Minimizing side-effects: the clinical impact of nurse-administered 'side-effect' checklists

Nurse-led physical health interventions for people with mental illness: an integrative review of international literature

BACKGROUND

People experiencing mental illness receive physical healthcare from nurses in a variety of settings including acute inpatient, secure extended care, forensic, and community services. While nurse-led clinical practice addressing sub-optimal consumer physical health is salient, a detailed understanding and description of the contribution by nurses to physical health interventions in people experiencing mental illness is not clearly articulated in the literature.

AIMS

The aim of this integrative review is to describe the state of knowledge on nurse-led physical health intervention for consumers, focusing on nursing roles, nursing assessment, and intervention settings.

METHODS

A systematic search of six databases using Medical Subject Headings from 2001 and 2022 inclusive was conducted. The Mixed Methods Appraisal Tool (MMAT) was utilised for quality appraisal.

RESULTS

Seventy-four studies were identified as "nurse-led". Interventions were most common among community settings (n = 34, 46%). Nurses performed varied roles, often concurrently, including the collection of 341 physical health outcomes, and multiple roles with 225 distinct nursing actions identified across the included studies. A nurse as lead author was common among the included studies (n = 46, 62%). However, nurses were not always recognised for their efforts or contributions in authorship.

CONCLUSIONS

There is potential gap in role recognition that should be considered when designing and reporting nurse-led physical health interventions.

Nurse-Led Physical Health Interventions for People with Mental Illness: A Scoping Review of International Literature

People with mental illness have a higher prevalence of co-occurring physical health conditions and poor health behaviors, leading a mortality gap of up to 16 years, compared with the general population. Nurses working in mental health settings play an important role in addressing factors influencing sub-optimal physical health. Therefore, this scoping review aimed to identify nurse-led physical health interventions and align interventions to eight recognized physical healthcare priority areas (i.e. Equally Well in Victoria Framework). A systematic search strategy was used to identify relevant literature. Data extraction included alignment to the Equally Well priority areas, research design, and indication of co-design (meaningful and collaborative involvement of consumers and significant others) and recovery-oriented practice (focusing on needs and goals of a consumer's recovery journey). All included papers (n = 74) were aligned to at least one of eight Equally Well priority areas. Papers were predominately quantitative (n = 64, 86%), with the remainder mixed methods (n = 9, 9%) or qualitative (n = 4, 5%). Most papers were aligned to improving metabolic health and support to quit smoking. One study focused on nurse-led intervention designed to reduce falls. Recovery-oriented practice was evident in six papers. No paper described evidence of co-design. A research gap was identified for nurse-led intervention to reduce falls and improve dental/oral care. Relative to mental healthcare policy, there is a need for future nurse-led physical health research to be co-designed and include recovery-oriented practice. Evaluation and description of future nurse-led physical interventions should seek to report perspectives of key stakeholders as these remain relatively unknown.

Self-rated familiarity with autism spectrum disorders among practicing nurses: a cross-sectional study in the palestinian nursing practice

Background

Autism spectrum disorders (ASDs) are one of the most prevalent neurodevelopmental disabilities of early childhood. Practicing nurses are in a key position to help patients with ASDs and/or their caregivers/families. This study was conducted to assess self-rated familiarity with ASDs among practicing nurses in Palestine. The study also aimed to identify the sociodemographic and practice variables that could predict high self-rated familiarity scores.

Methods

This was a cross-sectional study using a questionnaire. The study was conducted in the period between January 2019 and May 2019. The questionnaire collected: 1) the sociodemographic, pedagogic, and practice variables of the nurses, 2) their self-rated familiarity with signs and symptoms, treatment options, and community resources of ASDs, 3) their self-rated confidence in their abilities to provide counseling for parents/family/caregivers on the drugs prescribed for children/patients with ASDs and their potential adverse effects, and 4) their willingness to receive education/training on issues in ASDs.

Results

The questionnaire was completed by 357 practicing nurses. The practicing nurses self-reported inadequate familiarity with symptoms, treatment, and community resources of ASDs. The mean familiarity score was 35.8% (SD: 18.9%). The nurses also expressed low confidence in their ability to provide counseling services to caregivers/families of children with ASDs. About 75% of the nurses agreed that they could benefit from taking a continuing educational/training program in the area of ASDs and about 82% of the nurses agreed that the nursing school curriculum should include courses in the area of ASDs. The multiple linear regression model showed that higher familiarity scores were predicted by having longer practical experience, having a higher academic degree in nursing, and having a continuing educational course/program on ASDs.

Conclusion

Findings of this study highlighted inadequate familiarity with issues of ASDs among practicing nurses. Higher familiarity was predicted by the length of practical experience, higher academic degree in nursing, and having continuing educational course/program on ASDs. Specifically designed pedagogic interventions might be helpful in increasing familiarity of practicing nurses on ASDs. More investigations are still needed to evaluate if these interventions can improve familiarity and services provided to patients with ASDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00764-3.

Perspectives of nurses' role in interprofessional pharmaceutical care across 14 European countries: A qualitative study in pharmacists, physicians and nurses

OBJECTIVES

To understand healthcare professionals' experiences and perceptions of nurses' potential or ideal roles in pharmaceutical care (PC).

DESIGN

Qualitative study conducted through semi-structured in-depth interviews.

SETTING

Between December 2018 and October 2019, interviews were conducted with healthcare professionals of 14 European countries in four healthcare settings: hospitals, community care, mental health and long-term residential care.

PARTICIPANTS

In each country, pharmacists, physicians and nurses in each of the four settings were interviewed. Participants were selected on the basis that they were key informants with broad knowledge and experience of PC.

DATA COLLECTION AND ANALYSIS

All interviews were conducted face to face. Each country conducted an initial thematic analysis. Consensus was reached through a face-to-face discussion of all 14 national leads.

RESULTS

340 interviews were completed. Several tasks were described within four potential nursing responsibilities, that came up as the analysis themes, being: 1) monitoring therapeutic/adverse effects of medicines, 2) monitoring medicines adherence, 3) decision making on medicines, including prescribing 4) providing patient education/information. Nurses' autonomy varied across Europe, from none to limited to a few tasks and emergencies to a broad range of tasks and responsibilities. Intended level of autonomy depended on medicine types and level of education. Some changes are needed before nursing roles can be optimised and implemented in practice. Lack of time, shortage of nurses, absence of legal frameworks and limited education and knowledge are main threats to European nurses actualising their ideal role in PC.

CONCLUSIONS

European nurses have an active role in PC. Respondents reported positive impacts on care quality and patient outcomes when nurses assumed PC responsibilities. Healthcare professionals expect nurses to report observations and assessments. This key patient information should be shared and addressed by the interprofessional team. The study evidences the need of a unique and consensus-based PC framework across Europe.

Looking for the "Little Things": A Multi-Disciplinary Approach to Medicines Monitoring for Older People Using the ADRe Resource

Advances in medicines have increased the effectiveness of treatments and the social and cultural authority of doctors. However, as prescribing has become the dominant modality of treatment, the “pharmaceuticalization” of medical practice has often resulted in treatment “at a distance”, with doctors having limited contact with patients. Older and poorer people, who are socially distanced from medical prescribers, suffer more adverse drug reactions (ADRs) than the general population. A team approach to checking patients systematically for ADRs, as detailed in manufacturers’ literature, can minimise medication errors, but regular review is rare. This paper explains the benefits of medicines monitoring to protect older patients from iatrogenic harm, such as over-sedation, falls, or drug-induced Parkinsonism. We show how multidisciplinary initiatives to optimise prescribing can be supported by using a recognised resource—the adverse drug reaction profile (ADRe). The profile identifies and documents patients’ signs and symptoms of putative ADRs. Better monitoring allows professionals to adjust prescribing and respond to identified problems with agility. Implementation of systematic monitoring will require changes to the regulatory regime and better inter-professional cooperation. Providing carers, nurses and pharmacists with a structured system to monitor patients would democratise relevant medical knowledge and help address ageism and the socio-economic health divide.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Usability aspects of medication-related decision support systems in the outpatient setting: A systematic literature review

In this study, we evaluated the usability aspects of medication-related clinical decision support systems in the outpatient setting. Articles published between 2000 and 2016 in Scopus, PubMed and EMBASE were searched and classified into three usability aspects: Effectiveness, Efficiency and Satisfaction. Using Van Welie et al.’s usability model, we categorized usability aspects in terms of usage indicators and means. Out of the 1999 articles, 24 articles met the selection criteria of which the main focus was on reducing inappropriate medication, prescription rate and prescription errors. Evidence could mainly be found for Effectiveness and showed high rates of positive results in reducing medication errors. To date, the effects of Efficiency and Satisfaction of clinical decision support systems regarding medication prescription remain understudied. Usability aspects such as memorability, learnability, adaptability, shortcuts and consistency require more attention. Studies are needed for better insight into the user model and to design a knowledge/task model for clinical decision support systems regarding medication prescription.

Nurse-led medicines' monitoring in care homes study protocol: a process evaluation of the impact and sustainability of the adverse drug reaction (ADRe) profile for mental health medicines

INTRODUCTION

Improved medicines' management could lead to real and sustainable improvements to the care of older adults. The overuse of mental health medicines has featured in many reports, and insufficient patient monitoring has been identified as an important cause of medicine-related harms. Nurse-led monitoring using the structured adverse drug reaction (ADRe) profile identifies and addresses the adverse effects of mental health medicines. Our study investigates clinical impact and what is needed to sustain utilisation in routine practice in care homes.

METHODS AND ANALYSIS

This process evaluation will use interviews and observations with the participants of all five homes involved in earlier research, and five newly recruited homes caring for people prescribed mental health medicines. The ADRe profile is implemented by nurses, within existing resources, to check for signs and symptoms of ADRs, initiate amelioration and share findings with pharmacists and prescribers for medication review. Outcome measures are the numbers and nature of problems addressed and understanding of changes needed to optimise clinical gain and sustain implementation. Data will be collected by 30 observations and 30 semistructured interviews. Clinical gains will be described and narrated. Interview analysis will be based on the constant comparative method.

ETHICS AND DISSEMINATION

Ethical approval was conferred by the National Health Service Wales Research Ethics Committee. If the ADRe profile can be sustained in routine practice, it has potential to (1) improve the lives of patients, for example, by reducing pain and sedation, and (2) assist in early identification of problems caused by ADRs. Therefore, in addition to peer-reviewed publications and conferences, we shall communicate our findings to healthcare professionals, policy-makers and sector regulators.

TRIAL REGISTRATION NUMBER

NCT03110471.

Adverse Drug Reactions, Power, Harm Reduction, Regulation and the ADRe Profiles

The power and influence of healthcare systems comes largely from the ability to prescribe efficacious medicine. However, medicine can sometimes cause harm rather than bring benefits. Systematically checking patients for the adverse effects of medicines, as listed in manufacturers' literature, would protect patients from iatrogenic harm, but this is rarely undertaken. We argue for the benefits of this approach using the example of the prescription of antipsychotics to older adults. Prescribing antipsychotics to control challenging behaviours associated with dementia is a controversial matter, and regulatory intervention is under discussion. Improved regulatory systems could protect against iatrogenic harm, such as over-sedation, falls, tremor, or drug-induced Parkinsonism. However, measuring the impact and outcomes of regulatory interventions has proved difficult, not least because there are rarely systematic records of all adverse effects of medicines. We indicate how regulatory initiatives to reduce antipsychotic prescribing can be supported by systematic monitoring and documentation of patients' signs and symptoms of putative adverse drug reactions. Monitoring documentation then provides the rationale and support for professionals' responses to identified problems. Longitudinal monitoring records would improve understanding of the impact and outcomes of adverse drug reactions (ADRs) on health and wellbeing, and the many costs of ADRs.

Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial

BACKGROUND

People with dementia are susceptible to adverse drug reactions (ADRs). However, they are not always closely monitored for potential problems relating to their medicines: structured nurse-led ADR Profiles have the potential to address this care gap. We aimed to assess the number and nature of clinical problems identified and addressed and changes in prescribing following introduction of nurse-led medicines' monitoring.

DESIGN

Pragmatic cohort stepped-wedge cluster Randomised Controlled Trial (RCT) of structured nurse-led medicines' monitoring versus usual care.

SETTING

Five UK private sector care homes.

PARTICIPANTS

41 service users, taking at least one antipsychotic, antidepressant or anti-epileptic medicine.

INTERVENTION

Nurses completed the West Wales ADR (WWADR) Profile for Mental Health Medicines with each participant according to trial step.

OUTCOMES

Problems addressed and changes in medicines prescribed.

DATA COLLECTION AND ANALYSIS

Information was collected from participants' notes before randomisation and after each of five monthly trial steps. The impact of the Profile on problems found, actions taken and reduction in mental health medicines was explored in multivariate analyses, accounting for data collection step and site.

RESULTS

Five of 10 sites and 43 of 49 service users approached participated. Profile administration increased the number of problems addressed from a mean of 6.02 [SD 2.92] to 9.86 [4.48], effect size 3.84, 95% CI 2.57-4.11, P <0.001. For example, pain was more likely to be treated (adjusted Odds Ratio [aOR] 3.84, 1.78-8.30), and more patients attended dentists and opticians (aOR 52.76 [11.80-235.90] and 5.12 [1.45-18.03] respectively). Profile use was associated with reduction in mental health medicines (aOR 4.45, 1.15-17.22).

CONCLUSION

The WWADR Profile for Mental Health Medicines can improve the quality and safety of care, and warrants further investigation as a strategy to mitigate the known adverse effects of prescribed medicines.

TRIAL REGISTRATION

ISRCTN 48133332.

Medication monitoring in a nurse-led respiratory outpatient clinic: pragmatic randomised trial of the West Wales Adverse Drug Reaction Profile

Objective

To assess the clinical effect of medication monitoring using the West Wales Adverse Drug Reaction (ADR) Profile for Respiratory Medicine.

Design

Single-site parallel-arm pragmatic trial using stratified randomisation.

Setting

Nurse-led respiratory outpatient clinic in general hospital in South Wales.

Participants

54 patients with chronic respiratory disease receiving bronchodilators, corticosteroids or leukotriene receptor antagonists.

Intervention

Following initial observation of usual nursing care, we allocated participants at random to receive at follow up: either the West Wales ADR Profile for Respiratory Medicine in addition to usual care (‘intervention arm’ with 26 participants); or usual care alone (‘control arm’ with 28 participants).

Main Outcome Measures

Problems reported and actions taken.

Results

We followed up all randomised participants, and analysed data in accordance with treatment allocated. The increase in numbers of problems per participant identified at follow up was significantly higher in the intervention arm, where the median increase was 20.5 [inter-quartile range (IQR) 13–26], while that in the control arm was −1 [−3 to +2] [Mann-Whitney U test: z = 6.28, p<0.001]. The increase in numbers of actions per participant taken at follow up was also significantly higher in the intervention arm, where the median increase was 2.5 [1]–[4] while that in the control arm was 0 [−1.75 to +1] [Mann-Whitney U test: z = 4.40, p<0.001].

Conclusion

When added to usual nursing care, the West Wales ADR Profile identified more problems and prompted more nursing actions. Our ADR Profile warrants further investigation as a strategy to optimise medication management.

Trial Registration

Controlled-trials.com ISRCTN10386209

Medication monitoring for people with dementia in care homes: the feasibility and clinical impact of nurse-led monitoring

OBJECTIVES

People with dementia are susceptible to adverse effects of medicines. However, they are not always closely monitored. We explored (1) feasibility and (2) clinical impact of nurse-led medication monitoring.

DESIGN

Feasibility "before-and-after" intervention study.

SETTING

Three care homes in Wales.

PARTICIPANTS

Eleven service users diagnosed with dementia, taking at least one antipsychotic, antidepressant, or antiepileptic medicine.

INTERVENTION

West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines.

OUTCOME MEASURES

(1) Feasibility: recruitment, retention, and implementation. (2) Clinical impact: previously undocumented problems identified and ameliorated, as recorded in participants' records before and after introduction of the profile, and one month later.

RESULTS

Nurses recruited and retained 11 of 29 eligible service users. The profile took 20-25 minutes to implement, caused no harm, and supplemented usual care. Initially, the profile identified previously undocumented problems for all participants (mean 12.7 (SD 4.7)). One month later, some problems had been ameliorated (mean 4.9 (3.6)). Clinical gains included new prescriptions to manage pain (2 participants), psoriasis (1), Parkinsonian symptoms (1), rash (1), dose reduction of benzodiazepines (1), new care plans for oral hygiene, skin problems, and constipation.

CONCLUSIONS

Participants benefited from structured nurse-led medication monitoring. Clinical trials of our ADR Profile are feasible and necessary.

A systematic review of nurse physical healthcare for consumers utilizing mental health services

People with serious mental illness have higher rates of physical illness and are more likely to experience premature death than the general population. Nurse-led strategies to improve physical healthcare in mental healthcare services could potentially reduce these inequalities. However the extent of nurse involvement in physical healthcare (such as physical risk screening, health education and care co-ordination) in mental health settings is not known. A systematic review was conducted on nurse-led physical healthcare reported for consumers with serious mental illness (SMI) in mental health services, and their benefits. Electronic literature bases (CINAHL, Proquest, PsychINFO and Web of Science) were systematically searched, in conjunction with a manual search of literature reviews on physical healthcare in mental health services. Articles were included if they: (a) were published in the last 10 years; (b) were English language; (c) involved physical healthcare of adult consumers receiving mental healthcare services; and (d) reported nurse involvement in physical healthcare. Forty articles were included in the review. The distribution of types of care were: health education (47%), screening and/or monitoring (33.3%), care co-ordination and management (33.3%), lifestyle programme delivery (30.5%), follow-up actions to screening results (25%) and registers and data administration (5.5%). Overall, the evaluation of nurse-based physical healthcare is in early stages. Thus far, they appear to have positive implications for consumers with SMI.

Development and clinical gains of nurse-led medication monitoring profiles

AIM

This paper reports on the development of an instrument for nurse-led medication monitoring, the West Wales Adverse Drug Reaction profile for respiratory medicines, as part of a strategy to reduce avoidable adverse drug reactions.

BACKGROUND

Preventable adverse drug reactions account for 3.7% hospital admissions. Nurse-led medication monitoring may reduce drug-related harm. However, development of medication monitoring strategies is not reported elsewhere.

METHODS

The profile was developed by: (1) cognitive interviews (n = 4), (2) the content validity index (n = 10) involving academics, clinicians and service users prescribed respiratory medicines, (3) inter-rater reliability (n = 48) and clinical gains in a nurse-led outpatient clinic.

RESULTS

Cognitive interviews prompted more profile changes than either the content validity index or inter-rater reliability testing. Cohen's κ for inter-rater reliability for each item ranged from 0.73-1.00 (good to complete agreement). The profile identified previously unsuspected problems in all participants, including muscular weakness, skin and mouth problems.

CONCLUSIONS

The West Wales Adverse Drug Reaction profile was valid and reliable, and helped to detect and ameliorate drug-related harm.

IMPLICATIONS FOR NURSING MANAGEMENT

The West Wales Adverse Drug Reaction profile offers opportunities to improve care. Medication monitoring provides the structure to concurrently monitor known adverse drug reactions. Practice-based adverse drug reaction profiles benefit from cognitive, content validity and inter-rater reliability testing.

Physical health care for people with mental illness: training needs for nurses

AIM

People diagnosed with serious mental illness have higher rates of physical morbidity and decreased longevity, yet these people are not adequately served by health care systems. Nurses may provide improved physical health support to consumers with serious mental illness but this is partly dependent on nurses having necessary skills and interest in training opportunities for this component of their work. This survey investigated Australian nurses' interest in training across areas of physical health care including lifestyle factors, cardiovascular disease, and identifying health risks.

METHODS

A nation-wide online survey of nurse members of the Australian College of Mental Health Nurses. The survey included an adapted version of a sub-section of the Physical Health Attitudes Scale. Participants were asked to indicate their interest in various aspects of physical health care training.

RESULTS

Most (91.6%) participants viewed educating nurses in physical health care as of moderate or significant value in improving the physical health of people with serious mental illness. Interest in training in all areas of physical health care was over 60% across the health care settings investigated (e.g. public, private, primary care). Forty-two percent sought training in all nine areas of physical health care, from supporting people with diabetes, to assisting consumers with sexually-related and lifestyle issues.

CONCLUSIONS

The findings suggest that nurses in mental health services in Australia acknowledge the importance of training to improve physical health care of consumers with serious mental illness. Training programs and learning opportunities for nurses are necessary to reduce inequalities in health of people with serious mental illness.

Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service

This audit reviewed current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. A sample of 60 case files, care plans and prescriptions were audited, which is 31% of the total number of service users receiving depot injections in the mental health service region (n= 181). The sample audited had a range of diagnoses, including: schizophrenia, schizoaffective disorder, bipolar affective disorder, depression, alcoholic hallucinosis and autism. The audit results revealed that most service users had an annual documented medical review and a documented prescription. However, only five (8%) case notes examined had documentation recorded describing the condition of the injection site, and alternation of the injection site was recorded in only 28 (47%) case notes. No case notes examined had written consent to commence treatment recorded. In 57 (95%) of case notes, no documentation of recorded information on the depot and on side effects was given. The failure to monitor and record some blood tests was partly attributed to a lack of clarity regarding whose responsibility it was. A standardized checklist has been developed as a result of the audit and this will be introduced by all teams across the service.

The serious mental illness health improvement profile [HIP]: study protocol for a cluster randomised controlled trial

Background

The serious mental illness Health Improvement Profile [HIP] is a brief pragmatic tool, which enables mental health nurses to work together with patients to screen physical health and take evidence-based action when variables are identified to be at risk. Piloting has demonstrated clinical utility and acceptability.

Methods/Design

A single blind parallel group cluster randomised controlled trial with secondary economic analysis and process observation. Unit of randomisation: mental health nurses [MHNs] working in adult community mental health teams across two NHS Trusts. Subjects: Patients over 18 years with a diagnosis of schizophrenia, schizoaffective or bipolar disorder on the caseload of participating MHNs. Primary objective: To determine the effects of the HIP programme on patients' physical wellbeing assessed by the physical component score of the Medical Outcome Study (MOS) 36 Item Short Form Health Survey version 2 [SF-36v2]. Secondary objectives: To determine the effects of the HIP programme on: cost effectiveness, mental wellbeing, cardiovascular risk, physical health care attitudes and knowledge of MHNs and to determine the acceptability of the HIP Programme in the NHS. Consented nurses (and patients) will be randomised to receive the HIP Programme or treatment as usual. Outcomes will be measured at baseline and 12 months with a process observation after 12 months to include evaluation of patients' and professionals' experience and observation of any effect on care plans and primary-secondary care interface communication. Outcomes will be analysed on an intention-to-treat (ITT) basis.

Discussion

The results of the trial and process observation will provide information about the effectiveness of the HIP Programme in supporting MHNs to address physical comorbidity in serious mental illness. Given the current unacceptable prevalence of physical comorbidity and mortality in the serious mental illness population, it is hoped the HIP trial will provide a timely contribution to evidence on organisation and delivery of care for patients, clinicians and policy makers.

Trial Registration

ISRCTN: ISRCTN41137900

Non-psychiatric health problems among psychiatric inpatients with intellectual disabilities

BACKGROUND

Physical distress resulting from medical problems has been found to cause increased behaviour problems in patients with intellectual disabilities (ID). Despite this fact, little has been documented on the medical problems of individuals with ID admitted for inpatient psychiatric care. We conducted an exploratory investigation based on a retrospective chart review of the medical problems and medications for 198 people with ID who had been admitted to a specialised inpatient psychiatric unit. Most patients were referred for admission because of aggressive, disruptive and self-injurious behaviours. The average length of stay was 17.6 days.

METHODS

We tallied the total number of medical problems and medications listed in the patients' discharge summaries. Because longer stays are disruptive, costly and associated with greater overall impairment, we examined the relationship between length of stay and frequency of discharge medical diagnoses. We also assessed whether or not the number of psychoactive medications correlated with the number of medical diagnoses. The effects of other demographic and diagnostic variables on rates of medical diagnoses and medications were also evaluated, including gender, age group (16-25, 26-45, 46-60, >60), level of ID (mild, moderate or severe ID) and diagnosis of an autism spectrum disorder or Down syndrome (DS).

RESULTS

Inpatients with a higher number of medical diagnoses had longer lengths of stay (Spearman r = +0.32, P < 0.0001). There was a significant correlation between number of psychoactive medications and number of medical problems (Spearman r = +0.32, P < 0.0001). The most frequent medical comorbidity was constipation, reported in 60% of the inpatients (n = 118), while gastro-esophageal reflux disease was identified in 38% (n = 75). Older inpatients had an increased number of medical problems, as might be expected, but a diagnosis of an autism spectrum disorder, gender and level of ID had no detectible effect on rates of either medical diagnoses or medications. There were only 13 inpatients with DS; in this modest sample, it was found that they had higher rates of osteoarthritis, cardiac problems, hearing loss, hypothyroidism and sleep apnoea than peers without DS, as is consistent with previous findings on overrepresented conditions in this trisomy.

CONCLUSIONS

In the present study, individuals with ID admitted for inpatient psychiatric care exhibited high rates of medical problems, and these were associated with duration of inpatient stay. Based on these findings, further investigation of the effects of medical problems on behaviour among individuals with ID admitted for inpatient psychiatric care is warranted.

A structured observation of the interaction between nurses and patients during the administration of medication in an acute mental health unit

AIMS

This aims of this study are to describe current practice in the administration of medication in an acute psychiatric unit and explore factors that influence nurses' decisions regarding the administration of medication during 'rounds'. Background.  Medication 'rounds' form part of the ward routine in many inpatient mental health settings. Nurses make several clinical decisions about administrating medication; yet, concerns have been raised about the poor assessment of patients' needs and the quality of the information exchanged.

DESIGN

A structured non-participant observational design was used for this research.

METHOD

This study involved the observation of 20 medication 'rounds' over three months. The Ward Administration of Medication Schedule was used to report on the interactions between nurses and patients and aspects of their communication during each round.

RESULTS

From the rounds observed nurses appeared adept at communicating a positive interpersonal style but less so in demonstrating skills portraying collaboration and information giving. For example whilst nurses communicated warmth in 97% of cases, using non-verbal behaviours such as good eye contact, the provision of information was only initiated in 46% of cases. Enquiries regarding the patient's general health and medication taking (35% and 17% respectively) were less commonly observed. Verbal consent was sought in only 25% of cases. Procedural matters were adhered to overall.

CONCLUSIONS

Findings suggest limited collaboration between nurses and patients and the poor monitoring of health status and medication effects. Information exchange could be improved; however, this may be related to medication procedures that make it difficult to explore sensitive information with patients, rather than nursing skills and behaviour.

RELEVANCE TO CLINICAL PRACTICE

The Ward Administration of Medication Schedule can be used as a clinical or educational tool in the administration of medication. In both instances, it may be self-administered and used to reflect on personal skills or employed as an observational tool during peer review and audit.

A comparison of the clinical effectiveness and costs of mental health nurse supplementary prescribing and independent medical prescribing: a post-test control group study

BACKGROUND

Supplementary prescribing for mental health nurses was first introduced in the UK in 2003. Since then, a number of studies have reported stakeholders' perceptions of the success of the initiative. However, there has been little experimental research conducted into its effectiveness. This paper reports findings from the first known study to compare the cost and clinical impact of mental health nurse supplementary prescribing to independent medical prescribing.

METHODS

A post-test control group experimental design was used to compare the treatment costs, clinical outcomes and satisfaction of patients in receipt of mental health nurse supplementary prescribing with a matched group of patients in receipt of independent prescribing from consultant psychiatrists. The sample comprised 45 patients in receipt of mental health nurse supplementary prescribing for a minimum of six months and a matched group (by age, gender, diagnosis, and chronicity) of patients prescribed for by psychiatrists.

RESULTS

There were no significant differences between patients in the nurse supplementary prescribers' group and the independent prescribers' group in terms of medication adherence, health status, side effects, and satisfaction with overall care. Total costs per patient for service use were 803 pounds higher for the nurse prescribers' group but this difference was not significant (95% confidence interval--1341 pounds to 3020 pounds).

CONCLUSIONS

No significant differences were found between the health and social outcomes of patients in the mental health nurse supplementary prescribers' group, and those prescribed for by the independent medical prescribers. The cost appraisal also showed that there was no significant difference in the costs of the two types of prescribing, although the pattern of resources used differed between patients in the two prescriber groups. The results suggest that mental health nurse supplementary prescribers can deliver similar health benefits to patients as consultant psychiatrists without any significant difference in patients' service utilisation costs.

Evaluation of outpatient computerized physician medication order entry systems: a systematic review

This paper provides a systematic literature review of CPOE evaluation studies in the outpatient setting on: safety; cost and efficiency; adherence to guideline; alerts; time; and satisfaction, usage, and usability. Thirty articles with original data (randomized clinical trial, non-randomized clinical trial, or observational study designs) met the inclusion criteria. Only four studies assessed the effect of CPOE on safety. The effect was not significant on the number of adverse drug events. Only one study showed a significant reduction of the number of medication errors. Three studies showed significant reductions in medication costs; five other studies could not support this. Most studies on adherence to guidelines showed a significant positive effect. The relatively small number of evaluation studies published to date do not provide adequate evidence that CPOE systems enhance safety and reduce cost in the outpatient settings. There is however evidence for (a) increasing adherence to guidelines, (b) increasing total prescribing time, and (c) high frequency of ignored alerts.

Impact of psychotropic medication on sexuality: literature review

Psychotropic medication continues to be a central element in the care and treatment of people experiencing mental health problems. Nurses have a key role to play in patient education and in monitoring the benefits and side effects of prescribed drugs. However, evidence suggests that nurses tend to ignore or minimize side effects that impact on sexuality and sexual function. The focus of this article is on exploring the literature on psychotropic medication and sexual dysfunction.

Iatrogenic sexual dysfunction and the protective withholding of information: in whose best interest?

In recent years a growing body of evidence has highlighted the impact of neuroleptics and antidepressants on sexual function. Research from a service user's perspective suggested that service users are dissatisfied with the information that they received on drugs, and would like more education, in particular, on the side effects of medication that impact on sexual function. This paper reports some of the findings of a grounded theory study that explored how psychiatric nurses responded to issues of sexuality in practice. Emphasis within the paper is given to how nursing staff addressed the side effects of drugs that impact on sexual function. Findings suggested that nurse addressed the issue of prescribed medication and sexual function in practice, using a 'Veiling Sexualities Cycle', which had three subcategories: 'Hanging the Veil', 'Lifting the Veil' and 'Re-veiling'. In the light of contemporary mental health policy, findings from the study are discussed and recommendations for practice and education made.

Mental health nurse prescribing: issues for the UK

Supplementary nurse prescribing holds the key to rapid developments in psychiatric nursing and the care received by patients. In this paper, the origins, context and research data on nurse prescribing are reviewed, as a backdrop to a discussion on potential application of supplementary prescribing in a number of mental health settings. We describe a number of practice settings where nurse prescribing could be implemented, and argue that given service changes and informative educational preparation, access to care and user experience of that care will be enhanced. We conclude the paper by reviewing a number of clinical, organizational and research factors important for the success of nurse prescribing.

Monitoring adverse drug reactions: scales, profiles, and checklists

BACKGROUND

Globally, adverse drug reactions (ADRs) make a substantial contribution to ill health. Introducing a systematic approach to patient surveillance could mitigate these problems. Formalized medication monitoring schedules have been proposed as one strategy to diagnose and action side-effects and the problems emanating from adverse drug reactions. To date, most developments have been linked to antipsychotic medications. Several scales, checklists, and side-effect profiles are available, including the West Wales ADR (adverse drug reaction) profile. However, relatively little work has been undertaken on the clinical validity, reliability, and sensitivity of these instruments.

AIM

This paper describes the development of the monitoring schedule approach to medication management. It also reviews and compares the instruments available for monitoring the adverse drug reactions of antipsychotic medications. The UKU (Udvalg for Kliniske Undersogelser) scale and the West Wales ADR profile assess a broader range of physiological parameters and potential problems than other instruments. However, to be adopted in practice, such instruments must achieve a balance between clinical gain and practical cost, including the time spent in administration.

CONCLUSION

Further work is needed to explore the translation of formalized ADR surveillance programmes into clinical gains and improved outcomes for clients.

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.