Remedial action in the form of nurse intervention, pain assessment or treatment was not observed. Research conducted by Savundranayagam (2014) similarly identified carers affirmed resident pain during routine care but did not take a person-centred approach to resolve it.
It appeared that these nurses and carers might accept pain and old age as synonymous, as in the study by Barry, Parsons, Peter, and Hughes (2012). Research has explored pain in care home residents with dementia: high prevalence (Barry, Parsons, Passmore, & Hughes, 2015; Zwakhalen, Koopmans, Geels,
Berger, & Hamers, 2009), under-recognition and under-treatment (Closs, Barr, Briggs, Cash, & Seers, 2003; Husebo et al., 2008; Weiner, Peterson, & Keefe, 1999), pain assessment methods (Lin, Lin, Shyu, & Hua, 2011), analgesic treatment (Closs et al., 2003; Gilmore-Bykovskyi & Bowers, 2013), and systematic approach to treatment (Husebo, Ballard, Sandvik, Nilsen, & Aarsland, 2011). Research conducted by Husebo et al. (2008) identified residents with dementia do not suffer less pain intensity and even paracetamol use can reduce agitation and improve behaviour in care home residents with dementia (Husebo et al., 2011). During medication ‘rounds’, nurses and senior carers did not address resident pain or discuss analgesics with residents. In contrast, the nurses did address residents’ pain during GP surgeries.
7/1stF/LG/S014/S012
S014 – “Resident…had a fall. Seen by doctor yesterday. Bending knee – do not send for x-ray. Today walking difficult, problem with hip needs support. Not complaining of pain but facial expression seen. Anything for pain?” GP asks nurse if resident has had paracetamol. S014 – “Yes. After she did not complain.” GP advises regular paracetamol and provides form for X-ray today.
The event demonstrates a doctor was called, resident pain was acknowledged, PRN analgesia had been administered, and its effectiveness evaluated. This sequence reveals clinical decisions were taken by a nurse, although asking “Anything for pain?” suggested a lack of confidence in the judgment made to administer paracetamol PRN. GP surgeries provided a structured time to discuss a resident’s needs, which led to a better outcome than the decision-making observed during the medication ‘round’. A management plan was implemented by the GP but predisposing factors (disease, medication) and falls prevention were not discussed. It appeared to be accepted that in accordance with research findings (Kenkmann et al., 2010) old people in care homes fall.
Communication is a basic principle of nursing care (Department of Health, 2012b). Nurses and senior carers did not routinely inform residents of the medication they were given. This administrator demonstrates poor communication when handing this resident their medication.
9/2ndF/DR/S024
S024 – …makes a drink…takes tablet to R128. “Here is your tablet. I’ll get your breakfast.”
Marx, Witte, Himmel, and Kühnel (2011) undertook a systematic review regarding medication adherence and found inadequate communication was a barrier to adherence in older people with mental capacity. The medication review and observations identified that resident refusal of medication occurred. This is illustrated in the following event:
1/GF/DR/S014/R116
S014 dispenses one tablet for R116. R116 is eating dinner. R116 has water. Tablet not swallowed. R116 spits tablet out.
Cognitive ability can significantly affect medication adherence (Campbell, Boustani, Skopelja, & Gao, 2012). Barriers for older people with cognitive impairment include loss of memory (Vik et al., 2006), medication knowledge (Barat, Andreasen, & Damsgaard, 2001), and health literacy (Marx et al., 2011). Overlooking resident pain and communicating ineffectively has been identified in the data analysis.
7.5. Summary
This chapter has presented an analysis of the findings from observational data collected. Observational events of medication rounds, staff handovers, GP surgeries, medication management, and personal care occurrences are explained to illustrate aspects of the care home (nursing) culture and the context in which PRN medication management is conducted. Three main categories were extracted from the observation data: person-centred care, speech accommodation, and pain and dementia.
Differences in medication administration between senior carers and nurses were identified related to residents’ degree of independence/dependence. Organisational priorities and routine culture influenced the registered nurses’ activities. A minimal amount of resident involvement was identified in relation to
routine and PRN medication management decisions although staff had received person-centred dementia care training.
Speech over-accommodation was used by nurses and carers when communicating to residents, predominantly during the provision of personal care and medication ‘rounds’ and particularly with women. This could be interpreted in 2 ways. First as evidence of close relationships between staff and residents where terms of endearment were evocative of familial relationships. Second, and of more concern, is where it could be interpreted as evidence of patronizing speech. The former signifies a nurturing relationship with their carers that may help develop happiness and wellbeing and the other may render residents unable to participate in decision-making. In situations where English is not the first language of staff, caution should be exercised in distinguishing between learnt phrases that arise from a limited vocabulary rather than a lack of knowledge or awareness of the residents’ feelings and needs, as demonstrated by carer awareness of residents’ pain and discomfort. This knowledge was not always conveyed to the nurse in her role as the administrator of analgesia.
The frequent identification of resident pain by carers and a lack of formal assessment or treatment were observed. Findings suggest that preoccupations with governance and regulation surrounding medication management took precedence over person-centred care and linked activities of assessment and review of care. The administration of prescribed PRN medication was limited and opportunities to use analgesia in particular were not taken. There was, paradoxically, evidence of withholding prescribed medication based on residents’ assessment of need. This offers a different interpretation of what has previously been categorised as administration error.
There is evidence of a hierarchy of decision-making regarding routine and PRN medication. Carers do not make decisions nor do they participate in the process even though they hold important information about the resident. Resident involvement in decision-making is very limited, although there was evidence of some residents taking the initiative and taking medication without staff knowledge. The nurses’ role in clinical assessment and decisions regarding PRN
medication prescribing was complex. The complexity made explicit and competing priorities that influenced nurses’ decision-making.
Chapter 8 considers analysis of interview data and will explore the contribution that nurses and carers consider they make to PRN medication management in the care home (nursing). Their views on the influence of GPs and pharmacists in medication processes and the role of the resident and family will also be examined.
Chapter 8 Interviews
During phase 3 of the research study, participant interviews were conducted. The interviews with care home staff focussed on medication management. Phase 1 medication review findings established the PRN medication prescribed and level of administration (Chapter 6) and phase 2 observations identified the context and culture that affects PRN medication use and the limited involvement of residents in decision-making processes (Chapter 7). Thus the purpose of the interviews was to gather data that would inform about the experiences and perceptions of registered nurses and care workers regarding their role in the management of PRN medication in the care home.
This chapter presents the findings derived from inductive content analysis of the interview transcripts relating to the third and fourth research objectives:
3. To examine the extent to which care home activities, customs and the working culture influence the registered nurses' clinical practice in relation to PRN medication management.
4. To understand how ancillary staff and members of the primary care team influence PRN medication management in the care home (nursing).
An overview of the interviewee characteristics is given, followed by a presentation of 3 main themes identified in the interviews: medication governance and regulation, symptom assessment, and attitudes to aging. The chapter concludes with a summary of the results.
Narrative and quotations are used to report the findings. Quotations cited have a group code (N=nurse, SC=senior carer or C=carer) and their unique identification code/number, for example N/S022 denotes nurse participant S022. In addition, each quotation code contains a line number (for example N/S022/51) to identify where it occurs in the transcription. R denotes the
researcher. Bracketed words signify omitted vocabulary added by the researcher to clarify meaning.