Cuidado de personas de la tercera edad o discapacitados

Medications in the two nursing homes were administered by nurses and in the two non-nursing homes by senior care staff. However at Mirabelle Way nurses would occasionally use carers to physically administer medications to residents, especially to

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those residents with BPSD. This sub-administration was controversial, with the care specialist at the head office of the voluntary organisation and some staff against the practice. Administering staff members have to remove the correct medications and doses from, for example, a medicine bottle or dosette box in readiness to give to the resident. At this point they would sometimes pass the medications on to carers to administer and consequently, could lose the ability to be sure that the resident has taken them. Nurses (or within non-nursing homes, seniors or carers) have to sign for medication administrations and are accountable for the medication/s being taken, which in the case of sub-administration, they might not have personally witnessed; thereby making the practice problematic. The standards of medications management do allow the practice in principle:

‘A registrant (registered nurse) is responsible for the delegation of any aspects of the administration of medicinal products and they are accountable to ensure that the patient, carer or care assistant is competent to carry out the task’

(Nursing & Midwifery Council, 2007, 2010)

Thus, nurses have the responsibility for the medication administration even when carers are physically giving the medication to the resident. The argument for using sub- administration at Mirabelle Way centred on utilising the close relationships carers had with residents. Since carers generally spent more time working directly with residents than the nurses did, they had a better rapport with residents who would,

consequently, be more compliant taking their medications with them. Fay, a carer at Mirabelle Way, who often sub-administers for nurses, explains her technique:

‘No I’m quite direct with it really, I’m just like ‘here you go’ and then not make

too much of an ordeal out of it basically ... Sometimes it doesn’t work but, but then on other occasions, it doesn’t work initially and then I’ll say ‘well you know this is for such and such’ and then that will work sometimes, but then

sometimes it just doesn’t help (laughs) you know so ... Yeah just try and if you feel like you’re pushing them just walk away again like, obviously never force anyone, I think that’s the problem, sometimes they feel a bit forced and that probably puts them off taking them’ (Fay, Carer, Mirabelle Way)

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Fay touches on an interesting point here; the reluctance of residents to take their medications if they feel pressured or ‘forced’. Since nurses are busy, often with many medications to administer over a meal time, it is not difficult to see how residents may feel rushed. Carers often stay in the same room as residents at meal times; perhaps making their role more suitable to physically administer medications to residents without making them feel pressured. Sub-administration relied on the nurses being able to admit that others could be more successful than them, personally, at some tasks. Thus, they needed to be able to acknowledge limitations in their own practice. Sub-administration was not particular to Mirabelle Way, but occurred, to a lesser extent, in all the case study CHs. However, Mirabelle Way was the only home, which spoke of it in the context of a strategy to raise medication compliance with residents who experienced BPSD. In the other case study CHs the practice appeared to be in place to use time and staff more effectively. For example, if a resident was being assisted to eat their meal, the administering staff member would ask the carer feeding the resident to also assist them with their medication. This would usually, but not always take place under the watchful eye of the administering staff member.

Sometimes medications were administered covertly or overtly within foods. Overt administration of medications in food happened when the staff member administering the medications told and/or showed the resident they were putting them in the food before the resident ate it. Covert administration of medication in food was viewed as more contentious and this practice appears to occur less now than in the past. Janice, a night carer at Cherry-Plum for nearly twenty years, has noticed a change over the years:

‘They’re not drugged ... whereas I feel that we did use to do that ... You know to keep them quiet so they didn’t offer any challenging behaviour and things like that and there wasn’t so much concentration on medicine being, you know covertly, oh well, you just slipped it into a sweet and they eat it you know ... And nobody thought anything about it, so yeah I think dementia, how we manage people with dementia has changed a lot’ (Janice, Night Carer, Cherry-Plum)

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The excerpt shows that perceptions and practice of covertly administering medication (and heavily drugging residents with dementia) have changed over the years, along with the tightening of rules and regulations. Here Gill, the manager at Mirabelle Way, talks about what needs to happen for this the covert administration of medications to occur presently:

‘if you’re going to be thinking about a covert medication and you discuss it with the consultant and the GP and the family, you also still need to do a best

interests, why are you doing it, and if you cannot clearly say you’re doing it for the resident’s best interests, um then actually you’re doing it for the wrong reason’ (Gill, Manager, Mirabelle Way)

Currently, to allow this practice, a collaborative risk assessment with a resident’s GP and relatives has to be put into place to protect the resident and staff as Gill alludes to. Covert medication administration was important if a resident was assessed as not having the mental capacity to decide about taking their medication (or not) and could be paranoid, anxious or determined not to take medications. The use of this practice enabled residents to have their medical conditions controlled. A lot of medications were crushed up or put in food, especially at Gage Hill and Mirabelle Way where residents were generally very confused. The concept of swallowing medications was foreign to some residents with marked BPSD who did not understand what to do, whereas eating food was a familiar action and they were aware of how to do it. Written evidence, such as collaborative risk assessments were not viewed during the study.