Before the intervention, one group discussion (GD) with 10 GPs was conducted, one with 5 pharmacists and at the same time two GDs with 24 nurses from 10 NHs (duration 45–75 minutes).
After the intervention, one GD with 6 GPs and one with 5 pharmacists were performed. No GD was feasible with the nurses after the intervention. 2 nurses were interviewed separately with the same interview guideline as for the GDs. The interviewed persons were partly the same at both times of measurement. All post-interviews lasted from 15 to 25 minutes. Table 2 shows the characteristics of all participants.
Table 2
Characteristics of the interview participants
|
|
Nurses
|
GP’s
|
Pharmacists
|
|
|
pre inter-vention
(n = 24)
|
post inter-vention
(n = 2)
|
pre inter-vention
(n = 10)
|
post inter-vention
(n = 6)
|
pre intervention
(n = 5)
|
post inter-vention
(n = 5)
|
Female
|
N (%)
|
18 (75.0)
|
2 (100)
|
3 (30.0)
|
3 (50.0)
|
3 (60.0)
|
4 (80.0)
|
number of years of employment
|
Mean (SD)
|
18.5 (± 9.0)
|
38.5 (± 13.5)
|
18.1 (±7.7)
|
23.0 (±13.6)
|
17.2 (± 8.3)
|
17.2 (± 9.9)
|
Legend: GPs = General Practitioners, SD = Standard Derivation |
The themes discussed before and after the intervention could be assigned to a total of eight categories (Fig. 2). In this article, the central themes ‘cooperation and communication between the professional groups’, ‘change requirements at the beginning of the project’ and ‘changes due to the project’ are presented. The perceptions of each professional group are offered consecutively, common perceptions are presented together.
Main results of the interviews
Cooperation and communication between the professional groups
A functioning cooperation and communication at the beginning of the project was perceived when GPs took responsibility for the resident’s prescribed medication and checked it regularly. High numbers of treated residents, high frequency of visits during off-office-hours as well as regular visits in the NHs by the GP were perceived as responsible behavior by the nurses.
“There are GPs who come for rounds regularly every 14 days or every week, with whom you can work well because not only [the nurses] have questions, but [the GPs] also asks how his patients are doing.” (GD nurses_gr., 502).
GPs mentioned the nurses’ knowledge of drugs as important for a good cooperation as well as the organization of information transfer, e. g. about changes in medication (prescription of medical specialists) by faxing the updated medication plan of residents to the GPs.
All professional groups described the importance of the reachability of the others for a well working cooperation and communication. The nurses and GPs defined the accessibility of the pharmacy, especially outside opening hours, and a swift delivery of medications for an acute treatment in urgent cases as beneficial. The nurses also described support by the pharmacists in form of medication reviews in NHs and regular trainings by pharmacists as helpful as well as the proximity of local pharmacies for a better coordination of drug management. The pharmacists pronounced only rare contacts to GPs. They called a cooperation well-functioning when they informed the GPs via fax about medication problems.
Nurses described problems in the cooperation with the GPs, because of differences in the prescription of medication. Sometimes GPs might not prescribe special medications, like neurological drugs, or fail to recognize the resident-specific limitations in application, such as the prescription of tablets for persons with a feeding tube.
“… You don't know if the GP always knows what another specialist has prescribed. They are often quick on their visits and often rarely on the spot. If the GPs offices are distant away, they [the GPs] may visit every three months. During the visits by the pharmacy, it was noticeable that medication was still available that had been discontinued for a long time or that there were also no needs for the medication. That's where you have to start.” (GD pharmacists 1, 71–77).
Another aspect raised by the GPs was the missing information about prescriptions ordered by medical specialists, so that they were usually unaware about the total current medication of the residents and they mentioned missing information about drug-drug interactions by the pharmacists. In contrast, the pharmacists described different reactions of the GPs when informing them about problems of medication management. They experienced that most of the GPs did not want to be informed by pharmacists.
The pharmacists complained that their expertise was not acknowledged – neither by the GPs nor by the nurses, so that they lacked information about changes of the residents’ status, which could be helpful when reviewing possible medication problems.
For the GPs, an independent inspection of the resident’s documentation was not possible, because they normally had no free access to the used electronic documentation systems in NHs, and had to rely on the nurses’ access to the system, mostly without a regular contact person and with an organization-specific medication process. These circumstances inhibited GPs from frequently visiting a NH.
“One often has the problem in the homes that one must look for the nursing staff often for hours. This keeps the doctor from going to the home. You have to go into a room to ring the bell and then it takes another ten minutes. The biggest problem is that the nurses are not there. (GD GPs 1, 99–112).
Moreover, GPs and nurses interpreted the medication process differently. For example, GPs and nurses valued a medication order via telephone differently with regards to legal rules.
“Many orders come by phone. Even if you are working correctly yourself, you always think that the doctor should take a look at the resident first. The remote diagnoses (should) become a little less. One also doesn't know whether most [GPs] would take time for the documentation, it is spoken faster than written. (GD nurses_yel., 238–240).
Change requirements at the beginning of the project
All interviewed persons recognized the necessity of changes in cooperation and communication concerning the medication process, e.g. the need for better technical facilities in the face of medical prescription and the need to involve all professional groups in the medication process to cover different angles. The nurses demanded the GPs to show more responsibility for drug therapy safety and the whole medication process, especially regarding regular visits in the NHs and responsible prescription of drugs.
“It would be nice if the doctors showed more responsibility, did not settle everything by telephone if possible, but looked at the residents on the spot and receive their own impression and did not always have a blind faith that the nurses would pass on everything correctly. They should also show responsibility to look at the medication prescribed by specialists together, because they are the family doctors and responsible for the residents. However, they often say that they have nothing to do with it, which is perceived as difficult. (GD nurses_yel., 220).
In turn, the GPs expressed a better assumption of responsibilities by the nurses for the therapy observation as well as for the transfer of information to the GPs. The pharmacists correspondingly saw the need for changes in nursing strategies to improve the medication process by integration of medication safety into regular nursing activities. They also wanted to have regular visits with nurses and GPs.
Changes due to the project
After the intervention, all professional groups described different experiences as a result of the project. The GPs felt well-trained by the online education and experienced the networking as important. The pharmacists felt a higher acknowledgement of their expertise by the GPs and the nurses. After the intervention, they were contacted more often by the GPs seeking their advice and the communication was improved and more partner-like.
After the medication review of the pharmacists, the nurses observed a change in the GPs’ behavior in the form of increased responsibility and communication improved further during the project. More regular visits, a standardized exchange of medication and differences in the medication documentation between NHs and GPs offices, that became apparent during the intervention, sensitized the GPs and nurses to drug therapy safety because of the intervention. The GPs felt obliged to reflect on the medication plans of the residents following the medication review of the pharmacists. The onsite educational part was rated as beneficial as it created a new habit of periodically checking all medications.
“Just the fact that you really thought about it again and checked everything again. This also led to the discontinuation of medication. If you actually live what you have learned in advance during the courses [online modules] and perhaps bring in regularity, this awareness of the problem earns a lot.” (GD GP 2, 298–304).
The use of the online platform was a central topic after the intervention. It was described as a helpful device and a positive way to communicate. The pharmacists identified the benefit of electronic networking, because it enabled independence from personal attendances of all professional groups. The nurses were aware of the residents’ current situation by focusing on the therapy observation and the documentation of the other health care professionals in the tool. The GPs found the regular medication review by pharmacists supportive. The pharmacists experienced that the GPs responded to their inquiries and warnings. Problems because of local distances to the GPs office were reduced by the online platform. Since in German NHs medication reviews are usually not carried out and communicated, the pharmacist’s found it necessary to continue this practice after the intervention, e. g. regular communication with the GPs.
A change concerning the cooperation was the nurses’ reflection about their inadequate knowledge about storage and administration of drugs. At the same time, the GPs described the necessity of getting comprehensive information from nurses about possible problems with the administration. This created a gap in the communication flow, which could be closed by further education and communication.
All professionals noted an improved communication because of a greater awareness regarding drug safety. Direct communication was experienced as positive. However, the pharmacists also problematized their own role because of scrutinizing the GPs by conducting the medication review.