Despite advances in treatments for hypertension (HTN) over the past three decades, poorly controlled blood pressure (BP) remains a significant public health problem in the United States. Evidence-based care of patients with uncontrolled HTN requires collaboration of healthcare providers, patients, and the healthcare system within which the care occurs?in order for patients to achieve a full understanding of their disease, and to be adherent to medications that are needed to reduce elevated BP. While studies have consistently documented the beneficial effects of collaborative patient?physician relationships on improvements in medication adherence and attainment of disease control among patients with chronic diseases such as HTN, 40% of primary care visits do not include discussions about medication adherence, irrespective of patients' disease control status. When these conversations do occur, primary care physicians spend an average of 5% of the interaction discussing medications. As the largest segment of the healthcare workforce, nurses are integral members of the care team and thus, well poised to assist with critical tasks such as counseling for medication adherence. While interventions have targeted nurses' communication skills for patient adherence, they have not consistently led to improvements in nurse or patient-level outcomes. A major limitation has been the use of brief workshop-based interventions that include limited opportunity for nurses to practice the newly learned skills and the failure to integrate the new role into their daily work. The proposed study provides an opportunity to address this gap in the literature, and is a logical extension of Dr. Schoenthaler's excellent research trajectory focused on patient-provider communication and medication adherence, and builds on pilot data from Dr. Schoenthaler's K23 Career Development Award. Based on her findings, the current application will partner with clinic nurses as the primary target for a communication intervention in order to support primary care physicians in assessing and addressing barriers to medication adherence. Specifically, this proposal will utilize a three-phase approach that is informed by a theory-driven implementation framework to: 1) conduct a needs analysis in order to identify individual-, health care team-, and practice-level barriers and facilitators to conducting adherence counseling in safety-net primary care practices; 2) develop a virtual communication simulation designed to improve the quality of adherence counseling by allowing nurses repeated opportunities to practice discussing medication adherence with virtual patients; and 3) conduct a pilot study to evaluate the feasibility, acceptability and preliminary efficacy of the simulation on changes in: a) nurses' collaborative communication skills, b) medication adherence, and c) reduction in BP in a sample of 20 patients with uncontrolled HTN who are non-adherent to their medications.
Despite evidence of the importance of collaborative patient-provider communication for improving medication adherence among patients with hypertension (HTN), less than half of primary care physicians (PCPs) report routinely discussing patients' adherence. Given their education and training, nurses are ideally positioned to help PCPs increase the frequency and quality of adherence counseling in order to optimize care and improve outcomes in patients with poorly controlled HTN; yet interventions targeting nurse communication skills for patient adherence have not consistently led to improvements in nurse or patient-level outcomes. Innovative and potentially sustainable approaches that can be integrated within the culture of the clinic and incorporate repeated opportunities for practice and ongoing feedback will provide a needed approach to improve nurses' communication skills and address the pervasive problem of patient non- adherence in the primary care setting.
