Ms. Eisenmann is Care Coordination Specialist of Youth Services, Parkview Behavioral Health, Fort Wayne, Indiana.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. This article was written as part of the requirements of an MSN completion from the University of Saint Francis, Fort Wayne, Indiana.
The author thanks Mary Spath, PhD, RN, CNE; Dave Johnson, PhD, RN, CS, BC; Michele Regenold, MSN, RN, BC; and Kelley Kardys, BSN, RN, BC, for ongoing support and guidance during this program revision.
Address correspondence to Carmen M. Eisenmann, MSN, RN-BC, Care Coordination Specialist of Youth Services, Parkview Behavioral Health, 1720 Beacon Street, Fort Wayne, IN 46805; e-mail: firstname.lastname@example.org@aol.com.
Psychotropic medications are frequently used in the treatment of mental health disorders in children and adolescents. Promoting medication adherence through education is an important responsibility of mental health nurses, as adherence to medications during the child and adolescent years can improve overall treatment effectiveness and health (Worley & McGuinness, 2010a). The “how to” of engaging children and adolescents and their families in medication education can be challenging. The purpose of this article is to describe an initiative to revitalize the medication education provided to children and adolescents and their families on an inpatient mental health unit to increase knowledge, adherence, and satisfaction regarding their medication regimens.
Psychotropic medication adherence in youth is a well-documented problem. It has been documented that adherence rates for children taking psychotropic medications range anywhere from 34% to 89% (Hamrin, McCarthy, & Tyson, 2010). The consequences of nonadherence can be enormous and may include low remission rates, high relapse rates, unnecessary disease progression, increased risk of substance abuse, social issues, decreased quality of life, reduced functional abilities, and death (Hardeman & Narasimhan, 2010; Worley & McGuinness, 2010a).
Educating patients regarding prescribed medication is a helpful way to contribute to medication adherence. Education may also be associated with an increase in satisfaction of psychiatric services and a decrease in relapse (Swadi, Bobier, Price, & Craig, 2010). Education provides the patient with a sense of empowerment, improves the sense of alliance between the health care provider and the patient, and assists in the process of obtaining the child’s assent. Obtaining assent is a possible way to minimize nonadherence, especially among adolescents (Costea, Barreto, & Burns, 2008; Kavanagh, Duncan-MacConnell, Greenwood, Trivedi, & Wykes, 2003).
It is important for nurses to know what to include when providing medication education to facilitate accomplishing the goal of increased medication adherence. The following information is important to include when educating on medicine: the goal of medication therapy, target symptoms, potential side effects, consequences of nonadherence, how long the medication will take to work, how and when the medication should be taken, where the medication should be stored, and blood levels that may be needed to monitor efficacy and toxicity (Howland, 2009; Worley & McGuinness, 2010b).
Knowing how to present key information regarding medications is also essential. A report from the Joanna Briggs Institute (2007) stated that an easy-to-read fact sheet followed by discussion was more beneficial for the patient than the use of a fact sheet alone. Clarity, conciseness, and repetition were found to be important regarding medication education and mental health (Hardeman & Narasimhan, 2010; Joanna Briggs Institute, 2007).
When educating teenagers, facts should be straightforward, easy to retain, reinforced with illustration and repetition, and followed with a requirement for the learner to repeat back what was learned (Apa-Hall, Schwartz-Bloom, & McConnell, 2008). An inpatient adolescent psychiatric unit in Australia reported that using a variety of teaching tools is helpful in providing psychoeducation to meet diverse learning needs of the patients. Teaching tools this unit used included verbal interactions, videos, whiteboards, games, and written information (Swadi et al., 2010).
Education in a Group Setting
Medication education in a group setting is an efficient way to deliver information. Recent findings regarding the use of medication education groups, although sparse, indicate positive results. Kavanagh et al. (2003) reported on the results of an exploratory study examining educating acute adult psychiatric inpatients on medications in a group setting. The results showed an improvement in knowledge and insight, but no effect on adherence. The staff observed that the patients asked more questions about medications and had on overall increased interest in learning about medication (Kavanagh et al., 2003). A report from another in-patient psychiatric unit stated that education programs should be structured and systematic (Hätönen, Suhonene, Warro, Pitkänen, & Välimäki, 2010).
Tankel (2001) reported on a medication education group and game approach and stated that interactive educational activities can be particularly helpful for group settings to promote learner engagement and participation. Adding a game could provide an enjoyable learning environment that reinforces learning (Tankel, 2001). Billings and Halstead (2009) asserted that games can improve learning retention, motivate and engage learners, promote interpersonal learning, and provide immediate feedback.
Involving family in the education process is also important. Hardeman and Narasimhan (2010) reported that family involvement can decrease relapse and support medication adherence. Using a multifamily group approach to education is an intervention that may also decrease relapse, promote recovery, and increase knowledge level. It has been shown to be more effective in decreasing relapse and improving recovery than individual family work (Mullen, Murray, & Happell, 2002).
Identification of a Need
Working as a nurse on an acute child and adolescent inpatient psychiatric unit presents many challenges. Short hospital stays, high nurse-to-patient ratios, and floating between units can limit time with patients and decrease the ability to create patient-provider relationships. These issues may impair nurses’ ability to provide adequate medication education to patients; therefore, mental health nurses are challenged to find creative ways to meet the educational needs of patients. Nurses may ask themselves: What do the patients need to know about taking medications? Am I using evidence-based techniques when educating my patients? Are my patients receiving adequate information regarding their medication? These factors were all taken into consideration as the nursing staff on our inpatient unit assessed the medication education provided to our patients and their families.
Our inpatient mental health unit is composed of an 18-bed hall for adolescents (ages 12 to 18) and a 16-bed hall for children (12 and younger) located within a hospital-affiliated mental health inpatient facility. The average length of stay is 3 to 6 days. Patients are admitted into the hospital with diagnoses such as bipolar, major depression, anxiety, substance abuse, and psychotic disorders. A psychiatrist assesses each patient on a daily basis for medication management and review. Common medications prescribed include antidepressant, anxiolytic, antipsychotic, and anticonvulsant agents. Some patients who have never taken psychotropic medications are prescribed medications while in the hospital. In other cases, the inpatient stay is often a time to modify a patient’s medication regimen. In either case, medication education is crucial for patients and their families with regard to the purpose, side effects, and safety precautions of these psychotropic medications.
As in most facilities, efforts to improve the quality and outcomes of care are recognized as essential components of health care delivery. Therefore, process improvement projects that include staff member participation are initiated when a need is assessed. The focus of one particular project on our unit was medication education. This team included two staff nurses, the unit manager, the unit social worker, and the care coordination specialist (C.M.E.).
The need to revise and potentially improve our medication education on the children and adolescent unit was rooted in three assessment indicators. The first indicator was based on an item on our Press Ganey™ survey. Every family is given the opportunity to fill out this Likert-style satisfaction survey, which is used by 50% of hospitals in the nation to improve performance (Press Ganey, 2011). One item on the survey addresses how well nurses provide information regarding medication. Many patients and families on our unit do not respond favorably to this item, reflecting a need to improve the medication education process. A second factor regarding the need for improved education is that many of our patients, particularly on the adolescent unit, come into the hospital admitting that they have not been adherent to their medication schedule. Some of these patients have been previously hospitalized in our facility or one similar to ours. Finally, the third factor was the wide variability regarding when numerous nursing staff provide education. We decided it would be important to streamline the process of providing medication education to ensure our patients were receiving appropriate information. Nurses often voiced a need for additional resources when providing education to patients and family members.
Current Medication Education
The team then assessed the current medication program to plan for revisions. The current medication education program consisted of weekly nurse-run medication education groups provided to both the children and adolescents. Topics in these groups include name, dosage, and purpose of medication; time medication should be taken; safety precautions when taking medications; side effects; and medication interactions. Teaching strategies used by the group leader included fill-in-the-blank worksheets and a “medication ball game,” where the patients take turns reading and answering questions about medication that is written on the ball. This group is led by the care coordination specialist, who has 7 years of psychiatric nurse experience and is board certified in psychiatric and mental health nursing.
Also discussed was a previously existing medication education group program for parents led by one of the psychiatrists who specialized in child/ adolescent mental health. In the past, these sessions were generally well attended and appreciated by families. However, the program was abandoned several years ago due to the psychiatrist’s change in responsibilities and time constraints. A review of these interventions for the existing program was conducted as a foundation to deciding on revisions and/or additions for this new program initiative.
Planning for the Program Initiative
Based on our examination and discussions of the existing medication education program, the team identified the following goals for providing medication to our patients and their families:
- Improve the quality of medication education provided to both patients and their families through the use of a variety of evidence-based teaching strategies.
- Increase patient and parent engagement in learning.
- Involve parents in medication education by providing a weekly session for parents/guardians.
- Improve respondent feedback on the Press Ganey survey item regarding nurse-provided medication education.
Because we have such a short length of time with our patients, who have diverse educational needs, we wanted to provide additional evidence-based interventions to improve our medication education. When reviewing the literature, we decided that adding a game, providing fact sheets, and creating a medication education group for families were evidence-based interventions that could help us meet our goals.
Revised Program Contents
In keeping with the goals of the program to empower individuals through knowledge, the primary educator (care coordination specialist) of this program believed it was important to use humanism as an underlying educational framework during the revision, implementation, and evaluation. A primary focus of this theory is helping individuals learn how to attain knowledge and how to ask questions.
The nurse-run medication education groups for the children and adolescents continued to be provided as described previously. The children’s group meets for 30 minutes one to two times per week. No additional interventions were added to the children’s unit group. The adolescent group meets for 1 hour two times per week. The first group session for the adolescent patients consists of the fill-in-the-blank worksheet and “medication ball game,” as mentioned previously. To increase the engagement of the adolescent participants, we created a quiz show-type game that is played during the second group session. The game’s categories include: My Meds, True or False, Classes of Meds, Abuse, and Miscellaneous. The questions included in the game are a review of the material covered in the medication group. Sample questions from this game include:
- Pick one of your medications and state two potential side effects.
- Should you take your medication with food?
- What class of medications can take up to 4 to 6 weeks to be at full therapeutic effect?
- Name three potential complications that can happen when alcohol is mixed with medications.
Another strategy we used to evaluate knowledge attainment was to ask the patients at the end of the medication group, “What is one thing you learned in this group?” Asking the patients to paraphrase what they have learned is an important teaching strategy when working with children (Apa-Hall et al., 2008).
Medication education sheets containing bullet points of commonly prescribed psychotropic medications for patients and their parents were created and distributed. These were created to ensure patients and their families were receiving adequate information regarding their medication. The handouts provided essential information on a particular medication, including purpose and benefit of the medication, time of activation, and side effects. The handouts were used during the medication groups and were accessible to the unit nurses and psychiatric technicians for distribution to patients and their families. An example of a handout is provided in the Figure.
Figure. Sample medication education handout.
A final part of our team’s plan was to develop a nurse-run parent medication education session. This group was also provided by the care coordination specialist. The group met for 1 hour every Monday evening. A Microsoft® PowerPoint® presentation was created and then presented during each session. The topics of the presentation included signs and symptoms of common psychiatric illnesses in children and adolescents, classes of psychotropic medications, side effects, and frequently asked questions regarding psychotropic medications. A discussion and question-and-answer period followed each presentation.
Every parent/guardian who had a child admitted to the child or adolescent unit at the time of the group was invited to attend the parent medication group. On their child’s admission to the unit, parents/guardians were given a handout inviting them to the group. Flyers were also posted on the unit. Unit nurses, psychiatric technicians, social workers, and family therapists were educated on the purpose of the group and were asked to encourage and stress to parents the importance and potential benefits of their attendance.
Medication Education Groups for Adolescent Patients
The nurse-run medication education groups for adolescents are mandatory, and therefore are well attended. A challenge of these groups is attaining and maintaining enthusiasm and engagement, as many adolescents find the topic of medication “boring.” Adding the quiz show-type game to these groups sessions aided in the goal of increasing active participation and enthusiasm. At the end of the group session, the adolescents are each provided an opportunity to share thoughts on the group session. The educator asks the patients questions such as “Do you think this is a good way to learn about medications?” and “Do you have any suggestions on how to improve this group?” Comments at the conclusion of the sessions were positive. Adolescent comments included, “This was a really fun way to learn about medications!” and “I learned things I didn’t know.” In addition, ending the group with having the patients identify one thing they learned reinforced what they learned and assured the nurse that the patients did retain the information.
Medication Education Handouts
In regard to the education handouts, the primary educator of this program (care coordination specialist) asked nurses on the unit the following questions:
- Are you using the handouts?
- What feedback have parents given you regarding the handouts?
These questions were asked via short face-to-face interviews with six RNs who worked primarily on the children and adolescent unit. Nursing staff voiced gratitude for the accessible and reader-friendly medication handouts. The nurses believed they aided in providing consistent information regarding medication. However, nurses reported that additional medication sheets are needed, as we currently have handouts for only 22 medications. Also, nurses reported that they sometimes “forgot” the handouts were available and would welcome continued encouragement and reminders to make these available to patients and parents. When the handouts were used, the nurses reported hearing positive comments from families who appreciated the simplified, need-to-know information provided. In the future, it may be helpful to place copies of the handouts in areas accessible to parents to increase availability. Another suggestion is to give the appropriate handout to the parents when consent for medication administration is obtained or along with discharge instructions when the patient is released from the hospital.
Medication Education Group for Parents
Attendance at the parent medication education group has been disappointing. The sessions have been conducted weekly over the course of 15 weeks. A total of 9 families have attended, with one family attending two times. Total number of families that could have attended is approximately 245. One parent from each family generally attended the session. The majority of the parents have been from the children’s unit (8 of 9) and the child (patient) has not attended the group. Each attendant was given a handout of the PowerPoint presentation, followed by an informal discussion of medication education. The discussion was tailored to the needs of the families represented. Parents were engaged, and questions were encouraged by the group leader.
Each family that comes to the group is given a Likert-style evaluation form with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The evaluation form asked for feedback on the following statements:
- The format of this class suited my needs and kept my interest.
- This class was well organized.
- The knowledge and delivery style of the presenter enhanced my learning.
- Overall, I would rate this program as beneficial to me.
Eight evaluation forms were returned. Seven of the eight evaluation forms reported strongly agree on all four statements, and one form reported agree on all four statements. Additional comments such as “Thanks for taking the time to do this” and “I always wanted to know what my son’s medication was for and how it worked” were stated by those who took advantage of the medication education session. Another outcome from this group was that participants were able to share experiences, concerns, and frustrations with one another, which provided them with additional support and a feeling that they were not alone in having a child with a mental illness.
It is not clear why the parent group has been poorly attended. Based on information from staff members and conversations with several families who did not attend the educational sessions, it is concluded that possible reasons for nonattendance included transportation barriers, time constraints, bad weather, lack of understanding of the importance of medication education, and disinterest. As such, the process improvement team discussed ideas to improve attendance by providing incentives (i.e., food, gas gift cards, or prizes), offering the group on a different day or at multiple times during the week, changing the format of the group to an informal question-and-answer session, involving a psychiatrist, and videotaping sessions and having them available during visiting hours.
Implications and Conclusion
Providing medication education to patients is an important aspect of the nursing role. Having successful interventions in place may help promote medication adherence in our patient population, as medication adherence is an essential part of mental health care.
Providing such education to adolescent and children patients and families on an inpatient psychiatric unit can be challenging. Creativity, energy, and perseverance are important qualities in providing this type of education. Equally challenging are finding ways to revise and revitalize existing programs to promote better patient and family education. This article describes one unit’s attempt to improve the medication education provided to patients and their families. Interventions included adding a game during one of the adolescent medication education groups, creating medication education handouts, and developing and implementing a medication education group for parents/guardians. The adolescent patients enjoyed the group activities and were able to identify one thing they learned. The medication handouts were well received and appreciated, although not always used. The parents/guardians who participated in the medication education group gave positive feedback.
Although we did not find improvement in our Press Ganey satisfaction scores, we were not able to segregate the responses of those who participated in the parent sessions from those who did not; therefore, these findings are not reliable. In the future, it is recommended that evaluation of this medication education program be more specific to the program rather than heavily relying on the results obtained from the Press Ganey survey. In conclusion, we believe our initiatives improved patient education and are an initial step in increasing patient and family engagement in learning.
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