The RESPECT-brochure: Development of a tool to inform and empower residents and informal caregivers on the medicines' pathway in nursing homes

Objective

To develop and evaluate a tool to inform and empower nursing home (NH) residents and informal caregivers regarding the medicines' pathway.

Methods

Feedback on the tool's text, drafted by the research team, was collected from a professional organization; the lay-out was designed by an illustrator. The tool was pilot tested in NHs, focusing on feasibility, appropriateness, and meaningfulness. Semi-structured interviews and focus groups with residents, informal caregivers, and healthcare professionals were performed, as well as document analysis. Qualitative data were analyzed inductively.

Results

The RESPECT-brochure was developed and described each process of the medicines' pathway. Piloting showed that the tool was well perceived among residents and informal caregivers and offered opportunities to discuss medication-related questions and concerns, but that skills to tailor the conversation, especially given the changing NH population, a matching vision and local champion are required for the tool's uptake.

Conclusion

An informative and empowering tool has been successfully developed and pilot tested in NHs. Future research should investigate which strategies for implementation work best and can explore the impact of the tool's use in daily practice.

Innovation

The tool is the first in its kind and grants nursing home staff a new strategy to promote person-centered care.

GPs' and pharmacists' views of integrating pharmacists into general practices: a qualitative study

BACKGROUND

Practice-based pharmacists (PBPs) have been introduced into general practice across the UK to relieve some of the pressures within primary care. However, there is little existing UK literature that has explored healthcare professionals' (HCPs') views about PBP integration and how this role has evolved.

AIM

To explore the views and experiences of GPs, PBPs, and community pharmacists (CPs) about PBPs' integration into general practice and their impact on primary healthcare delivery.

DESIGN AND SETTING

A qualitative interview study in primary care in Northern Ireland.

METHOD

Purposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in Northern Ireland. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. Semi-structured interviews were recorded, transcribed verbatim, and analysed using thematic analysis.

RESULTS

Eleven triads were recruited from across the five administrative areas. Four main themes in relation to PBPs' integration into general practices were revealed: evolution of the role; PBP attributes; collaboration and communication; and impact on care. Areas for development were identified such as patient awareness of the PBP role. Many saw PBPs as a 'central hub-middleman' between general practice and community pharmacies.

CONCLUSION

Participants reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. Further work is needed to increase patient awareness of the PBP role.

Medication Decision-Making and the Medicines' Pathway in Nursing Homes: Experiences and Expectations of Involvement of Residents and Informal Caregivers

BACKGROUND

Information on how residents and their informal caregivers are involved in the medicines' pathway in nursing homes is scarce. Likewise, it is not known how they would prefer to be involved therein.

METHODS

A generic qualitative study using semi-structured interviews with 17 residents and 10 informal caregivers from four nursing homes was performed. Interview transcripts were analyzed using an inductive thematic framework.

RESULTS

Four themes were derived to describe resident and informal caregiver involvement in the medicines' pathway. First, residents and informal caregivers show behaviors of involvement across the medicines' pathway. Second, their attitude towards involvement was mainly one of resignation, but variation was noted in their involvement preferences, ranging from minimal information to active participation needs. Third, institutional and personal factors were found to contribute to the resigned attitude. Last, situations were identified that drive residents and informal caregivers to act, regardless of their resigned attitude.

CONCLUSIONS

Resident and informal caregiver involvement in the medicines' pathway is limited. Nevertheless, interviews show that information and participation needs are present and show potential for residents' and informal caregivers' contribution to the medicines' pathway. Future research should explore initiatives to increase the understanding and acknowledgement of opportunities for involvement and to empower residents and informal caregivers to take on their roles.

Resident and informal caregiver involvement in medication-related decision-making and the medicines' pathway in nursing homes: experiences and perceived opportunities of healthcare professionals

BACKGROUND

Person-centered care has been shown to be beneficial for nursing home residents. The know-how and attitude of healthcare professionals, however, can make its implementation difficult. Also, research on person-centered care with regard to medication decision-making and the medicines' pathway in nursing homes is lacking. This study aimed to provide an understanding of healthcare professionals' attitudes and perspectives on current resident and informal caregiver involvement in medication decision-making and the medicines' pathway in nursing homes.

METHODS

A qualitative, explorative study using semi-structured interviews with a sample of 25 healthcare professionals from four different nursing homes was performed. Interview transcripts were analyzed by means of an inductive thematic framework.

RESULTS

Three overarching domains were identified: 1) features of, 2) drivers and barriers for, and 3) perceived consequences of resident and informal caregiver involvement in medication decision-making and the medicines' pathway. Involvement was mainly initiated by residents and informal caregivers themselves, pointing towards information and participation needs among both groups. Nevertheless, actions of healthcare professionals towards resident and informal caregiver involvement were mainly reactive and fragmentary. Their actions were influenced by the perception of residents and informal caregivers' desire and capabilities to be involved, the perception of their own professional role, but also by organizational factors such as the nursing home's philosophy. Furthermore, organizational concerns tempered the motivation to provide residents and informal caregivers with more medication-related responsibilities.

CONCLUSIONS

Resident and informal caregiver involvement in medication decision-making and the medicines' pathway remains limited in nursing homes. Information and participation needs of residents and informal caregivers were not fully acknowledged by healthcare professionals. As such, we can conclude that there is a need for initiatives, both on an individual and on an organizational level, to create and improve awareness on opportunities to improve resident and informal caregiver involvement in medication decision-making and the medicines' pathway.

Older Adults Living in Sheltered Housing's Experiences of Involvement in Pro Re Nata Decisions. A Narrative Positioning Analysis

Decisions regarding pro re nata medications might be challenging due to the complex nature of the practice. The aim of this study was to expand our understanding of the experiences of older people living in sheltered housings with regard to shared decision-making concerning pro re nata medications. In this study, we conducted in-depth interviews with residents living in Norwegian sheltered housings. The analysis was inductive, based on a narrative positioning analysis. Twelve residents were interviewed, and three narratives representing participants’ variation are presented. People take different positions in shared decision-making of pro re nata medication, and they position themselves variously at different levels and situations. Prevailing master narratives affect the residents’ positions in shared decision-making. Contrasts in older adults’ experiences indicate that shared decision-making is not straightforward and is highly reliant on the context. Seemingly, they wish to be involved and not involved at the same time, a contradiction that healthcare providers need to consider.

Resident and family engagement in medication management in aged care facilities: a systematic review

Introduction: Medication-related harms may occur if residents and families are not involved when important medication decisions are made. We examined how residents and families engage in the management of residents' medications in aged care facilities.Areas covered: A systematic review was undertaken, which was registered with PROSPERO (CRD42020152700). Electronic databases were searched from inception until 27 August 2020 using MEDLINE/PubMed, CINAHL, PsycINFO and EMBASE. Data synthesis was undertaken using thematic analysis.Expert opinion: Forty studies were included. Communication tended to be unidirectional comprising consultations where residents and families provided medication information to health care providers or where health care providers provided medication information to residents and families. Many challenges prevailed that prevented effective engagement, including families' hesitation about making decisions, and the lack of adequately-trained health care providers. Testing of interventions often did not include residents or families in developing these interventions or in examining how they participated in medication decisions following implementation of interventions. Areas for improvement comprise actively involving residents and families in planning interventions for resident-centered care. Health care providers need to have greater appreciation of families' ability to detect dynamic changes in residents' behavior, which can be used to enable optimal alterations in medication therapy.

Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study

Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.

Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study

Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.

Drug interactions with oral anticoagulants in German nursing home residents: comparison between vitamin K antagonists and non-vitamin K antagonist oral anticoagulants based on two nested case-control studies

BACKGROUND

Vitamin K antagonists (VKAs) are susceptible to drug-drug interactions. Non-VKA oral anticoagulants (NOACs) have a decreased sensitivity to pharmacokinetic interactions and might be therefore considered superior in patients treated with multiple drugs. The objective of this study was to compare the risk of serious bleeding associated with interacting drugs in German nursing home residents treated with VKA or NOAC.

METHODS

Using claims data of new nursing home residents aged ≥ 65 years (2010-2014) we conducted separate nested case-control analyses within two cohorts of patients treated with VKA or NOAC, respectively. Cases were defined as patients hospitalized for serious bleeding. For each case, up to 20 controls were selected by risk-set sampling. Conditional logistic regression was used to obtain confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CI) for the risk of bleeding associated with VKA or NOAC use and interacting drugs compared with the use of the respective oral anticoagulant alone.

RESULTS

Among 127,227 new nursing home residents, 16,804 patients received oral anticoagulation. Based on 372 cases and 7281 matched controls, the highest risk of bleeding in VKA users was observed for the concomitant use of antibiotics (aOR 3.00; CI 2.11-4.27) vs. VKA use alone, followed by non-steroidal anti-inflammatory drugs (1.66; 1.13-2.43). Among 243 NOAC cases and 4776 matched controls, elevated risks for bleeding were observed for the use of heparins (2.05; 1.25-3.36) and platelet inhibitors (1.92; 1.36-2.72).

CONCLUSIONS

Concomitant medication needs to be prescribed cautiously and monitored closely in nursing home residents treated with oral anticoagulants.

Prevalence of cancer and management in elderly nursing home residents. A descriptive study in 45 French nursing homes

This study aimed to determine cancer prevalence occurring after the age of 75 in 45 French nursing homes (NH), as well as residents' characteristics and parameters associated with cancer-specific management. Descriptive retrospective study including 214 residents (mean age, 89.7 years) with cancer diagnosed after age 75. The studied parameters were sociodemographic, functional, nutritional and cognitive data; comorbidity assessment; date of tumoral diagnosis; cancer type; tumoral stage; treatment plan; multidisciplinary staff decision and oncologic follow-up. Our results showed that cancer prevalence in NH was 8.4 ± 1.1%, diagnosed before admission in 63% of cases. The most common tumoral sites were skin (26%), digestive tract and breast (18% for both); 12% had metastasis. Cognitive impairment was the most common comorbidity (42%), and 44% of the residents were highly dependent. Multivariate analysis showed that therapeutic decisions were associated with age. Older patients had less staging exploration (odd ratios [ORs], 0.90, 95% confidence interval [CI], 0.85-0.97) and underwent less cancer-specific treatment (ORs, 0.92; 95%CI, 0.86-0.99). Oncologic follow-up was more frequent in younger patients (ORs, 0.90; 95%CI, 0.81-0.99) and those with recent diagnosis (ORs, 0.37; 95%CI, 0.23-0.61). This study identified factors associated with substandard neoplastic management in elderly NH residents. It highlights needs for information, education and training in cancer detection to improve cancer consideration and care in NH.

Caring in nursing homes to promote autonomy and participation

Background:

Autonomy and participation are threatened within the group of older people living in nursing homes. Evidence suggests that healthcare personnel act on behalf of older people but are still excluding them from decision-making in everyday care.

Objective:

The purpose was to describe registered nurses’ experience of caring for older people in nursing homes to promote autonomy and participation.

Research design:

A descriptive design with a phenomenological approach was used. Data were collected by semi-structured individual interviews. Analysis was inspired by Giorgi’s method.

Participants and research context:

A total of 13 registered nurses from 10 nursing homes participated.

Ethical considerations:

Ethical approval was obtained from the Regional Research Ethics Committee. Informed consent was achieved and confidentiality guaranteed.

Findings:

The essence of caring for older people in nursing homes to promote autonomy and participation consisted of registered nurses’ awareness of older people’s frailty and the impact of illness to support health and well-being, and awareness of acknowledgement in everyday life and trusting relationships. Paying attention to older people by being open to the persons’ wishes were aspects that relied on registered nurses’ trusting relationships with older people, their relatives and surrounding healthcare personnel. The awareness reflected challenges in caring to promote older people’s right to autonomy and participation in nursing homes. Registered nurses’ strategies, hopes for and/or concerns about development of everyday life in nursing homes were revealed and mirrored their engagement in caring for older people.

Discussion and conclusion:

Awareness of older people’s frailty in nursing homes and the importance of maintained health and well-being were described as the main source for promoting autonomy and participation. Everyday life and care in nursing homes needs to be addressed from both older people’s and healthcare personnel’s perspectives, to promote autonomy and participation for residents in nursing homes.

A qualitative study exploring issues related to medication management in residential aged care facilities

BACKGROUND

Globally, the population of older people is on the rise. As families are burdened with the high cost of care for aging members, demand is increasing for medical care and nursing homes. Thus, medication management is crucial to ensure that residents in a care center benefit and assist the management of the care center in reducing the burden of health care. This study is aimed to qualitatively explore issues related to medication management in residential aged care facilities (RACFs).

PARTICIPANTS AND METHODS

A total of 11 stakeholders comprising health care providers, administrators, caretakers and residents were recruited from a list of registered government, nongovernmental organization and private RACFs in Malaysia from September 2016 to April 2017. An exploratory qualitative study adhering to Consolidated Criteria for Reporting Qualitative Studies was conducted. In-depth interview was conducted with consent of all participants, and the interviews were audio recorded for later verbatim transcription. Observational analysis was also conducted in a noninterfering manner.

RESULTS AND DISCUSSION

Three themes, namely medication use process, personnel handling medications and culture, emerged in this study. Medication use process highlighted an unclaimed liability for residents' medication by the RACFs, whereas personnel handling medications were found to lack sufficient training in medication management. Culture of the organization did affect the medication safety and quality improvement. The empowerment of the residents in their medication management was limited. There were unclear roles and responsibility of who manages the medication in the nongovernment-funded RACFs, although they were well structured in the private nursing homes.

CONCLUSION

There are important issues related to medication management in RACFs which require a need to establish policy and guidelines.

Modes of Decision Making Used by Nursing Home Residents and Their Families When Confronted With Potential Hospital Readmission

The purpose of the current study was to characterize the decision-making processes used by nursing home (NH) residents and their families when confronted with an acute change in condition and the choice of transfer to the hospital or treatment in the NH. Using cognitive task analysis, 96 residents and 75 family members from 19 NHs were asked how they would make this choice. Fifty-one residents (53%) and 61 family members (81%) used a deliberative mode characterized by seeking information and weighing risks and benefits. Ten residents (10%) and five family members (7%) used a predominantly emotion-based mode characterized by references to feelings and prior experiences in these facilities. Thirty-six residents (38%) and nine family members (12%) delegated the decision to a family member or provider. Age and resident/family status were associated with mode used; transfer choice, gender, religion, education, and ethnic group were not. Although classic theories of information processing posit two modes of decision making, deliberative and affective, the current data suggest a third mode, that of delegating the decision to trusted others, particularly family members and providers. [Res Gerontol Nurs. 2016; 9(6):288-299.].

Nursing Home Stakeholder Views of Resident Involvement in Medical Care Decisions

Demand by nursing home residents for involvement in their medical care, or, patient-centered care, is expected to increase as baby boomers begin seeking long-term care for their chronic illnesses. To explore the needs in meeting this proposed demand, we used a qualitative descriptive method with content analysis to obtain the joint perspective of key stakeholders on the current state of person-centered medical care in the nursing home. We interviewed 31 nursing home stakeholders: 5 residents, 7 family members, 8 advanced practice registered nurses, 5 physicians, and 6 administrators. Our findings revealed constraints placed by the long-term care system limited medical involvement opportunities and created conflicting goals for patient-centered medical care. Resident participation in medical care was perceived as low, but important. The creation of supportive educational programs for all stakeholders to facilitate a common goal for nursing home admission and to provide assistance through the long-term care system was encouraged.

"It's very complicated": a qualitative study of medicines management in intermediate care facilities in Northern Ireland

Background

Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery from illness and maximising independence. Older people are at increased risk of medication-related adverse events, but little is known about the provision of medicines management services in IC facilities. This study aimed to describe the current provision of medicines management services in IC facilities in Northern Ireland (NI) and to explore healthcare workers’ (HCWs) and patients’ views of, and attitudes towards these services and the IC concept.

Methods

Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with HCWs and patients from IC facilities in NI.

Results

Interviews were conducted with 25 HCWs and 18 patients from 12 IC facilities in NI. Three themes were identified: ‘concept and reality’, ‘setting and supply’ and ‘responsibility and review’. A mismatch between the concept of IC and the reality was evident. The IC facility setting dictated prescribing responsibilities and the supply of medicines, presenting challenges for HCWs. A lack of a standardised approach to responsibility for the provision of medicines management services including clinical review was identified. Whilst pharmacists were not considered part of the multidisciplinary team, most HCWs recognised a need for their input. Medicines management was not a concern for the majority of IC patients.

Conclusions

Medicines management services are not integral to IC and medicine-related challenges are frequently encountered. Integration of pharmacists into the multidisciplinary team could potentially improve medicines management in IC.

Ethical challenges in nursing homes--staff's opinions and experiences with systematic ethics meetings with participation of residents' relatives

BACKGROUND

Many ethical problems exist in nursing homes. These include, for example, decision-making in end-of-life care, use of restraints and a lack of resources.

AIMS

The aim of the present study was to investigate nursing home staffs' opinions and experiences with ethical challenges and to find out which types of ethical challenges and dilemmas occur and are being discussed in nursing homes.

METHODS

The study used a two-tiered approach, using a questionnaire on ethical challenges and systematic ethics work, given to all employees of a Norwegian nursing home including nonmedical personnel, and a registration of systematic ethics discussions from an Austrian model of good clinical practice.

RESULTS

Ninety-one per cent of the nursing home staff described ethical problems as a burden. Ninety per cent experienced ethical problems in their daily work. The top three ethical challenges reported by the nursing home staff were as follows: lack of resources (79%), end-of-life issues (39%) and coercion (33%). To improve systematic ethics work, most employees suggested ethics education (86%) and time for ethics discussion (82%). Of 33 documented ethics meetings from Austria during a 1-year period, 29 were prospective resident ethics meetings where decisions for a resident had to be made. Agreement about a solution was reached in all 29 cases, and this consensus was put into practice in all cases. Residents did not participate in the meetings, while relatives participated in a majority of case discussions. In many cases, the main topic was end-of-life care and life-prolonging treatment.

CONCLUSIONS

Lack of resources, end-of-life issues and coercion were ethical challenges most often reported by nursing home staff. The staff would appreciate systematic ethics work to aid decision-making. Resident ethics meetings can help to reach consensus in decision-making for nursing home patients. In the future, residents' participation should be encouraged whenever possible.

A clinico-ethical framework for multidisciplinary review of medication in nursing homes

Residents in care homes are more likely to be prescribed multiple medicines yet often have little involvement in these prescribing decisions. Reviewing and stopping inappropriate medicines is not currently adopted across the health economy. This Health Foundation funded Shine project developed a pragmatic approach to optimising medicines in care homes while involving all residents in decision making.

The pharmacist undertook a detailed medication review using primary care records. The results were discussed at a multidisciplinary team (MDT) meeting involving the care home nurse and the resident's general practitioner (GP), with input from the local psychiatry of old age service (POAS) where appropriate.

Suggestions for medicines which should be stopped, changed or started, and other interventions (eg monitoring) were discussed with the resident and/or their family.

Over 12 months 422 residents were reviewed, and 1346 interventions were made in 91% of residents reviewed with 15 different types of interventions. The most common intervention (52.3%) was to stop medicines; 704 medicines stopped in 298 residents (70.6%). On average, 1.7 medicines were stopped for every resident reviewed (range zero to nine medicines; SD=1.7), with a 17.4% reduction in medicines prescribed (3602 medicines prescribed before and 2975 after review). The main reasons for stopping medicines were: no current indication (401 medicines; 57%), resident not wanting medicine after risks and benefits were explained (120 medicines; 17%), and safety concerns (42 medicines; 6%).

The net annualised savings against the medicines budget were £77,703 or £184 per person reviewed. The cost of delivering the intervention was £32,670 (pharmacist, GP, POAS consultant, and care home nurse time) for 422 residents; for every £1 invested, £2.38 could be released from the medicines budget.

This project demonstrated that a multidisciplinary medication review with a pharmacist, doctor, and care home nurse can safely reduce inappropriate medication in elderly care home residents.

The effects of pharmacist intervention on emergency department visits in patients 80 years and older: subgroup analyses by number of prescribed drugs and appropriate prescribing

Background

Clinical pharmacist interventions have been shown to have positive effect on occurrence of drug-related issues as well as on clinical outcomes. However, evidence about which patients benefiting most from the interventions is limited. We aimed to explore whether pharmacist intervention is equally effective in preventing emergency department (ED) visits in patients with few or many prescribed drugs and in those with different levels of inappropriate prescribing.

Methods

Patient and outcome data from a randomized controlled trial exploring the clinical effects of a ward-based pharmacist intervention in patients, 80 years and older, were used. The patients were divided into subgroups according to the number of prescribed drugs (<5 or ≥5 drugs) and the level of inappropriate prescribing [using the Screening Tool Of Older People's potentially inappropriate Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) with a score of ≥2 (STOPP) and ≥1 (START) as cutoff points]. The effect of the intervention on the number of times the different subgroups visited the ED was analyzed.

Results

The pharmacist intervention was more effective with respect to the number of subsequent ED visits in patients taking <5 drugs on admission than in those taking ≥5 drugs. The rate ratio (RR) for a subsequent ED visit was 0.22 [95% confidence interval (CI) 0.09–0.52] for <5 drugs and 0.70 (95% CI 0.47–1.04) for ≥5 drugs (p = 0.02 for the interaction). The effect of intervention did not differ between patients with high or low STOPP or START scores.

Conclusion

In this exploratory study, the pharmacist intervention appeared to be more effective in preventing visits to the ED for patients who were taking fewer drugs before the intervention. Our analysis of STOPP and START scores indicated that the level of inappropriate prescribing on admission had no effect on the outcomes of intervention with respect to ED visits.

Discontinuing inappropriate medication in nursing home residents (DIM-NHR Study): protocol of a cluster randomised controlled trial

INTRODUCTION

Nursing home residents often have a high number of comorbidities resulting in polypharmacy. Inappropriate prescribing is therefore likely to occur, which in turn is expected to worsen cognitive impairment, to increase the fall risk and to decrease residents' quality of life. The objective of the 'Discontinuing Inappropriate Medication in Nursing Home Residents' (DIM-NHR) study is to examine the efficacy and cost-effectiveness of the Multidisciplinary Multistep Medication Review (3MR) that is aimed at optimising prescribing and discontinuing inappropriate medication.

METHODS

A cluster randomised controlled trial will be conducted. Elderly care physicians and their wards (clusters) will be randomised. Data will be collected at baseline and 4 months after the 3MR has taken place. Six hundred nursing home residents will be recruited of whom more than half are expected to suffer from dementia. The 3MR will be based on consensus criteria and the relevant literature and will be performed by the patient's elderly care physician in collaboration with a pharmacist.

ANALYSIS

Primary outcomes-the difference in proportion of residents who successfully discontinued inappropriate medication between the intervention and control group at follow-up. Secondary outcomes-undertreatment, exposure to anticholinergic and sedative medicines, neuropsychiatric symptoms, cognitive function, falls, hospital admission, quality of life and cost-effectiveness.

ETHICS AND DISSEMINATION

Participant burden will be kept at a minimum. The elderly care physician will remain free to adjust medication when symptoms relapse or adverse events occur, rendering serious adverse events highly unlikely. Study findings will be published in peer-reviewed journals and a 3MR toolkit will be developed.

TRIAL REGISTRATION NUMBER

This study has been registered at http://www.ClinicalTrials.gov (trial registration number: NCT01876095).

Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings

BACKGROUND

Communication problems contribute enormously to medication errors and adverse events. Encouraging patient engagement can help to facilitate effective medication management.

OBJECTIVES

To examine barriers and enablers affecting how patients engage with managing their medications in specialty hospital settings.

DESIGN

An exploratory qualitative design was used involving in-depth interviews with doctors, nurses, pharmacists, patients and family members.

SETTING

An Australian public, metropolitan teaching hospital was the study site and five specialty hospital settings were used, including cardiac care, emergency care, intensive care, oncology care and perioperative care.

RESULTS

In all, 21 health professionals, 11 patients and 12 family members participated in the study (n = 44). Barriers and enablers involved intrapersonal, interpersonal and environmental aspects, and differences in perceptions and experiences were found between the various settings. Health professionals had preconceived notions of what was appropriate behaviour in conveying information about medications. Many health professionals stated that they deliberately chose not to provide medication-related knowledge. Different barriers for patient engagement existed in various settings - in emergency care, patients could only stay for 4 h; in intensive care, medication changes regularly happened; in cardiac care, patients were discharged prematurely due to urgent need of beds; in oncology, there was lack of availability of oncology consultants; while in perioperative care, surgeons and anaesthetists were available just before surgery.

CONCLUSIONS

Complex barriers and enablers are associated with patient engagement in specialty clinical settings. By developing an understanding of these barriers and enablers, health professionals can help patients to understand and participate in their medication management.

Concept analysis: patient autonomy in a caring context

AIM

This paper is a report of an analysis of the concept of patient autonomy

BACKGROUND

Many problems regarding patient autonomy in healthcare contexts derive from the patient's dependent condition as well as the traditional authoritarian position of healthcare professionals. Existing knowledge and experience reveal a lack of consensus among nurses regarding the meaning of this ethical concept.

DESIGN

Concept analysis.

DATA SOURCES

Medline, CINAHL, The Cochrane Library and PsycINFO were searched (2005-June 2013) using the search blocks 'autonomy', 'patient' and 'nursing/caring'. A total of 41 articles were retrieved.

REVIEW METHODS

The Evolutionary Method of Concept Analysis by Rodgers was used to identify and construct the meaning of the concept of patient autonomy in a caring context.

RESULTS

Five attributes were identified, thus creating the following descriptive definition: 'Patient autonomy is a gradual, time-changing process of (re-)constructing autonomy through the interplay of to be seen as a person, the capacity to act and the obligation to take responsibility for one's actions'. Patient vulnerability was shown to be the antecedent of patient autonomy and arises due to an impairment of a person's physical and/or mental state. The consequences of patient autonomy were discussed in relation to preserving control and freedom.

CONCLUSION

Patient autonomy in a caring context does not need to be the same before, during and after a care episode. A tentative model has been constructed, thus extending the understanding of this ethical concept in a caring context.

Confirming delivery: understanding the role of the hospitalized patient in medication administration safety

The purpose of our study was to gain an understanding of current patient involvement in medication administration safety from the perspectives of both patients and nursing staff members. Administering medication is taken for granted and therefore suited to the development of theory to enhance its understanding. We conducted a constructivist, grounded theory study involving 24 patients and 26 nursing staff members and found that patients had the role of confirming delivery in the administration of medication. Confirming delivery was characterized by three interdependent subprocesses: engaging in the medication administration process, being "half out of it" (patient mental status), and perceiving time. We believe that ours is one of the first qualitative studies on the role of hospitalized patients in administering medication. Medication administration and nursing care systems, as well as patient mental status, impose limitations on patient involvement in safe medication administration.

Patients’ perspectives on person-centred participation in healthcare

The aim of this article was to critically analyse the concept of person-centred participation in healthcare from patients’ perspectives through a review of qualitative research findings. In accordance with the integrative review method of Broom, data were retrieved from databases, but 60 studies were finally included in the study. The diverse attributes of person-centred participation in healthcare were identified and contrasted with participation that was not person-centred and analysed through framework analysis. Person-centred participation in healthcare was found to be based on patients’ experiences, values, preferences and needs in which respect and equality were central. It manifested itself via three intertwined phases: the human-connection phase, the phase of information processing and the action phase. The results challenge in many aspects earlier concept analyses of patient participation in addition to illuminating patient participation that is not positively valued by patients.

Frail elderly patients' experiences of information on medication. A qualitative study

Background

Older patients generally have only poor knowledge about their medicines. Knowledge is important for good adherence and for participating in decisions about treatment. Patients are entitled to be informed on an individual and adequate level. The aim of the study was to explore frail elderly patients’ experiences of receiving information about their medications and their views on how the information should best be given.

Methods

The study was qualitative in design and was carried out in 2011. Twelve frail elderly (aged 68–88) participants taking cardiovascular medications participated in semi-structured interviews covering issues related to receiving information about prescribed medicines. The interviews were recorded, transcribed and subjected to content analysis, in which the text was analysed in five steps, inspired by Graneheim and Lundman.

Results

The results revealed that the experiences which the elderly participants had regarding the receiving of medical information fell into two main categories: “Comfortable with information” or “Insecure with information”. The elderly felt comfortable when they trusted their physician or their medication, when they received enough information from the prescriber or when they knew how to find out sufficient information by themselves. They felt insecure if they were anxious, if the availability of medical care was poor or if they did not receive enough information.

Conclusions

Factors that frequently caused insecurity about information and anxiety were too short consultations, lack of availability of someone to answer questions or of the opportunity to contact the physician if adverse effects are suspected. These factors could easily be dealt with and there must be improvements in the clinics if the patients´ feelings of security are to be increased.

How do the attitudes and beliefs of older people and healthcare professionals impact on the use of multi-compartment compliance aids?: a qualitative study using grounded theory

BACKGROUND

Low adherence of older people to multiple medicine regimens is of widespread concern, and multi-compartment compliance aids are frequently supplied to older people in an attempt to improve their ability to take all their medicines at home. However, the evidence base for the use of such aids is very limited, and there is some evidence that they are used inappropriately.

OBJECTIVE

We aimed to determine how the attitudes and beliefs of older people and healthcare professionals impacted on the use of multi-compartment compliance aids by older people living at home.

METHOD

This was a qualitative study using grounded theory. Semi-structured interviews were conducted with 15 older people (mean age 82 [range 72-92] years) living independently in the community and receiving primary healthcare from two health service organizations in a large northern UK city. We then interviewed 17 healthcare professionals working in primary, secondary or intermediate care and involved in the provision of multi-compartment compliance aids.

RESULTS

Maintaining independence and remaining in control was important for all the older people interviewed, and professionals supported the view that this influenced patients' attitudes towards using their aid. Some patients saw the aids as helping to maintain independence, others as casting doubt on their independence. The aids were often issued without discussion with the patient. The patients largely agreed that the aids did not help with memory problems and that the decision to issue an aid could be seen as paternalistic. A minority of patients had difficulties using the aids.

CONCLUSIONS

Careful multi-disciplinary assessment of older people is required before a compliance aid is provided. The views of the older person must be considered and respected. Further research is required to produce an evidence base for the use of such aids in this group of people.

[Detection of therapeutic non-compliance and pharmaceutical intervention in institutionalised geriatric patients]

OBJECTIVE

To detect and analyse therapeutic non-compliance in the institutionalised elderly patient who self-administer their own treatment in a geriatric residence. To assess the pharmaceutical intervention with a useful tool to detect non-compliance.

MATERIAL AND METHODS

An observational study on a population of 386 residents. A clinical interview was conducted on those who treated themselves by the Pharmacy Department. An individual case report card was prepared to record demographic and clinical data, and incidents found). An interview was conducted on their treatment (drugs, dose, posology, indication and administration form), together with the compliance test validated by Morinsky-Green. Non-compliance was calculated by comparing the responses with the pharmacotherapeutic information from the Pharmacy Department and from the medical prescription of the medical charts.

RESULTS

Eleven per cent of patients administered their own treatment. Their mean age was 84 years and all attended the interview, which detected a non-compliance of 41%. The compliance test only detected 55% of the non-compliers. The main errors were non-compliance to the time, incorrect dosage and not taking treatment when feeling better. There was 39% involuntary non-compliance. The cardiovascular system drug group was the most involved in errors. The error could have a clinically significant repercussion in 44% of the patients.

CONCLUSIONS

The interview helped to detect and analyse non-compliance. The test, although specific, was not very sensitive. The main errors were easy to correct and there no problems of acceptance by the patients. With it being fundamental to preserve function and to prevent progression to dependence, and adding to this the administering of drugs, pharmaceutical intervention is a useful tool to detect and correct errors and increase adherence.

Pharmacy interventions on prescribing in nursing homes: from evidence to practice

Prescribing of medicines for older people who live in nursing homes is a very common intervention. Undoubtedly, medicines have contributed to longevity and improved health outcomes in the population, but they are not without their side effects and can give rise to adverse events. The nursing home population is particularly at risk as residents have multiple comorbidities and receive multiple medications. Moreover, the quality of prescribing has been criticised with long-standing concerns about inappropriate prescribing, particularly overuse of medications which are not clinically indicated or which are no longer required. It has been suggested that pharmacists could use their skills to improve prescribing in the nursing home population and this review paper outlines the evidence for this type of intervention. The studies which have been included were rigorously designed and conducted. A number of interventions consisted of medication reviews, which often focused on specific drugs, notably antipsychotics, hypnotics and anxiolytics. In some cases, the pharmacist was solely responsible for the delivery of the intervention while in others a multidisciplinary approach was taken involving other key healthcare professionals. A number of outcome measures were employed to assess the impact of the intervention, ranging from a change in the number of inappropriate medications to differences in hospitalizations or health-related quality of life. Owing to the variation across studies, it is difficult to be definitive about the impact of pharmacy interventions in this setting. In an older, frail population such as nursing home residents, consideration needs to be given to appropriate and relevant outcome measures including a reduction in inappropriate prescribing, optimization of prescribing, reduced costs and improved health-related quality of life. Pharmacists and other healthcare professionals should continue to strive to meet these challenges in this particular demographic.

A relational perspective on autonomy for older adults residing in nursing homes

AIM

To review critically the traditional concept of autonomy, propose an alternative relational interpretation of autonomy, and discuss how this would operate in identifying and addressing ethical issues that arise in the context of nursing home care for older adults.

BACKGROUND

Respect for patient autonomy has been the cornerstone of clinical bioethics for several decades. Important though this principle is, there is debate on how to interpret the core concept of autonomy. We review the appeal of the traditional approach to autonomy in health care and then identify some of the difficulties with this conception.

METHODS

We use philosophical methods to explain and discuss the traditional and relational conceptions of autonomy and we illuminate our discussion with examples of various contextual applications.

CONCLUSION

We support the relational conception of autonomy as offering a richer, more contextualized understanding of autonomy which attends to the social, political and economic conditions that serve as background to an agent's deliberations. To illuminate these ideas, we discuss the situation of frail older adults who frequently find their autonomy limited not only by their medical conditions but also by cultural prejudices against the aged and by the conditions commonly found within the nursing homes in which many reside. We propose ways of improving the relational autonomy of this population.