Although medications are commonly used in hospitals, they are one of the most common sources of harm in hospitalised patients (Roughead, Semple, & Rosenfled, 2016), affecting 2-3% of all inpatients (McTier, Botti, & Duke, 2015). However, the majority of medication-related errors are preventable (Australian Commission on Safety and Quality in Health Care, 2013). Medication administration is almost solely under the control of the bedside nurse and approximately 25-33% of medication-related errors occur during the administration process (Armstrong, Dietrich, Norman, Barnsteiner, & Mion, 2017). The ‘rights’ of medication administration are guidelines to ensure patient safety during administration. Nurses are required to use these ‘rights’ to ensure accuracy in patient and drug identification, and adherence to the processes of medication administration. An important strategy for improving safety and quality in medication management is to increase opportunities for patients to participate in medication management (McTier, Botti, & Duke, 2015). Encouraging patients to be actively involved in health care delivery is increasingly recognised as important to improve efficiency of the health care system and to promote patient safety (Souliotis, 2016). The Australian Commission on Safety and Quality in Health Care (2017) includes Partnering with Consumers as one of the National Safety and Quality Health Service Standards to improve the quality of health service provision and promote safety. However, patients’ and nurses’ perceptions of engaging patients as care partners during medication administration have not been fully explored. In this study, patients’ and nurses’ perceptions of the acceptability of a knowledge translation patient engagement intervention was explored using a patient brochure, which provided information about the medication administration process and encouraged patients to ask questions.
Methods:
A qualitative exploratory descriptive approach was used. Data were collected at a publicly funded healthcare organisation in metropolitan Victoria, Australia, using individual interviews with patients (n=30) who had received inpatient care on two general medical wards, and focus groups with a purposeful sample of nurses (n=6) from one ward. Transcripts were analysed using content and thematic analysis strategies.
Results:
From the patient interviews, Trust emerged as the central theme related to engagement between patients and nurses during medication administration. Patients’ trust in nurses during the medication administration process developed because of three factors: i) patients assumed the required safety procedures were in place; ii) there was an assumption that since nurses were administering the medication, the nurses would know and follow the correct procedures; and iii) most patients had not previously knowingly experienced an error with medications they were administered whilst in hospital. In addition, there was trust in the nurses’ professionalism and their ‘authority’ to follow the required processes and doctors’ instructions. Patients’ trust in nurses led to confidence in the nurses’ work, and consequently, most saw no need to question the medication checking process, or to seek further clarification on the medications they were administered. Patients’ Respect for nurses and their role emerged as a minor theme that related to trust, and contributed to the trust that patients had in the medication administration process. There was respect for nurses and the work they did because ‘they all seem very professional’. Regarding the patient engagement intervention, only four patients were able to identify the purpose of the patient brochure. Patients described the content of the brochure as a ‘good idea’, ‘quite informative’, and able ‘to answer a lot of questions’. However, five patients also highlighted that the brochure could be further adapted to suit patients. They thought the brochure ‘was very wordy’, ‘had a little too much information’, and was too much for a sick person to read.
The nurses focused on patient-perceived barriers to patient engagement as partners in medication administration, and their interviews revealed four themes in this context: (i) unfamiliarity with the medication administration process; (ii) not pushing perceived nurse-patient boundaries; (iii) frustration with being in hospital and enduring repetitive routines; and (iv) the debilitating nature of the patients’ illness. The nurses felt that not all patients were aware of the checking processes that nurses followed during medication administration, and patients might be concerned that asking questions could result in negative consequences from nurses towards them. They acknowledged that, for patients, being hospitalised comes with inherent frustrations. Specific health issues, including pain, could render patients less likely to engage during medication administration. With regards to the knowledge translation patient engagement intervention, since implementation of the patient brochure, nurses reported observing an increase in patients telling the nurse their name during medication administration.
The nurses perceived that it was easy for patients to remember to tell the nurse their name as part of the checking process. However, nurses noted that patients were not as focused on volunteering their allergy status to the nurse. Nurses also reported observing that family members’ involvement during medication administration had increased, since families also had access to the patient brochure. In addition, nurses emphasised that the extent of patient engagement with the patient brochure was dependent on patients’ level of cognition, language ability and literacy, which would impact on their ability to read and understand the brochure (for this study was only available in English), and their length of stay on the ward. The nurses perceived that for patients who had a relatively short length of stay on the ward, i.e. less than three days, there would be insufficient time to enable full engagement with the brochure and the medication administration process.
Conclusion:
Patients must be safe during health care. Although engaging patients as care partners is increasingly recognised as necessary for efficient and appropriate health care delivery and to promote patient safety, operationalising this engagement during medication administration warrants clear communication between patients and nurses. It is important to address the challenges associated with enabling patient engagement and preferences for care. Interventions designed to inform and facilitate patients to participate in health care delivery may contribute to a reduction in medication errors. Patients must be empowered and encouraged to actively participate in health care delivery, and this study has explored patients and staff perceptions of engaging patients as partners during medication administration. The findings would inform revision of the patient brochure and further exploration of using a knowledge translation patient engagement intervention to engage patients and families as care partners, to promote safety during medication administration. Specifically, involving patients and their families from non-English speaking backgrounds, patients with lower levels of literacy, a cognitive impairment and lengths of stay less than three days.
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