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Medication safety in Mozambique

Why did we do this research?

Giving the correct dose of medication to patients is important for two main reasons; 1) to make sure the medication works, and 2) to make sure the patient is safe.  Giving the correct dose relies on nurses having strong drug calculation skills, as well as being able to use these skills in practice alongside daily distractions and stressors. These skills may be especially important for nurses in low-income countries where there are staff shortages, and so continuing skills training after nurses become qualified is essential.

The work described here was conducted by the Ipswich-Beira partnership, which aims to connect specialist health professionals in Ipswich Hospital Trust, UK and Beira Central Hospital, Mozambique to share expertise and offer practical assistance to improve hospital services for local people in Beira.

What did we hope to achieve?

This study had two aims:

  • To explore the impact of a medication safety training course on nurses in Beira, Mozambique.
  • To reflect on the role of health psychologists in helping educators apply behavioural science to the training content and evaluation.

How did we do it?

The health partnership project had been already operating for 18 months; the health psychologists joined towards the end of the project to help increase the impact of interventions and help evaluate them. There were two phases of work they were involved with:

Phase One – The nurses, doctors and pharmacists from the health partnership had worked together to develop a brief medication safety training package, with a focus on calculating drugs correctly. This training was adapted to be relevant to nurses working in Mozambique, and was translated into Portuguese, their official language. This training was then delivered by a local pharmacist to 87 Portuguese-speaking nurses in Beira, Mozambique.

The partnership’s health psychologists firstly watched its delivery and identified which Behaviour Change Techniques (BCTs) were used in the current version of the training. Behaviour change techniques are the smallest parts of an intervention, for example goal setting, and interventions are usually made up of bundles of these. The health psychologists then made suggestions to improve the content of the training, and how it was delivered.

Working with the team, the health psychologists also advised on another area of the partnership’s work: making changes to the drug charts (called cardex) used in the hospital, to help increase easy-to-use prompts for reviewing medications and specific spaces for recording allergies.

Phase Two- The training was changed following the suggestions made in phase one, and was delivered to 36 nurses in Mozambique. The health psychologists once again identified the BCTs used in the training. We measured the nurses’ confidence in correctly calculating medication doses, and whether they intended to make changes to their healthcare practice. We also collected feedback after the training through asking nurses to give written answers to set questions about the training, and through interviewing 12 of the nurses.

To see how the cardex was being used, the psychologists conducted an audit across 23 hospital wards. They then interviewed medical staff to find out how the new cardex could be used even more widely in the hospital.

The health psychologists also got involved with the third strand of the project, which was a program of medical equipment maintenance training, where a government engineer trained local technicians to be able to take care of their medical equipment such as medicine storage fridges without needing to send equipment off for fixing, improving local access to safe equipment and medicines. We held a group interview with 6 attendees and the lead trainer to explore how the training had worked.

What did we find?

Phase One – Six behaviour change techniques were used during the taught presentation. These were:

  • Instruction on how to perform behaviour
  • Demonstration of behaviour
  • Behavioural practice and rehearsal
  • Information about health consequences
  • Credible Source
  • Framing/reframing
  • Most techniques targeted nurses’ ability to calculate drug doses accurately. Suggestions made by the health psychologists included ways to increase nurses’ motivation and opportunity, which must be present for changes to occur.

Phase Two – The second training included an educational game and an extra seven behaviour change techniques, which were:

  • Adding objects to the environment
  • Goal setting
  • Action planning
  • Problem solving
  • Discrepancy between current behaviour and goal
  • Commitment
  • Feedback on behaviour

Nurses reported high confidence before and after the training, and intentions to use calculators to check drug calculations were higher than before the training. Interviews with nurses showed that the training was acceptable, enjoyable and led to practice changes.

The cardex evaluation found that 6 of the 23 wards had added the new record to their wards, and only 2 were using it as planned. As a result of the interviews and informed by behavioural science, key changes were made (e.g. layout and grouping of medication types). Medical staff appeared more motivated to use the updated record, and a follow up audit of 17 wards found 4 were using the record as planned (an increase of 2).

Six technicians from the medical equipment maintenance training said the training had provided them with a deeper understanding of the hospital equipment and the confidence for ongoing repair and maintenance. They found that as a result of their newly improved skills, they were gaining more respect and authority within the hospital and were looking forward to further funding opportunities from the medical director.

Our work shows that health psychologists can play a key role in improving medication safety, by using their skills and expertise to evaluate and enhance health professional training.

Where has this study been shared?

This has been published in the journal Globalization and Health, and is available for all to access here:

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-017-0265-1

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-017-0254-4

Who was involved in this work?

Partnership staff: Fonsesca Domingos Junior, Luana Vendramel Santos, Abigail Scott, Debo Ademokun, Zeferina Simiao, Wingi Manzungu Oliver, Fernando Francisco Joaquim, Sarah M. Cavanagh.

Health psychologists: Eleanor bull, Corina Weir, Jo Hart, Lucie Byrne-Davis

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