International Journal of Nursing Studies 40 (2003) 163–169

The effect of medication management training on communitymental health nurse’s clinical skills

Richard Gray*, Til Wykes, Kevin Gournay

Health Services Research Department, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK

Received 20 May 2002; accepted 3 July 2002

Abstract

Background. There is evidence that compliance therapy improves treatment adherence and clinical outcomes in

patients with schizophrenia. Community Mental Health Nurses (CMHNs) are ideally placed to deliver compliance

therapy but require training to develop the necessary clinical skills.

Aim. To explore whether a brief medication management training package is effective in developing the compliance

therapy skills of CMHNs.

Method. The study had a within subjects repeated measures design. A representative sample of 52 CMHNs entered

the study. They performed a role-play task pre- and post-training that was videotaped and blind rated by an

independent rater using the Cognitive Therapy Scale (CTS). Knowledge was assessed pre- and post-training using a

knowledge about medication management questionnaire. Trainees also completed a satisfaction with training

questionnaire at the end of the course.

Results. Following training there was a statistically significant improvement in mean scores on the primary measure

of skills, the CTS (mean pre-training CTS-total score 13.88, mean post-training CTS-total score 31.12; po0:01). Therewas also a significant categorical improvement in the number of trainees who demonstrated satisfactory skills.

Knowledge about medication management was significantly improved and trainees reported that training was

acceptable and relevant to their clinical practice.

Conclusions. In this uncontrolled study training improved the medication management skills of CMHNs.

r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Medication management; Compliance therapy; Training; Clinical skills

1. Background

Antipsychotic medication is the mainstay in the

effective treatment of schizophrenia reducing symptoms

and, when used as maintenance treatment, preventing

relapse (Davis and Andriukaitis, 1986). However,

translation of this success into clinical practice is

attenuated by poor compliance (Weiden and Olfson,

1995), reasons for which include beliefs about treatment,

insight, and side effects (Buchanan, 1992). A recent

systematic review of interventions to improve adherence

to prescribed medication identified that compliance

therapy (Kemp et al., 1998, 1996) is an intervention

where there is evidence of efficacy in enhancing

adherence with antipsychotic medication (Haynes et al.,

2002). In the UK the National Service Framework for

mental health has recommended that mental health

practitioners use compliance therapy to address the

problem of non-compliance with antipsychotic medica-

tion (DoH, 1999).

Compliance therapy is an intervention based on

cognitive behavioural therapy and motivational inter-

viewing. The key principles of compliance therapy are

working collaboratively with patients, emphasising

personal choice and responsibility and addressing*Corresponding author. Tel.: +44-20-7848-0139.

E-mail address: r.gray@iop.kcl.ac.uk (R. Gray).

0020-7489/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 4 5 - 7

patients concerns about treatment. Compliance therapy

is divided into three phases: reviewing the patients’

illness history, discussing common concerns about

treatment, and long term prevention and relapse (Kemp

et al., 1996). The intervention was evaluated in a rando-

mised controlled trial (Kemp et al., 1998, 1996).

Seventy-four psychotic inpatients were randomly as-

signed to receive either compliance therapy or non-

specific counselling. Patients received 4–6 sessions with a

research psychiatrist lasting, on average, 40min and

were assessed at baseline, post-treatment and 3, 6, 12,

and 18 month follow-up, using a battery of standardised

measures, including an observer rated measure of

compliance. Although an assessor blind to the treatment

condition performed the latter assessments the person

conducting the therapy undertook the initial interviews.

Treatment adherence was significantly better in the

compliance therapy group and was sustained through

follow-up. Unexpectedly, there was no significant

difference in psychopathology between the groups.

However, the improvements in compliance did result

in enhanced community tenure, with patients in the

compliance therapy group taking longer to relapse than

those who received non-specific counselling.

In the UK mental health nurses provide much of the

care that patients receive. If the potential benefits to

patient’s and services of compliance therapy are to be

realised then mental health nurses will need to deliver

the intervention. A recent survey of 250 Community

Mental Health Nurses (CMHNs) working in the UK

reported that they feel that improving and maintaining

compliance with treatment is an important part of their

role but report that they require more training in the

area (Gray et al., 2001). Training may be an effective

way of developing CMHNs clinical skills to enable them

to deliver compliance therapy in routine clinical

practice.

It is tempting to assume that training will improve

clinical skills and move to undertake an expensive and

time consuming trial evaluating the impact of training

on clinical outcomes. Several studies have shown that

psychosocial intervention training can potentially

improve clinical outcomes (Lancashire et al., 1997;

Brooker et al., 1994). However, there has been surpris-

ingly little research examining the impact of psychoso-

cial intervention training on skills acquisition probably

because it is so difficult to do in a reliable and replicable

way. Brooker and Butterworth (1993) showed that at the

end of family work training nurses were able to

demonstrate competent clinical skills as measured using

the Cognitive Therapy Scale (CTS; Vallis et al., 1986).

However, no baseline scores are reported making it

difficult to attribute skill acquisition to training. There is

a need to explore, as a first step, if targeted training is an

effective way of developing CMHNs compliance therapy

skills. If skills are enhanced following training further

investigation into the impact of training on clinical

outcomes is warranted.

2. Methods

The aim of this study is to explore whether medication

management training is effective in improving the

clinical skills of CMHNs.

2.1. Community mental health nurses

Sixty CMHNs were recruited from two large mental

health care providers in London, England during 1998

and 1999. They were accepted into the study if they were

registered nurses and had at least 12 months post-

registration experience.

2.2. Study design

The study had a within subjects repeated measures

design. A 10-min standardised role-play task derived

from the method described by Scott et al. (1999),

focusing on a patient’s specific problem with antipsy-

chotic medication, was performed pre- and post-train-

ing. An experienced third party ‘actor’ role-played the

patient. These were videotaped and blind rated, in a

random order, by a trained cognitive therapist, who was

not involved in the study, using the CTS (Vallis et al.,

1986). A multiple-choice knowledge about medication

management test was administered pre- and post-

training and a satisfaction with training questionnaire

was completed at the end of course.

2.3. Training

A medication management course curriculum was

developed by an experienced multi-disciplinary group of

clinicians, academics and service users. The aim of

training was to provide CMHNs with the skills that they

needed to deliver compliance therapy. Medication

management training consisted of 10 days of teaching

delivered to small groups of 10 nurses on a day release

basis over 10 weeks (a total of 80 h contact time).

Training was funded by local mental health services. The

four key components of the training were assessment,

cognitive and compliance therapy skills, psychopharma-

cology, and clinical supervision. A multi-disciplinary

team, including a combination of academic, clinical staff

and service users provided teaching.

In the first component of the course, trainees were

taught to use a battery of valid and reliable assessment

tools to evaluate treatment with antipsychotic medica-

tion and derive a formulation of the patient’s problems

and/or concerns about their treatment. The formulation

was used to guide the selection of targeted compliance

R. Gray et al. / International Journal of Nursing Studies 40 (2003) 163–169164

therapy techniques. Measures were selected based on the

following criteria:

* validity and reliability,* availability,* ease of use, and* acceptability to patients and clinicians.

The main measures taught were the Hogan Drug

Attitude Inventory (DAI-30; Hogan et al., 1983) the

Insight Scale for Psychosis (IP; Birchwood et al., 1994)

and the Liverpool University Neuroleptic Side Effect

Rating Scale (LUNSERS; Day et al., 1995).

The second component of the course focused on

developing trainees’ skills in using compliance therapy

techniques to enhance adherence. To facilitate teaching,

discrete clinical interventions were described (for exam-

ple, reviewing the patients illness history, examining

beliefs about treatment and exploring ambivalence).

Video role-play was used to allow trainees to rehearse

each discrete intervention, critique their own practice

and receive balanced feedback from other members of

the group (Gask, 1999).

Psychopharmacology formed the third component of

the course providing a comprehensive overview of drug

treatments in schizophrenia. The South London and

Maudsley NHS Trust Prescribing Guidelines (Taylor

et al., 2001) were used as a basis for teaching and to

provide trainees with evidential clinical practice guide-

lines. These were selected as they are the most widely

used and internationally recognised set of guidelines for

the treatment of mental health problems. Teaching,

using the guidelines as a template, focused on effective

treatment strategies, the management of antipsychotic

side effects, and the treatment of refractory illnesses.

Regular, weekly, clinical supervision formed a final

critical component of the course integrating skills learnt

in the classroom into clinical practice. Each trainee

presented a patient they were working with, concluding

the presentation by suggesting a supervision question for

discussion within the group. Following the discussion,

an action plan was agreed. Progress on the implementa-

tion of the action plan was monitored during the course.

2.4. Outcome measures

2.4.1. Primary outcome measure: cognitive therapy scale

(Vallis et al., 1986)

The CTS is extensively used internationally and is a

valid and reliable 10-item measure of clinicians’ general

and specific clinical skills. Each of the items—agenda

setting, feedback, understanding, interpersonal effec-

tiveness, collaboration, pacing and efficient use of time,

guided discovery, strategy for change, application of

specific compliance therapy techniques and an overall

clinician rating—were rated on a seven-point scale

ranging from poor (0) to excellent (6) producing a total

score of between 0 and 60. A satisfactory score for each

item is defined as 3, and for the total as 30. Each item

has four anchor points to facilitate rating.

2.4.2. Secondary outcomes measures

Two other measures were developed for this study

to assess the outcome of training. A knowledge about

medication management questionnaire (KAMMQ),

and a satisfaction with training questionnaire. It would

have been preferable to identify valid and reliable

measures from the literature but no appropriate

measures are available. The KAMMQ is a 16-item

multiple-choice questionnaire reflecting the medication

management course curriculum and recent develop-

ments in psychopharmacology, including the introduc-

tion of new drugs. Nurses are presented with 16

questions that relate to case vignettes with five possible

responses, of which only one is correct. The question-

naire produces a total score ranging from 0 to 16. The

questionnaire was designed to have content validity by

including questions on key aspects of medication

management taught within the course. To test this a

Consultant Psychiatrist and a Clinical Pharmacist

completed the questionnaire and were able to get

100% of the questions correct. Test re-test reliability

was established by correlating time one and time two

scores on the KAMMQ in a group of 10 mental health

nurses not associated with the project. A statistically

significant association was found (po0:05).The satisfaction with training questionnaire asked

nurses to rate how satisfied they had been with the

content of the course and the quality of the teaching.

They also rated how relevant the course was to their

clinical practice and if they were able to incorporate the

skills that they had learnt into their work with patients.

2.4.3. Nurse information

Nurses completed a brief questionnaire prior to

training detailing their age, gender, clinical and aca-

demic experience, grade and caseload. The trainer

throughout the course monitored attendance.

2.5. Statistical analysis

To identify within-group differences post-training the

t-test was used. Two-tailed tests were used as the most

conservative method of analysis even when the compar-

isons were supported by a specific hypothesis. The

McNmear test was used to test for changes in the

proportion of nurses achieving a satisfactory standard

on the CTS (items and total) following training.

Exploratory stepwise linear regression was used to

identify factors predictive of trainees’ knowledge and

skill following training (Kirkwood, 1998, p. 57–72).

R. Gray et al. / International Journal of Nursing Studies 40 (2003) 163–169 165

3. Results

3.1. Community mental health nurses

Fifty-two nurses entered the study and received

training: complete data are reported for 81% of the

sample. The demographic profile of the nurses who

entered the study was representative of mental nurses

currently working in the community in England and

Wales (Table 1; Brooker and White, 1997).

3.2. Withdrawals

All of the nurses who started training completed the

course. Average attendance was 8 out of 10 days (80%;

range 60–100%).

3.3. Primary training outcomes

3.3.1. Cognitive therapy scale total score (Fig. 1;

Tables 2 and 3)

Baseline scores on the CTS were indicative of clinical

skills that were inadequate to mediocre. None of the

trainees had a CTS-total score greater than 30 that

would indicate overall satisfactory clinical skills. Fol-

lowing training significant improvements in CTS-total

scores were observed (t ¼ �19:1; df ¼ 42; po0:01) andthe post-training mean score of 31.11 (s.d.=5.75) was

indicative of satisfactory clinical skills. Training also

produced a significant improvement in the proportion

of nurses demonstrating satisfactory clinical skills

(po0:01).

3.3.2. Cognitive therapy scale item scores (Tables 2

and 3)

Mean baseline scores for each of the CTS items were

consistent with the total score and indicative of barely

adequate/mediocre skills. A minority of nurses showed

satisfactory clinical skills on some of the CTS items before

training. The items where most nurses were able to

demonstrate satisfactory clinical skills were interpersonal

effectiveness (n ¼ 8; 15%) and collaboration (n ¼ 8;15%). Agenda setting was the item where fewest nurses

demonstrated satisfactory clinical skill (n ¼ 2; 4%).

Following training significant improvements were

observed in each of the 10 CTS items. The mean post-

training score for eight items suggested that a satisfac-

tory standard of skill had been achieved. The mean score

for items 9 and 10 (application of medication manage-

ment techniques; overall clinician rating), although

significantly improved, was just below a satisfactory

standard. Significant improvements in the proportion of

nurses who achieved a satisfactory standard on all of the

CTS items were also found. At least half of the nurses

who had received training were able to demonstrate

satisfactory skills on each of the items. Over 70% were

able to demonstrate satisfactory skill in the use of guided

discovery whilst half were skilled in strategy for change.

3.4. Secondary outcome measures

3.4.1. Knowledge about medication management

questionnaire (KAMMQ)

Baseline scores on the KAMMQ were indicative of

moderate levels of knowledge with nurse getting around

Table 1

Trainee demographics

Characteristic Mental health nurses (n ¼ 52) England and Wales census of nursesa

Mean s.d. Mean

Age 38.7 7.77 39

Experience in years 8.62 5.7 14

Caseload 35.8 8.5 38.3

n % %

Female 29 56 57

Senior clinical grade 31 60 61

Hold diploma or degree 26 50 No data

aBrooker and White (1997).

0

5

10

15

20

25

30

35

Pre-training Post-training

CT

S-to

tal

*

*p<.01 Satisfactory standard

Fig. 1. Changes in CTS-total score pre- and post-training.

R. Gray et al. / International Journal of Nursing Studies 40 (2003) 163–169166

half of the questions correct (mean=9.05, s.d.=2.15).

Following training significant improvements in

knowledge were observed (mean=12.43, s.d.=2.34,

t ¼ �11:04; df ¼ 38; po0:01) with nurses getting around

75% of questions correct.

3.4.2. Ratings of nurse satisfaction with training

All trainees (n ¼ 47; 100%) reported that they were

either very satisfied or satisfied with the content of the

course and the quality of the teaching. They also

reported that they were able to apply the skills they

had learnt to the patients on their caseload.

3.4.3. Safety and aceptability of training

Safety was examined by looking at the number of

trainees whose clinical skills had deteriorated at the

post-training assessment. The acceptability of training

was determined by examining the number of trainees

who dropped out of training. Clinical skills did not

deteriorate in any of the participants and none of the

CMHNs withdrew from training. There were no other

unexpected effects of training.

3.5. Prediction of change

Exploratory stepwise linear regression was used to

identify factors predictive of trainees’ knowledge and

skill following training. Post-training scores on the CTS

and the KAMMQ were the dependent variables. Base-

line scores were entered first and then the following

variables were entered on the second level using stepwise

procedures: Trainees’ caseload size, experience, clinical

Table 2

CTS total and item scores pre- and post-training

CTS item Pre-training (n ¼ 52) Post-training (n ¼ 43) p

Mean s.d. Mean s.d.

Agenda setting 0.93 0.95 2.95 0.96 o0.01

Feedback 1.40 1.1 3.25 0.99 o0.01

Understanding 1.22 0.85 3.36 1.03 o0.01

Interpersonal effectiveness 1.62 0.89 3.14 1.17 o0.01

Collaboration 1.60 0.96 3.02 1.37 o0.01

Pacing and efficient using of time 1.31 0.95 3.20 0.97 o0.01

Guided discovery 1.36 0.83 3.39 1.15 o0.01

Strategy for change 1.40 0.94 3.14 1.17 o0.01

Application of medication management techniques 1.44 0.81 2.84 1.03 o0.01

Clinician rating 1.58 0.83 2.77 0.89 o0.01

Total score 13.88a 4.27 31.12a 5.75 o0.01

aSatisfactory total score defined as X30.

Table 3

Proportion of mental health nurses whose skills were rated as satisfactory on the CTS pre- and post-training

CTS item Pre-training (n ¼ 52) Post-training (n ¼ 43)a p

n % n %

Agenda setting 2 4 31 60 o0.01

Feedback 7 13 33 64 o0.01

Understanding 2 4 33 63 o0.01

Interpersonal effectiveness 8 15 31 60 o0.01

Collaboration 8 15 27 52 o0.01

Pacing and efficient using of time 4 8 34 65 o0.01

Guided discovery 2 4 37 71 o0.01

Strategy for change 6 12 26 50 o0.01

Application of medication management techniques 3 6 27 52 o0.01

Clinician rating 5 10 30 58 o0.01

Total score 0 0 24 46 o0.01

aAs the most conservative method of handling missing values it was assumed that nurses who dropped out of the study did not have

satisfactory clinical skills.

R. Gray et al. / International Journal of Nursing Studies 40 (2003) 163–169 167

grade, highest academic qualification and attendance

(Kirkwood, 1998, pp. 57–72).

A model that included trainees’ highest academic

qualification, grade and attendance was predictive of

CTS scores post-training. Baseline scores alone ac-

counted for 67% of the variance in CTS scores

(R2 ¼ 0:67; F ¼ 109:34; po0:001). Highest academic

qualification, grade and attendance accounted for an

additional 29% of the variance (R2 ¼ 0:98 (adjusted

R2 ¼ 0:96), F ¼ 71:18; po0:001).Baseline scores on the KAMMQ were predicative of

trainees’ knowledge post-training (R2 ¼ 0:91; F ¼ 109:3;po0:001). No other significant predictors emerged.

4. Discussion

The aim of this study was to explore whether

medication management training was effective in im-

proving the clinical skills of CMHNs.

4.1. Were community mental health nurses

representative?

In this study the demographic characteristics of

participants were comparable with those in the recent

census of CMHNs (Brooker and White, 1997). This

suggests that they were representative of those currently

practicing in the UK.

4.2. Was training effective?

This study demonstrates that medication management

training for nurses improves clinical skills and knowl-

edge. The primary outcome measures showed statisti-

cally significant improvements in clinical skills post-

training. Significant improvements were also observed in

nurse’s knowledge about medication management.

Overall all nurses who attended training were satisfied

with the content of the course and reported that it was

relevant to their clinical practice.

The finding that, following training, clinical skills

have improved to a satisfactory standard is consistent

with Brooker and Butterworth (1993) and may suggest

that medication management training equips nurses with

the clinical skills and knowledge that are needed to

deliver compliance therapy in clinical practice safely and

effectively. However, this is an uncontrolled study and it

is not possible to rule out the possibility that clinical

skills may have developed over time independently

of training. It is also not possible to exclude that

training had non-specific effects that were not related to

the content of the course. That is to say attention

(exposure to a teaching environment) improves clinical

skills (the Hawthorne effect). It is also unclear from this

study whether the impact of training on skills is durable

over time. However, the findings of this study do suggest

that further exploration into the effects of medication

management training on nurse’s skills, practice and on

clinical outcomes is warranted.

4.3. Was training safe and acceptable?

Medication management training was acceptable to

nurses and did not result in unexpected findings with

regard to safety. Training involved the use of videotaped

role-play exercises that involve critical examination of

clinical skills. It is possible that this may have been

unacceptable to nurses. However, this did not seem to be

the case as satisfaction was high and there were no

withdrawals from training.

4.4. Predictors of response

A regression model found that clinical grade, level of

academic preparation and attendance was predictive of

skill but not knowledge acquisition. This may suggest

that senior, and more qualified, nurses are more

receptive to training and learning new skills. The model

also suggests that there is a dose dependent effect of

training. That is to say that the more exposure to

training the more skills develop.

4.5. Pre-training skills and knowledge

In a representative sample of CMHNs, pre-training

scores on the CTS were indicative of clinical skills that

were barely adequate. This finding is consistent with the

survey of reported practice by Gray et al. (2001) that

showed that CMHNs acknowledged that they needed

more training in interventions to improve adherence in

patients with schizophrenia. These findings suggest that

patients are being deprived of therapeutic approaches

that will benefit their mental symptoms and may reduce

unnecessary side effects they are experiencing from their

medication.

4.6. Methodological considerations

Clinical skills were measured by asking nurses to

undertake a 10-min role-play task that was videotaped

and then blind rated. This method is a proxy of the skills

used in actual clinical practice. However, it is possible

that improvements seen post-training could be attrib-

uted to a reduction in nurses’ anxiety about being

videotaped or rehearsal of how to perform during the

role-play. Brooker and Butterworth (1993) used an

alternative method: they asked participants to audiotape

sessions with patients that were subsequently submitted

for analysis. However, nurses are able to select which

session they submit for rating and there is the potential

for tapes not to be submitted. The method of measuring

R. Gray et al. / International Journal of Nursing Studies 40 (2003) 163–169168

clinical skills in this study represents a novel, practical

way of examining the impact of training on clinical

skills.

5. Conclusions and recommendations

Compliance therapy can improve clinical outcomes in

patients with schizophrenia by maximising the clinical

potential of antipsychotic medicines to treat psychotic

symptoms and prevent relapse. The British National

Service Framework for Mental Health (DoH, 1999) has

recommended that Compliance Therapy should be

incorporated into the routine clinical practice of

psychiatric professionals. This study aimed to demon-

strate that training was effective in developing CMHNs

medication management clinical skills and knowledge

enabling them to potentially deliver compliance therapy

safely and effectively in routine clinical practice.

Following training there were statistically significant

improvements in mean scores on the CTS and just under

half of the trainees demonstrated satisfactory clinical

skills. Knowledge improved significantly and there was

evidence that training was acceptable to nurses and did

not produce any unexpected outcomes. Whether these

improvements are translated into improved clinical

practice may warrant further examination.

Acknowledgements

This project was funded by the South London and

Maudsley NHS Trust and the Institute of Psychiatry,

Kings College, London. There are no conflicts of

interest.

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