Prescribing of Psychoactive Drugs for Older People in Nursing Homes: An Analysis of Treatment Culture

Abstract

BackgroundThere is increasing interest in how culture may affect the quality of healthcare services, and previous research has shown that ‘treatment culture’—of which there are three categories (resident centred, ambiguous and traditional)—in a nursing home may influence prescribing of psychoactive medications.ObjectiveThe objective of this study was to explore and understand treatment culture in prescribing of psychoactive medications for older people with dementia in nursing homes.MethodSix nursing homes—two from each treatment culture category—participated in this study. Qualitative data were collected through semi-structured interviews with nursing home staff and general practitioners (GPs), which sought to determine participants’ views on prescribing and administration of psychoactive medication, and their understanding of treatment culture and its potential influence on prescribing of psychoactive drugs. Following verbatim transcription, the data were analysed and themes were identified, facilitated by NVivo® and discussion within the research team.ResultsInterviews took place with five managers, seven nurses, 13 care assistants and two GPs. Four themes emerged: the characteristics of the setting, the characteristics of the individual, relationships and decision making. The characteristics of the setting were exemplified by views of the setting, daily routines and staff training. The characteristics of the individual were demonstrated by views on the personhood of residents and staff attitudes. Relationships varied between staff within and outside the home. These relationships appeared to influence decision making about prescribing of medications. The data analysis found that each home exhibited traits that were indicative of its respective assigned treatment culture.ConclusionNursing home treatment culture appeared to be influenced by four main themes. Modification of these factors may lead to a shift in culture towards a more flexible, resident-centred culture and a reduction in prescribing and use of psychoactive medication.Electronic supplementary materialThe online version of this article (doi:10.1007/s40801-016-0066-5) contains supplementary material, which is available to authorized users.

Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence

“…The studies were conducted in six different countries: UK (n=7), 19,[25][26][27][28][29][30] US (n=5), 18,[31][32][33][34] Australia (n=3), [35][36][37] Canada (n=1), 38 The Netherlands (n=1) 17 and South Africa (n=1). 39 Eleven of the studies employed a purely qualitative methodology, [17][18][19][25][26][27]30,[35][36][37]39 while seven utilized mixed-methods. 28,29,[31][32][33][34]38 A total of 1,609 unique participants were involved: nurses (n=479), other nursing home staff (n=657), family carers (n=239), physicians (n=144), pharmacists (n=49) and old age advocates (n=6).…”

“…One reviewer (KW) open coded the study findings of all included studies (results and discussion sections), focusing specifically on first-order interpretations (views of the participants) and second-order interpretations (views of the authors). To ensure credibility and dependability of coding, another reviewer (CS) coded the 'index paper' and two other randomly selected studies, 18,19 and differences in interpretation were discussed and consensus reached. 20 The four reviewers convened several times to discuss independently derived concepts and patterns from the studies.…”

“…The options for managing BPSD were generally perceived to be binary -antipsychotic prescribing or non-pharmacological interventions -with the former option considered to be the "quick-fix." 19,26,38…”

“…Resources and access to services: Understaffing and insufficient time to engage with residents, to conduct thorough assessments of underlying causes, and perform non-pharmacological interventions was mentioned throughout the reviewed studies: [17][18][19]26,27,29,30,32,33,[35][36][37][38][39] "The greatest impact on good outcomes for behaviour management is time limits. Nurses are always under pressure to hurry."…”

“…Nurses are always under pressure to hurry." 35 In some studies there was a suggestion that medication was used to compensate for poor staffing levels: 19,37 "sometimes [it's] easier to give a tablet." 19 This understaffing issue was further compounded by a lack of access to specialist services such as psychiatrists, therapists and pharmacists.…”