM has three general regimen domains (medication, diet, clinic attendance) and several treatment specific modules. Items assess knowledge of the prescribed regimen, self-reported adherence, organizational system used to manage the regimen, and perceived barriers to optimal management. The MAM is a screening tool that assists providers in identifying patients at risk for adherence problems, assessing the extent of nonadherence, and targeting specific barriers to care in interventions. The interview emphasizes a supportive patient-provider relationship with the goal of improving patient care.     

Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review

Poor adherence to treatment can have negative effects on outcomes and healthcare cost. However, little is known about the barriers to treatment adherence within physiotherapy. The aim of this systematic review was to identify barriers to treatment adherence in patients typically managed in musculoskeletal physiotherapy outpatient settings and suggest strategies for reducing their impact. The review included twenty high quality studies investigating barriers to treatment adherence in musculoskeletal populations. There was strong evidence that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support/activity, greater perceived number of barriers to exercise and increased pain levels during exercise. Strategies to overcome these barriers and improve adherence are considered. We found limited evidence for many factors and further high quality research is required to investigate the predictive validity of these potential barriers. Much of the available research has focussed on patient factors and additional research is required to investigate the barriers introduced by health professionals or health organisations, since these factors are also likely to influence patient adherence with treatment.     

The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures

CONTEXT: Cancer is a leading cause of morbidity and mortality in the USA and despite many recent advances in detection and treatment, over half a million cancer patients in this country will die from their disease each year. OBJECTIVE: Using cancer as a prototype, we provide a conceptual framework to identify and review barriers to optimal end-of-life care and propose examples of linked process and outcome measures that could be used to evaluate whether standards of optimal end-of-life care are being achieved. METHODS: We propose a conceptual model of end-of-life care and use this model to review the published literature to identify the key goals of optimal end-of-life care and summarize existing barriers to optimal end-of-life care. We then provide examples of process and outcome measures linked to the goals of optimal end-of-life care and domains within the conceptual framework. RESULTS: Within all components of care at the end-of-life--societal attitudes, health care system(s), providers, and patients and their families--there are significant barriers to the quality of care. Some of the most critical barriers to optimal care at the end-of-life in the USA are limited availability, and coverage of, co-ordinated service delivery; poor provider communication and diagnostic skills; limited opportunities for training in palliative care; patient fears and attitudes towards the sick role, and a lack of, or inadequate health insurance. Proposed patient, provider, and system level measures of the quality of care were guided by goals of optimal end-of-life care, and focus on communication about prognosis and risks and benefits of treatment, development of clear and informed treatment goals, delivery of services consistent with treatment goals, and promotion of quality of life. CONCLUSIONS: At present, there are substantial societal, health care system, provider, and patient barriers to obtaining optimal cancer care at the end-of-life. Ongoing discussions about appropriate measures of the quality of end-of-life care are gaining momentum, however. The proposed process and outcome measures for assessing optimal end-of-life care use cancer as a prototype, but are broadly applicable to other patient populations with life-threatening disease.     

Adherence to the dialysis prescription: partnering with patients for improved outcomes.

Nonadherence is common in the U.S. dialysis population. No single strategy has been definitely proven to yield universal and/or lasting improvements in adherence. However, using a patient-centered approach, including the removal of barriers to adherence, ongoing education, and cognitive behavioral strategies, may generate increased opportunities for patients and the nephrology staff to improve both adherence and outcomes.