Medication Management in Municipality-Based Healthcare: A Time and Motion Study of Nurses

Medication administration in aged care facilities: A mixed-methods systematic review

AIM(S)

To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42023426990.

DATA SOURCES

The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023.

REVIEW METHODS

Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed.

RESULTS

One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001).

CONCLUSIONS

Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care.

IMPACT

What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Multitasking during Medication Management in a Nursing Home: A Time Motion Study

BACKGROUND

 Multitasking, defined as performing two or more interventions simultaneously, increases the cognitive burden of clinicians. This may, in turn, lead to higher risk of medication and procedural errors. Time motion study (TMS) data for nurses in nursing homes revealed an extensive amount of multitasking while managing medications. Further investigation of multitasked nursing interventions will provide a foundation for optimizing medication management workflows.

OBJECTIVES

 Using a continuous observational TMS method, this study aimed to describe pairs of multitasked nursing interventions associated with medication management interventions, including preparing and administering medications, assessing medication effects, instructing on medications, and documenting medication administration.

METHODS

 An external nurse observer used 57 predefined Omaha System nursing interventions embedded within TimeCaT (version 3.9), TMS data recording software to collect observation data in a single nursing home. A total of 120 hours of time-stamped observation data from nine nurses were downloaded from TimeCaT and analyzed using descriptive and inferential statistics.

RESULTS

 The majority (74%) of medication management interventions were multitasked, resulting in 2,003 pairs of multitasked interventions. Of the 57 Omaha System nursing interventions, 35 were involved in these multitasking pairs. When nurses multitasked, the average duration of medication preparation was longer (non-multitasked: 81 seconds; multitasked: 162 seconds, p < 0.05), while the average duration of medication administration record documentation was shorter (non-multitasked: 93 seconds; multitasked: 66 seconds, p < 0.05).

CONCLUSION

 The findings reveal the complexity of medication management in nursing homes with numerous and diverse multitasking pairs. Findings provide a platform for in-depth study of medication management multitasking in the clinical context, and inform future efforts to create clinical and informatics solutions to optimize medication management workflow. This method may be also applied to examine medication management and multitasking in other clinical settings.

Medication management in Danish home health care: Mapping of tasks and time consumption

We aimed to map tasks related to medication management and time consumption in Danish home health care. Nursing staff (n = 30) from five municipalities were followed during a 10-week period and tasks related to medication management, time consumption and information on citizens' medication were registered. A total of 269 courses were registered, including 163 (61%) home visits, 76 (28%) in-office courses, 29 (11%) in-clinic courses and 1 (0.4%) acute visit. Of defined categories related to medication management, 'record-keeping and communication' (62%, n = 167), 'dispensing' (48%, n = 129) and 'identification' (30%, n = 81) were most often performed. During half of courses (55%, n = 147), the nursing staff was interrupted at least one time. The median time spent on medication management was less than the time allocated in most of allocated time slots (82%), with a median excess time of 5.1 min (range 0.02-24 min). Citizens (n = 32) used a median of 11 (interquartile range [IQR] 9-13) regular medications and 2 (IQR 1-4) as-needed, and 69% (n = 22) used high-risk situation medications. In conclusion, employees in Danish home health care perform diverse medication-related tasks and are frequently interrupted in their work. Employees spend less time than allocated but do not fully solve all tasks according to best practice guidance.

Human resource implications of expanding latent tuberculosis patient care activities

Introduction

The World Health Organization (WHO) declared increasing services for latent tuberculosis infection (LTBI) a priority to eliminate tuberculosis (TB) by 2035. Yet, there is little information about thehuman resource needs required to implement LTBI treatment scale-up. Our study aimed to estimate the change in healthcare workers (HCW) time spent on different patient care activities, following an intervention to strengthen LTBI services.

Methods

We conducted a time and motion (TAM) study, observing HCW throughout a typical workday before and after the intervention (Evaluation and Strengthening phases, respectively) at 24 health facilities in five countries. The precise time spent on pre-specified categories of work activities was recorded. Time spent on direct patient care was subcategorized as relating to one of three conditions: LTBI, active or suspected TB, and non-TB (i.e., patients with any other medical condition). A linear mixed model (LMM) was fit to estimate the change in HCW time following the intervention.

Results

A total of 140 and 143 HCW participated in the TAMs during the Evaluation and Strengthening phases, respectively. Results from intervention facilities showed an increase of 9% (95% CI: 3%, 15%) in the proportion of HCW time spent on LTBI-related services, but with a corresponding change of -11% (95% CI: -21%, -1%) on active TB services. There was no change in the proportion of time spent on LTBI care in control facilities; this remained low in both phases of the study.

Discussion

Our findings suggest that additional HCW personnel will be required for expansion of LTBI services to ensure that this expansion does not reduce the time available for care of active TB patients.

Toward ensuring care quality and safety across settings: examining time pressure in a nursing home with observational time motion study metrics based on the Omaha system

BACKGROUND

Meaningful data to determine safe and efficient nursing workload are needed. Reasoning a nurse can accomplish a finite number of interventions and location changes per hour, examination of time pressure using time motion study (TMS) methods will provide a comparable indication of safe and efficient workload for an individual nurse.

METHODS

An observer shadowed 11 nurses at a 250-bed nursing home in the Southeastern United States and recorded 160 h of observations using TimeCaT, web-based TMS data recording software. Predefined Omaha System nursing interventions (N = 57) and locations (N = 8) were embedded within TimeCaT. The time-stamped data were downloaded from TimeCaT and analyzed using descriptive and inferential statistics. Five time pressure metrics were derived from previous TMS findings in acute care settings.

RESULTS

Overall, nurses spent 66 s for each intervention, performed 65 interventions per hour, stayed 130 s at each location, changed locations 28 times per hour, and multitasked for 29% of working time. Computed hourly time pressure metrics enabled visualization of variability in time pressure metrics over time, with differences in multitasking by licensure, unit/role, and observation session time.

CONCLUSIONS

Nursing home nurses consistently experienced a high degree of time pressure, especially multitasking for one-third of their working time. To inform staffing decision making and improve the quality of care, resident outcomes, and nurse satisfaction, it is critical to identify ways to mitigate time pressure. Additional research is needed to refine and extend the use of the time pressure metrics.

Analysis of home care nurses' workload: A time-motion study

This observational-descriptive time and motion study was conducted to determine how heavy home care nurses' workload is and how they allocate their work time to home healthcare. It was carried out in the home health services of the district municipality.The Information form, Nursing Activities Report Form, Cheltenham Patient Classification Scale were used. The time-motion study method was implemented to perform the workload analysis. The nurses allocated 68.02 minutes to direct care, 61.02 minutes to indirect care, 53.26 minutes to their work unit-related activities, and 119.42 minutes to their personal activities.Among all the activities performed during the day, the longest time was allocated to educational activities. Another area that took a long time was the registration procedures. Performing workload analysis with different methods that will measure many concrete and intangible attempts of home care nurses will contribute to workforce planning in home care services, resolving of the unmet home care needs of patients and continuous quality improvement.

Medication management for patients with hip fracture at a regional hospital and associated primary care units in Norway: a descriptive study based on a survey of clinicians' experience and a review of patient records

OBJECTIVE

Patients with hip fracture are at high risk of medication errors due to a combination of high age, comorbidities, polypharmacy and several care transitions after fracture. The aim was to study medication management tasks concerning patient safety: medication reconciliation, medication review and communication of key medication information in care transitions.

DESIGN

Descriptive study comprising a self-administered clinician survey (MedHipPro-Q) and a retrospective review of hospital medical records of patients with hip fracture.

SETTING

Regional hospital and the associated primary care units (South-Eastern Norway).

PARTICIPANTS

The survey received responses from 253 clinicians, 61 medical doctors and 192 nurses, involved in the medication management of patients with hip fracture, from acute admittance to the regional hospital, through an in-hospital fast track, primary care rehabilitation and back to permanent residence. Respondents' representativeness was unknown, introducing a risk of selection and non-response bias, and extrapolating findings should be done with caution. The patient records review included a random sample of records of patients with hip fracture (n=50).

OUTCOME MEASURES

Medication reconciliation, medication review and communication of medication information from two perspectives: the clinicians' (ie, experiences with medication management) and the practice (ie, documentation of completed medication management).

RESULTS

In the survey, most clinicians stated they performed medication reconciliation (79%) and experienced that patients often arrived without a medication list after care transition (37%). Doctors agreed that more patients would benefit from medication reviews (86%). In the hospital patient records, completed medication reconciliation was documented in most patients (76%). Medication review was documented in 2 of 50 patients (4%). Discharge summary guidelines were followed fully for 3 of 50 patients (6%).

CONCLUSION

Our study revealed a need for improved medication management for patients with hip fracture. Patients were at risk of medication information not being transferred correctly between care settings, and medication reviews seemed to be underused in clinical practice.

An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings

INTRODUCTION

Medication errors are common events that compromise patient safety and are prevalent in all health-care settings. This umbrella review aims to systematically evaluate the evidence on contributory factors to medication errors in health-care settings in terms of the nature of these factors, methodologies and theories used to identify and classify them, and the terminologies and definitions used to describe them.

AREAS COVERED

Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google Scholar were searched from inception to March 2022. The data extraction form was derived from the Joanna Briggs Institute (JBI) Reviewers' Manual, and critical appraisal was conducted using the JBI quality assessment tool. A narrative approach to data synthesis was adopted.

EXPERT OPINION

Twenty-seven systematic reviews were included, most of which focused on a specific health-care setting or clinical area. Decision-making mistakes such as non-consideration of patient risk factors most commonly led to error, followed by organizational and environmental factors (e.g. understaffing and distractions). Only 10 studies had a pre-specified methodology to classify contributory factors, among which the use of theory, specifically Reason's theory was commonly used. None of the reviews evaluated the effectiveness of interventions in preventing errors. The collated contributory factors identified in this umbrella review can inform holistic theory-based intervention development.

Social interactions and quality of life of residents in aged care facilities: A multi-methods study

Background

The relationship between social contact and quality of life is well-established within the general population. However, limited data exist about the extent of social interactions in residential aged care facilities (RACFs) providing long-term accommodation and care. We aimed to record the frequency and duration of interpersonal interactions among residents in RACFs and identify the association between residents’ interpersonal interactions and quality of life (QoL).

Materials and methods

A multi-methods study, including time and motion observations and a QoL survey, was conducted between September 2019 to January 2020. Thirty-nine residents from six Australian RACFs were observed between 09:30–17:30 on weekdays. Observations included residents’ actions, location of the action, and who the resident was with during the action. At the end of the observation period, residents completed a QoL survey. The proportion of time residents spent on different actions, in which location, and with whom were calculated, and correlations between these factors and QoL were analysed.

Results

A total of 312 hours of observations were conducted. Residents spent the greatest proportion of time in their own room (45.2%, 95%CI 40.7–49.8), alone (47.9%, 95%CI 43.0–52.7) and being inactive (25.6%, 95%CI 22.5–28.7). Residents were also largely engaged in interpersonal communication (20.2%, 95%CI 17.9–22.5) and self-initiated or scheduled events (20.5%, 95%CI 18.0–23.0). Residents’ interpersonal communication was most likely to occur in the common area (29.3%, 95%CI 22.9–35.7), residents’ own room (26.7%, 95%CI 21.0–32.4) or the dining room (24.6%, 95%CI 18.9–30.2), and was most likely with another resident (54.8%, 95%CI 45.7–64.2). Quality of life scores were low (median = 0.68, IQR = 0.54–0.76). Amount of time spent with other residents was positively correlated with QoL (r = 0.39, p = 0.02), whilst amount of time spent with facility staff was negatively correlated with QoL (r = -0.45, p = 0.008).

Discussion and conclusions

Our findings confirm an established association between social interactions and improved QoL. Opportunities and activities which encourage residents to engage throughout the day in common facility areas can support resident wellbeing.

'It's good to have the knowledge and the confidence': Mental health student nurses' views of a medication workshop

The administration of medication in a safe manner is a key nursing role and nursing regulatory bodies mandate that it is part of undergraduate training. However, it has been noted that qualified nursing staff are dissatisfied with the knowledge demonstrated by students. As such, a 2-day evidence-based workshop on medication management for final-year nursing students was facilitated to address knowledge deficits. Content was delivered by academics and practicing nurses. The aims of this study were to evaluate internship mental health student nurses' experiences of a 2-day medication management workshop. A qualitative descriptive design was adopted. Three focus group interviews were held with student nurses who partook in the workshop. Data were analysed using reflexive thematic analysis. Three themes were identified: Developing Confidence around Medication Management, Reflections on Learning Gained from the Workshop, and Enhancing Awareness and Vigilance of Medication Errors. Overall, participation in the workshop was identified as having a positive impact on students' knowledge, competence, and confidence in relation to becoming a safe practitioner. Students reported that the timing of the workshop - during internship - was appropriate for their knowledge needs. Findings indicate that the right amount of information was delivered by the right people, at the right time, in the right way. This study has highlighted the positive impact of a 2-day workshop delivered in the final year of mental health student nurse training, on their confidence and competence in the area of medication management. It provides some insight into how a practical collaborative approach to this type of education between academics and clinicians can help students bridge the theory-practice gap.

Medication errors' causes analysis in home care setting: A systematic review

Many studies analyze the medication errors in the hospital setting, but the literature involving the home care setting seems scarce. The aim of this study is to identify the main risk factors that affect the genesis of medication errors and the possible solutions to reduce the phenomenon in the home care setting. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The critical analysis of the literature shows that medication errors in home care occur mainly during transitional care. The main risk factors related to transitional care are poor interprofessional communication, lack of a standardized process for medication reconciliation, the widespread use of computerized tools, and the inadequate integration of the pharmacist into the care team. The strategies to reduce the risk of errors from therapy at home are the implementation of the pharmacist in the health team to ensure accurate medication reconciliation and the use of computerized tools to improve communication between professionals and to reduce the dispersion of information.