Keywords

brown bag events, faith community nursing, geriatrics, medication safety, polypharmacy

 

Authors

  1. Shillam, Casey R.
  2. Orton, Valorie J.
  3. Waring, Debbie
  4. Madsen, Sandy

Abstract

ABSTRACT: Brown Bag Medication Review (BBMR) events, traditionally offered by pharmacists, improve medication management for older adults. This study incorporated faith community nurses (FCNs) in BBMR events, hypothesizing that support by the FCN during and following the event would reduce medication related problems and improve medication self-care practices of older adults. Results describe and support the role of FCNs in brown bag events.

 

Article Content

MEDICATION (MIS)USE?

Older adults, the fastest growing segment of the United States population, are recognized as a vulnerable population with multiple health challenges (National Center for Health Statistics, 2012). Although an estimated 40 million people age 65 and older account for only 13% of the total population (Federal Interagency Forum on Aging-Related Statistics [FIFARS], 2012), they purchase at least one-third of all U.S. prescriptions (Werder & Preskorn, 2003). In 2008, 16% of healthcare costs for Medicare enrollees were spent on prescription drugs, with an average cost of $2,834 per person. Around 15% of Medicare enrollees incurred costs of $5,000 or more (FIFARS, 2012). For American adults age 60 and older, more than 76% use two or more prescription drugs while 37% use five or more (Gu, Dillon, & Burt, 2010). Older adults also have concomitant use of prescription medications and dietary supplements that can cause problems (Nahin et al., 2009). Although this high level of medication use associated with chronic illness conditions found with increasing age is often therapeutically necessary, excessive prescribing still contributes to multiple complications.(Gu et al., 2010).

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Many factors influence safe medication management in older adults. Polypharmacy, the concurrent use of several different medications, can be a serious issue contributing to poor health outcomes (Fulton & Allen, 2005; Gu et al., 2010). Simply taking multiple medications does not necessarily create the problem; rather problems begin when more medications are prescribed than is clinically necessary for the underlying chronic conditions, or patients become confused about their medications. Polypharmacy becomes especially problematic for older adults when the medication regimen includes overlapping drugs for the same therapeutic effect, with the prescription of optional drugs for an effect that could be managed by nonpharmacological approaches, or with prescribing to treat adverse effects of medications (Shillam, 2011). Another complication: approximately 50% of older adults do not take medications as prescribed (Blackburn, Dobson, Blackburn, & Wilson, 2005; Lee, Grace, & Taylor, 2006).

 

Other considerations in medication management include financial hardship and the use of multiple pharmacies, especially when pharmacy data banks are not synchronized with one another. Drug interactions and side effects often are not reported as older adults don't want to bother their providers, so they adjust doses or omit taking medications without reporting these actions.

 

HEALTHCARE ACCESS

Access to healthcare goes beyond having insurance coverage or adequate numbers of healthcare providers (HCPs) in a geographical area; neither insurance nor availability of providers guarantees that those who need healthcare will receive healthcare. The Institute of Medicine (IOM, 2011) determined that increased access to timely, quality care that achieves the best possible health outcomes can be expanded by increasing the use of nursing roles outside of acute care settings such as in transitional care, primary care, and through roles such as faith community nursing. This distinction highlights the importance of two different concepts determining access to healthcare: attaining health services to reach optimal health outcomes, and the role that nurses have in that determination.

 

Faith community nurses (FCNs) are in favorable positions to assist vulnerable populations with access to healthcare. The American Nurses' Association and Health Ministries Association (2005) define the scope of FCN practice as a specialty that "focuses on the intentional care of the spirit as part of the process of promoting holistic health and preventing or minimizing illness in a faith community" (p. 7). Faith community nursing has been identified as a dynamic process of working with faith community members and their families to reach a wholeness of body, mind, and spirit (Patterson, 2003). Limitations in access to healthcare for older adults, including insufficient insurance coverage, inadequate numbers of providers, the inability to develop long-standing therapeutic relationships by many providers, and complex healthcare needs, creates an ideal role for the FCN to facilitate community healthcare.

 

IMPROVING MEDICATION SELF-CARE

The concept of "self-care" in medication administration is as complex as the chronic illnesses that require medications, and the activities involved in taking medicines. Medication administration entails multiple aspects of cognitive (thinking/processing) skills, psychomotor competencies, and affective domains. All areas must be assessed and evaluated to collaboratively decide successful strategies for older adults to safely maintain medication self-administration. Because of their long-term relationships with older adults, FCNs are ideally suited to assess knowledge levels and cognitive functioning, physical abilities, and beliefs and attitudes affecting medication management.

 

Basic medication knowledge is essential for effective medication management and patient safety (National Research Council, 2007). Patient and family engagement is a key factor in preventing adverse medication-related events. All HCPs should seek to ensure that patients and/or families and caregivers are knowledgeable about what medications they are taking, why they are taking them, and common side effects. However, simply providing relevant information is not adequate for changing behavior. Older adults may be challenged with cognitive decline (Swanlund, Scherck, Metcalfe, & Jesek-Hale, 2008) and sensory-processing deficits. Vision and hearing are critical pathways to assess: Can patients distinguish color, shapes, and numbers? Can they read the print on the label? Can they clearly hear the directions? Can they process complex directions? Many adults, regardless of age, fail to acknowledge they do not understand instructions, especially in the context of a hurried office visit or at a busy pharmacy counter. Many medication directions are complex. When the complexity of a medication regimen increases, compliance decreases (Griffiths, Johnson, Piper, & Langdon, 2004) and there is higher risk for medication administration error. Addressing knowledge deficits about medications and assessing cognitive/processing abilities is the first step to improving safe self-medication management practices for older adults.

 

Difficulty with psychomotor competencies can pose a significant barrier in medication self-care activities. Adequate hand dexterity is essential, whether that be removing pills from bottles or blister packs (Griffiths et al., 2004), drawing up liquids in droppers or syringes, or squeezing tubes or inhalers. Many prescriptions include directions such as "Take one-half pill two times a day." This requires using commercial pill-cutters or cutting the medication with a knife. Posture, mobility, and joint flexibility must be considered. A prescription for a foot cream will pose a significant problem for patients who cannot easily reach their feet. Unless intentionally assessed, psychomotor deficits can become an unanticipated barrier to medication self-care.

 

Attitudes, values, beliefs, and cultural practices can have a significant impact on medication self-care behaviors (Swanlund et al., 2008). This includes hoarding, improper storage, sharing medications, intentional "flexibility" in dosing based on real or perceived interference with lifestyle issues, and adherence to prescribed regimens based on symptoms or how one feels from day-to-day (Banning, 2006; Griffiths et al., 2004). Social networking and family dynamics, that is where patients seek medication information and obtain support for medication management, also can influence self-care for older adults.

 

BROWN BAG EVENTS

The community-based medication review program known as Pharmacy Brown Bag events has demonstrated effectiveness in evaluating current medication use and identifying potential polypharmacy issues for older adults (Demarzo, Skyer-Branywene, & Feudo, 2011). Brown bag events involve older adults bringing their current medications, vitamins, and other dietary supplements in a brown paper bag to a community location where the event is being held. Brown bag events can be held in conjunction with a health fair or other community-based events, or held individually at key locations such as senior centers, libraries, churches, or community pharmacies. The event allows for one-on-one evaluation of the medication list with the older adult. This makes possible a comprehensive discussion of potential medication management problems, and offers a more complete picture of an individual's current medication usage than medical or pharmacy records.

 

Many brown bag events have included only pharmacists. Although this provides the opportunity for older adults to receive important medication information, often there is difficulty in reaching community-based populations of older adults. In addition, pharmacists have limited follow-up after the event to ensure the information was understood and recommended follow-up with the primary care provider has been obtained. FCNs offer the consistency of continued relationship with the older adult within their faith community as well as the knowledge for supporting the older adult in successful medication practices. In a 2002 study, the introduction of an FCN to the interprofessional team to coordinate a Brown Bag Event resulted in successful recruitment of higher numbers of older adults and greater follow-up after the event. A program involving a pharmacist, the primary care provider, and an FCN resulted in significant decreases in the number of medications, fewer medication-related health problems, and improved health outcomes including increased knowledge about not only medications, but also underlying medical conditions (Schommer et al., 2002).

 

Including the FCN in the brown bag medication event recognizes that holistic, faith-based nursing includes, at the very center of practice, the spiritual dimension. Characteristics of spiritual nurturing include caring, presence, acceptance, patience, and compassion as FCNs bring their practice to brown bag medication events.

 

DO FCNs IMPROVE BROWN BAG EVENTS?

We conducted a study to describe the role of the FCN and medication practices among older adults who participated in Brown Bag Medication Review (BBMR) events provided by pharmacists and FCNs. It was hypothesized that with ongoing support by the FCN during and following the BBMR event, participants would experience a reduction in problems associated with medication administration and an improvement in medication self-care practices.

 

This study used a pretest-posttest design with purposive sampling of members of multiple faith communities in the Pacific Northwest Portland Metropolitan area. The study protocol was approved by the Institutional Review Boards of the sponsoring academic institution and informed consent was obtained by all participants. The BBMR teams included an FCN and a pharmacist on location at two hospitals and four churches. The original template for this BBMR was developed for Northwest Parish Nurse Ministries (NPNM) by Yves Vimegnon, MD. The FCN was added to the program with the intent of enhancing positive client outcomes.

 

An added benefit of including FCNs is their ability to network with community partners. In our study, this was helpful in engaging a small, local community hospital for hosting one BBMR event. This hospital was interested in addressing this issue due to the high numbers of emergency department visits as a result of medication errors. The hospital offered a comfortable facility with easy access (parking, bus, and lightrail access), along with library resources including Internet access to the Micromedex system, as well as reference periodicals (Physicians Drug Reference [PDR], Nursing Drug Reference, Herbal Reference Guides, etc.). For smaller faith communities, it was ideal to host the event at the hospital where multiple faith communities worked collaboratively to host the event.

 

Flyers, newsletters, and verbal announcements for the BBMR events were distributed in various faith community settings through FCNs in the Northwest Parish Nurse Ministry Network. Many participants received personal invitations from their FCN due to ongoing relationships where the FCN had personal knowledge of the client's polypharmacy situation based on home visits, hospital visits, blood pressure screenings, or other FCN activities. Additionally, the BBMR was open to all surrounding community members. Persons meeting inclusion criteria were invited to participate in the study prior to the BBMR. Inclusion criteria were (1) members of faith communities; and (2) taking at least one medication (either prescription, herbal, and/or over-the-counter) on a daily basis.

 

The announcements for BBMR events included a medication history sheet for clients to complete and bring to the event along with their brown paper sack(s) of medications. Clients were greeted by a volunteer then met privately with the FCN. Larger BBMR events hosting more than one congregation matched FCNs with clients from each FCN's own faith community. Even if the FCN was not part of a client's specific church, the role of the FCN was known to the majority of clients.

 

The intake assessment consisted of reviewing general health status and ensuring documentation of all medication information. Lifestyle issues and real or perceived problems with medications by the client or a family member were evaluated. A pharmacist provided a private consultation based on standard principles of brown bag review (Table 1) to evaluate the medication regimen with the older adult. An exit interview with the FCN was conducted individually with each participant to clarify follow-up recommendations, reinforce plans to follow recommendations, and to schedule nursing follow-up visits. Follow-up visits included interventions for education and support, advocacy, and referrals, and to answer emerging questions. Privacy areas for consultation were provided at all events.

  
Table 1 - Click to enlarge in new windowTable 1. Standard Components of Pharmacy Brown Bag Medication Review (BBMR) Events

Each of the FCNs conducting the exit interviews attended a training session regarding the investigator-designed survey. After the BBMR events, ongoing follow-up was provided by the FCN during personal interactions within the faith community or during a scheduled follow-up telephone call at 6 weeks after the BBMR. The survey was re-administered via telephone or in-person at 3 months after participation in the BBMR.

 

STUDY RESULTS

The FCNs collected data during the exit interview on an investigator-developed survey. The 12-item survey included demographic information and questions to indicate the number of times participants visited urgent care, the emergency department, their primary care provider, or talked with a pharmacist or FCN about medication-related issues. The survey also contained questions with yes/no responses for general experiences with taking medications such as forgetting to take medications, storage and proper disposal of medications, and use of multiple pharmacies to fill prescriptions. Copies of the exit-interview (time 1) and 3-month follow-up surveys (time 2) are available as supplemental digital content at http://links.lww.com/NCF-JCN/A18.

 

Twenty FCNs from a variety of Christian faith groups (including Catholic, Lutheran, Protestant) enrolled 67 participants in the study at time 1 (at end of BBMR), with 49 still enrolled at time 2 (3 months after BBMR) for a 73% retention rate. The mean age of the 49 participants was 75.8 +/- 8.9 years (range 50-95 years). Participants were predominantly female (73%); 61% had a high school degree or some college, and 31% held a college or postgraduate degree. Time spent with clients between the pharmacist and FCN at the BBMR events was 1.5 to 2 hours.

 

Exit interview data immediately after the BBMR (time 1) indicated that 37.3% of the sample had experienced a problem with medications in the previous 6 months requiring a visit to their primary care provider, a pharmacist, or the emergency department/urgent care center. Keeping old medications (51%), forgetting to take a medication (31%), and using more than one pharmacy to fill a prescription (30%) were the most encountered medication management problems. More medication characteristics for the sample are found in Table 2.

  
Table 2 - Click to enlarge in new windowTable 2. Self-Reported Medication Practices of Older Adults Attending the BBMR Events

A one-tailed t-test was used to evaluate if a significant difference than could be explained by random chance alone occurred in the number of medications taken before and after the BBMR and 3-month follow-up. A statistically significant decrease occurred in the number of medications taken daily by participants between time 1 and time 2. At time 1 the sample took an average of 9.7 +/- 5.1 medications daily. After the BBMR and FCN follow-up, time 2 data revealed 6.7 +/- 5.5 medications daily (t(66) = 3.83, p < .001). In addition, at time 1, 14.3% of participants reported they received important medication information from their FCN, and at time 2 this increased to 30.9%. At time 2, 32% of the sample reported they changed their medication behaviors as instructed by the FCN.

 

FCNs MAKE A DIFFERENCE

FCNs serve as educators, advocates, and social supports to members of their faith communities, connecting their clients with multiple healthcare resources within the community. The FCNs participating in this study reported they were able to provide ongoing education and follow-up with their clients on critical medication issues as shown in Table 3. Table 3 also reveals that in addition to standard procedures undertaken in a BBMR (Table 1), the use of the FCN role added unique elements to the events and to follow-up. Stories from the FCN's relay the importance of their role in medication review.

  
Table 3 - Click to enlarge in new windowTable 3. Unique Contributions Reported by Faith Community Nurses in the BBMR Events and Follow-Up

One FCN reported a case identifying a male client using two different pharmacies-one supplying a Coumadin prescription, and another supplying a Warfarin; the client did not realize he was receiving a double-dose of the same medication. At 2 weeks, the FCN called to confirm his follow-up appointment with his physician. At that time, the client still had not made the appointment, and the FCN was able to speak with his wife on the phone emphasizing the critical nature of the medication error. The follow-up appointment was finally made and his prescriptions were corrected.

 

The 20 FCNs reported significant time was spent researching what resources were available to help with medication self-care. In one case, a woman who used syringes/needles to administer medications reported having multiple full needle boxes in her home, but did not know how to properly dispose of them. The FCN explored what the client had been told by her primary care provider, what resources were available in the community for disposal procedures, and the cost involved for disposal. Eventually the FCN helped the client identify a mail order disposal service.

 

Additional stories demonstrate the impact of financial strains when making decisions about taking medications. One client stated "eating half an apple is better than eating no apple" and he had applied this to his medications. Not understanding dosing and therapeutic medication levels he told the FCN, "At least I get some benefit if I make it [the medication] last longer." Another client described keeping her house at 50 degrees in the winter and wearing many layers of clothes along with using blankets so that money was available for medications. The FCN's found it difficult to uncover such information due to patient shame and embarrassment. Interventions included connecting the clients with community resources, and collecting money from the church for needed items or services. The FCN who discovered the client who kept her home at 50 degrees collected funds to pay the client's electric bill and also provided gift certificates to a local grocery store.

 

STUDY LIMITATIONS AND RECOMMENDATIONS

A limitation of this study was lack of control over and assessment of what the FCNs did with clients at the BBMR events and in follow-up. The small sample size and a low retention rate at time 2 (3 months after BBMR) and only 33% at time 3 (6 months after BBMR), limit the broad application of study results. Because the sample was predominantly female, it is not known what impact having more male participants would have had on study results. To more fully understand implications of the FCN role in BBMR events, future studies need to control and measure the delivery of the FCN interventions more closely, attempt to recruit males and females equally, and engage participants to remain in the study.

 

Despite these limitations, this study supports the FCN role in promoting medication self-care in older adults. Although FCNs are not typically a part of BBMR events, the FCN added a valuable dimension to the program (Table 3), allowing for sustained relationships and follow-up with older adults of the faith community. Future studies may consider adding a measure of spiritual care or religious practice to the evaluation to allow quantifying the many components FCNs provide in their nursing care. We also recommend incorporating reliable, valid measures for capturing the concepts of quality of life and quality of health in the older adult participants.

 

SUSTAINED BENEFITS

Our findings suggest that including an FCN in the BBMR results in sustained follow-up and in improved medication management behaviors in community-dwelling older adults. Because the FCN already is a member of the faith community to which the client belongs, a level of trust is formed or already present when participating in the BBMR. The already-present bond facilitates an acceptance by the FCN of clients and their medication practices, as well as honest disclosure by the client to the FCN so self-care medication practices can be enhanced. The trusting and supportive relationship with the FCN can lead to education, advocacy, and effective interventions that maximize therapeutic benefits and limit safety concerns.

 

These findings suggest that the FCN can be instrumental to coordinate and facilitate the effective management of medications in older adult populations. Older adults comprise the largest group of those attending churches, synagogues, or other meeting spaces for faith groups: over 65% of older adults identify themselves as religious and over 55% attend religious services on a weekly basis (Pew Research Center, 2008). The FCN scope-of-practice emphasizes facilitation of interdisciplinary teamwork and communication to decrease risks and maximize optimal health outcomes for members of the faith community. This definition of nursing practice aligns itself well with the role of the FCN described in this intervention of the BBMR event. The integration of faith and health in conjunction with the often long-term relationship within the faith community strengthens older adults' level of trust and willingness to participate in BBMR events conducted by FCNs, thereby improving their medication self-care practices.

 

Acknowledgments

The authors presented the findings of this study at the 43rd Annual Western Institute of Nursing "Communicating Nursing Research" Conference in Las Vegas, Nevada. This study was funded by the Omicron Upsilon Chapter of Sigma Theta Tau International.

 

Web Resources

 

* Brown Bag Toolkit- http://www.ohiopatientsafety.org/meds/default.htm

 

* Brown Bag Event Planning- http://www.ca.uky.edu/hes/fcs/heel/factsheets/HEEL-LEJ.100d.pdf

 

 

American Nurses' Association and Health Ministries Association. (2005). Faith community nursing: Scope and standards of practice. Silver Springs, MD: Author. [Context Link]

 

Banning M.(2006). Medication review: The role of nurse prescribers and community matrons. Nurse Prescribing, 4(5), 198-204. [Context Link]

 

Blackburn D. F., Dobson R. T., Blackburn J. L., Wilson T. W.(2005). Cardiovascular morbidity associated with nonadherence to statin therapy. Pharmacotherapy, 25(8), 1035-1043. [Context Link]

 

Demarzo L., Skyer-Branywene N., Feudo D.(2011). Assessing older adults' perceptions of medication reviews offered by pharmacists. Journal of the American Pharmacists Association, 51(2), 271. [Context Link]

 

Federal Interagency Forum on Aging-Related Statistics. (July 2012). Older Americans 2012: Key indicators of well-being. Retrieved from http://www.agingstats.gov/Main_Site/Data/Data_2012.aspx[Context Link]

 

Fulton M. M., Allen E. R.(2005). Polypharmacy in the elderly: A literature review. Journal of the American Academy of Nurse Practitioners, 17(4), 123-132. [Context Link]

 

Griffiths R., Johnson M., Langdon R.(2004). A nursing intervention for the quality use of medicines by elderly community clients. International Journal of Nursing Practice, 10(4), 166-176. [Context Link]

 

Gu Q., Dillon C. F., Burt V. L.(2010). Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. National Center for Health Statistics (NCHS) Data Brief Number 42 September 2012. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db42.htm

 

Institute of Medicine.(2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. [Context Link]

 

Lee J. K., Grace K. A., Taylor A. J.(2006). Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: A randomized, controlled trial. Journal of the American Medical Association, 296(21), 2563-2571. [Context Link]

 

Nahin R. L., Pecha M., Welmerink D. B., Sink K., DeKosky S. T., Fitzpatrick A. L.(2009). Concomitant use of prescription drugs and dietary supplements in ambulatory elderly people. Journal of the American Geriatrics Society, 57(7), 1197-1205. [Context Link]

 

National Center for Health Statistics. (2012). Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2011 DHHS Publication No. (PHS) 2013-1583. Retrieved fromhttp://www.cdc.gov/nchs/data/series/sr_10/sr10_255.pdf[Context Link]

 

National Research Council. (2007). Preventing medication errors: Quality chasm series. Washington, DC: National Academies Press. [Context Link]

 

Patterson D.(2003). The essential parish nurse: ABCs for congregational health ministry. Cleveland, OH: Pilgrim. [Context Link]

 

Pew Research Center.(2008). Religious affiliation: Diverse and dynamic. U.S. Religious Landscape Survey. Retrieved from http://religions.pewforum.org/pdf/report-religious-landscape-study-full.pdf[Context Link]

 

Schommer J. C., Byers S. R., Pape L. L., Cable G. L., Worley M. M., Sherrin T.(2002). Interdisciplinary medication education in a church environment. American Journal of Health-System Pharmacy, 59(5), 423-428. [Context Link]

 

Shillam C. R.(2011). Geriatric patients. In T. Woo & A. Wynne (Eds.). Pharmacotherapeutics for nurse practitioner prescribers (3rd ed., pp. 1423-1438). Philadelphia, PA: F.A. Davis. [Context Link]

 

Swanlund S. L., Scherck K. A., Metcalfe S. A., Jesek-Hale S. R.(2008). Keys to successful self-management of medications. Nursing Science Quarterly, 21(3), 238-246. [Context Link]

 

Werder S., Preskorn S.(2003). Managing polypharmacy: Walking the fine line between help and harm. Current Psychiatry Online, 2(2). Retrieved from http://www.currentpsychiatry.com/2003_02/0203_polypharmacy.asp[Context Link]