Exploring the challenges to safer prescribing and medication monitoring in prisons: A qualitative study with health care staff

Abstract

Introduction Research suggests that patients who are prisoners experience greater morbidity, increased health inequalities and frequent preventable harm, compared to the general population. Little is known about the process and influencing factors for safe prescribing in the unique prison environment, which may limit the development efforts to improve the quality of care in prisons. This study aimed to understand the process and challenges associated with prescribing in prisons, explore the causes and impact of these challenges, and explore approaches to improve prescribing safety in prisons. Methods Grounded theory informed data collection and analysis of a nominal group discussion by seven participants and semi-structured telephone interviews with twenty prison healthcare staff, including GPs, pharmacists, psychiatrists and nurses. Findings The underlying complexity of prescribing in prison settings increased the level of challenge and influenced the safety of this process. Multiple contributors to the challenges of safe prescribing were identified (comprising governance and policy; the prison structure; staff retention, training and skill mix; IT systems and interface; polypharmacy and co-morbidity; tradability and patient behaviour) with overarching constructs of variations in practice/policy and the influence of prison culture. Participants identified measures to address these challenges through multi-disciplinary collaborative working, increased consistency in processes, and the need for more innovation and education/training. Conclusions Our study highlighted that healthcare provision in prisons is unique and needs to tailor the care provided to patients without enforcing a model focused on primary, secondary or tertiary care. Participants emphasised a necessary shift in workplace culture and behaviour change to support improvements. The COM-B model of behaviour change may be effectively applied to develop interventions in organisations that have in-depth understanding of their own unique challenges.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study

“…These include poor information technology, security rules for ambulance release or medication management, staffing levels, the availability of appropriately trained staff and prison overcrowding [15]. For example with prison electronic health records it has been reported how limitations affecting interfacing with external systems may delay verification of medication records if the information needed is not available when required [19], and there are ongoing discussions across UK healthcare considering how inter-operability and sharing of health information (including with patients) could address challenges such as these [56][57][58]. However, such issues can have deleterious consequences on physical and psychological morbidity, high rates of mortality, self-harm, and substance misuse [10].…”

“…For people detained in prison in England, the average age of death is 56 years [16]. Whilst people in prison may also access healthcare more often than those in the community [17,18], health practitioners deliver care where strict security regimes may take precedent [19]. The structure of secure environments may restrict the delivery of health care within and outside prisons, for example through high rates of missed hospital appointments [20] which may be due to a lack of security escort.…”

“…The influence of security also extends to medication management where patients may not be permitted to hold their own medications (i.e. 'in-possession' medication) and prescribing decisions may need to consider the risk of medication diversion or abuse [19,21]. When considered alongside increasing numbers in custody and high prisoner turnover rates [22], it is important to focus on care quality and safety as a priority in this environment.…”

Medication-Related Outcomes and Health Equity: Evidence for Pharmaceutical Care

“…Such inequities in medication-related experiences and outcomes can occur in any stage of the medication use process, such as the prescription, dispensing and administration of medication, and a sample of these issues is presented in Table 2. The available evidence suggests that members of ethnic minority groups [4,5,[15][16][17][18][19][20], people who are institutionalised [17,21], incarcerated [22,23] or homeless [24][25][26] and people of sexual minority groups [27] are more likely to experience medication-related problems than the general population. This is also true for people with certain health statuses, such as those with sensory impairment, either auditory or visual [17,28], older people with intellectual disabilities [29] and those who experience cognitive impairment, severe mental illness and frailty [17].…”

“…For example, these people experience a higher prevalence of morbidity, polypharmacy, mental health and substance misuse issues than the general population. These patient-level factors add complexity to the individual factors, e.g., the prescriber, and organisational factors, e.g., the integration of information, in these contexts [22][23][24][25]36,37]. We identified one study that reported the patients' perspectives of their issues or needs in the homeless setting and none referring to the prison setting [25].…”