A theory-based exploration of the medicines management process provided to older people residing in the nursing home setting in the Republic of Ireland

Abstract

Introduction While the population is ageing globally, this does not necessarily mean that they are living healthier. The multimorbidity and polypharmacy in the older population (age> 65 years) increases their risk of experiencing medication-related problems and undesirable consequences. Coupled with the increased dependency of older people on carers and the lack of services to keep them in their own homes, this cohort often resides in nursing homes (NHs). The medicines management process (MMP) in the NH setting is reported to be complex due to various factors including the high prevalence of polypharmacy, frailty in this cohort and the involvement of multiple carers in various settings. The aim of the research programme was to explore the interprofessional MMP services which are provided in the Irish NH setting, using a theoretical basis. Methods A systematic review and meta-analysis was conducted to explore the effectiveness of interprofessional MMP interventions, involving pharmacists and provided to older people in NHs. The care team and their roles, and stages of MMP targeted were identified. Assessment of the effectiveness of interventions on the most reported outcomes was undertaken. The findings of this study supported undertaking interviews with care team of NH residents in the Republic of Ireland (RoI) to explore perceptions of MMP services. This was conducted using the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 model, to explore work systems and their components (elements, external environment, interactions and outcomes) that influence the MMP journey. Further exploration of the MMP was conducted from the perspective of statutory regulatory body of NHs: Health Information and Quality Authority (HIQA) using mixed methods secondary analysis of HIQA?s NH inspection reports over a four-year period. The reporting of MMP-related regulations was quantitatively described, and the SEIPS 3.0 was applied to qualitatively explore work systems and their components; and finally qualitative and quantitative results were triangulated. Results Eighteen studies were included in the systematic review and highlighted (i) that medication reviews were the most commonly reported interventions and demonstrated a beneficial effect on improving the appropriateness of prescribing; (ii) the involvement of non-HCPs (NH residents and their families) as a part of the care team; and (iii) the lack of reporting of any intervention?s theoretical underpinning. Seventeen interviews were conducted with the care team and identified eight work systems in the NH resident MMP journey featuring one central work system, namely, Internal NH. Barriers to achieving desirable outcomes included inconsistent communication and ambiguity in service provision and role clarity. The use of technology that was triggered by the COVID-19 was identified to facilitate desirable outcomes. The findings were synthesised to create the first NH resident MMP journey map in the RoI. The mixed methods secondary research analysed 319 NH inspection reports published for 119 NHs in the RoI. Quantitative findings analysis suggested that (i) > 50% of NHs were compliant with Regulation 29 (Medicines and Pharmaceutical Services); (ii) There was no statistically significant association between reporting and compliance with Regulation 29 and NH characteristics; and (ii) administration was the most frequently inspected MMP stages followed by storage across the four years. The qualitative analysis explored the internal NH setting work system and identified (i) inconsistent interprofessional collaboration; and (ii) majority of reports inspected described administration stage of the MMP. Triangulation of quantitative and qualitative findings identified that (i) some stages of MMP that are inspected in the free text are not a part of Regulation 29; (ii) Pharmacist records were inspected in 25-35% of NHs, however, the free text identified that records inspected are not limited to pharmacists interventions but to all other relevant HCPs; (iii) work system elements that facilitated compliance and desirable outcomes: people, tasks, organisational, tools and technologies, external environment; and finally (iv) Barriers to the MMP contributing to non-compliance and undesirable outcomes include organisational, physical and external environments interactions. Discussion/Conclusion The need to improve interprofessional MMP practice for older people residing in NHs is widely acknowledged due to the nature of aging, multimorbidity and the high prevalence of MRPs. To our knowledge, this is the first study to explore the interprofessional MMP practice provided to older people in the RoI from different perspectives. Initially, a systematic review and meta-analysis was conducted to report on the nature and impact of interprofessional MMP interventions, that involve a pharmacist and are provided to older people in NHs. The outcome of the systematic review involving a pharmacist in interprofessional MMP provision to older NH residents is beneficial to improving some outcomes However, there is an absence of reporting the theoretical basis of these interventions. Exploration of the extent of MMP service provision from HCPs and non-HCPs in the RoI using SEIPS 3.0 model provided evidence that the MMP is a complex process, with opportunities to overcome barriers. The SEIPS-based analysis facilitated identifying dimensions of the MMP that can be used by researchers in this area to develop a complex interprofessional MMP intervention. Deeper exploration of additional work systems and their components that contribute to the complexity of the MMP will complement the work presented in this thesis and further serve to optimise patient safety in the RoI. The gap in a consolidated approach to interprofessional MMP in the RoI could encourage national and international regulators to refine the current suggested approach to the MMP in the Irish NH setting and therefore improve outcomes experienced both by NH residents and HCPs.