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Pharmacovigilance in municipal elderly care: From a nursing perspective
Mälardalen University, School of Health, Care and Social Welfare. (PriLiv)ORCID iD: 0000-0001-7490-6735
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Medication management constitutes a large part of registered nurses' (RNs) daily work in municipal elderly care. They are responsible for monitoring multimorbid older persons with extensive treatments, and they often work alone, without daily access to physicians. RNs’ drug monitoring is, in this thesis, based on the concept of pharmacovigilance. Pharmacovigilance is about the science and the activities that aim to improve patient care and safety in drug use, that is, to detect, assess, understand and prevent drug-related problems.

The overall aim was to explore conditions for pharmacovigilance from a nursing perspective, focusing on implications of RNs’ competence and use of a computerized decision support system (CDSS). Both quantitative and qualitative research methods were used, including a questionnaire (I), focus group discussions (II), individual interviews (III) and an intervention study (IV). In total 216 RNs and 54 older persons participated from 13 special accommodations, located in three different regions.

RNs who had completed further training in pharmacovigilance rated their medication competence higher than those who had not. However, there was no difference between groups in the number of pharmacovigilant activities they performed in clinical practice (I). The RNs appeared to act as “vigilant intermediaries” in drug treatment. They depended on the nursing staff's observations of drug-related problems. The RNs continuously controlled the work of staff and physicians, and attempted to compensate for shortcomings in competence, accessibility and continuity (II). RNs’ use of a CDSS was found to affect drug monitoring, including aspects of time, responsibility, standardization of the work, as well as access to knowledge and opportunities for evidence-based care (III). The CDSS detected significantly more drug-related problems when conducting medication reviews, than the RNs did. Nevertheless, this did not result in any significant improvement in the quality of drug use in the follow up, three and six months later (IV).

This thesis contributes to the recognition of pharmacovigilance from a nursing perspective. Increased medication competence seems to be insufficient to generate pharmacovigilant activities. RNs depend on other health care professionals and organizational conditions in order to perform their work. A CDSS has the potential to support RNs, both in structured medication reviews and in daily clinical practice. Inter-professional collaboration is crucial, with or without a CDSS, and the entire team needs to be aware of and take responsibility. Other important conditions is the existence of well-functioning communication channels, competence across the team, and established procedures based on current guidelines.

Place, publisher, year, edition, pages
Eskilstuna: Mälardalen University Press , 2017.
Series
Mälardalen University Press Dissertations, ISSN 1651-4238 ; 222
Keyword [en]
competence, computerized decision support systems, content analysis, drug monitoring, inter-professional collaboration, nurse, older person, patient, pharmacovigilance, pharmacovigilant activities, phenomenography
National Category
Medical and Health Sciences Health Sciences
Research subject
Care Sciences
Identifiers
URN: urn:nbn:se:mdh:diva-34750ISBN: 978-91-7485-309-4 (print)OAI: oai:DiVA.org:mdh-34750DiVA: diva2:1069999
Public defence
2017-03-24, Filen, Mälardalens högskola, Eskilstuna, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2017-01-31 Created: 2017-01-31 Last updated: 2017-03-03Bibliographically approved
List of papers
1. Nurses' self-reported medication competence in relation to their pharmacovigilant activities in clinical practice
Open this publication in new window or tab >>Nurses' self-reported medication competence in relation to their pharmacovigilant activities in clinical practice
2015 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 21, no 1, 145-152 p.Article in journal (Refereed) Published
Abstract [en]

Rationale, aims and objectives

Adverse drug reactions (ADRs) represent a major health problem and previous studies show that nurses can have an active role in promoting medication safety. The aim of this study was to describe and evaluate nurses' self-reported competence and pharmacovigilant activities in clinical practice and also to explore the impact of age, education, workplace and nursing experience on these matters.

Methods

This cross-sectional study was based on a questionnaire covering areas related to nurses' medication competence, including knowledge, assessment and information retrieval, and pharmacovigilant activities within these areas, for example, the detection and assessment of ADRs. A 45-item questionnaire was 2013 sent out to 296 nurses in different settings and counties in Sweden. They were selected on the basis of having applied to a university course including pharmacovigilance during 2008–2011. One hundred twenty-four had participated in the courses (exposed) and 172 had applied to the courses but not participated (unexposed).

Results

Completed questionnaires were obtained from 75 exposed (60%) and 93 unexposed (54%) nurses. Overall nurses rated themselves high in medication competence but low in pharmacovigilant activities. Significant (P ≤ 0.001) differences between groups were observed regarding medication competence. The exposure of completed dedicated courses in pharmacovigilance was the strongest factor for self-reported medication competence when adjusted for age, other education, workplace and experience. No significant differences between the groups were found regarding the number of pharmacovigilant activities during the 6 months prior to answering the questionnaire.

Conclusion

Dedicated university courses improved nurses' self-reported competence in pharmacovigilance but did not increase the number of related activities. Education per se seems to be not sufficient to generate pharmacovigilant activities among nurses.

Keyword
education, medication management, nurse, patient safety, pharmacology, pharmacovigilance
National Category
Health Sciences
Research subject
Care Sciences
Identifiers
urn:nbn:se:mdh:diva-26745 (URN)10.1111/jep.12263 (DOI)000350447800021 ()2-s2.0-84923613157 (Scopus ID)
Available from: 2014-12-01 Created: 2014-12-01 Last updated: 2017-01-31Bibliographically approved
2. Nurses in municipal care of the elderly act as pharmacovigilant intermediaries: A qualitative study of medication management
Open this publication in new window or tab >>Nurses in municipal care of the elderly act as pharmacovigilant intermediaries: A qualitative study of medication management
Show others...
2016 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 34, no 1, 37-45 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To explore registered nurses experience of medication management in municipal care of the elderly in Sweden, with a focus on their pharmacovigilant activities. Design: A qualitative approach using focus-group discussions was chosen in order to provide in-depth information. Data were analysed by qualitative content analysis. Setting: Five focus groups in five different long-term care settings in two regions in Sweden. Subject: A total of 21 registered nurses (RNs), four men and 17 women, aged 27-65 years, with 4-34 years of nursing experience. Results: The findings reveal that RNs in municipal long-term care settings can be regarded as "vigilant intermediaries" in the patients drug treatments. They continuously control the work of staff and physicians and mediate between them, and also compensate for existing shortcomings, both organizational and in the work of health care professionals. RNs depend on other health care professionals to be able to monitor drug treatments and ensure medication safety. They assume expanded responsibilities, sometimes exceeding their formal competence, and try to cover for deficiencies in competence, experience, accessibility, and responsibility-taking. Conclusion: The RNs play a central but also complex role as "vigilant intermediaries" in the medication monitoring process, including the issue of responsibility. Improving RNs possibility to monitor their patients drug treatments would enable them to prevent adverse drug events in their daily practice. New strategies are justified to facilitate RNs pharmacovigilant activities. Key points This study contributes to the understanding of registered nurses (RNs) role in medication management in municipal care of the elderly (i.e. detecting, assessing, and preventing adverse drug events or any drug-related problems).RNs can be considered to be "vigilant intermediaries" in elderly patients drug treatments, working at a distance from staff, physicians, and patients. RNs occasionally take on responsibilities that exceed their formal competence, with the patients best interests in mind. In order to prevent adverse drug events in municipal care of the elderly, new strategies are justified to facilitate RNs pharmacovigilant activities. 

Keyword
Adverse drug event, drug monitoring, elderly, general practice, nurse's role, patient safety, pharmacovigilance, qualitative research, Sweden
National Category
Health Sciences
Identifiers
urn:nbn:se:mdh:diva-31348 (URN)10.3109/02813432.2015.1132891 (DOI)000372023200007 ()2-s2.0-84960474361 (Scopus ID)
Available from: 2016-03-24 Created: 2016-03-24 Last updated: 2017-01-31Bibliographically approved
3. Nurses' use of computerised decision support systems affects drug monitoring in nursing homes
Open this publication in new window or tab >>Nurses' use of computerised decision support systems affects drug monitoring in nursing homes
Show others...
2017 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 25, no 1, 56-64 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To describe variations in nurses' perceptions of using a computerised decision support system (CDSS) in drug monitoring. Background: There is an increasing focus on incorporating informatics into registered nurses' (RNs) clinical practice. Insight into RNs’ perceptions of using a CDSS in drug monitoring can provide a basis for further development of safer practices in drug management. Method: A qualitative interview study of 16 RNs. Data were analysed using a phenomenographic approach. Results: The RNs perceived a variety of aspects of using a CDSS indrug monitoring. Aspects of ‘time’ were evident, as was giving a ‘standardisation’ to the clinical work. There were perceptions of effects of obtained knowledge and ‘evidence’ and the division of ‘responsibilities’ between RNs and physicians of using the CDSS. Conclusion: The RNs perceived a CDSS as supportive in drug monitoring, in terms of promoting standardised routines, team-collaboration and providing possibilities for evidence-based clinical practice. Implications: Implementing a CDSS seems to be one feasible strategy to improve RNs’ preconditions for safe drug management. Nurse managers’ engagement and support in this process are vital for a successful result.

National Category
Medical and Health Sciences Health Sciences
Identifiers
urn:nbn:se:mdh:diva-34691 (URN)10.1111/jonm.12430 (DOI)000393687500007 ()2-s2.0-84994045637 (Scopus ID)
Available from: 2017-01-23 Created: 2017-01-23 Last updated: 2017-03-16Bibliographically approved
4. Implications of computer-supported medication reviews in Swedish nursing homes, led by nurses
Open this publication in new window or tab >>Implications of computer-supported medication reviews in Swedish nursing homes, led by nurses
(English)Manuscript (preprint) (Other academic)
Keyword
Decision support-systems, drug monitoring, drug-related problem, older people, medication reconciliation, nurse, pharmacovigilance
National Category
Medical and Health Sciences
Research subject
Care Sciences
Identifiers
urn:nbn:se:mdh:diva-34749 (URN)
Available from: 2017-01-31 Created: 2017-01-31 Last updated: 2017-02-02Bibliographically approved

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