The general aim of this thesis was to investigate how delegation of medication is handled in municipal home care. Specific aims were to 1) explore the prevalence of medication use in older adults over time; 2) describe district nurses’ experiences of the delegation of medication management to municipal home care personnel; 3) explore and describe how home care assistants experience receiving the actual delegation of the responsibility of medication administration; and 4) to describe how older adults, living at home, perceive receiving assistance from home care assistants to manage their own medication.
Study I: Changes were explored in medication use over a period of 20 years among three cohorts of older adults aged 78+ years and living in Stockholm, Sweden (1517 participated in 1987; 1581 in 2001; and 1206 in 2007). All were included, whether living at home or in an institution. Univariate analysis was carried out, as well as multivariate logistic regression models. The mean number of drugs increased for both genders in all age groups: from 2.8 in 1987 to 5.8 in 2007 for those aged 78+ years, the corresponding figures for 96+ years was 3.6 and 7.7. Overall (1987, 2001 and 2007), drugs for the cardiovascular system were most frequent (53.1%, 60.8% and 68.7% respectively). Prevalence of polypharmacy (concurrent use of five drugs or more) increased from 27.0% (1987) to 53.9% (2001), and 65.3% (2007). Adjusting for age, gender, education and cognition, the odds of using analgesics and psychotropics were significantly higher in 2007 compared to 1987; OR (95% CI) of 3.3 (2.8-4.0) and 1.3 (1.1-1.6) respectively. Cognitively intact elderly primarily used hypnotics, whereas cognitively impaired elderly used hypnotics, sedatives and antidepressants. People living at home used fewer drugs. For those living in institutions, polypharmacy increased from 24.4% in 1987 to 95.3% in 2007. Corresponding figures for those living in service buildings were 44.6% to 82.4%.
Study II: District nurses’ (DNs) perceptions of the concept of delegating the administration of medication to unlicensed personnel (home care aides, HCAs) working in municipal social care were described. Twenty DNs were interviewed and the interviews were audio taped. Data were collected from April 2009 to August 2010 and analysed using content analysis. Findings revealed that the statutes of delegation were outdated and appeared to be incompatible with day to day practice. Communication between DNs and HCAs, as well as tutoring, was regarded as important. The DNs found it imperative to be available to the HCAs and made an effort to create a trusting atmosphere. Delegation of administration of medication to a person, who lacked knowledge of medication, for example when it is proper to mix pills or blend them in a thick liquid, was reported by the DN as being stressful. This was explained by various responsible authorities and the growing number of social service groups. Despite this, the DNs did not see any major problems with the fact that the HCAs work for a separate authority (the county council vs. the municipality). Study III: The purpose was to explore and describe how HCAs experience receiving the delegation of medicine management, and how they handle the responsibility that comes with the delegation. Four focus groups consisting of 19 HCAs were conducted. Data were analysed using qualitative content analysis. According to the HCAs, health and social care depends on delegation arrangements to function effectively, but mainly it relieves a burden for DNs. Even when the delegation had expired, administration of medication continued, placing the statutes of regulation in a subordinate position. There was low awareness among HCAs of the content of the statutes of delegation. Accepting delegation to administer medication was an inevitable and a routine fact, regarded as a mandatory task that had become an implicit prerequisite for social care work in the municipality.
Study IV: Finally, we wanted to describe how older people, living at home, experience the use and assistance of administration of medicines in the context of social care. Ten older adults, aged 68 to 94 years, were interviewed in their own homes. Latent content analysis was used. There were divided feelings about being dependent on assistance in handling medication, since it interfered with their autonomy at a time of health transition. On the other hand, the assistance eases daily life with regard to practical matters and improves adherence to a medicine regimen. Participants were balancing empowerment and a dubious perception of the home care assistants’ knowledge of medicine and safety. The trust in the physicians’ and DNs’ knowledge about medication routines was seen as a guarantee with regard to medicines in general and the medicine regimen in particular. The perceived strained work situation for HCAs risks placing older people in an adverse position in relation to HCAs with their heavy workload and limited schedules. This may negatively influence the care relationship and patient safety.
Conclusions: This thesis reports: 1) A dramatic increase in medication use in older adults from the late 1980s to the mid- 2000s in central Stockholm, Sweden; 2) DNs cannot manage their workload without delegating the administration of medication to unlicensed personnel (HCAs) in the present organisational model of health- and social care; 3) Accepting the delegation to administer medication was inevitable and had become routine to meet the needs of a growing number of older home care recipients; and 4) Assistance with handling medication eases daily life and medicine regimen adherence. Dependence on assistance may affect older adults’ sense of autonomy. Perceived safety varied relating to HCAs’ knowledge of medicine. We believe our results may contribute to a better understanding of how health and social care, two fields spanning sociology and nursing, perceive and adjust to the given frames; in the first place by indicating how delegated administration of medication to older people living at home is perceived by the care recipients, DNs, and HCAs and also by illustrating how the possibility of delegating medical chores can give temporary tasks a manifest transition from licensed to unlicensed personnel.
Key words: Delegation, district nurse, home dwelling, home care, home care assistant, health care, medication use, medication management, polypharmacy, population-based, time trends, task shifting, responsible authorities, older people