To crush, or not to crush? Unauthorised covert administration of medication in nursing homes.
aged care
covert administration
medications
nursing
nursing home
qualitative research
Journal
International journal of older people nursing
ISSN: 1748-3743
Titre abrégé: Int J Older People Nurs
Pays: England
ID NLM: 101267281
Informations de publication
Date de publication:
Sep 2021
Sep 2021
Historique:
revised:
21
04
2021
received:
10
08
2020
accepted:
20
05
2021
pubmed:
12
6
2021
medline:
26
10
2021
entrez:
11
6
2021
Statut:
ppublish
Résumé
This study aimed to explore the experiences and perceptions of nursing home staff and residents of unauthorised covert administration of medication. Prior studies identify that covert medication administration (crushing medication to administer in food or drink) is common in nursing home settings. Still, few recognise that this practice may occur without consultation or clinical authorisation. An exploratory qualitative study was conducted with nursing home staff and residents as part of a more extensive mixed-methods study on medication omissions and clinical decision-making. We conducted a qualitative study using focus groups and semi-structured interviews across four geographical areas in New Zealand to better understand nursing home staff and residents' experiences and perspectives on covert administration. Semi-structured interviews took place with 11 Clinical managers/leads and one senior Registered Nurse; role specific focus groups were held with Registered Nurses (n = 6), Health Care Assistants (n = 14), and Residents (n = 12). Data were analysed using thematic analysis. Participants described covert administration as a practical option if a nursing home resident refused medication but recognised it was a deception that carried ethical and clinical risks, particularly when unauthorised. Participants felt that unauthorised covert administration stemmed from doubts about residents' competence and the competing demands staff face during medication administration. Staff, who typically relied on advice from their pharmacies around which medications were safe to crush, expressed a need for more education. This study provides evidence that unauthorised covert administration of medications is an ongoing practice, using New Zealand nursing homes as an example. The results emphasise that nursing home staff and residents are aware that this practice carries ethical and clinical risks and requires a certified process to legitimise its authorised form.
Sections du résumé
BACKGROUND AND OBJECTIVES
OBJECTIVE
This study aimed to explore the experiences and perceptions of nursing home staff and residents of unauthorised covert administration of medication. Prior studies identify that covert medication administration (crushing medication to administer in food or drink) is common in nursing home settings. Still, few recognise that this practice may occur without consultation or clinical authorisation.
DESIGN
METHODS
An exploratory qualitative study was conducted with nursing home staff and residents as part of a more extensive mixed-methods study on medication omissions and clinical decision-making.
METHODS
METHODS
We conducted a qualitative study using focus groups and semi-structured interviews across four geographical areas in New Zealand to better understand nursing home staff and residents' experiences and perspectives on covert administration. Semi-structured interviews took place with 11 Clinical managers/leads and one senior Registered Nurse; role specific focus groups were held with Registered Nurses (n = 6), Health Care Assistants (n = 14), and Residents (n = 12). Data were analysed using thematic analysis.
FINDINGS
RESULTS
Participants described covert administration as a practical option if a nursing home resident refused medication but recognised it was a deception that carried ethical and clinical risks, particularly when unauthorised. Participants felt that unauthorised covert administration stemmed from doubts about residents' competence and the competing demands staff face during medication administration. Staff, who typically relied on advice from their pharmacies around which medications were safe to crush, expressed a need for more education.
CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
CONCLUSIONS
This study provides evidence that unauthorised covert administration of medications is an ongoing practice, using New Zealand nursing homes as an example. The results emphasise that nursing home staff and residents are aware that this practice carries ethical and clinical risks and requires a certified process to legitimise its authorised form.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e12393Informations de copyright
© 2021 John Wiley & Sons Ltd.
Références
Attride-Stirling, J. (2001). Thematic networks: An analytic tool for qualitative research. Qualitative Research, 1(3), 385-405. https://doi.org/10.1177/146879410100100307
Barber, N., Alldred, D., Raynor, D., Dickinson, R., Garfield, S., Jesson, B., Lim, R., Savage, I., Standage, C., Buckle, P., Carpenter, J., Franklin, B., Woloshynowych, M., & Zermansky, A. (2009). Care homes' use of medicines study: Prevalence, causes and potential harm of medication errors in care homes for older people. Quality and Safety in Health Care, 18, 341-346. https://doi.org/10.1136/qshc.2009.034231
Barnes, L., Cheek, J., Nation, R., Gilbert, A., Paradiso, L., & Ballantyne, A. (2006). Making sure the residents get their tablets: Medication administration in care homes for older people. Journal of Advanced Nursing, 56(2), 190-199. https://doi.org/10.1111/j.1365-2648.2006.03997.x
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa
Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed method approaches (4th ed.). Sage Publications.
Dillon, D. R., O'Brien, D. G., & Heilman, E. E. (2000). Literacy research in the next millennium: From paradigms to pragmatism and practicality. Reading Research Quarterly, 35(1), 10-26. https://doi.org/10.1598/RRQ.35.1.2
Farrar, H., Steward, C., & Sturdevant, D. (2012). Covert medication administration: The practice of hiding medications in long-term care settings. Journal of Gerontological Nursing, 38(8), 14-20. https://doi.org/10.3928/00989134-20120703-06
Fontana, A., & Frey, J. H. (2005). The interview: From neutral stance to political involvement. In N. K. Denzin, & Y. S. Lincoln (Eds.), The SAGE handbook of qualitative research (3rd ed., pp. 695-728). SAGE Publications.
Garratt, S. M., Kerse, N., Peri, K., & Jonas, M. (2020). Medication omission rates in New Zealand Residential Aged Care Homes: A national description. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01674-w
Garratt, S. M., Kerse, N. M., Peri, K., Jonas, M. F., & Scahill, S. L. (2020). Pharmacoepidemiology of medications omitted in New Zealand Residential Aged Care Homes. Australasian Journal of Ageing, 39(4), 1-7. https://doi.org/10.1111/ajag.12812
Guidry-Grimes, L., Dean, M., & Victor, E. K. (2021). Covert administration of medication in food: A worthwhile moral gamble? Journal of Medical Ethics, 47(6), 389-393. https://doi.org/10.1136/medethics-2019-105763
Haw, C., & Stubbs, J. (2010). Covert administration of medication to older adults: A review of the literature and published studies. Journal of Psychiatric and Mental Health Nursing, 17(9), 761-768. https://doi.org/10.1111/j.1365-2850.2010.01613.x
Health & Disability Commissioner (2012). Code of health and disability services consumers' rights. Health & Disability Commissioner. https://www.hdc.org.nz/media/1241/code-of-rights-july-2012.pdf .
Health and Disability Commission (2009). 08HDC17105 Decision: Standard of care in dementia unit. Health and Disability Commission. https://www.hdc.org.nz/decisions/search-decisions/2009/08hdc17105/
Health and Disability Commission (2013). 12HDC01495 Decision: Medication administration and seizure management in patient with brain injury. Health and Disability Commission. https://www.hdc.org.nz/decisions/search-decisions/2013/12hdc01495/
Health and Disability Commission (2018). 16HDC01148 Decision: Care of elderly man prone to falls. Health and Disability Commission. https://www.hdc.org.nz/decisions/search-decisions/2019/16hdc01162/
Health and Disability Commissioner (2006). 05HDC18726 Decision: Medication errors in a dementia unit. Health and Disability Commissioner. https://www.hdc.org.nz/decisions/search-decisions/2006/05hdc18726-decision/ .
Hughes, R., & Huby, M. (2002). The application of vignettes in social and nursing research. Journal of Advanced Nursing, 37(4), 382-386. https://doi.org/10.1046/j.1365-2648.2002.02100.x
Hung, E. K., McNiel, D. E., & Binder, R. L. (2012). Covert medication in psychiatric emergencies: Is it ever ethically permissible? Journal of the American Academy of Psychiatry and the Law Online, 40(2), 239-245. http://jaapl.org/content/jaapl/40/2/239.full.pdf
Jenkins, N., Bloor, M., Fischer, J., Berney, L., & Neale, J. (2010). Putting it in context: The use of vignettes in qualitative interviewing. Qualitative Research, 10(2), 175-198. https://doi.org/10.1177/1468794109356737
Kala, A. K. (2012). Covert medication; the last option: A case for taking it out of the closet and using it selectively. Forum: Qualitative Social Research, 54(3), 257-265. https://doi.org/10.4103/0019-5545.102427
Kandemir, A., & Budd, R. (2018). Using vignettes to explore reality and values with young people. Qualitative Research, 19(2), 1-23. https://doi.org/10.17169/fqs-19.2.2914
Kelly, L. M., & Cordeiro, M. (2020). Three principles of pragmatism for research on organizational processes. Methodological Innovations, 13(2), 205979912093724. https://doi.org/10.1177/2059799120937242
Kirkevold, Ø., & Engedal, K. (2009). Is covert medication in Norwegian nursing homes still a problem?. Drugs & Aging, 26(4), 333-344. https://doi.org/10.2165/00002512-200926040-00004
Kirkevold, Ø., & Engedal, K. (2010). What is the matter with crushing pills and opening capsules? International Journal of Nursing Practice, 16(1), 81-85. https://doi.org/10.1111/j.1440-172X.2009.01814.x
McDerby, N., Kosari, S., Bail, K., Shield, A., Peterson, G., & Naunton, M. (2019). The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial. Journal of Clinical Pharmacy and Therapeutics, 44(4), 595-602. https://doi.org/10.1111/jcpt.12822
McDerby, N., Kosari, S., Bail, K., Shield, A., Peterson, G., Thorpe, R., & Naunton, M. (2020). The role of a residential aged care pharmacist: Findings from a pilot study. Australasian Journal on Ageing, 39(3), 466-471. https://doi.org/10.1111/ajag.12784
Mental Health (Compulsory Assessment and Treatment) Act (1992). New Zealand Government, Parliamentary Counsel Office. https://www.legislation.govt.nz/act/public/1992/0046/latest/whole.html#whole. Accessed 18 April 2021.
Mercovich, N., Kyle, G. J., & Naunton, M. (2014). Safe to crush? A pilot study into solid dosage form modification in aged care. Australasian Journal on Ageing, 33(3), 180-184. https://doi.org/10.1111/ajag.12037
Ministry of Health (2011). Medicines care guides for residential aged care. Ministry of Health. https://www.health.govt.nz/system/files/documents/publications/medicines-care-guides-for-residential-aged-care-may11.pdf
Ministry of Health (2020). Rest homes: Certified providers in New Zealand. Ministry of Health. https://www.health.govt.nz/your-health/certified-providers/aged-care
Munden, L. M. (2017). The covert administration of medications: Legal and ethical complexities for health care professionals. The Journal of Law, Medicine & Ethics, 45(2), 182-192. https://doi.org/10.1177/1073110517720647
New Zealand Aged Care Association (2020). Aged residential care industry profile 2019-2020. New Zealand Aged Care Association. https://nzaca.org.nz/wp-content/uploads/2020/08/ARC-Industry-Profile-2019-20-Final.pdf
New Zealand Nurses Organization (2014). Guidelines for nurses on the administration of medicines.. Wellington: New Zealand Nurses Organization.
O'Hara, M. (2011). Successful dissertations: The complete guide for education, childhood and early childhood studies students. Continuum International Pub. Group.
Paradiso, L. M., Roughead, E., Gilbert, A., Cosh, D., Nation, R. L., Barnes, L., Cheek, J., & Ballantyne, A. (2002). Crushing or altering medications: What's happening in residential aged-care facilities? Australasian Journal on Ageing, 21(3), 123-127. https://doi.org/10.1111/j.1741-6612.2002.tb00432.x
Parsons, C., Lapane, K., Kerse, N., & Hughes, C. (2011). Prescribing for older people in nursing homes: A review of the key issues. International Journal of Older People Nursing, 6(1), 45-54. https://doi.org/10.1111/j.1748-3743.2010.00264.x
Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice (4th ed.). SAGE Publications.
Simpson, C. (2017). Covering it up? Questions of safety, stigmatization, and fairness in covert medication administration. The Journal of Law, Medicine & Ethics, 45(2), 204-211. https://doi.org/10.1177/1073110517720649
Spalding, N. J., & Phillips, T. (2007). Exploring the use of vignettes: From validity to trustworthiness. Qualitative Health Research, 17(7), 954-962. https://doi.org/10.1177/1049732307306187
Stange, K. C., Crabtree, B. F., & Miller, W. L. (2006). Publishing multimethod research. Annals of Family Medicine, 4(4), 292-294. https://doi.org/10.1370/afm.615
Stubbs, J., Haw, C., & Dickens, G. (2008). Dose form modification - A common but potentially hazardous practice. A literature review and study of medication administration to older psychiatric inpatients. International Psychogeriatrics, 20(3), 616-627. https://doi.org/10.1017/S1041610207006047
Treloar, A., Beats, B., & Philpot, M. (2000). A pill in the sandwich: Covert medication in food and drink. Journal for the Royal Society of Medicine, 93, 408-411. https://doi.org/10.1177/014107680009300805
Tweddle, F. (2009). Covert medication in older adults who lack decision-making capacity. British Journal of Nursing, 18(15), 936-939. https://doi.org/10.12968/bjon.2009.18.15.43563
Wong, J. G. W. S., Poon, Y., & Hui, E. C. (2005). I can put the medicine in his soup, Doctor!. Journal of Medical Ethics, 31(5), 262-265. https://doi.org/10.1136/jme.2003.007336