Journal of Orthopaedic Nursing (2007) 11, 15–19

www.elsevierhealth.com/journals/joon

Journal ofOrthopaedic Nursing

A pilot project of single nurse administrationof oral morphine on a trauma ward

Julie Gregory RN, ONC, BA (Hons) MSc Pain Management Acute Pain NurseSpecialist *, Julie Bramwell RN, DPSN, BSc (Hons) Staff Nurse

Pain Management Office, Royal Bolton Hospital, Minerva Road, Bolton BL4 0JR, United Kingdom

Summary Pain and its treatment is an important aspect of orthopaedic nursing.Delays in the administration of analgesia can be due to a variety of factors. Possiblefactors are discussed briefly and the delays due to controlled drug regulations areexamined in more detail. Controlled drug legislation is also discussed. A smallchange in the administration of oral morphine was piloted on a trauma ward andresulted in a significant reduction in delays in its administration and evaluated pos-itively by researchers from a local university. The change is currently beingextended to other surgical and medical wards in the Royal Bolton Hospital.

�c 2006 Elsevier Ltd. All rights reserved.

KEYWORDSOrthopaedic nursing;Pain;Oral morphine

1d

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Editor’s commentsThis small, direct and manageable project is an excellent example of how to bring about significant changes in nursing practiceusing a pragmatic but focused approach. PD

Introduction

This paper describes how a small change in theadministration of oral morphine enabled nurseson a trauma ward to provide pain relief in a moretimely way. This small change at ward level has re-duced delays in the administration of oral mor-phine and has been described as ‘commendable

361-3111/$ - see front matter �c 2006 Elsevier Ltd. All rights reseoi:10.1016/j.joon.2006.12.002

* Corresponding author. Tel.: +44 1204 390763; fax: +44 120490187.E-mail address: Julie.Gregory@rbh.nhs.uk (J. Gregory).

and an effective and efficient use of nursing time’(Ormandy et al., 2006).

It is no longer acceptable to see pain as a naturalconsequence of injury or trauma that will graduallyreduce over time as unrelieved pain can lead tocomplications and increased length of hospitalisa-tion. Effective pain relief can reduce harmful sideeffects associated with surgery such as chest infec-tion, Venous Thromboembolism and improve pa-tient outcomes (Macintyre and Ready, 2002).Patients whose pain is within tolerable limits orcontrolled are able to tolerate treatment such as

rved.

16 J. Gregory, J. Bramwell

physiotherapy and more fully co-operate with nurs-ing interventions (Gregory, 2005a).

For orthopaedic and trauma patients pain is com-monly experienced and is particularly found onmoving (Davis, 1997). Nurses provide the essentiallink in providing pain relief in orthopaedic patients,communicating and liaising with the patient, theirfamily and members of the multi disciplinary team.Pain is a known consequence of surgery and traumathat may lead to serious complications. The princi-ples of pain management include ongoing regularassessment and regular administration of analgesics(Buck and Paice, 1994).

As part of a secondment to the Acute Pain Ser-vice one of the authors (JB) investigated the issuessurrounding oral morphine, including its use, legis-lation and classification (Bramwell, 2004). This pa-per examines one change introduced as a result ofour investigation into transforming the way oralmorphine was administered on a trauma ward aspart of a pilot project.

Challenges

The barriers to effective pain management on atrauma ward are numerous and complex. The clini-cal environment is multifaceted. Pivotal to painmanagement is the decision to intervene which isoften affected by the demands of the case loadand the nurses’ level of knowledge and experience.Poor staffing levels and increasingly busy wardsmean that nurses are not always able to give analge-sia promptly (Mann and Redwood, 2000). There issometimes only one qualified nurse on duty espe-cially at night on the trauma wards. Delays may alsooccur due to the distractions and interruptions of adynamic working environment (Botti et al., 2004).For example, handling telephone calls from rela-tives, enquiries from members of the multi disci-plinary team and other competing nursing demands.

There are also more subtle institutional andbureaucratic barriers that contribute to preventingtimely and effective pain relief (Mann and Red-wood, 2000). One potential institutional barrier ishospital policy and controlled drug (CD) regulation.Whilst important and often necessary this results ina significant amount of time taken to administerstrong analgesia (Hawthorn and Redmond, 1998;Mann and Redwood, 2000).

Morphine is an effective analgesic for all typesof pain, and is considered a strong analgesia andclassed as a controlled drug. A CD is a substancecontrolled by the Misuse of Drugs Act 1971 to whichthe principle restrictions of the Misuse of DrugsRegulations 2001 (UK) apply. These drugs are sub-

ject to safe custody and regulation due to problemswith abuse and addiction. Schedule 2 drugs such asdiamorphine, morphine and cocaine are subject tofull CD requirements relating to prescriptions, safecustody and the need to keep a register (BNF,2005).

Morphine is the cornerstone of analgesia for se-vere pain (Buck and Paice, 1994) and when the pa-tient is well enough to tolerate oral fluids followingsurgery can often be administered as an oral opi-oid. There would seem little difference betweenoral and the traditional Intra muscular (IM) routeof administration to speed of onset for pain relief(Day, 1997). In the UK there are two strengths oforal morphine, 10 mg in 5 ml, which is a Prescrip-tion only Medicine (PoM) and is not classified as acontrolled drug. Oral morphine becomes a con-trolled drug when there is more than 13 mg or moreof morphine in 5 ml. The official classification oforal morphine 10 mg in 5 ml is a schedule 5 drug.A substance controlled by the Misuse of DrugsAct, but which is exempt from all restrictions underthe regulations, except that the invoice, or a copyof it, must be kept for 2 years.

Other drugs within the same classification in-clude: Co-Codamol 30/500, Codeine Phosphateand Diazepam. These drugs, however, are routinelykept in the ward drug trolley, are dispensed by onenurse, with no record of administration other thanthat recorded on the patient’s prescription chart.

Oral morphine (10 mg in 5 ml) has traditionallybeen treated and stored as a controlled drug atthe authors’ hospital, and many other hospitalsacross the UK. In some NHS Hospital Trusts it hasnever been subject to CD regulation for exampleManchester Royal Infirmary and other Hospitalshave changed the status of oral morphine. In PooleHospital, oral morphine (10 mg in 5 ml) is stored inthe drugs trolley with a single nurse administration(Crouch, 2004). Such changes have resulted in thereduction of delays in administrating analgesia.

As a CD, oral morphine is often administeredbased on established hospital policies as outlinedin Fig. 1. An audit at Rotherham District GeneralHospital, UK found 52% of patients waited over15 min for oral morphine to be administered withthis form of CD regulation (Roddison, 2004). In asmall questionnaire survey (nine registered nurseson medical and surgical wards) regarding oral mor-phine and its administration, seven nurses indi-cated that the administration of oral morphinetook 10 min and the remaining two nurses signifi-cantly more than 10 min. The main reason for thedelay in administering oral morphine cited by allrespondents was finding a second nurse to checkthe drug, four felt it was due to lack of staff and

Patient in severe acute pain

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Informs nurse

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Nurse assesses pain

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Nurse checks prescription

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Nurse decides appropriate drug and route

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Nurse decides Oramorph most appropriate analgesia

↓

Have to find CD key

↓

Have to find another available qualified nurse

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Find appropriate page in CD register

↓

Unlock cupboard

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Check stock levels

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Measure out dose

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Lock away remainder

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Fill in CD register

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Two nurses administer medication to patient

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Two nurses sign prescription chart

Figure 1 Traditional hospital algorithm for administer-ing oral morphine.

A pilot project of single nurse administration of oral morphine on a trauma ward 17

finding the drug keys was also problematic. Allrespondents felt the delay affected patients’ wel-fare and as a consequence, eight of the nine nursesthen offered an alternative analgesic (Gregory,2005b).

Pilot project

It was agreed to trial the administration of ora-morph with one nurses’ signature in the CD regis-ter, rather than full deregulation, to maintain

records of administration and checks. Howeveroramorph was still requisitioned, supplied andstored as a CD. The main change was; once thedecision was made to administer analgesia theregistered nurse (RN) then administers Oramorphwithout the need to find a second RN and thus re-duce delays. The trial took place over a fourmonth period during 2005. A report was thenpublished evaluating changes and recommenda-tions. The trauma ward was selected due to thelarge number of doses of oramorph being admin-istered on a daily basis to their patients. Theward manager was enthusiastic and eager to re-duce delays in analgesic provision. The Director-ate Senior Nurse and Matron also supported theinitiative.

A short informal education session was held atthe patient handover to introduce the proposedchange. The session included information about:

� the action of oramorph;� decision making in the use of oral, IM or IVadministration;� a brief review of the legal classification of CD’s;� the proposed change in practice;� gaining agreement by the clinical staff on theproposed guideline on the administration of oralmorphine with one signature (Table 1).

Evaluation

Over the four month trial of single nurse deliveryof oral morphine 782 doses had been adminis-tered, without any discrepancies and the originalhospital CD policy adhered to except for therequirement of two RN signatures. A question-naire was distributed to the nurses based on thetrauma ward after one month of the trial to cap-ture their initial experience of the change inpractice. Ten registered nurses out of 14 re-sponded, representing day and night staff and arange of clinical experience from a few monthsto over 20 years. Their comments on how it feltto administer oral morphine without a secondnurse check included:

� unsure at first. . ... but pleased that oromorphcould be administered immediately;� easier to administer instead of waiting aroundfor another qualified nurse who was free causingthe patient to wait longer for their medication;� much better. . ..no waiting. . .. . .although feltuncomfortable unlocking the CD cupboard onmy own;

Table 1 Rationale for the proposed guideline

Barriers to timelyadministration

Possible solutions to over come thebarriers identified

Solutions from single nurseadministration

Low staffing levels No immediate solution Available staff can use timeeffectively; not waiting for secondnurse to check

Increasingly busy wardsand complex dependantpatients

No immediate solution and nocontrol over situation. Increasededucation on management of thesepatients

Increased nurses’ knowledge of oralmorphine, its action and monitoringrequired

Interruptions when obtaininganalgesia

Find ways of avoiding interruptionsand administer analgesia directly topatient

Interruptions are reduced as RNadministers morphine directly withoutwaiting for second nurse. (Nurses areoften interrupted and asked forinformation, or help when waiting forsecond nurse)

Regulations concerningstorage and administration oforal morphine

Review policy and deregulate thestorage and administration of oralmorphine from CD restriction

The policy for administration of oralmorphine has been changed to includeone signature. Improved daily checksof CD’s have resulted

18 J. Gregory, J. Bramwell

� at first I felt a little apprehensive. . .. . .. I felt Iwas breaking the rules of administering a CDwithout a second nurse. . .. . ..felt I was beingwatched as I was entering the CD cupboard alone.

The nurses were asked what, if any, were thebenefits of administering oral morphine alone. Allthe nurses responded that it had improved thetimeliness and that patients received theiranalgesia quicker. Some also described the delaysor waits for a second nurse meant that other‘work’ was delayed, as a result of the singlecheck this was no longer the case. One describedthe change as ‘immediate pain relief’. As regardschallenges presented by the change, two nurseswere concerned about discrepancies althoughthe majority did not feel there were anyproblems as one commented; ‘oromorph is pre-scribed just like any other drug’. The benefitsto patients of single nurse administration of oro-morph are:

� A patient had asked for oral morphine and waited30 min for two nurses to check it. This patientwas worried about being in pain and not gettinganalgesia quick enough. She was relieved andconfident when I came back with oral morphinestraight away. She was less anxious.� Working on a very busy orthopaedic ward, themornings are hectic with patients needing painrelief and to be given their analgesia straightaway without having to wait for another memberof the nursing team to be available. This was so

much better because the patient had almostinstant pain relief instead of having to wait any-thing up to 10–15 min.� My patient was suffering from severe abdominalpain. Asking took 3 min from administering theoral morphine to checking her identity. If I hadto ask another nurse to check it could take upto 10 min all this time the patient is sufferingin pain. By saving 7 min the patient’s pain hadstarted to ease.� I have given oral morphine regularly since notneeding a second signature. It has made differ-ence to the patient each time as they have nothad to wait, and therefore the pain has beeneased sooner. This prevents the patient’s painescalating.

All of the nurses responding to the surveywanted to continue to administer oral morphinewith one signature and made further positivecomments:

� much better being able to administer oral mor-phine with one nurse signature. . ..let’s hope itcontinues. . .. . .� I feel if nurses are competent and feel satisfiedthat they can assess the situation and give oralmorphine as required there should not be anyproblems. . .. . . nurses are accountable for theirown actions, and if uncomfortable with the situ-ation, e.g. frequency, dose, side effects canalways seek help or wait prior to administeringthe drug. . ...

A pilot project of single nurse administration of oral morphine on a trauma ward 19

� there would be no problem with stock control asall CD’s are checkedona regular basis anyway. . ...

In addition to the participating nurses’ feed-back, the ward sisters and matron were also inter-viewed for feedback on the scheme. They wereasked for their opinion of single nurse administra-tion of oral morphine and any concerns about itsregulation or control in practice:

� wonderful. . .. . ..a good idea. . .. . ..medication isgiven when requested, not waiting and so muchbetter. . .. . ...� it enables better pain control and nurses can geton with their jobs. . .. . ..� nurses are responsible for their own actions.� it is no different to two nurses checking. . .. . ...� I expect R/N’s to know their own (professional)limitations. . .. . .

As regards the last comment most nurses did notfeel oromorph would be administered inappropri-ately as the decision to administer was based onassessing the patient need and if anything tendedto give lower doses. One staff nurse who partici-pated in the pilot project had since moved to an-other trauma ward and noted frustration havingto wait for another nurse to finish something beforein order to double check the oral morphine:

� with one nurse it’s given when the patient needsit, not when it’s convenient to nurses. . .. . .

A significant factor in the use of single nurse deliv-ery of oromorph has been a reduction in time in itsadministration from an average of 10 to 5 min. As aresult of the pilot project and the positive feedbackfrom the RN’s and their managers, the scheme hassince been extended to another trauma ward. Thestaff on that ward are also evaluating the changepositively and the intention is to introduce singlenurse administration of oral morphine to medicalas well as surgical wards in the hospital.

Conclusion

The literature and experience of other acute NHShospitals in the UK suggest that low dose oralmorphine should be treated as a prescription only

drug to facilitate the control of pain. This pilotproject has removed the restriction of needingtwo RN’s to sign the CD register to just one andhas halved the time taken to administer oral mor-phine. This modest, but significant change hasalso incorporated managing such a risk throughcomprehensive documentation of the number ofdoses administered and amount of drug remainingon the ward. The RN’s on the ward dealing di-rectly with their patients in pain have found thatthis change has made a positive difference totheir practice, increased their accountability andautonomy in practice and conclude that the needfor two RN’s to safely administer oral morphinenow appears detrimental to the well-being oftheir patients.

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