Essay: Self administration of medicines (SAM) schemes

Enabling patients to manage their own medication while in hospital has been around for more than half a decade. When leaving nursing some 20 years ago giving patients control of their medication was not widely practised nor was it the integral part of NHS medicine management it is today. Self administration of medicines (SAM) in the hospital setting came to the fore in the UK when it was nationally recognised by the National Service Framework for Older People (2001) which required all hospital, where appropriate, to establish self administration for medicines schemes for older people. This was swiftly followed by the Audit Commission’s briefing paper on SAM in 2002 and in the same year it was introduced as a performance indicator set by the Health Care Commission (Richardson et al., 2014; Wright et al., 2006). A few years later the National Service Framework for people living with long-term conditions (Department of Health, 2005) while not directly referring to self-medication, a strong emphasis was placed on the self-management for individuals with complex long-term conditions paving the way for more active patient involvement in their care, including medicines management. On returning to nursing practice in 2016 it was evident that SAM was part of good nursing practice and firmly embedded within the Nursing and Midwifery Council’s (NMC) Medicine Management standards and practice since 2007.
The term self administration of medicines (SAM) was define by Salmon (2002) as “selected patients being responsible for storing and administering their own medicines, with the nurse and pharmacist acting as educators and supervisors of this process. This system of medicine administration ensures that drugs are correctly and safely taken and that patients have a better understanding their medicines and drug regime”. The philosophy behind SAM according to NHS Education for Scotland (2012) is the belief that patients should be as independent as possible, should participate in their own care, make decisions about their treatment in partnership with nursing, midwifery, medical and pharmacy staff, and therefore be able to make informed choices. The purpose of SAM, was summarised by the National Prescribing Centre (NPC) as the following three aims:
(1)“establishing ‘a standardised approach for determining the ability of patients to take their own medication correctly,
(2) safely increasing the patient’s knowledge and understanding of their medication, and
(3) promoting and maintaining patient independence and autonomy’”(Richardson et al., 2014).
There has already been three literature reviews into this subject area over the past twenty years by Richardson and colleagues (2014), Wright and colleagues (2006) and Collingsworth and colleagues (1997). A number of themes emerged from these reviews including patient compliance, drug errors, patient satisfaction, staff satisfaction and workload. This literature review will examine the existing research and publications to determine how effective SAM schemes have been in achieving the above three aims as defined by the NPC. The review will focus primarily on the impact of SAM on nursing practice within the NHS and will be limited to publications in the English language, primarily from UK.
The initial intention was to focus on more recent studies and articles however as both the 2014 and 2006 reviews drew on research that goes back more than 10 years it was therefore felt necessary to include older research where more recent studies are not available. The literature search also involved key word searches in the NICE evidence archives, Google scholar, and the Staffordshire University online library resources.
 
Aim 1. A Standardised Approach
The first SAM aim to be explored its role in establishing “a standardised approach for determining the ability of patients to take their own medication correctly “(NPC,2002). Fundamental to this standardised approach is a nursing assessment that ensures the patient has the mental capacity to give consent and are capable of safely perform the self administration task. According to the criteria established within The Mental Capacity Act 2005 the nurse’s assessment should consider whether or not patient can read a medicine labels, can understand dosage instructions and open medicine containers or packaging. Given that the patient’s health, and thereby their mental capacity, may fluctuate while in hospital it is important that this assessment process is not simply a ‘one-off’ event and that the nurse regularly checks mental capacity to ensure that the patient is still able to safely self-administer. According to NMC (2007) guidance professional judgement is needed when the nurse is deciding whether it is safe to transfer responsibility for medicines administration to the patient. SAM will not be appropriate for all patients, such as those with a history of substance misuse, therefore if the nurse is “at all unhappy to let the patient self-administer, then the patient should be excluded and reassessed at another point.” (NMC, 2007)
A key element in the nursing assessment is ensuring that patients are competent in self administration and safe to administer their own medication. Past studies have indicated that health professional are not always good at predicting the patient’s ability to perform activities, such as self administering their medicines (Applegate et al., 1990). To assist nurses in their role of assessing patient competency and ensuring greater consistency across practitioners, a number of assessment tools have been developed assessing the patient’s capacity and capabilities for SAM. The SAM tool-kit for practitioners developed by NHS Education Scotland (2012) recommended that a robust, objective, validated tool should be used to assess a patient’s ability to self-administer. Their tool-kit however only offered one example and without reference to supporting research evidence showing its validity and reliability. Available SAM assessment tools are varied though, according to Anderson and colleagues (2014), only three are comprehensive and consider patient functional ability, cognition and medication knowledge, such as the Self Medication Risk Assessment Instrument developed by Fuller and Watson (2005). Manias and colleagues (2006)also developed and tested a simple SAM assessment tool which was found to be both reliable and valid. It was difficult to know how widely any of these tool are used by nursing staff across NHS trusts. Both the 2014 and 2006 literature reviews on SAM (Richardson et al., 2014; Wright et al.,2006) did not consider in any depth the assessment process or tools. Only one recent Australian study testing a SAM tool could be found (Anderson J et al., 2014). Anderson and colleagues (2014) recommended nurses use a SAM tool as it provided a more objective measure to ensure patient competence rather than relying on variable subjective appraisal. They also felt that using reliable and valid tools may given nurses and other health professionals the confidence to overcome any reluctance to allow patient’s the opportunity to participate in the self-administration of medicines.
Based on the limitations of this review it is difficult to establish to what extent a standardised approach to SAM risk assessment has been used across the NHS. Given that other standardised and well tested tools now widely used in nursing assessments, such as the Waterlow Score, it is difficult to understand why a similar approach has not been adopted in respect of the SAM assessment. Standardising SAM assessment processes and procedures may go some way towards ensuring greater compliance with promoting good practice.
Determining compliance with the SAM protocols and assessment processes was also not considered within the scope of Richardson and colleagues (2014) and Wright and colleagues (2006) literature reviews. They did however explore health staff satisfaction and workload which can impact on the implementation of SAM protocols. According to Richardson and colleagues (2014) most studies found that nursing staff were generally positive about SAM schemes. They cited a the study by Desborough and colleagues (2009) where 91% of staff preferred to use SAM schemes and reported benefits from using the scheme. On the negative side the same staff reported SAM as being time consuming, increasing work stress and workload (Richardson et al., 2014). A Canadian non RCT study by Jensen (Richardson et al, 2014) found that despite high staff satisfaction levels with SAM, only a third (34%) of nurse participants would have chosen to use SAM schemes rather then the traditional nurse administration of medications. Whether this division between theory and practice is due to the pressures on nursing staff, the time it takes, the work stress and workload was not established. It is also unlikely that these negative pressures on nursing staff will have changed and are more likely to have increased given the constant organisational change faced by the NHS, coupled with pressures on hospital beds and a reduction in the average length of patient stay. Much of the research conducted into SAM was at a time when the average length of patient’s stay was much longer; e.g. 10days in 1990 (OHS,2008) and this has now fallen to 5.2 days (HSCIC,2013). More recent anecdotal evidence that nurses are still expressing stress and workload pressures associated with SAM was found in a study by Lindsay and colleagues (2014), though the numbers of staff involved were low.
Aim 2. To Safely Increase the Patients Knowledge and Understanding of their own Medication
The second NPC aim focuses on the role that SAM plays in ensuring the patients know and understand their medication. Ensuring patients are knowledgeable about their medication is essential given that patients, after a short stay in hospital, will generally return home and manage their own medications. Educating patients about their medication prior to discharge is also felt to be an important preventative measure, and helpful in preventing the likelihood of re-admission due to drug errors. According to a recent study 5-8% of unplanned hospital admissions are due to medication issues related to failures to monitor and properly encourage and instruct the patient (Frontier, 2014). Significant cost savings could therefore be achieved through preventing admissions by improving patient education by nursing staff and other members of the multi-disciplinary team.
SAM scheme’s patient education has played a key role in improving the patient’s knowledge and understanding of their medicines which can be linked to improvements in ‘drug compliance’ (taking medication as prescribed) and a reductions in drug errors. Both Richardson and colleagues ( 2014) and Wright and colleagues (2006) reviews looked into studies about the patients\’ knowledge of their own medicines in areas such as drug names, purpose, appearance, dosage, frequency (or time of administration), and side-effects. As these studies did not use similar tools for measuring patient knowledge, compliance and drug errors it was difficult for the researchers to make comparisons and draw any firm conclusions. They also found the terminology used varied between the studies though the outcome measures were often the same. Despite these limitations Richardson and colleagues (2014) found that just under half (8 of 19 studies) showed a positive improvement in the patients’ knowledge of their medication attribute to the education provided within SAM schemes. Likewise SAM patient education significantly reduced non-compliant behaviours (e.g. varying the recommended medication management) at the point of discharge and a non-significant increase in compliant behaviours (e.g. having strict routines for regular medication use) in a recent study by Lam and colleagues (2011). Other studies in this area while largely descriptive also reported compliance to prescribed medication ranging from 40% to 100% (Richardson et al, 2014).
Both literature reviews (Richardson et al., 2014; Wright et al., 2006) found an increase in patient knowledge of their medicines in four out of five Randomised Controlled Trials (RCT) in SAM participants when compared with the control participants. However, according to Richardson’s and colleagues (2014) review, this benefit did not always last beyond discharge from as shown in Trapp and colleagues 1998 comparison of compliance over time. Trapp and colleagues were unable to identify factors that would account for these changes due to design limitation. However a more recent review into medication errors by Keers and colleagues (2013) showed the factors were often complex and multi-factorial.
Few studies appear to have compared differing approaches and tools available to nursing staff for assist with patient education within SAM scheme. Richardson and colleagues (2014) review cites a 20 yr old study by Wanless and Davie work in 1977 which interestingly showed that patients made significantly more drug errors after receiving standard verbal instructions regarding each drug and a calendar aid than patients who had received the standard verbal instructions and a medication card. A third group receiving only verbal instructions made significantly more errors than both of the other two groups. Despite its age this study raises questions about the nurses role appropriate approaches to patient education including the use of aid memoires.
While the evidence is mixed about whether SAM patient education will significantly reduce drug errors and improve drug compliance, this is still an important role for the nurse supported by the NMC (2007). There is a danger that recent innovations, such as blister packs,while helpful to patients whose mental capacity is impaired in ensuring drug compliance there is a danger if not used appropriately it can turn medicines administration into a ‘robotic task’ (RPS, 2013). It could lead to a gradual loss in the knowledge and understanding of the patient’s medicines by nursing staff and compromise their ability to educate those patients who have the capacity to self administer . It is therefore important that nursing staff maintain and practice their skills in educating patients to become more knowledgeable about their medicines as part of good nursing care.
Educating patients about their medicine is still an important role for nurses, despite the limitations of the research evidence. Many nurses have taken on the role of prescribing and The National Institute for Health and Care Excellence guidance requires all prescribers to, ‘when possible, support patients to take responsibility for their medicines and self-manage their conditions’ (NICE, 2012). The task of supporting SAM is not wholly the responsibility of nursing staff as SAM has an impact on the role of the pharmacist too. The NHS Education Scotland’s SAM Toolkit (2012) indicated that both nurses and pharmacists had a role in patient education and assessment. The recent joint publication by the Royal Pharmaceutical Society and the Royal College of Nursing‘ Working together to help patients make the most of medicines’ (2014) advocated the need for closer partnership between nursing and pharmacy staff in medicines management including patient education. The report also highlighted some of the barriers which make multidisciplinary team working difficult to achieve in the busy work of the NHS such as professional language, communication and resource constraints. Despite these limitations it only by working in partnership that the best outcome in medicines management will be achieved for the patient.
Finally patient education about their medicines is also a preventative measure which could play a role in reducing the number of preventable readmissions due to non-compliance with medication or medication errors. Despite the cost savings to be achieve this does not appear to have been an area subjected to further analysis and research.
Aim 3. Promoting and Maintaining Patient Independence and Autonomy
The final and third aim of self administration of medicines in hospital is the promotion and maintenance of patient independence and autonomy. This NPC aim acknowledges the value of the patient’s own expertise, which is particularly important when they have a long term condition and have managed their own medicines prior to hospitalisation. In this section we will consider how nurses have responded to this shift in professional control and seek evidence of whether empowering the patient through SAM schemes has impact on either the individual patient’s experience and structures/culture within the NHS.
The traditional method of nurse led medicine management within hospital has supported the patient in adopting a passive role while in hospital. The move towards the SAM philosophy in medicines management has required nurses develop new skills for encouraging more active participation and involvement by the patient. In promoting independence and greater involvement the nurse ‘s focus move from professional control to working alongside the patient in responding to the patient’s care needs, as well as acting as an educator and role model. Individual nurses have been at the forefront of promoting the shift towards self management and the patient independence within the NHS, through initiatives such as the SAM schemes and Expert Patient Programme (EPP) in managing long term conditions.
The changing focus towards promoting patient independence and autonomy stems from an underlying economic need for patients to take more responsibility for their own health and well-being. In addition greater patient autonomy has been shown to achieve better healthcare outcomes (Anderson et al., 1995; WHO,2014). However the move away from the traditional professional control and paternalism has not been an easy journey or without its challenges. Wilson and colleagues (2006 & 2007) and Blakeman and colleagues (2006) studies found a continuing tension between health professionals’ sense of professional responsibility and accountability when facing changing expectations from active patient participation, such as the Expert Patient Programme, over which they have little or no control.
This drive towards greater patient independence and autonomy has been reflected in changes within the NMC code since 2008 and is now firmly embedded in the current 2015 professional standards. Nurses are required to treat patients as individuals, to work in partnership, encourage and empower people to share in decisions about their treatment and care. Despite these NMC standards and guidance there is still evidence that some nurses are not enabling patients to self-administer their medication and offering this opportunity widely enough. Ahmed and colleagues (2013) study of 50 inpatients with diabetes found that of the 25 receiving oral medication none were allowed to self-administer. Just under half (43%) were not even aware of the local SAM policy and would have liked to have been given the opportunity to self-administered. Differences were also found between patient on insulin injections and oral diabetic medication with those requiring insulin injections being more likely to be allowed to self administer. Of those who were insulin dependent only 56% were allowed to do so and the remaining 45% were not given the opportunity to self-administer but would have liked to. The researchers noted a ‘perceivable, but not qualified, ambivalence’ amongst the staff about the SAM policy. The limiting factors quoted by staff were the time constraints, that risk assessments were time consuming and the need for regular review as the patient’s condition may change. They recommended that nurses receive training to learn new skills and work differently to adapt to the changing needs for greater patient autonomy. Management commitment and willingness to promote and audit staff’s adherence to their SAM policy could also help motivate staff.
A similar resistance by nurses was also noted by Millar and colleagues (2015) in their study into 12 intermediate care facilities in Northern Ireland. They found in 11 of these facilities patient self-administration of medicines was uncommon. Health staff including nurses were found to be the main barrier to SAM as they felt the need to be in control of the patients’ medicines in order to preserve patient safety. A further barrier came from the patients themselves who seemed happy to let the staff take control of their medicines and expected a loss of autonomy upon entering a healthcare setting. Several researchers (Millar et al., 2015; Mohsin-Shaikh et al., 2014; Deek et al., 2000) have found that not all patients prefer to be passive and that those patients who had experience of SAM schemes had preferred this approach to the traditional nurse administration option. According to Millar and colleagues (2015) the key to successfully implementing SAM schemes requires a re-examination and acknowledgement of a shared responsibility between both staff and patients. A further barrier to promoting patient independence arose from the nurses having to reconcile cost-efficiency and professional accountability with their desire to provide quality nursing care based on the patient’s needs and preferences. This conflict was evident in Mohsin-Shaikh and colleagues (2014) findings which showed that both nurses and patients groups desired a higher level of patient involvement with their medication while in hospital than the patients had experienced. They recommended the development of interventions to bridge the gap between desired and actual patient involvement. A potential solution, according to Kieft and colleagues (2014), would be for nurses to gain more professional autonomy over their own practice in order that they can then improve the patient experience of involvement.
While these findings show the importance of SAM schemes in fostering self-management, patient independence and autonomy there were still gaps in the research and areas for improvement within nursing practice. Much of the evidence around empowering patients through SAM has been around the impact on the individual patient’s experience of SAM within the NHS but it is questionable whether these self management programmes have had an wider impact and challenged the traditional NHS structures which reinforce professional control.