Medication administration (MA) is a central focus of the medication nurse on inpatient psychiatric units. MA involves direct patient interactions with nearly, if not all patients on the clinical unit. Direct nurse to patient interactions provide an opportunity for the nurse to begin building a therapeutic rapport with patients. Upon initiating this type of rapport, the nurse-patient trust relationship can be cultivated. Cultivation of this type of professional bond can be the catalyst for therapeutic interventions, including patient compliance with MA. Compliance with MA on the inpatient unit, along with applicable education can lead to compliance with prescribed medications after discharge.

Michelle D (2016) Psychiatric Nursing Medication Administration: Is it just a Med Pass? Ann Psychiatry Ment Health 4(1): 1058.

•    Medication administration
•    Compliance
•    Therapeutic rapport

Current studies investigating the effectiveness and outcomes of interpersonal interactions during structured, inpatient psychiatric MA passes are minimal. The majority of observational studies in this area are rooted in assessing processes aimed at safe and effective delivery of medications based upon basic principles of MA.

Patients in an inpatient psychiatric setting are often receiving new medications or dosage adjustments of medications in order to minimize psychiatric symptoms. As a result, the medication nurse is in a key position to educate, display understanding/ empathy, and build a therapeutic rapport with patients. Education and therapeutic interpersonal interactions are essential since patients often become non-compliant with MA as a result of side effects, lack of understanding regarding efficacy of medication(s) and even a sheer adversity to clinically needing prescribed medications. In the literature, correlations between therapeutic interpersonal interactions between patients and medication nurses were identified [1]. Additionally, other studies [2] identified a direct correlation between a patient’s non-compliance with medication administration and a nurse’s feelings of irritation and overall lack of empathy. Likewise, factors discussing safe and effective MA in order to gain patient compliance were discussed. One factor was related to implementing a more humanistic versus robotic nature during MA [3]. These particular authors discussed how often MA is deemed as a robotic process due to its time sensitive nature.

While these types of studies provide valuable insight into the proficient skill set needed to safely administer medications, little is mentioned about interactions that occur between medication nurses and psychiatric patients during structured inpatient medication administration. Likewise, there is minimal evidence that identifies clear and effective processes for MA within this population. Thus, assessment and astute observations during structured medication passes are prudent strategies for building therapeutic processes while administering medications. These types of processes are becoming increasingly important since emotional outbursts and behavioral changes can quickly emerge during medication time within this population.

An unstructured observational design was implemented in order to observe MA passes overtly on three different inpatient psychiatric nursing units over a three month period. A total of 22 MA passes were observed. MA passes included a medication nurse assigned to the medication room for the entire shift. Patient expectations include coming to the medication room at designated times to received ordered medications. High volume administration times (where most, if not all patients were ordered medications) were after breakfast, before dinner, after dinner and at bedtime. MA passes were observed on the daylight and evening shifts. Medication nurses included both RN’s and LPN’s employed either full time or part time on the respective nursing unit. There were no supplemental or float pool nurses in this role. Each observed unit had an assigned medication nurse on each shift that was solely responsible for MA for all patients on the unit. A consistent focus on answering the following questions was implemented.

1. Are there any consistent outcomes associated with patients who are questioning prescribed medications, including dosages?
2. Are there any consistent interpersonal interactions associated with behaviors displayed by the medication nurse and patient outcomes during MA?

 Setting

A total of twenty two (22) medication administration passes, which included five hundred and twenty four (524) nursepatient interactions at the medication window were observed over a three month period. A total of twelve (12) nurses, both RN’s and LPN’s completed MA. All nurses were members of the nursing staff of each respective unit. No supplemental or float pool nurses were staffed in the medication room. A total of ten (10) nurses were employed full time and two (2) were part time. The mean age was fifty nine (59) and eleven (11) were female and one (1) was male. All observed MA nurses voluntarily agreed to participate. An educational session was held regarding the aim and process of the study three weeks prior to implementation of the unstructured observations. Additionally, MA nurses did not know specific times of the observations, in order to minimize the Hawthorne Effect.

Common themes emerged throughout the unstructured MA observations. Identified themes were merged into each respective research question as applicable.

1. Are there any consistent outcomes associated with patients who are questioning prescribed medications, including dosages?

 Theme

In relationship to patients questioning prescribed medications, changes in medications, including dosages and/or newly prescribed medications the following were observed.

A total of 56 patients became increasingly upset as evidenced by verbal outbursts when no explanation was given by the nurse as to why a medication was discontinued, added, or a dosage was changed. Each of these verbal escalations by the patient were followed by the nurse abruptly stating comments such as “I don’t know why the Dr. changed your orders, ask him tomorrow during rounds”. A total of 18 of these patients became verbally aggressive after the nurse’s tone of voice became abrasive towards the patient. As a result all 18 patients left the medication room angry and did not take any prescribed medications. Additionally, the MA nurse’s frustration based up non-verbal gestures and tone of voice were consistently observed during the above interactions. On each occasion the nurse carried over feelings of frustration with the next patient coming to the medication window. As a result, the majority of these patients fed in to the negativity of the nurse by eliciting negative comments about why medications were needed.

     2.   Are there any consistent interpersonal interactions associated with behaviors displayed by the medication nurse and patients outcomes during MA?

Theme

On a consistent basis, nurses displaying a calm manner and tone of voice were notably more effective in increasing positive patient interactions and medication compliance.

On the contrary, nurses displaying an abrasive manner and abrupt tone of voice were notably more ineffective in promoting positive patient interactions and increased non-compliance with medications. It was also noted on a consistent basis that patients responded positively to nurses that greeted them at the window and expressed thanks for medication compliance. In many of these observations, patients smiled and discussed portions of their daily activities.

Studies cite valuable connections between direct observation, or visually assessing patients during nurse-patient interventions, including medication administration. The integration of one’s senses during observation assists the observer in more accurately describing interpersonal interactions and associated outcomes. Additionally, during unstructured observation, it is imperative for the observer to be open-minded and unbiased throughout the emerging time period [4]. For example, observations should be consistent and holistic, unstructured and focused, with the observer attempting to document as much as possible about the setting and participants in order to identify associated themes. Additionally, the researcher reports in narrative style about observations, interactions, events that align with stated the research questions [4].

MA on inpatient psychiatric units is a time sensitive and highly focused intervention. MA provides the patient the opportunity to ask medication related questions along with building a trusting rapport with the medication nurse. Additionally, this interaction allows the patient to have direct one on one time, if only momentarily with a nurse. Abruptness and or hurriedness on the nurse’s part can elicit negative emotions and behaviors from the patient. As a result, non-compliance with medications and even a sense of unimportance related to the need for medications can ensue. Thus, is it just a med pass? Without a doubt, the answer is no! It is a time to build nurse-patient relationships, foster medication understanding, empower the patient to inquire and take control over medication compliance after discharge and display respect for all patients.

1. Haglund K, Von Knorring L, Von Essen L. Forced medication in psychiatric care: patient experiences and nurse perceptions. J Psychiatr Ment Health Nurs. 2003; 10: 65-72.

2. Carey N, Jones SL, O’Toole AW. Do you feel powerless when a patient refuses medication? J Psychosoc Nurs Ment Health Serv. 1990; 28: 19- 25.

3. Wolf Z. R. Nurse’s Work. The Sacred and the Profane. University of Pennsylvania Press. 1988.

4. Bowling A. Research Methods in Health. Open University Press. 1997.