The role of the nurse practitioner in promoting a reduction in the causes and outcomes of problematic polypharmacy among nursing home residents in British Columbia

Abstract

Problematic polypharmacy is an ongoing issue for older adults throughout Canada, and specifically among nursing home residents (Maher, Hanion, & Hajjar, 2013). Despite interventions that are currently in place in British Columbia (BC) to reduce the causes and outcomes of this issue, problematic polypharmacy continues to pose a risk for residents among BC nursing homes. This integrative review asks how nurse practitioners (NPs) can best promote a reduction in the causes and outcomes of problematic polypharmacy among residents in BC nursing homes.The background information of this project outlines the concept of problematic polypharmacy and the prevalence of contributing factors and outcomes. Nursing home demographics are also highlighted to demonstrate the risk this population faces to the causes and outcomes of problematic polypharmacy, and the subsequent effect this issue has on the health care system. Furthermore, the background provides an overview of the concept role overlap which exists between health care professionals in order to demonstrate how multiple health care professionals may share roles or parts of roles in reducing the causes and outcomes of problematic polypharmacy. Barriers faced by staff are also examined.Through a comprehensive review of the literature and critical appraisal, nine articles are found to address the research question. Key interventions that specifically demonstrate effectiveness in reducing causes and outcomes of problematic polypharmacy in the context of nursing homes emerged. These interventions are put forth as recommendations for NP practice and include: medication reviews while screening for inappropriate medications by using the Beers Criteria, computerized clinical decision support systems (CCDSS), and the Cockcroft Gault Score; assessing functional status for changes to assure instances of problematic 3 polypharmacy are not missed by using the Minimum Data Set -Activity of Daily Living (MDS-ADL) scale; education targeted for all staff members to detect, prevent, and manage problematic polypharmacy; multidisciplinary team meetings to facilitate a collaborative approach in reducing problematic polypharmacy and case conferences to provide resident-centered care.An important finding is that most interventions require participation from two or more health professionals, highlighting the concept of role overlap and the necessity of a multidisciplinary approach. In light of NP practice, this provides insight surrounding how NPs can influence and encourage other staff members to sustain their roles and overcome barriers for an ultimate reduction in the causes and outcomes of problematic polypharmacy with implications for practice, policy, education, and research.

The Development of a Deprescribing Competency Framework in Geriatric Nursing Education

“…Despite the lack of existing evidence related to nursing involvement in deprescribing, thematic analysis of the literature revealed three main domains of deprescribing competencies for geriatric nurses: (a) Education and training in deprescribing (Ailabouni et al, 2017;Hermanowski et al, 2016;Hugtenburg et al, 2013;ISMP, 2018;Jassar, 2016;Lim et al, 2010;Liu, 2014;Maher et al, 2013;McGrath et al, 2017;Midão et al, 2018;Mortazavi et al, 2016;Page et al, 2016;Reeve et al, 2014;Reeve & Wiese, 2013;Salazar et al, 2007;Shah & Hajjar, 2012); (b) Continuing education and professional development in medication optimization (Ailabouni et al, 2017;Frank & Weir, 2014;Hermanowski et al, 2016;Jassar, 2016;Liu & Chi, 2013;Lueras & Lueras, 2017;Maher et al, 2013;McGrath et al, 2017;Page et al, 2016;Reeve et al, 2014;Salazar et al, 2007;Thompson & Farrell, 2013;Wang et al, 2015); (c) Multidisciplinary collaboration in medication management (Ailabouni et al, 2017;Frank & Weir, 2014;Gillis et al, 2016;Harriman et al, 2014;Hugtenburg et al, 2013;ISMP, 2018;Liu & Chi, 2013;Liu, 2014;…”

“…Providing geriatric nurses with continuing education and professional development opportunities is an important facilitator to support the development of deprescribing competency. The literature suggested assessing nursing knowledge using yearly competency checklists, which address best practices, procedures, guidelines, and policies related to deprescribing (Jassar, 2016). Additionally, bi-annual seminars, interactive annual conferences, and webinars should be available to nurses to ensure they are aware of any policy or process changes to medication management (Jassar, 2016).…”

“…The literature suggested assessing nursing knowledge using yearly competency checklists, which address best practices, procedures, guidelines, and policies related to deprescribing (Jassar, 2016). Additionally, bi-annual seminars, interactive annual conferences, and webinars should be available to nurses to ensure they are aware of any policy or process changes to medication management (Jassar, 2016). The literature also recommended that nurses should have professional development pertaining to alternative approaches and non-pharmacological measures when dealing with medical problems such as poor sleep hygiene, pain management, symptoms of depression and anxiety, and other mental health concerns (Gillis et al, 2016).…”

“…Out of the 24 reviewed literature, 11 of these articles underscored the need of having regular medication reconciliation with a health care professional, the patient, and patient's caregiver to facilitate deprescribing, particularly in high-risk settings such as long-term care (LTC) due to the high prevalence of polypharmacy. A research study conducted in LTC settings indicated that nurses in LTC should have ongoing training in performing medication reconciliations on admission, after a transfer back from acute care and when resident status changes (Jassar, 2016). During these medication reviews, nurses are able to apply their pharmacological skills, address the impact of ADRs, and make recommendations for the potential need for deprescribing.…”

“…Medication reconciliations allow nurses to explore patients' misconceptions, or beliefs about the medication regimen that may influence their uptake of deprescribing (McGrath et al, 2017). Along with the process of medication reconciliation, it is recommended that nurses in LTC must develop the knowledge and skills to regularly conduct assessments that examine the physical function of adults and the degree of change associated with ADRs and deprescribing, such as the Minimum Data Set Activities of Daily Living (MDS-ADL) (Carpenter et al, 2006;Jassar, 2016). These assessment tools are facilitators to support geriatric nurses in deprescribing by allowing them to make informed decisions on how best to gradually taper off a specific medication based on older adult's physiological status (Page et al, 2016).…”