Evaluating interprofessional collaboration, normalisation and implementation fidelity of an on-site pharmacist intervention within Australian residential aged care facilities

Abstract

The Australian population is ageing with residents living in residential aged care facilities (RACFs) continuing to be at higher risk of, and more likely to experience medication-related harm. Reducing medication-related harm in older people is an important health priority internationally and in Australia. RACF medication management is complex and current efforts to improve medication management are inadequate. There have been recently accelerated efforts to improve RACF medication management with one suggested approach relating to integrated pharmacists working within Australian RACFs i.e. an on-site pharmacist (OSP) intervention. This research was undertaken to evaluate interprofessional collaboration, normalisation and implementation fidelity of an OSP intervention within Australian RACFs. Evaluation of these key components of the OSP intervention have supported an expanded knowledge and understanding of the OSP role as well as the perceived (or potential) benefits of OSPs working within RACFs to help improve medication management. This research was nested within the Pharmacists in Residential Aged Care Facilities (PiRACF) study wherein a part-time OSP was directly employed by a RACF to improve medication management. The PiRACF study was conducted as a cluster randomised controlled trial which commenced in 2020. The first study of this thesis was a scoping review which explored the evaluation approaches, tools and aspects of implementation employed in the current Australian and international evaluated peer-reviewed pharmacist RACF intervention literature. This scoping review identified potential gaps in the current literature which informed this thesis’s subsequent research questions and overall aim. The second study was a mixed methods study which was underpinned by an existing collaboration model (McDonough and Doucette’s conceptual model for the development of pharmacist-physician collaborative working relationship). It explored the extent and nature of interprofessional collaborative relationships between OSPs and prescribers, managers and nursing staff (health care team members). The third study was a mixed method study which was underpinned by an existing theory (Normalisation process theory). It evaluated the extent to which OSPs became part of routine practice (i.e. normalised) from the perspective of health care team members, OSPs, residents and family members. The final mixed methods study was underpinned by an existing framework (Hasson’s conceptual framework for implementation fidelity). It also assessed the implementation fidelity of OSP intervention delivery and identified moderating factors which influenced delivery of the intervention. The scoping review identified three potential research gaps, namely, limited evaluation of interprofessional collaboration, sparse use of theory to guide evaluation and limited consideration of implementation fidelity in the current evaluated peer-reviewed pharmacist intervention in RACF literature. The OSP role is relatively new in Australia and this thesis contains the first studies that have evaluated interprofessional collaboration, normalisation and implementation fidelity of an OSP intervention within Australian RACFs. The second study concluded that OSPs were able to establish and maintain positive interprofessional collaborative relationships with health care team members based on the findings of semi-structured interviews (n=33) and an adapted survey which was distributed at two time points (T1: n=33; T2: n=19). These promising findings suggested that further exploration of the OSP intervention was warranted. The third study indicated that OSPs were generally considered to be part of routine practice within their respective RACFs based on the findings of semi-structured interviews (n=47) and an adapted survey (n=16). The findings of this study could help inform the future role of OSPs working within RACFs, particularly in relation to supporting residents and their family members to have increased medication knowledge and thereby feel more confident and empowered when discussing medication management decisions with health care team members e.g. prescribers. The fourth study evaluated the overall fidelity of each intervention RACF as being of medium fidelity. That is, the OSP intervention was generally delivered as intended based on three quantitative data sets relating to the range of OSP intervention activities delivered, a random sample of medication reviews assessed for quality, and the proportion of residents who received at least one medication review as part of the OSP intervention. A range of moderating factors contributed to the overall medium fidelity across the intervention RACFs with a number of potential barriers and facilitators to optimal delivery of the OSP intervention identified from the semi-structured interviews (n=14). The identified potential barriers and facilitators may help or hinder OSPs working in real-world RACFs, and would likely impact the extent to which the OSP intervention is delivered as intended. Medication-related harm experienced by residents living in Australian RACFs remains a problem. To date, efforts to improve medication management within RACFs have been inadequate. Integrated pharmacists working within RACFs i.e. an OSP intervention, is a recent approach which has been suggested which may help improve RACF medication management. This research found that OSPs can positively contribute to interprofessional collaborative care within RACFs, that OSPs can become part of routine RACF practice and that the OSP intervention can generally be delivered as intended in real-world RACFs. The findings of this research constitute an original contribution to knowledge and are timely. Based upon these promising findings, recommendations for further OSP research have been made. Moreover, this research has identified some important policy and practice implications for the roll out of OSPs within Australian RACFs commencing from 2023.

Date of Award	2023
Original language	English
Supervisor	Karen Strickland (Supervisor), Sam KOSARI (Supervisor), Joanne Lewis (Supervisor), Mark NAUNTON (Supervisor) & Rachel DAVEY (Supervisor)