Medication administration process in a residential aged care home: An observational study

Do healthcare professionals work around safety standards, and should we be worried? A scoping review

BACKGROUND

Healthcare staff adapt to challenges faced when delivering healthcare by using workarounds. Sometimes, safety standards, the very things used to routinely mitigate risk in healthcare, are the obstacles that staff work around. While workarounds have negative connotations, there is an argument that, in some circumstances, they contribute to the delivery of safe care.

OBJECTIVES

In this scoping review, we explore the circumstances and perceived implications of safety standard workarounds (SSWAs) conducted in the delivery of frontline care.

METHOD

We searched MEDLINE, CINAHL, PsycINFO and Web of Science for articles reporting on the circumstances and perceived implications of SSWAs in healthcare. Data charting was undertaken by two researchers. A narrative synthesis was developed to produce a summary of findings.

RESULTS

We included 27 papers in the review, which reported on workarounds of 21 safety standards. Over half of the papers (59%) described working around standards related to medicine safety. As medication standards featured frequently in papers, SSWAs were reported to be performed by registered nurses in 67% of papers, doctors in 41% of papers and pharmacists in 19% of papers. Organisational causes were the most prominent reason for workarounds.Papers reported on the perceived impact of SSWAs for care quality. At times SSWAs were being used to support the delivery of person-centred, timely, efficient and effective care. Implications of SSWAs for safety were diverse. Some papers reported SSWAs had both positive and negative implications for safety simultaneously. SSWAs were reported to be beneficial for patients more often than they were detrimental.

CONCLUSION

SSWAs are used frequently during the delivery of everyday care, particularly during medication-related processes. These workarounds are often used to balance different risks and, in some circumstances, to achieve safe care.

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.

Thinking strategies used by registered nurses during drug administration in nursing homes-An observational study

AIM

To explore registered nurses' thinking strategies during the drug administration process in nursing homes.

DESIGN

An exploratory qualitative design.

METHODS

Eight registered nurses, one male and seven female, in five nursing home wards in Mid-Norway were observed during 15 drug dispensing rounds (175 drug dispensing episodes). Think Aloud sessions with follow-up individual interviews were conducted. The Think Aloud data were analysed using deductive qualitative content analysis based on Marsha Fonteyn's description of 17 thinking strategies. Interview data were used to clarify missing information and validate the content of Think Aloud data.

RESULTS

The registered nurses used all 17 thinking strategies described by Fonteyn, including several variants of each strategy. The three most frequent were 'providing explanations', 'setting priorities' and 'drawing conclusions'. In addition, we found two novel thinking strategies that did not fit into Fonteyn's template, which were labelled 'controlling' and 'interacting'. Among all strategies, 'controlling' was by far the most used, serving as a means for the registered nurses to stay on track and navigate through various interruptions, while also minimising errors during drug dispensing.

CONCLUSION

The study highlights the diverse thinking strategies employed by registered nurses in nursing homes during medication administration. The findings emphasise the multifaceted nature of medication administration and underscore the importance of skilled personnel in ensuring medication safety. Recognising the significance of these findings is crucial for maintaining patient well-being and upholding medication safety standards in healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

Understanding the thinking strategies employed by registered nurses can inform training programmes and enhance the clinical judgements of health care professionals involved in medication administration, ultimately leading to improved patient outcomes and reduced medication errors in practice.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in this study as recipients of drugs which the nurses distributed during the observations. The patients were involved as a third party and consent to the observations was either given by the patients themselves or relatives in cases where the patient was not competent to consent. No personal information was collected about the patients.

REPORTING METHOD

The reporting of this study adhered to the COREQ checklist.

Adopting an electronic medication administration system in long-term care facilities: a key stakeholder interview study in Macao

To improve medication safety for residents in long-term care facilities (LTCFs), electronic medication administration records (eMARs) are widely adopted in Macao. This study aimed to (1) develop a logic model for adopting eMAR in LTCFs and (2) explore the contextual factors relevant to the implementation. Semi-structured interviews were conducted with key stakeholders (managers, doctors, nurses, pharmacy staff and other frontline workers) experienced with eMAR in LTCFs in Macao between February and March 2021. Purposive sampling was used for recruitment and thematic analysis followed the theoretical framework of the logic model. All 57 participants were positive about eMAR. Financial and nonfinancial resources were critical to adopting eMAR. eMAR was mostly used for its functions in documentation, e-prescribing and monitoring. Immediate output included simplified working process, reduced errors, closer monitoring of residents' conditions, and timely communication among staff. The outcomes mainly related to efficiency, safety and quality of care, workload redundancy, and data unification. Key influencing factors included eMAR flexibility, stability, and technical support. Adopting eMARs is highly consuming and the benefits in improving quality of care can only be realized with appropriate implementation, precise execution, regular evaluation and responsive adjustment. The proposed logic model framework serves as a roadmap for LTCFs, both current and future users of eMAR.

Interventions to optimize medication use in nursing homes: a narrative review

PURPOSE

Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes.

METHODS

We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting.

RESULTS

Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels.

CONCLUSION

Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.

A work system analysis of the medication administration process in a Norwegian nursing home ward

Nursing home patients often have multiple diagnoses and a high prevalence of polypharmacy and are at risk of experiencing adverse drug events. The study aims to explore the dynamic interactions of stakeholders and work system elements in the medication administration process in a nursing home ward. Data were collected using observations and interviews. A deductive content analysis led to a SEIPS-based process map and an accompanying work system analysis. The study increases knowledge of the complexity of the medication administration process by portraying the dynamic interactions between the major stakeholders in the work system, and the temporal flow of the activities involved. Secondly, it identifies facilitators and barriers in the work system linked to the medication administration process. Most barriers and facilitators are associated with the work system elements - tools & technology, organisation and tasks - and occur early in the medication administration process.

Contradictions in information technology mediated work in long-term care: An activity theoretic ethnographic study

BACKGROUND

The growing demand for aged care services coupled with a global shortage of skilled nursing staff has hindered long-term care facilities' ability to provide necessary services to their residents. Healthcare information technology is expected to mitigate this challenge by streamlining nursing work, while also improving quality of care and productivity.

OBJECTIVES

This study set out to examine how nurses and care workers work, the role of information technology (IT) in their work and what contradictions they face in their IT mediated work.

DESIGN

Ethnographic study informed by six components of activity theory: subject, object, tool, rule, community and division of labor.

SETTING

Eight care units in two long-term care facilities in Australia.

PARTICIPANTS

Eleven staff from two long-term care facilities including registered nurses (n = 2), endorsed enrolled nurses (n = 5) and personal care workers (n = 4) participated in this study.

METHODS

Participants were shadowed during morning shifts (6:30 am to 3:00 pm). A total of 24 morning shifts were observed over four months. Field notes were created based on observational data and informal interviews, in addition to document review.

RESULTS

Through the lens of activity theory, the work activity system of nurses and care workers in the long-term care facilities consisted of the subject (nurses and care workers), their object (resident care), tools used for work including IT, rules of work, community, and division of labor. These components interacted through work processes; therefore, a "process" component was added in the activity system. Special attention was given to the role of IT as the conduit of information in the work processes. Although IT helped track medication rounds, automated documentation and communication among the staff, it introduced contradictions. Seven contradictions involving IT were identified, including contradictions within the IT tool, between the IT tool and the object of work, between the subjects and documentation rules, between the work activity system using paper records and the system using IT, and between the activity system within the long-term care facility and the pharmacists' work activity system outside the facility.

CONCLUSIONS

Activity theory provided a theoretic framework to model the work activity system of nurses and care workers. Information technology played an important role in supporting information flow in this system, however it also caused contradictions.