Medicine management can be defined as ‘the clinical, cost-effective and safe use of medicines to ensure patients get the maximum benefit they need, while at the at the same time minimising potential harm. ’ (Medicines and Healthcare products Regulatory Agency (MHRA) 2004). This essay will analyse the role and responsibility of the nurse in medicine management. It will then examine the complexities which arise when applying this clinical skill in the context of learning disability nursing in a medium secure forensic environment, before finally considering implications and recommendations for practice.
It has been argued that medication administration is one of the most time consuming nursing duties, accounting for 40% of a nurse’s workload. (Armitage & Knapman 2003). Safe practice in the management and administration of medication is an essential part of the role of the nurse (NMC 2008). Although drug administration is a multidisciplinary task, the nurse has the final responsibility of checking the medication before it is administered to the patient (Davey et al 2008).
Managing and administering medication is the highest risk of nursing duties (Anderson & Webster 2001), with medication error the most frequent cause of illness and preventable death in hospitals (Adams & Koch, 2010). Medication error can be defined as failure in the drug treatment process that leads to or has the potential to lead to harm to the patient (Aronson 2009). It has been estimated that 38% of medication errors are serious or fatal, and 42% of those are preventable (Gurwitz et al 2003).
Lack of competence and safety in the delivery of medicine management can also result in a financial burden to the NHS. The National Patient Safety Agency (2007) estimated that harm by medicines which could have been prevented could cost over ? 750 million each year. Medicine management involves more than the administration of drugs to the patient (White 2004). The NMC (2008) states that the duty of the nurse is to act as an advocate and provide relevant information and support to those in their care.
The nurse is therefore responsible for informing patients about the medication they are receiving, including its function for their health and any possible side effects. The nurse thus acts to empower the patient by using professional knowledge and skills to provide them with information they are lacking. This is an example of paternalistic empowerment, where the expertise gap is the main characteristic of the nurse-patient relationship (Gomm 1993). It also establishes a person-centred approach, which is necessary in the area of medicines management (Great Britain.Department of Health 2008) and in meeting the health and social care needs of people with learning disabilities (Great Britain. Department of Health 2009).
Any information must be provided in a way the patient can understand (NMC 2008). In learning disability nursing, where there may be reduced understanding or communication skills, the nurse must ensure service users receive the relevant information in a way they can understand, this could be by using a range of communication methods such as signs, symbols or makaton.
Collaborative working is essential for good practice in medicine management and has become more important with the development of clinical risk management in healthcare in recent years (Nursing Times 2007). The nurse must understand the drugs which their patients are taking (Hemingway et al 2011). This can be achieved by working with pharmacists and doctors at all stages of prescribing, administration and medication changes. Effective multi-disciplinary work may also result in the development of education and training in medicine-related issues.
The administration of medication in an institutionalised setting involves adherence to relevant local trust policies and procedures in addition to legal frameworks and professional standsards such as the Medicines Act (Great Britain. Medicines Act 1968) and the NMC Standards for Medicine Management (2008). Local policies which specify how medication is administered to patients are constantly changing and it is the professional duty of the nurse is to ensure that their knowledge is up to date (NMC 2008).
Care must be delivered on the best available evidence or best practice (NMC 2008) and when administering medication the nurse must be able to justify their decisions and technique with a valid and reliable evidence base. There are certain principles of medication administration which must be adhered to for safe and competent practice (NMC 2008). These have been referred to as the five rights of medication administration, that the right patient receives the right dose of the right drug by the right route and and at the right time (Eisenhauer et al 2007).
Nurses must administer the right medicine to the right patient. Research has shown that as many as one third of medication errors involved the patient being given the wrong medication (Selbst et al, 1999; LaPointe and Jollis, 2003). Patients can be verified verbally but it should not be the only method used, Elliot & Liu (2010) suggest both name and medical number should be identified on the medication chart and patient wristband, however they acknowledge this may not be possible in some settings such as mental health inpatients, and suggest extra care may be needed here.
The nurse must also verify whether a patient has an allergy to the medication before administration (NMC 2008), the prescription on the label of the medicine to be administered must be clearly written and the medications not expired (NMC 2008). Studies have found that a third or more of medication errors involve the incorrect dose being administered (LaPointe and Jollis, 2003; Tang et al, 2007). In addition to checking the dose, they must also ensure that the prescribed dose is within the known dose range by consulting the British National Formulary.
Cohen (2006) has underlined the importance of calculations in the volume of medications where the administration of 5mls of morphine 20mg/ml, instead of 5mg resulted in a patient being given 100mg of morphine. The nurse should also not ‘blindly follow’ what has been prescribed. If the prescriber has made an error, such as ordering a toxic medication dose, the nurse should not administer it (Elliot & Liu 2010). Nurses are only allowed to administer medications by the route prescribed, though sometimes the prescriber may give a choice.
The nurse must understand the differences between these routes such as the rate of absorption or onset of action and also ensure that the form of the medication is correct for the route of administration (Elliot & Liu 2010). The NMC (2008) also states that medications must be administered at the correct time to ensure the therapeutic effect of the medication. However, evidence suggests has been found that administration at the incorrect time can account for 31% of all medication errors (Deans, 2005). The nurse must consider each patient on an individual basis taking into account their condition and any co-existing therapies.
In this way the administration of medication by a nurse is not a mechanistic task but rather requires thought and professional judgement (NMC 2008). A study by Gurwitz et al (2003) emphasised the importance of the nurse in monitoring the effect of medication post-administration, revealing that inadequate patient monitoring after medication administration occurred in 36% of adverse drug events. The nurse must contact the prescriber where contraindications are discovered, where the patient develops a reaction, or where assessment indicates the medicine is no longer suitable (NMC 2008).
Record keeping is an important aspect of good practice in medicine management and is also a legal responsibility (Woodrow 2007). Nursing staff must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, records must be completed as soon as possible after the event has occurred and must be clearly and legibly signed, dated and timed (NMC 2008). Failure to do this could result in double administration of the medication, where the dose is repeated.
Nurses have professional accountability to gain consent before beginning any treatment or care (NMC 2008) and failure to do so can result in accusations of battery and negligence (Dimond 2008). For consent to be valid, it must be informed, voluntary and made with capacity (Great Britain. Department of Health 2009). The management and administration of medication is complex where individuals may lack the mental capacity needed to consent and the nurse must ensure that all guidelines in capacity law are strictly adhered to (Great Britain. Department of Health 2005).
The issue of consent is yet more complex in a forensic secure hospital setting where the law allows treatment to be given without consent for patients detained under the Mental Health Act (1983). It is essential that the nurses understands consent to treatment in relation to the Mental Health Act (1983) and Part 4, whereby treatment for mental disorder can be given without consent for those detained under sections 2, 3, 36, 37, 38, 45A, 47 or 48.
Medication for mental disorder can lawfully be administered under the direction of the registered clinician for the first 3 months of detention and following this period, with the approval of an independent Second Opinion Appointed Doctor. The nurse must then ensure that Form T2 or T3, representing the legal authority to continue administering medication to a detained patient who is subject to section 58 is present and includes “as required” (or ‘prn’) medication.
The use of as required or ‘prn’ medication is frequent in inpatient psychiatric settings to reduce agitation, distress and aggression. Administering medication to manage violence and aggression is known as rapid tranquilisation (Dickinson et al 2009) and should only be used if the nurse decides all other less coercive and non-pharmacological methods such as de-escalation, distraction and the use of a low stimulus environment have been unsuccessful (NICE 2005).
Dickinson et al (2009) stress the need for rapid tranquilisation to be used as a management strategy rather than a primary form of treatment. However, studies have found that it has been often used as a first line to manage situations due to deficiencies in skills, clinical experience, time or staffing levels (Baker et al 2007), a lack of physical space and a tense and anxious ward environment (Usher et al 2009). Donat (2005) has also emphasised the unnecessary reliance by nurses on prn medication for behaviour management.
Although it is argued that administering medication to control aggressive or harmful behaviour is in the best interests of the patient and can enable the avoidance of seclusion and physical restraint (Lind et al 2004), Thapa et al (2003) argue that the use of medication for its sedative effect can disable and deskill patients, removing their ability to find their own way to resolve conflict and Duxbury et al (2010) that it can be seen as punitive or disempowering by patients.
It is the duty of the registered nurse in charge to make decisions about when rapid tranquilisation should be used, which of the prescribed drugs to choose and the dosage (Usher et al 2009). The nurse must therefore be competent in assessing and managing the risks of the drug used, for example benzodiazepines are associated with confusion, nausea, vomiting and over-sedation, particularly in older people (Antai-Otong 2008).
The nurse must be aware of recent evidence on drugs used for rapid tranquilisation, for example the need to avoid risperidone and olanzapine with patients who have dementia (MHRA 2009), that intramuscular lorazepam should not be given within one hour of intramuscular olanzapine, and that oral lorazepam should be used with caution because it can cause excessive sedation and cardiorespiratory depression (NICE 2005, Electronic Medicines Compendium 2008).
It is also essential the nurse is aware that two drugs of the same class should not be used for the purpose of rapid tranquillisation (Dickinson et al 2009). The intervention selected should be a reasonable and proportionate response to the risk posed by the patient (NICE 2005). Local policies and procedures must be followed and the practitioner must choose the safest and most ethical approach to treatment. Initially, oral medication (liquid or soluble) should be offered and intramuscular injection should only be used when oral medication has been tried or is considered inappropriate (NICE 2005).
The nurse must understand the physical risks of rapid tranquilisation (arrhythmias and sudden cardiac death) and must therefore be able to use and maintain the equipment needed for cardiopulmonary resuscitation (NICE 2005). Before administering medication the nurse needs to check for co-morbid medical illnesses, such as cardiac disease or diabetes. After administering rapid tranquillisation, the patient’s vital signs must be monitored and recorded and the responsible clinician informed of the patient’s response (Dickinson et al 2009). There are many ways to improve practice in medication management.
Although it is the duty of the nurse to ensure practice is up to date and based on the best available evidence (NMC 2008), the poor pharmacology knowledge base of many nurses undertaking medicine management has been widely recognised (Morrison-Griffiths et al, 2002; Banning, 2004) and it is universally acknowledged that with the advancement of technology, there is an increasing need for nurses to increase their scientific knowledge base for the competent administration of new drugs (Dilles et al, 2009; Hemingway & Ely, 2009; Hutton et al, 2010). This includes developing knowledge of side effects and contraindications.
Failure to do this can increase risks of adverse drug events when unfamiliar medicines are prescribed and administrated. It is also important that nurses are aware of local practice guidelines for the administration of drugs. A study by Usher et al (2009) found that not all nurses in the research were familiar with local policies and procedures for administration of psychotropic drugs, this is supported by Armitage and Knapham (2003) who found many errors occur as a result of nurses not following ward policies and procedures when administering medication.
Environmental and contextual factors such as stress and tiredness from a heavy workload and distractions and interruptions which prevent the nurse being able to concentrate on administering medication have been cited as common causes of medication errors Deans, 2005; Fry & Dacey 2007). An awareness of these factors which contribute to medication errors may help nurses address these issues and better manage their working environment. It may also encourage service providers to establish systems to promote safer practice. Nurses’ difficulties with drug calculations have also been acknowledged (Banning, 2004; Hutton et al, 2010).
The NMC (2008) states it is good practice when dealing with complex calculations for a second registered professional to double-check the calculation independently, to reduce the risk of error (NMC, 2008). Criticisms that contemporary nurse training fails to link the theory of pharmacology to practice and the need to deliver medicine management training which is clinically relevant has been well documented (Banning, 2004; Turner et al, 2007, 2008). The Healthcare Commission (2007) has also emphasised the need for NHS trusts to assess the competency of all clinicians working with medication.
Some universities and trusts have established practices to test practitioner knowledge and skills in safe drug administration. E-learning is increasingly popular in providing such assessments. (Hare, 2006). An example of this is the Authentic World training programme, which can be used both pre and post-registration to develop and assess the competencies required for safe medication dosage calculation. Wider use of this programme may address weaknesses in skills and knowledge and provide the understanding needed for clinical competence in medicine management.
Finally, it has been suggested that nursing staff in the psychiatric setting may rely too heavily on pharmacological treatments to control behaviour due to deficiencies in their ability to manage these situations by other means (Thomas et al, 2006, Deb et al 2006). It could therefore be argued that nurses need to improve their skills in de-escalation and management of violence and aggression. This essay has emphasised that safe and competent practice in medicine management is a fundamental role of the nurse from both a general and branch-specific perspective.
It has demonstrated the vital and wide-ranging role of the nurse in this area and has emphasised the importance of a reliable and up to date knowledge base in all aspects of this clinical skill. The need for advanced clinical decision making skills and knowledge of guidelines and laws to enable a high standard of practice in medicine management has also been highlighted. Whilst organisational as well as personal factors can lead to errors in medication, nurses have an important role in protecting their patients and error prevention and therefore recommendations to promote safer practice have also been suggested. 2730 words.