Barriers for Nurses to Safe Medication Management in Nursing Homes

Statement on medication simplification in long-term care facilities by the Japanese Society of Geriatric Pharmacy: English translation of the Japanese article

Many older adults who are certified for long-term care services live or stay in long-term care facilities (LTCFs), where they receive medical and nursing care. These individuals often encounter medication-related problems, such as polypharmacy and complex medication regimens, including frequent administration schedules. Although considerable attention has been paid to polypharmacy in the context of optimizing medication use in older adults, little emphasis has been placed on simplifying these regimens. Recently, the Japanese Society of Geriatric Pharmacy issued statements on medication simplification in LTCFs based on a scoping review of the literature and expert opinions. In these statements, medication simplification is defined as the process of reducing the number of medication administration times, ideally to once during lunchtime. The statements outline principles and processes to achieve medication simplification through interprofessional collaboration, including consolidating and reducing the number of medication administration times a day to minimize the risk of medication errors and ensure medical safety. Medication simplification will play a substantial role in alleviating the burden of medication intake for residents, and in reducing and equalizing the workload of medication administration for staff members throughout the day in LTCFs. These statements suggest that administering medication during lunchtime is beneficial when an adequate number of staff members are available in LTCFs. We hope that these statements will help ensure patient safety, and facilitate successful medication optimization for all medical, nursing and social care professionals working in LTCFs. Geriatr Gerontol Int 2025; 25: 14-24.

Medication Management in Portuguese Long-Term Care Facilities: A Preliminary Cross-Sectional Study

BACKGROUND/OBJECTIVES

Population ageing has been a pressing global issue for decades. Older adults, especially those residing in long-term care facilities (LTCFs), often experience frailty and polypharmacy, which can lead to negative clinical outcomes. In Portugal, LTCFs provide essential care for individuals aged 65 or older, offering temporary or permanent accommodation. These facilities are not considered healthcare providers, and as a result, pharmaceutical services are not mandatory. This study aimed to evaluate medication management practices in Portuguese LTCFs, identify which professionals are responsible for managing medications, and identify potential gaps in safety and efficacy.

METHODS

A cross-sectional electronic questionnaire was sent by email to 2552 Portuguese LTCFs from the Portuguese "Carta Social" database. Data collection took place between 20 July and 2 August 2023, yielding a response rate of 15.4% (392 institutions).

RESULTS

Most LTCFs (94.39%) oversee their resident's medication, with 75.95% using the same pharmacy. Individualised medication packaging is used by 57.84% of facilities, and 97.84% provide medication reconciliation and review, mainly conducted by physicians and nurses. Medication is often stored in nursing offices (81.12%) but also in kitchens or dining rooms. Nurses are responsible for medication storage (87.50%) and preparation (81.89%), although non-nursing staff are also involved. In 63.27% of LTCFs, the same individual is responsible for both the preparation and verification of medication. Assistants are involved in both the checking (30.56%) and administering (45.66%) of medication.

CONCLUSIONS

The results presented illustrate the current status of LTCFs in Portugal. Medication management presents a significant challenge, and it is notable that the role of the pharmacist in this process is not as prominent as it is in other countries.

Treatment and Care for Nursing Home Residents with COVID-19: A Qualitative Study

Purpose

Coronavirus disease 2019 (COVID-19) placed a significant strain on nursing homes, leading to numerous outbreaks and high mortality rates. This situation created considerable stress and challenges for residents, their physicians and nurses, as well as family caregivers. By understanding these challenges, we can gain new insights and learn valuable lessons. Thus, the purpose of this study is to examine the treatment and care provided to nursing home residents with COVID-19, as experienced by physicians, nurses, and family caregivers.

Participants and Methods

This study is a secondary analysis of 35 interviews with physicians, nurses, and family caregivers, each with personal experience caring for nursing home residents diagnosed with COVID-19. The interviews took place from December 2020 to April 2021. We analyzed the transcriptions based on Braun and Clarke's reflexive thematic analysis model and followed a qualitative descriptive design as outlined by Sandelowski.

Findings

The analysis produced three themes: 1) Balancing medical treatment, 2) The need for increased systematic monitoring of vital functions, and 3) Determining the treatment level for nursing home residents. These themes were explored through the unique perspectives of the three participant groups: physicians, nurses, and family caregivers. The findings revealed several challenges related to treatment and care for nursing home residents diagnosed with COVID-19. This applied both to relief of symptoms, monitoring of vital functions, assessment of treatment level and use of advance care planning.

Conclusion

Drawing from the experiences of physicians, nurses, and family caregivers, there should be a unified plan at the municipal or national level for competency development in nursing homes to prepare for future crises like pandemics or epidemics. Additionally, the safe engagement of family caregivers and relatives should be given priority.

Pharmacology Knowledge Among Nurses Working in Nursing Homes in Norway: A Cross-Sectional Study

Introduction

The administration of drugs is an important part of nurses' professional practice. A basic knowledge of pharmacological principles is required to make accurate decisions about drug management and conduct patient medication education. However, several studies have suggested that nurses have inadequate knowledge of pharmacology and medication management.

Objective

To explore the level of knowledge in pharmacology and medication management among nurses working in nursing homes (NHs).

Methods

We conducted a cross-sectional study at 24 NHs in Norway. The nurses took a multiple-choice test in pharmacology with 35 questions at their workplace. Each question had four alternative answers with one answer being correct. One point was awarded for a correct answer and zero for a wrong answer. The test included categories in general pharmacology, clinical pharmacology, and medication management.

Results

In total, 145 nurses completed the questionnaire. In the range of 0-35 correct responses, the mean score for the sum of all questions was 22.5, which equates to 66% of responses being correct. Linear multiple regression showed no association regarding gender, age distribution among the nurses, years since completing basic education in nursing, years of work experience in NHs, postgraduate education, and knowledge of pharmacology and medication management. Knowledge was better in the category medication management (p < 0.001) than in the category's general pharmacology and clinical pharmacology. When evaluating specific test questions, 38.9% of the nurses answered a question on opioids correct, 64.1% a question on anticoagulants correct, 33.5% knew the prerequisites for generic substitution, and 45.5% did not know the difference between agonists and antagonists.

Conclusion

Our results are in line with previous findings. The participating nurses working in the NHs have insufficient knowledge in pharmacology and medication management. This may cause harm and undermine patient safety.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Stepwise development of a quality assessment instrument for the medicines' pathway in nursing homes

BACKGROUND

Quality of care in nursing homes (NHs), and especially the quality of the medicines' pathway, remains a concern.

OBJECTIVES

To develop a quality assessment instrument to support NHs to evaluate the quality of their medicines' pathway, and to formulate recommendations for its implementation.

METHODS

A stepwise approach was used. First, a performance questionnaire for coordinating physicians, pharmacists and head nurses was developed, alongside a set of quality indicators (QIs). Next, a feasibility study regarding the QIs was performed in 4 NHs, followed by two pilot studies to optimize the instrument (in 14 and 9 NHs, respectively). Focus groups were held to formulate recommendations for instrument implementation.

RESULTS

The QI feasibility and first pilot study showed that the clarity and feasibility of QIs was insufficient. All QIs were therefore integrated in the performance questionnaire. The first pilot study also showed low response rates for certain questions in the performance questionnaire and resulted in a revision of questions with the aim to target the right type of healthcare professional, including quality coordinators and general practitioners. The final instrument targets all involved healthcare professionals (i.e. coordinating physicians, pharmacists, head nurses, general practitioners, and quality coordinators), and applies a sequential approach: a quick scan to set priorities, followed by a detailed scan to detect specific working points. The second pilot study showed appreciation for this approach. Last, five recommendations were made to promote the instrument's implementation.

CONCLUSIONS

A series of feasibility and pilot studies allowed the stepwise optimization of a quality assessment instrument for the medicines' pathway in NHs and resulted in modifications to improve its clarity and feasibility. Participants' recommendations will promote the successful implementation of the quality assessment instrument.

Effects of the Interruption Management Strategy "Stay S.A.F.E." During Medication Administration

PURPOSE

This study measured the impact of the Stay S.A.F.E. intervention on nursing students' management of and response to interruptions during medication administration. Time to return to the primary task, performance (procedural failures and error rate), and perceived task load were evaluated.

DESIGN

This experimental study used a randomized prospective trial.

METHODS

Nursing students were randomized into two groups. Group 1 (the experimental group) received two educational PowerPoints: the Stay S.A.F.E. strategy and medication safety practices. Group 2 (the control group) received educational PowerPoint on medication safety practices. Nursing students participated in three simulations where they were interrupted during a simulated medication administration. Eye tracking of students' eye movements determined focus, time to return to the primary task, performance including procedural failures and errors, and fixation time on the interrupter. The perceived task load was measured using the NASA Task Load Index.

RESULTS

The intervention group, which was the Stay S.A.F.E. group, demonstrated a significant reduction in time away from task. There was a significant difference in perceived task load across the three simulations, including decreased frustration scores for this group as well. The control group members reported a higher mental demand, increased effort, and frustration.

CLINICAL RELEVANCE

Rehabilitation units often hire new nursing graduates or individuals with little experience. For new graduates they have typically practiced their skills without interruptions. However, interruptions in performing care, particularly in medication management, occur frequently in real-world situations. Improving the education of nursing students related to interruption management has the potential to improve their transition to practice and patient care.

CONCLUSION

Students who received the Stay S.A.F.E. training, a strategy to manage interruptions in care, had decreasing frustration over time and spent more time on the task of medication administration.

[The role of nurses in pharmaceutical care in Germany: A qualitative analysis]

BACKGROUND

In 13 European countries, laws have been passed that allow nurses to prescribe medicines, but mostly within a limited framework and with a doctor involved. Germany is not among these countries. Only the prescription of medical aids has already been included into the development of extended nursing competencies. We investigated the views of the health care professions involved (doctors, pharmacists and nurses) regarding the role of nurses in pharmaceutical care.

METHOD

We conducted 22 semi-structured interviews with 23 members of the three professional groups involved in the European research project DeMoPhaC. These data collected in Germany were analysed using qualitative content analysis. Five main categories were developed.

RESULTS

Pharmaceutical care by nurses can be described within the following main categories: 1. Knowledge and competences, 2. Patient care, 3. Communication, 4. Multi-professional team and 5. System. The communication between the professional groups involved and with patients and caregivers is of particular importance. Interaction in the multi-professional team is just as crucial. Pharmaceutical care takes place within the health system which sets the framework and often boundaries as well. The current and ideally conceived roles of nurses are seen differently in the respondents' respective contexts. Between the professional groups there is both agreement and dissent on the topics addressed. However, the development of nursing roles requires collaborative and transparent processes in teams and organisations. Particularly in the hospital setting, the participants saw a great need for change in order to achieve cooperation at eye level.

DISCUSSION

The results show that nurses play their role in the complex field of pharmaceutical care under very heterogeneous circumstances. The empowerment of nurses, which was called for by some participants, cannot be achieved from within the professional group alone. Cooperation from all the players involved is needed. The development of nursing roles in the medication process with simultaneous expansion of qualifications and competences can contribute to making the nursing role more attractive. Clear role models promote the transparency of processes for all involved. If all players know what they can expect of nurses, tasks can be redistributed in the multiprofessional team.

CONCLUSION

The above-mentioned diversity of perspectives can be a resource for development and individual solutions. However, it can also be interpreted negatively as a sign of uncertainty and less standardised ways of working. In view of the data evaluated here, the prescription of medicines by non-medical professionals remains a distant goal for developments in the German health care system. First of all, structures and processes are required that permanently guarantee safe pharmaceutical care with equal participation of all relevant stakeholders.

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.

Interprofessional care of patients with type 2 diabetes mellitus in primary care: family physicians’ perspectives

Background

There is a lack of understanding of the team processes and factors that influence teamwork and medication management practices in the care of patients with type 2 diabetes mellitus (T2DM). The purpose of the study was to explore physicians’ perspectives of barriers and facilitators to interprofessional care of patients with T2DM within team-based family practice settings.

Methods

This was a qualitative, descriptive study. Participants included physicians affiliated with a primary care network providing care to patients with T2DM in an interprofessional team-based primary care setting in Edmonton, Alberta, Canada. Participants’ contact information was obtained from the publicly available College of Physicians and Surgeons of Alberta and respective primary care network websites. Interview questions addressed physicians’ perspectives on factors or processes that facilitated and hindered the care and medication management of adult patients with T2DM in primary care team-based clinical practice. Interviews were audio-recorded, transcribed, and analyzed using qualitative content analysis and a constant comparative approach.

Results

A total of 15 family physicians participated in individual interviews. Family physicians identified facilitators of interprofessional team-based care and medication management of patients with T2DM in three theme areas—access to team members and programs, knowledgeable and skilled health professionals, and provision of patient education by other health professionals. Two themes emerged as barriers to interprofessional care – lack of provider continuity and the loss of skills from delegation of tasks.

Conclusion

Family physicians perceive both benefits and risks to interprofessional team-based care in caring for patients with T2DM. Successful functioning of team-based care in family practice will require overcoming traditional professional roles.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01688-w.

The art of making the right exception to the "rule": Nurses' experiences with drug dispensing in nursing homes

Nurses are key professionals in ensuring safe drug management in nursing homes, and their practice is regulated by a number of guidelines. The present study aimed to explore nurses' experiences of dispensing drugs to older people in nursing homes by using an exploratory qualitative design. Focus group interviews were conducted in three nursing homes in central Norway; the data were analyzed using qualitative content analysis. The results indicated that drug dispensing was perceived as a complicated process during which both anticipated and unforeseen challenges arose that influenced the nurses' abilities to follow professional standards. In these situations, the nurses had to apply their knowledge and make various adjustments based on conditions in the organization and the needs of individual patients. The findings have implications for facilitating nurses' working conditions and resources to avoid drug administration that limit the discretion of nurses and threaten patient safety in nursing homes.

Linking the processes of medication administration to medication errors in the elderly

BACKGROUND

Older people are more prone to chronic diseases than younger ones and typically receive multiple medications. Medication rounds in long-term care facilities (LTCFs) are usually lengthy, with most errors occurring during the administration phase. How nurses apply medication administration processes can affect resident outcomes.

AIM

To determine the processes of medication administration followed by nurses in LTCFs as self-reported by them to identify possible factors associated with medication errors.

SETTING

Twenty-eight LTCFs for the elderly in the Western Cape province, South Africa.

METHODS

A non-experimental cross-sectional descriptive design was applied, using a quantitative approach. A stratified sampling method obtained equal samples of nurses from funded and private LTCFs, thus N = 123 respondents. Data collection was via self-administered questionnaires. The Statistical Package for the Social Sciences (SPSS27) was used for descriptive and inferential analysis.

RESULTS

Nurses' self-reported medication errors such as the sharing of medication between residents (83%), the omission of doses (64.8%), neglecting to sign after medication administration (57%), and medication administered at the wrong time (50.8%). Frequent interruptions during medication rounds were the most common reason for medication errors (75.6%).

CONCLUSION

Multiple medication administration process errors were self-reported by the nurses. LTCFs should provide mandatory medication training, monitor the adherence to correct medication administration procedures, and implement risk-management strategies.

CONTRIBUTION

The identified factors associated with medication errors during medication administration processes can assist with developing risk management strategies and policies in the LTCFs and improve evidence-based practice and resident outcomes.

Organization factors influencing nurse ability to prevent and detect adverse drug events in public hospitals using a patient safety model

The objective of this study was to measure organization factors that can influence the ability of nursing staff to prevent and detect ADEs in public hospitals using Systems Engineering Initiative for Patient Safety (SEIPS) model.

METHODS

This was a multi-center cross-sectional study. The study included a self-administered paper-based survey which was distributed and collected between October through December 2019. The study participants were nurses from 11 public hospitals located in two Iraqi provinces. Binary logistic regression was used to measure the relationship between the independent SEIPS factors (persons, organizations, tools, tasks, and environments) and the incidence of ADEs (outcome variable).

RESULTS

The study recruited 603 nurses (68.3% men) from 11 public hospitals across two provinces. Less than half (48.8%) of the nurses received enough training to detect ADEs, 43.1% had adequate experience to detect ADEs, and 69.8% had to report ADEs in a special record. More than three-quarters (78.4%) believed that their jobs need fast work. Two of the five SEIPS model domains had significant negative association with the incidence of ADEs including organization (nurse-physician collaboration) and nurse experience in ADE detection.

CONCLUSIONS

Nursing staff face several challenges to prevent and minimize ADEs including shortages in nurses, inadequate nurse experience in ADE detection, no training for ADE detection was received, fear of reporting ADEs, and a lack in monitoring equipment. Increasing nurse/patient ratio and providing more monitoring equipment and training courses can minimize ADEs and enhance their detection.

The influence of simulated medication administration learning on the clinical performance of nursing students: A comparative quasi-experimental study

BACKGROUND

Medication administration is a main role of nurses, and by mastering this skill, medication errors can be reduced. Simulation provides a safe environment for learning and improving medication administration. Simulation design may influence the students' learning curve and ability to transfer skills into the clinical setting.

OBJECTIVE

To examine the influence of simulation-based learning of the medication administration process, on satisfaction, self-perception of preparedness, and clinical performance of students who practice simulation either individually or in a group.

DESIGN

A comparative quasi-experimental study.

SETTING

A public university in southern Israel.

PARTICIPANTS

Third-year nursing students in two consecutive academic years (78 in the individual sample and 50 in the group sample).

METHODS

Nursing students participated in a scenario-based simulation for medication administration either individually or in a group. Self-reported questionnaires evaluated participants' satisfaction with the simulation experience, and perception of preparedness before and after the simulation. Faculty members observed and evaluated participants' medication administration during the simulation and in the clinical setting. Paired t-tests were performed to compare preparedness before and after the simulation experience. Linear regression models were formulated to elicit the predictors of preparedness after simulation and evaluations for medication administration in the clinical setting.

RESULTS

The simulation experience increased participants' preparedness both when designed for an individual student and for a group of students. Simulation performance was the main contributor to the participant preparedness among the individual sample (β = 0.51, p < 0.01), whereas previous preparedness was the main contributor among the group sample (β = 0.42, p < 0.01). The association between simulation performance and clinical performance was mediated by preparedness after simulation in the individual sample, but not in the group sample.

CONCLUSIONS

Simulation improves students' preparedness for medication administration. Individual simulation also impacts clinical performance, via preparedness. Further research is needed to identify other factors that facilitate skills transfer into the clinical setting.

Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes

Pharmaceutical care necessitates significant efforts from patients, informal caregivers, the interprofessional team of health care professionals and health care system administrators. Collaboration, mutual respect and agreement amongst all stakeholders regarding responsibilities throughout the complex process of pharmaceutical care is needed before patients can take full advantage of modern medicine. Based on the literature and policy documents, in this position paper, we reflect on opportunities for integrated evidence-based pharmaceutical care to improve care quality and patient outcomes from a nursing perspective. Despite the consensus that interprofessional collaboration is essential, in clinical practice, research, education and policy-making challenges are often not addressed interprofessionally. This paper concludes with specific advises to move towards the implementation of more interprofessional, evidence-based pharmaceutical care.

Development of a Wearable Camera and AI Algorithm for Medication Behavior Recognition

As many as 40% to 50% of patients do not adhere to long-term medications for managing chronic conditions, such as diabetes or hypertension. Limited opportunity for medication monitoring is a major problem from the perspective of health professionals. The availability of prompt medication error reports can enable health professionals to provide immediate interventions for patients. Furthermore, it can enable clinical researchers to modify experiments easily and predict health levels based on medication compliance. This study proposes a method in which videos of patients taking medications are recorded using a camera image sensor integrated into a wearable device. The collected data are used as a training dataset based on applying the latest convolutional neural network (CNN) technique. As for an artificial intelligence (AI) algorithm to analyze the medication behavior, we constructed an object detection model (Model 1) using the faster region-based CNN technique and a second model that uses the combined feature values to perform action recognition (Model 2). Moreover, 50,000 image data were collected from 89 participants, and labeling was performed on different data categories to train the algorithm. The experimental combination of the object detection model (Model 1) and action recognition model (Model 2) was newly developed, and the accuracy was 92.7%, which is significantly high for medication behavior recognition. This study is expected to enable rapid intervention for providers seeking to treat patients through rapid reporting of drug errors.

Drug modification by nurses in Norwegian nursing homes: A cross-sectional study

Crushing and dividing pills among older patients in nursing homes appears to be a common yet not harmless practice. Because few updates exist regarding the role of nurses and their dispensing of drugs in nursing homes, this study sought to describe the occurrence, methods, and causes of nurses' drug modification and to examine possible factors associated with drug modification in this context. A cross-sectional study of 273 dispensing episodes of solid oral drugs made by nurses, were observed during day and evening shifts. Modifications were made in 20.5% of the dispensing episodes, including 80.4% where alterations were made by crushing and 19.6% where alterations were made dividing. The most commonly reported reasons for modification were 'swallowing difficulties' (53.6%) and 'lack of understanding by the patient' (19.6%). The logistic regression analysis showed a significant association between the occurrence of drug modification and both cognitive impairment and administration method.

Nurses', Pharmacists' and Family Physicians' Perceptions of Psychotropic Medication Monitoring in Australian Long-Term Care Facilities: A Qualitative Framework Analysis

BACKGROUND

Current evidence suggests that despite modest benefit in using targeted psychotropic medications in the geriatric population, there is significant iatrogenic morbidity and mortality. Monitoring of the use of psychotropic medications by health care professionals (HCPs) to reduce adverse effects is often suboptimal; however, there have been few theoretically informed studies as to why this is so.

OBJECTIVE

This study aimed to elucidate facilitators and barriers to psychotropic medication monitoring in long-term care facilities (LTCFs) from the viewpoint of nurses, pharmacists and family physicians. Secondly, it intended to identify targets for tailored intervention strategies to improve monitoring practices.

METHODS

A purposive sample of 31 HCPs working in LTCFs in Sydney, New South Wales, Australia was recruited. Three cohorts consisted of twelve registered nurses, ten pharmacists and nine family physicians. Semi-structured interviews were conducted, assessing perceptions of psychotropic medication monitoring in LTCFs, facilitators, barriers and proposed solutions. Interviews were transcribed verbatim and thematically analyzed through an inductive coding approach. Themes were then mapped to Ferlie and Shortell's 'Four Levels of Change' framework for improving quality in healthcare.

RESULTS

Monitoring was revealed as a multi-faceted concept, influenced by factors across individual, group, organization and system levels. Thematic analysis revealed six key themes pertinent to psychotropic monitoring in LTCFs: (1) engagement with monitoring, (2) monitoring capability, (3) opportunity to monitor, (4) roles and responsibilities, (5) communication and collaboration and (6) guidance and regulation. HCPs conceptualized monitoring differently, but consistently felt that monitoring in LTCFs was suboptimal, recognizing a need for guidance and resources to aid collaborative monitoring of psychotropic medications. HCPs internally situated within LTCFs (nurses) viewed psychotropic medication monitoring as a dynamic and ongoing phenomenon, occurring both formally and informally on a day-to-day basis. In contrast, externally situated HCPs (pharmacists and family physicians) typically associated medication monitoring with structured medication reviews and conceptualized monitoring as an intermittent and planned activity.

CONCLUSIONS AND IMPLICATIONS

Psychotropic monitoring is perceived by all HCPs as a shared responsibility; however, the conceptualization of monitoring differs between HCPs. HCPs' beliefs and attitudes require consideration when designing implementation strategies for interventions to ameliorate suboptimal monitoring practices.

The use of the community of inquiry survey in blended learning pedagogy for a clinical skill-based module

AIM AND OBJECTIVES

The primary aim of this study was to examine the effectiveness of the blended learning pedagogy in a clinical skill-based module using the Community of Inquiry (CoI) framework. The secondary objectives were to assess the effectiveness of blended learning in improving the nursing knowledge, and students' satisfaction with this approach.

BACKGROUND

Blended learning is increasingly adopted in education as more online resources are made available for tutors to use for the benefit of their students. That implied a reduction in the face-to-face contact time in replacement for online teaching, which therefore warrants a need to examine the effectiveness of blended learning approach. The application of CoI framework could evaluate the blended learning approach to assist teaching faculty with evidence-based practices on online teaching.

DESIGN

This study used the quasi-experimental, pretest-posttest design, and results were presented according to the Transparent Reporting of Evaluations with Nonrandomised Designs (TREND) guidelines.

METHODS

This study was conducted in a university and recruited 219 Year 1 nursing students who completed a clinical-based module.

RESULTS

The results of the CoI survey found that teaching presence scored the highest mean, followed by cognitive and social presence. The design of the blended learning was effective in enhancing students' knowledge but they only expressed a moderate level of satisfaction.

CONCLUSIONS

Blended learning is a feasible pedagogical strategy for a clinical skill-based module. However, further investigation is required to explore the factors and strategies which could improve students' satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Blended learning has become one of the contemporary trends in education. Refining teaching strategies may meet the learning needs of today's generation and improve students' learning outcomes.

Risk management in community pharmacy practice in Abu Dhabi Region: a cross-sectional study

Objectives

Pharmacy risk factors impose a major threat to general healthcare outcomes. Risks that can directly affect patients are known as clinical risk factors, and other, non-clinical risk factors may also affect a pharmacist's performance and pharmaceutical profession. This study aims to evaluate the risks, which occur in community pharmacies in Abu Dhabi, and to investigate the protective plans followed in such incidence.

Methods

A self-administrated online questionnaire was distributed to community pharmacists in Abu Dhabi. The questionnaire items were tested by content and face validity in a panel of experts and pilot study. The Statistical Package for the Social Sciences (SPSS) program was used for the data analysis.

Key findings

Medication errors and computer system malfunction occur monthly, as reported by 40% of the participants (n = 131). Theft cases were reported by 37.6% (n = 121) of the pharmacists. Violence was categorized as verbal, psychological and physical abuse, and the frequency was 56.8% (n = 183), 30.4% (n = 98) and 14.3% (n = 46) respectively. Almost all the participants belief that communication skills, alertness and experience are the most important internal factors affecting performance. Environmental factors such as the availability of restrooms were cited as important external factors enhancing performance. Chain pharmacies were found to address electrical failure and dealing with look-alike sound-alike/high-alert medication efficiently.

Conclusions

Different types of clinical and non-clinical risk in pharmacy practice were identified, and risk mitigation techniques were proposed. A positive attitude of community pharmacists was observed towards identifies risks and on the suggested mitigation techniques. It is necessary to publish a universally referenced validated risk factor list for evaluating current risk management plans to maintain safe pharmacy practices and include management courses within pharmacy curriculum.

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.

The Effect of a Tailored Health Education Programme on Medication Management in the Elderly

Background

Empowering the elderly by education programs can decrease medication problems, morbidity, and mortality.

Methods

A cross-sectional study to identify trends and baseline medication management among the elderly in nursing homes followed by an interventional study (tailored educational programme) offered within the same population followed by reassessment of the same medication management domains.

Results

There was no effect regarding nursing home participants' medication knowledge before and after intervention, while there were variable degrees of significant statistical differences in how the participants obtain and take their medications as well as their total deficiency scores before and after intervention. Other domains were also variably affected.

Conclusion

It is vital to ensure that patients have sufficient knowledge regarding their medications and how to handle and administer them. Different domains may variably be affected by educational programmes mainly due to preassessment deficits. Educational programmes need to be tailored according to the requirements of the population targeted.

A Qualitative Evaluation of Adverse Drug Reaction Reporting System in Pakistan: Findings from the Nurses' Perspective

The contribution of all key healthcare professionals is vital to promote an efficient adverse drug reaction (ADR) reporting system. In this context, nurses are important as they are in a better position to observe a patient's response regarding the drug therapy and to report an ADR. The aim of the study was to explore the perspectives of nurses about ADR reporting system in Lahore, Pakistan. A total of 21 nurses were interviewed. The thematic content analysis of the qualitative interviews yielded six major themes and eight subthemes. Major themes included: (1) Knowledge about the concept of the medication safety & the ADR; (2) Knowledge regarding pharmacovigilance activities; (3) Willingness to report; (4) Practices related to the ADR reporting; (5) Barriers to the ADR reporting; (6) Facilitators to the ADR reporting. The majority of the nurses were aware of medicine safety and ADRs, but in many cases, they were unable to report these ADRs. The study pointed out considerable concerns regarding the knowledge and practices of nurses about pharmacovigilance activities in their workplace, mainly due to increased workload, due to the absence of a reporting system and legal liability. The main challenges turned out to be the lack of knowledge and training, as well as the implementation of guidelines. Based on the findings, it is suggested that outcome of this study can serve as a guide to design policies that support ADR reporting by nurses in Pakistan.

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

Effectiveness of three-dimensional visualisation on undergraduate nursing and midwifery students' knowledge and achievement in pharmacology: A mixed methods study

BACKGROUND

Historically nursing and midwifery students have reported difficulty understanding the concept-based science underpinning the interactions between drugs and their targets. This knowledge is crucial for the administration and monitoring of the therapeutic and adverse effects of medications. Immersive three-dimensional technology is reported to enhance understanding of complex scientific concepts but the physical effects of motion sickness may limit its use.

OBJECTIVES

This project compared the effectiveness of three-dimensional immersive visualisation technology with two-dimensional visualisation technology as a teaching method to improve student understanding of a pharmacological concept, and to assess levels of student discomfort and satisfaction associated with the experience.

DESIGN

Traditional lecture content and presentation about drug-receptor binding was followed by exposure to either a two- or three-dimensional artifact visualising β-adrenoceptor binding. Two student groups were compared by type of exposure: Group 1 watched the artifact via a three-dimensional immersive facility and Group 2 on a wide, two-dimensional screen.

SETTINGS

School of Nursing and Midwifery in a regional university in Southeast Queensland, Australia.

PARTICIPANTS

Two hundred and two second year undergraduate nursing and midwifery students.

METHODS

The study used mixed methods methodology. Pre- and post- testing of student knowledge was collected using five multiple-choice questions. A post-intervention survey elicited students' self-assessed perceptions of discomfort and satisfaction with the learning experience.

RESULTS

The three-dimensional immersive learning experience was comparable to the two-dimensional experience in terms of satisfaction and comfort but resulted in statistically significant improvements in post-test scores.

CONCLUSIONS

The three-dimensional experience improved understanding when compared to two-dimensional viewing, satisfied students leaning needs, and caused minimal discomfort. The results are encouraging in terms of using three-dimensional technology to enhance student knowledge of pharmacological concepts necessary for competency in medication management.

Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team

BACKGROUND

In Canada, most patients with type 2 diabetes mellitus (T2DM) are cared for in the primary care setting in the practices of family physicians. This care is delivered through a variety of practice models ranging from a single practitioner to interprofessional team models of care. This study examined the extent to which family physicians collaborate with other health professionals in the care of patients with T2DM, comparing those who are part of an interprofessional health care team called a Primary Care Network (PCN) to those who are not part of a PCN.

METHODS

Family physicians in Alberta, Canada were surveyed to ascertain: which health professionals they refer to or have collaborative arrangements with when caring for T2DM patients; satisfaction and confidence with other professionals' involvement in diabetes care; and perceived effects of having other professionals involved in diabetes care. Chi-squared and Fishers Exact tests were used to test for differences between PCN and non-PCN physicians.

RESULTS

170 (34%) family physicians responded to the survey, of whom 127 were PCN physicians and 41 were non-PCN physicians (2 not recorded). A significantly greater proportion of PCN physicians vs non-PCN physicians referred patients to pharmacists (23.6% vs 2.6%) or had collaborative working arrangements with diabetes educators (55.3% vs 18.4%), dietitians (54.5% vs 21.1%), or pharmacists (43.1% vs 21.1%), respectively. Regardless of PCN status, family physicians expressed greater satisfaction and confidence in specialists than in other family physicians or health professionals in medication management of patients with T2DM. Physicians who were affiliated with a PCN perceived that interprofessional collaboration enabled them to delegate diabetes education and monitoring and/or adjustment of medications to other health professionals and resulted in improved patient care.

CONCLUSIONS

This study sheds new insight on the influence that being part of a primary care team has on physicians' practice. Specifically, supporting physicians' access to other health professionals in the primary care setting is perceived to facilitate interprofessional collaboration in the care of patients with T2DM and improve patient care.

Lessons learned from introducing huddle boards to involve nursing staff in targeted observation and reporting of medication effect in a nursing home

Background

Medication administration and management in nursing homes can occur during all phases of the medication process. The aim of this study was to investigate if an introduction of a systematic use of huddle board led to an increased amount of documentation in the patient record of observations of effects and side effects following a change in medication.

Methods

A three-layer intervention approach combining huddle boards, educating the entire staff in medication observation and documentation, and frequent feedback to the staff about the outcome was applied. A standard was set for the expected reporting. Correlation between expected and actual reporting as an average was calculated and the staff received weekly updates on their observation–reporting results.

Results

The huddle board became a hub in providing an overview of the expectations of observations. To visualize the impact of the intervention, use of a run chart gave comprehensive information about the extent to which the expected goal of documentation was reached. Four different organizational steps and one individual action in the last step were taken to improve the observation–reporting. The identifying of the nonreporting nurses and individual staff guidance to these nurses resulted in a significant improvement in observation–reporting. The expected goal of 100% average reporting was achieved 6 months after all wards were included in the improvement project.

Conclusion

The combination of huddle boards, educating the entire staff in observation and documentation, and frequent feedback to the staff about the outcome proved to be a useful approach in medication safety work in nursing homes.

Nurse-led medicines' monitoring in care homes study protocol: a process evaluation of the impact and sustainability of the adverse drug reaction (ADRe) profile for mental health medicines

INTRODUCTION

Improved medicines' management could lead to real and sustainable improvements to the care of older adults. The overuse of mental health medicines has featured in many reports, and insufficient patient monitoring has been identified as an important cause of medicine-related harms. Nurse-led monitoring using the structured adverse drug reaction (ADRe) profile identifies and addresses the adverse effects of mental health medicines. Our study investigates clinical impact and what is needed to sustain utilisation in routine practice in care homes.

METHODS AND ANALYSIS

This process evaluation will use interviews and observations with the participants of all five homes involved in earlier research, and five newly recruited homes caring for people prescribed mental health medicines. The ADRe profile is implemented by nurses, within existing resources, to check for signs and symptoms of ADRs, initiate amelioration and share findings with pharmacists and prescribers for medication review. Outcome measures are the numbers and nature of problems addressed and understanding of changes needed to optimise clinical gain and sustain implementation. Data will be collected by 30 observations and 30 semistructured interviews. Clinical gains will be described and narrated. Interview analysis will be based on the constant comparative method.

ETHICS AND DISSEMINATION

Ethical approval was conferred by the National Health Service Wales Research Ethics Committee. If the ADRe profile can be sustained in routine practice, it has potential to (1) improve the lives of patients, for example, by reducing pain and sedation, and (2) assist in early identification of problems caused by ADRs. Therefore, in addition to peer-reviewed publications and conferences, we shall communicate our findings to healthcare professionals, policy-makers and sector regulators.

TRIAL REGISTRATION NUMBER

NCT03110471.

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

AIMS

To understand the medication administration process in residential aged care homes.

BACKGROUND

Understanding actual processes that nurses follow is critical to guide improvement efforts and to develop robust systems to ensure safety in medication administration.

METHODS

Seven nurses were observed for 12 morning medication rounds at two units of a residential aged care home in Australia. Observations were guided by an activity theoretical framework.

RESULTS

Nurses followed a common work process to administer medication. This process included actions from preparing medication trolley, locating a resident, preparing and administering medication to this person, documenting the administration, to finally checking medication charts to ensure all residents received medication. We identified 15 process deviations that may hinder safe medication administration. Electronic medication administration records appeared to be able to prevent a deviation associated with the paper-based documentation process.

CONCLUSIONS

This study elaborated the medication administration process in a residential aged care home and identified process deviations. It suggests a safety checklist that can be used to evaluate nursing practice and improve medication administration process.

IMPLICATION FOR NURSING MANAGEMENT

To develop robust systems for medication safety, nursing managers need to understand the actual nursing process, identify process deviations, and investigate the context in which these deviations occur.

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

The objective of this observational time and motion study was to increase our understanding of how nurses in home healthcare currently distribute their work time with a focus on the medication management process. The research was conducted in four municipalities in the southern part of Sweden. Participants were nurses working in home healthcare. The study measured proportion of time, comparison of proportions of time, proportion of time spent multitasking, and rate of interruptions per hour. Of total observed time, 20.4% was spent on medication management and of these tasks the highest proportion of time was spent on communications and dispensing medications. Nurses in nursing homes spent more time (23.0% vs. 17.4%, p = 0.001) on medication management than nurses in private homes. Nurses spent 47.9% of their time completing tasks with someone else, including patients, but had minimal interaction with prescribers. We observed a rate of 1.2 (95% CI 1.1-1.4) interruptions per hour on average and 30% of all interruptions occurred during medication management tasks. Nurses spent 3.7% of their time multitasking. Interruptions while performing medication-related tasks were common, as well as multitasking. Causes and consequences of the results need to be addressed in order to improve the safety of medication management for patients receiving municipality-based home care.

Factors contributing to serious adverse events in nursing homes

AIMS AND OBJECTIVES

To identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to the improvement of safe nursing care.

BACKGROUND

There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable.

DESIGN

This was a retrospective study, with a total sample of data regarding adverse events (n = 173) in nursing homes, concerning nursing care reported by healthcare providers in Sweden to the Health and Social Care Inspectorate. The reports were analysed with content analysis, and the frequencies of the adverse events, and their contributing factors, were described with descriptive statistics.

RESULTS

Medication errors, falls, delayed or inappropriate intervention and missed nursing care contributed to the vast majority (89%) of the serious adverse events. A total of 693 possible contributing factors were identified. The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication.

CONCLUSIONS

The contributing factors frequently interacted yet they varied between different groups of serious adverse events. The resident's safety depends on the availability of staff's competence as well as adequate documentation about the resident's condition. Lack of competence was underestimated by healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

Registered nurses and assistant nurses need to have awareness of contributing factors to adverse events in nursing care. A holistic approach to improve patient safety in nursing homes requires competence of the staff, safe environments as well as resident's and relative's participation.

Self-management of medication during hospitalisation: Healthcare providers' and patients' perspectives

AIMS AND OBJECTIVES

To explore healthcare providers' and patients' perspectives on self-management of medication during the patients' hospital stay.

BACKGROUND

Self-administration of medications relates to the process in which hospitalised patients-instead of healthcare professionals-prepare and consume medications by themselves. Literature suggests possible advantages of medication self-management such as increased patient satisfaction, adherence to pharmacotherapy and self-care competence.

DESIGN

A qualitative descriptive study design was adopted, using semistructured interviews and qualitative content analysis to examine data.

METHODS

Six physicians, 11 nurses, six hospital pharmacists and seven patients were recruited from one regional hospital and two university hospitals, situated in Belgium. Interviews were conducted between October 2014-January 2015.

RESULTS

Strengths of medication self-management were described by participants, relating to benefits of self-management for patients, time-saving benefits for nurses and benefits for better collaboration between patients and healthcare providers. Weaknesses were also apparent for patients as well as for nurses and physicians. Opportunities for self-management of medication were described, relating to the organisation, the patient and the process for implementing self-management. Threats for self-management of medication included obstacles related to implementation of self-managed medications and the actual process of providing medication self-management. A structured overview of conditions that should be fulfilled before allowing self-management of medication concerned patient-related conditions, the self-managed medication and the organisation of self-management of medication.

CONCLUSIONS

This study provides new insights on the strengths, weaknesses, opportunities and threats from the perspectives of key stakeholders. Interpretation of these findings resulted in an overview of adaptations in the medication management process to facilitate implementation of self-management of medication.

RELEVANCE TO CLINICAL PRACTICE

A medication management process for self-management of medication was proposed. Further interventional studies are needed to test and refine this process before implementing it in daily practice.

Safe medication management in specialized home healthcare - an observational study

BACKGROUND

Medication management is a complex, error-prone process. The aim of this study was to explore what constitutes the complexity of the medication management process (MMP) in specialized home healthcare and how healthcare professionals handle this complexity. The study is theoretically based in resilience engineering.

METHOD

Data were collected during the MMP at three specialized home healthcare units in Sweden using two strategies: observation of workplaces and shadowing RNs in everyday work, including interviews. Transcribed material was analysed using grounded theory.

RESULTS

The MMP in home healthcare was dynamic and complex with unclear boundaries of responsibilities, inadequate information systems and fluctuating work conditions. Healthcare professionals adapted their everyday clinical work by sharing responsibility and simultaneously being authoritative and preserving patients' active participation, autonomy and integrity. To promote a safe MMP, healthcare professionals constantly re-prioritized goals, handled gaps in communication and information transmission at a distance by creating new bridging solutions. Trade-offs and workarounds were necessary elements, but also posed a threat to patient safety, as these interim solutions were not systematically evaluated or devised learning strategies.

CONCLUSIONS

To manage a safe medication process in home healthcare, healthcare professionals need to adapt to fluctuating conditions and create bridging strategies through multiple parallel activities distributed over time, space and actors. The healthcare professionals' strategies could be integrated in continuous learning, while preserving boundaries of safety, instead of being more or less interim solutions. Patients' and family caregivers' as active partners in the MMP may be an underestimated resource for a resilient home healthcare.

Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES

To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND

Pain management in end-stage dementia is a fundamental aspect of end-of-life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN

A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS

Twenty-four registered nurses caring for people dying with advanced dementia were recruited from 10 nursing homes, three hospices and two acute hospitals across a region of the UK. Interviews were conducted between June 2014-September 2015.

RESULTS

Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS

Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE

Nurses considered pain management fundamental to end-of-life care provision; however, nurses working in acute care and nursing home settings may be undersupported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology.

Drug administration via enteral feeding tube in residential care facilities for individuals with intellectual disability: A focus group study on guideline implementation

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present qualitative study aimed to identify barriers and facilitators experienced by RCF staff members to following guidelines on medication administration via EFT, by conducting focus group interviews. Time constraints, lack of knowledge, lack of clear administration instructions, lack of necessary materials, and limited gastric fluid tolerance in certain residents were identified as barriers to following guidelines. Other influencing factors were the number of staff members, residents, and medications; habits; and the residents' comfort and well-being. To optimize care for this vulnerable patient population with EFT, an intervention can be set up focusing on improving staff members' medication-related knowledge and providing clear administration instructions and the necessary materials.

The psychotropic education and knowledge test for nurses in nursing homes: striving for PEAK performance

OBJECTIVES

The psychotropic education and knowledge test for nurses in acute geriatric care (PEAK-AC) measures knowledge of psychotropic indications, doses and adverse drug reactions in older inpatients. Given the low internal consistency and poor discrimination of certain items, this study aims to adapt the PEAK-AC, validate it in the nursing home setting and identify factors related to nurses' knowledge of psychotropics.

METHOD

This study included nurses and nurse assistants employed by nursing homes (n = 13) and nursing students at educational institutions (n = 5) in Belgium. A Delphi technique was used to establish content validity, the known groups technique for construct validity (n_respondents = 550) and the test-retest procedure for reliability (n_respondents = 42). Internal consistency and item analysis were determined.

RESULTS

The psychotropic education and knowledge test for nurses in nursing homes (PEAK-NH) (n_items = 19) demonstrated reliability (κ = 0.641) and internal consistency (Cronbach's α = 0.773). Significant differences between-group median scores were observed by function (p < 0.001), gender (p = 0.019), educational background (p < 0.001), work experience (p = 0.008) and continuing education (p < 0.001) for depression, delirium and pharmacotherapy topics. Items were acceptably difficult (n_items = 15) and well-functioning discriminators (n_items = 17). Median PEAK-NH score was 9/19 points (interquartile range 6-11 points). Respondents' own estimated knowledge was related to their PEAK-NH performance (p < 0.001).

CONCLUSION

The PEAK-NH is a valid and reliable instrument to measure nurses' knowledge of psychotropics. These results suggest that nurses have limited knowledge of psychotropic use in nursing homes and are aware of their knowledge deficits. The PEAK-NH enables educational initiatives to be targeted and their impact on nurses' knowledge to be tracked.

Nurses in municipal care of the elderly act as pharmacovigilant intermediaries: a qualitative study of medication management

OBJECTIVE

To explore registered nurses' experience of medication management in municipal care of the elderly in Sweden, with a focus on their pharmacovigilant activities.

DESIGN

A qualitative approach using focus-group discussions was chosen in order to provide in-depth information. Data were analysed by qualitative content analysis.

SETTING

Five focus groups in five different long-term care settings in two regions in Sweden.

SUBJECT

A total of 21 registered nurses (RNs), four men and 17 women, aged 27-65 years, with 4-34 years of nursing experience.

RESULTS

The findings reveal that RNs in municipal long-term care settings can be regarded as "vigilant intermediaries" in the patients' drug treatments. They continuously control the work of staff and physicians and mediate between them, and also compensate for existing shortcomings, both organizational and in the work of health care professionals. RNs depend on other health care professionals to be able to monitor drug treatments and ensure medication safety. They assume expanded responsibilities, sometimes exceeding their formal competence, and try to cover for deficiencies in competence, experience, accessibility, and responsibility-taking.

CONCLUSION

The RNs play a central but also complex role as "vigilant intermediaries" in the medication monitoring process, including the issue of responsibility. Improving RNs' possibility to monitor their patients' drug treatments would enable them to prevent adverse drug events in their daily practice. New strategies are justified to facilitate RNs' pharmacovigilant activities.

KEY POINTS

This study contributes to the understanding of registered nurses' (RNs') role in medication management in municipal care of the elderly (i.e. detecting, assessing, and preventing adverse drug events or any drug-related problems). RNs can be considered to be "vigilant intermediaries" in elderly patients' drug treatments, working at a distance from staff, physicians, and patients. RNs occasionally take on responsibilities that exceed their formal competence, with the patients' best interests in mind. In order to prevent adverse drug events in municipal care of the elderly, new strategies are justified to facilitate RNs' pharmacovigilant activities.

Managing pain medications in long-term care: nurses' views

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

Medication monitoring in a nurse-led respiratory outpatient clinic: pragmatic randomised trial of the West Wales Adverse Drug Reaction Profile

Objective

To assess the clinical effect of medication monitoring using the West Wales Adverse Drug Reaction (ADR) Profile for Respiratory Medicine.

Design

Single-site parallel-arm pragmatic trial using stratified randomisation.

Setting

Nurse-led respiratory outpatient clinic in general hospital in South Wales.

Participants

54 patients with chronic respiratory disease receiving bronchodilators, corticosteroids or leukotriene receptor antagonists.

Intervention

Following initial observation of usual nursing care, we allocated participants at random to receive at follow up: either the West Wales ADR Profile for Respiratory Medicine in addition to usual care (‘intervention arm’ with 26 participants); or usual care alone (‘control arm’ with 28 participants).

Main Outcome Measures

Problems reported and actions taken.

Results

We followed up all randomised participants, and analysed data in accordance with treatment allocated. The increase in numbers of problems per participant identified at follow up was significantly higher in the intervention arm, where the median increase was 20.5 [inter-quartile range (IQR) 13–26], while that in the control arm was −1 [−3 to +2] [Mann-Whitney U test: z = 6.28, p<0.001]. The increase in numbers of actions per participant taken at follow up was also significantly higher in the intervention arm, where the median increase was 2.5 [1]–[4] while that in the control arm was 0 [−1.75 to +1] [Mann-Whitney U test: z = 4.40, p<0.001].

Conclusion

When added to usual nursing care, the West Wales ADR Profile identified more problems and prompted more nursing actions. Our ADR Profile warrants further investigation as a strategy to optimise medication management.

Trial Registration

Controlled-trials.com ISRCTN10386209

Reducing interruptions during medication administration: the White Vest study

The well-established Institute of Medicine report entitled To Err is Human: Building a Safer Health System highlighted the importance of preventative errors in medicine, suggesting interruptions are a contributing factor. Patient safety organisations, such as The Joint Commission, acknowledge that interruptions contribute to preventable medical errors. The aim of this research is to examine the most frequently observed interruptions experienced by nurses administering medications and evaluate an intervention designed to reduce those interruptions. The primary intervention consisted of a White Vest worn during administration stating: ‘Please do not interrupt while passing medications’. A quasi-experimental design was employed. Nurses were observed for 2 weeks during routine administration of morning medications. The vest was then introduced and worn during administration for 2 weeks for post-intervention data collection. The hospital unit, date, time, duration, and description of the interruption were recorded. Data collection was conducted in four hospital units sequentially. A content analysis revealed the most frequently observed interruptions were comments/questions by hospital staff, phone calls, and seeking supplies. As hypothesised, the overall number of interruptions during medication administration (MA) declined after implementation of the intervention. This study illustrates implications and policy changes with regards to nursing practices and MA.

[Medication error management climate and perception for system use according to construction of medication error prevention system]

PURPOSE

The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use.

METHODS

The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis.

RESULTS

Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed.

CONCLUSION

The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.