Medication management in acute mental health settings: A comparison of the views of staff and patien

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Medication management in acute mental
health settings A comparison of the views of
staff and patients

• Dr Joy Duxbury
• Karen Wright

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Aims

• to describe current practice in the
  administration of medication during rounds on an
  acute psychiatric unit
• to identify factors that influence nurses and
  patients when making decisions regarding the
  administration of psychotropic medication.

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Background

• Psychotropic medication is a key component of
  many inpatient mental treatment plans (Haglund et
  al 2004, Higgins 2007)
• Clinical effectiveness of medication within acute
  psychiatry is yet to be established (Geffen et al
  2002, Whicher et al 2003).
• Research examining the quality of acute
  psychiatric inpatient care has identified
  medication management as a focus for much needed
  improvement (SNMAC 1999). ward routine.
• Concerns have been raised about the poor
  assessment of
• patients before and after its
  administration.
• Research has identified that nursing staff have a
  poor knowledge and skill base in this area (Usher
  et al 2001, DH 2002, Richards et al 2007).

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Further research needed in

• decision making
• rationales for choosing to dispense medication,
• factors pertaining to consent
• therapeutic actions enabling the service user to
  take part in treatment decisions,
• information giving
• Usher et al 2003

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Method

• Observation of nurses carrying out medication
  rounds (30) - WAMS
• Semi-structured face-to-face interviews
• Patient Surveys LUNSERS, DAI
• Staff surveys SANTI
• In total 57 service users and 24 qualified
  nurses were recruited from three acute admission
  wards in an inner city hospital in Northern
  England.

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Research questions

• What information do nurses use when making
  decisions about the administration of medication
  to service users?
• What styles of interaction are used in making
  decisions between nursing staff and service
  users?
• How much influence do service users have in the
  making of this decision?
• How do nurses determine the effectiveness of the
  decision made?

• What is the prevalence of side effects within the
  unit?
• What are the service users and nurses attitudes
  towards medication and its management?

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ResultsNurses

• WAMS
• Interviews
• SANTI

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Nurses interviews

• Four themes emerged
• ward environment,
• communication with service users,
• communication with colleagues
• information giving.

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Ward Environment
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We just dont have the time It takes a long
time. Staff get called out of the drug round to
attend to other things. We get distracted all the
time. Hectic, demanding, chaotic- especially
on ward round days Acute wards are very busy
and we will not compromise on medication It
is stressful trying to manage the queue of
impatient patients and checking the cards
properly.
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Communication withservice users
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Have to be careful not to ask private things
when others are there. Being aware of their
vulnerability they may disclose information
whilst others are present. Try to protect them by
saying that you will talk with them after the
round.
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Information Giving

• The patients question us. We lose
  professionalism and integrity if unable to
  respond
• Getting doctors to talk to patients about
  changes in meds as well as nurses.
• I wish the doctors would inform the patients
  more about when they make changes to the
  patients medication. Often the first they know
  is when they come for their meds

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Consent

• Consent can be
• implied, given verbally
• Or written (DOH 2002)
• Implied consent was
• clearly the approach
• relied upon

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Summary

• Nurses have good fundamental therapeutic
  communication skills
• Information giving is seen as important but less
  well embedded in practice
• Collaboration and issues pertaining to consent
  clearly cause a degree of dissonance

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ResultsPatients

• WAMS
• Interviews
• LUNSERS
• DAI

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Service users views

• 4 themes emerged
• therapeutic effects,
• time,
• therapeutic relationships and
• information giving.

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Therapeutic Effects (of medication)
The medication is doing me the world of good

• I think the medication does take the edge off it
  (the stress)

• Calms you down a bit

It helps me to settle down-gives me more
confidence. It helps me to control my thoughts
and slows down my aggression.
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Side effects

• Meds make me sleep more and put weight on
• It doesnt do anything but give me side-effects
• Nothing useful just side effects
• The medication makes it so I dont hear the
  voices any more, but I am getting bad side
  effects as well in that it stops me getting an
  orgasm.

• LUNSERS
• Cognitive effects
• Concentration
• Memory
• Depression
• Physical effects
• Weight gain
• Tired
• Shakes
• Dizzy
• Behavioural effects
• Restlessness
• Difficulty sleeping
• Tension

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I cant concentrate on anything when I am on meds
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I would rather be ill than take medication
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The good things about medication outweigh the bad
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Time
It takes a long time, you end up queuing, you
could wait here until 10.20pm to get your tablets
at night, especially if Im waiting for pain
killers, youre standing up in pain. Its
degrading.
Sometimes its a long time waiting (queuing). It
takes a long time to get medicines especially
when you are feeling desperate.
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Therapeutic Relationship

• Its important he listens to me and finds out my
  personality

I was able to relieve grief, resentment, fear
and anger from my mind by talking to the nurse
giving out medication.

• Patients are not good or well at explaining
  themselves and are fearful of medication time. We
  just cooperate because of past experiences.

The staff are absolutely brilliant and very
sincere
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Information giving
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The biggest difference between a good experience
and a bad is them including me asking my
opinion explaining things to me.
I dont get any information about my tablets.
If I ask they tell me about side-effects
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Implications

• Training
• Confidence
• Power
• Location and procedural issues
• Confidentiality and consent

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Findings

• Nurses felt under pressure to deliver a service
  for which some felt unprepared
• Environment is chaotic and stressful
• Confidentiality is an issue
• Nurses are aware of need to monitor effects and
  side effects but are frequently hard-pressed to
  meet these within the acute environment.
• In the main, most service users were happy with
  the way their medication was administered by the
  nursing staff. BUT TIME A FACTOR
• Some patients felt that improvements could be
  made around the interactions that occurred in
  relation to information giving and side effect
  management.

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And so

• Relationship building is good
• Therapeutic alliance with regards to the
  provision of information may need more attention
• Procedural issues to do with the medication
  round! Take into consideration confidentiality.
• Training may be best aimed at collaboration
  practices and information giving strategies.
• Side effect management and consultation
• Managing consent in the decision making process
• PRN and post round not explored here
• Use of audit tools like WAMS

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• If we tell them they wont take their
• medication!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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Training and education
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Contact

• Dr Joy Duxbury
• University of Central Lancashire
• Preston
• Lancashire
• PR1 2HE
• JDuxbury_at_uclan.ac.uk
• 01772 895110