Physical health, pharmacology and medication monitoring Let’s get physical May 2008

1. Physical health, pharmacology and medication monitoringLet’s get physicalMay 2008 Sue Jordan Senior lecturer School of Health Science, Swansea University s.e.jordan@swansea.ac.uk

2. ASSESSING EDUCATIONAL EFFECTIVENESS: THE IMPACT OF A SPECIALIST COURSE ON THE DELIVERY OF CARE Jordan S., Coleman M., Hardy B., Hughes D. 1999 ‘Assessing Educational Effectiveness: The Impact Of A Specialist Course On The Delivery Of Care’ Journal of Advanced Nursing : 30 : 4 : 796-807

3. Classroom theory to clinical practice O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, Haynes RB, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000409. Thomson O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(2):CD003030 Lu CY, Ross-Degnan D, Soumerai SB, Pearson SA. Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature - 2001-2007. BMC Health Serv Res. 2008 Apr 7;8:75 Jordan S. 2000 Educational Input And Patient Outcomes: Exploring The Gap. Journal of Advanced Nursing: 31 : 2 : 461-71 • Education input and patient outcomes • Prescribing practice most amenable to change • Passive education least likely to change practice

4. Case study of a single cohort • Course: pharmacology module for community mental health nurses, 30 taught hours 1996-97 • Cohort: all 7 students completing the course and returning to the NHS • Comparators (7) matched from local community teams • Data collection: summer 1996, summer 1997, winter 1997-98

5. Data collection

6. Numbers of nurses not undertaking specified monitoring actions with clients prescribed anti-psychotic medication

9. Educational effectiveness It [the course] has changed the way that I explore things with my clients, like I am much more likely to dig into issues that maybe in the past I didn’t. ... My awareness of the fact that there are things that can make life much easier in terms of measuring for side effects.

10. Attitude Greater awareness of potential adverse physical problems caused or exacerbated by medication, means that I am far more likely to monitor patients’ physical state, and push for blood tests than I was prior to the project.

11. Table 2. Observed changes in students’ clinical practice

12. Kolb learning cycle (1984) R3 Concrete experience Observe sedation Problem: sedated at 6.00 pm. every day Experimentation Approach prescriber to reduce dose frequency Reflective observation Consider causes of sedation Conceptualisation Identify chlorpromazine 4 times daily as likely cause Observation of a community mental health nurse seeing a lady of 37, with a 19 year history of schizophrenia, after the course,

13. Confidence Student immediately post-course: I do feel more confident in my view - now that it is based on knowledge. ... Knowing that things have been used inappropriately, not audited properly, dosages and things are not looked at sufficiently. ... What I am aware of now is the need for a structured assessment, as well as where you perhaps monitor people’s BP and other vital signs and different things like that. I think that is something that should be done on a more structured basis and more regularly, for all, not just if you think that there might be a problem. ... There should be more structured assessment in place.

14. Monitoring physical problems Student, immediately post-course: My views have definitely changed. The big thing for me is how we are just complacent about medication. If people are given medication, yes we monitor the effects, but I certainly haven’t, up to now, pretended to have the knowledge or the experience to look wider than that and look at the physical effects that medication can have on people. I don’t think people have enough tests for their physical problems, just things like ECGs. People are not monitored routinely, and that is certainly something that I’ll be looking at in future.

15. Teaching/ research synergism • The research is going to make sure that I do what I say I’m going to do for the benefit of the patients. Student • The research does make you more aware about practice and how you approach medication, and patients’ responses and the physical aspects of their health. I’d always been aware, but this focuses on it during this time, which is good. Comparator

16. Barriers • Pressure of work • Professional boundaries/ systems • Resistance to change/ knowledge

17. Pressure of work It’s because I’ve got so much of everything to do (...) The girls in our office are very stressed because of the actual numbers of patients.

18. Professional territory Specific and general issues ECGs have been discussed with appropriate consultant, who feels that it is not realistic. Student R5 immediately after the course

19. Specific issues Student, R5, six months after the course: It’s all very well suggesting that Joe Bloggs have an ECG, but if the GP won’t sign the thing, then tough. It’s not done on the ward. If they’ve had a relapse and been on loads of medication, they come back from the ward, but if it’s not done then, when there are no costs attached, what chance of you having it done once they’re out? (...) But I’ve never known anybody have an ECG in my whole ten years of working at (name of hospital), and that’s people who have been on anti-psychotics for 10 or 15 years, in huge doses. (...) We are only going to get frustrated in the end, because we think that someone should have an ECG, but the doctor won’t request it.

20. Three professionals involved

21. Three professionals involved Monitor medicines ?

22. Entrenched attitudes • Resistance to change • Difficulties of change

23. Student after the course: I have increased awareness about certain aspects of my work, which are important, and I don’t have the time to implement or develop. I feel that I am not doing my clients justice, or myself maybe. It’s frustration more than anything. You gain new knowledge, and you can’t really do anything with it, and other people are not really interested or they take the **** out of you because you have ‘gone all academic’. It’s my job, I’m trying to do my job better than I did before so that’s hard. (...) They’re not interested at all. (...) The managers in theory go for it, but with regard to practical support, as in time or space, not really. And I think other colleagues aren’t particularly interested. Everyone feels overworked and undervalued and people don’t want to take on any more, or they can’t.

24. Outcomes • 4/7 students introduced monitoring checklists • 2/7 comparators introduced monitoring checklists + 2 more intending to

25. Numbers of Respondents Introducing checklists.

30. Medication management Prescribe medicines: usually doctors Monitor medicines ? Dispense medicines: usually pharmacists Administer medicines: nurses or patients