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PRN) Medicines in the Care Home (Nursing): a Case Study of Decision- Making, Medication Management and Resident Involvement

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PRN) Medicines in the Care Home (Nursing): a Case Study of Decision- Making, Medication Management and Resident Involvement The Role of the Registered Nurse Managing Pro Re Nata (PRN) Medicines in the Care Home (Nursing): a Case Study of Decision- making, Medication Management and Resident Involvement Lorraine Odette Murray Submitted to the University of Hertfordshire in partial fulfillment of the requirements of the degree of DHRes. January 2016 i Abstract The aim of this study was to analyse the role of the registered nurse in the management of pro re nata (PRN) medication in a care home (nursing) for older people. Studying PRN medication provides insights into the role of the nurse in care homes (nursing) who act as assessor, decision maker and evaluator in residents’ care. It also provides a lens by which to explore how residents and their carers interact and participate in day-to-day care decisions about residents’ health. The case study draws on ethnography. It is a multi-method study, using documentary and medication reviews, observations and interviews to answer the research questions. Thirty-four residents were recruited to the study and 60 care home staff. Findings showed that 88.2% of residents (n=30) were prescribed PRN medication and that all residents were on a minimum of 1 and a maximum of 7 medication. During each 28-day MAR sheet period between 35 and 44 PRN prescriptions were written. They contributed 12.7% of all medication prescribed, accounting for between 1.2 and 1.5 medication per resident. Nurses were found to administer PRN medication, but a finding of this study was that this activity could be delegated to carers who were identifying resident needs. There was some evidence of resident engagement but this was often a three-way process between resident, GP and family or resident, carer and nurse. A percentage of medication that could have been PRN were routinely prescribed. Observations also identified that nurses would decide not to administer routine medication in certain circumstances and that this was directly related to their assessment of the resident. The process of medication management was dominated by the regulations and governance processes of the care home. Observations and interviews found that ii care home staff recognised and affirmed residents’ pain but did not take action for analgesia to be administered. They were familiar with the use of pain assessment tools for older people living with dementia and had received training in dementia care. Many of the staff were also able to interpret signs and symptoms of a resident’s distress. Nevertheless, their preoccupation with meeting internal and external regulator standards was a barrier to addressing residents’ needs. This is the first study that has looked at an aspect of medication management to understand how nurses and care home staff work for and with residents to moderate and address their health care needs. It suggests that additional training in aspects of medication management and resident assessment may not be able to address deeper seated issues of autonomy and how the nursing role is understood and enacted in care home settings. iii Acknowledgements The support and encouragement from my supervisors, Claire Goodman and Robyn Martin made this submission possible. To them I extend my thanks for their knowledge and endless support. Robyn Martin and Sally Kendall had the dream and Hilary Thomas provided the direction for the professional doctorate in health research that has provided a route for me to undertake this study. Claire Goodman has unselfishly shared her vast subject knowledge. The time, interest, and encouragement given by those in the School of Nursing and Social Work and those in the Department of Nursing and Primary Care, where I am employed, formed a motivating experience. To the older people resident at the research site, their understanding families, the care home Managers, nurses and carers, I thank you for sharing your personal and professional experiences. My family have encouraged and supported me throughout the study and writing of this submission. To them I owe the most. The support received has provided an opportunity for me to study part-time and to pursue and develop my work and expertise in nursing research. It is an opportunity I feel privileged to have had. iv v Table of Contents Abstract ................................................................................................................................. i Acknowledgements .......................................................................................................... iii Table of Contents .............................................................................................................. v Table of Figures ................................................................................................................ xi Table of Tables ................................................................................................................ xiii Chapter 1 Introduction ................................................................................ 1 1.1. Care Homes (Nursing) Perceptions ...................................................................... 1 1.2. Ageing Society .......................................................................................................... 3 1.3. Rise and Regulation of Care Homes ..................................................................... 4 1.4. Medication in Care Homes and Use of PRN ...................................................... 5 1.5. Submission Outline .................................................................................................. 6 Chapter 2 Background ................................................................................ 9 2.1. Care Homes .............................................................................................................. 9 2.1.1. Facilities ............................................................................................................. 9 2.1.2. Residents ......................................................................................................... 12 2.1.3. Work Force ..................................................................................................... 14 2.2. Medication Use in UK Care Homes (Nursing) ................................................. 16 2.2.1. Medication and Care Home (Nursing) Legislation .................................. 16 2.2.2. Medication Needs of Residents ................................................................... 17 2.3. Summary .................................................................................................................. 17 Chapter 3 Literature Review ..................................................................... 19 3.1. Systematic Search Strategy .................................................................................... 19 3.2. Review of Included Studies .................................................................................. 22 3.2.1. Medication Prescribing and Identified Issues ........................................... 23 3.2.2. Pharmacy Interventions and Identified Issues .......................................... 28 3.2.3. Medication Administration and Identified Issues .................................... 30 vi 3.2.4. Resident Involvement ................................................................................... 33 3.2.5. PRN Medication Administration in Care Homes .................................... 34 3.3. Summary .................................................................................................................. 35 3.4. Research Question and Objectives ...................................................................... 36 Chapter 4 Methodology ............................................................................ 37 4.1. Research Paradigm ................................................................................................. 37 4.2. Research Methodology and Methods Overview ............................................... 38 4.3. Ethics Approval and Obligations ........................................................................ 43 4.4. Study Site ................................................................................................................. 45 4.5. Study Participants ................................................................................................... 46 4.5.1. Nursing and Care Staff Recruitment .......................................................... 46 4.5.2. Resident Recruitment .................................................................................... 49 4.6. Phase 1: Documentary Review ........................................................................... 54 4.6.1. Case Records and Medication Administration Records .......................... 55 4.6.2. Care Home Documents ............................................................................... 59 4.6.3. Phase 1 Impact on Phases 2 and 3 ............................................................. 59 4.7. Phase 2: Observations .......................................................................................... 59 4.7.1. Observations .................................................................................................. 60 4.7.2. Observation Field Notes .............................................................................. 67 4.7.3. Phase 2 Impact on Phase 3 .......................................................................... 67 4.8. Phase 3: Interviews ..............................................................................................
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