The main findings of two phases of the PAR are presented in this section.
After analyzing focus group discussions, three major themes with subthemes were extracted from discussions: 1) Attitudes toward medication management, 2) Barriers toward medication management, and 3) Facilitators of medication management.
Attitudes toward medication management: Representatives described feeling responsible for medication safety. However, they perceived unfavorable conditions and reported mostly negative attitudes toward implementing new plans for medication management in the ED.
- Discontinued implementation of new medication management approaches
In some situations, medication management procedures, even those that were relatively recently implemented, were changed due to the appointment of a new manager. This led to a negative attitude toward new plans.
“Sometimes before we adopt new plans, the new manager comes and try to change it, so we prefer to stay in routines” (Focus group discussion 2)
- Attitude toward superiors
The importance of respective status differentials between managers and clinicians was mentioned by all representatives. This reportedly induced humiliation and reluctance in many clinicians to expressing their negative perceptions regarding existing medication management approaches.
“I’m reluctant to complain about current medication management conditions to my superiors, because it may offend him…” (Focus group discussion 1)
- Medication therapy in complicated moments
Participants questioned the responsiveness of medication management process, particularly during ED high volume periods.
“How about the shift works that we concurrently are surrounded with lots of acute patients? How is medication management applicable in these situations?” (Focus group discussion 1)
Barriers toward medication management: There were many barriers toward medication management in ED reported by representatives. These barriers influenced clinicians’ attitudes toward medication management.
- Individual-oriented perspective of failure
Representatives stated that medication errors are often considered as active failures. This means that individuals are perceived as responsible for medication errors.
“Many superiors believe that everyone is solely responsible for the safety of the medication therapy he or she is doing, but it’s short-sighted view” (Focus group discussion 3)
- Lack of effective feedback
The need for appropriate feedback regarding medication therapy from a qualified person was stressed by representatives.
“…it seems there are few efforts for giving proper feedbacks on medication therapy…” (Focus group discussion 1)
Facilitators of medication management: Several facilitators were identified as potentially supporting the improvement of medication management and positive attitudes toward improving medication management.
- Medication safety training
Representative endorsed that, when clinicians become more knowledgeable about medication therapy and medication management, they are more likely to participate in the improvement of medication management plans.
“The more effort is put into pharmaceutical education, the more people's knowledge and perception of safe medication will be improved” (Focus group discussion 3)
- Enhancing a system-oriented perspective
Participants stated that to benefit from medication management, a shift toward system-based practice was required. This suggested the benefit of sequential medication management steps and the application of resources to provide medication therapy that is of optimal value.
“…medication management is a systemic function, the more holistic we consider it, the better we will achieve…” (Focus group discussion 3)
- Interprofessional collaboration
Participants perceived that interprofessional forums, education and practice are required to allow clinicians from different professions to understand each other roles regarding medication, which would facilitate greater collaborative work.
“The medical and nursing professionals need to recognize each other’s responsibility… when we are knowledgeable on the other professions’ role through the medication management, so we can do it collaboratively…” (Focus group discussion 3)
Actions in the first phase included interprofessional courses on medication management and placement of clinical pharmacists. Clinical pharmacists led the actions and all ED clinicians participated collaboratively. The planned and implemented actions in phase I is described in Table 2.
The fourth focus group discussion was run for observing the impact of actions. During this session, representatives discussed their experiences and attitudes toward new medication management procedures. Major categories derived from this group discussion were as follows:
- Increased willingness to adhere to medication management protocols
After training and interactive discussions, clinicians were encouraged to adhere to medication management protocols.
“…now we’re noticed about the importance of guidelines. Before the courses with considered them as boring written materials…” (a nurse with 7-year experience)
- Motivated medication error reporting
During training, medication error scenarios were presented, which assisted clinicians to recollect similar situations and recall their mistakes. Hence, they were motivated to and confident to report their medication errors.
“…presented cases about medication errors were great, we imagined ourselves in those situations ...” (a nurse with 12-year experience)
- Interprofessional collaboration
As clinicians became aware of each other’s roles, they were more committed to participating in new medication management procedures.
“…now I believed that medication management is like a puzzle and healthcare professionals should try to solve it collaboratively.” (an emergency medicine specialist with 8-year experience)
At four months post-implementation, informal interviews with nine clinicians (participants) were conducted to allow for reflection on new medication management procedures. Major extracted categories can be labeled into two groups:
Satisfaction with current action:
- Well-informed clinicians: Participants reported being satisfied with the courses and training on medication guidelines. ED clinicians reported being more knowledgeable regarding safe and collaborative medication management.
- Robust medication safety: Clinicians stated that improved medication management had increased the robustness of medication therapy, such that peak ED volume did not lead to disruptions in medication policy adherence.
Suggestions for new actions:
- Context based guideline development: Participants believed that the current instructions regarding medication management and safety-related issues needed to be better promoted. They deduced that general guidelines and instructions were not sufficiently contextualized and practical.
- Clinician-oriented actions: Although clinicians mostly emphasized that the PAR approach was indeed participative and they collaboratively managed medication therapy, they still felt potential for a more active role. They mentioned that actions in the first phase were mostly pharmacist-led.
Based on data gathered and analyzed in the reflection stage of the first phase, the professional co-development group decided to continue implementing new actions for an additional four months. They decided that the interprofessional courses on medication management needed to be continued to stabilize the newly created safety climate. Development of more structured, context-specific and evidence-based medication management guidelines reflected another action. This new guideline which was developed collaboratively by ED clinicians aimed to diminish the authoritarian approach induced by previous guidelines and help clinicians to promote an understanding of their important role. The actions that were employed in the second phase are summarized in Table 3.
We conducted six interviews in the second phase observation stage with representatives. Three main categories emerged from data analysis regarding participants’ evaluation of new actions:
Overall, participants assumed that new procedures improved medication safety.
“If I want to make a comparison about medication management since last year, the most important change is more safety…” (a nurse with 9-year experience)
Through the PAR, clinicians developed confidence in the ability of share their opinions, especially regarding medication management.
“…I think I have gained more courage to express my ideas for improving the system…” (a nurse with 5-year experience…)
Participants assumed that the new actions resulted in apparent and effective outcomes.
“…there had been a lot of research and plans before, but usually the results were not very obvious, this time it was different…” (an emergency medicine specialist with 4-year experience)
The final reflection stage was the final PAR component. This included results from informal interviews with 10 clinicians. Most of the participants indicated that the actions in both phases had improved medication management and patient safety. We classified findings into two groups:
Safety attitudes improvement related to medication management: Findings under this theme related to changes and improvement in clinician safety attitudes, perceptions and behaviors following new actions in the ED:
- Inter and intra professional teamwork: Collaborative implementation of actions affected clinicians’ perception of safety climate and teamwork. Participants emphasized the role of teamwork as major element to progress medication therapy among and between medical, nursing and pharmacy professionals.
- Psychological support: A more positive attitude not only resulted in safety-based practice, but also enhanced clinician wellbeing by limiting stress related to medication-related anxieties.
- Communication pathway: Participants realized that managers facilitated more reliable communication. This accompanied perceptions of openness and support among clinicians related to sharing their views and concerns.
- Perceived accountability: Participants perceived that no matter what profession or role, they are responsible for developing strong and positive safety attitudes regarding medication therapy.
Safety tool induced improvement in medication management: These findings related to the impact of newly introduced safety tools and related actions:
- Respected professional competence: Involving participants and their representatives in planning and implementing actions, especially in the development of new guidelines as a safety tool was interpreted as respecting clinicians’ professional competence.
- Continuous improvement: Clinicians perceived that participating in courses and educational events led by pharmacists were important continuing in-service education that benefited their practice.