Nurse and Pharmaceutical Care (NuPhaC)

PhD project of Tinne Dilles, under supervision of prof. dr. Monique Elseviers and prof. dr. Robert Vander Stichele.

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Summary: 

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The high incidence of drug related problems (DRPs) in nursing
homes, has extensively been described in international literature.
The PHEBE study created awareness on problems in pharmacotherapy
and medication management in Belgian nursing homes.
The goal of this study was to address DRPs in nursing homes from a nurse
perspective. The idea of developing an electronic support system for nurses
existed from the beginning. Yet, after the first contacts with nurses and physicians
about the idea, it became clear that there was much uncertainty about
nurses’ role in drug monitoring and their competences. Starting with the
development of a support system seemed not an option before the basics
of the problem had been clarified. Our hypothesis was that the detection of
DRPs in nursing homes could be improved when nurses’ role, as members of
an interdisciplinary team, is highlighted, when barriers in the execution of
their role are identified and, finally, when a system would be developed to
support nurses in their role, taking into account the barriers identified.
This hypothesis was translated into 5 research objectives, which were all
addressed in different chapters of this thesis.
Objective 1: To describe nurses’ practices in pharmacotherapeutic care in
nursing homes.
Objective 2: To define and measure barriers for nurses to safe medication
management in nursing homes and to identify opportunities for improvement.
Objective 3: To investigate the educational preparation of nurses to take up
their role in pharmacotherapy
Objective 4: To develop a support system for nurses in pharmacotherapeutic
care in nursing homes, based on their role, their competences and the
barriers they experience.
Objective 5: To test the effect of the support system on pharmacotherapy in
nursing homes in an intervention study.

To describe nurses’ practices in pharmacotherapeutic care, a cross-sectional
study was set up, questioning nurses about giving medication information,
observing non-adherence and identifying adverse drug reactions
(Chapter 1). The comparison of the activities of 260 nursing home nurses,
82 community care nurses and 1070 hospital nurses enabled to describe the
unique situation in nursing homes.
Nursing homes had a lower number of male nurses, nurses were generally
older and had more years of experience. More important were the significant
differences in educational level and engagement in continuing education.
Only 42% of the nursing home nurses had a Bachelor’s degree and only
26% engaged in continuing education, which is significantly less compared

to community care and hospitals. The lower educational level had implications
for drug monitoring. Bachelor’s degree holders were 35% more likely
than diploma holders to have observed an adverse drug reaction in the past
month. In general it could be concluded that nurses assume considerable
pharmacotherapeutic practices, especially in nursing homes.

Nurses’ actual involvement in pharmacotherapeutic practices did, however,
not mean they were convinced that these practices were explicitly a
part of their job content. Therefore, in the study on barriers (Chapter 2), extra
attention was given to this aspect. In drug monitoring in nursing homes, 80%
of the nurses believed that following the therapeutic effects of medication
was part of their job, and 95% felt as if it should be. On the other hand, only
76% of the nurses believed that monitoring side effects was part of their job
and 92% felt as it should be. These uncertainties in nurses’ role in drug monitoring
have never explicitly been described before. They do, however, envisage
a lack of nurse attention to drug monitoring. Furthermore, when nurses
are uncertain about their own responsibilities, the responsibilities will not
be clear to other professionals in the interdisciplinary team either, impeding
interdisciplinary cooperation.
In 20 nursing homes, 246 nurses and 270 nurse assistants were asked to
score the relevance of barriers in every aspect of the medication management
process and pharmacotherapy which were identified in an expert meeting
(chapter 2). When focusing on the results in the stage of drug monitoring the
following barriers were perceived to be the most important: not receiving
enough information of physicians; a lack of interdisciplinary communication;
not enough attention of nurses to report observations; and a lack of knowledge
on adverse drug reactions.

The lack of pharmacological knowledge was confirmed in a test questioning
1484 nurses, employed in nursing homes, community care and acute
hospitals. These results encouraged to investigate nurses’ educational preparation
in pharmacology in more detail. The Medication Knowledge and Calculations
test (MKC-test) was developed and 613 graduating nursing students
were evaluated (Chapter 3). The mean results on pharmacology knowledge
were only 52% in diploma level students and 55% in Bachelor’s students. On
the calculation exercises the mean results were respectively 53% and 66%.
The results confirmed the lack of pharmacology knowledge. Newly graduated
nurses were insufficiently prepared to safe medication management
and pharmacotherapy. This was reflected in the students’ self rated readiness
to safe medication care, which was 5 or less on a scale of 10 in 27% of the

students. The descriptions of pharmacology education in Flemish nursing
schools showed a wide variation in organizational characteristics such as the
number of teaching hours, the organization of separate courses or integrated
modules and the profession of the teachers, … Recommendations for improvements
in nursing education were formulated.

From the first three chapters the following main problems in drug monitoring
were identified:
• Uncertainty about nurses’ role in drug monitoring;
• A lack of attention to report nurse observations of medication effects;
• A lack of interdisciplinary cooperation;
• A lack of pharmacology knowledge.
These problems needed to be addressed when developing a support system
for nurses in drug monitoring.
Literature was searched for existing screening methods for DRPs. On the
one hand, interventions seldom involved nurses. On the other hand, authors
stressed the importance of interdisciplinary cooperation, as well as nurses’
observational skills and ideal position in close contact to the resident, to detect
DRPs. Consequently, it was decided to develop a drug related problem
trigger tool for interdisciplinary medication review in nursing homes (Chapter
4) with the following functionalities:
1. The combination of a trigger tool, direct nurse observations and chart review.
2. The use of a personalized, resident specific trigger tool, generating triggers
from the residents’ own medication chart.
3. The clarification of nurses’ role by clearly describing their role in screening
for DRPs using the trigger tool (direct observations) and the participation
in interdisciplinary chart review.
4. The creation of standardized communication reports for nurses to report
DRPs to physicians/ pharmacists.
5. The stimulation of interdisciplinary cooperation by clarifying nurses’ role in
the team and by organizing interdisciplinary medication review.
6. The generation of DRP triggers for nurses, which allow targeted observations
even in the absence of advanced pharmacological knowledge,
adapted to nurses’ terminology and observable in nursing homes without
an authorization of a physician and without external laboratory analyses.
7. The inclusion of triggers for detection of medication administration problems.
Non-adherence or swallowing problems are examples of administration
problems which can threaten effective pharmacotherapy and which

are mainly observable by nurses. These problems were not included systematically
in medication review interventions before.

Finally, the DRP trigger tool for interdisciplinary medication review in
nursing homes was developed to support nurses in pharmacotherapy and
tested in an intervention study in 8 nursing homes (Chapter 5).
The trigger tool has been used in a printed form, presented in two major
parts. The first part is a list of DRPs to guide nurses in patient observations.
It consists of a computer-generated, resident-specific list of potential ADRs,
based on the residents’ medication chart, completed with four potential administration
problems. Nurse observations can be reported on the trigger
tool form to inform the family doctor. The second part is a guide for the interdisciplinary
medication review process. It gives an overview of the residents’
medication, the associated potential DRPs and the observations by nurses.
During medication review, nurse observations of potential DRPs can, therefore,
immediately be linked to the medications which may cause the problem.
The family doctor, together with the nurse have to perform the medication
review. The contribution of a pharmacist and CRA in medication review
is advised.
As a result of the use of the trigger tool, nurses observed 1527 potential
ADRs in 81% of the 418 residents. Administration problems were observed in
45% of the residents. About half of the DRPs observed, were confirmed the
family doctor in medication review. As a result, 214 medication changes were
planned in 21% of the residents because of ADRs and in 5% of the residents
because of administration problems. Medications were changed more frequently
in the intervention group than in the control group (without trigger
tool and medication review). However, the number of medications and the
classes of medication used by the residents did not change. The DRP trigger
tool for interdisciplinary medication review in nursing homes revealed to
positively influence nurse observations, nurse reports of DRPs and interdisciplinary
cooperation. The confirmation of DRPs and subsequent medication
changes are indications of the value of the nurse observations for physicians
in medication review. More support in medication review is, however, needed
so that medication alterations do improve the quality of prescribing.

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