The goal of this study was to assess the patient knowledge gained from the new pharmacist-run inpatient medication education group that was recently started on the inpatient psychiatry unit at the William S. Middleton VA Hospital in Madison, Wisconsin. The primary objective was to compare the scores from the modified Medication Understanding and Use Self-Efficacy Scale (MUSE) medication adherence tool and modified Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER) medication side effects tool between patients who attended the new group versus patients who did not attend the group. The results for the MUSE and FIBSER scores for those who attended the medication education group were slightly lower than those who did not attend the group; however, none of the scores showed any statistical differences. The medication education group on the inpatient psychiatric unit at the William S. Middleton VA was developed to increase patients' knowledge about their medications and to increase patients' access to pharmacists.

Pharmacists are an important part of the mental health treatment team.1 A retrospective, historical control (before-after design) study in a Veterans Affairs (VA) psychiatric outpatient clinic utilized pharmacists who provided drug monitoring and weekly medication groups. Pharmacists also prescribed and adjusted medications using a protocol. The study duration was three months and included nineteen patients in the intervention group. A significant decrease in medication adverse effects was demonstrated in patients who received interventions from pharmacists (P<0.005). There was a significant decrease in the number of prescribed medications, a decrease in 1.32 medications per patient per month (P<0.05) and an improvement in patient's medication knowledge (53% knowledge score in patients not receiving intervention versus 77% knowledge score in the intervention group, P<0.05) was also demonstrated in this population.1,2 The impact pharmacists can have on mental health patients to help increase medication knowledge inspired the new service provided at the inpatient psychiatry unit at the Madison VA Hospital, named the inpatient psychiatric medication education group.

Group psychotherapy has progressively been used by mental health professionals. Group therapy is beneficial as a large number of patients can be treated at the same time; it is also a resourceful way to utilize staff's time by providing therapy to multiple patients concomitantly. Group therapy can have numerous therapeutic factors which are effective for patients. Some factors include instilling hope, universality, altruism, development of socializing techniques, imitative behavior, and group cohesiveness.3 

When starting the inpatient psychiatric medication education group at the William S. Middleton VA in Madison, WI it was necessary to determine the intended setting and size of the group. Inpatient groups on the psychiatric unit usually meet more often than outpatient groups and have patients in an acute psychiatric crisis.3 On the inpatient psychiatric unit at the William S. Middleton VA, patients were already participating in numerous therapy groups. The groups often occur in the dining area or in the day rooms. The size of the group usually reflected the ward status and was open to any patient interested in joining the group. Groups ranged from one to fourteen patients, with an average size of about four to five patients. Membership criteria were also determined.3 Persons who were thought not to derive benefit from the group were invited to participate in alternative activities during group time.

The second part of establishing a therapy group was determining time constraints and determining how to complement the current daily therapy activities on the unit. The time slot allowed for the inpatient medication education group was thirty minutes. This was determined after looking at the available time slots with the other therapy groups offered on the inpatient unit. This time length was selected as it was thought to be a tolerable timeframe for persons in acute crisis who may not be able to maintain focus over an extended time period. The group occurred twice a week and covered two different topics: medication side effects and medication adherence.

Misunderstanding about how to take medications is a primary patient safety concern; medication errors often result from misunderstanding or non-adherence with medications. To assess the outcomes of the inpatient psychiatric medication education group two self-report assessment tools were chosen. A patient's ability to successfully implement a behavior which produces an outcome is termed self-efficacy. Self-efficacy has been determined to be an important predictor of patients' health behaviors, such as medication adherence.4 The Medication Understanding and Use Self-Efficacy (MUSE) scale is a brief 8 item, validated and reliable tool created to determine patients' confidence with taking medications. The tool is at the 6th grade reading level, as determined by Lexile analysis. The domains assessed by the MUSE scale include taking medications and learning about medications.4 The MUSE scale was converted from a verbally read scale to a written handout for patients to complete on their own. A question which addresses patients' understanding of importance of taking medication daily was also added. These changes were made to make it easier to administer with the scale for the program evaluation and to gain knowledge about the inpatient medication education group.

Side effects can also affect patients' adherence to medications. The Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) Scale, is a brief self-report validated and reliable tool which was used in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial to assess medication side effects.5 The tool assess three specific domains of side effects which include frequency, intensity, and burden of side effects. The FIBSER Scale was modified by adding a question at discharge to assess if patients, while being on the inpatient psychiatric unit, have learned ways to cope with medication side effects. Using these two assessment tools can help assess patient's confidence in medication use and also assess the effectiveness of the Medication Education Group. Both assessment tools used have not been validated statistically with the modifications made for this study. Assessment tools are available upon request.

A pharmacist facilitated group occurred twice a week. The first 30-minute group focused on medication side effects. This was a discussion based group, which included handouts with tips for minimizing medication side effects and a word find with the most common side effects discussed. Additionally veterans received a craving converter information handout which discusses foods patients may crave and healthier options to try, for example if craving ice cream a healthier option may be berries and cream. The second 30 minute group covered medication adherence. This was a discussion based group, which used a Jeopardy® game format to facilitate discussion. The patients received handouts with tips for managing medications and received a medication management planning grid which was a paper document where patients could write the medication names, how they look, and when to take them. Use of medication organizers were also encouraged and this organization tool is made available to patients prior to discharge. Medication organizers were provided from the pharmacy department. All handouts are available upon request.

This was a patient knowledge program evaluation of inpatient psychiatric patients admitted to the Madison VA Psychiatry Unit. The program evaluation used modified rating scales (MUSE and FIBSER) which were administered to all patients at the William S. Middleton VA Hospital inpatient psychiatry unit at admission and at discharge. The objective was to assess the patient knowledge gained from the new inpatient psychiatric medication education group recently started on the inpatient psychiatry unit. This assessment could potentially identify if knowledge on medication side effects and medication adherence improved in patients who attended the new inpatient medication education group.

Patients were included if they were greater than 18 years of age, without regard to ethnicity, had the ability to complete the assessment tools individually, and were admitted on the William S. Middleton VA inpatient psychiatric unit after the protocol was approved by the Institutional Review Board (IRB) and VA Research and Development (R&D) Committee, from 1/18/2012 to 5/30/2012. Patients were excluded if they were on 24 hour observation for detoxification from substances or if patients were not receiving any medications.

Patients who were admitted to the inpatient psychiatry unit had the program evaluation eligibility criteria applied and inpatient nursing staff then administered the medication education assessment tools at admission and discharge from the unit. Patients who were admitted and discharged from the unit were required to fill out necessary paperwork. The addition of the medication education assessment paperwork was included in the admission and discharge procedures. This was thought to require limited additional work for the nursing staff. All patients admitted to the Inpatient Psychiatric Unit were offered the opportunity to fill out medication assessment forms.

The following baseline demographic data were collected: gender, age, DSM-IV diagnosis at discharge, number of days admitted, and number of Inpatient Medication Education Sessions attended. Additionally, medications a patient was on at admission and at discharge were gathered. No identifying information was collected.

Descriptive statistics (percentages) were reported for all recorded baseline variables by group. For the assessment tool scores analysis and other continuous and ordinal variables the Mann-Whitney U Test was used. For categorical data the Fisher Exact Probability Test was used due to small sample size.

Within the four months of program evaluation, four patients were excluded from the assessment due to being on 23 hour observation for detoxification from substance abuse. Ninety patients were offered the opportunity to complete the assessment paperwork. Out of the 90 patients offered to participate seven patients refused, with reasons not noted. Forty nine patients completely filled out the admission and discharge paperwork, thus were included in the assessment process.

Forty-five percent (22/49) of the patients with completed paper work attended the new medication education group, with 59% (13/22) and 64% (14/22) of the patients attending the topics of side effects and medication adherence, respectively. Eighteen percent (4/22) of the patients attended both topics of the medication education groups. Baseline characteristics are shown in Table 1. The average age among those who attended group was 47.6 years of age (90% male) and 48.9 years of age (93% male) for the control group. The average length of stay for those who attended group was 6.3 days and the control group was 4.9 days.

Table 1.

Baseline Demographic Data

Baseline Demographic Data
Baseline Demographic Data

Common diagnoses seen on the inpatient unit are shown on Table 2. The most common diagnosis seen was mood disorders and about half of the patients had an anxiety disorder and/or a substance use related disorder. Additionally, one-third of patients had an Axis II diagnosis. Between the two groups, there were no statistical differences between baseline demographics or common diagnosis.

Table 2.

Common Diagnoses

Common Diagnoses
Common Diagnoses

Around 90% of the patients on the inpatient unit had medication adjustments, (see Table 3). Approximately 65% had received a new medication, with an average of 1 new medication per patient. A third of the patients had a medication discontinued, with an average of 0.54 medications discontinued per patient. Approximately 40% of the patients had their medication increased, while approximately 5% had a medication decreased. Between the two groups the medication changes did not show any statistical differences.

Table 3.

Medication Changes While in the Hospital

Medication Changes While in the Hospital
Medication Changes While in the Hospital

Out of the 22 patients who attended the new medication education group, patients attended an average of 1.2 groups per patient with a range of 1 to 3 groups attended per person. Pharmacy interventions completed at the medication education groups included: 27% of patients had side effects which required the pharmacist to alert the treatment team, 32% of patients were ordered a medication box, 27% of patients were ordered tablet splitter, and 4.5% of patients received easy open caps (See Table 4).

Table 4.

Medication Education Group and Interventions

Medication Education Group and Interventions
Medication Education Group and Interventions

The discharge average scores for each of the assessment questions on the MUSE and FIBSER scales are shown on Table 5. For the MUSE scores, the control group had slightly higher discharge score averages for all of the questions except number seven which states, “It is easy for me to understand instructions on my medication bottles” than those who attended the group. For the FIBSER scores the control group had reported less frequent side effects, less interference of side effects with day-to-day functions, and patients felt they obtained more ways to cope with medication side effects than those who attended the group.

Table 5.

MUSE and FIBSER Scores

MUSE and FIBSER Scores
MUSE and FIBSER Scores

The change of scores from admission to discharge was calculated and is shown on Table 5. For the MUSE scale the control group also had a greater change in scores with improvement of scores from admission to discharge; however, none of these showed any statistical difference from those who attended the medication education group. With the FIBSER scale the control group had a greater improvement in change of scores for frequency of side effects than those who attended the group. Those who attended the group showed an improvement in daily functioning due to decreased side effects impairment from side effects with day-to-day functions and patients had felt they obtained more ways to cope with medication side effects. There were no statistical differences between the groups.

The results of the MUSE and FIBSER scale scores were not consistent with the authors' hypothesis. However, it is important to note the low sample size for this study was a major limitation and may have affected the results. Although the scores of the control group were slightly higher than those who attended the medication education group, they were not significantly different.

Even though the assessment scores were slightly higher for the control group than those who attended the medication education group, it is important to note that the average scores for the MUSE were greater than a score of three for both groups. Three indicated that the patients slightly agreed and four indicated that patients strongly agreed with the statement. All of the scores indicated that patients slightly agreed with the adherence questions, which demonstrates that on average patients understand how to take their medications. With the FIBSER side effect scale, most patients were experiencing slight side effects, slight intensity of side effects, and slight impairment of day to day activities from side effects. Patients also felt that they learned new ways to cope with their side effects while being on the inpatient psychiatric unit. However, based on these results, cannot definitely rule out that attendance at the medication education group was actually harmful to the patients. It may be possible that it may have reduced their medication understanding or potentially caused confusion about their medication regimen.

There were many challenges with receiving complete admission and discharge assessment tools from the patients on the unit. There were 83 patients who completed either admission or discharge assessment tools, with only 45% completing both. The admission assessment and discharge assessment tools were included in the patient folders on the unit. The discharge paperwork in the patient's folder was often overlooked by the nursing staff at discharge. To overcome this barrier a new process was initiated. All patients on the inpatient unit have small baskets with their personal items in the nursing office. Due to the normal procedure of patients receiving their personal items prior to discharge, the discharge assessment tool was then placed in each patient's personal basket. This process change increased the number of discharge assessment tools returned completed. Changing a process on an inpatient unit was a challenge and took many different trials to increase the completion of assessment tools.

There were also other limitations to the evaluation of the medication education group that are important to mention. One limitation was that this study did not did not account for health literacy which may have played a role with the patients who refused to take the MUSE and FIBSER scales. Since the scales require health literacy this study could have possibly missed patients with knowledge deficits and lower health literacy. Also, there might also have been a selection bias with this study. Patients who agreed to participate in the medication education group may have been people who were more active on the unit. While the patients who did not attend the group often stayed in their rooms, these patients may be the ones who could potentially benefit the most from attending an interactive group. However, our study showed that those that did not attend group had a greater improvement in scores than those who did attend. It is important to note that those who did not attend the group had shorter lengths of stay and potentially were less likely to be severely ill. Also, since the evaluation was not randomized there were no guarantees that the forms were completed after attending the medication group which may also affect the outcome of the scores. Finally, it is also important to point out that the results may not be generalized to the general public as the population included in this study was mainly male veterans.

Finally, the improvements in the assessment scores cannot be separated out from the medication education group only. The scores may also be influenced by other factors on the inpatient unit such as interaction with the treatment team or interaction with the pharmacist at medication reconciliation and at discharge. These interactions may have played a bigger role in patients' determination of how to complete the assessment scores as it was shown that the controls had slightly higher scores than those who attended the group. These limitations need to be taken into consideration when viewing the results.

Future directions from the results of this study will likely be continuation of the inpatient psychiatric unit medication education group. Objectively, the patients who are admitted to the inpatient psychiatric unit selected they understood why it is important to take medications daily and reported they obtained ways to cope with medication side effects. Subjectively, patients have commented how they appreciate the accessibility of pharmacists at the group and enjoy the interactive game. Patients have also had the opportunity to receive medication boxes, tablet splitters, and easy open caps for the medication bottles. These small interventions are a great way to increase pharmacy involvement on the inpatient psychiatric unit. The impact of these interventions may not become apparent until after discharge, which was not assessed in this study. In the future it would be interesting to see how these interventions effect patient compliance with their medications. Finally, the other providers on the unit also have stated how they notice the patients enjoy learning about their medications and how this has improved the medication knowledge of their patients. The new medication education group is a valuable service that is provided to the veterans.

The MUSE and FIBSER discharge scores and change in scores for those who attended the medication education group were slightly lower than those who did not attend the group; however, none of the scores showed any statistical differences. The medication education group on the inpatient psychiatric unit at the William S. Middleton VA was developed to increase patients' knowledge about their medications and to increase patients' access to pharmacists. The inpatient medication education group will likely continue to be provided by the Inpatient Psychiatric Pharmacist and the incoming Psychiatric Pharmacy Resident.

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