Patients and their Use of Medicines: a Discourse Analysis of Encounters with Nurse Prescribers

Abstract

Patients’ use of medicines is widely recognised as sub-optimal with a high proportion of patients with a long-term condition not taking their medicines as prescribed. Research and policy guidance emphasise the importance of partnership within the patient-prescriber encounter in enhancing patients’ use of medicines. There is however considerable evidence that this is not usually achieved by medical prescribers, limiting the extent to which shared decision-making occurs about prescribed medicines. There is a general assumption that nurse prescribers, who within the United Kingdom have comparable prescribing rights to medical doctors, demonstrate greater abilities in collaborative working with patients leading to an enhanced use of medicines. Research evidence is however limited, particularly in relation to the ways in which patients’ use of medicines is discussed and negotiated within the patient-nurse prescriber encounter. This study focused on the management of patients’ use of medicines within the patient-nurse prescriber encounter. Seven nurse prescribers, working within a number of clinical specialities in both primary and secondary care settings, were recruited to the study together with their patients who were living with one or more long-term conditions (n=21). Data collection involved the non-participant observation of out-patient consultations to examine the management of patients’ use of medicines within the encounter and semi-structured interviews with both patients and prescribers. Discourse analysis was undertaken to examine underpinning assumptions, views and beliefs regarding the management of patients’ use of medicines. Asymmetry was evident within the encounters with prescribers controlling the agenda for discussion and interrupting patients’ attempts to demonstrate their knowledge. Patient accounts of the moral approach adopted in managing their condition in the context of their everyday lives were also ignored. Biomedical and contrasting moral discourses are examined. An interpretive framework derived from the work of Michel Foucault is used to explain the operation of disciplinary, pastoral and bio-political power within the encounter and the extent to which subjugation of patients’ knowledge and resistance were evident. Foucault’s concept of technologies of the self is examined to explore its potential application in enhancing patients’ medicines use.