Improving mental health service users' physical health through medication monitoring: a literature review

nash m . (2011) Journal of Nursing Management  19, 360–365
Improving mental health service users’ physical health through medication monitoring: a literature review Aim To explore the importance of improving physical health in mental health service users through medication monitoring. Background Mental health service users’ physical health is frequently poor, although many have contact with health-care services. Adverse drug reactions are a unique risk factor for poor physical health. However, medication monitoring remains inconsistent. Evaluation A literature review was conducted using search terms: medication monitoring, adverse drug reactions, physical health/illness, mental health/psychiatric nursing. Databases searched included PsychINFO, Pubmed, CINHAL and the British Nursing Index. Key issue Structured medication monitoring is required to enhance physical health and reduce the risk of adverse events. Implications for nursing management Nurse managers should promote a culture of evidence-based practice in medication monitoring. Practitioner learning needs and competencies should be assessed to provide relevant education and skills training. Conclusion Nurse managers require strategic leadership to transform practice and enhance mental health service users’ physical health through medication monitoring. Good practice guidelines should be implemented to improve quality of care and reduce the risk of adverse events. Addition to current knowledge This paper illustrates the importance of medication monitoring in improving physical health.     

Managing adverse drug reactions: an orphan task

BACKGROUND: Nurse prescribing initiatives have potential to impact on medication management for long-term conditions. Over time, the adverse effects of medications become increasingly onerous. This 'side-effect burden' is particularly heavy for users of antipsychotic medication. Although consensus exists that strategies are needed to alleviate these problems, currently, they are not clearly the responsibility of any one professional group. AIM: This paper explores the introduction of nurse-administered evaluation checklists, in relation to nurse prescribing initiatives and division of professional responsibilities for medication management. METHODS: This was an observation study, with a quasi-experimental comparator group design, undertaken with clients receiving long-term antipsychotic medication. In both intervention and comparator groups, before and after introduction of evaluation checklists in the intervention group, 20 nurse-client interactions were observed. Problems actioned by the nurses, with and without the checklists, were compared. Stakeholders' views were sought concurrently. FINDINGS: Implementation of evaluation checklists increased the numbers of adverse effects detected and actioned by nurses. They also served to apportion aspects of medication management between nurses and medical prescribers. Most actions taken by nurses to alleviate adverse effects concerned clients' physical health and advice on health-promotion. However, the nurses' interventions would have been more effective had they been able to supply clients with certain medicines either by prescribing from the Nurse Prescribers' Formulary or issuing under Patient Group Directions. For some clients, ameliorating the adverse effects of medication would have involved changes to prescribed antipsychotic medication; here decisions were more equivocal. IMPLICATIONS: The identification of previously unattended problems, together with the views of service users, suggests that empowering nurses to address the 'care gaps' in medication management may benefit service users. The 'checklist evaluation' approach warrants further investigation, ideally in conjunction with nurse prescribing initiatives.     

Assessing educational effectiveness: the impact of a specialist course on the delivery of care

An exploratory study was undertaken in South Wales to assess the changes in clinical practice brought about by a specialized pharmacology module designed for Community Mental Health Nurses (CMHNs), in our institution. The respondents were the seven CMHNs who completed the course in 1997 and returned to clinical practice, and seven CMHN comparators, matched on the basis of work experience and location. In order to assess the impact of the module, the practice, attitudes and knowledge of the respondents were investigated before and after the course and 6 months later, using semistructured interviews, nonparticipant observation and questionnaires. The three data sets were analysed using the constant-comparative method, and relevant themes were identified and refined. While we obtained some objective measures of positive educational impact, these should be considered in relation to contextual and confounding variables. Both reported and observed behaviours indicated that the main benefit from the course was increased awareness and monitoring of the side-effects of medication. Respondents had not implemented change uniformly; several factors determined how they modified working practices, including service pressures and the support of colleagues.     

Adverse drug reactions: treatment burdens and nurse-led medication monitoring

Gabe M.E., Davies G.A., Murphy F., Davies M., Johnstone L. & Jordan S. (2011) Journal of Nursing Management  19, 377–392
Adverse drug reactions: treatment burdens and nurse-led medication monitoring Aim This paper focuses on adverse drug reactions and the potential for introduction of nurse-led medication monitoring. Background The prevention of patient harm caused by health-care organizations was accorded international priority over a decade ago, yet adverse drug reactions remain a significant treatment burden to patients. Evaluation This paper reviews the literature to summarize existing knowledge and understand treatment burdens associated with adverse drug reactions. Key issues While epidemiological studies explore the magnitude and complex nature of adverse incidents in health-care organizations, the monitoring of prescribed medications and their adverse effects remains an area of concern. Nurse-led medication monitoring has been highlighted as an initiative to minimize unnecessary drug-related patient harm. Conclusion This paper indicates that nurses are well-placed to monitor and reduce drug-related morbidity, and builds upon previous work which prioritizes the monitoring of prescribed medicine in a nurse-led adverse drug reaction profile. Implications for nursing management Nurse-led medication monitoring presents a unique opportunity to curtail unnecessary treatment burdens. However, important considerations including, patients’ and professionals’ time, added paperwork, nurse education and training and inter-professional communication need to be explored. Further work is now needed to establish the clinical gains and patient outcomes of nurse-led medication monitoring.     

Patients' knowledge and perceptions of the side-effects of OTC medication

OBJECTIVE: To investigate the knowledge of patients with regard to the side-effects of over-the-counter medicines. METHOD: This took the form of ethnographic interviews and focus groups. RESULTS: Patients generally had poor knowledge of the potential side-effects of their medication. However, this appeared not to affect their ability to identify adverse drug reactions (ADRs). A number of the patients had experienced ADRs, and they identified a medicine as the cause because of the timing or unexpected nature of the symptom. The patients obtained information about medicines from many sources, including health care professionals, friends and family. Despite wide availability, patient information leaflets were rarely used by the patients. The leaflets were usually only read if the medicine was new or if a side-effect was experienced. Negative views of the leaflets included poor design and long lists of side-effects. CONCLUSION: Accurate information and advice from health care professionals could serve to reassure patients and to ensure they are well informed about the medicines they take.     

A patient's perspective: the impact of adverse drug reactions on patients and their views on reporting

What is known and objective: Adverse drug reactions to prescribed medication are relatively common events. However, the impact such reactions have on patients and their attitude to reporting such events have only been poorly explored. Previous studies relying on self‐reporting patients indicate that altruism is an important factor. In the United Kingdom, patient reporting started in 2005; though, numbers of serious reports remain low. Method: A purposive sample of fifteen patients who had been admitted to an inner city hospital with an adverse drug reaction were interviewed using a semi‐structured questionnaire. Patients were asked to relate in their own words their experience of an adverse drug reaction. Patient’s reactions to the information leaflet, adherence to treatment and use of other sources of information on medication were assessed. Interviews were recorded, and a thematic analysis of patients’ responses was performed. Results and discussion: Analysis of the patient interviews demonstrated the reality of being admitted to hospital is often a frightening process with a significant emotional cost. Anger, isolation, resentment and blame were common factors, particularly when medicines had been prescribed for acute conditions. For patients with chronic conditions, a more phlegmatic approach was seen especially with conditions with a strong support networks. Patients felt that communication and information should have been more readily available from the health care professional who prescribed the medication, although few had read the patient information leaflet. Only a minority of patients linked the medication they had taken to the adverse event, although some had received false reassurance that the drug was not related to their illness creating additional barriers. In contrast to previous studies, many patients felt that adverse drug reporting was not their concern, particularly as they obtained little direct benefit from it. The majority of patients were unaware of the Yellow Card Scheme in the UK for patient reporting. Even when explained, the scheme was felt too cold and impersonal and not a patient’s ‘job’. What is new and conclusion: Patients having a severe adverse drug reaction following an acute illness felt negative emotions towards their health care provider. Those with a chronic condition rationalized the event and coped better with its impact. Neither group felt that reporting the adverse reaction was their responsibility. Encouraging patients to report remains important but expecting patients to report solely for altruistic purposes may be unrealistic.     

Assessing clinicians' perspectives about the identification and management of antipsychotic medication side‐effects: Psychometric evaluation of a survey questionnaire

Eliciting clinicians' views about antipsychotic medication side‐effects may assist in understanding strategies that could enhance the identification and management of these side‐effects. The present paper details the development and psychometric evaluation of a questionnaire that captures clinicians' perceptions about these issues. An initial item set was derived from a literature review, and then refined by an expert content validity panel that assessed the relevance of the items. The online questionnaire was distributed to Australian mental health nurses and 140 fully completed questionnaires were returned. Principal components analysis yielded two robust scales that conceptually tapped “system responsibility” and “personal confidence”. These scales may be used to advance knowledge about how mental health nurses' attitudes towards the assessment and management of antipsychotic medication side‐effects influences their clinical behaviour.     

Adverse drug reactions: managing the risk

Aim  This study aims to assess the need to formalize medication monitoring strategies in electronic records in two crisis resolution home treatment (CRHT) teams in one UK NHS Trust.
Background  The management and monitoring of prescribed medications has long been a cause for concern. As a result of the potential adverse drug reactions associated with commonly prescribed medication, clients of mental health teams are vulnerable to iatrogenic risk linked to physical health problems.
Method  Electronic records for all clients receiving care in two CHRT teams in one UK mental health Trust in November 2007 were examined for evidence of monitoring for potential adverse drug reactions. Findings were compared with the sample of paper records submitted to a national audit.
Results  Electronic records omitted important aspects of medication monitoring, for example: 14 out of 57 clients had blood pressure recorded; 15 out of 57 had heart rate recorded; 13 out of 57 had weight recorded. However, the teams' paper records were significantly better than both the electronic records and a national audit sample at recording blood pressure and obesity. We found few differences between our two teams.
Conclusions  The format of our electronic records requires modification to ensure that systems are in place to document adverse drug reactions and the physical health of those with mental illness.
Implications for nursing management  The transition to electronic records needs to be carefully managed to ensure that information on adverse drug reactions is included. The West Wales Adverse Drug Reaction profile, version II, is one strategy to achieve this in mental health.     

Factors influencing the effectiveness of clinical supervision

Clinical supervision is widely accepted as an essential prerequisite for high quality nursing care. This paper reports findings from a study that aims to identify the factors that may influence the effectiveness of clinical supervision for community mental health nurses (CMHNs) in Wales, UK. Two hundred and sixty (32%) CMHNs from an estimated total population of 817 completed the Manchester Clinical Supervision Scale (MCCS) and a demographic questionnaire. The MCCS is a 36-item questionnaire measuring the quality and effectiveness of the supervision received. Three-quarters of CMHNs reported having participated in six or more sessions of supervision in their current posts. Clinical supervision was more positively evaluated where sessions lasted for over one hour, and took place on at least a once-monthly basis. Perceived quality of supervision was also higher for those nurses who had chosen their supervisors, and where sessions took place away from the workplace. These findings have important implications for the organization and delivery of mental health nursing services.     

Development of a group model of clinical supervision to meet the needs of a community mental health nursing team

Clinical supervision is an important tool in the development of quality nursing care. It involves a process of reflection upon practice, the aim of which is to improve clinical practices and hence improve patient outcomes. The term 'clinical supervision' is itself problematic in that it implies an hierarchical, rather than a nurse-centred and reflective, process. In addition there are a variety of models of supervision which range from the purely managerial to the clinical. This gives rise to confusion and in some cases suspicion, in clinicians. This paper reports on the development, implementation and evaluation of a group model of clinical supervision developed by a small team of mental health nurses in a community mental health setting. This team recognised the need for a formal clinical supervision model but was unsure as to the model which best suited their practice situation and needs. Through collaboration with a university department of nursing, this group developed its own model of group clinical supervision. This paper reports on the development of the model and its evaluation. The model was developed with a small team of community nurses and hence may not be applicable to other teams and other settings. However, the methods described may be useful as a guide to other nurses who wish to plan, implement and evaluate a model of clinical supervision in their workplace.     

Changing the mental health nursing culture: the nursing clinical development unit approach

Developments in nursing as a profession have been accompanied by a perceived need to increase the relevance of research to nursing practice. The increased exposure to research in nursing curricula and the development of nursing academia has had little impact on either the conduct of clinical research or its utilization within the work place culture. Nursing Clinical Development Units (NCDU) were established with the view to overcoming some of these barriers through partnerships between academia and the clinical field. The aim of NCDU is to strive for improved patient outcomes. Education and research activities should be directed to achieve this patient-orientated outcome. The aim of this paper is to describe the NCDU program introduced by the Centre for Psychiatric Nursing Research and Practice (CPNRP) in Melbourne, Victoria. The way in which the program is designed to facilitate the relationship between CPNRP and the clinical field with the aim of contributing to improved patient outcomes will be emphasized. An evaluation of the program to date suggests that such links will be strengthened, and that this partnership will contribute to a greater involvement in clinically based research.     

临床药师在呼吸科开展药学服务的实践与体会

目的介绍我院临床药师在呼吸科开展药学服务的工作模式,探讨专科临床药师如何更好地参与临床治疗、促进合理用药。方法通过列举部分药学服务实例,总结临床药师在呼吸科开展药学服务的方式与经验。结果临床药师通过参与药物治疗方案的制订或优化、解答医护人员的用药疑问、对患者进行用药教育、关注药品不良反应及药物相互作用等方式服务于临床,对合理用药起到积极的促进作用。结论临床药师要根据所在专科的特点,明确进行药学服务的切入点,并不断提高自己的专业水平,深入临床实践,更好地开展药学服务。     

Medication management: an exploratory study into the role of community mental health nurses

The recent emphasis on community care for those with mental illness has changed working patterns and modified inter-professional role boundaries within multi-disciplinary teams. Clients with serious mental illness are usually prescribed medications, which have a wide range of side effects. However, it is uncertain who is responsible for monitoring clients for the side effects of their medications, ensuring clients' and carers' understandings of their prescribed medications and optimizing compliance with medication. This paper discusses the findings of the first phase of an ongoing study designed to assess the role of community mental health nurses (CMHNs) in managing clients' medication and the provision of appropriate continuing professional education. Our respondents were 14 CMHNs, seven of whom were preparing to undertake a pharmacology module as part of a higher education diploma, and seven who were to act as comparators. Data from questionnaires, interviews and clinical observations were triangulated. All respondents felt that issues surrounding clients' medication were not accorded a sufficiently high profile and that it was, in part, their responsibility to expand their roles to meet these unmet needs of clients. Administering and managing clients' medications were considered to be the main area of 'occupational territory' which distinguished CMHNs from social workers. However, the nurses felt that their practice was limited by lack of appropriate educational preparation.     

An evaluation of the adequacy of outpatient monitoring of thyroid replacement therapy

OBJECTIVES: Hypothyroid patients managed with excessive or insufficient thyroid replacement therapy are often difficult to clinically recognize. Monitoring may prevent or minimize the consequences of adverse drug events (ADEs). We sought to develop an explicit model of medication monitoring and to evaluate monitoring processes and ADEs in patients taking levothyroxine. METHODS: A retrospective chart review of 400 outpatients receiving levothyroxine therapy between 1 January 2000 and 1 January 2001 at a large North American tertiary care hospital. We measured the proportion of patients satisfying minimum monitoring criteria, experiencing specific monitoring errors and having levothyroxine-related ADEs. Explicit monitoring criteria were derived from the literature and through expert opinion. Adverse drug events were identified using structured implicit reviews. RESULTS: Overall, only 56% (95% confidence interval [95% CI] 51-62%) of the patients prescribed levothyroxine received the minimal recommended monitoring. Errors were identified at all stages of the monitoring model. Patients who received the recommended monitoring had fewer levothyroxine-related ADEs (1% vs. 6%, P=0.013) than those who did not. Minority status (white people 2% vs. black people 4% vs. Hispanics 14%, P=0.023) and primary language (English 3% vs. Non-English 20%, P=0.002) were the patient characteristics associated with levothyroxine-related ADEs. CONCLUSION: Only half of outpatients taking levothyroxine at one tertiary care hospital received the recommended monitoring during one year of follow-up. Levothyroxine-related ADEs were more frequent in patients with lower-quality monitoring and in minorities and non-English speakers.