Difficulties in administering medication to older mental health inpatients.
Geoff Dickens, RMN, BSc, Dip N; Jean Stubbs, MSc, MRPharmS; Camilla Haw, MA, MB, BChir, MRCP, MRCPsych
Geoff Dickens is research nurse/research co-ordinator; Jean Stubbs is head pharmacist; both at St Andrew’s Hospital, Northampton; Camilla Haw is consultant psychiatrist at Isham House, St Andrew’s Hospital, Northampton.
Administering medication to older mental health patients. Nursing Times; 103: 15, 30–31. This article reports on a survey that was undertaken to investigate the difficulties nurses face in administering medication in mental health wards for older people and to identify their training needs. The survey demonstrated that nurses need regular training with clear guidelines about medication administration, as well as professional guidance on covert administration. This is a summary: the full paper and reference list can be accessed at nursingtimes.net.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
We wanted to identify the difficulties nurses face when administering medications in an elderly mentally ill (EMI) setting, what current training they receive related to this role and whether there are further training needs.
Mental health settings
We searched the CINAHL, BNID, AMED, PsychINFO and MedLine databases and found only nine studies specifically related to medication administration conducted in psychiatric or learning disability settings. Most of these studies focus on the nature and frequency of medication errors in psychiatry as identified by incident report or chart review (Haw et al, 2005; Dickens et al, 2006). Nurses working in psychiatric or learning disability settings were observed undertaking medication administration in only three studies. Thurtle (2000) studied medication administration in learning disability group homes but made only 16 observations. Branford et al (1997) observed medication administration in day centres for people with learning disabilities but made only a brief description of nursing practice. Haglund et al (2004) observed medication administration on two Swedish short-stay acute psychiatric wards and gave a very brief description of nursing practice. Interviews with nurses and patients in this study suggested that time spent undertaking medication administration represents for nurses an opportunity to develop interpersonal contact with patients. The authors concluded that nurses should be given guidelines about how to perform routines connected with medication administration. None of the studies we identified examined nurses’ existing training or their reported training needs.
Medication administration in elderly care settings
A recent report (Commission for Social Care Inspection, 2006a) has highlighted the issue of medicines management in UK elderly care settings. In elderly psychiatric care, issues of capacity, consent and patient confusion compound the difficulties of medication administration (Dewing, 2002; Griffith, 2003a). Other issues include the covert (also referred to as disguised or surreptitious) administration of medicines (Treloar et al, 2001), tablet crushing (Griffith, 2003b), swallowing difficulties (Mistry et al, 1995), hiding, spitting out or chewing medication (Wright, 2002) and the use of non-registered care workers to assist with medication administration (Commission for Social Care Inspection, 2006b). Little is known about the prevalence of such difficulties in care environments for older adults with mental illness, or about the training received or needed by nurses who work in these settings.
We used two methods to achieve our aims. First, we surveyed nurses in one hospital about their views and training needs in relation to medication administration for older adults with mental illness. We devised a literature-based questionnaire and used it to conduct a cross-sectional survey design to investigate nurses’ views. Secondly, we observed nursing practice on two inpatient wards during medication rounds, collected quantitative data about nursing practice and also made qualitative, descriptive accounts of our observations and discussions. This study formed part of a larger inquiry into medication administration errors in psychiatry.
The survey was undertaken in the Townsend Hospital, a six-ward, 105-bed inpatient unit for older adults with mental disorder. The hospital is a part of St Andrew’s Healthcare, a UK charitable sector provider of mental health care. The observational study took place on two wards of the hospital, here called ward A and ward B. Ward A is a 13-bed mixed-sex, locked ward for older people with dementia and challenging behaviour. Ward B is a 20-bed mixed-sex ward for physically frail older adults with enduring mental illness including dementia, and offers nursing-home type care.
All nurses (n=49) were invited to participate in the survey. All nurses from wards A and B (n=12) were asked to participate in the observational research.
The study was approved by an NHS Research Ethics Committee. The questionnaire was distributed in December 2005, consent was assumed by its return and participation was anonymous. Written, informed consent was sought from nurses for participation in the observational study. Observation was undertaken by two of the researchers. JS recorded the activity of the administering nurse (such as medication given, whether tablets were crushed) while GD made field notes about environmental distractions and patient activity. Our observation was largely non-participatory but participants frequently volunteered information about their role and we occasionally asked questions to clarify our observations. Observation only occurred in communal areas of the wards. Brief details about patient gender, diagnosis and any swallowing difficulties were collected from their consultant psychiatrist. The study took place on ward A during March 2006, and on ward B during June and July 2006. Each medication round was discussed on its completion by the observers in order to identify salient issues. Field notes were subjected to qualitative analysis for commonly-occurring themes. Numerical data from the survey was entered into SPSS 14.0 (SPSS, 2005) for analysis.
Results: Nurse Survey
Characteristics of respondents
Completed questionnaires were returned by 27/49 (55%) nurses. Twelve (44%) respondents had been qualified for more than five years, and two (7%) for less than one year. Twenty (74%) respondents were D and E grade nurses and the remaining seven (26%) were F grade and above.
Training received on medication administration
Twenty-three (85%) respondents stated they had undergone some form of training in medication administration in the past 12 months. Four (15%) had received some formal training, 10 (37%) had received ‘on the job’ training, for instance with a colleague, and 19 (70%) had undertaken self-directed learning such as reading articles or using the internet. Some nurses reported receiving more than one type of training. Fifteen (56%) nurses said that the training they had received was adequate and relevant to their role.
Reported difficulties in administering medication
Our questionnaire included a list of 19 issues that can cause difficulty in medication administration and we asked respondents whether, in their experience, each item occurred frequently, occasionally or never. Table 1 shows that the items most often cited as ‘frequent issues’ were related to characteristics of the patient group (‘confused patients who do not understand the need to take medication’, ‘patients with swallowing difficulties’ or ‘patients refusing to swallow medicines’), the crushing of tablets as part of overt or covert administration, and environmental factors including noise and distraction.
Table 1. Reported frequency of the ‘regular occurrence’ of difficult or problematic issues in medication administration (n=27)
|Medication administration issue||Regularly occurring issueN (%)|
|Confused patients who do not understand that they need to take medicines||13 (48.1)|
|Having to crush or dissolve medicines in order to administer them (when the patient is aware of what you are doing)||10 (37.0)|
|Patients refusing to swallow medicines||10 (37.0)|
|Patients having difficulty swallowing medicines||9 (33.3)|
|Having to administer a large number of medicines to one patient at the same time||9 (33.3)|
|Difficulty in concentrating as distracted by noise or other patients or staff||8 (29.6)|
|Having to crush or dissolve medicines in order to administer them (when the patient is not aware of what you are doing)||8 (29.6)|
|Patients who become aggressive when you attempt to administer medicines||7 (25.9)
|Time pressures (many tasks to complete in a limited time)||7 (25.9)|
|Problems with the layout of the clinic room or area where drugs are administered||5 (18.5)
|Having to leave (and lock) the medicines trolley while administering medicines to a patient||5 (18.5)|
|Complex prescriptions with frequent dosage changes||4 (14.8)|
|Difficulty in reading the prescription as doctor’s handwriting is not clear||4 (14.8)|
|Ambiguous prescriptions - it is not clear what the prescribing doctor intended||3 (11.1)
|Having to calculate the dosage, for example when administering a liquid medicine||2 (7.4)|
|Patients who are drowsy or asleep and hard to wake up to give them their medicines||2 (7.4)|
|Communication problems with other staff, for example the doctor has said to omit a medicine but has not written in the notes||1 (3.7)|
|Difficulty in concentrating as feeling tired or upset||1 (3.7)|
|‘Runner’ unfamiliar with identity of patients on ward||0 (0.0)|
We asked respondents under which circumstances they would covertly administer medication. Twenty-four (89%) respondents said they would administer disguised medication without the patient’s knowledge if a multidisciplinary team decision had been made to do so. Thirteen (48%) respondents stated that they would administer disguised medication if the patient lacked capacity to make an informed decision. Of these, six commented that this would be contingent upon the multidisciplinary team having made the decision to do so. Five respondents (18%) would administer disguised medication ‘to a patient who has capacity to make an informed decision but refuses’. Eleven (41%) respondents had seen disguised medicines being given but most of these had not viewed this in their current workplace.
Results: Observational Study
Of 12 nurses who were approached, nine (75%) agreed to participate. Participants had been registered from six months to 21 years. We observed 1,423 medication events (1,313 administrations of medicines and 110 omissions) to 32 patients over 36 medication rounds (20 on ward A and 16 on ward B). Medication rounds lasted between 20 minutes and 90 minutes. Similar numbers of morning, lunchtime, teatime and night time rounds were observed on each ward. Medication administration on both wards was conducted in communal ward areas from a lockable trolley. Thematic analysis of our field notes suggested that multiple issues contributed to make medication administration in this setting difficult.
Timing and location of medication administration
With the exception of the night time (10pm) drugs, medication rounds on wards A and B were scheduled to coincide with mealtimes. On ward A the trolley was sometimes situated in the dining area during mealtimes and on ward B it was always located in the dining room during meal times. Medication administration therefore was frequently undertaken in an already busy environment with meals being served and patients being helped to eat. On occasions when medication administration was conducted away from mealtimes or, at least, preparation occurred in a separate area the atmosphere seemed calmer and more conducive to accurate preparation.
Noise and environmental distraction
We noted numerous examples of noise and other obvious distractions. Specific examples included one patient shouting sexual remarks loudly and repeatedly, and another frequently screeching. There were several instances of patients using verbal and physical aggression in the close vicinity of the nurse undertaking medication administration. Distractions were not solely caused by patients; we noted noise from the activity of workmen, distractions caused by other staff making unrelated enquiries during medication administration, telephone calls and pagers. The environment on both wards was often bustling. Administration in the dining room on ward B contributed to cramped conditions, and this was exacerbated by heat and poor lighting.
Of the 32 patients observed during medication administration, 21 (66%) were judged by their consultant psychiatrist to lack capacity to consent to treatment. We noted numerous examples of patients appearing confused, for example patients approaching the medicines trolley and attempting to touch medicines. Thirteen (41%) patients reportedly regularly refused or spat out medicines and 13 (41%) patients had swallowing difficulties (dysphagia). We observed a number of patients spitting out or refusing medicines.
Nurses frequently voiced doubt about the correct procedures for crushing tablets. We noted that a quarter of all solid oral medication doses were crushed before administration. Medicines were sometimes served in food, for example stirred into yoghurt or mixed on a spoon with jam. Food portions with medication in them were frequently left partially uneaten making it difficult to ascertain the dose ingested. Crushed or liquid medications placed in patients’ food did not appear to be done so covertly. Some patients received multiple medications (range 1 to 14 items) at one time.
Single or dual nurse administration
We observed three distinct practices related to single or dual nurse administration. In single nurse administration the administering nurse prepared medications and then gave them to the patient. In dual nurse administration two nurses undertook the medication round together. Sometimes, the second nurse checked the actions of the first (such as correct drug, correct dose) and usually acted as a ‘runner’ by taking and giving medicines to the patient. A third practice used care workers to undertake the role of ‘runner’ and give medications to patients that had been prepared by a registered nurse. Administration of multiple medications was the norm, and the 1,322 doses offered to patients during our observation comprised 404 interactions. Single nurse administration accounted for 108 interactions and dual nurse administration for 207. Care workers administered medication prepared by a nurse on the remaining 89 occasions. On 49 (55%) of these 89 occasions the care worker was in direct sight of the administering nurse, and was out of her sight on 40 (45%) occasions.
Survey of nurses
Nurses working in an inpatient service for older adults with mental illness frequently experience difficulties when administering medicines. The issues most commonly cited as problems in our survey were patient confusion, tablet crushing, swallowing difficulties, patient concordance, and noise or other distractions. Only just over half of respondents (56%) stated that the training they had received was adequate and relevant to their role. Most training undertaken was self-directed (70%). About one in five (18%) respondents said they would administer disguised medicines to a patient who had capacity to consent but refused them.
Some respondents commented on the circumstances under which such administration might be justifiable, usually citing issues of physical emergency such as a diabetic collapse where administration against the explicit wishes of the patient might be life-saving, or in the patient’s best interest. Such views are not necessarily uncontroversial: Kellett (1996) describes a case where a nurse was suspended for administering disguised tranquilising medicine to a hypomanic 91-year old man in a day hospital on the instruction of the consultant. The judgement remained on the nurse’s record even though the consultant was found to be behaving professionally. Our survey demonstrates the need for regular training for nurses incorporating clear guidelines about medication administration, and professional guidance on covert administration of medicines (United Kingdom Central Council for Nursing and Midwifery, 2001).
Our observational study sheds further light on some of the difficulties associated with medication administration, and the development of training interventions and guidelines should incorporate our findings. Noise and distractions during medication administration were apparent throughout our observation. Distractions and interruptions have previously been implicated in error causation in non-mental health settings (Armitage and Knapman, 2003). Arguably, an inpatient mental health ward with numerous confused patients who wander or shout loudly may prove even more distracting. In such circumstances, then, it is hardly surprising if every nuance of policy is not translated into practice.
Nevertheless, we felt that a number of interventions to manage the environment may have facilitated the process of medication administration. Combining medication administration with meal times ensured that these periods were very hectic. This was, in particular, the case on one ward where administration was usually conducted in the dining area. It would be wise to consider separating meal times and medication administration rounds. Nurses conducting medication administration should also pay careful attention to the positioning of the trolley; in particular we noted that placing it in the middle of the room meant that patients could approach unseen from behind. Before starting a medication round checks should be made to ensure appropriate lighting and heating, and to ensure the trolley is fully stocked to help avoid breaks in the administration process. There should be sufficient staffing to ensure that interruptions are minimised.
In this study we observed both single and dual nurse administration, with dual nurse administration being most common. We also observed the use of care workers to assist in administration. Kruse et al (1992) found that double-checking by a second nurse significantly reduces the incidence of medication errors and there is evidence to suggest that specially trained healthcare workers can effectively undertake the role of checker (Dickens et al, 2006). We felt that, on balance, appropriate use of care workers was defensible, but we acknowledge that staffing levels on the wards studied was high and all care assistants were very familiar with the patient group. Training should address the issues of double-checking and the appropriate role of care workers in the medication administration process. Tablet crushing was commonly observed and reported by nurses as being a difficulty. There is a need for adherence to clear guidelines on crushing tablets, including ensuring the prescriber has authorised crushing (who has in turn ascertained the safety of crushing), and training should address this.
Our survey was small-scale and was conducted on one site in a hospital caring for some very challenging patients. The hospital is a charitable sector provider and results may not be applicable to NHS settings. Response rate was moderate (55.1%), and was limited by participant anonymity and our subsequent inability to send personalised reminders. We do not know if non-respondents differed from respondents. Generalisation of findings from our observational study to other areas may also be limited by its scale and independent sector setting. We only report on observable behaviours and not on processes that could not be observed. The presence of observers may have affected the behaviour of nurses administering medicines.
Our investigation indicates that nurses experience many difficulties in medication administration to older adults with mental illness. Regular, standardised training should be provided and this should include guidance on managing the environment, crushing medicines, the use of care workers in administration, and on covert administration. Priority must be given to minimising potential environmental distractions and ensuring medication administration occurs in a calm, quiet setting whenever possible. Reporting of all errors and near misses should be encouraged and individual blame avoided, in order to facilitate an open, learning culture.
Implications for Practice
- Medication administration in psychiatric and elderly care settings provides many unique challenges and difficulties. Safe practice must be a priority. There should be adequate staffing to ensure that there is sufficient time available to plan and conduct medication administration safely.
- Nurses working in these settings should stay updated about issues related to medication and administration. If possible an annual refresher should be provided.
- Nurses should consider the timing and location of medication administration. Carefully consider whether it is safe to conduct administration at meal times, and think about the levels of lighting, noise and other distractions.
- Nursing and multidisciplinary teams should adopt clear guidelines about the delegation of administration to other nurses or care workers, covert administration, tablet crushing and managing patients with swallowing difficulties.
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