Nurse-led Medicines' Monitoring in Care Homes: a Process Evaluation of the Impact and Sustainability of the West Wales Adverse Drug Reaction (WWADR) Profile and Pharmacist Involvement
Conditions: Dementia
Sponsor: Swansea University

Nurse-led medicines’ monitoring in care homes: a process evaluation of the 
impact and sustainability of the West Wales Adverse Drug Reaction 
(WWADR) Profile and pharmacist involvement 
 
Preventable adverse drug reactions (ADRs) account for 5-8% UK unplanned hospital 
admissions1, costing the NHS £1-2.5bn pa27. Over-prescribing for older adults is rife, with up 
to 29% prescriptions inappropriate13, and linked to distressing and costly hospitalisations14.  
This consensus around over-prescribing has encouraged WG to prioritise reduction of 
antipsychotic prescribing (personal communication, Dr. Dai Lloyd, WG chair of Health, Social 
Care and Sport committee, 20.10.16). However, there is no consensus for implementation of 
change to routine care (Page et al 2016, 2-7 above). It appears that the UK government’s 
National Dementia Strategy, launched 2009, and MHRA recommendations (MHRA 2012), 
have not reduced antipsychotic prescribing (Szczepura et al 2016), whilst our intervention 
succeeded (Jordan et al 2014, 2015). Our intervention is about optimisation of nursing 
documentation and multidisciplinary team involvement in medicines' management. 
 
When used by nurses without pharmacists’ involvement, WWADR Profiles reduced 
prescribing of mental health medicines in care homes15, and benefited all participants, e.g. 
by reducing pain, behaviour problems, dry mouth, constipation, poor food and/or fluid intake, 
ataxia, and identifying high risk cardiovascular conditions15,20,21, drug-induced Parkinson’s18, 
infections22, chest pain and valproate-induced pancreatitis23. We now aim to explore how this 
can be sustained in practice.  There are 2 aspects to the study: 
 
1. Observation in care homes 
2. Stakeholder interviews 
 
1. The participants of our previous research and 5 newly recruited care homes will be asked 
to either continue using the Profile in routine practice or adopt it within routine practice. We 
shall ask to observe this routine practice, debrief in interviews and read reflective diaries/ 
accounts. We are interested to see if the Profiles are used as intended, participants' 
experiences of their use, and any barriers and facilitators. For example, are all items 
completed? What happens if a problem is found? Are guidelines consulted if there are 
problems? How easy is it to get access to a prescriber? 
 
Care Homes 
Inclusion criteria: 

 
Providing residential or nursing care or both to >4 service users meeting inclusion 
criteria below. 
 
Willing to use the WWADR monitoring Profile in routine practice 
Exclusion criteria: 
 
<5 residents meet the inclusion criteria 
 
Unwilling or unable to volunteer to undertake nurse-led medicines’ monitoring 
Service users / Residents / patients 
 Inclusion criteria:  
 
Resident at the care home and expected to continue to be for 1 year;  
 
Currently taking at least one of antipsychotics, anti-epileptics/ mood stabilisers, 
antidepressants, benzodiazepines, Z drugs;  
 
Diagnosis of dementia, or dementia related condition, recorded; permanent local 
authority funding for dementia care; permanent cognitive impairment, but no 
diagnosis in care home notes; 
 
Willing and able to give informed, signed consent themselves, or where capacity is 
lacking, a consultee*, who is willing to give advice.  
Exclusion criteria:  
 
Not well enough to participate, as screened by their nurses;  
 
Aged <18;  
 
Receiving active palliative care.  
 
* Consultees may be either a) personal consultees, such as a relative or b) a clinician not 
involved in the research, even if paid in their role as clinician (MRC 2007).   
2. We shall interview nurses/ managers, service users (or their families), pharmacists, 
prescribers and strategic leads to hear their experiences of medication use, medication 
management, adverse effects and barriers and facilitators of medicine monitoring, and how 
electronic devices can enhance nurse-led monitoring. 
Professionals 
Inclusion criteria 
 
Involved in the provision of care for service users described above 
 
Willing to participate in the study 
Exclusion criteria 
 
Not involved with service users in care homes 
 
Unwilling to consent to participation 
 
The 2 data sets will be analysed using the common themes of: 
 
Clinical gain 
 
Barriers  
 
Facilitators 
 
Implementation strategies 
 
 
 
 
 

 
Summary Diagram V1 1.11.16 
Medicines’ monitoring 
Title of study:  
Nurse-led medicines’ monitoring in care homes: a process evaluation of the impact and 
sustainability of the West Wales Adverse Drug Reaction (WWADR) Profile and pharmacist 
involvement 
Short title: medicines’ monitoring 
 
 
 
 
Recruit  
  
 
Care homes 
 
 
 Stakeholders 
 
ABMU 
 
 
 Wales  
 
 
 
 
  
5 from 
previous 
study 
 
5 new 
 
 30 
↓ 
 
↓ 
 
 ↓ 
1 nurse  
Observe x3 
Reflective 
accounts 
 
1 nurse 
Observe x3 
Reflective 
accounts  
 
 Nurses, managers, 
prescribers,  
pharmacists,  
strategic leads,  
service users and  
their families 
↓ 
 
↓ 
 
 ↓ 
3 residents 
Observe x1 
 
3 residents 
Observe x1 
 
 Interview x1  
 
 
 
 
 ↓ 
 
Clinical gain, 
barriers and 
facilitators  
Observed 
 
 
 Clinical gain, 
barriers and  
facilitators reported 
or anticipated. 
 
 
 
Analyse for 
common 
themes 
 
  
 
 
 
Study Duration 1.10.16 to 31.12.17 
Fieldwork duration 1.1.17-31.7.17 
Duration of participation: 
Care homes and their nurses: 3 contacts 1.1.17 to 31.7.17 
Care home residents / service users: 1 contact 
Interviewees: 1 contact 1.1.17-31.7.17 
 
Number of Participants 
Care homes: 10 
Nurses: 10 
Care home residents / service users: 30 (3 per home) 
Interviewees: 30 stakeholders 
Location 
Care homes in ABM UHB 
Stakeholder interviews across Wales 
 

Sj 1.11.16 
Summary 
Preventable adverse drug reactions (ADRs, known as side effects) have caused 5-8% 
of unplanned hospital admissions for the last decade (Pirmohamed et al 2004, NICE 
2015). They cost the NHS up to £2.5 billion each year (Frontier Economics 2014).  
 
The West Wales Adverse Drug Reaction (WWADR) Profiles are designed to identify 
and ameliorate problems that may be attributable to or exacerbated by prescribed 
medicines. The WWADR Profile for mental health medicines lists problems that might 
be associated with these medicines, and asks nurses to monitor these and inform 
prescribers or pharmacists. It contains a structured template of ~80 items to be 
completed over 1-4 clinical contacts, as needed.  We have shown in randomised 
controlled trials and observation studies that structured nurse-led medicines’ 
monitoring using the WWADR Profile benefits patients, for example, by reducing pain 
and sedation and identifying high risk cardiovascular conditions. We now aim to 
understand what is needed to sustain implementation of the WWADR Profile in 
routine practice and explore future directions.  
 
11.11.16 from Jonathan Bidmead  
My father had Alzheimer at the end of his life and lived for periods in care homes. Homes are 
often overcrowded with sometimes uncaring staff. It is at this time that our loved ones are 
most vulnerable even though they are sometimes short staffed, the staff that are present do 
there best. It is important that there is some check that medication proscribed and 
administered under such difficult conditions and the best for the patient and that staff give the 
patients the best possible attention circumstances permit.