Is psychotropic medication use related to organisational and treatment culture in residential care

Perspectives of aged care home staff and health care professionals on the Psychotropic medicines use in Residents And Culture: Influencing clinical Excellence (PRACTICE) tool ©

INTRODUCTION

High use of psychotropic medications continues to be common in residential aged care homes despite the risk of harm and limited efficacy in people living with dementia. Research has shown that the organizational culture of aged care homes influences psychotropic medication use in residents with dementia. The Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool was developed to evaluate the organizational culture of aged care homes specific to the use of psychotropic medications.

OBJECTIVES

To evaluate the comprehensibility, relevance, and comprehensiveness of the PRACTICE tool among end-users.

METHOD

Cognitive interviews were conducted with participants representing a broad range of health disciplines across Australia. Interviews were performed using a combination of the think-aloud technique and verbal probing. Interviews were transcribed and content coded for participants' perceptions of the PRACTICE tool. Items were modified based on findings from the cognitive interviews, participants' suggestions for rewording of items and discussions with the research team.

RESULTS

A total of 20 cognitive interviews were conducted. Based on the cognitive interviews, 48 out of 63 items were modified. Reasons for modification were categorized into three themes: 1) Items changed to align with the aged care home staff's scope of practice; 2) Items adjusted to prevent unintended blame from reading the items; and 3) Items modified to prevent potential misinterpretation of their intended meaning. Three items were added to improve the comprehensiveness of the tool. Most participants reported that they understood the items and considered them as relevant and acceptable for the evaluation of organizational culture and use of psychotropic medication in aged care homes.

CONCLUSION

This study confirms that the PRACTICE tool is a comprehensive tool appropriate for the assessment of organizational culture specific to psychotropic medication use and is important for aged care home settings.

Psychotropic Medication Prescribing Practice Among Residents With Dementia in Nursing Homes: A Person-Centered Care Approach

Despite multiple national initiatives to improve quality of life in nursing home (NH) residents with dementia, inefficiencies still exist regarding inappropriate psychotropic medication use to manage communication of distress. The goals of the current article are to: (a) create a person-centered care plan/process for NH community staff to manage challenging dementia behaviors; (b) provide guidelines for geriatric practitioners (GPs) to decrease psychotropic medication use in residents with dementia; (c) discuss organizational culture and its relationship to the management of non-cognitive neuropsychiatric symptoms (NPS) of dementia; and (d) emphasize nonpharmacological approaches as first-line treatment of NPS in NH residents with dementia. [Journal of Gerontological Nursing, 46(2), 9-17.].

Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool©. A development and content validation study

INTRODUCTION

Psychotropic medicines are often prescribed in nursing homes to manage behavioral and psychological symptoms of dementia despite marginal clinical effects alongside harmful adverse events. Organizational culture has been identified as a key factor that contributes to the high-level prescribing of psychotropic medicines in nursing homes. There are gaps in existing tools used to link organizational culture to the use of psychotropic medicines. The aim of this research was to develop and content validate a tool that evaluates organizational culture specific to the use of psychotropic medicines, named the Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool^©.

METHODS

Schein's theory of organizational culture was used to guide the development and content validation of the PRACTICE tool^©. The PRACTICE tool^© was developed based on a comprehensive systematic review, qualitative research and generated by the research team. Content validity was assessed using the CVI (Content Validity Index). The content relevance and importance of the PRACTICE tool^© items were rated by an expert panel with relevant knowledge and experience. Any modified or re-worded items were presented to the panel members in a subsequent survey for re-rating.

RESULTS

Across the two rounds, the PRACTICE tool^© had 68 items that assessed all aspects of culture according to Schein's theory. Sixty-two items out of 68 (91%) met predefined cut-off values (≥0.78) for the I -CVI. The remaining six items (9%) did not fully meet the cut-off values but were deemed important to be included in the tool based on the systematic review, qualitative research and discussions with the research team.

CONCLUSIONS

The PRACTICE tool^© is a step forward in validating an instrument that will help inform managers and policy makers to identify target areas for improvement to create a culture of appropriate psychotropic prescribing in nursing homes.

Shaping the use of psychotropic medicines in nursing homes: A qualitative study on organisational culture

Psychotropic medicines have limited efficacy in the management of behavioural and psychological disturbances, yet they are commonly used in nursing homes. Organisational culture is an important consideration influencing use of psychotropic medicines. Schein's theory elucidates that organisational culture is underpinned by basic assumptions, which are the taken for granted beliefs driving organisational members' behaviour and practices. By exploring the basic assumptions of culture we are able to find explanations for why psychotropic medicines are prescribed contrary to standards. A qualitative study guided by Schein's theory was conducted using semi-structured interviews with 40 staff representing a broad range of roles from eight nursing homes. Findings from the study suggest two basic assumptions influenced the use of psychotropic medicines: locus of control and necessity for efficiency or comprehensiveness. Locus of control pertained to whether staff believed they could control decisions when facing negative work experiences. Necessity for efficiency or comprehensiveness concerned how much time and effort was spent on a given task. Participants' arrived at decisions to use psychotropic medicines that were inconsistent with ideal standards when they believed they were helpless to do the right thing by the resident and it was necessary to restrict time on a given task. Basic assumptions tended to provide the rationale for staff to use psychotropic medicines when it was not compatible with standards. Organisational culture is an important factor that should be addressed to optimise psychotropic medicine use.

Prevalence of, and Resident and Facility Characteristics Associated With Antipsychotic Use in Assisted Living vs. Long-Term Care Facilities: A Cross-Sectional Analysis from Alberta, Canada

Background

Potentially inappropriate antipsychotic use in long-term care (LTC) facilities has been the focus of significant policy and clinical attention over the past 20 years. However, most initiatives aimed at reducing the use of these medications have overlooked assisted living (AL) settings.

Objective

We sought to compare the prevalence of antipsychotic use (including potentially inappropriate use) among older AL and LTC residents and to explore the resident and facility-level factors associated with use in these two populations.

Methods

We performed cross-sectional analyses of 1089 residents (mean age 85 years; 77% female) from 59 AL facilities and 1000 residents (mean age 85 years; 66% female) from 54 LTC facilities, in Alberta, Canada. Research nurses completed comprehensive resident assessments at baseline (2006–2007). Facility-level factors were assessed using standardized administrator interviews. Generalized linear models were used to estimate odds ratios for associations, accounting for clustering by facility.

Results

Over a quarter of residents in AL (26.4%) and LTC (31.8%) were using antipsychotics (p = 0.006). Prevalence of potentially inappropriate use was similar in AL and LTC (23.4 vs. 26.8%, p = 0.09). However, among users, the proportion of antipsychotic use deemed potentially inappropriate was significantly higher in AL than LTC (AL: 231/287 = 80.5%; LTC: 224/318 = 70.4%; p = 0.004). In both settings, comparable findings regarding associations between resident characteristics (including dementia, psychiatric disorders, frailty, behavioral symptoms, and antidepressant use) and antipsychotic use were observed. Few facility characteristics were associated with overall antipsychotic use, but having a pharmacist on staff (AL), or an affiliated physician (LTC) was associated with a lower likelihood of potentially inappropriate antipsychotic use.

Conclusion

Our findings illustrate the importance of including AL settings in clinical and policy initiatives aimed at reducing inappropriate antipsychotic use among older vulnerable residents.

Electronic supplementary material

The online version of this article (doi:10.1007/s40266-016-0411-0) contains supplementary material, which is available to authorized users.

A qualitative study exploring visible components of organizational culture: what influences the use of psychotropic medicines in nursing homes?

BACKGROUND

The influence of organizational culture on how psychotropic medicines are used in nursing homes has not been extensively studied. Schein's theory provides a framework for examining organizational culture which begins with the exploration of visible components of an organization such as behaviors, structures, and processes. This study aimed to identify key visible components related to the use of psychotropic medicines in nursing homes.

METHODS

A qualitative study was conducted in eight nursing homes in Sydney, Australia. Purposive sampling was used to conduct semi-structured interviews with 40 participants representing a broad range of health disciplines. Thematic analysis was used to derive concepts.

RESULTS

Three visible components were related to psychotropic medicine use. These were drugs and therapeutics committee meetings, pharmacist led medication management reviews and formal and informal meetings with residents and their families. We found that only a few nursing homes utilized drugs and therapeutics committee meetings to address the overuse of psychotropic medicines. Pharmacist led medication management reviews provided a lever to minimize inappropriate psychotropic prescribing for a number of nursing homes; however, in others it was used as a box-ticking exercise. We also found that some nursing homes used meetings with residents and their families to review the use of psychotropic medicines.

CONCLUSION

This study was the first to illustrate that visible components of organizational culture do influence the use of psychotropic medicines and explains in detail what of the culture needs to be addressed to reduce inappropriate psychotropic prescribing.