Mouna Sawan

A qualitative study exploring visible components of organizational culture: what influences the use of psychotropic medicines in nursing homes?

BACKGROUND The influence of organizational culture on how psychotropic medicines are used in nursing homes has not been extensively studied. Scheins theory provides a framework for examining organizational culture which begins with the exploration of visible components of an organization such as behaviors, structures, and processes. This study aimed to identify key visible components related to the use of psychotropic medicines in nursing homes. METHODS A qualitative study was conducted in eight nursing homes in Sydney, Australia. Purposive sampling was used to conduct semi-structured interviews with 40 participants representing a broad range of health disciplines. Thematic analysis was used to derive concepts. RESULTS Three visible components were related to psychotropic medicine use. These were drugs and therapeutics committee meetings, pharmacist led medication management reviews and formal and informal meetings with residents and their families. We found that only a few nursing homes utilized drugs and therapeutics committee meetings to address the overuse of psychotropic medicines. Pharmacist led medication management reviews provided a lever to minimize inappropriate psychotropic prescribing for a number of nursing homes; however, in others it was used as a box-ticking exercise. We also found that some nursing homes used meetings with residents and their families to review the use of psychotropic medicines. CONCLUSION This study was the first to illustrate that visible components of organizational culture do influence the use of psychotropic medicines and explains in detail what of the culture needs to be addressed to reduce inappropriate psychotropic prescribing.

Relationship between Organizational Culture and the Use of Psychotropic Medicines in Nursing Homes: A Systematic Integrative Review

BackgroundPsychotropic medicines are commonly used in nursing homes, despite marginal clinical benefits and association with harm in the elderly. Organizational culture is proposed as a factor explaining the high-level use of psychotropic medicines. Schein describes three levels of culture: artifacts, espoused values, and basic assumptions.ObjectiveThis integrative review aimed to investigate the facets and role of organizational culture in the use of psychotropic medicines in nursing homes.MethodFive databases were searched for qualitative, quantitative, and mixed method empirical studies up to 13 February 2017. Articles were included if they examined an aspect of organizational culture according to Schein’s theory and the use of psychotropic medicines in nursing homes for the management of behavioral and sleep disturbances in residents. Article screening and data extraction were performed independently by one reviewer and checked by the research team. The integrative review method, an approach similar to the method of constant comparison analysis was utilized for data analysis.ResultsTwenty-four studies met the inclusion criteria: 13 used quantitative methods, 9 used qualitative methods, 1 was quasi-qualitative, and 1 used mixed methods. Included studies were found to only address two aspects of organizational culture in relation to the use of psychotropic medicines: artifacts and espoused values. No studies addressed the basic assumptions, the unsaid taken-for-granted beliefs, which provide explanations for in/consistencies between the ideal use of psychotropic medicines and the actual use of psychotropic medicines.ConclusionsPrevious studies suggest that organizational culture influences the use of psychotropic medicines in nursing homes; however, what is known is descriptive of culture only at the surface level, that is the artifacts and espoused values. Hence, future research that explains the impact of the basic assumptions of culture on the use of psychotropic medicines is important.

Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool©. A development and content validation study

INTRODUCTION Psychotropic medicines are often prescribed in nursing homes to manage behavioral and psychological symptoms of dementia despite marginal clinical effects alongside harmful adverse events. Organizational culture has been identified as a key factor that contributes to the high-level prescribing of psychotropic medicines in nursing homes. There are gaps in existing tools used to link organizational culture to the use of psychotropic medicines. The aim of this research was to develop and content validate a tool that evaluates organizational culture specific to the use of psychotropic medicines, named the Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool©. METHODS Scheins theory of organizational culture was used to guide the development and content validation of the PRACTICE tool©. The PRACTICE tool© was developed based on a comprehensive systematic review, qualitative research and generated by the research team. Content validity was assessed using the CVI (Content Validity Index). The content relevance and importance of the PRACTICE tool© items were rated by an expert panel with relevant knowledge and experience. Any modified or re-worded items were presented to the panel members in a subsequent survey for re-rating. RESULTS Across the two rounds, the PRACTICE tool© had 68 items that assessed all aspects of culture according to Scheins theory. Sixty-two items out of 68 (91%) met predefined cut-off values (≥0.78) for the I -CVI. The remaining six items (9%) did not fully meet the cut-off values but were deemed important to be included in the tool based on the systematic review, qualitative research and discussions with the research team. CONCLUSIONS The PRACTICE tool© is a step forward in validating an instrument that will help inform managers and policy makers to identify target areas for improvement to create a culture of appropriate psychotropic prescribing in nursing homes.

Discussion of patients’ goals for pharmaceutical care is central to managing polypharmacy

men by consolidating administration times and considering alternative formulations. A ‘universal medical schedule’ of four standard administration times has been proposed to aid consistency and efficiency of consolidation for prescribers and patients. The Victorian Government Department of Health and Human Services is currently trialling a new quality indicator measure ‘more than four medication administration times’ for residential aged care services. The Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) is a new five-step implicit tool to facilitate medication regimen simplification that has been validated by pharmacists. Implementation of MRS GRACE is being investigated as part of the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) study, an ongoing cluster-randomised controlled trial being conducted across eight residential aged care services in South Australia. Complexity is an aspect of medication management in older people that should be addressed systematically, in conjunction with the other established processes such as medication reconciliation, medication review and deprescribing. When speaking about simplicity, Steve Jobs also said ‘[the hard work is] worth it, in the end, because once you get there, you can move mountains.’ In our case, it is not mountains we want to move, but medication.

Organisational culture must be addressed to reduce psychotropic prescribing in Residential Aged Care Facilities

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