(2) - ResearchGate

12
Medicines management
The Medicine with Respect Project (MwR)
Phase 1: implementing a pathway toward
competency in medicine administration for
mental health nurses
Steve Hemingway et al discuss the first two stages of a ‘stepped’ approach to medicines management,
highlighting collaboration between academia and trusts
Steve Hemingway
Senior Lecturer in Mental Health, University of
Huddersfield
Robert Maginnnis
Formerly practice effectiveness manager
South West Yorkshire Partnership Foundation
Trust
Hazel Baxter
Lead for older peoples & learning disabilities
services
Clinical Governance Support Team, South
West Yorkshire Partnership NHS Foundation
Trust
George Smith
Assistant director of nursing education
Leadership and Development, South West
Yorkshire Partnership Foundation Trust
James Turner
Principal lecturer in nursing
Professional lead end of life and supportive
care, Sheffield Hallam University
Jacqueline White
Lecturer – mental health nursing
University teaching fellow, University of Hull
Abstract
This article reports the initial development
and evaluation of stages 1 and 2 of the
‘stepped approach’ to ‘medicines
management’ (MM) and concentrates on the
collaboration between the University of
Huddersfield and South West Yorkshire
Partnership NHS Foundation Trust. A
snapshot of results of a pilot audit of mental
health nurses’ experience who have
completed the assessment of competency is
presented. We identify the impact of resource
issues and overload of student assessment
on the project development. We conclude by
outlining the next steps in the project’s
development and evaluation.
Key words
Medicines management, student, assessment,
collaboration, university, trust, pilot
Reference
Hemingway S, Maginnnis R, Baxter H, Smith
G, Turner J, White J (2010) The Medicine with
Respect Project (MwR) Phase 1: implementing
a pathway toward competency in medicine
administration for mental health nurses Mental
Health Nursing 30(3): 12-16.
Introduction
In the context of the project, ‘medicines
management (MM) is not purely concerned
with the administration of medicines by the
mental health nurse (MHN) (NPC 2002, NMC
2008). It encompasses all of the activity that
addresses the needs of the person who is
prescribed medication, including side-effect
assessment, management and information
exchange (White, 2004). Funded by the
Psychopharmacological Theory (1)
Administration of
Medicines
Competency (2)
Fig.1: Stepped approach to medicine management
Yorkshire and Humber NHS Region, our
project built on work undertaken in 2000 to
support MM within trusts which signed up for
the National In-Patient Practice Development
Network (Norman et al, 2000). Known as
‘Medicines with Respect’ (MwR), this initiative
focussed on registered MHNs in practice,
and sought to demonstrate that MHNs who
are empowered with knowledge and skills to
competently administer psychotropic
medicines, can improve the experience of the
patient who is prescribed medicine (Turner et
al, 2007; 2008). Following recommendations
from the HCC (2007) that staff who work with
medicines in mental health need appropriate
knowledge and training, the Universities of
Huddersfield, Hull and Sheffield Hallam
collaborated with their associated trusts to
develop and support a new education and
training programme to support MM, building
on and redeveloping the original MwR
programme content.
The project steering group agreed the preregistration and preceptorship stages in MHN
development should mirror the first two
stages of the ‘skills escalator’ programme. If
the nurse is to go on to successfully work
Medicines
Management
Module
(Credit rated) (3)
Non-medical
Prescribing
(Credit rated) (4)
13
assessments, but with a similar overall
learning effect anticipated.
Medicines management
Addressing medicine administration competency needs to involve collaboration between
educational and service providers with shared goals and active joint planning.
Implementing a ‘stepped approach’ involves the universities becoming an active member of
the trust orgaisations’ MM strategy, which then invests in turn in student nurse education.
There are resource and organisational issues that need to be addressed by both trusts and
HEIs, so that change can be implemented that does not overburden the structures in place.
Work-based learning strategies can guide HEIs and trust organisations in planning and
implementing shared objectives to achieve outcomes.
competently and confidently in all aspects of
MM, then an appropriate post-graduate
course that furthered knowledge and
expertise was considered the next step
(stage 3). Finally, if the MHN is to make the
transition to prescribing medicines (stage 4)
then the suggested ‘stepped approach’ in Fig
1 would support development along a defined
career pathway.
Psychopharmacological
theory
Student nurses on entering their branch
programme (year 2 of training) are given a
psychopharmacological workbook to
complete, in addition to related lectures and
achievement of portfolio competencies.
Developed in collaboration with nursing and
pharmacy colleagues across the region, the
workbook encompasses questions
addressing the theory of how each individual
medication works and the application of the
principles of pharmacokinetics and
pharmacodynamics to practice. It covers the
spectrum of mental health medicines in use:
acetylcholinersterase inhibitors,
anxiolytics/hypnotics, antidepressants, mood
stabilisers and antipsychotics (oral and
intramuscular), and includes additional
questions related to the role of the nurse in
side-effect assessment and management,
information exchange and rapid
tranquilisation. A range of drug calculations
of increasing levels of complexity are
included for the student to complete.
The aim of the workbook is to prompt
scholarship and enquiry to enable the student
to develop a thorough baseline knowledge of
the medicines they see in clinical practice,
and to build a useful resource to inform their
future practice. It is interesting that some of
the students’ mentors and colleagues from
other disciplines have reported to us that
they have found the questions set in the
workbook both useful and challenging.
Administration of medicines competency
is determined by two assessments.
Assessment of the administration of
medicine competency frameworks (oral
and intramuscular)
These documents use a standard format
utilising evidenced-based, structured criteria,
and aim to minimise the risk of medicine
errors by defining and setting procedures for
safe administration. They have been
developed from the MwR project, updating an
original oral administration framework and
adding an intramuscular one. The two
documents set out four stages integral to the
safe administration of medicine
1. Environmental factors
2. Preparation prior to administration
3. Administering the medication
4. Assessment questions.
This allows the assessor and assessee to
work with the same criteria. The frameworks
have also been identified as a useful tool to
prompt discussion and promote team
development. When used for assessment,
this is carried out by an appropriate clinical
mentor or designated senior practitioner,
typically one who has studied medicines
management as part of their post-registration
development. Two of the universities within
this collaboration are utilising the oral and
intramuscular frameworks as ‘good practice
guides’ rather than for summative
The Observed Structured Clinical
Examination (OSCE)
The OSCE set in the skills laboratory at the
University of Huddersfield has a written
element; a case study with related questions,
which tests the students’ ability to navigate
the British National Formulary, as
appropriate, and calculate the required dose.
Subsequently, the student is then assessed
on their performance in terms of
understanding the medication, adhering to
safe practice and justifying their action in
administering medication from the case study
based on the four stages of the competency
framework (detailed above) in simulated
practice. Conducted in the late second or
early in the third year of pre-registration, the
OSCE is a timely reminder to students of all
the necessary ingredients to safe medicines
practice. Early feedback on the OSCE noted
that student nurses improve their
performance if they fail the first attempt – it
really focuses them towards learning the
framework stages for safe and competent
practice. The assessment is carried out by
university lecturers and senior practitioners,
who work with medicines everyday.
Assessors are either MHNs who work as nonmedical prescribers, in medicine
management clinics or who are clinical
mentors from inpatient wards. This mixture of
university and clinical staff in the OSCE
evaluates well, and is valued and respected
by students. Clinical staff engaged as
assessors in the OSCEs report that their
expertise is being utilised positively towards
the student experience.
Embedding MwR assessments
in the practice and university
contexts
Trust perspectives
The need to develop robust education and
training programmes and competency
checking processes for MHNs who
administer medication is unchallenged.
However, there have been issues for the
trusts and university organisations to
address an initiative such as the MwR
project. In common with the national picture,
the trust has extensive statutory and
14
Medicines management
mandatory training schedules to ensure it
meets national standards for healthcare
provision, and so adding yet another process
for staff to undergo could add to already
stretched resources. As a compromise, the
MwR assessment has only been made
compulsory during preceptorship and for
new starters. There was a slight concern
that the project would not be embraced by
other nursing colleagues. However, in reality,
individual teams have embraced MwR,
demonstrating a commitment by team
leaders and individual nurses to implement
best practice guidelines, as exemplified by
the MwR frameworks and trust medicine
management policy.
A major issue for the project has been
identifying who is competent to assess the
administration of medicines. For example,
can someone who does, or has not
administered medicine for some time, act as
an assessor? Generally, individual teams have
taken a responsible approach and nominated
senior MHN practitioners, who take
responsibility for MM as part of their role, as
the designated MwR assessor. This is in line
with the original MwR project, which had
‘experts’ on each ward to drive the
medication management change agenda
(Baker, Duxbury and Turner 2009). With no
discreet training for MwR assessors, the
problem of inter-rater reliability could be an
issue; despite the assessment documents
being set out in a simple, linear way. To try to
address this, a DVD has been produced to
accompany the assessment frameworks. The
DVD explains the assessment criteria, how to
assess and what to assess, and can be used
collaboratively between the assessor and
assessee prior to embarking upon the
assessment itself.
University perspectives
The need to prepare nurses adequately in
medicine administration is unquestioned and
a priority (DH, 2006). Adding a new and
extensive assessment to an already heavy
academic and clinical assessment schedule
Table 1: Sample characteristics
Work context
Banding
Education
Inpatient 85% (n=17)
Band 5 55% (n=11)
Diploma 45% (n=9)
Community10% (n=2)
Band 6 25% (n=5)
Certificate 15% (n=3)
*NR 5% (n=1)
*NR 20% (n=4)
Degree 5% (n=1)
--------------------------
-------------------------
PG Dip 5% (n=1)
--------------------------
-------------------------
*NR 30% (n=6)
* NR = Non response
required discussions and thorough planning
to embed the OSCE and competency
frameworks in the university curricula. There
were concerns that the student nurses should
not be ‘over-assessed’ compared to students
from other branches of nursing. Initially, the
OSCEs and competency frameworks were
introduced as good practice initiatives in the
university clinical practice module and
assessed formatively. Subsequently, they
have become summative, replacing less
clinically related assessments, and giving
value, focus and academic credit to the
OSCE experience.
Work-based learning
This project’s collaborators understood that
to develop the stepped approach
successfully, a clinically focussed or workbased learning strategy needed to be
adopted. The aims and objectives of the
higher education and trust partners needed
to be agreed. Thus, fitness to practise (or
competence in MM) for the graduate or
practising MHN was the overall objective,
with specific objectives for student nurses
up to the point of registration and beyond.
Work-based learning involves: an increasing
partnership between HEIs and partners;
pathways of learning compatible with the
workplace; and facilitation of engagement in
continuing development (Chalmers et al,
2001). Medicines safety is ‘everybody’s
business’ (DH, 2008) and this project
collaboration starts to demonstrate what can
be achieved when the outcome of learning,
in this case more robust medicines
management, is agreed.
Pilot audit of MwR project
frameworks
A mixed method survey questionnaire was
developed in liaison with the trust’s clinical
governance department, to evaluate the
MHN experience of the oral and IM
assessment frameworks. The 20-item
questionnaire consisted of fixed response
and open-ended questions. This was then
piloted with a small deliberate sample of
MHNs (n=20) and subject to statistical and
content analysis by the governance
department. The results here present a small
snapshot of the overall audit results.
Results
Sample characteristics
The sample consisted of MHNs (n=20). They
were deployed within different care settings,
across clinical grading structures and had
differing post-graduate qualifications. The
majority were from the inpatient setting with
community based. The bandings cover the
practitioner level where medicine
administration occurs. The academic
background of the sample was broad,
reflecting the different educational preregistration experience of the sample. The
significant number of non-responses may be
due to the location of the demographic
Table 2: Types of administration, assessment and timing
Type of administration
Type of assessment
Date of assessment
Oral 85% (n=17)
Oral 90% (n=18)
12-24 months 60% (n=12)
IM 40% (N=8)
IM 20% (N=4)
6-12 months 20% n=4)
-----------------------------------------< 6 months 20% n=4)
15
35%
30%
25%
Preceptorship 2 (25%)
KSF 3 (15%)
20%
Personal
development 7 (35%)
15%
Result of drug
incident 1 (5%)
10%
Identified need for
team 5 (25%)
5%
Other 5 (25%)
0%
Table 3: Why were you assessed?
information at the back of the questionnaire.
The following full audit will include these
questions at the start of the questionnaire.
Types of administration,
assessment and timing
Most of the sample regularly administered
medication. Unsurprising, perhaps, given that
most respondents worked in the inpatient
environment (but still administered IM a
significant amount of times). Subsequently,
the most common method of assessment
was the oral framework. The assessments
were completed for the sample at different
times. In the main audit it will be interesting
to see what the results are for respondent
MHNs who experienced the MwR assessment
at different dates.
Why assessed?
This multi-response question received 27
responses (see table 3). Participants were
assessed for differing reasons. Personal
development rated highly, with others
completing it as part of preceptorship, as a
KSF-identified competency (NHS Knowledge
and Skills Framework), used for team
development; and one specified the reason
being a medication error. Five participants
did not answer the question.
Value of the assessment
Table 4 provides information into what the
participants found useful, with the highest
rating item being the ‘discussion with the
assessor’; perhaps reflecting the meaningful
dialogue that the assessment stimulates.
70%
60%
50%
40%
Environmental 3 (15%)
Preparation 6 (30%)
Administration 7 (35%)
30%
Assessing
questions 8 (40%)
20%
Discussion with
assessor 13 (65%)
10%
0%
Table 4: The Value of the Assessment
Responses noted the usefulness of the
assessment questions, test of knowledge
was the next most useful, with the
administration and preparation parts almost
equally useful. The lowest rated item was
environmental, which perhaps surprisingly
rated lower than other aspects of the
framework. A noisy or distracting
environment can be a major reason why
medication error’s occur (DH, 2004) it will be
interesting to see what the main sample
experiences of the assessment are.
Barriers to safe administration
Table 5 indicates the participants’ reasons why
medication errors may occur. In contrast to the
previous question, which rated the environmental
preparation as the least valued aspect of the
competency assessment, the same sample then
rates this as the biggest barrier to safe
administration. The reasons for this are not
clear, and warrant further investigation.
Complicated documentation and time
management are also something that the
sample identifies as barriers to safe practice.
Pharmacological knowledge and the ability to do
drug calculations are something that is
addressed by the MwR project in the form of
calculation within the workbook and as
appendixes to the oral and IM documents, as
well as universities adopting the ‘Authentic World’
training programme. This is something that is
addressed for mental health nursing students,
but assumes MHNs trained before ‘Authentic
World’ was available are competent with
calculations. It will be interesting to compare
these findings with the local and national data
relating to medicine errors, and to see if there is
a need to extend this part of medicine
management training. Service user adherence
and cultural factors are issues that the MHN
needs to be aware of. Beliefs based on culture
and the perception of medicines need to be
addressed if the nurse is to make administration
of medicines safe and individualised.
Has the Medicines with Respect
programme increased your
confidence in administering your
medication?
This question seemed to indicate that the
MwR assessment was increasing the
confidence of MHNs who had completed the
assessment of competence in medicine
administration. This in turn does not ensure
16
Medicines management
References
70%
Environmental 12 (60%)
60%
Pharmacology 7 (35%)
50%
Complicated
documentation 8 (40%)
40%
Drug
calculations 3 (15%)
30%
Service user
adherence 5 (25%)
20%
Time
management 6 (30%)
10%
Cultural
factors 2 (10%)
0%
Table 5: Barriers to safe administration
Table 6 Confidence
Very Confident
Quite Confident
NR
40% (n=8)
55% (n=11)
5% (n=1)
medicine safety, but is a useful indicator of
the assessment framework’s value.
Conclusion
A full data collection will take place across all
of the participating organisations, and results
and analysis will be reported in the evaluation
of the MwR project, due to be published in
the autumn of this year. The qualified MHN
survey will be followed by an evaluation of
the student experiences of the project. The
experiences of teams who have utilised the
MwR frameworks will be sought via focus
groups. In addition, workshops for each
university and associated trusts will be held
that will present the results from the
evaluation and seek the opinion of the MHNs
who have experienced parts of the
programme, and will also give the
stakeholders a say in what should be the next
steps in the development of the stepped
approach. MHN
Baker J, Duxbury J, Turner J (2009) Key issues for
medicines management in in-patient settings, Chapter
13. In: Harris N, Baker J, Gray, R (2009) Medicines
Management in Mental Health Care. Wiley Blackwell:
223-244.
Chalmers C, Swallow VM, Miller J (2001) Accredicted
work-based learning: an approach for collaboration
between higher education and practice. Nurse
Education Today 21: 597-60.
Department of Health (2004) A scoping study to describe
interventions used to reduce errors in calculation of
drug doses. Available at:
www.publichealth.bham.ac.uk/psrp/pdf/Paediatric%20m
edication%20errors.doc (Accessed on 2 Dec 2009).
Department of Health (2006) From values to action: The
Chief Nursing Officers’ review of mental health
nursing. Available at:
www.dh.gov.uk/en/Publicationsandstatistics/Publicati
ons/PublicationsPolicyAndGuidance/DH_4133839.
Department of Health (2008) Medicines Management:
Everybody’s Business a guide for service users,
carers and health and social care practitioners.
Available at:
www.dh.gov.uk/en/Publicationsandstatistics/Publicati
ons/PublicationsPolicyAndGuidance/DH_082200.
Healthcare Commission (2007) Talking about medicines:
the management of medicines in trusts providing
mental health services. Available at:
www.cqc.org.uk/_db/_documents/Talking_about_med
icines_mht_report_tagged.pdf
NMC (2008) Standards for medicines management.
London: NMC.
Turner J, Gardner B, Staples P, Chapman J (2007)
Medicines with Respect: developing an Integrated
collaborative approach to medication management.
Mental Health Nursing 27(6):16-19.
Turner J, Gardner B, Staples P, and Chapman (2007)
Medicines with respect: developing a collaborative
approach to medication management (2). Mental
Health Nursing 27(1): 11-14.
White J (2004) Medication Management. In: Ryan T,
Pritchard J (Eds) (2004). Good Practice in Adult
Mental Health. London: Jessica Kingsley: 90-107.
Books, CDs, DVDs or websites relevant to mental health nurses
If you have been involved in
the creation of a resource
relevant to mental health
nurses, then why not send it
to your journal for review?
We are interested in all
material that supports the
education, CDP requirements
or practice of mental health
nursing; from reference books
to innovative websites. Don’t
hide your achievements –
share them with your
colleagues!
To discuss a resource review,
contact the journal editor:
[email protected]ocom
If you would like to advertise in MHN
please contact Parminder Sangha on
020 7878 2367
or email at [email protected]