Investigating organisational culture to understand psychotropic prescribing practices in nursing homes: The perspective of on-site and visiting staff

Abstract

Psychotropic medicines have a role in the management of behavioural and psychological disturbances to treat distressing symptoms. However, a balance is required to be achieved between benefits of these medicines, which are often modest, and the risk of harm, which has the potential to be significantly detrimental to the resident. Controversy exists over the high-level use of psychotropic medicines and there is significant variation in the use of psychotropic medicines across nursing homes. Organisational culture has been proposed as a factor influencing psychotropic prescribing decisions in nursing homes. However, what is known of culture and the use of psychotropic medicines is limited. The overall aim of the research was to identify how and why organisational culture influences psychotropic prescribing practices in nursing homes from the perspective of on-site (nursing home managers, licensed registered nurses, enrolled nurses and nursing assistants) and visiting staff (GPs, community pharmacists, accredited pharmacists, specialist medical practitioners, nurse practitioners and clinical nurse consultant). The research presented in this thesis was underpinned by a detailed theoretical framework – Schein’s Theory of Organisational Culture. This theory conceptualises culture into three levels: i) artifacts (visible artifacts and organisational climate), ii) espoused values and iii) basic assumptions. Findings from the systematic review confirmed that a more in-depth understanding of how and why organisational culture influences psychotropic prescribing was required. Three qualitative studies that involved on-site and visiting staff from diverse backgrounds and roles established an in-depth understanding of the role of organisational culture in the use of psychotropic medicines. The research showed that visible artifacts of culture that influenced the use of psychotropic medicines were drugs and therapeutics committee meetings, pharmacist led medication management reviews and formal and informal meetings with residents and their families. The investigation of organisational climate identified a number of factors which played an important role in the use of psychotropic medicines: perceptions of staffing, managerial expectations and teamwork and communication among on-site and visiting staff. Two basic assumptions explained the in/consistencies between the ideal standards and actual use of psychotropic medicines described by participants. These were: locus of control and necessity for efficiency or comprehensiveness. Locus of control pertained to whether staff believed they could control decisions when facing negative work experiences or helpless to attempt control. The Necessity for efficiency or comprehensiveness related to how much time and effort was spent on a given task. The qualitative studies collectively highlighted that organisational culture is an important factor that shaped psychotropic prescribing decisions. Informed by a systematic review and qualitative data, a tool was developed and then content validated using a rigorous process involving key experts with knowledge and experience in nursing homes. The tool is the first to be developed that specifically addressed all three levels of culture related to the use of psychotropic medicines. While the survey will help nursing homes build a culture of appropriate psychotropic prescribing, further validation of the tool using psychometric testing is needed