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] If you would like to advertise in MHN please contact Parminder Sangha on 020 7878 2367 or email at [email protected]
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