Deprescribing and the Impact on Recruitment and Retention

A Continuing Care Retirement Center (CCRC) has found itself continually recruiting and orienting nursing staff only to have them leave their positions within a few months of hire.  In fact, there had been several RNs who left after a week, citing the volume of work and their perception of inadequate staff.  The skilled nursing facility component has a budgeted PPD of 3.7 and often exceeds the budget to over 4.0 nursing hours.  Why then is there a perception of understaffing and a constant turnover of licensed staff?

The answer was quickly discovered by the new director of nursing (DON) who found herself “on the cart” on her fourth day of hire.  Aside from the impact this made on the nursing staff who’s previous DON could not be described as “hands on,” this DON learned first-hand that the massive amount of medications tied the nurses to the cart and made it impossible to do much else beyond passing pills. Although some staff will feel a certain degree of control when they are assigned to the medication pass, many others will express exasperation about not being able to use their clinical skills to the fullest extent possible if all they do is administer medication.

The regulation requiring all medications be administered within a two-hour window actually increases the risk of error as nurses hurry to complete the 9 am medication pass between 8-10 am. In many cases, the heavy number of medications slated for administration at 9 am made it nearly impossible to comply with the time parameters. 

Facilities located in states where the pharmacy consultant is mandated to be separate from the pharmacy provider may have more opportunities to decrease unnecessary medications than those who have consultants and dispensing pharmacies from the same company.  The amount of work required of pharmacy consultants in long-term care may also negatively impact their ability to look proactively to ways to reduce medications.

As a consequence of the DON’s observations, the recruitment and retention committee searched for ways to encourage deprescribing. They worked on eliminating duplicative or unnecessary medications, and changed the medication administration times to two-three times per day rather than explicitly requiring 9-1-5-9 medication passes. 

In the January 2020 issue of the Journal of the American Geriatrics Society, Parag Goyal, MD, and colleagues examined the attitudes of geriatricians, general internists, and cardiologists regarding their attitudes on deprescribing cardiac medications. The authors identified the principle reason for all three physician groups to deprescribe a cardiac medication was the adverse reaction the individual already experienced.  Geriatricians said that their second most frequently cited reason for discontinuing a cardiac medication was based on the limited benefit given a limited lifespan. However, this was not a major consideration for the cardiologists responding to the survey.  Geriatricians also cited a concern for future adverse effects, the lack of clinical trial representation of older adults for a particular medication, and concern about how cognition would adversely impact the individual’s ability to safely manage their medication regimen. In contrast, cardiologists identified a concern about future adverse effects, the lack of apparent indications, the lack of clinical trials involving older adults and medication cost as the principle barriers to their reduction of cardiac medications.  In general, the responses by the internists were more consistent with those of the cardiologists as compared to the geriatricians.

The authors also noted the respondents concerns regarding the barriers to deprescribing of cardiac medications.  Here, all three groups identified the same principle concern: interfering with the prescriptions by other physicians.  All of the respondent groups also cited patient reluctance towards deprescribing as a major barrier. 

In descending order, other major barriers to deprescribing for all groups included:

• lack of patient understanding regarding deprescribing;
• insufficient time to discuss the issue with the patient;
• medical-legal concerns;
• insufficient evidence that deprescribing is beneficial;
• concerns regarding upsetting the patient or his/her family;
•  insufficient time to engage in complex decision-making;
• limited formal training on the process of deprescribing; and
• the lack of reimbursement for reducing medications.

The responses by the physicians in this survey should be used to directly address the role of the medical director, attending physicians and pharmacists in ensuring the appropriateness of medical therapy.  Consideration must be given to the effect of the number of medications given to an individual resident as well as the impact on the nursing staff who are responsible for the administration of these medications. 

Is the excessive amount of prescribed medications adversely impacting the health of the nursing staff at your facility?

Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, has been practicing nursing for 33 years, specializing in the care of geriatric patients. Dr. Warner-Maron is the president of the Institute for Continuing Education and Research, providing educational programs for individuals seeking licensure in nursing home administration.             

Reference:

Goyal P, Anderson TS, Bernacki GM, et al. Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults. J Am Geriatr Soc. 2020;68(1):78–86. doi:10.1111/jgs.16157