WARFARIN USE IN THE ELDERLY: THE NURSESÕ …

1 19 Australian Journal of advanced Nursing 2006 Volume 23 Number 3 ABSTRACTO bjective: To explore the barriers to WARFARIN use from theperspective of nurses working in aged : A qualitative study, involving a semi-structuredgroup interview, during March-April and Subjects: Eleven nurses, employed within the catchment ofthe Northern Sydney Area Health Service, who wereinvolved in the care of elderly warfarinised outcome measure: Identification, via thematic analysis, of the mainthemes underpinning the nursing perspective onwarfarin use in this setting, with regard to theirperceived role/s, experiences with patients, andpotential strategies for managing the : Five main themes were identified:perceived patientattitude toward WARFARIN ; barriers to the use of WARFARIN ;expressed lack of confidence in the processes involved;nurses role in WARFARIN use; and strategies to improvewarfarin use.

2 Nurses were concerned about warfarinuse in the elderly , but felt they had a limited capacityto : Nurses are potentially underutilised as a resourceand support for both patients and prescribers, in themanagement of WARFARIN , the professional role of nurses is quitediverse, ranging from patient care on the ward orin the community, through to specialist servicesin the capacity of clinical consultants, specialists,educators, and practitioners. However, there is oneclinical area, within Australian practice, that has notutilised the nursing profession to its fullest potential:anticoagulant therapy.

3 Although nurses may work in anticoagulation clinicsor in post-acute care teams that liaise with anticoagulatedpatients, the extent to which they engage with warfarintherapy appears to be somewhat restricted and perhapssuperficial. This is unfortunate, as nurses maintain aunique relationship with patients, which is unlike otherhealth , there has been greater appreciation of the nurses role in this setting, including nurse-ledanticoagulation monitoring systems (Brown et al 1998;Beata V Bajorek, BPharm, DipHPharm, PhD, Lecturer inPharmacy Practice, University of Sydney, Research Associate,Clinical Pharmacology and Aged Care and Rehabilitation, Royal North Shore Hospital, New South Wales, Australia Krass BPharm DipHPharm PhD, Senior Lecturer inPharmacy Practice, Faculty of Pharmacy, University of Sydney,New South Wales, AustraliaSusan J Ogle, MBBS, FRACP Head Aged Care andRehabilitation Medicine, Royal North Shore Hospital, ClinicalSenior Lecturer in Medicine, University of Sydney, New SouthWales.)

4 AustraliaMargaret J Duguid, BPharm, Head Department of Pharmacy,Royal North Shore Hospital, New South Wales, AustraliaGillian M Shenfield, DM, FRCP, FRACP, Head Department ofClinical Pharmacology, Royal North Shore Hospital, New SouthWales, AustraliaAccepted for publication June 2005 WARFARIN USE IN THE elderly : THE NURSES PERSPECTIVERESEARCH PAPERKey words: aged care, anticoagulation, clinical services, professional role, drug therapyAustralian Journal of advanced Nursing 2006 Volume 23 Number 3 Connor et al 2002; Hennessy et al 1998; Taylor et al 1997), hospital-based nurse practitioner-ledanticoagulation services utilising computerised decision-support systems (Vadher et al 1997), and nurse-led nearpatient testing in GP surgeries (Fitzmaurice et al 1998).

5 Exploring the role of allied health professionals,particularly nurses, in this clinical area has becomeparamount as the number of patients requiringanticoagulation, for common indications such as atrialfibrillation (AF), is increasing. Despite pivotal evidenceto support the use of WARFARIN therapy in AF (AtrialFibrillation Investigators 1994; Hart et al 1999), severalAustralian studies have demonstrated that, even in theabsence of apparent contraindications, WARFARIN therapyremains underutilised (Ang et al 1998; Elliott et al 1999;Stewart et al 1999), particularly in the target population ofelderly patients with AF (Bajorek et al 2002).

6 One reasonfor this suboptimal use includes a lack of support servicesto assist both prescribers and elderly patients with theinitiation and subsequent management of this view of the recognised underutilisation of warfarintherapy in the elderly , and lack of local support services,the aim of this study was to explore the issuessurrounding the long-term use of WARFARIN in elderlypatients by examining, in depth, the unique perspectivesof nurses working in aged care. The specific objectiveswere to: describe nurses experiences and attitudes towardthe use of WARFARIN in elderly patients; explore nurses perceptions regarding the risks and benefits of warfarintherapy in elderly patients; identify any barriers to the long-term use of WARFARIN as perceived and/orexperienced by nurses.

7 And investigate nurses perceivedroles regarding WARFARIN DesignIn this qualitative study, a group interview (focusgroup) was conducted to draw upon attitudes, feelings,beliefs, experiences and reactions in a way that would notbe feasible using observation, one-to-one interviewing, or questionnaire surveys alone (Morgan and Kreuger1993). A semi-structured process was used where eachdiscussion was moderated by a facilitator, co-facilitator,and scribe using a set of broad open-ended questions toelicit the nurses experiences with WARFARIN , and theiropinions on how WARFARIN use could be optimised.

8 Thesequestions reflected the pre-determined research objectivesand were pre-tested in mock interviews. Demographic data was collected separately using aspecifically designed questionnaire. Each session wastape-recorded with additional note-taking by the scribe,who also observed and noted any non-verbal behaviour(facial expressions, body language, paralanguage etc) thatreinforced significant statements. Recruitment of ParticipantsNurses involved in the inpatient and/or outpatientmanagement of elderly patients were recruited via studyflyers displayed in key locations around the projecthospital and larger community, including the: aged careward, community aged care assessment team, acute post-acute care team that oversees the hospital-to-communitycare of warfarinised patients, and community nursingservices.

9 Additionally, information was conveyed duringweekly clinical meetings, departmental seminars, andward rounds. Sampling was opportunistic to capture the key nursing population, and purposive to find nurses willing to discuss their experiences; each wasscreened upon enquiry, to ensure that they worked withwarfarinised elderly patients, by asking for a briefdescription of their experiences. Participants provided their informed written consent totake part and, to compensate for any losses incurred byattendance (eg.)

10 , time off during working hours, loss oflunch hours, travel costs) all were offered a nominalpayment of $ , additional reimbursement of travelexpenses, and a light meal. The study was approved bythe institutional human research and ethics analysisThe audio-taped discussion was transcribed verbatim,then manually analysed to identify emergent analysis breaks the text down ( reduction ) intodefined units (words, statements) that are categorised into themes. A phenomenological approach was used,focusing on understanding the essence of experiencesabout a phenomenon via statements, meanings, themes,and general descriptions of the experience (Husserl 1931;Moustakas 1994).