1

THE ROLE OF THE NURSE PRACTITIONER IN PROMOTING A REDUCTION IN
THE CAUSES AND OUTCOMES OF PROBLEMATIC POLYPHARMACY AMONG
NURSING HOME RESIDENTS IN BRITISH COLUMBIA
by
Sukhwant Jassar
BScN, University of Victoria, 2011
Emergency Nursing Speciality, British Columbia Institute of Technology, 2012

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENT FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING - FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
October, 2016
©Sukhwant Jassar, 2016

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Abstract
Problematic polypharmacy is an ongoing issue for older adults throughout Canada, and
specifically among nursing home residents (Maher, Hanion, & Hajjar, 2013). Despite
interventions that are currently in place in British Columbia (BC) to reduce the causes and
outcomes of this issue, problematic polypharmacy continues to pose a risk for residents among
BC nursing homes. This integrative review asks how nurse practitioners (NPs) can best promote
a reduction in the causes and outcomes of problematic polypharmacy among residents in BC
nursing homes.
The background information of this project outlines the concept of problematic
polypharmacy and the prevalence of contributing factors and outcomes. Nursing home
demographics are also highlighted to demonstrate the risk this population faces to the causes and
outcomes of problematic polypharmacy, and the subsequent effect this issue has on the health
care system. Furthermore, the background provides an overview of the concept role overlap
which exists between health care professionals in order to demonstrate how multiple health care
professionals may share roles or parts of roles in reducing the causes and outcomes of
problematic polypharmacy. Barriers faced by staff are also examined.
Through a comprehensive review of the literature and critical appraisal, nine articles are
found to address the research question. Key interventions that specifically demonstrate
effectiveness in reducing causes and outcomes of problematic polypharmacy in the context of
nursing homes emerged. These interventions are put forth as recommendations for NP practice
and include: medication reviews while screening for inappropriate medications by using the
Beers Criteria, computerized clinical decision support systems (CCDSS), and the Cockcroft
Gault Score; assessing functional status for changes to assure instances of problematic

3
polypharmacy are not missed by using the Minimum Data Set – Activity of Daily Living (MDSADL) scale; education targeted for all staff members to detect, prevent, and manage problematic
polypharmacy; multidisciplinary team meetings to facilitate a collaborative approach in reducing
problematic polypharmacy and case conferences to provide resident-centered care.
An important finding is that most interventions require participation from two or more
health professionals, highlighting the concept of role overlap and the necessity of a
multidisciplinary approach. In light of NP practice, this provides insight surrounding how NPs
can influence and encourage other staff members to sustain their roles and overcome barriers for
an ultimate reduction in the causes and outcomes of problematic polypharmacy with implications
for practice, policy, education, and research.
Key words: polypharmacy, problematic polypharmacy, inappropriate medication,
inappropriate prescribing, medication management, nursing home, long term care, intervention,
nurse practitioner

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Acknowledgements
I would like to thank my supervisory committee Erin Wilson, MSN, NP-F, and Shanda Rojas,
MSN, NP-F, for their continual guidance, dedication, and contributions to my project.
I would also like to thank my partner, family, friends, and classmates in their support and
encouragement throughout my graduate studies.

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Table of Contents
Abstract……………………………………………………………………………............ 2
Acknowledgements……………………………………………………………………….. 4
Tablet of Contents………………………………………………………………………... 5
Glossary………………………………………………………………………………….... 6
Chapter 1

Introduction……………………………………………………………….. 8

Chapter 2

Background..…………………………………………………………….... 10
Concept of Problematic Polypharmacy……...……………………………. 10
Nursing Home Population Demographics.…..……………………………. 12
Prevalence of Problematic Polypharmacy…………………..…………….. 13
Consequences of Problematic Polypharmacy……..………………………. 16
Nursing Home Organization…….…………………………………...……. 17
Health Care Professional Roles & Barriers…………………..……………. 18
Problematic Polypharmacy Reduction Strategies………….……………… 27

Chapter 3

Search Methods…………………………………………………………... 32
Search Databases………………………..……………………………….… 32
Search Terms……………...……………………………………………….. 32
Inclusion & Exclusion Criteria……………………..……………………… 33
Search Outcomes…………………….…………………………………….. 35

Chapter 4

Findings…………………………………………………………………… 38

Chapter 5

Discussion………………………….……………………………………… 75
Medication Review & Screening Criteria…………………………………. 76
Functional Status Assessments………………………………..……...……. 78
Educational Intervention……………..………………………...……….…,. 78
Multidisciplinary Meetings & Case Conferences………...………...…….... 80
Limitations & Implications at the Organizational or System Level……….. 83
Conclusion……………………………………….……………………….... 85

References……………………………………………..…………………………………... 87
Appendix A: Search Term Combinations……………………………………………….… 98

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Glossary
Adverse drug reaction
“Adverse reactions are undesirable effects to [drugs] … drugs include both prescription and nonprescription pharmaceuticals.”
(Health Canada, 2012, para 1)
Collaboration
“Multiple health workers from different professional backgrounds provide comprehensive
services by working with patients, their families, caregivers and communities to deliver the
highest quality of care across settings.”
(World Health Organization [WHO], 2010, p. 13).
Drug-Related Problems
Drug-related problems can be described by seven different categories including unnecessary
drug therapy, wrong drug, dose too low, dose too high, adverse drug reactions, inappropriate
adherence, and need for additional drug therapy.
(Cipolle, Strand, & Morley, 2012)
Frail elderly
“Health state associated with getting older; involving multiple serious health issues that increase
an individual’s vulnerability for extended acute care or end-of-life care … usually associate with
noticeable losses in person’s physical, mental or social function.”
(Canadian Frailty Network, 2013, para. 1)
General Physician
“Provide broad care and medical attention to individuals and families and refer patients to
specialist physicians when needed.”
(Province of British Columbia [PBC] 2016a, para. 2)
Geriatric syndromes
“[Term] used to capture those clinical conditions in older persons that do not fit into discrete
disease categories. Many of the most common conditions cared for by geriatricians, including
delirium, falls, frailty, dizziness, syncope, and urinary incontinence, are classified as geriatric
syndromes.”
(Inouye, Studenski, Tinetti, Kuchel, 2007)
Health Authority
“The Ministry of Health works together with a provincial health authority [delivers provincial
programs and specialized services], five regional health authorities [plan and deliver care within
their geographical areas], and a First Nations health authority [aims to improve health outcomes
for First Nations people in BC] to provide high quality, appropriate and timely health services.”
(PBC, 2016b, para. 1)

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Interdisciplinary
“Coordinated and coherent linkages between disciplines resulting in reciprocal interactions that
overlap disciplinary boundaries, generating new common methods, knowledge, or perspectives.”
(Newhouse & Spring, 2010, p. 2)
Medication Management
“Patient-centered care to optimize safe, effective and appropriate drug therapy.”
(Institute for Safe Medication Practices Canada, 2016)
Multidisciplinary
“The basic efforts of multiple disciplines working together to solve a problem without
challenging disciplinary boundaries.”
(Newhouse & Spring, 2010, p. 2)
Nursing Home
“A facility with a domestic-styled environment that provides 24-hour functional support and care
for persons who require assistance with activities of daily living and who often have complex
health needs and increased vulnerability”
(Sanford et al., 2015, p. 183)
Older Adult
“Most developed world countries have accepted the chronological age of 65 year as a definition
of ‘elderly’ or older person/[older adult].”
(WHO, 2016, para. 1)
Potentially Inappropriate Medications
“Prescriptions in which risks outweigh benefits.”

(Rancourt et al., 2004, p. 2)

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CHAPTER 1
Introduction
Problematic polypharmacy is a growing issue among Canadian older adults. This issue is
particularly a concern among older adults residing within nursing homes (Maher, Hanion, &
Hajjar, 2013). The concept of problematic polypharmacy is multifaceted and is discussed in
detail in the background, along with its causes and outcomes. There is a need to address this
issue as it is linked to detrimental effects for nursing home residents, including increased
mortality (Gill et al., 2007; Liperoti et al., 2009; Musicco et al., 2011).
Health care professionals who work within nursing homes, such as nurses, health care
assistants (HCA), NPs, physicians, and pharmacists, have roles to address and reduce the causes
and outcomes of problematic polypharmacy. Interventions that address these concerns are
available for use within a multitude of contexts. However, within some nursing homes, including
facilities in BC, staff face barriers that impede the optimal integration of interventions. For
example, funding (McGrail, McGregor, Cohen, Tate, & Ronald, 2007), co-location (Divisions of
Family Practice [DOFP], 2016), and time constraints (Murphy, 2006; Singh, 2016) are some
factors that pose a barrier for health care professionals to prioritize their focus on implementing
interventions to reduce the causes and outcomes of problematic polypharmacy.
This integrative review focuses on reviewing interventions implemented in the context of
nursing homes to answer the research question: how can NPs best promote a reduction in the
causes and outcomes of problematic polypharmacy among BC nursing home residents? The
Methods chapter describes the approach taken to gather literature to inform the research
question, and the findings include critical analyses of literature meeting the inclusion and
exclusion criteria. The goal of this integrative review is to reveal evidence-based implications for

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NP practice to reduce the causes and outcomes of problematic polypharmacy in a way that
considers the complexity of resident care needs, and barriers faced by staff, as well as
implications for policy, education, and research.

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CHAPTER 2
Background
To gain perspective surrounding the complexity of problematic polypharmacy, and to
acknowledge when it is in effect, the causes and outcomes of this issue are put forth. Nursing
home demographics are also shared to address why there is an increasing likelihood of
problematic polypharmacy within this context. Furthermore, an overview of health care
professionals’ roles within nursing homes is warranted to ascertain their individual functions
with medications prescribed, such as assessing residents, dispensing medications, and monitoring
for side effects. Clarifying these responsibilities may allow targeting interventions among health
care professionals appropriately. This process also provides clarity in how NPs may address
problematic polypharmacy both independently and through ensuring how interventions that are
best implemented by other health care professionals can be sustained.
Concept of Problematic Polypharmacy
The overall concept of polypharmacy is often interpreted in a negative light, though this
is a misconception. Polypharmacy is described as the use of multiple medications (Duerden,
Avery, Payne, 2013). A numerical threshold to define this concept is controversial due to the
wide range in number of medications said to define polypharmacy. For example, definitions can
range from between three medications to 10 or more medications (Hajjar, Cafiero, Hanlon,
2007). Given this variance, it is less accurate to describe polypharmacy in this manner; however,
there is still a place to consider the quantity of medications within a regimen. For instance, an
increasing amount of medications could subject residents to a greater likelihood of drug-to-drug
interactions and adverse effects. Thus, researchers most often examine the effects of an

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intervention on reducing polypharmacy, referring to the number of medications, as a specific
outcome measure.
A way in which polypharmacy can be identified more accurately is by determining if it is
either appropriate or problematic. These instances can be further identified by causes and
outcomes. Causes of problematic polypharmacy include, but are not limited to when: interactions
between medications are missed; unsafe medications are inappropriately prescribed; the
resident’s choice is overlooked (Duerden et al., 2013). Causes of problematic polypharmacy also
includes polypharmacy that increases the likelihood of drug-to-drug interactions. Outcomes that
indicate medications are problematic include, but are not limited to when: medications cause
adverse effects; medications do not reach their postulated benefit; the harm of medications
outweighs the benefit (Duerden et al., 2013). Given the factors that are causes and outcomes of
problematic polypharmacy, there are various terms within the literature that refer to this issue.
Examples of these terms include inappropriate medications, potentially inappropriate
medications, inappropriate prescriptions, polypharmacy, drug-related problems, and adverse drug
reactions. Reductions in these terms are often sought as effective outcome measures in research
studies. For the purpose of this paper, problematic polypharmacy can be considered an overarching term referring to the causes and outcomes listed above.
Appropriate polypharmacy can be described as when the “use of medications has been
optimised, [medications] are prescribed according to best evidence, can extend life expectancy,
and improve a patient’s quality of life” (Wise, 2013, p. 1). Given the definition of appropriate
polypharmacy, there are also various terms within the literature that are used to address
problematic polypharmacy, such as optimizing prescribing, and medication management.
Reducing problematic polypharmacy helps promote and can result in appropriate polypharmacy.

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To better understand why those residing within nursing homes are particularly at risk for
problematic polypharmacy, I now turn to examine nursing home demographics. Factors that
impact the complexity and unique needs of residents helps highlight why problematic
polypharmacy in this population is an important issue requiring sustained attention from NPs.
Nursing Home Population Demographics
As of July, 2015, nearly one in six Canadians (16.1%) is 65 years or older (Statistics
Canada, 2015). The growth rate of this cohort is 3.5%, which is approximately four times the
growth rate of the total population (Statistics Canada, 2015). This trend is expected to continue
to rise, as the baby boom population continues to age (Statistics Canada, 2015). By July 2, 2024,
those 65 years and above are expected to reach 20.1% of the population (Statistics Canada,
2015).
With aging, the probability of comorbid disease is likely to increase. For instance, in
2012, 85% of older adults between the ages of 65 to 79 years, and 90% of older adults aged over
80 years, reported having at least one chronic condition (Canadian Institute for Health Research
[CIHR], 2013). Approximately 24% of all older adults reported having three or more chronic
diseases (CIHR, 2013). Increasing comorbidity with aging subjects this population to greater risk
of being prescribed multiple medications and inappropriate medications over the years, and this
contributes to the likelihood of problematic polypharmacy (Nobili, Garattini, & Mannucci,
2011). Furthermore, older adults are particularly at risk for problematic polypharmacy as the use
of multiple medications may have a different impact on them compared to younger cohorts. For
example, physiological changes which come with aging vary among individuals and can have
different impacts upon drug metabolism (Heppner et al., 2012). Also, many medications have not
been adequately studied among older adults, as older adults are often excluded from clinical

13
trials (Zulman et al., 2011), subjecting this population to potential adverse effects that are not
seen in the general population.
Aging and comorbidity are two main factors patients have to contend with. Older and
sicker patients may move to nursing homes due to a loss of independence and for increased and
ongoing support (Statistics Canada, 2011). Common problems affecting nursing home residents,
which may also be factors that cause older adults to relocate to nursing homes for ongoing
support services, include dementia, musculoskeletal conditions such as fractures and missing
limbs, urinary and bowel incontinence, diabetes, chronic lung or heart conditions, chronic pain,
and cancer diagnoses (Canadian Institute for Health Information [CIHI], 2013).
Older adults account for the majority of nursing home residents, which may increase the
likelihood of comorbidity in this context. For example, in 2011 a total of 352,205 (7.1%) of
Canadians over the age of 65 lived in a nursing homes, and of the 7.1%, a total of 30% were
above the age of 85 (Statistics Canada, 2011). Increased age and comorbidity necessitate
recognition as they also suggest an increased likelihood of problematic polypharmacy within
nursing homes. Thus, next I turn to examine the prevalence of this issue in the context of nursing
homes.
Prevalence of Problematic Polypharmacy
Available research surrounding the prevalence of problematic polypharmacy usually
focuses on the quantity of medications residents take. For instance, Ramage-Morin (2009) found
that more than half of nursing home residents were taking more than five medications per day,
which may be a higher value compared to other contexts given aging and comorbidity among
this population.

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Referring to problematic polypharmacy solely based on the quantity of medications, for
which the number varies throughout the literature, may inaccurately represent this issue, and
create difficulty in determining a reduction in outcome measures. Problematic polypharmacy
may also be bigger than is currently understood, as causes other than quantity, and outcomes of
problematic polypharmacy are overlooked. Finally, basing the prevalence of problematic
polypharmacy solely on the quantity of medications may not be appropriate among nursing home
residents who are more likely to have multiple comorbidities requiring multiple medications
compared to a younger population.
There are some known data surrounding factors that are concrete causes and outcomes of
problematic polypharmacy, which provides more accurate insight surrounding the prevalence of
this issue. For instance, some medications have been studied among older adults and are found to
be unsafe as they cause adverse effects. However, these inappropriate or potentially
inappropriate medications continue to be commonly prescribed. Examples of these medications
include antipsychotics, benzodiazepines, tricyclic antidepressants, and anticholinergics.
(Campanelli, 2012).
Focusing on antipsychotics, Health Canada (2013) issued a warning in 2005 advising
about the risks of antipsychotic use among older adults with dementia, especially atypical
antipsychotics (Liperoti et al., 2009). Studies of older adults taking these medications
demonstrated links to increased mortality (Gill et al., 2007; Liperoti et al., 2009; Musicco et al.,
2011). The National Institute of Mental Health (2015) advised that antipsychotic use among
older adults may also lead to stroke, fractures, kidney injury, as well as increased risk of
mortality.

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In light of these warnings, the Ministry of Health (MOH, 2011) examined the use of
antipsychotics among older adults throughout BC nursing homes from April 2010 to June 2011.
They used family and stakeholder consultations, as well as PharmaNet (MOH, 2011), a patient
medication profile database used widely in BC (Government of BC, 2016). The data put forth by
the MOH (2011) indicated that 50.3% of nursing home residents in BC were prescribed an
antipsychotic. However, information surrounding how long each medication was used, and the
condition for which the medication was prescribed, was not provided. This information is
required in order to decipher whether there was a rational and well-informed indication to the use
of antipsychotics, or if these instances were truly problematic.
CIHI (2013) collected data pertaining to antipsychotic use through 2011 to 2012 from
nursing homes across Canada, and found an average of 32% of residents were receiving
antipsychotic medications in the absence of a mental health condition, such as schizophrenia.
Upon investigating reasons for antipsychotic use, a CIHI (2009) review found that the majority
of antipsychotic use among older adults was used to treat behavioural and psychological
symptoms of dementia. Antipsychotics were prescribed to attempt to manage symptoms of
delusions, aggression, and agitation (CIHI, 2009), despite a lack of support for these indications.
The use of medications for the indications listed above are clear examples of problematic
polypharmacy and its prevalence. It is more accurate to target a reduction in comprehensive
causes and outcomes of problematic polypharmacy to guide outcome measures, rather than
referring to the quantity of medications that varies within the literature. Timely inquiry into how
these causes and outcomes can be best reduced in nursing homes is necessary. For further
rationale surrounding the necessity of ongoing recognition and intervention for this issue,
consider the next section which discusses consequences of problematic polypharmacy.

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Consequences of Problematic Polypharmacy
Problematic polypharmacy is directly linked to adverse resident outcomes. For example,
the relationship between problematic polypharmacy and falls is explicitly related to medications
that influence balance or alertness (Hammond & Wilson, 2013). Residents are already at greater
risk for falls due to mobility issues, advanced dementia, and other comorbidity (Public Health
Agency of Canada [PHAC], 2014). Research suggests that falls in general have been the direct
cause of 95% of all hip fractures (PHAC, 2014). Unfortunately, after falling and sustaining a hip
fracture, survival and functional outcomes is poor for nursing home residents (Neuman et al.,
2014). As problematic polypharmacy may cause falls, and falls lead to fractures, which
potentially result in death, it is crucial to reduce falls by preventing problematic polypharmacy.
Adverse resident outcomes caused by problematic polypharamacy also increase the use of
emergency departments and resulting hospitalizations (McGregor et al., 2014). These
consequences are preventable and can be reduced with ongoing and persistent interventions that
address problematic polypharmacy among nursing home residents.
Not only has problematic polypharmacy had a direct negative impact on residents, but it
also contributes to high costs within the health care system. Prescription medications are a
significant portion of Canada’s health care expenses, as it was forecasted to reach $33.0 billion
dollars in 2012 (CIHI, 2012a), coming second after hospital usage (CIHI, 2012b). Furthermore, a
study conducted by Morgan et al. (2016) aimed to quantify the cost and frequency of
inappropriate prescribing among older adults in Canada, and found that $419 million dollars
were spent in 2013 alone. Considering a large portion of funding spent on medications is
inappropriate and unwarranted, considerable savings and improved resident outcomes could be
seen with appropriate intervention.

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Next, an overview of the organization of nursing homes is put forth. This is to provide
insight as to how implementing interventions to reduce the causes and outcomes of problematic
polypharmacy can be understood in this context.
Nursing Home Organization
In BC, nursing homes are owned and operated by either for-profit or not-for-profit
agencies. Not-for-profit care is delivered by religious, cultural, other community-based societies,
regional health authorities, or by publicly owned acute care hospitals (McGregor et al., 2005).
For-profit care is delivered by sole operators or by management groups that are part of larger
business entities (McGregor et al., 2005). For the purpose of this integrative review, how
problematic polypharmacy can be best reduced will be considered among both organizational
models. Interventions can be applied regardless of the organizational model, as both models
employ the same health care professionals. However, both models face varying degrees of
challenges that impede the optimal implementation of interventions to reduce the causes and
outcomes of problematic polypharmacy.
Both for-profit and not-for-profit facilities are allotted the same amount of public funds
per resident for care requirements (McGrail et al., 2007). However, there is no legislated minimal
requirements for staffing in nursing homes (McGrail et al., 2007), thus how funds are allocated
can be dependent on the organizational model. For example, in BC not-for-profit facilities
provide more hours of direct resident care by health care professionals than for-profit facilities
(McGregor et al., 2005). Less resident care hours within for-profit facilities may reflect a
situation of understaffing in these facilities, in order to divert some funding to profit (McGrail et
al., 2007).

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Not-for-profit facilities in BC also demonstrate lower hospital transfer rates (McGregor et
al., 2014). Lower hospital transfer rates may be facilitated in not-for-profit facilities by providing
more time on direct resident care (McGregor et al., 2005), and connections and collaboration
with acute care hospitals and health authorities (McGrail et al., 2007). This allows not-for-profit
facilities to benefit from these affiliations through greater access to specialized professionals,
who are able to develop and implement care policies (McGrail et al., 2007).
Overall, these factors highlight how understaffing and subsequent reduced time spent on
resident care may negatively impact residents. For instance, interventions include appropriate
follow-up and discussions with residents to assess the effects of medications. Follow-up is less
likely in understaffed facilities where insufficient time may be a barrier in appropriately
implementing time-sensitive interventions
Regardless of the funding model, nursing home residents are cared for by multiple health
care professionals who spend varying amounts of time with residents. Although the main focus
of this review is NPs, as residents are cared for a multitude of health care professionals,
deciphering the roles of how they each influence decisions about medications prescribed is
warranted. This provides clarity in how NPs may address problematic polypharmacy partly
through ensuring interventions best implemented by other health care professionals are sustained.
Thus, this integrative review also focuses on the roles of HCAs, registered nurses (RN), licensed
practical nurses (LPN), pharmacists, and physicians.
Health Care Professional Roles & Barriers
It is important to discuss role overlap between health care professionals to provide clarity
surrounding how and why more than one particular professional may influence similar decisions
surrounding medications prescribed, such as prescribing medications, and monitoring for adverse

19
effects. For the purpose of this integrative review NP roles are explored alongside physician
roles as their roles are more comparable and influence medication use alike.
In BC, there are 26 health care professionals covered under the Health Professions Act
(HPA), including physicians, NPs, RNs, LPNs, pharmacists (PBC, 2016c), and excluding HCAs.
Within the HPA, health care professionals are not bound by exclusive scopes of practice, but are
rather subject to controlled and uncontrolled acts (Baranek, 2005). Controlled acts are performed
by health care professionals who are designated to these acts by law, and more than one
profession can be authorized to perform the same, or parts of the same controlled acts (Baranek,
2005). Uncontrolled acts are under the public domain and may be performed by anyone
(Baranek, 2005).
The variability in who may perform acts allows for greater flexibility as to which health
care professional delivers health care services. This in turn allows for a measure of cost-savings
seen with staffing choices (CIHI, 2012b), which may also help explain staffing choices in some
nursing homes. The organization of the HPA also allows for advances in health professions’
scopes of practice, in order to meet changing population health needs (Nelson et al., 2014),
decreasing wait times, while increasing access to care across Canada (Royal College of
Physicians and Surgeons of Canada, 2013).
In nursing homes, RNs, LPNs, and HCAs spend the most direct time with residents.
While they are each required to uphold many competencies to adequately care for nursing home
residents, I will focus on those related to the causes and outcomes of problematic polypharmacy.
In comparing nursing, including RNs and LPNs, roles to HCA roles related to medication use, it
is apparent that there is role overlap. For instance, they are all responsible for maintaining the
physical and psychological health of residents, and a safe environment, such that the use of

20
physical and chemical restraints can be minimized, and rather nonpharmacological approaches
are promoted to manage behavioural symptoms (Acker et al., 2014; Canadian Gerontological
Nursing Association [CGNA], 2010. They are all also responsible for recognizing changes in
health status and communicating these promptly to the team, including family members (Acker
et al., 2014; CGNA, 2010). These competencies demonstrate where nurses and HCAs both play a
part in the process of reducing the causes and outcomes of problematic polypharmacy at the
front-line. Nurses and HCAs are present to detect changes with resident behaviour and alertness,
while minimizing the use of optional inappropriate medications, such as antipsychotics.
Nurses have additional education and subsequently additional competencies that
influence medications prescribed. These include specialized assessment skills, such as
conducting risk assessments, including falls risks, to prevent adverse effects that can be related to
problematic polypharmacy (CGNA, 2010). Nurses are responsible for administering medications
that also require resident assessments and clinical reasoning before administrating (College of
Registered Nurses of British Columbia [CRNBC], 2016a). However, it is important to note that
some nurses are found to lack knowledge surrounding medication management and adverse drug
reactions (Lim, Chiu, Dohrmann, & Tan, 2010).
Despite nurses who have a broader range of roles, and specialized roles that impact
medication use and other care requirements for residents, HCAs have had increased contact time
with residents compared to nurses over the years (Hospital Employees Union [HEU], 2009). This
is made feasible due to role overlap related to direct resident care where agencies and
management groups are able to cut costs by staffing more HCAs over nurses. However, HCAs
have not received the same degree of educational preparedness as nurses. A lack of consideration
of educational preparedness by agencies and management groups can lead to errors with the mix

21
of staff and nurse-to-resident ratios (Baranek, 2005). This can result with clinical errors and
adverse resident outcomes (Baranek, 2005).
Errors with staff mix in terms of nurse-to-resident ratios are further complicated by
current staffing recommendations put forth by the British Columbia Nurses Union, the voice for
BC RNs and LPNs (BCNU, 2015). Within nursing homes, BCNU (2015) suggests only one fulltime RN supervisor is required on site at all times. For facilities with 100 beds or more, only one
RN assistant director of nursing, and only one full-time RN director of in-service education are
mandatory (BCNU, 2015). Additionally, only one regulated nurse such as a RN, LPN, and/or an
HCA is required for every 25 residents (BCNU, 2015). These recommendations advocate for
nurses to move away from bedside care, and rather be occupied in supervisory and leadership
roles within nursing homes.
Inadequate staffing and current staffing recommendations are increasingly problematic
within nursing homes, making many BC nursing homes below provincial guidelines for resident
care hours (Office of the Seniors Advocate, 2016), which subjects residents to poor outcomes
(Clarke & Donaldson, 2008). Staffing fewer nurses, and solely staffing nurses in a supervisory
role, may subject nurses to feelings of increasing liability, less support, decreased job satisfaction
(Berry, 2012), suboptimal quality of care measures, and adverse resident outcomes (Murphy,
2006). A supervisory role takes nurses away from specialized bedside assessments, and informed
medication administration. This may be further complicated by time constraints experienced by
HCAs. For example, there is also a degree of inadequate HCA staffing (HEU, 2009), that may
impede their careful assessment of residents, and communication of their findings with the team
to inform medication use. Essentially, the staffing choices add constraints for the team from

22
direct-care staff, to supervisory staff, and residents pay the ultimate price with less-informed
medications administration and suboptimal follow-up for monitoring.
Given the issues raised above, consider how a reduction in problematic polypharmacy
may be difficult to achieve among residents with dementia, which is a common diagnosis in
nursing homes (CIHI, 2013). Dementia requires well-planned approaches to care, in order to
avoid relying on inappropriate medications for behavioural management, which some facilities
rely upon (MOH, 2011; CIHI, 2013). The Alzheimer’s Association (2009) states many elements
are required for effective dementia care, including a dependency on therapeutic relationships
between care staff and residents. This is a prominent focus for nurses and HCAs who are held to
spending the most amount of time with residents, which is not feasible due to current staffing
models. Effective dementia care also involves interdisciplinary efforts in assessing the resident’s
abilities, updating care plans with effective strategies to reduce behavioural symptoms,
appropriate staffing patterns, and it is important to create an environment which fosters
community (Alzheimer’s Association, 2009).
Facilitating interdisciplinary efforts, updating care plans, implementing appropriate
staffing patterns, and creating an environment which fosters community are not well-defined as
functions for particular health care professionals. Rather, these efforts are made by and decided
upon by the collective team, and those who take leadership, in facilitating a culture that strives to
improve resident outcomes, and advocates for practice and policy changes. These unspecific but
critical functions inform the research question of this project, as each of the functions mentioned
above require recognition and proper facilitation to be successfully implemented and evaluated.
Pharmacists are health care professionals who are particularly important to discuss
considering problematic polypharmacy, as they encompass expertise in pharmacology.

23
Pharmacists have some role overlap with physicians and NPs, as they also conduct patient
assessments and make medication-related therapeutic substitutions when they are warranted
(Canadian Pharmacists Association, 2016). A pharmacist may also identify potential avoidable
side effects and suggest an alternative medication (College of Pharmacists of BC [CPBC],
2016a). This instance reduces aspects of problematic polypharmacy that is often overlooked.
Additionally, pharmacists can hold prescriptions of medications recognized to be unsafe, and
clarify the order with the prescriber prior to dispensing rather than risk harming the resident
(CPBC 2016b). Nurse practitioners require a comprehensive understanding of pharmacists’ roles
and functions in order to best support their ability to prevent problematic polypharmacy.
According to the HPA, and specifically within BC nursing homes, pharmacists are
responsible for conducting thorough medication reviews, health histories, making medication
recommendations, and reviewing drug regimens with the resident’s provider every six months,
given the provider is available (CPBC, 2014). If providers are unavailable, pharmacists are to
collaborate with RNs or facility staff members who are approved by the medication safety and
advisory committee (CPBC, 2014). It is important to note that a lack of direct communication
between pharmacists and providers can lead to disagreement and failed collaboration (Rigby,
2010). Thus, as physicians or NPs have the ultimate prescriptive authority within nursing homes,
the CPBC (2014) state effective communication between physicians/NPs and pharmacists is key.
In light of the research question, collaboration and communication between NPs and the care
team is important in order to take advantage of the team’s individual abilities to impact
medications prescribed, and to collectively reduce the causes and outcomes of problematic
polypharmacy.

24
Collaboration involving effective communication specifically between pharmacists and
physicians is not without limitations. Pharmacists have suggested that physician attitudes and
practices are critical for facilitating or impeding prescription adaptation (Marra, Lynd, Henrich,
Joshi, & Grindrod, 2010). Perceptions, attitudes, and practices of physicians in relation to
adaptation services conducted by pharmacists identified six key concerns including:
compromised patient monitoring; physician liability; physician burden; pharmacist’s abilities to
make appropriate adaptation; conflict of interest; and impact on physician-pharmacist
relationships. Specifically to the concern regarding the pharmacist’s abilities to make appropriate
adaptations, physicians lack information surrounding the clinical background and training of
pharmacists (Marra et al., 2010). Barriers in collaborating with pharmacists requires recognition
and intervention as pharmacists are a valuable health care professional in reducing problematic
polypharmacy, as demonstrated with their ability to identify inappropriate medications that
subject residents to side effects.
Physician roles related to medication use are often faced by many barriers within nursing
homes. Given role overlap and similar practice models between physicians and NPs, exploring
these roles and barriers also help inform NP practice in reducing causes and outcomes of
problematic polypharmacy.
Physician practice models impact time spent with nursing home residents. Less time with
residents may mean shorter assessments, and this may overlook instances where desprescribing
is warranted. For example, in Vancouver, BC most physicians who work for nursing homes are
paid on a fee-for-service basis. These physicians also run their own personal office practices.
Despite compensation for more time-consuming tasks within nursing homes, these tasks may
compete with personal office practice priorities. The DOFP (2016) highlight challenges that can

25
exacerbate these barriers, such as time required to commute to different facilities, challenges
with locum coverage, and insufficient remuneration that may lead to unsustainable practice
patterns. Due to these limitations, many physicians care for few residents and struggle to visit
residents proactively (DOFP, 2016). On the other end, a few physicians take many residents
under their care, which results in gaps in care for many residents when these physicians become
unavailable (DOFP, 2016). These factors highlight how it may be difficult to follow-up on
residents and assure limited consequences. They also suggest there may be limited access to the
physician for the health care team. These circumstances have implications for how NPs select
and advocate for practice models in their roles.
Some physicians are contracted independently to provide services to nursing homes. This
means that they decide their own resident roster and on-call terms. Harriman et al. (2014) found
that these models may promote suboptimal communication with the care team as
interdisciplinary approaches are not optimally upheld. The timing of meetings may not be
suitable for physicians who are contracted independently and have competing priorities.
Interdisciplinary team meetings offer a time when the care team may come together to discuss
resident status updates and thoughts surrounding their medication regimen. These are times
especially informative for physicians who spend less time on direct resident care to learn more
about the status of residents under their care.
While nursing home staff members recognize the barriers inherent in this model,
physicians working within this model see other issues that hinder deprescribing and allow
problematic polypharmacy to persist. Physicians mention nursing unavailability, and subsequent
insufficient resident supervision, and a lack of detecting and reporting of symptoms as barriers to
deprescribing medications that are problematic in some form (Harriman et al., 2014). Physicians

26
also voice family member unavailability as a barrier to deprescribing medications (Harriman et
al., 2014), as family availability may not overlap with physician time on-site to gather and
incorporate family decisions surrounding medications.
Physician roles in reducing the causes and outcomes of problematic polypharmacy are
similar for NPs. Nurse practitioners are registered nurses, who have a Master’s degree, and
advanced nurse practice competencies, such that they are able to autonomously diagnose and
treat acute and chronic illnesses, including prescribe most medications (CRNBC, 2016b). Their
autonomy, advanced education, and regulated scope of practice distinguishes their roles from
nurses and pharmacists, and provides role overlap that most closely correlates with physicians.
For example, NPs have full prescriptive authority, are able to independently plan care for
residents, and are obligated to use strategies to reduce problematic polypharmacy, such as
deprescribing medications no longer necessary.
The ongoing complex health care needs of nursing home residents are recognized by
health care authorities, and as a result many health authorities have implemented a role for NPs
within nursing homes (Canadian Nurses Association, 2013). Researchers from the University of
Victoria conducted a survey to examine practice patterns of NPs across BC (Sangster-Gormley,
2012). Though it is unclear how many NPs were contacted, 31 responded, and out of the 31
respondents, 48% were community/primary health care practice NPs (n=15), and 16% of NPs
worked within nursing homes (n=5) (Sangster-Gormley, 2012). For NPs working for nursing
homes throughout Canada, including BC, practice patterns vary. Practice models that have been
studied include full-time NPs who are employed in one or multiple sites, community NPs who
devote practice time to individual residents, and NPs employed as on-call for nursing homes
(Donald & Martin-Misener, 2011). The different practice patterns among for-profit and not-for-

27
profit nursing homes demonstrates on-going experimentation in the degree of NP utilization to
meet needs (Donald & Martin-Misener, 2011). Nurse practitioners who work among these
various practice patterns may experience similar barriers faced and voiced by physicians seeking
to reduce the causes and outcomes of problematic polypharmacy.
This section illustrates that there are many health care professionals involved in the
reduction of causes and outcomes of problematic polypharmacy. Many of the roles of these
professionals overlap, allowing agencies and management bodies to choose more affordable
staffing. However this may result in some resident care being administered under conditions
whereby professionals and staff have gaps in educational preparedness, and there may be staffing
shortages. Also practice models are less than ideal in terms of time primary care providers, such
as NPs or physicians, are able to spend with residents, family, or other team members. These
barriers lead to challenges with gathering accurate resident assessments and also issues in
effectively communicating these findings between health care professionals to inform a
reduction in the causes and outcomes of problematic polypharmacy.
The work environment within nursing homes is quite complicated. Fortunately, there are
various interventions that aim to help health care professionals identify and facilitate a reduction
in causes and outcomes of problematic polypharmacy, and some are specific to BC. These are
examined next, though to inform the findings, as it is not known if these are best promoted
within the context of nursing homes.
Problematic Polypharmacy Reduction Strategies
Strategies currently in place begin with those that provide a base for screening causes of
problematic polypharmacy, such as inappropriate medications. In BC, the PharmaNet program
provides those with access to the resident’s purchased medication history (Government of BC,

28
2016). Prescribers can scan this list of medications to prevent medication duplications and
interactions (Government of BC, 2016). An additional second scan can be conducted by
pharmacists before the medications are dispensed. However, a study conducted by Price, Bowen,
Lau, Kitson, & Bardal (2012) compared the accuracy of PharmaNet profiles against medication
histories taken by pharmacists, and found that 16% of medication profiles were accurate, while
48% of the discrepant profiles were considered clinically significant in inaccuracy. The most
common error was missing medications, and medications that appear falsely inactive (Price et
al., 2012). Also herbal, over-the-counter, HIV, and hospital dispensed medications are not
included within PharmaNet (Government of BC, 2016; Price et al., 2012). Discussing the
comprehensive list of medications with residents, and/or their family members, by means of
medication reviews, and using other tools in conjunction, is important.
Upon conducting medication reviews, there are many criteria from around the world that
can be used to identify inappropriate medications among older adults. The Beers Criteria is
evidence-informed, has recently demonstrated superiority in identifying potentially inappropriate
medications (Oliveira et al., 2015), and it is the most utilized criteria over the past 20 years
(Lemay & Dalziel, 2012). This demonstrates its ongoing clinical usefulness. Some of the
medications included within the list to avoid, or to use with caution among older adults include:
medications with high anticholinergic properties such as first-generation antihistamines,
antispasmodics, and tricyclic antidepressants; antipsychotics that can increase the risk of strokes
and mortality in those with dementia; benzodiazepines that can increase the risk for cognitive
impairment, delirium, falls, and fractures; hypoglycemic agents such as glyburide that can cause
prolonged hypoglycemia; non-selective anti-inflammatories (NSAIDs) that can increase the risk
of gastrointestinal bleeding (American Geriatrics Association, 2012).

29
Computerized systems are also largely available across practice settings, such as the
electronic medical record (EMR) and electronic health record (EHR). These systems provide
clinical information to improve efficiency and workflow (PBC, 2016d). For example, the EMR
allows for tracking data over time, such as blood pressure readings, enabling providers to
conduct accurate assessments surrounding the continuation or deprescribing of medications
(Garrett & Seidman, 2011). However, the EMR is limited to one practice setting and does not
allow for information exchange between providers (Garrett & Seidman, 2011). The EHR
provides comprehensive information exchange through multiple settings allowing providers to be
aware of the resident’s health history and potential medications also provided or prescribed
within the hospital setting. These are often factors that are missed and can exacerbate
problematic polypharmacy (Rambhade, Chakarborty, Shrivastava, Patil, & Rambhade, 2012).
Another useful tool used in reducing problematic polypharmacy includes the MedStopper
application, which has been available since 2015. It is a decision support tool developed largely
through expert opinion to help prescribers prioritise individual patient medications for potential
discontinuation, or dose reduction based on the drug’s ability to improve symptoms, reduce
future illness, and avoid harm (MedStopper Beta, 2015). It also guides the prescriber through a
safe discontinuation process (MedStopper Beta, 2015). A lack of deprescribing guides have been
a barrier voiced by physicians (Harriman et al., 2014). Physicians working within nursing homes
have rated the MedStopper application useful overall (Cassels et al., 2015).
Launched in 2013, another guide aimed at helping prescribers deprescribe specifically in
nursing homes is put forth by the Ontario Pharmacy Research Collaboration (OPRC). The
guidelines developed by OPRC appear to be the first of their kind in that they guide prescribers
through instances where it is appropriate to stop/taper a medication, while monitoring for adverse

30
drug reactions (OPRC, n.d.). Thus far, three specific guidelines have been produced pertaining to
proton pump inhibitors, benzodiazepines, and antipsychotics (OPRC, n.d.). The guidelines
encompass algorithms to help in the process of deprescribing that include assessing for
symptoms to determine the next steps (OPRC, 2015).
There are also educational services to help providers improve their prescribing practices
that include the Provincial Academic Detailing Service (PADS) and the Therapeutics Initiative
(TI). The PAD service is led by pharmacists where they offer 30 to 40 minute evidence-based
onsite and web-based seminars for prescribers to enhance prescribing practices throughout BC
(PADS, n.d.).
The TI is a great resource that provides health care professionals with information to
make overall informed medication decisions (TI, 2010). Because of the TI’s research, BC spends
on average 8.2% less per capita for their drugs compared to other provinces (Gagnon, 2010). The
team conducts independent assessments of drug therapy despite information put forth by drug
industries (TI, 2010). They have many working groups, one of which conducts regular drug
assessments and publishes letters bimonthly (TI, 2010). The TI also produces evidence-based
clinical guidelines that are accessible online surrounding medications that are more affordable
and demonstrate comparable efficacy (Gagnon, 2011). The TI’s information is also available via
podcasts (TI, 2010), and they hold many conferences featuring problematic polypharmacy,
where they introduce their systematic reviews and steps to deprescribing (TI, 2014).
Introduced in 2014 by the General Practice Services Committee (GPSC), is an
intervention specifically targeted for physicians referred to as the Residential Care Initiative. The
goals of this initiative are to improve resident services and outcomes including those related to
problematic polypharmacy (GPSC, 2015a). Medication reviews are to be completed by

31
physicians, and preferably with expertise provided by pharmacists upon admission into a nursing
home, and at least every six months thereafter, as well as in instances of resident status changes
or transfer back from acute care (GPSC, 2015b). Physicians and pharmacists are to collectively
address the goals of care for the individual resident, current medication indications versus
potential for adverse events, total number of medications, medications that may be of low value
or no longer needed, and care staff time taken to administer multiple medications (GPSC,
2015b).
Many strategies reviewed within this section are not specifically mentioned within the
findings as they have not been studied in the context of nursing homes, and many are not
specifically targeted to an isolated issue of problematic polypharmacy. The strategies are also
generally focused on improving prescribing. For instance, they do not explicitly indicate how
different team members are involved in reducing the causes and outcomes of a comprehensive
problematic polypharmacy issue. Many strategies are also fairly new and have not been
rigorously studied. However, these strategies can be used to inform successful interventions that
are identified within the findings.
Next, the Methods chapter outlines the approach taken to gather literature to inform the
research question of this project. The research question is to ascertain how NPs can best promote
a reduction in the causes and outcomes of problematic polypharmacy among residents in BC
nursing homes. A review of the literature that is specific to the context of nursing homes is
required in order to consider the complexity of resident care needs, and barriers faced by nursing
home staff.

32
CHAPTER 3
Methods
An integrative review of the literature is undertaken to answer the research question. The
search is organized below guided by Whittemore and Knafl’s (2005) approach to integrative
reviews.
Search Databases
In order to enhance the rigour of this review per Whittemore and Knafl (2005), multiple
databases were used for a comprehensive search of the literature. Databases included PubMed,
CINAHL, and Cochrane Collaboration, as well as grey literature through Google Scholar for
unpublished and published data. A hand search of references from key articles was also
conducted.
Search Terms
The following terms were searched in various combinations: polypharmacy;
inappropriate medication; inappropriate prescribing; medication; nursing home; long term care;
nurse practitioner. Combinations of search terms with numerical results are found in Appendix
A. The search term combinations are intended to bring forth evidence-informed interventions
that help reduce the causes and outcomes of problematic polypharmacy.
The term problematic, which is used to describe polypharmacy in this review, was not
among search terms. This is because polypharmacy has not been universally described using the
term problematic, and using this term limits the search. The search term polypharmacy, which is
a cause of problematic polypharmacy, was the foundation of most searches, as it is an issue of
interest, is not universally isolated to the number of medications, and brings forth an array of

33
literature inclusive of interventions to reduce the causes and outcomes of problematic
polypharmacy.
Literature brought forth while using the search term combinations target health care
professionals who work in nursing homes, with the exception of NPs. Some interventions are
specifically applicable to NPs given role overlap, and some interventions allow an assessment of
how NPs can support other care staff to sustain their roles in reducing causes and outcomes of
problematic polypharmacy.
A lack of literature that specifically informs NP practice in reducing causes and outcomes
of problematic polypharmacy prompted the addition of the term nurse practitioner to search term
combinations. These limitations in literature may relate to the specificity of the issue of interest
and the specificity of the context that may not have received specific attention from NPs. This
may be the case as the integration of NPs is fairly new, especially in BC (CRNBC, 2015), thus
attention may be focused on broader health care concerns.
Due to limited randomised-controlled trials encompassing NPs, a practical hand search
of articles related to problematic polypharmacy within nursing homes was undertaken. There
were few articles found with the search term combination nurse practitioner, nursing homes, and
polypharmacy. These studies explored broader primary practice gaps within nursing homes, such
as emergency transfers and hospitalization. Some included brief discussions surrounding
problematic polypharmacy. Thus these articles were included for an analysis of how NPs have
specifically facilitated a reduction in the causes and outcomes of problematic polypharmacy.
Inclusion and Exclusion Criteria
The inclusion criteria consisted of a timeframe from 2005 to 2016 in order to obtain
current data to inform practice. Evidence-based health care is recognized as being informed by

34
research from different disciplines and conducted through various research methodologies
(Flemming, 2007), as is to be reflected by integrative reviews (Whitttemore & Knafl, 2005).
Thus, all types of research were considered for this review in identifying interventions that
reduce the causes and outcomes of problematic polypharmacy, and not solely intervention
studies. Systematic reviews, randomised-controlled trials, non-randomized controlled studies,
qualitative data, as well as guidelines developed through systematic review were considered for
inclusion.
Research that addresses interventions to reduce the causes and outcomes of problematic
polypharmacy, but do not include NPs as participants, met the inclusion criteria. This is
considered due to the aforementioned role overlap allowing interventions to be transferrable
across health professions, and also to assess how NPs can assure other care staff sustain their
roles in reducing causes and outcomes of problematic polypharmacy.
Systematic reviews that are published within the given timeframe, though analyze some
studies published prior to 2005, were included for review. Due to limited data within Canada,
research conducted in the United States and overseas was included. Non-English studies were
excluded. Research conducted outside the context of nursing homes was also excluded in order
to inform the specific context and population. However, many strategies conducted outside of
nursing homes may be useful as efforts to reduce problematic polypharmacy before older adults
require transition to a nursing home environment may reduce the prevalence of the causes and
outcomes of problematic polypharmacy within this context. It is recognized that efforts to reduce
this issue in other practice settings are important for NPs to adhere to and advocate for.

35
Search Outcomes
Due to the extent of information on polypharmacy, the search strategy identified 1,227
results between all four databases. Duplicates between each database were removed leaving
1,108 results. After an analysis of titles, literature conducted outside the context of interest were
excluded. For example, some contexts included hospitals, home care, and community. Titles that
identified literature that solely focused on the prevalence, factors associated, and outcomes of
problematic polypharmacy within various settings and populations were also excluded as they do
not aid to inform how causes and outcomes of this issue may be reduced
After reviewing abstracts, of the remaining 452 papers, studies found to be in the trial
phase were excluded. Other reasons for excluding articles included those conducted outside the
context of nursing homes, or focused on other factors, such as outcomes and the prevalence of
polypharmacy among certain disease states, rather than interventions to reduce the causes and
outcomes of this issue.
In the phase of full-text review, 18 articles were examined. Many studies were found to
be in the trial phase and excluded. One study simply had staff rate interventions that reduce
causes and outcomes of problematic polypharmacy according to their personal perception of
importance. This study was excluded, as it did not provide evidence-based information
surrounding the efficacy of interventions within nursing homes. One article was excluded as it
was not guided by a particular method of data collection, and appeared to be a synopsis of a
systematic review.
Two systematic reviews were found, and the first of these is inclusive of most studies
retrieved from this search process. However, the first review focused on those with severe

36
dementia. Though dementia is a common diagnosis within nursing homes, the second and older
review was kept to assure effective interventions are not missed.
One article retrieved examined the role of an NP caring for nursing home residents, with
one outcome measure, among other broader outcome measures, that explores reductions in the
causes and outcomes of problematic polypharmacy. This article, including two retrieved from its
references, were included for review. The two articles identified within the references also
review the role of NPs in the context of nursing homes with some discussion surrounding how
causes and outcomes of problematic polypharmacy can be reduced. An analysis of these three
studies within the integrative review may allow for specific insight surrounding how NPs can
impact the issue at hand within nursing homes. Also one guideline formulated in 2012 targeting
NPs was included for review.
The critical appraisal process is guided by tools and checklists created by the Critical
Appraisal Skills Programme (CASP, 2013). These tools are easily accessible online and include
straight forward checklists for a variety of different types of research. The CASP tools do not
include a tool to assess the quality of guidelines and non-randomized studies. To address this
gap, a tool created by Downs and Black (1998) that has held up in terms of rigour and
usefulness, making it one of the most commonly used tools (Quigley, Thompson, Halfpenny, &
Scott, 2014), is used to analyze non-randomized studies included in this review. To ensure robust
critical appraisal of the guideline included in this review, the Appraisal of Guidelines for
Research and Evaluation (AGREE 2) tool is used, as it is current, commonly used, and
comparable to other tools (Eikermann, Holzmann, Siering, and Ruther, 2014). It additionally
requires an external review process which enhances the quality assessment (Eikermann et al.,

37
2014). A total of 9 studies are kept for inclusion in this integrative review. A search flow chart
outlining the process described above is found below.
Figure 1
Search Flow Chart

Studies conducted within the specific context of nursing homes are sparse. However an
array of interventions are found within studies, reviews, and the guideline, which are undertaken
by different health care professionals. The two systematic reviews provide a comprehensive
understanding of interventions. The three studies specific to NPs provide additional insight
surrounding how NPs can undertake a reduction in the causes and outcomes of problematic
polypharmacy. The next chapter is an overview of the 9 articles included for review, including
critical appraisal, and an analyses and critique of the results.

38
CHAPTER 4
Findings
Nine studies are selected to address the research question of how NPs can best promote a
reduction in the causes and outcomes of problematic polypharmacy among residents in BC
nursing homes. The findings are discussed based on individual article in order to provide clear
analysis and critique. Analyses of each article touches on the aim, method of data collection,
sample, and setting for critical appraisal and strength of evidence. There are many guides for
evaluating the strength of evidence throughout the literature. A modified compilation put forth
by Mazurek and Fineout-Overhold (2011) is used to rate studies as it is more inclusive of various
types of studies. Results are also synthesized individually per article with critical analyses for
clarity in answering the research question.
This integrative review begins with exploring the sole practice guideline found within the
literature search. An analysis and critique of two systematic reviews follows, and subsequently
research published after these systematic reviews. The goal is to reveal implications for practice
inclusive of evidence-based interventions that reduce the causes and outcomes of problematic
polypharmacy in a way that considers the complexity of resident care needs, and barriers faced
by staff within nursing homes, as well as implications for policy, education, and research.
Bergman-Evans & Schoenfelder (2012). Evidence-based practice guideline: Improving
medication management for older adult clients residing in long-term care facilities. University
of Iowa, School of Nursing, Center for Gerontological Excellence.
Guideline Aim
The purpose of this guideline was to improve medication management practices for older
adults who reside in nursing homes (Bergman-Evans & Schoenfelder, 2012). This was

39
undertaken by putting forth interventions that demonstrate effectiveness within this context,
along with specific outcome measures that can be used to reflect a reduction in problematic
polypharmacy (Bergman-Evans & Schoenfelder, 2012). The guideline targets a reduction in
polypharmacy, described in the way of number of medications, as well as reductions in
inappropriate prescribing. These are two causes of problematic polypharmacy and collectively
inform this review. This guideline is directed to NP practice, though other members of the
interdisciplinary team including nurses, pharmacists, physicians, and physician assistants may
also benefit from incorporating the recommendations (Bergman-Evans & Schoenfelder, 2012).
Method of Data Collection, Sample, & Setting
The overall quality of this guideline is strong (Brouwers et al., 2010). The researchers use
a sound and comprehensive method of data collection through systematic review. However, it
is difficult to assess the rigour of the 118 individual studies used for formulating this guideline,
as the researchers do not provide study specific information, including methodological features,
such as methods of data collection (Brouwers et al., 2010). Researchers do explicitly link their
findings with supporting evidence (Brouwers et al., 2010), and support their recommendations
while using a grading schema that refers to the types of studies that were used. Furthermore,
inclusive studies are relevant to the research question as they were each conducted in the context
of nursing homes, which considers the specific complexity of resident care needs towards
reducing the causes and outcomes of problematic polypharmacy.
To improve the validity of this guideline, the researchers include an external review
(Brouwers et al., 2010) conducted by two experts knowledgeable about research on improving
medication management for those residing in nursing homes (Bergman-Evans & Schoenfelder,
2012). They suggest additional evidence and changes to the guideline to enhance the clinical

40
usefulness (Bergman-Evans & Schoenfelder, 2012). These recommendations are clearly
identified and rated as level D, referring to expert opinion (Bergman-Evans & Schoenfelder,
2012). Other levels of evidence include level B1 (high quality evidence-based practice
guideline), and C1 (observational studies with consistent results, including correlational and
descriptive studies), overall making this guideline a well-researched and informed systematic
review of the literature, with level one evidence per Mazurek and Fineout-Overhold (2011).
Results
Four different outcome measures were presented in this guideline in regard to assuring
the causes and outcomes of problematic polypharmacy were limited. Outcome measures that
target causes of problematic polypharmacy include minimizing inappropriate prescribing and
polypharmacy (Bergman-Evans & Schoenfelder, 2012). Measures that target the outcomes of
problematic polypharmacy include assessing functional status and avoiding adverse drug
reactions among nursing home residents (Bergman-Evans & Schoenfelder, 2012). The outcome
measure of reducing inappropriate medications was supported by interventions with the strongest
evidence per the grading schema, representing level B1 (Bergman-Evans & Schoenfelder, 2012).
However, all interventions are limited, as it is difficult to determine the statistical significance of
each intervention, as these values are not provided.
Reducing inappropriate medications focused on utilizing existing accessible criteria, such
as the Beers Criteria, as well as consulting pharmacists for their clinical expertise (level B1), to
inform the appropriateness of medication prescriptions (Bergman-Evans & Schoenfelder, 2012).
Reducing polypharmacy was another strategy identified, which is described as the number of
medications. This acknowledges an increased likelihood of interactions with increasing
medications among nursing home residents, who undergo varying degrees of physiological

41
change that effects drug metabolism (Bergman-Evans & Schoenfelder, 2012). The researchers
also acknowledged time constraints faced by nursing staff who must prepare and administer
medications, as well as monitor numerous residents, while confounded with interruptions, which
increased the risk for medication errors (Bergman-Evans & Schoenfelder, 2012). Thus emphasis
was applied on reducing medication regimens to decrease the likelihood of interactions among
residents, and the burden on staff.
To reduce the burden on staff and the likelihood of interactions among residents,
researchers advised prescribers to conduct medication reviews at each mandated periodic visit,
and to record the total number of scheduled and as needed medications (Bergman-Evans &
Schoenfelder, 2012). The goal was to prevent an increase in medications, with no more than nine
medications, which are scheduled no more than three times daily for ease of administration (level
C1) (Bergman-Evans & Schoenfelder, 2012). Capping regimens at nine medications is a
numerical threshold that reinforces the variability of polypharmacy definitions within the
literature. Many residents may require more medications given increasing comorbidity.
Additionally, while medication administration times isolated to three times daily is beneficial for
nurses, many medications have interactions necessitating ample spacing, require administration
on an empty stomach, half-hour before meals, and other variables that may make this
recommendation difficult to implement.
Researchers also advised an assessment of creatinine clearance, while using the
Cockcroft Gault Score (level D) on admission, upon changes in condition, and at least annually
(level C1) to prevent adverse resident outcomes due to physiological changes (Bergman-Evans &
Schoenfelder, 2012). This is an excellent recommendation for providers, including NPs. It
prompts preventative assessments, considers changes in pharmacokinetics and

42
pharmacodynamics that come with aging, and reduces the risk for inducing causes and outcomes
of problematic polypharmacy. To facilitate this recommendation, it may be timed with other
investigations residents may need throughout the year.
Reducing polypharmacy was also supported by having nursing staff implement
nonpharmacological approaches to manage behavioural symptoms (Bergman-Evans &
Schoenfelder, 2013). However, reduced nursing staff, holding nurses in supervisory roles as
opposed to being more involved with direct-resident care, and lack of knowledge in effectively
implementing these approaches may make this intervention difficult.
Maintaining functional status as an intervention is unique within the literature obtained
for this project. Decline in functional status was identified as a poor outcome for residents and
could result in increased workload for staff (Bergman-Evans & Schoenfelder, 2013). The
researchers suggested it is important to detect and discuss these changes within interdisciplinary
meetings (Bergman-Evans & Schoenfelder, 2013). An assessment of functional status was
effectively conducted while using the MDS-ADL scale designed to be administered within 14
days of admission, quarterly, and during status changes (level C1) (Bergman-Evans &
Schoenfelder, 2013). This interval is reasonable as a baseline is obtained, routine screening
assures changes are not missed, and acute incidents are well-assessed. The MDS-ADL scale
assesses the resident’s bed mobility, transfer, walk in room and corridor, locomotion on and off
unit, dressing, eating, toilet use, and personal hygiene (Bergman-Evans & Schoenfelder, 2013).
The scale is limited in that these assessments are subjective and dependent on individual skill.
The elements of the scale may be best informed by staff who spend the most time with residents
during these processes, such as HCAs who conduct most personal care. However, as HCAs are
provided with less educational preparedness in detecting medication-related decline, assessments

43
are also warranted by other care staff, such as nurses, and NPs, especially upon acute status
changes.
The last outcome measure that assured a safe medication regimen among residents, and
minimized outcomes of problematic polypharmacy, was to avoid adverse drug reactions
(Bergman-Evans & Schoenfelder, 2012). If medications were identified as causing an adverse
drug reaction, emergency transfers, or hospitalizations, they were to be discontinued, though
only after establishing a mutually agreed-on plan with care staff (level C1) (Bergman-Evans &
Schoenfelder, 2012). A mutually agreed-on plan encompassed monitoring residents for
symptoms of reoccurrence and/or withdrawal reactions (Bergman-Evans & Schoenfelder, 2012).
This is important evidence, as it provides physicians support in deprescribing when staff support
in monitoring residents is guaranteed; however, limited staffing that contributes to limited
availability from nurses and HCAs, may make this plan increasingly difficult to assure.
Shortfalls in knowledge surrounding adverse drug reactions and medication management
is shown among nursing staff (Lim et al., 2010). This may be particularly problematic for HCAs
who receive less education and training compared to nurses. Improving knowledge with an
educational intervention is not put forth as a specific outcome measure to reduce causes and
outcomes of problematic polypharmacy and to improve medication management in this
guideline. An analysis of an educational intervention is warranted to determine its efficacy and
strength of evidence.
This guideline recommends four outcome measures that address the causes and outcomes
of problematic polypharmacy. Conducting medications reviews while utilizing the Beers Criteria
are informative interventions for NPs to implement. Nurse practitioners also benefit from
pharmacist expertise, thus can work with these professionals to inform medications prescribed.

44
The effective interval of these reviews is yet to be determined. Monitoring for functional decline
and physiological changes are excellent ways to assure the causes and outcomes of problematic
polypharmacy are limited. The optimum interval in discussing functional assessments also needs
consideration. Though each outcome may not target NPs specifically, multiple health care
professionals are involved with implementing interventions, and NPs can help ensure nurses and
HCAs sustain their roles, which may involve advocating for practice and policy changes to
promote staffing improvements and time for direct resident care.
Kroger et al. (2015). Medication use among nursing home residents with severe dementia:
Identifying categories of appropriateness and elements of a successful intervention. Journal
of the American Medical Directors Association, 16(7), 1-17.
Study Aim
This review had three specific aims. The first aim was to determine how to identify
inappropriate medications among nursing home residents with severe dementia. Secondly, they
aimed to identify interventions likely to succeed in improving medication use among residents
that considered reducing the causes and outcomes of problematic polypharmacy. Lastly,
researchers aimed to adapt findings to the context of Quebec, Canada (Kroger et al., 2015).
Though the review focused on those with severe dementia, which is not identified as a focus for
this project, it is a common diagnosis among nursing home residents, and commonly associated
with problematic polypharmacy.
Method of Data Collection, Sample, & Setting
The overall quality of this systematic review is strong (CASP, 2013), with level 1
evidence per Mazurek & Fineout-Overhold (2011). The internal validity is enhanced as a quality
assessment of inclusive studies were rated moderate to strong (Kroger et al., 2015). These studies

45
have a strong method of data collection, and represent primarily level two and three evidence per
Mazurek & Fineout-Overhold (2011), and quantitative data. Interventions will be identified with
their corresponding level of evidence throughout this review.
Inclusive studies focused on the causes of problematic polypharmacy, including
inappropriate medications, specific studies pertaining to inappropriate antipsychotic use, and
three studies that generally addressed polypharmacy (Kroger et al., 2015). Studies also focused
on outcomes of problematic polypharmacy, such as drug-related problems. This review is a good
representation of the literature, as the 35 studies included represent worldwide research, nonEnglish studies, and those published from 1987 to December 2013 (Kroger et al., 2015).
Although this review aimed to examine interventions effective among nursing home residents
with severe dementia, most studies inform general nursing home demographic, assuring
interventions are generalizable across nursing home residents.
This review is limited in that most inclusive studies were conducted outside of Canada,
with the exception of three from Quebec, and one from Ontario. A 15-member Delphi panel was
formulated to evaluate the applicability of the findings of this review to nursing homes in
Quebec, Canada (Kroger et al., 2015). To assure no limitations, the Delphi panel was inclusive of
a multidisciplinary team, including geriatricians, physicians, nurses, pharmacists, social workers,
and an ethicist (Kroger et al., 2015). The Delphi panel assessments determined that interventions
are generally applicable to Quebec, though some may be affected by understaffed facilities. This
is a generalizable statement to the BC context given current barriers within some facilities. It is
important to note that per Mazurek & Fineout-Overhold (2011), the strength of evidence using
the Delphi process is least evidence-based (level seven); however, expert opinion is beneficial in
gaining a view surrounding the clinical significance and feasibility of findings.

46
Results
Upon analyzing interventions that come through within studies to reduce the causes and
outcomes of problematic polypharmacy, each intervention demonstrated reductions in their
specified outcome measure. However, the findings are limited as statistical analyses, such as
probability values, are not provided.
In addressing the causes of problematic polypharmacy, researchers advised the use of
screening criteria to identify inappropriate medications (Kroger et al., 2015). They referred to the
Beers Criteria and the Screening Tool of Older People’s Potentially Inappropriate PrescriptionsScreening Tool to Alert Doctors to Right Treatments (STOPP-START) as effective criteria
(Kroger et al., 2015).
Sixteen of 35 studies in this review included education or training as an intervention for
staff, including physicians and nurses. Each of the 16 studies demonstrated an improvement in
the appropriateness of medications, thus causes of problematic polypharmacy, determined by
reductions in antipsychotics, hypnotics, benzodiazepines, and NSAIDs (Kroger et al., 2015).
Each of the 16 studies also represent strong evidence, rated as level two or three per Mazurek &
Fineout-Overhold (2011). It is specifically noted that active involvement of pharmacists in
education or training of other health care professionals improved pharmacotherapy for older
adults by reducing the causes and outcomes of problematic polypharmacy (Kroger et al., 2015).
Nurse practitioners could benefit from pharmacist-led education in improving their prescribing
practices, such as participating in PAD services. In analyzing forms of education, interactive
educational approaches with direct feedback appeared to be the most effective (Kroger et al.,
2015).

47
It is difficult to determine the long-term efficacy of educational interventions as most
studies do not indicate a follow-up period. Studies that do indicate a follow-up period at 9, 12,
and 18 months, each remained effective in reducing inappropriate medications, although to a
lesser extent (Kroger et al., 2015). There is no determined interval of reintroducing and
implementing education interventions. Specific elements of education are put forth for an
assessment of generalizability to the Quebec context by the Delphi panel. These included
education surrounding nonpharmacological approaches, and considering the resident’s life
expectancy upon prescribing, in which all were considered applicable to the Quebec context
(Kroger et al., 2015), and are likely applicable to nursing homes across Canada, including BC.
Twenty-one studies included medication reviews which were led by pharmacists,
physicians, or a multidisciplinary team (Kroger et al., 2015). Each of these studies were effective
in reducing causes of problematic polypharmacy including polypharmacy, and inappropriate
medication, such as antipsychotics and benzodiazepines (Kroger et al., 2015). Medication
reviews also demonstrated reductions in outcomes of problematic polypharmacy, including
reduced falls and hospital transfers (Kroger et al., 2015). These studies all represent strong
evidence, and are rated as level two or three evidence (Mazurek & Fineout-Overhold, 2011).
Medication reviews led by pharmacists was particularly promising in improving
medication use among older adults (Kroger et al., 2015), which may stem from their
pharmaceutical expertise. However, the implementation of pharmacist recommendations were
often suboptimal among studies. This highlights ongoing collaborative challenges within nursing
home settings. These findings also indicate that enhancement of interdisciplinary education
among health professions surrounding the roles, knowledge, and expertise of team members is

48
timely in order to facilitate better uptake of recommendations by various professionals, including
pharmacists.
Regular follow-up meetings were also suggested to discuss the resident’s medication
regimen. This suggestion is quite vague, as the interval and makeup of health care professionals
warranted at these meetings are not established. The multidisciplinary Delphi panel
acknowledged how these meetings may not be feasible in Quebec facilities that are understaffed
(Kroger et al., 2015), which is also applicable to BC. The appropriate interval for regular
medication reviews has not been determined. Currently in BC pharmacists are mandated to
conduct medication reviews every six months (CPBC, 2014), which requires reconsideration for
shorter intervals, or more meaningful reviews, given persisting causes and outcomes of
problematic polypharmacy.
Interdisciplinary approaches were among 15 of 35 studies (Kroger et al., 2015). These
approaches included team meetings and group discussions where medications were discussed in
general, and/or case conferences where medications were reviewed in the context of individual
resident (Kroger et al., 2015). All of these approaches demonstrated effectiveness in reducing
causes of problematic polypharmacy, such as inappropriate medications, including
antipsychotics, benzodiazepines, and NSAIDs (Kroger et al., 2015). Team meetings also
specifically demonstrated detecting untreated conditions, which reduced potential adverse
resident outcomes (Kroger et al., 20150. This is likely feasible as the team is provided an
opportunity to share findings and benefit from each other’s expertise. All 15 studies represent
level three and four evidence (Mazurek & Fineout-Overhold (2011).
Specific elements of this interdisciplinary intervention that assured its success were to
relay that participation from nursing home staff was expected, and to encourage staff

49
involvement in care (Kroger et al., 2015). The multidisciplinary Delphi panel again raised issues
of understaffing within Quebec nursing homes that would hinder the feasibility of these elements
(Kroger et al., 2015), which is also applicable to the BC context. Nonetheless, it is noteworthy
that interdisciplinary team meetings and case conferences continue to be presented as effective
means of reducing causes and outcomes of problematic polypharmacy, and implications for
staffing and policy changes are warranted for an effective follow-through.
Although interventions are overall successful, and studies that involve a follow-up period
remain to demonstrate reductions in the causes and outcomes of problematic polypharmacy,
follow-up results are not as effective and rather demonstrated a trend towards effects fading over
time (Kroger et al., 2015). It is not mentioned if this is the case despite interventions consistently
in place, or if this is demonstrated over time after the cessation of interventions. Thus
determining the appropriate and feasible interval of implementing effective interventions is
important.
It is important to note that NPs and HCAs are not particularly targeted within this review.
However taking part in interdisciplinary case conferences and team meetings are transferable to
the participation of these two members. Nurse practitioners can benefit from interdisciplinary
case conferences where they can be updated with resident assessments that may otherwise be
overlooked. Nurses and HCAs play an important role within these meetings, which is not always
feasible due to time constraints, thus the collective team, including NPs, have a role in
advocating for practice and policy changes to improve staffing levels. Conducting medication
reviews is well within the scope of NP practice, though it is particularly regarded to collaborate
and benefit from pharmacist-expertise with medication reviews, as well as receiving pharmacistled education. Thus, NPs may elect to involve pharmacists in medication reviews at alternating

50
intervals in order to delegate functions allowing for a more feasible workload. Nurse
practitioners can also encourage pharmacists’ participation among interdisciplinary team
meetings where educational opportunities can be undertaken, and prescribing practices can be
improved. A common aspect of effectively implementing most interventions is the requirement
or benefit of involving multiple health care professionals.
The focus of this systematic review was to determine interventions specifically effective
among residents with severe dementia. However, very few studies inform this population, and
most inform the general nursing home demographic (Kroger et al., 2015), thus results are
generalizable. To assure effective interventions are not missed, the next review is inclusive
within this integrative review, as it aimed to examine interventions that broadly address nursing
home residents.
Loganathan, Singh, Franklin, Bottle, & Majeed. (2011). Interventions to optimise
prescribing in care homes: Systematic review. Age and Ageing, 40(2), 150-162.
Study Aim
The aim of this review was to examine the effects of interventions that are implemented
to optimize prescribing specifically in nursing homes (Loganathan et al., 2011). Thus, this
review brings forth interventions that reduce the causes of problematic polypharmacy, such as
inappropriate prescribing.
Method of Data Collection, Sample, & Setting
The overall quality of this systematic review is strong (CASP, 2013), with level one
evidence per Mazurek & Fineout-Overhold (2011). The majority of the 16 studies inclusive for
review represented high quality studies with mean scores of 20/27 and above (Loganathan et al.,
2011). Two studies had much lower scores, potentially due to selection bias and confounding

51
(Loganathan et al., 2011). Each study helps in answering the research question, as studies were
conducted within the context of nursing homes, represented a mean age above the age of 65
years, and evaluated the effects of an intervention on prescribing, and improving appropriate
prescribing (Loganathan et al., 2011). An advantage of this review over the previous two, is that
an assessment of statistical significance is feasible, as statistical analyses is provided, such as
probability values. This review includes strictly level two and three evidence per Mazurek &
Fineout-Overhold (2011). Though this review is comprehensive in that it includes studies from
1990 to April 2010, non-English studies were excluded, thus potentially missing relevant studies
(CASP, 2013). Also all but two studies were conducted outside the context of Canada, thus an
assessment surrounding the generalizability of interventions is conducted.
Results
The interventions that came forth in this review are organized into four categories.
Categories include staff education for prescribers and/or care home staff (n=8), pharmacist-led
medication reviews (n=3), multidisciplinary team meetings that were usually chaired by the
prescribing physician (n=3), and computerized clinical decision support systems (CCDSS, n=2)
(Loganathan et al., 2011). However, the categorization of studies was not straight forward and
brings forth limitations for an accurate assessment of interventions, as some studies took a
combination of approaches (Loganathan et al., 2011). This in turn demonstrates that problematic
polypharmacy is a multifaceted topic that may require multiple interventions to successfully
reduce its causes and outcomes.
Of the studies that examine the impact of educational interventions, six of eight
demonstrated reductions in causes of problematic polypharmacy, such as inappropriate
prescribing, with the longest follow-up at 13 months (p<0.05). Of these studies, an “interactive”

52
component was present (Loganathan et al., 2011). Interactive components also demonstrated
effectiveness among Kroger et al.’s (2015) review. For example, academic detailing was
particularly effective in reducing inappropriate prescribing, and used interactive components
(Loganathan et al., 2011). Academic detailing is described as when a trained health care
professional meets with a prescriber in their practice setting to provide evidence-based
information (Jin et al., 2012), such as PAD services. Within the studies in this review, academic
detailing used interactive components with face-to-face interaction between a group of experts
and the prescribing physician. Groups of experts within studies included psychiatrists, geripsychiatrists, and pharmacists (Loganathan et al., 2011). Academic detailing using pharmacist
expertise was particularly effective in reducing antipsychotic use (Loganathan et al., 2011).
These are opportunities for prescribers, including NPs, to draw on specialist expertise.
Education provided to multiple members of the team, rather than just the prescriber, was
shown to be more effective in reducing inappropriate prescriptions (Loganathan et al., 2012). For
example, education with interactive components that were found to be effective, also involved
nurses and families as their audience through workshops (Loganathan et al., 2011). This
highlights the importance of a team understanding surrounding the causes of problematic
polypharmacy, as multiple staff are involved in the care of residents. For example, nurses and
HCAs can detect adverse health changes, and communicate these to the team, or manage
behavioural symptoms with proper techniques, and without the use of inappropriate
prescriptions. Thus, enhanced psychosocial care training with focus on behaviour management
through the use of nonpharmacological approaches that were taught through role play
demonstrated reductions in inappropriate neuroleptic use (Loganathan et al., 2011).

53
One study extended to examine the effects of educational intervention on reducing
inappropriate prescribing after five years. Although this study demonstrated a reduction in the
use of hypnotics before nine p.m. (p<0.01), there was an overall increase in the proportion of
residents that were receiving hypnotics (Loganathan et al., 2011). This may represent an increase
in the complexity of nursing home residents over the five years who are living longer with more
comorbidy. It may also represent growing staff constraints that promote the use of these
medications, or a lack of continual educational intervention within the five years.
Studies that were comparatively less successful with an educational intervention found
poor attendance by participating physicians (Loganathan et al., 2011). Physicians are an
important target for educational intervention that are aimed at improving prescribing practices, as
they have prescriptive authority. This also applies to NPs who have comparative roles in
reducing causes of problematic polypharmacy. The lack of success within these studies
highlights the importance of prescriber attendance. Thus, the researchers formulated implications
for policy and practice and suggested implementing educational interventions that employ
several complementary techniques, and are directed at all healthcare professionals, as well as
family members (Loganathan et al., 2011). However, the appropriate interval of interventions has
not been determined, and the method of delivery through which the educational intervention
would be implemented needs consideration, as staff may not find it feasible to attend formal
information sessions.
Upon reviewing studies that implemented pharmacist-led medication reviews, only one
of three demonstrated statistically significant changes (p<0.0001) in optimizing prescribing
within nursing homes with follow-up at six months (Loganathan et al., 2011). However, the other
two studies used a reduction in medications as an outcome measure, rather than appropriateness

54
of medications, which may not have reflected the effectiveness of the intervention appropriately
(Loganathan et al., 2011). Also it was not indicated whether the intervention was not effective
because of a lack of uptake of pharmacists’ suggestions, as found in Kroger et al. (2015), or an
ineffective medication review. Thus despite mandated regular medications reviews in BC, this
review highlights the importance of meaningful medications reviews. For instance, the
successful medication review involved consultation with residents and their carer, such as a
family member (Loganathan et al., 2011). This approach makes medication reviews more
meaningful, as the resident is the cornerstone to decisions being made. Ongoing exploration is
needed to establish the factors contributing to a meaningful medication review and their efficacy.
Two of three studies examined the effects of multidisciplinary team meetings and
demonstrated statistically significant changes in medication-related outcomes (Loganathan et al.,
2011). It is noteworthy that one successful study was pharmacist-led, and the other involved
experts from other disciplines, such as geriatricians. This again emphasizes the effectiveness of
pharmacist expertise, and also suggests involving specialty fields in tackling the issue of
problematic polypharmacy among this complex population. A general multidisciplinary team
meeting that was used by the study without demonstrable outcomes may be just as effective, as it
was noted that this study may have been subject to selection bias (Loganathan et al., 2011).
These meetings are also informed by direct-care staff that share resident status updates. The
timing of multidisciplinary team meetings must be considered in order to be mindful of staffing
shortages.
Of the two studies focused on CCDSS, one study evaluated the appropriateness of drug
orders, based on maximum daily dose, frequency of administration, medications to be avoided,
and kidney function. With a follow-up at 12 months, this study demonstrated improvements in

55
prescribing (CI 95%). The other study evaluated the systems effects on preventing drug-to-drug
interactions, though the results were statistically insignificant (Loganathan et al., 2011). The
effectiveness of CCDSS needs further investigation to establish its efficacy in reducing aspects
that contribute to problematic polypharmacy.
Overall, Loganathan et al. (2011) suggested that a combination of interventions are likely
to be required to improve prescribing among nursing homes residents (Loganathan et al., 2011).
Upon assessing the generalizability of interventions to the BC context, although the two CCDSS
studies were conducted in Canada, this intervention is only applicable to nursing homes who
have computerized systems in place, such as EMR and EHR. There are no technical constraints
surrounding educational interventions, medication-reviews, and multidisciplinary approaches,
and they are generalizable to the BC context.
In light of NP practice, enhancing prescribing practices is beneficial through education
informed by pharmacist-expertise. These opportunities are also beneficial for other health care
professionals, such as nurses, for whom NPs can promote ongoing participation. Determining the
appropriate interval and methods of delivery, such as formal versus informal, needs
consideration. Medication reviews are a necessity as they provide an overview of resident
medications. Nurse practitioners can assure these are updated and more meaningful by double
checking with PharmaNet, and consulting with residents and their families. Inappropriate
medications can be identified by utilizing screening criteria, such as the Beers Criteria. The
appropriateness of medications can also be gathered by drawing on specialist expertise, and
gaining assessment information from nurses and HCAs within multidisciplinary team meetings.
As multiple health care professionals are required in the care of residents and reducing the causes

56
and outcomes of problematic polypharmacy, NPs can advocate for practice and policy changes to
assure staffing ratios are improved and time for direct resident care is enhanced.
Ilic, Bukumiric, & Jankovic, (2015). Impact of educational intervention on prescribing
inappropriate medication to elderly nursing home residents. Journal of the Serbian Medical
Society, 134(3-4), 174-179.
Study Aim
Loganathan et al.’s (2011) review, suggests an educational intervention to facilitate a
reduction in causes of problematic polypharmacy in the context of nursing homes, such as
inappropriate prescribing. Though interactive approaches are highlighted, the method of delivery
is vague, such as formal versus informal. The aim of this study was to evaluate the effectiveness
of a specific form of staff education and its ability to increase appropriate prescribing in a cluster
of nursing homes (Ilic et al., 2015).
This study was conducted in three phases, including a three-month phase of recording
prescribing practices, one-month phase of educational intervention, and a three-month phase of
recording and analyzing prescribing practices at a six-month follow-up (Ilic et al., 2015). The
intervention was two-faceted targeting physicians and residents. For physicians, one-hour
lectures were provided by a medical doctor who had a Master of Science in pharmacology about
the pharmacokinetics and pharmacodynamics of drugs in the elderly, the Beers, START, and
STOPP criteria, and screening tools to alert physicians to the right treatment (Ilic et al., 2015).
One-hour lectures were also provided to nursing home residents about adherence, adverse drug
reactions, and drug-to-drug interactions. Separate brochures were provided to physicians and
residents with the identical content that they were each provided in lectures (Ilic et al., 2015).

57
Method of Data Collection, Sample, & Setting
This study is a nonrandomized controlled before-and-after trial of educational
intervention (Ilic et al., 2015). The quality of this study is strong (Downs & Black, 1998), with
level three evidence per Mazurek & Fineout-Overhold (2011). However, the external validity of
this study is compromised as residents with major psychiatric diseases and dementia were
excluded. These residents were excluded to promote full participation (Ilic et al., 2015). Those
excluded represent a large portion of nursing home residents, thus the findings must be
generalized with caution. A total of 104 residents met the inclusion criteria that included those 65
years of age and older, and residents that have at least two chronic health disorders (Ilic et al.,
2015). This study was conducted during 2012 and 2013 among 20 nursing homes located in
Belgrade, Serbia, and included 27 physicians who provided resident care (Ilic et al., 2015). The
organization of nursing homes was not indicated, i.e. not-for-profit versus for-profit. The
findings are assessed for generalizability to the BC context. The Beers, START, and STOPP
criteria were used to assess medication appropriateness before and after the intervention (Ilic et
al., 2015).
Results
During phase one of this study, residents were found to be taking 10.2 +/- 2.3 prescribed
medications and 3.2 +/- 1.5 over-the-counter medications (Ilic et al., 2015). After the educational
intervention, inappropriate medications were found to reduce from 349 to 37 medications
according to the Beers Criteria, and from 70 to 20 medications according to the STOPP criteria
(Ilic et al., 2015). The START criteria omitted 143 appropriate medications before the
intervention which reduced to only 67 appropriate medications after the intervention (Ilic et al.,
2015). All findings were with statistical significance (p<0.001) (Ilic et al., 2015). Beyond the

58
overall educational intervention, the findings highlight the effectiveness of screening tools. The
Beers Criteria is specifically effective, as it continues to identify significantly more inappropriate
medications.
The educational intervention demonstrated long-term efficacy of providing physicians
and residents education in lecture form, as a reduction in inappropriate medications remained
reduced at six-month follow-up. However, a limitation to this study is that it is not clear whether
residents had an impact on deciding the appropriateness of medications. It cannot be for certain
that an agreeable plan was formulated between this team to improve prescribing, or if results
were solely facilitated by physicians. The longevity of this intervention is also compromised
within nursing homes, as residents may no longer be able to participate upon facing a degree of
functional decline and memory impairment. Also, this intervention does not indicate whether
there is an interactive component that was highlighted in Kroger et al. (2015), and Loganathan et
al.’s (2011) reviews. Different forms of education that can be provided throughout the year may
be optimal to solidify and utilize knowledge.
This study is limited for generalizability across nursing homes, as the resident sample is
not a strong representation of nursing home demographics. Many nursing home residents suffer a
degree of memory impairment, and cannot participate in this intervention. The likelihood of
implementing this intervention in its entirety is compromised.
This intervention could be used with NPs who are also primary care providers that make
medication-related decisions. For more meaningful decisions and if appropriate, NPs can
encourage family involvement within the intervention to represent residents who suffer a degree
of cognitive impairment. The information provided within these seminars are also important
teaching points for other care staff, such as HCAs and nurses. Nurse practitioners can encourage

59
nurses and HCAs to attend seminars. As there are time constraints that subject direct care staff to
competing priorities, NPs can promote educational preparedness by encouraging staff to refer to
brochures.
da Costa et al. (2016). Drug-related problems identified in a sample of Portuguese
institutionalised elderly patients and pharmacists’ interventions to improve safety and
effectiveness of medicines. Real World Outcomes, 3(1), 89-97.
Study Aim
This study provides current analysis surrounding pharmacist-led intervention, which was
statistically insignificant within two of three studies presented by Loganathan et al. (2011). The
objective of this study was to determine the prevalence and nature of drug-related problems
(DRPs) among older adults residing in nursing homes who are subject to polypharmacy, and to
test the acceptability of a pharmacist’s intervention (da Costa et al., 2016).
This integrative review focuses on the intervention aspect of the study, and not the
prevalence and nature of DRPs. The intervention consisted of a prioritisation of DRPs by
pharmacists, and then a subsequent report of these after establishing what were identified as
clinically relevant by prescribers and nurses (da Costa et al., 2016). After determining what was
clinically relevant, pharmacists provided recommendations surrounding these medications,
which were mailed to physicians (da Costa et al., 2016).
Method of Data Collection, Sample, & Setting
This study is a randomised-controlled trial, and the quality of this study is strong (CASP,
2013), with level two evidence per Mazurek & Fineout-Overhold, (2011). This study was carried
out between August and September 2014 among four Portuguese nursing homes (da Costa et al.,
2016). Residents meeting the inclusion criteria were those 65 years of age and older, and subject

60
to polypharmacy, described as taking five or more medications (da Costa et al., 2016). Solely
assessing for DRPs among those who received five or medications may have subjected
researchers to missing DRPs among those who received fewer medications. This does not affect
an assessment of the pharmacist’s intervention. The intervention and control groups consisted of
63 residents each (da Costa et al., 2016). The results of the intervention were evaluated one
month later in October 2014 (da Costa et al., 2016).
Results
Pharmacists identified 1002 DRPs, while 697 were found to be clinically relevant by
physicians and nurses (da Costa et al., 2016). Pharmacists made 63 recommendations for nurses,
which were mainly based on changing administration times (da Costa et al., 2016). It is
noteworthy to mention that in Bergman-Evans & Schoenfelder’s (2012) guideline, they
identified that a delay in and/or missed medications contributed to adverse drug reactions. As a
result, and as mentioned by Loganathan et al. (2011), a combination of interventions may be
necessary, where education surrounding adverse effects and timing of medications is provided
for all professionals involved in caring for nursing home residents. Given current barriers
surrounding staffing shortages and subsequent time constrains in some BC nursing homes,
administrating medications at the recommended time may be difficult. As improper timing of
medications may subject residents to adverse effects, advocating for staffing and policy changes
is important.
Pharmacists made 539 recommendations to physicians, including dosage changes,
suspension or addition of medications, and request of additional complementary exams to
evaluate the necessity of medications (da Costa et al., 2016). However, physicians only
responded to 172 recommendations, and only 15 recommendations were accepted (8.7%) (da

61
Costa et al., 2016). The researchers attributed the response rate to possible technical
communication problems, or lack of cooperation between different healthcare providers. A lack
of cooperation was favoured, as most non-response cases were from a nursing home where a
culture that facilitated cooperation was lacking (da Costa et al., 2016). The organization of this
nursing home, i.e. for-profit, was not identified. On the other hand, the response rate of 172
recommendations with an acceptance of only 15 recommendations may indicate that there were
many insignificant recommendations. Also it may be difficult to address a large volume of
recommendations in one given time. Physicians may have also rejected many recommendations
due to a lack of front-line support for monitoring residents and/or a lack of clear deprescribing
guidelines.
The findings in this study are also applicable to NP practice. Similar to physicians and
other health care professionals, NPs also have competing priorities where a large sum of
recommendations may be difficult to address. Feeling overwhelmed may significantly impact
implementing interventions to reduce causes and outcomes of problematic polypharmacy, and
important recommendations could be overlooked. Thus an examination of the exact
recommendations is warranted to determine how recommendations could be improved for
clinical usefulness. Nonetheless, pharmacist-led recommendations are highly valuable due to
their expertise in pharmacotherapy, thus they are essential members of the healthcare team in
reducing causes and outcomes of problematic polypharmacy.
Given recommendations may not be implemented due to a lack of front-line support, it is
important for NPs to address these concerns, as opposed to allowing residents subject to
inappropriate medications. Nurse practitioners can utilize deprescribing guidelines put forth by
the TI and OPRC. A mutually agreed upon assessment plan with HCAs and nursing staff, as put

62
forth by Bergman-Evans & Schoenfelder (2012) guideline, is necessary to assure residents are
properly monitored and adverse effects are limited during deprescribing. Advocating for practice
and policy changes is warranted as this approach may be impeded by understaffing and staffing
choices surrounding nurses and HCAs.
Marasinghe. (2015). Computerised clinical decision support systems to improve medication
safety in long-term care homes: A systematic review. British Medical Journal, 5(5), 1-8.
Review Aim
This review focused on providing current analysis surrounding the use, benefits, and
effectiveness of CCDSS within nursing homes (Marasinghe, 2015). In reviewing CCDSS, the
aim of this review was to reduce causes of problematic polypharmacy by enhancing medication
safety and quality of care in nursing homes. Furthermore, the aim was to also reduce outcomes of
problematic polypharmacy by limiting the added burden of medication-related issues on the
healthcare system, such as hospitalizations, as well as improve healthcare system efficiency
(Marasinghe, 2015).
Method of Data Collection, Sample, & Setting
This is the first systematic review to explore the role of CCDSS in improving medication
safety in nursing homes (Marasinghe, 2015). The quality of this review is strong (CASP, 2013),
with level one evidence per Mazurek & Fineout-Overhold (2011). This review was
comprehensive, as there were no limitations to the year of publication of inclusive studies until
February 2014; however, non-English studies were excluded (Marasinghe, 2015). A quality
assessment of the seven articles that met the inclusion criteria were generally good and fair, with
average scores of 19 out of 26 (Marasinghe, 2015); however, a limitation to this review is that
there was only one reviewer, and statistics analyses, such as probability values, were not

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provided for most studies. Inclusive studies are mostly randomized-controlled trials and nonrandomized controlled studies, and are relevant to the research question as they are each
conducted in the context of nursing homes, and evaluate the effectiveness of CCDSS to improve
medication safety (Marasinghe, 2015).
Results
Five of seven studies demonstrated improvements in medication safety by identifying
causes and pending outcomes of problematic polypharmacy (Marasinghe, 2015). Messages
included recommendations for dosing corrections, frequency corrections, missing information,
adverse drug reaction detections, side effect detections, and alerts related to laboratory warnings
(Marasinghe, 2015). The system was able to identify these warnings simultaneously in a short
period of time, which is not feasible by prescribers (Marasinghe, 2015). As a result the
proportion of final drugs orders were improved (Marasinghe, 2015). Furthermore, when resident
specific risk estimates were allotted into the system, i.e. falls risk, CCDSS provided an effective
method to reduce risk of injury by identifying medications that increased risks (Marasinghe,
2015). These instances demonstrated improvements in medication safety for residents, and also
reduced the burden on the healthcare system, such as preventable falls, fractures,
hospitalizations, and added cost (Marasinghe, 2015).
One study demonstrated positive results in the amount of warning messages triggered;
however, there was a negative response from prescribers to alerts, which requires further
investigation surrounding prescribers’ perception of alerts (Marasinghe, 2015). Researchers
stated that a high volume of alerts, which were considered irrelevant, may have affected
physician confidence in CCDSS, or may have caused alert burden, which warranted further
modifications to the systems (Marasinghe, 2015).

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In some studies CCDSS was added to pre-existing computerized systems, such as EMR.
These systems, including EHR, have many advantages in collecting resident data. Combining
these systems will allow greater informed decisions surrounding medications prescribed.
However, despite the advantages of computerized systems, the accuracy of programs will depend
on consistent data entry that requires effort from multiple health care professionals. Furthermore,
studies examining health professionals’ perceptions of CCDSS report the usability of these
systems, including technical and practical constraints, and the local practice culture, including a
facilities openness to these systems, as barriers to implementation (Moja et al., 2014).
With modifications to prevent alert burden, NPs can encourage a shift in culture by
creating awareness surrounding the advantages of computerized systems. They can also facilitate
an uptake of these systems by promoting in-services for ease of use.
Klaasen, Lamont, & Krishnan. (2009). Setting a new standard of care in nursing homes.
Canadian Nurse, 105(9), 24-30.
Study Aim
The aim of this study was to evaluate overall resident services after implementing a fulltime NP, who worked in collaboration with the medical director (Klaasen et al., 2009).
Discussions also included how the NP facilitated a reduction in the causes and outcomes of
problematic polypharmacy. Physicians working for the nursing home resigned for unknown
reasons (Klaasen et al., 2009). The NP’s willingness to expand her resident roster as physicians
trended out of their positions, demonstrates the NP’s ability to provide care in times of need.
Method of Data Collection, Sample, & Setting
The quality of this historically-controlled trial is fair (Downs & Black, 1998), with level
three evidence per Mazurek & Fineout-Overhold (2011). Both qualitative and quantitative data

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was collected to evaluate the full-time NP’s overall effectiveness in improving resident care
between the time period of September 2007 to August 2008 (Klaasen et al., 2009). The NP
worked within an interdisciplinary team in a 116-bed Winnipeg, Manitoba non-profit nursing
home (Klaasen et al., 2009). All residents were inclusive and represented nursing home
demographics well, thus inform the research question.
Among unstructured interviews, a variety of staff from different disciplinary backgrounds
were interviewed (n=15), pertaining to their perception of the NP (Klaasen et al., 2009);
however, a theoretical framework for this arm of the study is not provided, and it is unknown
how staff were selected, subjecting this arm of the study to selection bias. Family satisfaction
was determined through pre. and post-intervention surveys, though it is unknown how many
family members were included. The quantitative data collection pertaining to drug cost,
polypharmacy, inappropriate antipsychotic use, and emergency transfers is strong, as pre and
post-intervention data is accessible through the same data sources; however, statistical analyses
such as probability values are not provided.
Results
Within the quantitative data analysis, there was a 17% reduction in drug cost, 55%
reduction in the rate of polypharmacy that was described as nine or more medications, and a 63%
reduction in the use of inappropriate antipsychotic medications for the management of
behavioural and psychological symptoms associated with dementia. Furthermore, there was a
20% reduction in emergency transfers, and a 24% increase in family satisfaction (Klaasen et al.,
2009).
Through NP interviews, it was determined that comprehensive literature reviews,
experience, and consultation with clinical experts, contributed to supporting the NP in

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developing a specific list of strategies to reduce the causes and outcomes of problematic
polypharmacy (Klaasen et al., 2009). One strategy included a medication review, in which the
NP asked an array of questions that took a resident-focused approach. For example, if the
resident would live long enough to benefit from the medication at hand (Klaasen et al., 2009).
Strategies also included considering nonpharmacological interventions first, weighing the
pharmacological intervention against quality of life, reducing/discontinuing the medication to
assess whether it was truly needed, involving the resident and family in the decision-making
process, and educating staff/residents/family about monitoring parameters after discontinuing the
medication, among others (Klaasen et al., 2009). The last approach upholds an important factor
put forth by Bergman-Evans & Schoenfelder’s (2013) guideline in improving medication use in
nursing homes. A safe environment for deprescribing is created, when staff, residents, and family
are aware of adverse signs. Involving residents and family members, if appropriate, also provides
nurses and HCAs the support in identifying these instances in understaffed facilities.
Through staff interviews, the NP was found to increase access for staff and residents and
was available throughout weekdays to work with the interdisciplinary team (Klaasen et al.,
2009). Increased availability allowed for regular participation in interdisciplinary care planning,
family conferences, quarterly reviews of the residents’ medications, and thus care plans were
comprehensively formulated and updated (Klaasen et al., 2009).
Within interviews, it was also found that nursing staff were pleased with the timely
clinical education that they received from the NP, and referred to the NP as a role model
(Klaasen et al., 2009). Staff also particularly regarded the reduction of antipsychotic medications,
which may have been due to the NPs ongoing dialogue and follow-up with residents, families,
and staff (Klaasen et al., 2009).

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Overall, NPs were encouraged to lead medications reviews and consult clinical experts
for their expertise. However, NPs experienced barriers for collaboration from some physicians
(Klaasen et al., 2009). This is specifically problematic when concerns are raised about
medications prescribed by different providers, in which consultation with these specialists is
highly valuable and required. Furthermore, NPs are encouraged to provide NP-led education for
staff and to continue follow-up with staff and residents with dialogue surrounding medications
prescribed. These instances may be impeded with role confusion. For instance the NP was often
consulted for tasks within the RN or LPN scope of practice (Klaasen et al., 2009), possibly
taking away from the NP’s optimal use of time for implementing interventions. Implications for
education warrant interdisciplinary education to assure optimum consultation and effective
collaboration.
The NP’s abilities to demonstrate a reduction in causes and outcomes of problematic
polypharmacy may have been achievable in this study due to the benefits of working within a
full-time practice model. This requires consideration prior to generalizing the efficacy of the NP
and interventions across practice models.
Peri, Boyd, Foster, & Stillwell. (2013). Evaluation of the nurse practitioner in aged care.
Auckland, NZ: University of Auckland.
Study Aim
The aim of this study was to evaluate the impact of resident care provided by a
collaborative model involving an NP and physician against a non-collaborative model (Peri et a.,
2013). Broader outcome measures that may be a result of problematic polypharmacy were the
focus of this study, such as emergency transfers, hospital admissions, and preventable transfers,
with brief discussions on problematic polypharmacy. Intervention to reduce all outcome

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measures are reviewed, as they may be potentially linked. Other outcome measures that were not
specifically the focus of this study, analyse staff and family perceptions surrounding their
relationship with the NP, and their perceptions of the NP role (Peri et al., 2013). A description of
NP activities during resident consultations are also sought (Peri et al., 2013). These descriptions
highlight what was done to best minimize outcome measures.
Method of Data Collection, Sample, & Setting
This study uses a quasi-experimental method of data collection (Peri et al., 2013). The
quality of this study is fair (Downs & Black, 1998), with level three evidence per Mazurek &
Fineout-Overhold (2011). Chart audits were used to collect quantitative data, and informant
interviews, and focus groups comprised of various staff and a family member, were used to
collect qualitative data (Peri et al., 2013). The qualitative data is limited as no residents and only
one family member is included within interviews. Also there is no theoretical framework for this
arm of the study. Researchers are not blinded to the intervention and comparative arms, which
may affect the rigor of evaluation. Three nursing homes (n=177) received collaborative care
involving the NP, and three nursing homes (n=165) were among the control arm, all within
Levin, New Zealand (Peri et al., 2013). Interventions to reduce the causes and outcomes of
problematic polypharmacy are assessed for generalizability to the BC context.
Results
Through interviews and focus groups staff recognized a reduction in polypharmacy,
which was also demonstrated via randomized chart audits (Peri et al., 2013). However, the
definition of polypharmacy is not provided, as well as objective data pertaining to polypharmacy
reduction, which would strengthen these results. Staff state that the NP’s presence increased
access to the provider for themselves and for residents (Peri et al., 2013). This subsequently

69
reduced stress experienced by staff, as NPs were available for questions/concerns (Peri et al.,
2013). Through increased availability and access, NPs were able to conduct timely assessments,
which allowed for the discontinuation of medications that were no longer needed (Peri et al.,
2013). Staff, and the family member, appreciated the holistic and resident-centered care provided
by the NP (Peri et al., 2013). Increased access, timely assessments, and resident-centered
approaches were also promoted by NPs found by Klaasen et al. (2009). Staff also appreciated the
NP’s high degree of collaborative practice and the competence targeted education they provided
(Peri et al., 2013). An educational role delivered by NPs was also found by Klaasen et al., while
also demonstrating an effect on reducing factors related to problematic polypharmacy, as the
study at hand.
Chart audits demonstrated a reduction in emergency transfers by 28%, compared to a
21% increase in the control arm (p=0.001) (Peri et al., 2013). There was a 22% reduction in
hospital admissions, compared to a 21% increase among the control (p=0.027) (Peri et al., 2013).
There was a 26% reduction in preventable transfers, compared to an 18% increase among the
control, though this was not statistically significant (p=0.07) (Peri et al., 2013). It was not
mentioned what preventable transfers were attributed to. They could very well include
preventing adverse resident outcomes related to problematic polypharmacy, as reductions in
polypharmacy were demonstrated among interviews and chart audits.
Physicians found that the NP decreased their workload, and from this experience they
recognized the benefits of collaboration, and building trusting relationships for better residentcare (Peri et al., 2013). Physicians were also more inclined to work within these nursing homes,
as they could foresee a less stressful workload, due to the NP’s presence, and a subsequent strong

70
nursing structure (Peri et al., 2013). These factors may make physicians more inclined to
deprescribe, as they have stronger nursing support, and clinician support from NPs.
Overall, the cornerstone of interventions that come through in this study were the NP’s
ability to increase time spent on resident care, which was made feasible through the practice
model. Nurse practitioners are encouraged to provide staff with education to allow for safe
deprescribing, as front-line support is established for monitoring residents. It is interesting to find
that co-location and the NP-to-resident ratio is not a barrier for the NP in improving resident
care. Though the NP strictly works among three nursing homes, and does not have priorities
within a personal practice. Nurse practitioners work among multiple nursing homes in the BC
context, thus the results of this study are generalizable.
Peri et al. (2013) found a lack of knowledge surrounding the NP role from staff and the
public as barriers for effectively implementing interventions, as found by Klaasen et al. (2009).
There were also some collaborative challenges with physicians (Peri et al., 2013). These barriers
reveal ongoing implications for education and efforts to improve collaboration between all
professions’ roles to facilitate significant reductions in the causes and outcomes of problematic
polypharmacy.
Stolee, Hillier, Esbaugh, Griffiths, & Borrie. (2006). Examining the Nurse
Practitioner role in long-term care. Journal of Gerontological Nursing, 32(10), 28-36.
Study Aim
The aim of this study was to retrospectively examine the effect of one NP, who provided
health care services when consulted, among three different nursing homes (Stolee et al., 2006).
Outcome measure that were the focus of this review related to reducing both causes and
outcomes of problematic polypharmacy and included interventions proven effective in prior

71
studies. For example this study examined the NP’s effect on care planning and conducting preadmission assessments, treatment recommendations for complex biopsychosocial problems, and
facilitating communication and multidisciplinary approaches to care (Stolee et al., 2006).
Brief discussions pertained to the NP’s impact on improving staffings’ ability to conduct
assessment and skills related to medication usage, and also the NP’s ability to complete
medication reviews. Researchers also aimed to identify factors that facilitated or impeded the
implementation of the NP role (Stolee et al., 2006), and thus their subsequent impact on reducing
causes and outcomes of problematic polypharmacy.
Method of Data Collection, Sample, & Setting
This study is a retrospective cohort study and the quality of this study is strong (Downs &
Black, 1998), with level 4 evidence per Mazurek & Fineout-Overhold (2011). Surveys were used
to gather information from facility staff (Stolee et al., 2006). The response rate was 41% (nurses:
n=32; HCAs: n=45; allied health care professionals: n=11; physicians: n=3; administration and
directors: n=10) (Stolee et al., 2006). Surveys are strengthened by including questions that are
not part of the NP role, to ensure validity of responses. However, the response rate was low,
which may reflect time constraints within nursing homes (Stolee et al., 2006). Furthermore, only
three of six physicians responded to the survey, thus there was a limited understanding of
nonparticipating physician perceptions on the NP role (Stolee et al., 2006). In-depth interviews
were also conducted with the NP (Stolee et al., 2006).
This study was implemented among three nursing homes in Ontario, Canada, including
two not-for-profit (A: n=63, B: n=141), and one for-profit (C: n=170) (Stolee et al., 2006). This
organizational distinction helps to inform barriers between the two models in implementing
interventions to reduce causes and outcomes of problematic polypharmacy.

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Results
Only 11.6% of respondents indicated that the NP had a positive impact on preadmission
assessments (Stolee et al., 2006). Among interviews, NPs stated that time constraints between
facilities posed a barrier for comprehensive admission assessments, and unfamiliarity with
residents, given NP-to-resident ratios, posed a barrier for medication reviews (Stolee et al.,
2006). Improved outcomes are expected with more practical NP to facility/resident ratios and
practice models. For example, as demonstrated by Klaasen et al. (2009), where the NP practiced
full-time, Monday to Friday, and within Peri et al. (2013), where the NP practiced among three
nursing homes, though within a regularly implemented collaborative approach, versus a
consultative model.
Most respondents found that the NP had a positive impact on continuity of care and
timely access to care (Stolee et al., 2006). This was also demonstrated in Klaasen et al.’s (2009)
study, in which ongoing dialogue and follow-up with residents, families, and staff was promoted.
The majority of staff also found that the NP had a positive impact on communication with
residents and families (56.5%), between nursing staff and physicians (54%), and within the
facility (53%), though only 19.2% felt that communication among the three nursing homes was
enhanced (Stolee et al., 2006).
The NP stated challenges in assuming non-direct initiatives among the team, such as
educational initiatives, due to a high clinical workload and time constraints posed between three
different facilities (Stolee et al., 2006). Nonetheless, the majority (68%) of nursing staff found
that with education provided by the NP, their assessment skills, including factors related to
medication usage, were enhanced (Stolee et al., 2006). Forty-eight percent of nursing staff found
that the NP had a positive impact on their skill level particularly through informal education

73
(Stolee et al., 2006). Interactive educational approaches also demonstrated effectiveness in
reducing the prevalence of problematic polypharmacy within Loganathan et al. (2011) and
Kroger et al.’s (2015) reviews.
Surveys indicated that not-for-profit (A & B) nursing homes were double satisfied with
the NP’s effectiveness, compared to the for-profit (C) nursing home (Stolee et al., 2006). Surveys
also indicated that only a few (2.9%) of respondents interacted with the NP on a daily basis,
while 40.4% of respondents interacted once or more times a week, and 36.5% hardly ever or
never interacted with the NP, while varying across all nursing homes (Stolee et al., 2006). Staff
who interacted with the NP more often, versus staff who hardly interacted, found the NP to be
more effective and were significantly more satisfied with care (Stolee et al., 2006). These staff
members were not differentiated surrounding the organizational model that they worked within.
The differences in satisfaction with the NP role and NP effectiveness ratings between staff who
did consult the NP and staff who did not, demonstrates the variance in outcomes when consulting
NPs is up to staff, versus an NP practice model that facilitates NP leadership and initiative.
The NP found that her role was implemented fully and more accepted among not-forprofit facilities (A & B), where there was also a culture of staff accompanying NPs/physicians
during assessments (Stolee et al., 2006). For-profit facilities (C) were found to have more
physician support and they conducted assessments independently (Stolee et al., 2006). Staff
accompanying NPs during assessments also allowed for informal teaching opportunities. This
culture within not-for-profit facilities is more likely to facilitate multidisciplinary approaches that
have been found to demonstrate reductions in causes and outcomes of problematic polypharmacy
(Bergman-Evans & Schoenfelder, 2012; Klaasen et al., 2009; Kroger et al., 2015; Loganathan et
al., 2011; Peri et al., 2013).

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The NP recognized that a negative work environment was created by overworked,
undervalued, and underpaid staff, which led to challenges for collaboration, as there was little
incentive for staff to improve their knowledge and skills (Stolee et al., 2006). It is uncertain
whether these findings are more prevalent in not-for-profit, versus for-profit nursing homes.
Nonetheless, these findings reveal implications to work towards improving the work
environment for nursing staff and HCAs, in order to allow effective team processes in reducing
causes and outcomes of problematic polypharmacy.
Overall, NPs are encouraged to provide informal and interactive education for staff to
assure they are able to identify causes and outcomes of problematic polypharmacy, and to allow
for safe deprescribing processes. However, the consultative model hinders these opportunities, as
well as the ability to conduct medication reviews, and subjects NPs to unmanageable resident-toNP ratios. Suboptimal NP time on site and support for direct care staff adds to the negative work
environment faced by staff. These instances reveal implications for practice and policy changes
for more available practice models and to improve HCA and nursing staff ratios.
Similar to barriers found within Klaasen et al. (2009) and Peri et al. (2013), barriers
within this study also surrounded resistance from some physicians in establishing collaborative
working relationships (Stolee et al., 2006). There was also a lack of administrative support that
was required to introduce the NP role and to encourage its utilization due to a high degree of
administration and nursing staff turn-over (Stolee et al., 2006). These factors not only emphasize
implications for education surrounding the NP role for staff, residents, and families, but also
highlight extreme downfalls with policy and practice that subject nursing homes to increasing
turn-over rates.

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CHAPTER 5
Discussion
The literature revealed 9 sources of evidence that informs the research question that asks
how NPs can best promote a reduction in the causes and outcomes of problematic polypharmacy
among BC nursing homes residents. The findings are strengthened as three sources are
systematic reviews, with level one evidence per Mazurek & Fineout-Overhold (2011).
The specific goal of this integrative review is to reveal evidence-based implications for
NP practice to reduce the causes and outcomes of problematic polypharmacy in a way that
considers the complexity of resident care needs, and barriers faced by staff, as well as
implications for policy, education, and research. Nurse practitioner practice models, as well as
nursing and HCA staffing patterns, are important to consider, as these determine the time team
members are able to spend on resident care, and their subsequent ability and frequency for
implementing effective interventions to reduce the causes and outcomes of problematic
polypharmacy.
The identified practice implications are most often subject to implications for policy,
education, and/or research given barriers faced by staff. Barriers faced by individual staff are
important determinants for all health care professionals working within nursing homes. This is
determined as most interventions require a shared approach with active participation and
communication between multiple health care professionals for an effective reduction in causes
and outcomes of problematic polypharmacy. Thus, constraints experienced by one health care
professional, inevitably affects others involved. Next, an overview of implications for practice
are revealed with their subsequent implications for policy, education, and/or research, as well as
limitations of this integrative review.

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Medication Reviews & Screening Criteria
Practice Implications. An important preliminary intervention for NPs to implement into
their practice in order to gather a comprehensive understanding of the resident’s medication
regimen, and to reduce potential causes of problematic polypharmacy, includes a medication
review. The findings are not clear surrounding how frequently medication reviews are to be
completed. An interval following the Residential Care Initiative is sound, consisting of on
admission, every six months, after transfer back from acute care, and during resident status
changes. As pharmacists are mandated to conduct medication reviews for nursing home residents
every six months, sharing the implementation of this intervention with pharmacists will ease
strain of this function being performed only be NPs. Nurse practitioners may consider
conducting medication reviews on admission to gather a baseline understanding of the resident’s
medication regimen, after transfer back from acute care to assure the medication regimen is
updated, and during resident status changes to assure adverse-drug-effects are considered among
differential diagnoses. Pharmacists can conduct medication reviews every six months after
admission, at which time their recommendations can also be considered. For a more meaningful
medication review, the accuracy of regimens can be assessed using PharmaNet and EHR, and by
also consulting residents and their family (Klaasen et al., 2009; Loganathan et al., 2011).
In deciding the appropriateness of medications during medications reviews, NPs can
access effective screening criteria online, such as the Beers Criteria (Ilic et al., 2015; Oliveira et
al., 2015). The MedStopper Application can also be accessed online to identify medications for
potential discontinuation (MedStopper Beta, 2015), as well as OPRC guidelines that go further to
guide the deprescribing process (OPRC, 2015). Medication reviews can also be accompanied by
assessments of creatinine clearance by using the Cockcroft Gault Score (Bergman-Evans &

77
Schoenfelder, 2012) to assure current medications are safe for continuation and inappropriate
medications with subsequent adverse resident outcomes are minimized.
To prevent the likelihood of missing critical information, NPs can encourage the
implementation of CCDSS (Marasinghe et al., 2015), and EMR/EHR if they are not currently in
place. Nurse practitioners can provide their opinion of alerts to assure modifications to systems
are made and the clinical usefulness of CCDSS is enhanced.
Policy Implications. To assure pharmacist medication recommendations are not
overlooked, and rather appropriately examined and considered, NPs can facilitate policy that
schedules mandatory meetings to review and discuss recommendations. For practicality,
meetings can be set at six month intervals during mandated pharmacist-led medication reviews.
To promote the implementation of CCDSS into nursing homes, Nurse practitioners can
facilitate policy for mandatory in-services. In-services can be facilitated over two days to prevent
information overload and retention of knowledge. Nurse practitioners can also advocate for
remuneration for attendance at in-services outside working hours.
Nurse practitioners can advocate for policy to include medication reviews conducted at
the aforementioned intervals. Implementing policy for these intervals are to assure medication
reviews are completed by primary care providers, including NPs, in order to set a standard of
care.
Research Implications. To determine the efficacy of scheduled medication reviews and
utilizing screening tools, NPs can collect pre. and post. intervention data pertaining to emergency
transfers and hospitalizations caused by adverse-drug-reactions. Data can be collected via chart
audits.

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Functional Status Assessments
Practice Implications. To identify residents at increased risk for adverse outcomes due to
functional limitations, and to identify acute functional changes potentially related to
inappropriate medications, NPs can use the MDS-ADL scale for an assessment of functional
status (Bergman-Evans & Schoenfelder, 2012). These scales can be implemented at the same
intervals as medications reviews to allow for a baseline assessment, routine screening, and
monitoring. Nurse practitioners can complete these scales as part of their initial resident
assessment to gather a baseline understanding of the resident’s function, as well as during
resident status changes and transfer back from acute care in order to promptly discontinue or
hold unsafe medications. To ease strain of this function being only performed by NPs, they can
encourage RNs and LPNs to complete these scales thereafter, as these team members also spend
more time with direct resident care. Health care assistants can also communicate functional
status changes with nurses and NPs. For practicality, forms can be kept among clipboards outside
resident rooms. Forms can be reviewed during multidisciplinary team meetings, unless changes
indicate prompt communication.
Policy Implications. NPs can facilitate a culture that upholds a high standard of care by
implementing biannual mandatory chart audits. The intention of chart audits is to encourage staff
in appropriately completing MDS-ADL forms and to determine if appropriate contact with the
NP is made upon functional status changes.
Educational Intervention
Practice Implications. A combination of educational techniques are helpful for
improving prescribing practices and can be facilitated year round to solidify and utilize
knowledge. Nurse practitioners can arrange for educational opportunities that include a variety of

79
techniques, such as interactive, informal, face-to-face methods (Kroger et al., 2015; Loganathan
et al., 2011; Stolee et al., 2006), in lecture form (Ilic et al., 2015), as well as web-based.
To improve prescribing practices, NPs may benefit from specialist expertise that can be
facilitated by arranging on-site pharmacist-led academic detailing (Kroger et al., 2015;
Loganathan et al., 2011). Intervals for educational intervention are not established, though it is
reasonable for NPs to arrange PAD services biannually with education focused on efficacy of
treatments and length of therapy among older adults with projections for deprescribing, safe
dosing considerations among older adults, side effects, and interactions.
Nurse practitioners can also attend conferences offered by TI aimed at improving
medication management and guidelines for deprescribing when they are offered. Podcasts and
web-resources are also an option if NPs are unable to attend conferences. This information will
help NPs stay current with best practices and knowledge can be disseminated among other health
care professionals within multidisciplinary team meetings.
Informed resident assessments are extremely important in identifying and preventing
adverse resident outcomes related to problematic polypharmacy. As nurses and HCAs spend
most direct care time with residents, NPs can facilitate biannual seminars including pharmacistled education for these staff members with focus on timing of medications (da Costa et al.,
2016), interactions, and identifying side effects and adverse signs.
Nurses and HCAs will also benefit from interactive and informal NP-led education
during direct resident care (Klaasen et al., 2009; Peri et al., 2013; Stolee et al., 2006). Nurse
practitioners can focus on providing education surrounding signs of adverse effects and
nonpharmacological approaches to manage psychosocial care (Bergman-Evans & Schoenfelder,
2012; Klaasen et al., 2009; Kroger et al., 2015; Loganathan et al., 2011) in order to reduce the

80
use of inappropriate medications, such as antipsychotics. Nurse practitioners can enhance the
frequency of these opportunities by creating a culture that facilitates staff accompanying NPs
during resident assessments (Stolee et al., 2006), such that educational opportunities can be taken
on a continuum.
Policy Implications. Nurse practitioners can work towards creating policy for mandatory
continuing education among nurses and HCAs through the web-based course catalogue
registration system (Vancouver Coastal Health Authority, 2008). Yearly competency checklists
can be formulated and can be encouraged to complete by the first quarter of the year.
Remuneration for completing checklists can be formulated based on standard time required to
complete courses.
Research Implications. To determine and demonstrate the efficacy of enhancing
prescribing practices among NPs, data can be collected pre. and post. intervention. Data
collection can include the number of medications residents receive, the classification of
medications, and use of as needed medications before and after the intervention.
Multidisciplinary Meetings/Case Conferences
Practice Implications. For enhanced communication, NPs can facilitate regular team
meetings and case conferences. Team meetings can be arranged monthly to facilitate ongoing
support and collegiality, and case conferences can be arranged biannually with encouragement
for resident and family attendance, if appropriate, to facilitate resident-centered care.
An understanding of different disciplinary backgrounds and role overlap are important
for staff to acknowledge and understand in order to decipher how different team members
contribute to reducing causes and outcomes of problematic polypharmacy as part of the team.
Nurse practitioners can incorporate interdisciplinary education within team meetings to assure

81
staff effectively communicate and collaborate with appropriate staff. This can be undertaken by
arranging professional speakers to share their background and expertise, and where their roles
overlap with other professionals. Nurse practitioners can also encourage staff participation by
allowing different team members to lead meetings by providing a summary of their role and their
viewpoints.
Within team meetings, NPs can encourage discussions surrounding nonpharmacological
approaches in order to gain staff experiences, to provide support, and to tease out and address
barriers and limitations to these approaches. In these instances, NPs can help to arrange for
specialists in behaviour management who can provide educational content while using
interactive approaches, such as role play (Loganathan et al., 2011).
Team meetings are also an excellent opportunity to disseminate educational content
learned through PAD services and TI in an interactive manner. Nurse practitioners can lead or
promote the benefits of these meetings and can also arrange for PAD specialists to participate.
Each case conference should encourage residents and their family to share their thoughts
and/or concerns. Nurse practitioners may use case conferences as a time to initiate and update
care plans (Bergman-Evans & Schoenfelder, 2012; Klaasen et al., 2009; Kroger et al, 2015;
Loganathan et al., 2011) while informed by nurses, HCAs, physicians, pharmacists, residents,
and their family. These include updating safety concerns to prevent adverse resident outcomes by
reviewing trends in functional status provided by MDS-ADL scales. Advanced-care planning can
be established upon resident admission into the nursing homes to gather resident desires with
medication therapy. Nurse practitioners can continue to inform residents and their family with
evidence surrounding the efficacy of medications with aging to determine deprescribing within
case conferences. If deprescribing is established, a mutually agreed upon plan with nursing staff

82
and HCAs is necessary in order to assure a safe taper, where residents are monitored for
symptom recurrence and withdrawal (Bergman-Evans & Schoenfelder, 2012). Family members
and residents, if feasible, can also be informed of this process and red flags/adverse effects
(Klaasen et al., 2009) for safety, and to provide nursing staff and HCAs with support in detecting
changes at the front-line.
Policy Implications. Nurse practitioners can promote policy that supports one hour
monthly multidisciplinary team meetings at an optimal time, such as between meals and after
medication administration, that may be best between two and three pm. These meetings can
alternate staff participation to assure residents have continued access to care. The content of
meetings related to problematic polypharmacy can be decided and arranged on a monthly basis
that includes contacting appropriate specialists. Deciding the content of meetings on a monthly
basis enhances the usefulness of meetings when dependent upon identified learning needs that
can be shared anonymously.
An important policy consideration is to assure case conferences are held biannually to
allow resident-centered care. Half an hour can be allotted per case and steered by the NP and in
collaboration with the most responsible nurse.
Research Implications. In continuing to monitor the effects of intervention to reduce the
causes and outcomes of problematic polypharmacy, NPs can establish the efficacy of
multidisciplinary team meetings and case conferences by collecting pre. and post. intervention
surveys. Surveys can include staff perceptions surrounding ease of implementing
nonpharmacological approaches for behaviour management, their knowledge base in identifying
adverse resident outcomes, and their perceptions of MDS-ADL scales and variability in

83
subjective assessments, as well as family and resident satisfaction surrounding care related to
medication use.
Limitations and Implications at the Organizational or System Level
Practice Implications. In order to uphold all NP roles in reducing the causes and
outcomes of problematic polypharmacy, including implementing interventions, supporting direct
care staff, and conducting research, NPs will require dedicating adequate time to each aspect of
their role. To facilitate adequate time for these roles, NPs can take an important approach using
leadership. By taking leadership, NPs can facilitate a strong team dynamic within nursing homes
by supporting staff in order to gain collaborative working relationships, and in order to facilitate
a culture that shares the workload towards reducing the causes and outcomes of problematic
polypharmacy. Creating this environment and collegiality can allow NPs to also form strong
collaborative working relationships with physicians who may be more inclined to lead
multidisciplinary team meetings, case conferences, and medication reviews when a stronger
support structure is formulated (Peri et al., 2013). Administrative staff can support in collecting
pre. and post. intervention data. Creating this environment can allow NPs to allot ample time for
deprescribing while being informed and supported by the team.
Based on the evidence, in order to effectively reduce the prevalence of causes and
outcomes of problematic polypharmacy, it is necessary for NPs to implement interventions
across practice settings. For instance, within the hospital setting NPs can use interventions to
assure the outcomes of problematic polypharmacy, such as adverse effects, are linked to
inappropriate medications and adjustments are appropriately made. Furthermore, NPs can use
interventions to routinely screen older adults within community practice settings to limit the
chances of problematic polypharmacy transpiring among vulnerable older adults who transfer to

84
nursing homes for ongoing support. Nurse practitioners have a responsibility of obtaining access
to PharmaNet and to be familiar with interventions discussed in identifying and reducing
instances of problematic polypharmacy.
Policy Implications. Nurse practitioners can encourage nursing staff and HCAs to share
their front-line experiences surrounding time constraints and suboptimal staffing patterns to
promote bottom-up advocacy. These experiences can be shared with BCNU and HEU who can
collectively lobby for policy changes to improve working conditions and direct resident care
hours in order to allow for improved assessments and identifying causes and outcomes of
problematic polypharmacy.
Nurse Practitioners can also advocate for more NP positions within nursing homes and
practice model changes in order to allow adequate time for direct resident care, including the
implementation of problematic polypharmacy reduction interventions, supporting staff, and
conducting research. They may work alongside policy makers, the British Columbia Nurse
Practitioner Association (BCNPA), the voice for BC NPs (BCNPA, 2016), and the Office of
Seniors Advocate to lobby for changes to assure BC nursing homes are meeting baseline
guidelines for resident care hours. Advocating for practice models may include full-time models
(Klaasen et al., 2009), and collaborative models between nursing homes (Peri et al., 2013).
Consultative practice models (Stolee et al., 2006), and working between nursing homes and
personal/community practices may subject NPs to competing priorities and subsequently less
time for implementing recommendations put forth within this discussion.
Education Implications. Nurse practitioner educational curriculums may benefit from
including opportunities for students to work with older adults within nursing homes among
clinical rotations, especially as it is a growing subset of the population with likely projections for

85
ongoing employment opportunities. The curriculum may also benefit from ensuring problematic
polypharmacy discussions are embedded in course content alongside content related to older
adults, such as identifying inappropriate medications among this population by utilizing
interventions discussed.
Research Implications. Most research within this integrative review is conducted outside
the Canadian context, and specifically BC. This integrative review is strengthened in that only
studies conducted in the context of nursing homes are included, and nursing home residents
share similar demographics internationally. However, it is difficult to compare international
organizational characteristics to assure interventions are effective in the BC context. Thus the
applicability of interventions to the BC context are most often subject to practice and policy
changes that promote optimal resident-to-provider ratios to assure interventions are not
competing with other practice priorities.
Research also rarely explicitly states the organizational model of nursing homes, such as
for-profit and not-for-profit, upon examining the effects of intervention on reducing the causes
and outcomes of problematic polypharmacy. Research that focuses on the organization of
nursing homes is needed to provide stronger projections surrounding the feasibility of
interventions in BC nursing homes. Research is also needed to compare provider practice models
and nursing/HCA staffing levels in implementing interventions and facilitating a reduction in the
causes and outcomes of problematic polypharmacy. The findings from these studies may provide
stronger incentive to create change.
Conclusion
In conclusion, problematic polypharmacy is a profound issue with serious consequences
for nursing home residents. My experience as an emergency nurse, and through providing care

86
for many nursing home residents who transfer to the emergency department due to adverse-drugeffects, led me to research the issue of problematic polypharmacy. The background uncovered
that nursing home residents have complex care needs, including increasing comorbidity that
subjects them to problematic polypharmacy. Providing optimal care is hindered due to barriers
faced by health care professionals who provide resident care. Thus the goal of this integrative
review was to reveal evidence-based implications for NP practice that considers the complexity
of resident care needs, and barriers faced by staff, as well as implications for policy, education,
and research.
After conducting an integrative review of the literature, specific interventions
demonstrate promise in reducing the causes and outcomes of problematic polypharmacy for
residents within the context of nursing homes. Most interventions are embedded with a need for
multidisciplinary and interdisciplinary approaches, highlighting the importance of a strong
collaborative relationship among nursing home teams. However, the literature that addresses this
issue in the context of nursing homes is mostly conducted in countries outside of Canada, and
specifically BC. Organizational characteristics and staff barriers are rarely addressed. Due to
known barriers faced by staff within some BC nursing homes, to allow the ongoing use of
effective interventions among complex nursing homes residents, the implications put forth for
policy, education, and research are warranted to reduce problematic polypharmacy among this
population.

87
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Database
CINAHL Database

Cochrane

Appendix A: Search Term Combinations

Term Combination
Polypharmacy + nursing
home

Inclusion Criteria
2005-2016; peer reviewed

7

Polypharmacy +
long term care

2005-2016; peer reviewed

4

Inappropriate medication +
nursing home

2005-2016; peer reviewed

0

Inappropriate medication +
long term care

2005-2016; peer reviewed

0

Inappropriate medication +
nurse practitioner

2005-2016; peer reviewed

0

Inappropriate prescribing +
nursing home

2005-2016; peer reviewed

0

Inappropriate prescribing +
long term care

2005-2016; peer reviewed

0

Inappropriate prescribing +
nurse practitioner

2005-2016; peer reviewed

0

Medication + nursing home

2005-2016; peer reviewed

7

Medication + long term
care

2005-2016; peer reviewed

0

Nurse practitioner + nursing
home

2005-2016; peer reviewed

0

Nurse Practitioner

2005-2016; peer reviewed;
randomised controlled trial
2005-2016

72

Polypharmacy + long term
care

2005-2016

15

Polypharmacy + nurse
practitioner

2005-2016

0

Inappropriate medication +
nursing home

2005-2016

13

Inappropriate medication +
long term care

2005-2016

9

Inappropriate prescribing +
nursing home

2005-2016

23

Polypharmacy + nursing
home

25

Results

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Google Scholar

PubMed Database

Inappropriate prescribing +
long term care

2005-2016

12

Nurse Practitioner +
nursing home

2005-2016

13

Nurse Practitioner + long
term care
Polypharmacy + nursing
home

2005-2016

8

2005-2016; terms in title

20

Polypharmacy + long term
care

2005-2016; terms in title

8

Polypharmacy + nurse
practitioner

2005-2016; terms in title

0

Inappropriate medication +
nursing home

2005-2016; terms in the title

10

Inappropriate medication +
long term care

2005-2016; terms in the title

4

Inappropriate prescribing +
nursing home

2005-2016; terms in title

7

Inappropriate prescribing +
long term care

2005-2016; term in title

5

Nurse practitioner + nursing
home

2005-2016; terms in title

3

Nurse practitioner + long
term care
Polypharmacy + nursing
home

2005-2016; terms in title

9

2005-2016

270

Polypharmacy + long term
care

2005-2016

213

Polypharmacy + nurse
practitioner

2005-2016

29

Inappropriate medication +
nursing home

2005-2016

183

Inappropriate prescriptions
+ nursing home

2005-2016; clinical trials

15

Medication + nursing home

2005-2016; clinical trials

196

Nurse Practitioner +
nursing home

2004-2016; clinical trials

33

Nurse Practitioner + long
term care

2005-2016; clinical trials

26

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