Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20

Pharmacists’ Interprofessional Communication About Medications in Specialty Hospital Settings Sascha Rixon, Sandra Braaf, Allison Williams, Danny Liew & Elizabeth Manias To cite this article: Sascha Rixon, Sandra Braaf, Allison Williams, Danny Liew & Elizabeth Manias (2015) Pharmacists’ Interprofessional Communication About Medications in Specialty Hospital Settings, Health Communication, 30:11, 1065-1075, DOI: 10.1080/10410236.2014.919697 To link to this article: http://dx.doi.org/10.1080/10410236.2014.919697

Published online: 15 Oct 2014.

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Date: 06 November 2015, At: 07:23

Health Communication, 30: 1065–1075, 2015 Copyright © Crown Copyright ISSN: 1041-0236 print / 1532-7027 online DOI: 10.1080/10410236.2014.919697

Pharmacists’ Interprofessional Communication About Medications in Specialty Hospital Settings Sascha Rixon and Sandra Braaf

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Melbourne School of Health Sciences University of Melbourne

Allison Williams School of Nursing and Midwifery Peninsula Campus, Monash University

Danny Liew Chair in Clinical Epidemiology University of Melbourne and Melbourne EpiCentre Royal Melbourne Hospital

Elizabeth Manias School of Nursing and Midwifery Deakin University and Department of Medicine Royal Melbourne Hospital

Effective communication between pharmacists, doctors, and nurses about patients’ medications is particularly important in specialty hospital settings where high-risk medications are frequently used. This article describes the nature of communication about medications that occurs between pharmacists and other health professionals, including doctors and nurses, in specialty hospital settings. Semistructured interviews with, and participant observations of, pharmacists, nurses, and doctors were conducted in specialty settings of an Australian public, metropolitan teaching hospital. Twenty-one individuals working in the settings of emergency care, oncology care, intensive care, cardiothoracic care, and perioperative care were interviewed. In addition, participant observations of 56 individuals were conducted in emergency care, oncology care, intensive care, and cardiothoracic care. Detailed thematic analysis of the data was performed. Across all of the settings, pharmacy was less visible than medicine and nursing in terms of pharmacists’ work performed, pharmacy documentation and resources, and pharmacists’ physical visibility. Pharmacists, doctors, and nurses largely worked alongside one another rather than with each other. When collaboration occurred, the professional groups engaged in mostly reactive communication to accomplish specific medication tasks that needed completing. Interprofessional differences in attitudes toward medications and medication management communication behaviors were evident. Pharmacists need to engage in more proactive communication in order to reduce the risk of medication errors occurring.

Correspondence should be addressed to Sascha Rixon, PhD, Research Fellow, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Australia. E-mail: [email protected]

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Medications are frequently used in hospitals. High-risk medications, which are medications with an increased risk of causing significant patient harm if used incorrectly, such as chemotherapeutic agents (Cohen, Smetzer, Tuohy, & Kilo, 2007), are extensively used in specialty hospital settings such as oncology care. Doctors, nurses, and pharmacists are the key health professionals involved in the management of patients’ medications. Clinical pharmacists not only dispense medications but also provide pharmaceutical care to patients through the provision of clinical services, and thus are members of the multidisciplinary health care team (Gallagher & Gallagher, 2012; Kaboli, Hoth, McClimon, & Schnipper, 2006). Effective interprofessional communication between doctors, nurses, and pharmacists about patients’ medications is pivotal to safe medication management. Within health care institutions in Victoria, Australia, breakdowns in communication are a contributing factor in 14% of all sentinel events, which are adverse events that result in serious harm to patients (Department of Health, 2012). Clinical activities of hospital pharmacists within inpatient settings can include participating in medical ward rounds and reconciling patients’ medications on admission to and at discharge from hospital (i.e., comparing patients’ previous medications with medication prescriptions on admission to and at discharge from hospital, and communicating any discrepancies with doctors and/or nurses). This participation has been shown to improve patient outcomes through improved safety and quality of health care (Kaboli et al., 2006). However, while these pharmacy interventions are realized through pharmacists’ communication with health professionals of different professional groups, there are no known published studies focused specifically on hospital pharmacists’ interprofessional communication about medications. In contrast, a growing body of research exists that explores nurses’ and doctors’ interprofessional medication communication in hospitals. Observational and survey research have shown variation in the level of interprofessional communication and collaboration involving pharmacists. In terms of less communication and collaboration, Bolster and Manias (2010) reported a lack of medication communication and collaboration between nurses and pharmacists, and Creswick and Westbrook (2010) and Reeves and Lewin (2004) described infrequent communication and little collaboration between doctors, nurses, and allied health professionals (including pharmacists). In terms of more communication and collaboration, Manias, Aitken, and Dunning (2005) reported regular medication communication between graduate nurses and pharmacists. A time and motion study of pharmacists’ work patterns in an Australian hospital reported that when pharmacists were present on wards, more than 10% of their time was spent on medication-related spoken communication

with patients, their relatives, and other health professionals. Communication that was initiated by other individuals was more frequent and took up a greater proportion of pharmacists’ time than pharmacist-initiated communication (Lo, Burke, & Westbrook, 2010). Conversely, Reeves and Lewin (2004) found pharmacists initiated more communication with both doctors and nurses in an observational study of interprofessional collaboration in two general medical wards in a hospital in England. Interactions between doctors and staff from other health care disciplines have been characterized as being shorter, more task-focused, and containing less social talk than interactions between nurses and staff from other healthcare disciplines (Reeves & Lewin, 2004). Professional tensions, problematic working relationships, and ineffective communication between pharmacists and doctors have been reported (Elliott, 2006; Gallagher & Gallagher, 2012; Rubin & Sleath, 1997). Scholars have argued that when pharmacists communicate with doctors about medication issues, they are excessively polite and deferential, giving doctors the ultimate authority for decision making and therefore patient outcomes (Lambert, 1995, 1996; Liu, Manias, & Gerdtz, 2013; Mesler, 1989, 1991). Past research that has described pharmacists’ interprofessional communication has largely focused on communication between pharmacists and doctors as compared to communication between pharmacists, nurses, and doctors, and communication within the context of general medical wards. Analyses of pharmacists’ interprofessional communication have been limited. They are either more macro analyses of actual, real-life communication in studies that have not focused specifically on pharmacists’ communication (Mesler, 1989, 1991), or they are more micro analyses of elicited, simulated communication (Lambert, 1995, 1996). To the best of our knowledge, there is no published research that has focused specifically on pharmacists’ interprofessional medication communication in specialty hospital settings. Given these limitations and gaps in existing research, the current study seeks to answer the following research question: What is the nature of the communication about medications between hospital pharmacists and health professionals from other discipline groups in specialty hospital settings?

METHODS This exploratory qualitative study employed semistructured interviews with, and participant observations of, pharmacists, nurses, and doctors in specialty settings of a public, metropolitan teaching hospital in Victoria, Australia. Interviews were first conducted in emergency care, oncology care, intensive care, cardiothoracic care, and perioperative

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care, and observations were then performed in all of these settings except for perioperative care.1 This study was approved by the University and Hospital Ethics Committees. Health professionals were recruited by members of the research team via information sessions, by referrals from clinical staff, and by approaching individual health professionals. After receiving an overview of the study, health professionals who expressed interest in participating were provided with more detailed written information about the study. All health professionals who participated provided informed written consent prior to data collection. Face-to-face semistructured individual interviews were conducted by the first author and three research assistants with health professionals in quiet locations within the hospital. Health professionals were first asked how they communicate with their colleagues about managing patients’ medications. They were then asked questions about the problems in how patients’ medication needs are managed, the barriers and facilitators to effective interprofessional medication communication, and how these barriers could be overcome. Interviews typically lasted about 30 minutes, and were audio-recorded and transcribed verbatim. Participant observations of health professionals were conducted by the first and second authors. Observations were performed over different time periods during the working day and on different days of the week. Individual health professionals were followed by an observer for typically between 2 and 4 hours of their working day. Observations in which health professionals were moving around were audiorecorded and observations in which health professionals were in a fixed location were video-recorded. Health professionals’ spoken and written communication was additionally recorded by the observer taking field notes. Where possible, all observed activities involving communication about medications were documented, noting the time and location of the activity, the participant(s) and participant configuration, the communication mode used, and a brief description of the communication including the name(s) of the medication(s) involved. All instances of spoken medication communication involving pharmacists were transcribed verbatim. The observers took several measures to reduce the impact of their presence and the recording on the naturalness of the data collected. First, individual observations were typically conducted over several hours, and participants’ awareness of being observed and recorded and any associated changes to their behavior appeared to decrease over time. For example, some of the participants explicitly oriented to being observed 1 Observations were not conducted in perioperative care as data saturation of themes was reached after observations had been performed in the other specialty settings. There were preoperative and postoperative patients located within the other specialty settings when the observations were undertaken.

at or near the start of the observation and this lessened or disappeared as the observation progressed. The most common means of orienting to being observed was through referring to the observation (e.g., a nurse asked “How am I going?”) or the recording device (e.g., a pharmacist commented “I just swore on the tape”), and these references decreased or disappeared over time. Second, observations within a setting took place over many weeks and staff became more familiar and comfortable with the observers’ presence and recording over time. The results reported are mostly from the observations of pharmacists, as it was in these observations that most of pharmacists’ interprofessional medication communication was observed. Pharmacist observations commenced after the observers had been present in a setting for a period of time. Third, the observers attempted to minimize the intrusiveness and impact of the recording devices on the participants observed and the work activities undertaken. They did this by carrying a digital audio-recorder in their trouser pocket and by wearing a small lapel microphone for audiorecorded observations, and by occupying a peripheral position while operating a video camera for video-recorded observations. In total, 73 unique health professionals participated. Twenty-one individuals participated in interviews. Seventysix participant observations of 56 individuals were conducted. Seventy-two observations were audio-recorded and four observations were video-recorded (see Tables 1 and 2). Detailed thematic analysis of the transcribed interview and observation data and field notes was performed using the five-stage framework approach of Ritchie and Spencer (1994). This involved (a) reading through all of the data to become familiar with them, and noting potential themes; (b) rereading through the data to identify themes and create a thematic framework; (c) systematically applying the thematic framework to the data; (d) rearranging the data according to themes; and (e) reviewing the thematically

TABLE 1 Overall Demographic Characteristics of Health Professionals (n = 73) Characteristics Gender Male Female Professional group Pharmacy Medicine Nursing Mean age in years (range in years) Mean years of experience as a registered health professional (range in years) Mean years of experience in specialty practice setting (range in years)

n

23 50 13 14 46 32.7 (22−62) 9.3 (0.2−41) 5.2 (0.0−24)

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TABLE 2 Demographic Characteristics of Health Professionals by Interview and Observation (n = 73)

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Characteristics Professional group Pharmacists Doctorsc Nurses Specialty practice setting Emergency care Oncology care Intensive care Cardiothoracic care Perioperative care

Interviewed participants (n = 21), n

Observed participants (n = 56),a n

Observations (n = 76),b n

4 5 12

9 10 37

19 12 45

4 3 3 5 6

13 13 16 14 —

18 18 20 20 —

a Four

health professionals were both interviewed and observed. health professionals were observed twice. One health professional was observed four times. c Medical professionals were, in increasing seniority, residents, registrars, and consultants. b Seventeen

organized data by comparing and contrasting cases within themes and searching for patterns between themes, and then interpreting the data as a whole. Data analysis was initially undertaken by the first author and was regularly discussed by members of the research team to ensure consensus for analysis was achieved. In the results section, data excerpts are given to demonstrate the themes and have been chosen for their illustrative power. Excerpts are accompanied by a code that identifies the interview or observation from which it was derived. For instance, an excerpt coded “observation2-pharmacist1oncology” means that it has been drawn from the second observation of the first pharmacist observed within oncology care. Within transcripts, transcribers’ comments and individuals’ nonverbal actions are included in double parentheses.

RESULTS Thematic analysis of the data revealed four themes: (a) task focused interprofessional communication, (b) little interprofessional collaboration, (c) interprofessional asymmetries in behavior, knowledge and attitudes, and (d) lesser visibility of clinical pharmacy. Theme 1: Task-Focused Interprofessional Communication In almost all cases, pharmacists’ interprofessional spoken medication communication was reactive and outcomesfocused, in that it was responding to and centered on specific medication activities that had to be completed. The topics of spoken and written communication related to

medication stock, medication review, medication information, and patient movement. First, communication in regard to medication stock was usually about the supply of in-patient and discharge medications. Nurses in all settings requested the supply of in-patient medications that had run out or were not stocked. Pharmacists granted these requests by supplying medications to the settings, often handing medications to bedside nurses. In preparing patients for discharge, pharmacists were asked to dispense discharge medications through doctors and nurses placing prescriptions in a pharmacist’s in-tray (i.e., a tray for incoming documents requiring attention) or handing prescriptions to pharmacists. Doctors sometimes prescribed brand-name medications that pharmacists were unable to dispense as these medications were not listed on the hospital formulary. As a result, pharmacists needed to communicate with doctors to request that these prescribed medications to be changed to medications that were stocked by the hospital: Extract: observation1-pharmacist1-cardiothoracic (Pha = pharmacist, Res = resident) Pha: . . . Sally’s ((another resident’s)) charted Caltrate Plus which we don’t keep. Res: Yep. Pha: Are you happy just to give her calcium and vitamin D separately? Res: Okay. Pha: ‘Cause that’s essentially what’s in Caltrate Plus. Res: Yep . . .

Second, communication arose from pharmacists reviewing patients’ documentation such as medication charts and medication history on admission forms, and identifying medication issues that needed to be resolved. Pharmacists attempted to communicate with doctors and nurses right away about more urgent prescription and administration issues, including those that posed a potential risk to a patient’s safety. Pharmacists communicated with doctors and nurses in person when they were in the same location, and via an initial page and a subsequent telephone conversation when they were in different locations. Less urgent issues, including those that that did not pose a potential risk to a patient’s safety, were conveyed by pharmacists in writing, leaving a sticky note on a patient’s medication chart. Pharmacists’ interventions resulted in many errors being rectified in patients’ prescribed medications, including omitted medications, unnecessary medications, and incorrect doses. Third, there were communication encounters where health professionals sought or provided information or advice about patients’ medications. Doctors and nurses appeared to prefer to reactively satisfy their immediate medication information needs through engaging in spoken communication with ward pharmacists rather than consulting written medication information resources:

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Extract: observation1-pharmacist2-emergency (Nur = nurse, Pha = pharmacist) Nur: . . . I was just going to ask a question. Pha: Yep. Nur: . . . Um treatment for meningitis. Dexa ((dexamethasone)), Pha: What sort of meningitis? Nur: Well, she ((the patient)) had viral last time, so we haven’t actually- the tests haven’t all finished, we’re assuming it’s the same. Pha: Yep. Nur: Um they’ve ((the doctors have)) got ((prescribed)) two grams of ceftriaxone twelve hourly and ten milligrams of dexa four hourly. Is that about rightish? . . .

Finally, there was communication about patients’ medications related to patients’ movement in the hospital. This movement included coordinating patients’ discharge from hospital to the community and was usually communicated between nurses and pharmacists. Almost all of these discussions involved an exchange of logistical information, such as whether a patient’s planned discharge had been confirmed, and when a patient was scheduled to be discharged. There were almost no interprofessional discussions between pharmacists, nurses, and doctors about patients’ medication education needs that could inform the pharmacists’ counseling of patients about their discharge medication. There were only a few instances of pharmacists’ interprofessional spoken medication communication that were learning- rather than outcomes-focused communication encounters about medications. For example, there was a robust pharmacist–medical consultant discussion in emergency care about using indomethacin as a first-line nonsteroidal anti-inflammatory drug in treating renal colic pain. Due to time constraints and busyness, interactions were largely focused on efficient task accomplishment. Many interactions were short, lasting less than 1 minute. Medication stock-related interactions tended to be shorter pharmacist–nurse interactions. However, some interactions were longer, lasting more than 4 minutes. Medication review-related interactions tended to be longer interactions, particularly those relating to medication reconciliation, where a number of medication issues often needed to be discussed. Theme 2: Little Interprofessional Collaboration Subtheme: Little Collaboration in Informal Communication Forums Pharmacists largely worked in parallel alongside other health professionals, performing medication management tasks independently, rather than working together. Pharmacists’ interprofessional spoken communication about patients’ medications overwhelmingly comprised informal face-to-face discussions, which were not prearranged. Pharmacists, doctors, and nurses all opportunistically

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initiated communication upon seeing health professionals with whom they wished to interact. For instance, an in-charge nurse in oncology care, upon seeing the ward pharmacist walk past, asked a bedside nurse with whom she had been speaking to give a discharge prescription to the pharmacist. Subtheme: Little Collaboration in Formal Communication Forums Medical ward rounds are a formal communication forum to support multidisciplinary collaboration. However, these were not constructed as interprofessional events due to pharmacists’ absence and nurses’ variable presence and participation. There were only a few instances of communication involving pharmacists during medical ward rounds; however, these instances occurred as isolated interruptions to rounds, rather than as communication through sustained involvement. Theme 3: Interprofessional Asymmetries in Behavior, Knowledge, and Attitudes Asymmetry, or difference, was a pervasive feature of pharmacists’ interprofessional medication communication. It was manifest on several levels, namely, in participation, in knowledge and practice, and in attitudes toward medications. Subtheme: Interprofessional Asymmetries in Participation Significant differences in participation between the health professions were noticeable in regard to initiation of communication and communication behaviors. Pharmacists initiated most of the initial communication on specific topics or issues with doctors. Nurses initiated most of the initial communication on specific topics or issues with pharmacists. Pharmacists used certain interaction opening and closing devices more frequently than doctors. For instance, pharmacists greeted doctors more often than doctors greeted pharmacists. Pharmacists routinely introduced themselves by name and profession to staff members they did not know, whereas doctors tended to do this less often. In interactions they initiated, pharmacists often expressed their appreciation at the end of the interaction by thanking the person with whom they interacted, whereas doctors only sometimes thanked pharmacists. When discussing treatment options and decisions, pharmacists always deferred to doctors’ legitimate authority as the legal prescribers of medications through treating doctors as the health professionals with the ultimate responsibility for medication decisions. Pharmacists made suggestions and recommendations, and when necessary requested doctors’ permission to make changes to prescriptions that were within their scope of practice. Pharmacists often communicated indirectly with doctors in interactions regarding medication reconciliation and the review of drug charts:

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Extract: observation2-pharmacist1-emergency (Pha = pharmacist, Res = resident) Pha: . . . Are you happy for her to have Nurofen ((ibuprofen)) short-term with Res: Yeah yeah. Pha: ARV ((antiretroviral medication)) and an antagonist ((candesartan)) and a diuretic ((hydrochlorothiazide))? Res: Oh really? Is she, uh yeah Pha: For that combination. Yeah she’s on Atacand Plus ((a medication containing candesartan and hydrochlorothiazide)). Res: Okay. No Nurofen then . . .

In this example, the pharmacist implied she was not happy for the patient to go home on Nurofen (ibuprofen) because of its effect on the candesartan and hydrochlorothiazide combination but she did not explicitly state this or recommend that the patient not be discharged on Nurofen. The pharmacist provided information about the patient’s medications that the doctor was unaware of that influenced the doctor’s decision to not prescribe Nurofen. By asking whether the doctor was happy with the medication combination through the use of the construction “Are you happy . . . ” the pharmacist positioned the doctor as the professional responsible for the medication decision, thereby deferring to doctors’ ultimate responsibility for medication decisions. Subtheme: Interprofessional Asymmetries in Knowledge and Practice Pharmacists often possessed information about patients’ home medications that doctors did not. There were occasions where pharmacists requested doctors to do prescription work that doctors did not readily agree to do, as doctors had contradictory information or beliefs about patients’ medications. These different understandings resulted in extended interactions to resolve these contradictions. This is illustrated in the following example where a pharmacist asked a resident to prescribe a lunchtime dose of a medication for a patient and the resident did not grant this request straight away as he believed the patient took the medication in the morning and at night: Extract: observation2-pharmacist1-emergency (Pha = pharmacist, Res = resident) Pha: She’s also Parkinson’s. Res: Yes. She is. Pha: And she hasn’t had her lunch-time dose of levodopacarbidopa. Res: I was under the impression that she’s only having it twice a day. Pha: But she has her the um- she takes one strength half a tablet twice a day, and she said that’s for her lunch-time. Res: Oh right. Pha: I put the list ((medication history on admission form)) in her file.

Res: Yep. Pha: And I spoke to her daughter and her daughter said she hasn’t had the dose today . . . Is that alright? Res: Yeah. I’ll do that ((prescribe levodopa-carbidopa)) now. Pha: Great. Thank you.

These knowledge differences were in part due to interdisciplinary variations in practice. While both doctors and pharmacists took patients’ medication histories on admission to hospital, only pharmacists utilized a structured medication history on admission form to guide their history-taking. Pharmacists’ discussions with doctors arising from reconciling patients’ home medications with their prescribed medications highlighted gaps in doctors’ medication historytaking, resulting in incomplete or inaccurate medication charts for patients: Extract: interview-pharmacist-cardiothoracic The medications on admission are written in the doctor’s admitting notes. I have to say, about 99% [of all of these] are incorrect . . . there’s at least one [medication] there that’s incorrect . . . And if they’ve already got this list then of course the drug chart is going to be wrong.

Another interdisciplinary difference in practice was that when reviewing patients’ medications pharmacists would undertake checks, such as reviewing patients’ renal function and checking patients’ weight, that doctors had not completed before writing prescriptions. Pharmacists detected many prescription errors and inappropriate prescriptions in this way. This detection resulted in pharmacists needing to communicate with doctors to have these issues rectified. For example, an oncology ward pharmacist asked a resident to review a patient’s prescription for Clexane (exoxaparin sodium). The resident had dosed the Clexane based on the patient’s previous weight of 87 kilograms (prior to having had chemotherapy), rather than on the patient’s current weight of 83 kilograms. Subtheme: Interprofessional Asymmetries in Attitudes Toward Medications Differences in health professionals’ attitudes toward medications were evident, namely, that medications were a priority for pharmacists whereas they were less of a priority for nurses and for doctors. Doctors and nurses did not view educating patients on their discharge medications as a shared responsibility. Instead, this role was delegated to pharmacists. Doctors’ lower prioritization of medications and medication issues was evident in their behavior, including in their medication history taking and prescribing, in their responses to pharmacists’ communication about prescription issues, and in their response times to pharmacists’ communication. Doctors sometimes attempted to negotiate with pharmacists to minimize the prescribing work they needed to do (e.g.,

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“Don’t make me rewrite this”), or made light of prescribing issues (including prescribing errors), thus indicating that medication issues were a lower priority for doctors than they were for pharmacists:

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Extract: observation2-pharmacist-intensive care (Pha = pharmacist, Res = resident) Pha: . . . So I think she’s ((the patient’s)) got noradrenaline running Res: Right. Pha: but, there’s no order, so Res: Yeah, it happens. Pha: Yep I know.

In the preceding extract, when the pharmacist points out there is no written medication order for a patient’s noradrenaline infusion, rather than right away offering to write the order, the resident makes light of the issue by saying “Yeah, it happens.” Doctors were often slow to respond to pharmacists’ communication, resulting in pharmacists initiating repeated communication in order to resolve medication issues. Pharmacists learned through experience to communicate with specific doctors within a unit who responded more quickly, rather than with other doctors within the unit. Some units, such as surgical units external to the specialty settings, were known to not respond in a timely manner. Consequences of this untimely resolution of medication issues included delayed medication supply, delayed patient discharge from hospital, and medication errors, including missed doses and medications being given late. An example to illustrate some of these negative consequences took place in an observation of a pharmacist in cardiothoracic care. The pharmacist had to request the cardiology doctors to change a patient’s Seretide prescription (from a metered-dose inhaler to an accuhaler—the accuhaler was a breath-activated dry powder inhaler, which was the form the patient used at home) on four separate occasions over the course of a day using a variety of communication modes, namely, a sticky note placed on the patient’s medication chart, a page to the cardiology doctors, a face-to-face conversation, and another page, before the change was made. The pharmacist was only then able to supply the medication but the patient had missed his morning dose. Theme 4: Lesser Visibility of Clinical Pharmacy The profession of pharmacy was less visible in clinical work than the professions of nursing and medicine. This lesser visibility of pharmacy was evident on three levels: (a) the work pharmacists’ performed, (b) pharmacy documentation and resources, and (c) the physical visibility of pharmacists. Subtheme: Lesser Visibility of Pharmacists’ Work Much of pharmacists’ interprofessional communication was written, and pharmacists’ work was often out of view

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of nurses and doctors. When reviewing patients’ medication charts as a whole and individual medication orders, pharmacists supported nurses through providing written information, most commonly in the form of written notes in the columns of medication orders, to aid nurses in administering patients’ medications, and supported doctors through making changes to medication orders that were within their scope of practice. Pharmacists’ clinical work was less visible than the clinical work of nurses and doctors to patients. Pharmacists tended to only perform clinical work with patients at the start and at the end of a patient’s hospital stay, when conducting a medication history interview and performing discharge counseling, while doctors and nurses conducted clinical work with patients throughout a patient’s hospital stay. Pharmacists’ clinical work was also less visible to other health care professionals, including nurses and doctors. Sometimes this “hidden” work was made visible in spoken communication encounters, as in the following example, where a hematology registrar was surprised to learn from an oncology ward pharmacist that another oncology ward pharmacist would have corrected a prescription error the registrar had made: Extract: observation2-pharmacist1-oncology (Reg = haematology pharmacist, Res = resident) Extract: registrar, Pha = pharmacist) Reg: Is it ((the unit of dosage)) grams or milligrams? Pha: Grams. The cytarabine? Reg: No. For metho ((methotrexate)). Pha: Grams. Reg: Is it? Pha: Yep. Reg: What have I been doing on the other side ((another ward))? Pha: Grams? Reg: I don’t know. I think I wrote ((on an order)) milligrams. Pha: Oh they ((the pharmacist)) would have changed it for you. Reg: ((surprised sounding)) So ((first name of other oncology ward pharmacist’s)) just ((pause)) yep okay. Pha: Yep.

Subtheme: Lesser Visibility of Pharmacy Documentation and Resources There was no evidence of doctors utilizing a patient’s medication history on admission form where a pharmacist had documented a patient’s home medications. This form was filed in a patient’s medical record, and would have assisted doctors in their prescribing. An oncology ward pharmacist, when educating an intern pharmacist on the process of taking a patient’s medication history on admission, told the intern, “If you’re lucky the doctor will read it [the medication history on admission form], but in most cases they don’t.” In intensive care, a pharmacist had developed a resource to help doctors in their prescribing who were new to the

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setting. A card containing prescription tips was at every bedside. An intensive care pharmacist interviewed said, “We try and highlight the existence of the guide to the new residents and registrars.” However, observation data did not support this view:

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Extract: observation2-pharmacist-intensive care (Res = resident, Pha = pharmacist) Res: Is norad ((noradrenaline)) six in a hundred? Pha: Oh. I’ll need to check. Um, I’ve got my sheet here. Yep six in a hundred, five percent glucose. One to ten. Res: Oh you’ve got a helpful chart. Pha: They’re, Res: I wish I had one of those. Pha: They’re on everyone’s bedsides. Res: Never seen it!

Subtheme: Lesser Physical Visibility of Pharmacists Pharmacists were also physically less visible in a number of ways. First, there was only one pharmacist or, in some settings, two pharmacists assigned to a ward at any one time as compared to a number of nurses and doctors. Second, pharmacists did not have allocated space on wards and spent a considerable amount of time off wards dispensing medications. Third, in observations, pharmacists in all settings except emergency care were missing from formal communication forums in which patients’ medications were discussed and decisions were made. Pharmacists in emergency care increased their visibility through attending shift-change clinical handovers between medical staff.

DISCUSSION This study provides new knowledge on hospital pharmacists’ communication about medications with other health professionals in specialty hospital settings. It supports previous research findings that demonstrate the importance of hospital pharmacists’ medication management interventions in patient safety and quality of health care (Kaboli et al., 2006). Findings revealed that across all of the specialty settings studied, pharmacists were less visible than doctors and nurses, and that health professionals of the various disciplines largely worked alongside one another. When they did work together, it was overwhelmingly to accomplish medication tasks that needed completion. Interprofessional differences in attitudes and behaviors were uncovered. However, there were intersetting variations in the extent to which these themes were operative. The different nature of health professionals’ work and different information-seeking practices contributed to pharmacists’ lesser visibility than doctors and nurses. While the majority of pharmacists’ work tasks were performed alone, most of doctors’ work tasks were completed collaboratively (Lo et al., 2010; Westbrook, Ampt, Kearney, & Rob, 2008).

Pharmacists preferred to consult written resources prior to engaging in spoken communication (Mesler, 1991). Nurses and doctors, however, preferred spoken communication, consulting human rather than written resources (Coiera & Tombs, 1998). Despite the rhetoric of health professionals collaborating as part of a multidisciplinary team, in practice, pharmacists largely accomplished medication management tasks independently of nurses and doctors (Bolster & Manias, 2010; Creswick & Westbrook, 2010; Lewin & Reeves, 2011; Reeves & Lewin, 2004). Individual rather than shared responsibility for medication management tasks militated against collaboration. Pharmacists were delegated the responsibility of educating patients on their discharge medications. Doctors were held as ultimately responsible for treatment decisions and thus patient outcomes, leading to a lack of shared decision making, with doctors making decisions and pharmacists supporting doctors’ decision making (Liu et al., 2013; Mesler, 1989, 1991). Ad hoc, opportunistic communication predominated and comparatively little planned communication occurred (Lewin & Reeves, 2011; Lo et al., 2010; Reeves & Lewin, 2004). Due to time constraints and therefore work being performed according to priorities, pharmacists did not attend medical ward rounds. As such, they neither learned about patients’ conditions and progress during ward round consultations nor participated in the bulk of information exchange and decision making about patients’ treatments and discharges that occurred during ward rounds. Subsequently, they needed to spend a significant amount of their time finding out this information, and getting prescription errors corrected. Communication was largely reactive and outcomes focused, responding to and centered on specific medication tasks that needed completing. This has been observed by Manias et al. (2005) with respect to nurse–pharmacist medication communication and by Lewin and Reeves (2011) and Reeves and Lewin (2004) in regard to interprofessional communication more generally. Many interactions were short, as they were opportunistic and focused on single tasks (Reeves & Lewin, 2004). Much of the communication positioned doctors, nurses, and pharmacists in their traditional roles of prescribing, administering, and dispensing medications, respectively. Reactive communication in which traditional roles were enacted accounted for pharmacists initiating most of the communication with doctors, about medication prescription matters, and nurses initiating most of the communication with pharmacists, about medication supply matters. While the ideal clinical pharmacy role involves pharmacists providing informal and formal clinical education about medications to other health professionals (Mesler, 1991), little proactive education was observed to take place in spoken communication encounters.

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Interprofessional differences in attitudes about medications and medication management behaviors are related to professional roles and responsibilities. Medications are a higher priority for pharmacists than doctors and nurses. The provision of pharmaceutical care to patients is the primary concern of pharmacists, whereas medication tasks and providing medication-related care to patients comprises only part of nurses’ and doctors’ workload and care they provide to patients. Pharmacists’ main focus on medications means they have more time than doctors to devote to medication tasks that they are both responsible for, such as taking patients’ medication history and reviewing patients’ pathology results related to therapeutic drug monitoring. Pharmacists’ greater time to perform medication historytaking, together with using the structured communication tool to guide their history-taking, could in part explain why pharmacists elicited more accurate and complete medication histories than doctors. While shared responsibilities and duplication of processes are meant to ensure patient safety, it may also lead to doctors becoming complacent in these medication tasks, expecting and relying on pharmacists to perform them and to fix any resulting prescription errors. Nurses and, in particular, doctors appeared to prioritize their own work tasks over medication tasks brought to their attention by pharmacists. This prioritization of other tasks resulted in poor responses to pharmacists’ communication and the untimely resolution of medication issues. Poor responses to nurses and doctors’ communication have been described in past research (Coiera & Tombs, 1998). Interprofessional differences in interactional behaviors were apparent, including pharmacists’ more frequent use than doctors of interaction opening devices such as selfintroductions and greetings and closing devices such as appreciations, and pharmacists’ indirectness when communicating with doctors. Past studies have similarly noted doctors’ neglect of such interaction opening devices (Lewin & Reeves, 2011) and pharmacists’ excessive politeness and indirectness when communicating with doctors (Lambert, 1995, 1996; Mesler, 1989, 1991). These differences have typically been explained in terms of doctors’ higher power and position in the healthcare hierarchy. Interprofessional differences in communicative actions performed could have also contributed to these differences. Pharmacists’ roles require them to regularly initiate with doctors communication that has a negative basis for the communication, whereas the reverse does not hold for doctors’ communication with pharmacists. Pharmacists bring to doctors’ attention prescription errors and thus initiate their correction, and in so doing request them to do corrective work. Pointing out others’ errors and requesting others to do work are face-threatening acts as they threaten people’s intrinsic desire to be respected and not to be imposed upon (Lambert, 1995, 1996). Pharmacists pointed out doctors’ mistakes in such a way so as to remain on good terms

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with them in the future. Consequently, pharmacists had a greater need to build and maintain relationships with doctors through using social niceties such as greetings and appreciations and being tactful and diplomatic when pointing out prescription errors than doctors did with pharmacists. In terms of intersetting variations, there was greater interprofessional collaboration and communication in emergency care and oncology care than in cardiothoracic care and intensive care. The clinical role of the pharmacists in emergency care and oncology care was more “extended” in that there was more frequent and varied utilization and input of the pharmacists in these settings. The organizational imperative of moving patients out of emergency care within 4 hours of presentation facilitated greater interdisciplinary teamwork, collaboration, and communication in emergency care. In oncology care, doctors depended on pharmacists’ specialist knowledge, skills, and expertise in the use of chemotherapeutic agents thereby facilitating greater interdisciplinary collaboration and communication in this setting. Pharmacists in cardiothoracic care and intensive care had only been working in these settings for a couple of weeks and thus were relatively invisible to staff. In regard to implications for practice, pharmacists should take a more proactive stance in their interprofessional medication communication. Pharmacists need to preemptively inform and educate other health professionals when they are new to a setting and ongoingly, including referring health professionals to written medication resources rather than just reactively answering their questions. Organizational support needs to be provided so that pharmacists can attend medical ward rounds. In rounds, doctors need to facilitate pharmacists’ participation so they can contribute their skills, knowledge, and expertise and play an active role in medication decision making and optimize treatment decisions at the point of prescription. This process could then prevent prescription errors from being made and potentially reaching patients, and reduce the need for pharmacists to engage in communication with doctors to get prescription errors rectified. TeamSTEPPS is a highly regarded, evidence-based teamwork training system that includes an interprofessional communication module (Baker & Gallo, 2013), and could serve as a guide for improving health professionals’ interprofessional communication. This study has some limitations. Only one metropolitan, teaching hospital participated, so the findings might not be transferable to other hospitals. Observations were not conducted in the perioperative care setting and it is possible that one or more new themes could have emerged in this setting. While the current study was a descriptive study without an overarching theoretical framework, the findings inform health communication theory more broadly. McDonough and Doucette (2001) developed a theoretical framework of pharmacist–physician collaboration, namely the Collaborative Working Relationship (CWR) model. This is a five-stage model of pharmacist–physician relationship

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development that describes the effect of a pharmacist and physician’s relationship on their communication along a continuum, with the first stage, professional awareness, which is characterized by almost no pharmacist–physician interaction, and the fifth stage, which involves commitment to collaborative working relationships, associated with two-way communication. The model takes into account the effects of three sets of characteristics, namely, individual, context, and exchange characteristics, on the development of a collaborative working relationship. Each set of characteristics includes multiple variables. Individual characteristics are attributes of the individual health professionals and include age, ethnicity, and physician specialty. Context characteristics encompass the environment in which the health professionals interact, and include the pharmacist’s practice setting (e.g., hospital, chain pharmacy) and pharmacist–physician professional interactions. Exchange characteristics denote the nature of social exchanges between the health professionals, and include relationship initiation, trustworthiness, and role specification. While this model has been empirically tested in several studies (e.g., Liu & Doucette, 2011; Liu, Doucette, & Farris, 2010; Zillich, McDonough, Carter, & Doucette, 2004), these studies have been quantitative in nature in which the investigators mostly surveyed either pharmacists or physicians to elicit their perspectives of pharmacist–physician collaboration primarily in the community rather than in hospital settings. Zillich et al. (2004) and Liu and Doucette (2011) have highlighted the need to identify other factors that influence collaborative working relationships between pharmacists and physicians. The current study’s findings suggest that the particular hospital setting in which the pharmacist and physician work and the communication forum in which pharmacist–physician interaction occurs are additional context characteristics that shape pharmacist–physician collaboration. In regard to the context characteristic of the particular hospital setting, the “four hour rule” and the types of medications used were setting-specific factors that facilitated greater pharmacist–physician collaboration and communication in emergency care and oncology care, respectively. The communication forum in which pharmacist–physician interaction occurs is another context characteristic for collaborative care. Communication in formal communication forums, such as medical ward rounds, could facilitate better pharmacist–physician collaboration than communication in informal communication forums, such as impromptu bedside discussions. This context characteristic of the communication forum could be used to discriminate collaboration in earlier as compared to later stages of the model, which has been an objective of two of the more recent empirical studies that have tested the model (i.e., Liu & Doucette, 2011; Liu et al., 2010). Our qualitative findings could inform future quantitative research implementing the CWR model in that the contextual characteristics of hospital setting and communication

forum could be included to ascertain whether or not statistically significant relationships exist between the independent variables of hospital setting and communication forum and the dependent variable of collaborative care.

CONCLUSION Patients depend on the knowledge, skills, and expertise of pharmacists for their safety. Pharmacists need to take responsibility for patient outcomes and make better use of their limited time through engaging in more proactive rather than reactive communication. In this way, pharmacists could more effectively collaborate with other health professionals in expanded roles by bringing their unique competencies to bear on treatment decisions in order to prevent medication errors, rather than reactively collaborating with other health professionals in traditional roles to rectify errors. This is particularly important in specialty hospital settings where there is frequent use of high-risk medications that can cause significant harm to patients if used incorrectly.

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