Impact of a pilot community pharmacy system redesign on reducing over-the-counter medication misuse in older adults.

BACKGROUND: No interventions have attempted to decrease misuse of over-the-counter (OTC) medications for adults aged 65 years or older (older adults) by addressing system barriers. An innovative structural pharmacy redesign (the Senior Section) was conceptualized to increase awareness of higher-risk OTC medications. The Senior Section contains a curated selection of OTC medications and is close to the prescription department to facilitate pharmacy staff-patient engagement to reduce misuse. OBJECTIVE: This pilot study examined the Senior Section's effectiveness at influencing OTC medication misuse in older adults. METHODS: A pretest-post-test nonequivalent groups design was used to recruit 87 older adults from 3 pharmacies. Using a hypothetical scenario, the participants selected an OTC medication that was compared with their medication list and health conditions, and their reported use was compared with the product labeling. Misuse outcomes comprised drug-drug, drug-disease, drug-age, and drug-label, with 5 subtypes. Patient characteristics were compiled into a propensity score matching logistic regression model to estimate their effects on the Senior Section's association with misuse at pre- or postimplementation. RESULTS: Patient characteristics were uniform between pre- and postimplementation, and, once entered into a propensity score matching model, drug-label misuse (exceeds daily dosage) statistically significantly lessened over time (z = -2.42, P = 0.015). In addition, the Senior Section reduced drug-label misuse (exceeds single dosage) for both the raw score model (z = -6.38, P = 0.011) and the model in which the patient characteristics propensity score was added (z = -5.82, P = 0.011). Despite these limited statistical effects, misuse was found to decrease after implementation for 7 of 11 comparisons. CONCLUSION: These nascent outcomes begin providing an evidence base to support a well-conceived, pharmacy-based OTC medication-aisle redesign for reducing older adult OTC medication misuse. The Senior Section, when broadly implemented, creates permanent structures and processes to assist older adults to access risk information when selecting safer OTC medications.

A nurse staffing model for an unprecedented event.

Lessons learned from one hospital's COVID-19 experience.

Utilizing an Evidence-Based Practice Approach to Examining Infusion Therapy Practices in Non-hospital Outpatient Ambulatory Clinic Settings.

The types of infusion therapy services provided in ambulatory care settings are expanding. The Infusion Therapy Standards of Practice can be applied across service locations/care settings; however, no specific literature was found to indicate how these recommendations have been applied in ambulatory care settings. This article demonstrates how an Ambulatory Care Shared Governance Practice Council led a systemwide evidence-based practice (EBP) initiative to improve infusion therapy over an 18-month period (May 2017 to December 2018). The initiative, based on the Iowa Model Revised, strengthened the nurses understanding of EBP and successfully standardized infusion therapy care across ambulatory care settings.

Improving Patient-Pharmacist Encounters with Over-The-Counter Medications: A Mixed-Methods Pilot Study.

BACKGROUND AND OBJECTIVES: Over-the-counter (OTC) medication use has increased safety risks for adults older than 65. Most older adults purchase OTC medications from community pharmacies, where the considerable distance or visual obstructions between the prescription area and OTC aisles undermine pharmacists' ability to assist patients with OTC medication decisions. An innovative redesign of an abbreviated medication section specifically for older adults (called the Senior SectionTM ) can facilitate pharmacy staff/patient interaction, potentially improving safe medication selection and use. This study evaluated the impact of the Senior Section on the frequency and content of OTC encounters between pharmacy staff and patients. RESEARCH DESIGN AND METHODS: An intervention mixed-methods design generated data from patient OTC encounters, and interviews with two pharmacists and two technicians, throughout the study. NVivo was used to code interview transcripts, and frequencies and chi-square analyses demonstrated pre/post-intervention comparisons for the OTC encounter variables. RESULTS: After Senior Section implementation, pharmacy staff were more likely to initiate (and be involved in) patient encounters, address more topics or problem/symptoms, provide details about OTC products, discuss appropriateness of OTC use, and discuss medication classes highlighted in the Senior Section. Pharmacy staff were less likely to need to leave the prescription department for extended periods; they also had fewer prolonged encounters or encounters about product location. Importantly, the Senior Section did not impede pharmacy workflow. DISCUSSION AND IMPLICATIONS: The Senior Section prompted more frequent, effective, and efficient engagements between pharmacy staff and patients, which may substantially reduce OTC-related harms among older adults.

A pilot study of decision factors influencing over-the-counter medication selection and use by older adults.

BACKGROUND AND OBJECTIVES: Despite their availability without prescription, OTC medications pose a risk for significant harm for older adults due to higher likelihood of polypharmacy, drug interactions, and age-related physiological changes. The purpose of this study is to identify the individual decision factors that influence how older adults select and use over-the-counter medications. METHODS: A pilot study was conducted with 20 community-dwelling older adults. Older adults met the interviewer at a regional mass merchandise store where they were given both pain and insomnia standardized scenarios. Participants described how they would select and then hypothetically use a given medication to treat the problem described in the scenario. RESULTS: OTC medication selection and reported use were influenced by several person-level decision-making factors including: personal beliefs/knowledge about OTCs, assessment of the ailment, and medical constraints. CONCLUSION: The findings from this investigation provide direction for interventions to address unsafe OTC medication selection by older adults.

The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research.

With increased longevity and growth in the number of older adults comes rising rates of individuals with cognitive impairment and dementia. The expansion of this population has important implications for research on aging and dementia syndromes, namely increased enrollment of older individuals in clinical research. Ethical prerogatives, as well as historical underrepresentation of persons with dementia in research studies due to the perceived burden of traditional decisional capacity evaluations, necessitates the development of pragmatic approaches to ascertain decisional abilities in research settings. We outline a protocol used in the Wisconsin Alzheimer's Disease Research Center (ADRC) that adopts a stepped approach to the evaluation of decisional capacity meant to maximize study visit efficiency while preserving participant safety and autonomy. The protocol specifies the structure of the consent process and incorporates a brief semi-structured interview based on Appelbaum & Grisso's theoretical model for evaluating a patient's decisional capacity to provide informed consent to participate in research. This protocol is easily implemented in a research study visit and is designed to minimize participant burden and ensure reliable assessment of decisional capacity in older adults across a wide range of research protocols. The protocol emphasizes capacity optimization, using memory aids and other compensatory strategies to preserve participant autonomy while protecting welfare.

Applying participatory design to a pharmacy system intervention.

BACKGROUND: Stakeholder engagement is an important component of the research process for improving the use and uptake of patient-centered health care innovations. Participatory design (PD), a method that utilizes the involvement of patients and other stakeholders, is well-suited for the design of multifaceted interventions in complex work systems, such as community pharmacies, that have diverse and dynamic end-users. OBJECTIVE: The objective is to describe a blueprint for how to use PD when designing a community pharmacy intervention. This paper outlines the steps of PD and highlights the advantages and disadvantages of this method. METHODS: PD is explained step-wise to underscore the considerations required of researchers unfamiliar with PD. This includes the development of a tailored PD approach, PD session preparatory work, data collection, and intervention development and evaluation. The stakeholders recruited for the community pharmacy intervention were pharmacy staff and older adult patients who received prescriptions at the pharmacy corporation in which the intervention was being implemented. The PD process was a series of six adaptive sessions: (1) problem identification, (2) solution generation, (3) convergence, (4) prototyping, (5) initial evaluation, and (6) formative evaluation. RESULTS: A description of the PD process to design a community pharmacy intervention is provided. The process led to the development of a patient-centered prototype. The advantages of using PD included the opportunity to clarify problems faced by stakeholders, generation of novel solutions to incorporate into the intervention, and the ability to vet and fine-tune stakeholder design ideas in an iterative fashion. The insight gained was unprecedented and invaluable to the researchers. The biggest challenge of employing PD was the time-sensitive and time-intensive nature of developing each session, collecting data, and reflecting on the results in order to design subsequent sessions. CONCLUSIONS: The PD process led to the development of a patient-centered prototype. PD enabled stakeholders to generate creative solutions and provide unique insight on addressing issues faced in healthcare redesign research and specifically in community pharmacies.

Continuous Improvement and Employee Engagement, Part 2: Design, Implementation, and Outcomes of a Daily Management System.

A daily management system (DMS) can be used to implement continuous quality improvement and advance employee engagement. It can empower staff to identify problems in the care environment that impact quality or work flow and to address them on a daily basis. Through a DMS, improvement becomes the work of everyone, every day. The authors of this 2-part series describe their work to develop a DMS. Part 2 describes the implementation and outcomes of the program.

Building a Culture of Continuous Improvement and Employee Engagement Using a Daily Management System Part 1: Overview.

A daily management system (DMS) can be used to implement continuous quality improvement and advance employee engagement. It can empower staff to identify problems in the care environment that impact quality or workflow and to address them on a daily basis. Through DMS, improvement becomes the work of everyone, every day. The authors of this 2-part series describe their work to develop a DMS. Part 1 describes the background and organizing framework of the program.

A preliminary examination of over-the-counter medication misuse rates in older adults.

BACKGROUND: Older adults are the largest consumers of over the counter (OTC) medications. Of the older adults who are at risk of a major adverse drug event, more than 50% of these events involve an OTC medication. OBJECTIVE: To explore how older adults select and hypothetically use OTC medications and if the selected medications would be considered safe for use. METHODS: Walking interviews were conducted with 20 community-dwelling older adults in a community pharmacy. Each participant selected an OTC medication for a hypothetical pain and sleep scenario. Data were analyzed for four types of misuse: drug-drug interaction, drug-disease interaction, drug-age interaction, and excess usage. RESULTS: At least one instance of potential misuse was found in 95% of participants. For sleep medications, drug-drug interactions and drug-age interactions were more common, affecting 50% and 65% of participants respectively. The most common type of misuse noted in the pain products selected was that of drug-drug interaction, with a total of 39 occurrences, affecting 60% of the participants. CONCLUSIONS: OTC misuse is common among older adults, and it is important for older adults to seek out resources, such as a pharmacist, to help them make safe OTC decisions.

Rest-Activity Patterns in Older Adults with Heart Failure and Healthy Older Adults.

The purpose of this investigation is to examine differences in rest-activity patterns and sleep characteristics in older adults with heart failure (HF) and healthy older adults. The sample included older adults with HF (n = 20) and a reference group of healthy older adults (n = 20). Traditional cosinor analysis was used to assess three parameters of rest-activity from wrist actigraphy data: amplitude (range of activity), mesor (mean activity), and acrophase (time of peak activity). Traditional sleep characteristics were also determined from actigraphy data: total sleep time (TST), sleep latency (SL), sleep efficiency (SE), and wake after sleep onset (WASO). The HF group demonstrated significantly lower mesor and amplitude than the reference group (p < .01). The HF group had significantly greater TST (p < .01), but the groups had similar SE, SL, and WASO. Despite similar sleep characteristics to healthy older adults, overall rest-activity patterns were significantly dampened in those with HF.

A Narrative Review of How Sleep-Related Breathing Disorders and Cardiovascular Diseases Are Linked: An Update for Advanced Practice Registered Nurses.

PURPOSE/OBJECTIVES: Sleep-related breathing disorders (SRBDs), including obstructive sleep apnea and central sleep apnea, are common among patients with cardiovascular disease (CVD), but clinicians often do not pay enough attention to SRBDs. The purpose of this narrative review is to update advanced practice registered nurses on the literature focusing on the relationship between SRBDs and CVD (eg, hypertension, heart failure, coronary artery disease, arrhythmias, and stroke) and on treatments that can improve SRBDs in patients with CVD. DESCRIPTION OF THE PROJECT: We conducted an electronic search of the literature published between 1980 and 2016 from PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Academic Search Premier, and related health resource Web sites to address the aims of this study. OUTCOMES: Fifty-six primary research articles (42 observational studies and 14 experimental and quasi-experimental studies) were selected based on our study aims and inclusion criteria. The studies revealed that individuals with CVD are at a greater risk for SRBDs and that SRBDs can worsen CVD. The findings from the studies also suggest that positive airway treatment could improve both SRBDs and CVD. CONCLUSIONS: This review found a close relationship between SRBDs and CVD. Advanced practice registered nurses are in key positions to identify and help patients manage SRBDs. In particular, advanced practice registered nurses can educate staff and establish standards of practice to improve outcomes for patients with CVD.

Building capacity for the conduct of nursing research at a Veterans Administration hospital.

Evidence is the bedrock of nursing practice, and nursing research is the key source for this evidence. In this article, we draw distinctions between the use and the conduct of nursing research and provide a perspective for how the conduct of nursing research in a Veterans Administration hospital can build an organization's capacity for nursing research.

Is sleep quality related to cognition in individuals with heart failure?

OBJECTIVE: To examine how self-reported sleep quality and daytime symptoms are associated with selected domains of cognitive function among individuals with heart failure (HF). BACKGROUND: HF patients suffer from poor sleep quality and cognitive decline. The relationship between sleep and cognition has not been well documented among individuals with HF. METHODS: In this descriptive, cross-sectional study, 68 individuals with HF (male: 63%, mean age = 72 years, SD = 11) completed sleep questionnaires and a neuropsychological battery. RESULTS: Participant had mean Pittsburgh Sleep Quality Index score of 5.04 (SD = 2.8). Regression analyses demonstrated neither sleep quality or excessive daytime sleepiness (EDS) were related to cognitive function, but daytime dysfunction was related to lower letter fluency and attention index. CONCLUSION: Contrary to some earlier reports, subjective sleep and EDS in this group of individuals was not associated with cognitive decline.

Psychosocial predictors of changing sleep patterns in aging women: a multiple pathway approach.

The authors of this investigation sought to examine changes in the sleep quality of older women over time and to determine whether dimensions of psychological well-being, health (subjective health and number of illnesses), and psychological distress (depression and anxiety) predict these changes. A secondary analysis was conducted with a longitudinal sample of aging women (Kwan, Love, Ryff, & Essex, 2003). Of 518 community-dwelling older women in the parent study, 115 women (baseline M age = 67 years, SD = 7.18) with data at baseline, 8 years, and 10 years were used for this investigation. Participants completed self-administered questionnaires and participated in in-home interviews and observations. Growth curve modeling was used to examine the overall linear trajectories of sleep quality. Growth mixture modeling was used to examine whether there were different patterns of change in sleep quality over time and to examine baseline predictors of each pattern. Sleep quality declined over time but not for all women. Two distinctly different sleep patterns emerged: good but declining sleep quality and disrupted sleep quality. Higher psychological well-being (positive relations with others, environmental mastery, personal growth, purpose in life, and self-acceptance), fewer illnesses, and lower depression scores at baseline predicted reduced odds for membership in the disrupted sleep group. Future research is needed to examine whether interventions focused on maintaining or enhancing psychological well-being could minimize later life declines in sleep quality.

Older breast cancer survivors' symptom beliefs.

PURPOSE/OBJECTIVES: To use Leventhal's Common Sense Model (CSM) to describe older breast cancer survivors' symptom representations, symptom management strategies, and perceived barriers to symptom management. DESIGN: A secondary analysis was conducted using data from three pilot studies that tested a theory-based intervention to improve symptom management in older breast cancer survivors. SETTING: Advanced practice nurses conducted open-ended interviews with older breast cancer survivors either in their homes or via telephone. SAMPLE: Participants were recruited from the community, an oncology clinic, and a state tumor registry. The women (N = 61, X age = 69.5) were an average of 4.7 years after breast cancer diagnosis and reported an average of 17 symptoms. METHODS: Content analysis was conducted with field notes taken during baseline interviews. MAIN RESEARCH VARIABLES: Symptom representations, symptom management strategies, and perceived barriers to symptom management. FINDINGS: Women described their symptoms as chronic, incurable, and uncontrollable, with multiple causes (usually not aging) and numerous negative consequences. Women described an average of six symptom management strategies, most typically self-care. The most frequent barrier to symptom management was communicating with healthcare providers. CONCLUSIONS: The CSM is a useful framework for understanding the symptom beliefs of older breast cancer survivors. IMPLICATIONS FOR NURSING: Addressing women's beliefs and barriers may result in better communication with healthcare providers and more effective interventions for symptom management.

An individualized representational intervention to improve symptom management (IRIS) in older breast cancer survivors: three pilot studies.

PURPOSE/OBJECTIVES: To test the feasibility and acceptability of an individualized representational intervention to improve symptom management (IRIS) in older breast cancer survivors and test the short-term effects of an IRIS on symptom distress. DESIGN: Two small randomized clinical trials and one pre-experimental study. SETTING: Oncology clinic and community. SAMPLE: 41 women with breast cancer (aged 65 years and older) in pilot study 1, 20 in pilot study 2, and 21 in pilot study 3. METHODS: In pilot study 1, women were randomized to the IRIS or usual care control. In pilot study 2, women were randomized to the IRIS or delayed IRIS (wait list) control. In pilot study 3, all women received the IRIS by telephone. Measures were collected at baseline, postintervention, and follow-up (up to four months). MAIN RESEARCH VARIABLES: Feasibility, acceptability, symptom distress, symptom management behaviors, symptom management barriers, and quality of life. FINDINGS: Across three pilot studies, 76% of eligible women participated, 95% completed the study, 88% reported the study was helpful, and 91% were satisfied with the study. Some measures of symptom distress decreased significantly after the IRIS, but quality of life was stable. Women in the IRIS group changed their symptom management behaviors more than controls. CONCLUSIONS: Preliminary evidence supports the need for and feasibility of an IRIS. IMPLICATIONS FOR NURSING: Nurses may help older breast cancer survivors manage their numerous chronic symptoms more effectively by assessing women's beliefs about their symptoms and their current symptom management strategies.

Patterns of pain and well-being in older women: a 10-year longitudinal study.

The relationships among pain, health, and psychological well-being were examined in a secondary analysis of a ten-year study of community-dwelling older women. Over time, there was an increase in the percentage of women reporting pain and a significant increase in the mean level of pain, although 24% of the women never reported pain. Subjective health declined as pain increased. Psychological well-being did not differ between women whose pain increased over time compared to women whose pain did not increase. Future research needs to examine how women maintain psychological well-being as they age in spite of increased pain.