Mental Health Medicines Management for Nurses

Stan Mutsatsa

• Publisher: Learning Matters
• Year: 2021
• ISBN:
  9781526473585
• Edition: 3
• Topic: Médecine
• Subtopic: Soins infirmiers

Mental Health Medicines Management for Nurses provides nursing students with guidance on how to manage medicines safely and effectively when treating patients with mental health conditions. It outlines how psychiatric drugs work, what the common treatments are, the ethical, legal, and person-centred aspects of working with psychiatric medicines, and how medicines can and should be used in mental health care. Using innovative activities and real-life case studies, this book has been carefully designed to be the ideal resource to build knowledge and confidence in this important area of practice. Key features:

• Updated in-line with the latest NMC standards of proficiency for registered nurses.
• Includes clear explanations of both the underlying biology and pharmacology as well as the wider practicalities of working with medicines.
• Highlights the most common mental health conditions and associated treatments, including coverage of the possible side effects for all drugs described in the book.
• NEW: Increased emphasis on prescribing with new content on consultation, history taking, and decision-making when prescribing.
• NEW: Updated sections on ethics, consent, pharmacokinetics, antipsychotics, and adverse drug reactions.

Chapter 1 Legal and ethical aspects of medicines management in mental health

Chapter aims

By the end of this chapter, you should be familiar with:

• accountability as a concept and the four different areas of accountability;
• legislation that impacts on prescribing and medicines management;
• ethical considerations in treatment.

Introduction: a little history

Before 1919, there was no register of nurses, and no national regulations or standards for nurse training. At that time, nurse training was normally for one year, and the general view was that most of what was essential could be learned in that short time; but it became clear that a longer period of training for nurses was necessary to produce a ‘professional’ nurse.

The Nurses Registration Act 1919 ended many years of conflict within the profession, and set standards for training, examination and registration. This introduced to nursing the concept of legal accountability, which serves to protect the public from malpractice. This chapter will outline the concept of accountability in nursing before discussing specific legislation. It will then discuss the Human Rights Act 1998, the Mental Capacity Act 2005 and the Mental Health Act 1983 before reviewing legislation that deals directly with medicines, such as the Medicines Act 1968, the Misuse of Drugs Act 1971 and the Prescription by Nurses etc. Act 1992. In addition, this chapter will discuss key ethical issues relating to medicines management and prescribing in practice.

Accountability

In common language, accountability may simply mean responsibility to someone or for some activity. In ethics and governance, the term is often used synonymously with concepts such as responsibility, answerability, blameworthiness and liability. However, Swansburg and Swansburg (2002) define accountability as:

The fulfilment of a formal obligation to disclose to referent others the purposes, principles, procedure, relationship, results, income, and expenditure for which one has authority.

(p364)

The Nursing and Midwifery Council (NMC) states that you should ‘be accountable for your decisions to delegate tasks and duties to other people’ (NMC, 2018b). Although the word ‘accountability’ is often used interchangeably with ‘responsibility’, it is important to make a clear distinction. Responsibility means having control or authority over someone or something. You can choose to take responsibility, but you have no power to decide to whom you should be accountable.

Scenario

Tom, a registered nurse who had no prescribing powers, altered a dose on the patient’s prescription chart, from 15 mg of diazepam per day to 20 mg per day, without consulting the prescriber. He administered this dose to the patient for a week before it was brought to his manager’s attention. Tom defended his action by saying that he knew the patient well and that he was always on a maintenance dose of 20 mg of diazepam. He was adamant that he acted the right way to ‘correct’ the dose. He was disciplined by his employer and dismissed from his post.

In the above scenario, Tom was responsible for adjusting the patient’s dose, and it was his choice to do so. However, he was accountable to his employers for his action, and it was his employers – not him – who decided to terminate his employment.

The purpose of accountability

The nursing profession requires nurses to be accountable for what you do, as it is nurses’ obligation to give explanations for their actions and omissions. This is to ensure that the public and patients are not harmed by a nurse’s actions and omissions, as well as providing redress to those who have been harmed. Healthcare workers, including nurses, have a moral, professional, ethical and legal obligation to provide care to the highest standard, because patients are entitled to this, irrespective of who is delivering that care. For these reasons, even student nurses are accountable for their actions and omissions.

To achieve this, accountability has the following aims:

• The public must be protected from a nurse’s actions and omissions that might cause harm. The nurse can be called to account for their conduct and competence if it is thought that they have fallen below the standards required of a nurse.
• The nurse must be held to account to protect the public and patients by discouraging acts that the professional body (the NMC) considers as misconduct or unlawful. Registered nurses must always act in a manner worthy of a nurse at work, both in public and in private.
• To make the nurse accountable to a range of higher authorities, the law regulates the nurse’s behaviour. The regulatory framework makes it clear what standards of conduct and competence a registered nurse should comply with.
• To be accountable, the nurse must: (1) be able to perform the task; (2) accept the responsibility for doing the task; and (3) have the authority to perform the task within the job description, as well as within the policies and protocols of the organisation.

The registered nurse can be called to account and be asked to justify their actions. The public can hear the case, with a view to reassuring patients that the professional body only tolerates the highest standards of nursing. Public scrutiny of a nurse’s conduct allows other members of the profession to learn from the mistakes and misconduct of others (Griffith and Tengnah, 2017).

Scenario

A registered nurse was struck off the professional register in 2010 after he was found sleeping on duty and had failed to administer medication to patients in a nursing home. He initially denied the charges, but later admitted to the offence after other employees had testified that he had been caught sleeping on three separate occasions within two months. The committee found him unworthy of being a registered nurse.

Because the registered nurse has a formal obligation to answer for their actions to several higher authorities, they must justify their actions to these authorities, and if they fail to do so sanctions can be applied against them. For example, during training, a university or an NHS trust can take disciplinary action against a nurse or student nurse, which in extreme cases can result in dismissal for the individual. In this regard, the nurse is accountable to:

• the patient;
• the professional body;
• society;
• the employer.

Accountability to the patient

Registered nurses are accountable to the patient who is under their care, and for this reason civil law allows the patient to seek redress if they believe they have suffered harm due to the nurse’s actions. Over the years, the NHS has been paying out increasingly large sums of money – over £0.5 billion per year – because of the clinical negligence of staff. A fundamental ethic of healthcare is that you should do your patients no harm. Where harm occurs because of a nurse’s negligence, patients can seek compensation from the nurse and the nurse’s employer through the courts. The nurse–patient relationship gives rise to a duty of care.

Quite often nurses have argued that they are accountable to themselves for their practice. Although it is accepted that a nurse who harms a patient through their acts will feel remorse, if the definition of accountability is considered, we see that nurses cannot impose sanctions on themselves.

Accountability to the professional body

Registered nurses are accountable to their professional body in accordance with the Nurses, Midwives and Health Visitors Act 1997. This legislation’s aim is to protect the public by establishing standards for education, training and conduct. The basis of the NMC’s role is to place those who intend to practise on a nursing register. A detailed description of the role of the NMC is beyond the scope of this book, so you are advised to consult a more appropriate textbook in this regard or visit the NMC’s website (www.nmc.org.uk).

Accountability to society

Registered nurses are subject to the laws of the country they work in, like everyone else. If a nurse is accused of committing a crime at work or outside of work, the country in which they reside may call them to account under its laws. This can have a bearing on the nurse’s ability to practise, as the following scenario demonstrates.

Scenario

Bridget was a registered nurse working in a prison, but she was later arrested and convicted of supplying class A drugs to a prison inmate. She was sentenced to three years in prison and was subsequently removed from the professional register.

Accountability to the employer

A registered nurse is accountable to their employing organisation through the terms and conditions of their employment contract. An employer is vicariously liable for the actions of its employees. For example, if a nurse commits a civil wrong, the employer is responsible for the nurse’s action. The following scenario gives an example of what this means in practice.

Scenario

Hamid is a patient on phenobarbitone who was found unconscious after a nurse, Shelley, gave him three times the prescribed dose. Hamid had to be admitted to a hospital intensive care ward and fully recovered four days later. The mistake occurred because Shelley did not follow the correct procedures for the administration of medicines. Although Hamid survived, his family persuaded him to take legal action through the courts, and he won a substantial settlement from the hospital. In turn, Shelley was disciplined and was sent for retraining in medicines management.

In the scenario above, we see that Hamid came to some harm because of Shelley’s carelessness. However, it was the hospital, not the nurse, that was sued and paid compensation to the patient. The hospital is vicariously liable. ‘Vicarious liability’ is a legal term that holds one person liable for the actions of another when engaging in some form of joint or collective venture. Both the hospital and the nurse are engaged in a collective venture, but the hospital has vicarious liability. As the number of nurses who prescribe increases, the concept of accountability assumes greater importance, as we will discuss later.

Human Rights Act 1998

Rights can be defined as claims or entitlements that deserve respect. After the Second World War, nations around the world were determined to take steps to guarantee the protection of human rights in national and international law. The first concrete manifestation of this was the American Declaration of the Rights and Duties of Man in 1948. This was followed by the Universal Declaration of Human Rights drawn up by the UN in the same year. These documents concentrate on protecting civil and political rights, such as freedom of expression, freedom of religion and freedom of association.

In the UK, human rights are enshrined in the Human Rights Act 1998, which has its basis in the European Convention on Human Rights (ECHR). All public authorities have a legal duty to act compatibly with the ECHR (and hence the Human Rights Act 1998). The NHS is a public authority and therefore must adhere to the Human Rights Act 1998. Domestic courts are obliged to interpret all laws consistently with the Act. In mental health, courts and mental health tribunals have an obligation to interpret the Mental Health Act 1983 (amended 2007) consistently with the Human Rights Act 1998. The Human Rights Act 1998 thus has the effect of bringing human rights to the centre of both the legal and health systems. The ECHR is divided into ‘Articles’, which set out the rights that are protected by the Convention. For medicines management and prescribing in mental health, only Articles 2, 3 and 8 are relevant, so it is these that we will discuss next.

Article 2

This Article states:

1. Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
2. Deprivation of life shall not be regarded as inflicted in contravention of this article when it results from the use of force which is no more than absolutely necessary:
   • (a) in defence of any person from unlawful violence;
   • (b) to effect a lawful arrest or to prevent the escape of a person lawfully detained;
   • (c) in action lawfully taken for the purpose of quelling a riot or insurrection.

The Article imposes on the state the obligation to protect the lives of its citizens, and this responsibility extends to the healthcare system. Before you go any further, complete Activity 1.1.

Activity 1.1 Reflection

You are working on a ward where a patient, detained under section 3 of the Mental Health Act 1983, attacked a fellow patient, causing serious harm. The aggressor was physically restrained and placed in seclusion to allow time for him to ‘cool down’. He was then given an injection of 10 mg of olanzapine and a concomitant (augmenting) dose of 2 mg of lorazepam. Two hours after the administration of the injection, the patient fell asleep (at 1900 hours). Although the hospital policy stipulates that a patient who is administered an intramuscular (IM) olanzapine injection must have their vital signs monitored regularly for the first 24 hours, this was not complied with for fear of waking the patient. There were also insufficient staff on duty to cope with any potential acts of violence during the night.

Five hours later, a member of staff found that the patient could not be roused, and immediately sent him to the local general hospital where he was taken to the intensive care unit. After a period in hospital, he fully recovered, but he sued the hospital for breaching his rights under the Human Rights Act 1998.

• Is the hospital in breach of Article 2 of the Human Rights Act 1998?

An outline answer is provided at the end of the chapter.

The most obvious example of the application of Article 2 is in cases where a member of staff deliberately kills a patient, as in the Harold Shipman cases (see the useful websites section at the end of the chapter), but Article 2 extends beyond that, as exemplified by a test case (Stewart v United Kingdom [1984]). Moreover, it is not necessary for the victim to die to be in breach of Article 2. It is enough to put the person at ‘material risk’, as the scenario above demonstrates. Clearly, it was the responsibility of the nursing staff to observe the patient’s vital signs regularly after administering an IM injection of olanzapine and lorazepam, but this was not done. As such, the staff placed the patient at material risk by their act of omission, therefore breaching Article 2.

Article 2 further stipulates that where there is a threat to the life of someone in state custody (in this case, the hospital), there is an increased responsibility to provide care and protection. In the UK, this was brought about by a test case (Osman v United Kingdom [2000]). After the death of a family member in custody, the family sued the police for failing to protect the family member adequately even though there were clear warning signs of risk to the individual. The judge in the case commented that where the authorities know of a ‘real and immediate threat’ to a person’s life, there is an obligation to take preventive operational measures to protect that person.

The responsibility to protect life is not an unlimited one. Specifically, there is only a breach of Article 2 where there is demonstration that the authorities knew or ought to have known that the person posed a real risk to life. Where the authorities can demonstrate that they took reasonable steps to protect the person, after being deemed to be at risk of losing life, or where there were no indications that the person was at risk of losing life, the death will not result in a breach of Article 2.

In summary, Article 2 imposes both positive and negative responsibilities. It i...