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Get a grip on glaucoma!
A group based patient education programme to improve
adherence to glaucoma eye drops
Heather Waterman
Professor of Nursing & Ophthalmology
Jane Mottershead
Glaucoma Specialist Nurse
Glaucoma
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Glaucoma is progressive and incurable
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Treatable – medications for life
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Glaucoma is the leading cause of permanent blindness and partial sightedness worldwide
(Quigley & Broman 2006)
Adherence
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Poor adherence highly prevalent in chronic asymptomatic disease such as glaucoma
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Poor adherence can result in –
• disease progression → visual loss → Quality
• additional medications
• surgery
• more hospital appointments
• Increased costs
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of Life
Education and behaviour change interventions have been shown to improve adherence
behaviour
Olthoff et al 2005; Sleath et al 2009; Hoevenaars et al 2008; Chen, Chen, Sun 2009
The evidence…
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Previous study showed :
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Minimal nursing input within the MREH OPD
Patients lack of knowledge about glaucoma
Poor rates of adherence to ocular hypotensive medication
(Gray TA, Fenerty C, Harper R, Lee A, Spencer F,Campbell M, Henson DB, Waterman H. (2009)
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Comparable findings with other published research about patient knowledge and
adherence to long term medications
The research study
Action research study
Close collaboration between patients, researchers & clinicians
May 2009 - 2011
1. To investigate the mode of delivery,
content & duration, patient health education
needs, adherence
Aims
2. To pilot the group education
programme, to test its
feasibility & acceptability
Long term vision – to carry out a full RCT & roll
the programme out across the country if results
favourable
The study overview
Aim 1 - Qualitative research
• 27 patients with glaucoma
• Face to face qualitative interviews to identify patients’ health education needs
Aim 2 – Before and after evaluation
• 25 patients – 2 groups
• Interviews immediately after & 3 months
• Questionnaires – knowledge, illness perception, empowered, health beliefs
• pre & post (immediately after & 3 months) educational intervention
• M.E.M.S – medication event monitoring system to look at daily adherence patterns
Educational needs identified through
listening to patients
‘…after that I was never
‘you read books
about it and it’ll
scare the life out of
you’ Pt 10
‘I think my
biggest fear was
actually putting
drops in my eyes’
Pt 03
‘I just said the drug was no
good…I wasn’t using it, but if I
had enough information, I would
be using that drug, even if my
eyes are reddish’ Pt 13
‘He said ‘…your pressure’s 17’ which
didn’t particularly mean a lot to me at
the time. [if] you haven’t a clue about
the subject…you’ve no sensible
questions’ Pt 11
really officially diagnosed…
nobody actually sat down and
explained to me what I had
and why I had it’ Pt 04
‘I was reluctant, I don’t do very
well with drugs. I’m a bit
suspicious of them. I mean
they’ve got to do their business
and they’ve obviously got to be
toxic .... But, err, yeah, I... I just
don’t do medicines’ Pt 07
‘…they didn’t warn me about the
dangers, they did not warn me
about …what the glaucoma…does
to you, I’ve got glaucoma and
that’s it’ Pt 15
9 patient educational needs identified
1. To understand glaucoma
2. To understand their diagnosis/understand difficulties in giving a diagnosis
3. To understand the implications of eye drops, eye drop side effects & how to renew eye
drops
4. To feel confident in putting eye drops in
5. To put condition into perspective
6. To feel confident asking questions of clinicians
7. To be able to navigate the healthcare system
8. To understand & manage their own adherence behaviour
9. To be able to access other information sources
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Patients’ opinions re group based education
Group based education
Patient opinions..
2 ½ hours
2 sessions
1 week apart
Programme run twice 2 groups of patients
Group based education
Programme content planned in response to listening to
patients
Session 1
•Group discussion: patient stories
•Professional narrative:
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A&P of the eye
Glaucoma
Eye drops
•Practical workshop
•Adherence planning:
• Understanding and planning own
adherence
• Self management plan
•Information sources & contact details
Group based education
Session 2
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Feedback of action plans
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What to expect at an eye clinic
appointment?
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Confidence building/asking
questions
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Advice on DVLA
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Lifestyle advice
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Evaluation
Reflections on the session
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Liked the models and the A&P section
Practical sessions: patients liked been shown self instillation techniques or being
reassured that they were doing it right
Sorted out incorrect prescriptions 1-2 per group.
Worries about the DVLA for newly diagnosed
Voiced different reasons for non-adherence
None of the patients liked asking questions in clinic
Lifestyle section patients really liked this
Listened to others’ experiences
Younger people had googled glaucoma but not necessarily the right information
Post course participant evaluation
- The education programme was very well received
‘…it turned out to be very
useful indeed in that he can
now put in his own eye drops
and I don’t have to worry
about being back home to do
it’ GB08’s carer
‘…liked the fact that they told
us, when you go to clinic, don’t
be afraid to ask questions…so
when I go next time I shall be
firing all the questions
(laughs)…GB01
‘I thought the course was
fantastic…didn’t expect to
learn as much as I did’
‘Jane was an excellent
teacher…very good at
imparting knowledge’.
GB14
‘Every single person
with glaucoma should
be made to go on this
course…it’s brilliant’
GB20
‘Now I realise how little I
knew about my own illness’
2013
‘Not only enjoyable but
educational as well. I
have learnt loads’ 2013
Results
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We compared
• Perceptions of glaucoma as an illness
• Feelings of being enabled to look after their eyes
• Beliefs about glaucoma medicines
• Quality of life
• Knowledge of glaucoma
• Daily percent adherence
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Results demonstrate significant improvement in:
• Illness perception
• Empowerment
• Health & wellbeing
• Knowledge of glaucoma
most of which was maintained at the three month time point
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M.E.M.S - Mean percentage adherence was maintained at nearly 90% adherent for
group one over time, 75% in group two, but only 30% for those who didnt attend the
educational intervention.
In conclusion…
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Patients need not only information but also motivation & skills
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Patient participation leading to evidence based clinical practice
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Group based education shows promise in glaucoma - Majority of patients liked group
based education finding it a positive experience
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BUT strategies to improve adherence need to be individualised
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Implementation of this programme redresses the balance of power between patients &
clinicians towards partnership in care
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It empowers patients and builds confidence in self management of their disease
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Implementing at other hospitals
Since the trial….
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The programme is still running
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Each session is evaluated to ensure that patients opinions are consistently sought
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The programme is adapted as necessary based on the evaluations to ensure that
patients needs and wishes are considered and respected.
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Evaluations continue to be positive
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Changing the way we recruit patients to ensure increased attendance
Acknowledgements
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Patients at the MREH
Staff at MREH, David Henson, Cecilia Fenerty, Fiona Spencer
Staff at University of Manchester School of Nursing, Midwifery and Social Work: Nicky
Olleveant, Mark Pilling, Cliff Richardson
Burdett Trust for Nursing for funding the study
Moving towards a partnership model of
care
How could you listen to your patients?
How could you respond to your patients to develop a more enhanced
partnership model of care?
What barriers do you anticipate in changing care?
How would you overcome these barriers?