Exploring the challenges to safer prescribing and medication monitoring in prisons: A qualitative study with health care staff

INTRODUCTION: Research suggests that patients who are prisoners experience greater morbidity, increased health inequalities and frequent preventable harm, compared to the general population. Little is known about the process and influencing factors for safe prescribing in the unique prison environment, which may limit the development efforts to improve the quality of care in prisons. This study aimed to understand the process and challenges associated with prescribing in prisons, explore the causes and impact of these challenges, and explore approaches to improve prescribing safety in prisons. METHODS: Grounded theory informed data collection and analysis of a nominal group discussion by seven participants and semi-structured telephone interviews with twenty prison healthcare staff, including GPs, pharmacists, psychiatrists and nurses. FINDINGS: The underlying complexity of prescribing in prison settings increased the level of challenge and influenced the safety of this process. Multiple contributors to the challenges of safe prescribing were identified (comprising governance and policy; the prison structure; staff retention, training and skill mix; IT systems and interface; polypharmacy and co-morbidity; tradability and patient behaviour) with overarching constructs of variations in practice/policy and the influence of prison culture. Participants identified measures to address these challenges through multi-disciplinary collaborative working, increased consistency in processes, and the need for more innovation and education/training. CONCLUSIONS: Our study highlighted that healthcare provision in prisons is unique and needs to tailor the care provided to patients without enforcing a model focused on primary, secondary or tertiary care. Participants emphasised a necessary shift in workplace culture and behaviour change to support improvements. The COM-B model of behaviour change may be effectively applied to develop interventions in organisations that have in-depth understanding of their own unique challenges.