Health Education / Promotion & Concordance (including ideal medications before discharge i.e. follow-up treatment.)

1. Health Education / Promotion& Concordance(including ideal medications before discharge i.e. follow-up treatment.) EBL Group 1 Carol, Marina, Sophia & Wendy

2. Compliance or Concordance? • Compliance relates to how a patient is expected to conform with advice and treatment given by the health professional (i.e. Do what they are told!). This puts a greater responsibility for recovery onto the patient.

3. Concordance incorporates a partnership between the patient and health professional. An agreement is reached regarding treatment taking into consideration the patient’s personal circumstances and allowing for a holistic assessment of the patient’s needs. The success of treatment is therefore shared between the patient and health professional.

4. Concordance in relation to ethical principles • Concordance allows a greater respect for patient autonomy and enables the patient to make informed decisions about their care and treatment. It values the patient’s perspective and acknowledges the impact of treatment on quality of life. Patients will be more likely to be concordant if they are involved in shared decision making.

5. Concordance with asthma medication. • Asthma cannot be cured but can be controlled well with the right treatment. • 5.2 million people have asthma in the UK. Of these more than half do not have adequate symptom control (Asthma UK 2004). • 500,000 people have asthma that is difficult to control with available medication and are thought to be resistant to corticosteroids. • For 2.1 million people, asthma is poorly controlled for other reasons, including non-concordance with medication.

6. Concordance with asthma medication: the nurse’s role. • Non-concordance with asthma medication may be explained by an unwillingness to take asthma medication and patients not knowing the most effective way to take it. • Other factors include: • Lack of information • Lack of understanding about the condition • Concern about the side effects of medication • Difficulty using the devices • Feeling well and thinking they do not need or can manage without their medication.

7. Long term daily peak flow monitoring is helpful in managing patients with moderate or severe persistent asthma in evaluating responses to changes in therapy. • Difficulty in maintaining adherence to monitoring is often due to inconvenience, lack of required level of motivation or lack of a specific treatment plan based on peak flow.

8. For many of the 5.2 million people with asthma in the UK, daily medication is essential. Nearly half of people with asthma who have to pay for their prescriptions find it difficult to afford them. (other long-term conditions such as diabetes and epilepsy are exempted from charges) Patient’s are often forced to make life threatening decisions to not take medication leading to poor management which can in turn lead to unscheduled emergency hospital visits (National Asthma Campaign).

9. A government -commissioned study by the Medicines Partnership has suggested that poor knowledge of how drugs and inhalers work, coupled with complex prescribing regimes, are contributory factors in up to half of the 1,400 fatal cases of asthma in the UK each year.

10. An estimated 1.5 million people with asthma follow their prescriptions only a third of the time. • Among people with asthma, the most typical example of non-compliance is under-use of preventer medication, which can lead to over-use of reliever inhalers and in some cases asthma attacks and emergency hospital admissions.

11. The most common reasons for not following guidelines are people not understanding their condition or their treatment, forgetting to take medicines or being in denial that they have asthma. Patients may also neglect their medication because they fear side-effects, because they have to take frequent doses or because treating their asthma involves several types of medicines.

12. Triggers • Scullion J. (2005) A proactive approach to asthma. Nursing Standard 20 (9) p.57-65

13. Trigger avoidance • Trigger factors can be allergic in nature or act as irritants on inflamed airways. • Any factors that induce asthma symptoms should be avoided whenever possible to help prevent exacerbations and reduce the level of medication needed to maintain good asthma control.

14. Trigger avoidance • House dust mites - the concentration of house mites can be reduced by regular vaccuming, the use of allergen covers for bedding and washing duvets and pillows every 1 or 2 months. • Pet allergens - patients who are allergic to their pets should be advised to remove the animal if possible. If the pet remains in the home, it should be kept out of the bedroom and off soft furnishings. The removal of carpets can reduce allergen concentrations.

15. Pollen - Difficult to avoid. Avoidance measures can include using pollen filters in cars, not walking in open grassy spaces especially during the evening, wearing sunglasses (reduces eye symptoms), staying indoors with the windows shut when pollen levels are high. • Moulds and fungal spores - present in the air in late summer and autumn. They are associated with damp areas (poor housing) and areas of high humidity such as bathrooms. Mould growth should be cleaned away regularly.

16. Drugs - (Aspirin, NSAID’s, Beta blockers) - These should be avoided in patients with asthma. Non-selective beta blockers can induce acute bronchospasm even when administered as eye drops. NSAID’s and aspirin have been known to induce sudden, severe, life threatening bronchospasm. • Upper respiratory tract infections - even a mild cold can worsen asthma symptoms. Patients should be advised to monitor their asthma carefully at the first sign of a cold and increase their treatment accordingly.

17. Exercise - This may trigger asthma symptoms. However, patients with asthma should be advised to participate in exercise. Preventative action prior to starting exercise (e.g. use of a bronchodilator) will help to prevent exacerbations. • Occupational triggers - Symptoms may improve during days away from work or while on holiday. This suggests occupational asthma and indicates the need for further investigation with objective measurements.

18. Patient Education • To truly deliver patient centered care, nurses must work in partnership with patients to motivate and enable their patients to understand the rewards that can be gained in terms of improvement of quality of life (National Asthma Campaign 2000). • It is appropriate to say that in general, patients do wish to improve their quality of life. However, they may be unable to see the link between ‘compliance’ with medication and subsequent improvements in their own health status.

19. Past studies have shown that acute asthma attacks are less likely to occur in those patients who have a greater awareness of their disease and the importance of compliance. • Specific patient education tailored to each individual is vital if patients are to receive maximum therapeutic benefits.

20. Health professionals need to understand and address the patient’s own health beliefs with an open mind: choosing the most appropriate medication and delivery systems that the patient is comfortable with. • Treatment regimes should suit patients where possible and include regular follow-ups where additional support and advice can be given. • It is widely accepted that the education of patients is of paramount importance in all facets of asthma care. Patients need to understand the nature of the disease itself, the treatments involved to control and relieve the symptoms as well as how patients themselves can adopt self-management strategies.

21. Asthma education and the self-management approach offers a wide range of benefits including reduction in asthma symptoms and exacerbations, less need for steroid tablets, better compliance with prescribed treatment and a better quality of life. • The nurse/patient relationship is critical in promoting concordance with medication. • Sufficient time to communicate effectively and listen to patient’s needs and concerns should be allocated to ensure that the most effective devices are selected.

22. Education for a partnership in asthma care • Teach and reinforce at every opportunity: • Basic facts about asthma • Roles of medications • Skills: inhaler/spacer/holding chamber use, self monitoring • Environmental control measures • When and how to take rescue actions • Teach asthma self-management, tailoring the approach to the needs of each patient. Maintain a sensitivity to cultural beliefs and practices.

23. Encourage adherence by promoting open communication: individualizing, reviewing and adjusting plans as needed: emphasising goals and outcomes; and encouraging family involvement.

24. Educating patients about prevention is just as important as good asthma control. • Appropriate language is essential: to facilitate a patient centered approach the BTS recommends asking open ended questions such as ‘if we could make one thing better for your asthma, what would it be?’ • This approach emphasises working with the patients on their terms and acknowledges the importance of the consultative process.

25. Principles of Patient Education • Assess existing beliefs, theories and knowledge. • Assess learning needs. • Set learning objectives based on mutually agreed goals. • Assess readiness to learn. • Break down information or practical skills into components and explain or demonstrate these in stages, consistent with the patients rate of learning.

26. Avoid technical jargon in explanations and information giving. • Ensure advice is relevant and realistic. • Consider the sequencing and timing of the education. • Allow opportunities for clarification of information, practice and repetition of points and skills. • Use printed instructions to reinforce verbal information. • Allow opportunities for evaluating learning that has taken place. • Provide feedback to the patient.

27. Medication for Discharge • Prior to discharge, the medication should be adjusted to an oral and / or inhaled regimen. • Discharge medications should include a short acting inhaled beta 2 agonist (Salbutamol) and sufficient oral corticosteroids to complete the course of therapy or to continue therapy until the follow-up appointment. If inhaled corticosteroids are prescribed, they should be started before the course of oral corticosteroids is completed because their onset of action is gradual. • Referral to an asthma specialist should be considered for patients with a history of life threatening exacerbations or multiple hospitalizations (Simon Hope).

28. Preventative Medication • Beclometasone - Inhaled corticosteroid or nasal spray (to prevent or treat rhinitis). • Becotide - inhaled corticosteroid • Ciclesonide - a recently introduced inhaled steroid. At present there is insufficient evidence to compare with other steroid inhalers.

29. Inhalers • The best type of inhaler for the patient is the one that the patient can and will use. • The best inhaler device depends upon: • Convenience • Age • Co-ordination • Side-effects

30. Inhalers • Reliever inhalers • Preventer inhalers

31. Inhaler devices • Pressurised Metered Dose Inhalers (MDI) • Inhalers with spacer devices • Dry powder inhalers • Nebulisers

32. References • Caress, A. (2003) Giving information to patients. Nursing Standard. 17 (43) p.47-54. • Carroll, K. (2005) Ensuring appropriate care for patients with asthma. Emergency Nurse. 13 (4) p.26-31. • Davies-Gray, M. (2000) The health psychology of asthma. Emergency Nurse. 8 (2) p.10-17. • Hobden, A. (2006) Concordance: a widely used term, but what does it mean? British Journal of Community Nursing. 11 (6) p.257-60. • Hobden, A. (2006) Strategies to promote concordance within consultations. British Journal of Community Nursing. 11 (7) p.286-289. • Hunter, S. (2002) Asthma - the next steps. Journal of Community Nursing. 16 (2) p.4-8.

33. National Asthma Education and Prevention Program. Clinical Practice Guidelines. Guidelines for the diagnosis and management of asthma. [online] available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. [accessed 06 Feb 2006] • Newell, K. (2006) Concordance with asthma medication: the nurse’s role. Nursing Standard. 20 (26) p.31-3. • O’Connor, B. (2001) Inhaler devices: compliance with steroid therapy. Nursing Standard. 15 (48) p.40-42. • Roberts, J. (2002) The management of poorly controlled asthma. Nursing Standard. 16 (21) p.45-51. • Ryan, D. (2002) Asthma nurses: where do we go from here? Primary Health Care. 12 (7). P.27-31.

34. Scullion, J. (2005) A proactive approach to asthma. Nursing Standard. 20 (9) p.57-65. • Snelgrove, S. (2006) Factors contributing to poor concordance in health care. Nursing Times. 102 (2) p.28-30.