A Quality Improvement Project to Improve Nurse-Provider Communication and Antipsychotic Prescribing in Nursing Homes

Dementia diagnoses are more prevalent in nursing homes than in any other health care setting.¹ According to Harris-Kojetin and colleagues,1 dementia affects up to half of the 1.3 million nursing home residents. Antipsychotic medications are, at times, prescribed to nursing home patients with dementia. Up to 20% of these patients receive antipsychotic prescriptions.² Controversy exists over the appropriateness of these medications in the management of dementia. According to the Alzheimer’s Association,³ dementia is not an approved indication for antipsychotic use. Although some patients with dementia may benefit from antipsychotic medication treatment, the effectiveness of these medications to manage behavioral symptoms of dementia for all patients is questionable.^4,5 Furthermore, antipsychotic medications used off-label to treat dementia carry an increased risk for mortality, falls, stroke, diabetes, and heart attack.^4,5

Efforts to improve interprofessional communication in nursing homes should be emphasized to reduce inappropriate antipsychotic medication use in patients with dementia living in nursing homes.⁶ Ineffective interprofessional communication in health care has long been cited as a barrier for improved patient outcomes.⁷ Furthermore, lack of effective interprofessional communication is a significant cause of dissatisfaction among patients and health care providers, misdiagnosis, medication errors, increased hospitalization rates, and increased morbidity and mortality.^7,9,10 Ineffective interprofessional communication has also been cited as a barrier to effective medication management and to effective antipsychotic prescribing in nursing homes.^6,8,11 A communication tool such as Situation-Background-Assessment-Recommendation (SBAR) has the potential to improve nurse–provider communication and decrease antipsychotic use in nursing homes. The SBAR has shown to be effective in improving nurse–provider communication in nursing homes.¹² SBAR may also be effective in decreasing antipsychotic medication use in nursing homes.¹³

The purpose of this quality improvement project was to evaluate whether the implementation of an evidence-based communication tool affects nurse and medical provider perceptions of communication and quality of interactions in decision making, and whether it decreases the use of antipsychotic medications in patients with dementia.

There is strong evidence that standardized tools, such as SBAR, improve perception of interprofessional communication. SBAR has been found to increase the perception of efficient communication in nurses in nurse–physician interactions.¹² Dalky and colleagues¹⁴ found that SBAR not only improves the perceptions of communication but also increases nurses’ job satisfaction. The impact of SBAR on communication perception can also be applied to other disciplines. Cooper and colleagues¹⁵ found that using SBAR communication tools improved perceived confidence in interprofessional communication for doctor of nursing students. SBAR education has also improved ratings for perceived interprofessional confidence in communication, knowledge of the SBAR tool, and attitudes toward the SBAR tool for doctor of physical therapy students.¹⁵

Improving interprofessional communication is highly linked to improved patient outcomes. For example, improved nurse–provider communication in nursing homes may significantly improve patients’ nutritional status.¹⁶ Furthermore, improved interprofessional communication using SBAR has considerably decreased the number of transfers and avoidable hospitalizations.¹⁷ Similarly, in their systematic review, Müller and colleagues¹⁸ found moderate evidence of using SBAR for improved patient safety, with a focus on multiple patient outcomes, including a significant reduction in patient mortality following SBAR implementation. SBAR alone has been shown to decrease inappropriate prescribing of antibiotics in nursing homes.¹⁹ Barnes and Bradshaw,¹⁹ for example, achieved an 18% reduction in antibiotic prescribing after implementation of SBAR for antibiotic stewardship.

Improving interprofessional communication can lead to a decrease in antipsychotic drug prescribing in nursing homes. Gedde and colleagues²⁰ found that an advanced care planning intervention to improve communication between providers, nursing home staff, and patients led to a decrease in psychotropic drug use among nursing home patients with dementia. According to the study authors, patients whose psychotropic medications were reduced also experienced improved physical independence. It is important to note that in this study, psychotropic medication deprescribing did not lead to patient deterioration in behavioral disturbances.²⁰ Similarly, Flesner and colleagues¹³ found that using SBAR led to a decline in antipsychotic medications used in patients with dementia.

Setting

The setting for this quality improvement project was one long-term care facility in the southeastern United States. The facility has 120 beds and an average occupancy rate of 75% to 90%.

Sample

The sample included 18 nurses and seven providers. Per the inclusion criteria, nurses were employed by the facility as registered nurses (RNs) or licensed practical nurses (LPNs). Providers were physicians, physician assistants (PA), or nurse practitioner (NP) providing care to patients at the facility. Providers were either primary care providers or psychiatrists.

Medical records for all patients receiving antipsychotic medications were reviewed for antipsychotic use patterns pre- and postintervention. The same set of patients receiving antipsychotic medications were reviewed pre- and postintervention. Per the inclusion criteria, medical records for all patients receiving antipsychotic medications at the pre-intervention review were included in the study.

The long-term care facility adopted an SBAR communication tool for all patients receiving antipsychotic medications in the facility. The SBAR communication tool was tailored specifically to use of antipsychotic medications. For the Situation component of the SBAR tool, a checklist was incorporated that included antipsychotic medication, dosage, start date, last adjustment date, patient’s behaviors, improvement or decline in symptoms, and side effects. For the Background component of the SBAR tool, a checklist was incorporated that included primary diagnosis for nursing home admission, mental health history, behavioral concerns, pain management program, and any conditions related to antipsychotic use that apply to the patient, such as extrapyramidal symptoms, recent relevant laboratory test results, and allergies. In the Assessment component of the SBAR tool, a checklist was incorporated that included improving or worsening of symptoms, whether dose reductions were needed, and other potential causes of a patient’s symptoms of confusion, such as urinary tract infections, constipation, pain, and toileting needs. As part of the Recommendation component of the SBAR tool, a checklist was incorporated that included decreasing or increasing current dose of antipsychotics, discontinuation of antipsychotic, maintaining current dose of antipsychotic, and provider visit. The SBAR tool was designed to alert nurses to the types of information that are relevant and necessary to discuss with providers with regard to patients’ use of antipsychotics.

Participants (RNs, LPNs, NPS, and PAs) were recruited during the facility’s mandatory monthly staff meeting in August 2021. The researcher provided a brief overview of the study at the end of the staff meeting. At that point the potential participants were given the opportunity to register their email address for the study. In addition, a recruitment email was sent to the all of the nurses and providers whose email addresses were registered with the facility’s human resource department. The researcher’s contact information was also provided in a flyer at the facility’s staff lounge. A week after recruitment, a preintervention Collaboration and Satisfaction About Care Decisions Scale (CSACD) survey was provided to participants, with a request to complete it within 1 week. Once the preintervention CSACD survey was completed, the nursing administration and researcher provided an educational session to all nurses and providers about the SBAR communication tool for antipsychotic use. The educational session consisted of a 15-minute PowerPoint presentation with general information about antipsychotic use in older adults and dementia as well as how to use the SBAR communication tool. Three scheduled educational sessions at different shifts were offered so that providers and nurses could attend one. For nurses unable to attend one of the scheduled educational sessions, huddle sessions during their scheduled work shift were held to provide the education. An email with the PowerPoint education was sent to providers unable to attend one of the educational sessions. The education was completed in 1-week period.

Nurses at the facility completed an SBAR tool for all patients receiving antipsychotic medications over a 6-week period. The SBAR information was discussed with the provider via phone for decisions on antipsychotic medication prescribing. Participants were asked to complete the postintervention CSACD at the 8-week mark from the start of prentervention CSACD. Participants had 1 week to complete the postintervention CSACD form. Each pre- and postntervention questionnaire took approximately 15 minutes to complete. For antipsychotic use data, medical records were reviewed, and required data were collected during the educational session week. Medical records were again reviewed, and required data were collected during the week in which the postintervention CSACD was completed.

Measurement Tools

The CSACD was used for data collection on nurse and provider perceptions of communication. The CSACD was completed via online survey using Qualtrics database. The CSACD is a 9-item, 7-point Likert-type scale.²¹ The scale was developed to measure the quality of interaction in decision making and the satisfaction with the decision-making process in health care settings.²¹ The scale has six questions measuring the critical attributes of collaboration and one question measuring global collaboration. Responses for these subscales range from “I do not agree at all” to “I strongly agree.” The scale has two questions measuring satisfaction with collaboration. Responses for this subscale range from “not satisfied” to “very satisfied.” The higher the score, the stronger the degree of collaboration.

The CSACD is a valid and reliable tool. The reliability of the tool was supported by internal consistency with a Cronbach’s alpha of .93. Criterion validity was established with correlation (r=.87) between global collaboration and the six critical attribute items. Construct validity was established by the correlation (r=.66) between the six critical attributes of collaboration and the satisfaction with collaboration questions. The correlation between the two satisfaction with collaboration questions is r=.64. The correlation for the global collaboration question is r=.78 vs r=.50. The correlation between collaboration and satisfaction with decision-making process is r=.69. Lastly, the correlation between collaboration and satisfaction with decision is r=.50.2

Demographic data were collected. These data included position (RN, LPN, Physician, NP, PA), range of years of experience in the field, age range, and education level.

The facility collected data on antipsychotic use for quality improvement purposes. The researcher assisted in data collection. The researcher was given access to electronic medical records for the patients receivng antipsychotic medications at the pre-and postintervention data gathering points. Data collection included the patient’s eight-digit identifying number, patient diagnosis for antipsychotic use (dementia, schizophrenia, bipolar disorder, other), name of the antipsychotic medication used for the patient, and dosage of medication.

Ethical Considerations

The project was conducted with the approval of the institutional review board of Troy University. The nursing home administration also provided approval. A consent form was added to the CSACD. The consent form included a written explanation of the aim of the study, confidentiality, and voluntary participation. Participants were not asked any identifying information. Individual consent was implied by the participant beginning the questionnaire. No patient names were reported in any data collection forms, and all results were reported in aggregate.

A total of 25 participants completed the pre-and postintervention survey: 11 RNs, seven LPNs, three physicians, three NPs, and one PA. In the sample, 12% of the subjects reported having a doctoral degree, 20% reported having a master’s degree, 28% reported having a bachelor’s degree, 16% reported having an associate degree, and 24% reported having a vocational/technical diploma (Table 1). Six of the seven LPNs had a vocational degree (85.71%) and one (14.29%) had an associates degree. Three of the RNs (27.27%) had an associate's degree, seven of the RNs (63.64%) had a bachelor's degree, and one RN (.09%) had a master’s degree. All three NP participants and the one PA participant had master’s degrees. The three physicians were the only participants with doctoral degrees. One preintervention survey and one postintervention survey were not completed in entirety and were therefore not included in the sample.

Table 1. Characteristics of Study Stample (N=25)

The mean years in practice for all participants was 13.52 (SD, 10.46; range, 2-38). NPs had the lowest mean years in practice (6.67; SD, 1.53; range, 5-8). Physicians had the highest mean years in practice (27.67; SD, 8.96; range, 22-38)(Table 2).

Table 2. Years in Practice by Position Among Study Sample (N=25)

There were 14 medical records reviewed for pre- and postintervention antipsychotic medication use. In the sample, 57.1% were receiving an antipsychotic for the diagnosis of dementia, 21.4% for a diagnosis of schizophrenia, and 21.4% for a diagnosis of bipolar disorder. Furthermore, 64.3% of the sample were receiving quetiapine, 14.3% were receiving olanzapine, and 21.4% were receiving risperidone. After analyzing the data from the chart review, there were no changes in the actual antipsychotic medications used for each patient from pre- to postintervention (Table 3).

Table 3. Characteristics of Antipsychotic Use Among Patient Study Sample (N=14)

In the sample, there were no patients who had an antipsychotic medication discontinuation postintervention. However, 14.3% of the sample had a reduction in dosage of antipsychotic medication postintervention. One patient (7.1%) had an increase in dose of antipsychotic medication postintervention. This patient was receiving an antipsychotic medication for the diagnosis of dementia and was hospitalized for a urinary tract infection during the project implementation period. She returned to the facility on the same dose of antipsychotic. However, she continued intravenous antibiotic treatment for urinary tract infection while residing in the facility. Two days after readmission to facility, the patient’s behavioral symptoms increased and included combativeness, yelling, and slapping staff in the face. At that point, the provider increased the dose of the antipsychotic medication (Table 4).

Table 4. Postintervention Antipsychotic Use Among Patient Study Sample (N=14)

A Wilcoxon test was conducted to evaluate whether there was a difference in the pre- and postintervention nurse and provider perceptions of communication. The results indicated a significant difference pre- and postintervention for all nine survey questions in the CSACD questionnaire (z≤−2.174; P≤.030). The results indicated a statistically significant improvement in nurse and provider perceptions of communication rankings for all survey questions following project implementation (Table 5).

Table 5. Collaboration and Satisfaction About Care Decisions Scale Items With Significant Wilcoxon Signed Ranks Tests Among Study Sample (N=25)

^aP<.01.
^bP<.05.

Project findings included a statistically significant increase in scores on the CSACD items after the SBAR intervention. Nurse and provider perceptions of communication and perceptions of quality interactions in deicion making and satisfaction with the decision-making process had a statistically significant improvement postintervention for all items in the Likert scale. Project findings included a reduction in dosage of antipsychotic medication postintervention for two patients in the sample and an increase in dosage of antipsychotics postintervention for one patient in the sample. There were no antipsychotic medication discontinuation.

Findings from this quality improvement project support the previously published evidence that SBAR is an effective standardized tool to improve nurse and provider perceptions of communication.^12,15 However, it is important to mention Dalky and colleagues¹⁴ did not use the SBAR as a communication tool specifically for antipsychotic prescribing. Furthermore, Boscart and colleagues¹² implemented a multiphase intervention with SBAR as part of a larger intervention. While Cooper and colleagues15 focused on interprofessional collaboration in doctoral physical therapy students working in collaboration with doctoral nursing students rather than nurses and providers. Despite some methodological differences, the findings of improved nurse and providers perceptions of communication following SBAR implementation are similar.^12,14,15

Findings from this project support previously published evidence that SBAR implementation may help reduce unnecessary medication prescribing.^13,19,20 By using SBAR, Barnes and Bradshaw¹⁹ achieved an 18% reduction in antibiotic prescribing. Reduction in antipsychotic dose occurred in 14.3% of the patients on antipsychotics during the course of the project. It is important to note antipsychotic drug reduction poses individual and different challenges than the reduction of antibiotic use. It is also important to mention that Barnes and Bradshaw19 had a significantly larger sample size and were able to determine a statistically significant reduction in antibiotic prescribing after SBAR implementation.

Limitations

A limitation of this project was sample size. The sample size for both records of patients receiving antipsychotic medications (N=14) and nurses and providers (N=25) was small. Furthermore, the project was conducted at only one nursing home. This makes it difficult to examine how the dynamics of each specific nursing home may affect results in larger samples. Also, the sample of nurses and providers that completed the pre- and postintervention survey was weighted heavily on the nurses’ side. The higher number of nursing participants makes it difficult to examine the effect of each discipline’s perspectives on communication and how that may have affected the results. Lastly, limited time for project implementation may have affected the results for antipsychotic medication reduction due to the long amount of time needed to decrease antipsychotic medications gradually.

Recommendations for Future Research

Future research should focus on the providers’ perceptions of communication given that this project sample was 72% nurses. Lastly, future research should focus on the statistical significance of antipsychotic medication change over at least a 6-month period.

Improved interprofessional communication, using SBAR, leads to improved patient safety and considerable decline in transfers and avoidable hospitalizations.^17,18 Thus, the use of SBAR communication has the potential to improve patient care and outcomes in the nursing home. Although the statistical significance of the antipsychotic dosage reduction was not established, there was an increase in oversight of antipsychotic use in the facility. Appropriateness of use of these medications was increasingly monitored. Project results suggest that SBAR is at least useful to provide oversight on antipsychotic medication use and thereby improve the management of patients with dementia who receive antipsychotic medications, with the goal of decreasing inappropriate use of these medications among this population.

Maria Del Pilar Woods, DNP, FNP-BC, NE-BC^1,2 • Carrie Lee Gardner, PhD, DNP, FNP-BC² • Kelli Whitted, DNP, FNP-BC²

Affiliations:

¹United States Air Force

²Department of Nursing, Troy University , Troy, AL

Disclosure:

The authors report no relevant financial relationships.

Address correspondence to:

Carrie Lee Gardner, PhD, DNP, FNP-BC
Email: csgardner@troy.edu

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Annals of Long-Term Care or HMP Global, their employees, and affiliates.