Parents and caregivers experience in managing children's medicines after discharge from a New Zealand hospital.

AIM: To investigate the level of understanding parents/caregivers have regarding prescribed medicines for their sick children, and how they manage these medicines at home following hospital discharge. METHODS: English-speaking parents/caregivers of sick children were recruited if their child was admitted to Middlemore Hospital in New Zealand and prescribed two liquid medicines, specifically an analgesic and an antibiotic. A questionnaire was developed and used to interview parents/caregivers on three separate occasions. The questionnaire was firstly administered during their hospital stay; secondly, by telephone post-discharge; and thirdly via a home visit two to three days after the estimated completion date of the antibiotic course. RESULTS: Eighteen participants from the five main ethnic groups (Pacific Island n=7, NZ European n=5, Maori n=4, Asian n=2) completed all three interviews. Parents/caregivers had a reasonable understanding of the purpose of the medicines prescribed. Doctors, nurses and pharmacists provided variable medicines information to parents/caregivers on hospital discharge. Parents/caregivers used a variety of measuring equipment at home, but over a quarter (28%) were not supplied with an oral syringe to measure appropriate doses of medicines at home, and some lacked knowledge on safe storage and appropriate disposal of medicines. CONCLUSION: This study found variation and gaps in the information for medicines provided at discharge. To facilitate the safe use of medicines, consistent and clear information about the use, storage and disposal of medicines needs to be provided by all healthcare professionals involved; and accurate measuring equipment should be provided free of charge with instructions.

Identifying New Zealand Public Preferences for Pharmacist Prescribers in Primary Care: A Discrete Choice Experiment.

BACKGROUND AND OBJECTIVE: Given increasing patient populations, general practitioner workforce constraints and the growing demand for health services in New Zealand (NZ), the development and provision of pharmacist prescribing services could be used to improve people's access to medicines. A discrete choice experiment (DCE) was utilised to determine NZ public preferences for pharmacist prescribing services in primary care in NZ. METHODS: A D-efficient DCE design generated 20 choice questions in four blocks of five questions with three labelled alternatives per choice question. The online DCE used a NZ general public online research panel administered by an external organisation (SurveyEngine). The DCE included six attributes with two attributes each with two levels (location of consultation and consultation type), three levels (type of service and operating hours) and four levels (waiting time and cost). RESULTS: Nine hundred and twenty-four respondents completed the survey with 4620 observations available for analyses. Respondents preferred pharmacist prescribing services with the following characteristics: optimisation of medicines and changes to only current medicine service types (relative to repeat prescribing); lower consultation costs, shorter waiting times, longer operating hours and consultation by appointment (relative to walk-in and wait clinic). CONCLUSIONS: Prescribing policy could incorporate these public preferences to help develop accessible and effective primary care prescribing services utilising the skills of pharmacist prescribers to improve and reduce inequities in access to medicines in NZ. These results suggest the NZ public see pharmacists as part of the primary care prescribing team and are willing to utilise them if these services are implemented.

Examining non-medical prescribing trends in New Zealand: 2016-2020.

BACKGROUND: Population growth and general practitioner workforce constraints are creating increasing demand for health services in New Zealand (NZ) and internationally. Non-medical prescribing (NMP) is one strategy that has been introduced to help manage this. Little is known about the NMP practice trends in NZ. The aim of this study was to provide a current overview of the scale, scope, and trends of NMP practice in NZ. METHODS: All claims for community dispensed medicines prescribed by a non-medical prescriber were extracted from the NZ Pharmaceutical Collection for the period 2016-2020. Patient demographics were retrieved from the Primary Health Organisation enrolment collection. These national databases contain prescription information for all subsidised community pharmacy medicines dispensed and healthcare enrolment data for 96% of New Zealanders. RESULTS: The proportion of prescriptions written by all NMP providers and patients receiving NMP prescriptions increased each year from 1.8% (2016) to 3.6% (2019) and 8.4% (2016) to 14.4% (2019) respectively. From 2016 to 2019, the proportion of NMP patients who had at least one NMP prescription increased from 26% to 39% for nurse prescribers, from 1% to 9% for pharmacist prescribers, from 2% to 3% for dietitian prescribers, and decreased from 47% to 22% for dentists, and from 20% to 12% for midwives. The most commonly prescribed medicines were antibiotics (amoxicillin, amoxicillin with clavulanic acid, and metronidazole), and analgesics (paracetamol, and codeine phosphate). While some NMP providers were prescribing for patients with greater health needs, all NMP providers could be better utilised to reach more of these patients. CONCLUSIONS: This study highlights that although the NMP service has been implemented in NZ, it has yet to become mainstream healthcare practice. This work provides a baseline to evaluate the NMP service moving forward and enable policy development. Improved implementation and integration of primary care NMP services can ensure continued access to prescribing services and medicines for our communities.

Identifying Community Pharmacist Preferences For Prescribing Services in Primary Care in New Zealand: A Discrete Choice Experiment.

OBJECTIVE: Given increasing patient populations, general practitioner (GP) workforce constraints and increasing demand for health services in New Zealand (NZ), the development and provision of pharmacist prescribing services may need to increase to improve people's access to medicines. A discrete choice experiment (DCE) was utilised to determine community pharmacist preferences for prescribing services in primary care in NZ, and to understand how these factors could improve the provision of pharmacist prescribing services. METHODS: A D-efficient design generated 30 labelled choice questions in three blocks of ten, and three alternatives per choice question. The online DCE was emailed to practising community pharmacists in NZ. The DCE included two attributes with five levels (prescribing model, educational requirements) and three attributes with three levels (location, professional fee, change in income). A mixed multinomial logit model was used to estimate preferences. RESULTS: A total of 264 respondents completed the survey with 2640 observations for analyses. This DCE found pharmacists preferred pharmacy services with the following characteristics: ability to prescribe using minor ailments and independent prescribing models relative to the pharmacist-only medicines prescribing model; prescribing education by accredited learning modules relative to PGDipClinPharm + PGCertPharmPres; remuneration via a professional fee; and pharmacist prescribing services located in community pharmacies rather than in GP practices. CONCLUSIONS: Prescribing policy could incorporate these pharmacist preferences to help develop accessible and effective pharmacist prescribing services that not only improve access to medicines, but also address inequity of access to medicines in NZ. These DCE results are encouraging as they signal that the community pharmacists also see themselves and their pharmacies as part of the prescribing team in primary care in NZ.

Exploring Medicines Burden Among Adults in New Zealand: A Cross-Sectional Survey.

BACKGROUND: Using medicines regularly can be a burden for some people and can contribute to reduced adherence. In New Zealand, relatively few studies have examined people's medicine-taking experiences and most involved older people, although medicine burden is also an issue for younger people. The UK-developed "Living with Medicines Questionnaire" (LMQ-3) is an instrument designed to quantify medicine burden. OBJECTIVE: The objective was to quantify medicines burden among New Zealand adults, using the LMQ-3, to identify any sub-populations with high medicine burden and to identify specific issues that may need to be addressed. SETTING: The study was set in New Zealand and included seven national patient support group websites, and five community pharmacies in Dunedin. METHODS: The survey was distributed to adults ≥18 years using ≥ one medicine for ≥3 months. LMQ-3 scores and domain scores were compared by patient characteristics using descriptive statistics and statistical tests. RESULTS: In total, 472 responses were analysed: 327/417 (78.4%) from patient support group websites and 145/360 (40.3%) from community pharmacies. Most commonly participants were female (295, 62.5%), ≥65 years (236, 50.0%), European (422, 89.4%), retired (232, 49.2%), university educated (203, 43.0%), used medicines independently (449, 95.1%), and paid for prescriptions (429, 90.9%). Most used <10 medicines (415, 87.9%) and

Doctors and pharmacists provision and opinions of medicines information leaflets in New Zealand.

Background Providing verbal medicines information to patients may be insufficient. Providing medicine information leaflets could support verbal information, however New Zealand health professionals' opinions or use of leaflets is unknown. Objective To examine self-reported provision and health professionals' views about medicine information leaflets and to determine their support for tailoring patient leaflets. Setting A cross sectional survey of general practitioners (GPs) and community pharmacists in New Zealand primary care. Method GPs and pharmacists completed validated questionnaires. Data was collected using SurveyMonkey® and where applicable, Chi squared analysis was carried out. Main outcome measures Frequency of leaflet provision, how leaflets are used in practice and why, likes and dislikes of available leaflets, and opinions on providing tailored information. Results 143 GPs and 126 pharmacists responded. For new medicines, significantly more pharmacists than GPs reported providing leaflets all or most of the time. For repeat medicines, leaflets were more likely to be given only on request. Leaflets were given to ensure patients are well-informed. Most GPs and pharmacists report discussing sections of leaflets with patients. The likes and dislikes of leaflets were mostly about design and content. Both professions support tailoring leaflets to meet individual's requirements. Conclusions Provision of medicines information needs to be re-evaluated. Relying on verbal communication is inadequate and leaflet provision appears to be suboptimal. Making leaflets more patient-centred and accessible could improve health professionals' perceptions and use of them. Automated creation and provision of tailored summary leaflets would be beneficial. Further advantage could be gained by digital patient access.

Regulatory agencies' recommendations for medicine information leaflets: Are they in line with research findings?

The design of medicine information leaflets can determine whether a leaflet will be read or discarded by patients. It may also influence patients' ability to understand the information about their medicines within the leaflet. Researchers compared regulatory agencies' recommendations for medicine information leaflet design from New Zealand, the United Kingdom, the European Union, and the United States against recommended good design principles to determine the appropriateness, comprehensiveness, and consistency of their recommendations. Recommendations for medicine information leaflets varied between the regulatory agencies. There were some inconsistencies between the recommendations and some gaps were identified. There was little regulatory guidance given to creators of medicine information leaflets in New Zealand compared to other countries, and this could lead to manufacturer-produced information leaflets of a poorer quality. Up-to-date and enforceable guidance for creators of medicine information leaflets should be provided in all countries to ensure they are of an appropriate standard.

Non-medical prescribing in New Zealand: an overview of prescribing rights, service delivery models and training.

AIM: In this paper, we aim to provide an updated source of information for nonmedical prescribing (NMP) in New Zealand (NZ). METHODS: A variety of NZ sources were used to collect data: legislation, policy documents and information from professional and regulatory organizations, and education providers. RESULTS: In NZ, the legal categories for prescribers include authorized, designated, and delegated prescribers. Authorized prescribers include dentists, midwives, nurse practitioners, and optometrist prescribers. Designated prescribers include pharmacist prescribers, registered nurse prescribers, and dietitian prescribers. There are no delegated prescribers in NZ at this time. There is variation in the regulation, educational programmes and prescribing competencies used by the different prescribing health professionals involved in NMP in NZ. CONCLUSION: This update collates relevant information relating to NMP in NZ into one consolidated document and provides policy makers with a current overview of prescribing rights, service delivery models, training requirements, and prescribing competencies used for NMP in NZ. As NMP in NZ continues to expand and evolve, this paper will form a baseline for future NMP research in NZ. NZ needs to develop overarching NMP policy to enable consistency in the various aspects of NMP, thereby delivering a safe and sustainable NMP service in NZ.

Do Residents Need All Their Medications? A Cross-Sectional Survey of RNs' Views on Deprescribing and the Role of Clinical Pharmacists.

A cross-sectional survey was mailed to 307 RNs of a nationally representative sample of residential aged care facilities to investigate their views and perceptions on medication use and deprescribing in older adults. Questions were grouped according to each stage of the medication use process, and a dedicated section to explore nurses' views on deprescribing was included. Ninety-one questionnaires were received, yielding a 29.6% response rate. Respondents highlighted several challenges including achieving medication reconciliation for new residents, access to physicians to admit patients in a timely fashion, and issues pertaining to lack of clear medical information transcribing when transferring patients between health care settings. More than one half (67.4%) of nurses agreed or strongly agreed that deprescribing implemented with the help of a clinical pharmacist would be beneficial to residents and could improve medication adherence (44%), benefit residents' quality of life (50.5%), and reduce the length of time spent by nurses on medication administration (35.2%). Increased awareness regarding polypharmacy and potential deprescribing benefits is necessary to improve appropriate prescribing and medication use. [Journal of Gerontological Nursing, 43(10), 13-20.].

'What do patients want?' Tailoring medicines information to meet patients' needs.

Medicines information leaflets can equip patients to be in control of their own healthcare and support the safe and effective use of medicines. The design and content of leaflets influences patients' willingness to read them, and poor examples can cause patient confusion and anxiety. Researchers examined the literature over the past 8 years to determine the content and design of medicine information leaflets that patients prefer in order to read, understand, and use them effectively. It was found that existing leaflets do not meet patients' needs and appear ineffective. Leaflets lack the information patients seek and may contain non-essential material, affecting patients' perception of, and willingness to read them. Additionally, the acceptable leaflet length varies between patients. Application of good design principles improves readability, comprehension, and ability to locate information. Medicine information leaflets must meet patients' needs and be well designed. Tailoring information leaflets to patient characteristics and requirements would enhance effectiveness. Passive provision of pre-printed leaflets is outdated, unvalued and ineffective. Using automated computer systems for leaflet tailoring with the ability to further adapt patients' information might be the best way forward.

Improvements in the prescribing of antipsychotics in dementia and psychogeriatric units in New Zealand.

UNLABELLED: Background Despite warnings of possible serious events, and reports of little benefit, antipsychotic agents are commonly prescribed in residential care for older people with dementia. A residential care provider (RCP) in New Zealand sought to examine and improve prescribing in some of their facilities. Objective To examine changes following a range of interventions implemented by a RCP to improve the prescribing of antipsychotics. Setting Thirteen dementia and psychogeriatric units in New Zealand managed by a RCP. Method An audit (n = 228 residents) was undertaken in thirteen dementia and psychogeriatric units in New Zealand in July-September 2011. A modified Best Practice Advocacy Centre (bpac(nz)) tool was used to examine antipsychotic prescribing, the administration of "when required" (PRN) antipsychotic doses and antipsychotic-related documentation (e.g. documenting of "target behaviour identified" and "need to monitor for adverse effects"). Prescribing for some central nervous system agents and fractures and fall rates were also examined. Some educational, managerial, environmental, recreational and resident-specific interventions were implemented post-audit. The audit (n = 233) was repeated in July-September 2013. MAIN OUTCOME MEASURES: (1) Number of residents prescribed and administered antipsychotics (2) Documentation of antipsychotic-related information in residents' notes. Results The administration of antipsychotics and prescribing of regular doses (±PRN) decreased about a quarter from 2011 to 2013: 50.4-38.2, and 49.1-36.5 % (ORs 0.60, 0.57 respectively, both p < 0.001), and prescribing for any antipsychotic dose (including PRN only) decreased: 60.5-50.6 % (OR 0.67, p = 0.003). Documenting of "target behaviour identified" significantly increased from 54.3 to 71.2 %, (OR 1.99, p = 0.017) and documenting of the "need to monitor for adverse effects" increased non-significantly (30.4-46.6 %, p = 0.098); both falling short of the 90 % goal set by bpac(nz). Benzodiazepine prescribing significantly decreased [39.0-25.8 %, (OR 0.59, p < 0.001)]. Conclusions Following a range of interventions, antipsychotic prescribing, administration and some related documentation improved in dementia and psychogeriatric units in New Zealand. Future studies should aim to identify the most effective of these interventions so they can be considered for implementing in similar settings.

Using an Electronic Decision Support Tool to Reduce Inappropriate Polypharmacy and Optimize Medicines: Rationale and Methods.

BACKGROUND: Polypharmacy and inappropriate continuation of medicines can lead to a significant risk of adverse drug events and drug interactions with patient harm and escalating health care costs as a result. Thorough review of patients' medications focusing on the need for each drug can reduce the potential for harm. Limitations in performing effective medicine reviews in practice include consultation time constraints and funding for pharmacy services. We will aim to overcome these problems by designing an automatic electronic decision support tool (the medicines optimization/review and evaluation (MORE) module) that is embedded in general practice electronic records systems. The tool will focus on medicines optimization and reducing polypharmacy to aid prescribers in reviewing medicines and improve patient outcomes. OBJECTIVE: The objectives of this study are: (1) to develop an electronic decision support tool to assist prescribers in performing clinical medication reviews with a particular focus on patients experiencing multimorbidity and polypharmacy, and (2) evaluate and assess the use of the electronic decision support tool, providing pilot data on its usefulness in supporting prescribers during consultations with patients. METHODS: The first three study phases involve development of clinical rules outlining clinical interventions and the creation and validation of the MORE decision support tool. Phase four is a community-based, single-blind, prospective, 6-month controlled trial involving two interventions and two control general practices, matched for practice demographics. We will be measuring the number of times prescribers engage with the tool, total number of interventions suggested by the tool, and total number of times prescribers change medicines in response to recommendations. There will also be prospective follow-up of patients in the intervention group to examine whether changes to medications are upheld, and to determine the number of hospitalizations or emergency department visits within 6 months of a medicine intervention. Comparisons between control and intervention practices will measure the changes in proportions of patients with polypharmacy and inappropriately prescribed medicines before and after the introduction of the electronic decision support tool, proportions of patients receiving appropriate treatment in each practice, and changed, maintained, or improved health status, hospitalizations, and deaths in the study year. Initiation rates of inappropriately prescribed medicines will be measured as a secondary outcome. As well as external assessment of the extent of use and application of the tool, prescribers will receive monthly practice progress reports detailing the proportion of their patients experiencing polypharmacy and taking inappropriately prescribed medicines identified for review. RESULTS: Phase one has now been completed and the decision support tool is under development. Final data analysis is expected to be available in December 2016. CONCLUSIONS: This study will establish whether the MORE decision support tool stands up to real world conditions and promotes changes in prescribing practice.

Challenges and Enablers of Deprescribing: A General Practitioner Perspective.

AIMS: Deprescribing is the process of reducing or discontinuing medicines that are unnecessary or deemed to be harmful. We aimed to investigate general practitioner (GP) perceived challenges to deprescribing in residential care and the possible enablers that support GPs to implement deprescribing. METHODS: A qualitative study was undertaken using semi-structured, face-to-face interviews from two cities in New Zealand and a purpose-developed pilot-tested interview schedule. Interviews were recorded with permission and transcribed verbatim. Transcripts were read and re-read and themes were identified with iterative building of a coding list until all data was accounted for. Interviews continued until saturation of ideas occurred. Analysis was carried out with the assistance of a Theoretical Domains Framework (TDF) and constant comparison techniques. Several themes were identified. Challenges and enablers of deprescribing were determined based on participants' answers. RESULTS: Ten GPs agreed to participate. Four themes were identified to define the issues around prescribing for older people, from the GPs' perspectives. Theme 1, the 'recognition of the problem', discusses the difficulties involved with prescribing for older people. Theme 2 outlines the identified behaviour change factors relevant to the problem. Deprescribing challenges were drawn from these factors and summarised in Theme 3 under three major headings; 'prescribing factors', 'social influences' and 'policy and processes'. Deprescribing enablers, based on the opinions and professional experience of GPs, were retrieved and summarised in Theme 4. CONCLUSION: The process of deprescribing is laced with many challenges for GPs. The uncertainty of research evidence in older people and social factors such as specialists' and nurses' influences were among the major challenges identified. Deprescribing enablers encompassed support for GPs' awareness and knowledge, improvement of communication between multiple prescribers, adequate reimbursement and pharmacists being involved in the multidisciplinary team.

Geographic variation in psychotropic drug utilisation among older people in New Zealand.

AIM: To examine psychotropic drug utilisation in older people in New Zealand by age, sex, health board domicile and deprivation status. METHODS: A repeated cross-sectional analysis of population-based drug utilisation data stratified by age, sex, ethnicity, health board and deprivation status was conducted from 2005 to 2013. RESULTS: Psychotropic utilisation increased between 2005 and 2013 (ranging from 7.0 to 74.0%) across all the health boards. In people aged 85 years and above, the hypnotic and sedative prevalence ratio compared to the 65- to 69-year age group was 1.45 (95% CI 1.44, 1.46). Between 2005 and 2013, the antidepressants prevalence ratio increased (1.27 (95% CI 1.22, 1.33)) relative to anxiolytics. CONCLUSIONS: Overall psychotropic drug utilisation increased over time. Despite safety concerns, hypnotic and sedative utilisation increased in the oldest vulnerable group. Shifts from anxiolytics to antidepressants in some health boards were consistent with guidelines for extended indications of antidepressant drug use.

Temporal trends in the utilisation of preventive medicines by older people: A 9-year population-based study.

BACKGROUND: For older individuals with multimorbidity the appropriateness of prescribing preventive medicines remains a challenge. OBJECTIVE: Investigate the prevalence and temporal trends in utilisation of preventive medicines in older New Zealanders from 2005 to 2013 stratified according to age, sex, ethnicity and district health board domicile. METHODS: A repeated cross-sectional analysis was conducted on pharmaceutical dispensing data for all individuals' ≥ 65 years. Variable medication possession ratio (VMPR) was used to measure adherence. Prescribing of low-dose aspirin, clopidogrel, dipyridamole, warfarin, dabigatran, statins and bisphosphonates with a VMPR≥0.8 were examined. RESULTS: Aspirin utilisation increased by 19.55% (95% CI: 19.39-19.70), clopidogrel by 2.93% (95% CI: 2.88-2.97) and dipyridamole decreased by 0.65% (95% CI: -0.70 to -0.59). Utilisation of aspirin with clopidogrel increased by 1.78% (95% CI: 1.74-1.81) and aspirin with dipyridamole increased by 0.54% (95% CI: 0.50-0.58%).Warfarin decreased by 0.87% (95% CI: -0.96 to -0.78) and dabigatran increased by 0.65% (95% CI: 0.60-0.70). Statins increased by 7.0% (95% CI: 6.82-7.18) and bisphosphonates decreased by 2.37% (95% CI: -2.44 to -2.30). Aspirin, clopidogrel, dabigatran and statins utilisation showed a greater increase in males. Interestingly, clopidogrel, warfarin and statins use increased in older adults aged 85+ compared to the younger age groups (65-84 years). CONCLUSION: To our knowledge, this is the first study investigating the prevalence and trends of preventive medicines use in older people in New Zealand. This study may facilitate further research to examine the appropriateness of prescribing these medicines in older people with multimorbidity.

Impact of prescription charges on people living in poverty: A qualitative study.

BACKGROUND: Prescription charges or copayments have been shown to reduce consumption of medicines. For people living in poverty, prescription charges can prevent them from getting the medicines they need, and this can result in poorer health status. Prescription charges are low in New Zealand compared to many other countries, but those living in poverty are not exempt from fees. OBJECTIVES: The aim of this study was to explore the lived experience of people who struggle to pay prescription charges and to propose a model for how being unable to afford prescription charges might affect health. METHODS: Participants were recruited through organizations that provide services entirely or predominantly to low income persons. Semi-structured interviews were carried out with 29 people who had been identified as having problems paying for prescriptions. Approximately half of the sample population was Maori (indigenous New Zealanders). Ethical approval was obtained from the University of Otago. RESULTS: Participants reported having to make difficult decisions when picking up their prescription medicines. These included choosing some medicines and leaving others, such as choosing medicines for mental health rather than physical health; cutting food consumption or eating less healthy food so as to pay for medicines; or picking up medicines for children while leaving those for adults. Participants also reported strategies like reducing doses to make prescriptions last longer; and delaying picking up medicines. These led to sub-optimal dosing or interrupted treatment. CONCLUSIONS: Even low financial barriers can have a significant impact on low income people's access to medicines and reduce the effectiveness of treatment. Not being able to afford prescription medicines may impact negatively on people's health directly by preventing access to medicines, through reducing expenditure on other items need for health, and by potentiating stigma.

Quality use of antipsychotic medicines inresidential aged care facilities in New Zealand.

INTRODUCTION Antipsychotic medicines are used regularly or when required in residential aged care facilities to treat symptoms of dementia, but have been associated with several adverse effects. AIM The aim of this study was to examine 'quality use' of antipsychotic medicines in residential aged care facilities in New Zealand, by surveying nurse managers. METHODS A cross-sectional survey was mailed to 318 nurse managers working in a nationally representative sample of aged care facilities. A purpose-developed, pre-tested, 22-item structured questionnaire was used to explore practice related to the quality use of antipsychotic medicines. RESULTS Overall, 31.4% of nurse managers responded to the survey. They mostly (88%) had ≥ 1 year's relevant work experience and 83% of facilities provided care for those within the range of 21 to 100 residents. Respondents reported that staff education on dementia management occurred early in employment. Two-thirds of participants reported non-pharmacological interventions were commonly used for managing challenging behaviours, while less than half (45%) cited administering antipsychotic medicine. Respondents reported 'managing behavioural symptoms' (81%) as one of the main indications for antipsychotic use. Frequently identified adverse effects of antipsychotic medicines were drowsiness or sedation (64%) and falls (61%). Over 90% reported general practitioners reviewed antipsychotic use with respect to residents' target behaviour 3-monthly, and two-thirds used an assessment tool to appraise residents' behaviour. DISCUSSION Staff education on dementia management soon after employment and resident 3-monthly antipsychotic medicine reviews were positive findings. However, a wider use of behavioural assessment tools might improve the care of residents with dementia and the quality use of antipsychotic medicines.

One of us: Stories from two New Zealand rest homes.

In this article we explore the ways in which two aged residential care facilities in New Zealand construct and present themselves through the stories told by those who live and work in them. Ethnographic field notes and interviews were analysed using an immersion/crystallization method consistent with a narrative gerontology framework. Woven into residents' stories about their lives in the facility were tales of earlier lives and identities, immigration, occupations, marriage, tragedies and medical emergencies. Care workers, nursing staff and managers talked about vocation, the ethos and values of the institution and the importance that both staff and residents felt a sense of belonging and 'being one of us.' These stories, 'talk into reality' the aged residential care facility as a particular kind of rest home, in which residents feel 'at home'. In addition, as researchers who brought our own stories to the project, we actively contributed to the construction of each institution as a certain kind of facility.

Poverty, medicines and health care: It's the little things .

Small patient charges and policies and events that may seem minor to health care professionals can have a big impact on the wellbeing of people living in poverty. Despite good intentions, policies can have unintended consequences for those who are struggling to access health care.

An international comparison study of pharmacy students' achievement goals and their relationship to assessment type and scores.

OBJECTIVE: To identify pharmacy students' preferred achievement goals in a multi-national undergraduate population, to investigate achievement goal preferences across comparable degree programs, and to identify relationships between achievement goals, academic performance, and assessment type. METHODS: The Achievement Goal Questionnaire was administered to second year students in 4 universities in Australia, New Zealand, England, and Wales. Academic performance was measured using total scores, multiple-choice questions, and written answers (short essay). RESULTS: Four hundred eighty-six second year students participated. Students showed an overall preference for the mastery-approach goal orientation across all sites. The predicted relationships between goal orientation and multiple-choice questions, and written answers scores, were significant. CONCLUSION: This study is the first of its kind to examine pharmacy students' achievement goals at a multi-national level and to differentiate between assessment type and measures of achievement motivation. Students adopting a mastery-approach goal are more likely to gain high scores in assessments that measure understanding and depth of knowledge.