Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

CompreHensive geriAtRician-led MEdication Review (CHARMER): protocol for a feasibility study of a hospital deprescribing behaviour change intervention

INTRODUCTION

Over 50% of older adults are prescribed a medicine where the risk of harm outweighs the chances of benefit. During a hospital admission, older adults and carers expect medicines to be reviewed for appropriateness and any inappropriate medicines proactively deprescribed. While the principle of proactive deprescribing is an expectation of good prescribing practice, it is yet to become routine. The CompreHensive geriAtRician-led MEdication Review (CHARMER) study aims to develop and test a five-component behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe inappropriate medicines with older adults in hospital. This study aims to test the feasibility and acceptability of study processes and CHARMER implementation.

METHODS AND ANALYSIS

A two-arm purposive allocation feasibility study is being undertaken at four acute hospitals in England, UK (three intervention and one control). The target sample is 400 patients across all hospitals. Primary outcome measures are: (1) participant recruitment rate and (2) participant attrition rate. Secondary outcome measures are: (1) hospital readmission rate; (2) mortality rate and (3) quality of life. Quantitative data will be checked for completeness and quality, and practitioner and patient demographics descriptively analysed. We will undertake a rapid qualitative analysis on observations, interviews and study meeting minutes data. A subsequent thematic analysis will be undertaken with codes mapped to the Theoretical Domains Framework and Normalisation Process Theory. Triangulation of qualitative and quantitative data will be undertaken.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Wales Research Ethics Committee 1 (IRAS ID 312494) and study approval from the Health Research Authority (22/WA/0087). Informed consent will be sought from all hospital staff involved in data collection activities and for patients involved in enhanced data collection activities. The findings of this study will be disseminated in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION

ISRCTN11899506.

Co-design of a behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe medicines that are no longer needed or are risky to continue in hospital

BACKGROUND

Trials of hospital deprescribing interventions have demonstrated limited changes in practitioner behaviour. Our previous research characterised four barriers and one enabler to geriatricians and pharmacists deprescribing in hospital that require addressing by a behaviour change intervention. Six behaviour change techniques (BCTs) have also been selected by the target audience using the hospital Deprescribing Implementation Framework (hDIF). This research aimed to co-design and operationalise the content, mode of delivery and duration/intensity of the six selected BCTs to develop the CompreHensive geriAtRician-led MEdication Review (CHARMER) deprescribing intervention.

METHODS

We established co-design panels at three hospitals representing contextual factors likely to influence CHARMER implementation. Panels comprised geriatricians, pharmacists and other hospital staff likely to be involved in implementation. We convened two rounds of co-design workshops with each hospital to design a prototype for each BCT, which went for feedback at a final workshop attended by all three hospital panels.

RESULTS

The six BCTs were co-designed into an intervention comprising:(^1&2) Pharmacists' workshop with pros and cons of deprescribing activities, and videos of salient patient cases³ Regular geriatrician and pharmacist deprescribing briefings⁴ Videos of geriatricians navigating challenging deprescribing consultations⁵ Hospital deprescribing action plan⁶ Dashboard to benchmark deprescribing activitiesAutomated prompts to flag high-risk patients for deprescribing and a primary and secondary care deprescribing forum were proposed as additional BCTs by stakeholders. These were later excluded as they were not fidelitous to the theoretical determinants of geriatricians' and pharmacists' deprescribing behaviours.

CONCLUSIONS

This study illustrates the integration of theory and co-design methodology with the target audience and staff likely to be involved in implementation of a hospital deprescribing behaviour change intervention. The development of an intervention that remains faithful to the underpinning mechanisms of action of behaviour change is a strength of this approach.

Pharmacist-independent prescriber deprescribing in UK care homes: Contextual factors associated with increased activity

AIMS

The Care Home Independent Pharmacist Prescriber Study (CHIPPS) process evaluation hypothesized that contextual factors influenced the likelihood of deprescribing by pharmacist-independent prescribers. The aim of this paper is to test this hypothesis.

METHODS

From CHIPPS study data, medications deprescribed totalled 284 for 370 residents in UK care homes. Regression analysis was used to describe the relationship between the number of medicines stopped and contextual factors (number of residents cared for, pharmacist employment within associated medical practice, previous care home experience, hours active within trial, years' experience as a pharmacist and as a prescriber).

RESULTS

Number of residents and pharmacist-independent prescriber employment within a medical practice were positive predictors of deprescribing.

CONCLUSION

Previous experiences were not related to deprescribing likelihood. Increasing the number of residents increases the opportunity for deprescribing and therefore this relationship is intuitive. The location within a medical practice is an interesting finding that requires further exploration to understand its exact nature.

Developing a core outcome set for hospital deprescribing trials for older people under the care of a geriatrician

BACKGROUND

Half of older people are prescribed unnecessary/inappropriate medications that are not routinely deprescribed in hospital hence there is a need for deprescribing trials. We aimed to develop a Core Outcome Set (COS) for deprescribing trials for older people under the care of a geriatrician during hospital admission.

METHODS

We developed a list of potentially relevant outcomes from the literature. Using a two-round Delphi survey of stakeholder groups representing older people and carers, hospital clinicians, hospital managers, and ageing/deprescribing researchers, each outcome was scored according to Grading of Recommendations Assessment, Development and Evaluation, followed by two consensus workshops to finalise the COS.

RESULTS

Two hundred people completed Round 1 and 114 completed Round 2. Representing all stakeholder groups, 10 people participated in workshop 1 and 10 in workshop 2. Six outcomes were identified as most important, feasible and acceptable to collect in a trial: number of prescribed medicines stopped; number of prescribed medicines with dosage reduced; quality of life; mortality; adverse drug events and number of hospital stays. Three other outcomes were identified as important, but currently too burdensome to collect: number of potentially inappropriate medicines prescribed; burden from medication routine; and medication-related admissions to hospital.

CONCLUSIONS

A COS represents the minimum outcomes that should be collected and reported. Whilst uncommon practice for COS development, the value of considering outcome collection feasibility is demonstrated by the removal of three potential outcomes that, if included, may have compromised COS uptake due to challenges with collecting the data.

Evaluation of a training programme for Pharmacist Independent Prescribers in a care home medicine management intervention

BACKGROUND

The provision of independent prescribing rights for United Kingdom (UK) pharmacists has enabled them to prescribe within their area of competence. The aim of this study was to evaluate an evidence-based training programme designed to prepare Pharmacist Independent Prescribers (PIPs) to safely and effectively assume responsibility for pharmaceutical care of older people in care homes in the UK, within a randomised controlled trial.

METHODS

The training and competency assessment process included two training days, professional development planning against a bespoke competency framework, mentor support, and a viva with an independent General Practitioner (GP). Data on the PIPs' perceptions of the training were collected through evaluation forms immediately after the training days and through online questionnaires and interviews after delivery of the 6-month intervention. Using a mixed method approach each data set was analysed separately then triangulated providing a detailed evaluation of the process. Kaufman's Model of Learning Evaluation guided interpretations.

RESULTS

All 25 PIPs who received the training completed an evaluation form (N = 25). Post-intervention questionnaires were completed by 16 PIPs and 14 PIPs took part in interviews. PIPs reported the training days and mentorship enabled them to develop a personalised portfolio of competence in preparation for discussion during a viva with an independent GP. Contact with the mentor reduced as PIPs gained confidence in their role. PIPs applied their new learning throughout the delivery of the intervention leading to perceived improvements in residents' quality of life and medicines management. A few PIPs reported that developing a portfolio of competence was time intensive, and that further training on leadership skills would have been beneficial.

CONCLUSIONS

The bespoke training programme was fit for purpose. Mentorship and competency assessment were resource intensive but appropriate. An additional benefit was that many PIPs reported professional growth beyond the requirement of the study.

TRIAL REGISTRATION

The definitive RCT was registered with the ISRCTN registry (registration number ISRCTN 17,847,169 ).

Using routine healthcare data to evaluate the impact of the Medicines at Transitions Intervention (MaTI) on clinical outcomes of patients hospitalised with heart failure: protocol for the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) cluster randomised controlled trial with embedded process evaluation, health economics evaluation and internal pilot

INTRODUCTION

Heart failure affects 26 million people globally, approximately 900 thousand people in the UK, and is increasing in incidence. Appropriate management of medicines for heart failure at the time of hospital discharge reduces readmissions, improves quality of life and increases survival. The Improving the Safety and Continuity Of Medicines management at Transitions (ISCOMAT) trial tests the effectiveness of the Medicines at Transition Intervention (MaTI), which aims to enhance self-care and increase community pharmacy involvement in the medicines management of heart failure patients.

METHODS AND ANALYSIS

ISCOMAT is a parallel-group cluster randomised controlled trial, randomising 42 National Health Service trusts with cardiology wards in England on a 1:1 basis to implement the MaTI or treatment as usual. Around 2100 patients over the age of 18 admitted to hospital with heart failure with at least moderate left ventricular systolic dysfunction within the last 5 years, and planned discharge to the geographical area of the cluster will be recruited. The MaTI consists of training for staff, a toolkit for participants, transfer of discharge information to community pharmacies and a medicines reconciliation/review. Treatment as usual is determined by local policy and practices. The primary outcome is a composite of all-cause mortality and heart failure-related hospitalisation at 12 months postregistration obtained from national electronic health records. The key secondary outcome is continued prescription of guideline-indicated therapies at 12 months measured via patient-reported data and Hospital Episode Statistics. The trial contains a parallel mixed-methods process evaluation and an embedded health economics study.

ETHICS AND DISSEMINATION

The study obtained approval from the Yorkshire and the Humber-Bradford Leeds Research Ethics Committee; REC reference 18/YH/0017. Findings will be disseminated via academic and policy conferences, peer-reviewed publications and social media. Amendments to the protocol are disseminated to all relevant parties as required.

TRIAL REGISTRATION NUMBER

ISRCTN66212970; Pre-results.

Barriers and facilitators of successful deprescribing as described by older patients living with frailty, their informal carers and clinicians: a qualitative interview study

OBJECTIVE

To explore the barriers/facilitators to deprescribing in primary care in England from the perspectives of clinicians, patients living with frailty who reside at home, and their informal carers, drawing on the Theoretical Domains Framework to identify behavioural components associated with barriers/facilitators of the process.

DESIGN

Exploratory qualitative study.

SETTING

General practice (primary care) in England.

PARTICIPANTS

9 patients aged 65+ living with frailty who attended a consultation to reduce or stop a medicine/s. 3 informal carers of patients living with frailty. 14 primary care clinicians including general practitioners, practice pharmacists and advanced nurse practitioners.

METHODS

Qualitative semistructured interviews took place with patients living with frailty, their informal carers and clinicians. Patients (n=9) and informal carers (n=3) were interviewed two times: immediately after deprescribing and 5/6 weeks later. Clinicians (n=14) were interviewed once. In total, 38 interviews were undertaken. Framework analysis was applied to manage and analyse the data.

RESULTS

6 themes associated with facilitators and barriers to deprescribing were generated, respectively, with each supported by between two and three subthemes. Identified facilitators of deprescribing with patients living with frailty included shared decision-making, gradual introduction of the topic, clear communication of the topic to the patient and multidisciplinary working. Identified barriers of deprescribing included consultation constraints, patients' fear of negative consequences and inaccessible terminology and information.

CONCLUSIONS

This paper offers timely insight into the barriers and facilitators to deprescribing for patients living with frailty within the context of primary care in England. As deprescribing continues to grow in national and international significance, it is important that future deprescribing interventions acknowledge the current barriers and facilitators and their associated behavioural components experienced by clinicians, patients living with frailty and their informal carers to improve the safety and effectiveness of the process.

'Treated as a number, not treated as a person': a qualitative exploration of the perceived barriers to effective pain management of patients with chronic pain

OBJECTIVES

To identify barriers to effective pain management encountered by patients with chronic pain within the UK's National Health Service (NHS).

DESIGN

Secondary analysis of face-to-face, semistructured qualitative interviews using thematic analysis.

SETTING

A community-based chronic pain clinic jointly managed by a nurse and pharmacist located in the North of England.

PARTICIPANTS

Nineteen adult (>18 years) patients with chronic pain discharged from a pain clinic, with the ability to understand and speak the English language.

RESULTS

In general, patients were highly disappointed with the quality of pain management services provided both within primary and secondary care, and consequently were willing to seek private medical care. Barriers to effective pain management were divided into two main themes: healthcare professional-related and health systems-related. Three subthemes emerged under healthcare professionals-related barriers, namely (1) healthcare professionals' lack of interest and empathy, (2) general practitioners' (GP) lack of specialised knowledge in pain management and (3) lack of communication between healthcare professionals. Three subthemes emerged under health system-related barriers: (1) long waiting time for appointments in secondary care, (2) short consultation times with GPs and (3) lack of an integrated multidisciplinary approach.

CONCLUSIONS

The patients expressed a clear desire for the improved provision and quality of chronic pain management services within the NHS to overcome barriers identified in this study. An integrated holistic approach based on a biopsychosocial model is required to effectively manage pain and improve patient satisfaction. Future research should explore the feasibility, effectiveness and cost-effectiveness of integrated care delivery models for chronic pain management within primary care.

Mixed-methods research in pharmacy practice: recommendations for quality reporting. Part 2

This is the second of two papers that explore the use of mixed-methods research in pharmacy practice. This paper discusses the rationale, applications, limitations and challenges of conducting mixed-methods research. As with other research methods, the choice of mixed-methods should always be justified because not all research questions require a mixed-methods approach. Mixed-methods research is particularly suitable when one dataset may be inadequate in answering the research question, an explanation of initial results is required, generalizability of qualitative findings is desired or broader and deeper understanding of a research problem is necessary. Mixed-methods research has its own challenges and limitations, which should be considered carefully while designing the study. There is a need to improve the quality of reporting of mixed-methods research. A framework for reporting mixed-methods research is proposed, for researchers and reviewers, with the intention of improving its quality. Pharmacy practice research can benefit from research that uses both 'numbers' (quantitative) and 'words' (qualitative) to develop a strong evidence base to support pharmacy-led services.

Mixed-methods research in pharmacy practice: basics and beyond (part 1)

This is the first of two papers which explore the use of mixed-methods research in pharmacy practice. In an era of evidence-based medicine and policy, high-quality research evidence is essential for the development of effective pharmacist-led services. Over the past decade, the use of mixed-methods research has become increasingly common in healthcare, although to date its use has been relatively limited in pharmacy practice research. In this article, the basic concepts of mixed-methods research including its definition, typologies and advantages in relation to pharmacy practice research are discussed. Mixed-methods research brings together qualitative and quantitative methodologies within a single study to answer or understand a research problem. There are a number of mixed-methods designs available, but the selection of an appropriate design must always be dictated by the research question. Importantly, mixed-methods research should not be seen as a 'tool' to collect qualitative and quantitative data, rather there should be some degree of 'integration' between the two data sets. If conducted appropriately, mixed-methods research has the potential to generate quality research evidence by combining strengths and overcoming the respective limitations of qualitative and quantitative methodologies.

A combined nurse-pharmacist managed pain clinic: joint venture of public and private sectors

Chronic pain has become one of the most prevalent problems in primary care. The management of chronic pain is complex and often requires a multidisciplinary approach. The limited capacity of general practitioners to manage chronic pain and long waiting time for secondary care referrals further add to the complexity of chronic pain management. Restricted financial and skilled human capital make it hard for healthcare systems across the world to establish and maintain multidisciplinary pain clinics, in spite of their documented effectiveness. Affordability and accessibility to such multidisciplinary pain clinics is often problematic for patients. The purpose of this paper is to share our experience and relevant research evidence of a community based combined nurse-pharmacist managed pain clinic. The pain clinic serves as an example of public-private partnership in healthcare.

Development of a pharmacist-led cholesterol screening and lipid-lowering medication review service in coronary artery bypass graft patients

Objective

To assess the effects of pharmacist intervention on lipid management in coronary artery bypass graft (CABG) patients.

Method

Open study in which total cholesterol (TC) levels were measured in 43 elective CABG patients at visit 1 (pre-surgery) and visit 2 (six weeks post-discharge following surgery). Statin therapy was initiated (using atorvastatin) or statin doses were adjusted according to an agreed protocol.

Key findings

Prior to CABG surgery, 19 patients (44 per cent) did not have target TC values. Fourteen (74 per cent) of these patients were already receiving a statin while five patients (26 per cent) were not receiving statin therapy. At visit 2, 33 patients (77 per cent) had achieved target TC. Mean (SD) TC was 5.7 (0.72) mmol/L at visit 1 and 4.8 (0.68) mmol/L at visit 2 in the intervention patients (P<0.01). There was no significant difference between mean TC at visits 1 and 2 in the non-intervention patients (patients who had target TC values at visit 1). From a previous meta-analysis, the decrease in TC of 0.9 mmol/L (16 per cent) in the intervention patients equates to a 24 per cent risk reduction in coronary heart disease (CHD) mortality and an 18 per cent risk reduction in total mortality. The recent National Service Framework for CHD has set standards for improving the care of CHD patients. From this study, it appears that the management of raised TC in this high-risk population is sub-optimal.

Conclusion

This study has shown that the role of the pharmacist can be extended to encompass the management of raised total cholesterol in CABG patients, thereby contributing towards health care benefit.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

INTRODUCTION

Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

METHODS

A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

RESULTS

The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

CONCLUSIONS

That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial

OBJECTIVE

to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents.

DESIGN

randomised controlled trial of clinical medication review by a pharmacist against usual care.

SETTING

sixty-five care homes for the elderly in Leeds, UK.

PARTICIPANTS

a total of 661 residents aged 65+ years on one or more medicines.

INTERVENTION

clinical medication review by a pharmacist with patient and clinical records. Recommendations to general practitioner for approval and implementation. Control patients received usual general practitioner care.

MAIN OUTCOME MEASURES

primary: number of changes in medication per participant. Secondary: number and cost of repeat medicines per participant; medication review rate; mortality, falls, hospital admissions, general practitioner consultations, Barthel index, Standardised Mini-Mental State Examination (SMMSE).

RESULTS

the pharmacist reviewed 315/331 (95.2%) patients in 6 months. A total of 62/330 (18.8%) control patients were reviewed by their general practitioner. The mean number of drug changes per patient were 3.1 for intervention and 2.4 for control group (P < 0.0001). There were respectively 0.8 and 1.3 falls per patient (P < 0.0001). There was no significant difference for GP consultations per patient (means 2.9 and 2.8 in 6 months, P = 0.5), hospitalisations (means 0.2 and 0.3, P = 0.11), deaths (51/331 and 48/330, P = 0.81), Barthel score (9.8 and 9.3, P = 0.06), SMMSE score (13.9 and 13.8, P = 0.62), number and cost of drugs per patient (6.7 and 6.9, P = 0.5) (pounds sterling 42.24 and pounds sterling 42.94 per 28 days). A total of 75.6% (565/747) of pharmacist recommendations were accepted by the general practitioner; and 76.6% (433/565) of accepted recommendations were implemented.

CONCLUSIONS

general practitioners do not review most care home patients' medication. A clinical pharmacist can review them and make recommendations that are usually accepted. This leads to substantial change in patients' medication regimens without change in drug costs. There is a reduction in the number of falls. There is no significant change in consultations, hospitalisation, mortality, SMMSE or Barthel scores.