Critical reflection on practice

This article reflects on the change in practice at the Devon Partnership NHS Trust (DPT) in the south-west of England at a time when the secure facility based at the Langdon Hospital site consisted of four medium secure, two low secure and two open psychiatric in-patient rehabilitation wards.

Patients residing at Langdon Hospital had complex and specialist mental health needs. Connelly House was an OT-led, six-bed, open psychiatric rehabilitation in-patient ward situated on the Langdon site. Patients at Connelly House were deemed to be suffering from a serious mental illness that reached the threshold of risk requiring formal detention under a section of the Mental Health Act 1983 (MHA). Under the MHA, patients’ capacity to consent to treatment was formally assessed and the majority of patients at Connelly House were deemed to have good insight into their illness as well as capacity and had consented to their treatment. Connelly House transitioned from a traditional nurse-led in-patient ward to an occupational therapy-led ward focusing on individual's occupational skills and enabling a smooth transition to the community as part of a site-wide service development between November 2016 and December 2019. One of the most significant challenges to the change in service provision was that of medication management, primarily supporting the self-administration of medication.

The occupational therapy approach to medicines management in Connelly House was specifically focused on supporting the self-administration of medicines rather than administering medication to a patient. The Royal College of Occupational Therapists has recognised that any activities to enhance patients’ occupational performance may be considered within the professional scope of practice.¹⁰ Therefore, OTs at Connelly House endeavoured to support patients transitioning into the community to independently manage their medication through a graded rehabilitation programme designed by the Medicines Optimisation Team.

The switch to an OT-led provision necessitated the development of bespoke modified framework policy and procedures to ensure the legal, safe and effective delivery of care to Connelly House patients. More detailed research and specific national guidance on management of medication for OTs are required. Therefore, owing to the limited training available (and relative inexperience) for OTs managing medication in an in-patient environment, the change was carried out in a planned, stepwise and graded manner described in detail later in this article.

The first phase of the transition lasted approximately 19 months and saw OTs leading ward management duties including, but not limited to, shift planning, staffing and risk assessments. At the same time, patients attended a neighbouring ward so a registered nurse could administer medication. Although this process for medication administration was neither sustainable nor particularly patient-focused, it was necessary as part of a safe transition between programmes. During this period, de novo processes and polices had to be created and ratified at relevant DPT governance groups. Enhanced medicines training was provided to OTs during the transition period, which enabled initial teething problems to be identified and rectified before OTs took the lead on the management of medication unsupported by nursing colleagues.

The second phase involved OTs taking over the management of medicines on the ward, removing the requirement for patients to visit the neighbouring ward for the administration of medication by a nurse. During both the first and second phases, the OTs at Connelly House were regularly supported by pharmacists and pharmacy technicians and feedback was shared between the disciplines.

Training

The OTs working in Connelly House were required to complete enhanced medicines training facilitated by the Trust's Medicines Optimisation Team (Table 1). This was to ensure that they had the appropriate knowledge, were able to identify sources of information to enable a safe and effective service and could act as autonomous professionals in relation to the management of medication.

Table 1 Training requirements for occupational therapists (OTs) to be authorised to manage medicines in Connelly House

Training was an essential part of the project. The structure of the training provided to OTs was largely based on the existing provision for medical and nursing colleagues. It was acknowledged that OTs have different knowledge, awareness and skill set and it was important for the training to provide all OTs with the information and confidence to facilitate effective and safe medicines management. Face-to-face and individualised training allowed OTs to ask questions and allowed the assessor(s) to ensure that both parties were in agreement before the OT was signed off as competent to manage medication in Connelly House.

Service provision

OTs were present at Connelly House between 07.30 h and 20.30 h. Outside of these times there were no qualified OTs or registered nurses present on the ward; instead the ward was led by healthcare assistants and support workers, with support available from qualified nurses from other in-patient wards across the secure hospital site. Therefore, between 20.30 h and 07.30 h medicines were either self-administered by the patient or administered by a qualified nurse called to attend from another in-patient ward. Out of hours the medication keys were securely stored with a qualified nurse on another in-patient ward. Connelly House did not hold controlled drugs subject to special storage requirements; this was something that was being considered during the process, but it never manifested.

Self-administration of medication

The DPT self-administration of medication scheme (Table 2) was aimed at empowering patients to take an active role in managing their medication. This formed an integral part of the patient's recovery as well as encouraging them to learn about and take responsibility for their own treatment. Typically, the scheme was followed by registered mental health and intellectual disability nurses, who routinely managed medicines on in-patient wards. However, in Connelly House OTs had been trained and were authorised to follow the same process.

Table 2 Summary of the Devon Partnership NHS Trust self-administration of medication scheme

The scheme consisted of three stages that reflect the individual's knowledge and ability to manage their own medicines correctly. The multidisciplinary team (MDT) reviewed progress with the patient at regular intervals (usually during ward rounds/care review meetings). Movement between stages within the self-administration of medication programme was fluid, dependent on the individual's demonstrated ability, needs, goals and any relevant associated risks. If at any time it was deemed unsafe to continue on a particular stage of the scheme, this was communicated to the MDT and consideration given to reducing the stage accordingly.

OTs were limited to supporting the self-administration of medication, rather than directly administering medication to a patient. Connelly House had strict referral criteria, accepting only patients who were on stage 2 or 3 of the self-administration scheme or the equivalent. Initially, patients admitted to Connelly House were predominantly on stage 3 of the scheme, requiring few medication changes and with fairly simple medication regimes. However, as Connelly House evolved over time there were more patients on stage 2, with complex medication regimes requiring more frequent medication changes. Owing to the positive management of this change, Connelly House moved to a position of accepting referrals of patients who perhaps might not have initially been appropriate when the ward first switched to being OT-led.

Patient specific directions

The OTs followed patient specific directions (PSDs),¹¹ which had been agreed by the ward's consultant psychiatrist. Under UK law, a PSD is a legal document that is written by an authorised prescriber (either doctor, dentist or non-medical prescriber). The legal document must comply with Human Medicines Regulations 2012.¹² Across the DPT and at Connelly House, the prescription and administration chart was the document that acted as the PSD for OTs to follow. The front of each prescription and administration chart included the following statement:

Accompanying this was a specific care plan on the patient's electronic medical records. The following shows an example of a statement in a care plan:

Careful consideration was given to this new way of working and a thorough procedure was ratified following discussion at the DPT's Medicines Optimisation Governance Group, Directorate Medicines Optimisation Governance and Directorate Governance Board meetings. It is important that for OTs to manage medicines in Connelly House, it was clear that these OTs would not be administering medication, but rather supporting the self-administration of medication by patients on the ward. In light of this, it was paramount that OTs acted within their professional competence at all times when ensuring the safe and appropriate management of medicines.

At the time of writing, to our knowledge, there has been no research on the processes, implementation and effectiveness of OT practitioners following PSDs as a method of intervention within secure psychiatric rehabilitative in-patient services.

Feedback

Following the change in service provision in Connelly House, notable developments occurred. These included representation from Connelly House at the Langdon Hospital Medicines Optimisation Governance Group and increased communication and joint working between OTs and the Medicines Optimisation Team. There was also a positive learning culture embedded and the reporting of medicines-related incidents was promoted. Medicines-related incidents were reviewed and compared with those from Connelly House before the change in service provision – it was identified that the incidents reported by OTs were predominantly low in severity. The Medicines Optimisation Governance Group promoted a culture of incident reporting in order to identify trends, learn from incidents and change processes to reduce the risk of similar incidents in the future. Reporting medication-related errors within the Trust's incident reporting system formed part of the training for OTs before the service change.

A small sample of both patients and OTs were surveyed regarding their experience of the management of the self-administration of medication in Connelly House. The questionnaires integrated widely applied occupational therapy models,^{Reference Couldrick and Aldred13} primarily the principles within Kielhofner's model of human occupation (MOHO).^{Reference Kielhofner14} Volition, habituation, performance capacity and environment were utilised as concepts within the questionnaires to maintain the occupational therapy focus. The feedback sample was small and comprised the six residing patients and nine OTs involved in regularly supporting the self-administration of medication in Connelly House. The Medical Research Council/NHS Health Research Authority self-assessment form was completed in September 2019, which stated that ethical approval was not required as the work was a service development project rather than research. However, before submission of this article for publication, written informed consent was obtained from both patients and staff for the use of the information gathered from the questionnaires. The two short questionnaires were anonymised and contained five closed questions.

All patients identified the importance of having an established medication regime, and five out of six acknowledged an increase in their confidence and ability to manage their medication and in feeling able to maintain their established routine in the community (Table 3).

Table 3 Connelly House in-patient medication questionnaire – responses from six patients residing in Connelly House

Although the sample was small, the general opinion among the OTs was that, as a part of their role, they had developed the skill set and awareness to support and facilitate the self-administration of medication scheme. The majority said that they felt confident or very confident in their skill set to support patients in the self-administration of their medication (Table 4).

Table 4 Connelly House occupational therapist medication questionnaire - responses from nine occupational therapists who were involved with the management of medication in Connelly House

Interestingly, the feedback highlighted a significant disparity of opinion between patient and OT views regarding the environment in which the patients were supported with their medicines. The majority of the OTs identified feeling the environment was not fit for purpose, whereas all the patients considered it fit for purpose. Owing to the relatively small space available in Connelly House, medication was stored in the main office area, and at times distractions in the area made it difficult for OTs to concentrate on sorting medication. This prompted an alternative and more appropriate room to be identified within the building where the medicines cupboard was later moved.

The samples for each questionnaire were small and the restriction on the range of answers to the questions might have biased responses and limited the depth of analysis. However, for the purposes of this practice analysis, the questionnaire responses provided promising feedback in support of Connelly House OTs’ ability to manage medicines and their development of the appropriate skill set to support and facilitate the self-administration of medication scheme after they had completed the relevant training.

Summary

The support and interventions described in this article occurred following strict governance oversight, agreement and a detailed training plan. OTs followed PSDs as agreed by the MDT, which included a consultant psychiatrist. The number of reported medicines-related incidents increased during this period. This was recognised as a positive outcome because the reported incidents were deemed to be relatively minor in severity, prompting discussion and learning at the hospital Medicines Optimisation Governance Group. Overall, the feedback from patients and OTs was positive, highlighting that the service provided was well received. The Connelly House approach to facilitate the self-administration of medication within a psychiatric rehabilitation in-patient ward opens the doors for OTs in other regions to develop and fulfil similar roles and responsibilities in the future.

Key messages

• • OTs can facilitate patient independence in the self-administration of medication

• • OTs are an integral part of MDT discussions and should be part of discussions involving medication

• • Robust processes, training, governance and a suitable environment are essential for OTs to manage medication