Outline of Interview Schedule for Care Assistants

Outline of interview schedule for care assistants. My name is Catherine Shaw and I am a PhD student in the School of Pharmacy at Queen’s University, Belfast. I am carrying out research into how the cultures of care settings (in this case nursing homes) impacts on the way medicines are prescribed particularly in residents with dementia. This interview will be recorded to help me remember what is said. Are you okay with this? Please note that you will not be identified in any report or publication coming from this work. Thank you for taking time and agreeing to take part in this interview. Begin recording.

General questions To start with I would like to ask you a few questions about yourself. Could you tell me your first name, please? What is your job in this home? How long have you been a care assistant? How long have you worked in this home? Which shift do you normally work? (Day/evening/night)

Description of how prescribing is organised within the nursing home. Now, I would like to ask you about what happens in this nursing home when it comes to giving tablets to residents. You may not do this yourself but you can tell me about what you see other staff doing. In particular I want to understand what happens when a tablet is prescribed for the first time for a resident. Do you understand what I mean when I say “prescribed”? Can you explain to me what you think happens when a medication is prescribed for the first time? Prompts: Example of medication: pain killer, laxative… Excluding home remedies Initial decision to ask for one. Who makes the decision? Who is involved? Are family members involved? If not, why not? When does it happen? Any documentation?

A discussion on the procedures associated with the prescribing of psychoactive medications. Now, I want to talk about psychoactive medications. What I mean is tablets such as tranquilizers, sleeping pills and tablets for anxiety or distress. Examples include diazepam, temazepam, Seroquel, zopiclone. Are you familiar with tablets like these? Can you explain to me what you think happens when tablets like tranquilizers, sleeping pills and tablets for anxiety or distress are given to a resident, again, for the first time? Prompts: Initial decision to ask for one. Who makes the decision? When do you think it happens? Behavioural symptoms? Please specify the signs/symptoms Who do you think is involved? Do you think the resident’s family are involved? How much involvement? At what stage? Do you think residents are involved in decisions about their tablets? Is there any paper work to be completed? Please specify. Care plans Now, can you think about what you said earlier when talking about when residents receive tablets such as laxatives or pain killers for the first time and then what you said about residents receiving tablets like tranquilizers, sleeping pills or tablets for anxiety/distress are given for the first time? Do you think there are any differences between the two? Prompts: Give examples of tablets again. What is it that is different? Why do you think this is?

I want to understand what you think about how and why these psychoactive tablets are given to residents. What do you think about the use of these psychoactive medications? Prompts: Give examples of tablets again. Are they good or bad for a resident? Do you think that they work? Do you think they are given a lot?

Why do you think staff in the nursing home might ask for one of these tablets to be given to a resident? Prompts: When does it happen- time of day? Why do you think they are given e.g. for what symptoms/problems? Do you think other, different types of tablets could be given instead? Could anything else be done? Can you describe a situation when you think a tranquilizer or sleeping pill or tablet for anxiety/distress has been given to a resident? Are you aware of the valid reasons for treatment with a tranquilizer or sleeping pill or tablet for anxiety/distress?

The prescribing of medication to residents with dementia. Now, I want to ask you about what happens when tablets are given to residents who suffer from dementia. Do you understand what I mean by the term dementia? Sometimes residents with dementia will display behaviours that are disturbing to themselves and to other residents and staff. Such behaviours include wandering, restlessness, agitation and hallucinations. Do you understand what these symptoms are? If a resident is experiencing these types of symptoms, what do staff do to help make them feel better? Prompts: Resident is calmed down by nursing staff (eg interacting with the resident) A tablet is requested If a tablet is prescribed, is the way that this is done different to the way you described before? If so, how is it different? What types of medications are requested/prescribed? Do you think residents with dementia are more likely to receive a tranquilizer, sleeping pill or tablet for anxiety/distress? Do you think residents with dementia need these tablets to control these symptoms? Are there other ways to deal with the symptoms? Discussion about organisational culture

You may have heard the term ‘culture’ a lot in recent times in relation to health and social care. Sometimes individuals are afraid to admit to their mistakes and instead, try to cover them up, because they are afraid of getting into trouble for what they have done. This leads to problems because the safety of the public is at risk and the individual does not have the opportunity to learn from their mistakes. This is an example of “blame culture” and organisations have tried to change this by moving to a “no- blame culture” . This type of culture will be more open and fair and individuals are encouraged to admit to their mistakewithout feeling “blamed” for what went wrong and their colleagues are encouraged to learn from this mistake.

Another example of culture, which is quite topical at the minute, is the “culture of greed” shown by some politicians when claiming their expenses. .. Also, many say that a culture of greed within the banking system is to blame for the on-going credit crunch and recession.

So these are examples of specific types of culture and I now want to discuss a similar term known as organisational culture. You have probably heard people say something like “that’s how we do things around here” – possibly in relation to things like organising jobs in the nursing homes such as getting residents ready for meals at a particular time - well that is what organisational culture is often understood to mean. Does that make sense to you?

What does organisational culture mean to you? There are no right or wrong answers Prompts:

Take each word in turn

What do you think organisational means?

Think about the organisation (the nursing home) you work in.

Part of a large chain

Part of a small group

Independent Privately-owned

Government-owned

Charity

What do you think culture means?

Society

Behaviours

Traditions

Way of life/norms

Standards

Routine

Attitudes

Beliefs

Assumptions/values

Now that you have a better understanding of organisational culture, what does it mean to you in the context of nursing homes?

Prompts:

Ethics

Safety Culture

Patients

Can you describe, for me, the culture of this nursing home in one or two words?

What would stand out for you? Discussion about treatment culture.

In this research we are particularly focusing on ‘treatment culture’ which basically means “the way the prescribing and administration of medications are done around here”. Does that make sense?

What does treatment culture mean to you as a care assistant in a nursing home?

Prompts:

The way we are taught to do things in relation to medicines

The assumptions that are made e.g. all patients with dementia should be given psychoactive medication

Attitudes towards residents e.g. are individual needs taken into consideration?

In your opinion, do members of staff work together?

Prompts:

Attitudes towards each other

What about other healthcare professionals such as GP’s? Is there much teamwork?

So just to explain further, treatment culture can be divided into three categories;

1. Traditional

2. Resident-centred

3. Ambiguous Traditional – all residents are treated the same regardless of individual needs, healthcare staff (doctors, nursing home managers, nurses, care assistants) do not work together, high use of tranquilizers, sleeping pills and tablets for anxiety or distress (drugs such as Seroquel, temazepam, diazepam, zopiclone).

Resident-centred – resident treated as an individual, healthcare staff (doctors, nursing home managers, nurses, care assistants) work together, tranquilizers, sleeping pills and tablets for anxiety/distress avoided whenever possible (alternative therapies may be used instead).

Ambiguous – a mixture of the above two.

Overall how would you describe the treatment culture of this nursing home– traditional, resident-centred or ambigious?

In day-to-day work, what values or principles, if any, encourage you to do your best?

Prompts:

Does the nursing home have a motto/slogan?

If so, what is it?

If not, what do you think the philosophy of care or motto would be? (Not what it should be.)

What is it about this nursing home that makes it different to other nursing homes?

Prompts:

Have you worked in another nursing home before this one?

What do you think about the culture in other nursing homes?

Would they all be the same? Different?

Can you explain why that is? What is the worst thing about working here?

What is the best thing about working here?

Going back to what you said about the prescribing of psychoactive drugs (Seroquel, temazepam, diazepam, zopiclone are examples) in this NH, do you think culture has any influence on the prescribing of psychoactive drugs in this home? For example, do you think antipsychotics are given as a matter of routine (“the way things are done in this nursing home”) rather than for valid medical conditions?

The ways in which concerns over inappropriate prescribing of psychoactive medications can or cannot be raised and how these concerns are (or are not) dealt with. Now, can you think of a time when you have had concerns about a tablet, such as an antipsychotic (Seroquel), which is being given to a resident? If so, can you tell me about it? Prompts: Did you tell anyone? What happened? Did you ask your colleagues for advice? Did you speak to the named nurse if available? Did you speak to the manager of the home? Did you ask the prescriber about it?

If you haven’t had concerns in the past, can you tell me what you think you would do if you did have concerns about a medication being given to a resident? Prompts: Would you do something about it or would you leave it? Would you ask your colleagues for advice? Would you speak to the manager? Would you go straight to the prescriber?

Is there anything else that you would like to mention about prescribing in nursing homes?

If not, thanks very much for taking the time to take part in this interview.