How does the 'culture' within a nursing home influence the prescription of certain drugs?

Research project: The impact of contextual factors on the prescribing of psychoactive drugs with older people: An analysis of treatment culture in nursing homes

Lead Investigator: Professor Carmel Hughes
Institution: Queen's University, Belfast
Grant type: PhD studentship
Duration: 3 years
Amount: £73,690
Start Date: Sept 2012
End Date:  July 2016

What was the project, and what did the researchers do?

This project looked at how the 'culture' within nursing homes may affect the prescribing of mind-affecting medication in older people with dementia. Alzheimer's Society estimates that 2 out of 3 people with dementia are prescribed sleeping tablets, tranquilizers or antipsychotic medications unnecessarily. These drugs can cause complications such as an increased risk of stroke, and Alzheimer's Society has campaigned for a reduction in prescription, and for a more person-centred approach to care.

While there may be genuine medical need, there are homes with high levels of prescribing and homes with low levels of prescribing.  This suggests that there are non-medical influences on whether a prescription is given. This project explored why this happens. 

Nursing homes can be categorised according to their treatment culture as having:

  •  a 'traditional' culture, where the resident is not considered as an individual, people don't work together and there may be excessive use of medication and physical restraints
  •  a 'resident-centred' culture, where each resident is treated as an individual, emphasis is placed on nursing home staff, GPs, pharmacists and social workers working together, and trying to avoid the use of psychoactive medication as far as possible and not using physical restraints.
  •  an 'ambiguous' culture that lies somewhere in between resident-centred and traditional cultures. 

What we didn't know is why some homes have a resident-centred culture and others do not. This project aimed to understand what a resident-centred culture really 'looks like', and what promotes and encourages it. By understanding this, we may be in a better position to train staff and encourage the development of a resident-centred culture in nursing homes. 

The project took place in six nursing homes (two in each category), and involved three aspects:

  • Interviews of staff in nursing homes, and GPs who prescribe for the residents
  • Investigating in detail what actually happens day-to-day in three of the homes through watching, looking at nursing notes, and talking to staff
  • Helping awareness and change through development of a resource package to inform and assist with decision-making on mind-affecting medication

What were the key results and how will this benefit people with dementia?

Everyone interviewed agreed that mind-affecting drugs should be a last resort, but cultural differences were described

  • In 'traditional' nursing homes, the culture centred around a standardised management approach and maintaining reasonable relationships within the home. However staff didn't seem to challenge prescribing decisions made by doctors who did not visit often. 
  • In contrast, 'resident-centred' homes had a more flexible, individualised approach for care. They reported good working relationships with external healthcare professionals and felt able to question a GP's decision to prescribe a medication.
  • In 'ambiguous' homes, the culture was largely about routine, with a perception that larger homes were more impersonal and interested in making a profit. 

In the detailed investigation phase of the project, the researchers noted that:

  •  In the 'traditional' home there was indeed a higher incidence of mind-affecting drug prescribing.  This happened within a culture of a strict routine, little interaction between staff and residents and the administration of mind-affecting drugs without a non-drug alternative being tried first such as playing music or reassurance. 
  • In the 'resident-centred' or 'ambiguous' homes, there were fewer prescriptions, within cultures that had a greater focus on giving residents choice, individualised care and interaction between staff and residents.  There was more emphasis on non-drug treatments such as distraction and one-on-one attention.

Based on this work, an educational resource has been developed to help nursing home staff - and in particular nurses - make decisions about medications.  This provides some background to prescribing and culture, describes a number of scenarios for care home staff and asks them to reflect and document how they would handle certain situations with people with dementia.  Feedback from the staff has been collected, but the resource has been will require further testing before it can be made available.

What happened next? Future work and additional grants

The PhD student working on this project (Catherine Shaw) is preparing her PhD for submission, and is continuing to work in this field.

How were people told about the results? Conferences and publications


Shaw, C., et al.. Prescribing of psychoactive drugs for older people in nursing homes: an analysis of treatment culture. Drugs, Real World Outcomes 2016; 3: 121-130 25 

Conference abstracts 

Shaw, C.,et al. The impact of contextual factors on the prescribing of psychoactive drugs with older people: An analysis of treatment culture in nursing homes. International Journal of Pharmacy Practice 2013; 21 (S2): 61-62 

Shaw, C., et al.. The impact of contextual factors on the prescribing of psychoactive drugs with older people: an analysis of treatment culture in nursing homes using an ethnographic approach. International Journal of Pharmacy Practice 2015; 23 (S1): 17 


Catherine, the PhD student on this project, presented a poster at five conferences, and an oral presentation was presented at the Health Services Research and Pharmacy Practice conference, April 2015.