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Short Communication International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Renal nurses’ views of the potential role of pharmacists in outpatient dialysis centres: a qualitative study Teresa M. Salgadoa, Rebekah Molesb, Shalom I. Benrimojc and Fernando Fernandez-Llimosd a Research Institute for Medicines and Pharmaceutical Sciences (iMed.UL), dResearch Institute for Medicines and Pharmaceutical Sciences (iMed.UL), Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal, bFaculty of Pharmacy, University of Sydney, and cGraduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
Keywords Australia; dialysis centres; nurses; pharmacists; Portugal Correspondence Prof Fernando Fernandez-Llimos, Departamento de Sócio-Farmácia, Faculdade de Farmacia, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal. E-mail: [email protected] Received May 29, 2013 Accepted September 19, 2013 doi: 10.1111/ijpp.12082
Abstract Objectives The aim of this study was to explore the differences in the views of Australian and Portuguese renal nurses on the provision of clinical pharmacy services in outpatient dialysis centres. Methods Semi-structured interviews were conducted with Australian and Portuguese renal nurses. The interviews were recorded and thematically content-analysed. Key findings Three main themes were identified: nurses’ opinions towards pharmacists’ current role; nurses’ opinions towards pharmacists’ future role; and future clinical pharmacy services to be provided. While Australian nurses appeared to be aware of pharmacists’ competencies and viewed a role for pharmacists within the team, Portuguese nurses showed low expectations of pharmacists and regarded them as external to the team. Conclusions Previous or lack of exposure to pharmacists’ clinical skills and the existence of health policies that promote interprofessional collaboration appear to influence nurses’ views.
Introduction
Methods
Chronic kidney disease is a health problem of growing magnitude worldwide,[1] for which pharmacists show a potential contribution in improving clinical and economic outcomes.[2] Even though professional synergy between pharmacy and nursing has been advocated,[3] reports on the collaboration between these two professions in dialysis centres are scarce.[4] As nurses play a key role in caring for dialysis patients, exploring their receptivity is critical when planning the implementation of clinical pharmacy services in this setting. The aim of this study was to explore the differences in the views of Australian and Portuguese renal nurses on the provision of clinical pharmacy services in outpatient dialysis centres. We selected these two countries for the following reason: both have limited participation of pharmacists in patient clinical activities in dialysis centres; however, Australia is noted for its high implementation of other pharmacy services in community and hospital settings, while this implementation is lacking in Portugal.
An exploratory qualitative descriptive study employing semistructured interviews was conducted between February and December 2010 with a purposeful sample of Australian and Portuguese renal nurses. In Australia, dialysis centres are often affiliated with hospitals, hence they are serviced by hospital pharmacists who usually participate on the request of the outpatient dialysis staff and for specific patient needs. In Portugal, a new reimbursement regulation in 2008 established that medications are to be provided free-of-charge to patients in privately owned outpatient dialysis centres. As a result, pharmacists were specifically employed to perform logistical activities, such as managing medicines stocks, checking expiry dates, ensuring appropriate storing conditions and keeping a recording system for psychotropic drugs within the dialysis centre. Pharmacists, however, are not currently remunerated to perform any clinical activities with patients. Topics covered in the interview guide included dialysis patients’ needs, current role of pharmacists and potential clinical roles for pharmacists. The interviews were recorded
© 2013 Royal Pharmaceutical Society
International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Teresa M. Salgado et al.
301
and transcribed verbatim. A thematic content analysis was performed inductively for each transcript using N-Vivo 8 (QSR International Pty Ltd., Doncaster, Victoria, Australia). Attitudes or opinions of renal nurses towards pharmacists’ role were coded. Codes were then ordered by thematic similarity and clustered to reduce data to the main themes. Ethics approval was granted by two Boards in Australia and one in Portugal. Written consent was obtained from all participants.
Results Face-to-face interviews were conducted with 13 Portuguese and five Australian renal nurses (Table 1). Three main themes were derived from the analysis.
Nurses’ opinions towards pharmacists’ current role Australian nurses perceived a lack of hospital pharmacists’ involvement in outpatient dialysis centres because they were mostly dedicated to providing services to inpatients. Nevertheless, they viewed pharmacists as very helpful, accessible, reliable sources of information and knowledgeable about the correct dosages of renally excreted drugs. Nurses recognised pharmacists as the professionals who are better suited to provide drug information to patients. . . . even though there’s usually a little bit of general knowledge [about medicines] from the nurses . . . it’s maybe not always the right information. I think the pharmacist should always have the right information for the patient. (Australia 1) While some Portuguese nurses highlighted the importance of pharmacists in performing logistics roles, others viewed this Table 1
Characteristics of interview respondents
Participant demographics (n = 18) Age group 35–44 45–54 ≥55 Gender Male Female Country of origin Australia (AU) Portugal (PT) Years in clinical practice 5–14 15–24 ≥25
© 2013 Royal Pharmaceutical Society
function as an inspection role. In either case, pharmacists were perceived as external to the team because they were not physically present on a daily basis. Hence, clinical roles and contact with patients were thought to be unpractical and medications provision was undertaken by nurses. . . . the role of the pharmacist is at present only logistic . . . there is no chance for pharmacists to work closely with patients because that’s not how it is structured. (Portugal 10)
Nurses’ opinions towards pharmacists’ future role Australian nurses showed receptiveness towards pharmacists in dialysis centres and reflected that they should be more proactive and involved in dialysis patients’ care. Portuguese nurses commented that patients’ medication regimen was rarely modified and that pharmacists providing medications education would not be beneficial for patients, as physicians and nurses were already providing this service. Additionally, the presence of the pharmacist in Portugal was not perceived to be cost-effective. I don’t know if there would be benefits, I mean, having one more person explaining the medication, if they have the physician who prescribes and who explains what the medicine is, and the nurse who . . . delivers the medicines . . . (Portugal 3)
Future clinical pharmacy services to be provided Australian nurses appeared to be well aware of pharmacists’ competencies and mentioned several clinical pharmacy services that could be provided in the dialysis clinic, including taking comprehensive medication histories, eliciting medication lists, conducting medication reviews, managing anaemia and calcium/phosphate parameters, improving adherence and educating patients and staff.
No. of participants (%)
6 (33.3) 9 (50.0) 3 (16.7) 4 (22.2) 14 (77.8) 5 (27.8) 13 (72.2) 3 (16.7) 6 (33.3) 9 (50.0)
All those things [anaemia, calcium and phosphate levels] could be monitored by a pharmacist, yeah, and sort of discussed about what would be changed or increased or decreased . . . (Australia 5) Conversely, Portuguese nurses generally seemed to have little knowledge of pharmacists’ competencies. When questioned about potential roles for pharmacists, nurses showed hesitancy and stated ‘it is hard to answer that question’ (Portugal 6), admitting to have never thought of pharmacists as members of the multidisciplinary team. Potential future activities indicated by Portuguese nurses composed of participating in medicines provision, patient education and medication adherence monitoring. International Journal of Pharmacy Practice 2014, 22, pp. 300–303
302
Nurses’ views of pharmacists in dialysis
Discussion
Funding
Australian and Portuguese renal nurses showed disparate attitudes towards the inclusion of pharmacists in outpatient dialysis centres. In particular, Portuguese nurses were not aware of pharmacists’ expertise and had low expectations towards their contribution. This agrees with opinions of Portuguese nephrologists.[5] The main strength of this study is the differences identified in nurses’ opinions about the potential role of pharmacists in dialysis centres, apparently related to previous acquaintance with pharmacists’ clinical role. As in any qualitative study, the theoretical concept of data saturation can be a limitation. Two factors that may account for the divergent opinions of nurses from Australia and Portugal are as follows: (1) different exposures of nurses to pharmacists, arising from different histories of interprofessional collaboration; and (2) different collaborative practice regulations, with Australia being more active at this level.[6] Previous studies reported that nurses who worked with clinical pharmacists in the past were more likely to endorse having clinical pharmacists assigned to hospital wards and were more aware of their contribution to nursing practice.[7] The contributions of each professional working within a dialysis centre should be regarded as complementary rather than intrusive, while the roles of each need to be well defined to ensure effective teamwork.[8] It has been demonstrated that having pharmacists work directly with nursing staff on the wards fosters collaboration[9] and increases the frequency of pharmacist consultation by nurses,[9] as expected in dialysis centres.
This work was supported by Fundaçao para a Ciencia e a Tecnologia, Ministry of Education and Science, Portugal (Grant Number SFRH/BD/43999/2008).
Conclusions Different perspectives were given by Australian and Portuguese renal nurses, which might be the result of different exposures to pharmacists’ clinical skills, different healthcare systems and different health policies of interprofessional collaborative practice. Co-location and role definition appear crucial for an effective integration of the pharmacist within the dialysis centre team.
Declarations Conflict of interest The Authors declare that they have no conflicts of interest to disclose.
© 2013 Royal Pharmaceutical Society
Acknowledgements We acknowledge the invaluable contribution of Fresenius Medical Care in providing access to healthcare professionals working at their outpatient haemodialysis centres and to Baxter Portugal in supporting the cost of the transcription of the Portuguese interviews. We would also like to thank all the renal nurses who participated in this study and for sharing their views and experiences.
Authors’ contributions Teresa M. Salgado: Conception and design, acquisition of data, analysis and interpretation of data; drafting the article; final approval of the version to be published. Rebekah Moles: Analysis and interpretation of data; revising the article, providing intellectual content of critical importance to the work described; final approval of the version to be published. Shalom I. Benrimoj: Analysis and interpretation of data; revising the article, providing intellectual content of critical importance to the work described; final approval of the version to be published. Fernando Fernandez-Llimos: Conception and design, analysis and interpretation of data; revising the article, providing intellectual content of critical importance to the work described; final approval of the version to be published. All Authors state that they had complete access to the study data that support the publication.
Ethics approval The study was approved in Australia by the Human Research Ethics Committee at the University of Sydney (Protocol No. 13057) in September 2010 and by the Research Development Office at the Royal Prince Alfred Hospital, Sydney in November 2010 (Protocol No. X10-0282). In Portugal, approval was obtained from the Ethics Committee of Fresenius Medical Care in November 2009.
International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Teresa M. Salgado et al.
References 1. Atkins RC. The epidemiology of chronic kidney disease. Kidney Int Suppl 2005; 94: S14–S18. 2. Salgado TM et al. Pharmacists’ interventions in the management of patients with chronic kidney disease: a systematic review. Nephrol Dial Transplant 2012; 27: 276–292. 3. Gouveia WA, Shane R. Establishing professional synergy between pharmacy and nursing. Am J Health Syst Pharm 2001; 58: 2031. 4. Rizkala AR et al. Impact of a pharmacy/ nursing-driven anemia management program on hemodialysis patients of a
© 2013 Royal Pharmaceutical Society
303
hospital-based dialysis unit. Pharmacotherapy 2000; 20: 366. 5. Salgado TM et al. Exploring the role of pharmacists in outpatient dialysis centers: a qualitative study of nephrologist views. Nephrol Dial Transplant 2013; 28: 397–404. 6. Commonwealth of Australia, The Pharmacy Guild of Australia. The fifth community pharmacy agreement between the Commonwealth of Australia and the Pharmacy Guild of Australia. 2010. http://www.health.gov.au/internet/ main/publishing.nsf/Content/8D21C5 E188499A03CA257BF0001C963A/ $File/5CPA%20Agreement%2005%20
August%202010.pdf (accessed 7 September 2011). 7. Chevalier B, Neville HL. Evaluating clinical pharmacy services on a surgical patient-care area: a nurses’ satisfaction survey. Int J Pharm Pract 2011; 19: 61–69. 8. Makowsky MJ et al. Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. J Interprof Care 2009; 23: 169–184. 9. Fairbanks RJ et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J 2007; 24: 716–718.
International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Short Communication International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Renal nurses’ views of the potential role of pharmacists in outpatient dialysis centres: a qualitative study Teresa M. Salgadoa, Rebekah Molesb, Shalom I. Benrimojc and Fernando Fernandez-Llimosd a Research Institute for Medicines and Pharmaceutical Sciences (iMed.UL), dResearch Institute for Medicines and Pharmaceutical Sciences (iMed.UL), Department of Social Pharmacy, Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal, bFaculty of Pharmacy, University of Sydney, and cGraduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
Keywords Australia; dialysis centres; nurses; pharmacists; Portugal Correspondence Prof Fernando Fernandez-Llimos, Departamento de Sócio-Farmácia, Faculdade de Farmacia, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal. E-mail: [email protected] Received May 29, 2013 Accepted September 19, 2013 doi: 10.1111/ijpp.12082
Abstract Objectives The aim of this study was to explore the differences in the views of Australian and Portuguese renal nurses on the provision of clinical pharmacy services in outpatient dialysis centres. Methods Semi-structured interviews were conducted with Australian and Portuguese renal nurses. The interviews were recorded and thematically content-analysed. Key findings Three main themes were identified: nurses’ opinions towards pharmacists’ current role; nurses’ opinions towards pharmacists’ future role; and future clinical pharmacy services to be provided. While Australian nurses appeared to be aware of pharmacists’ competencies and viewed a role for pharmacists within the team, Portuguese nurses showed low expectations of pharmacists and regarded them as external to the team. Conclusions Previous or lack of exposure to pharmacists’ clinical skills and the existence of health policies that promote interprofessional collaboration appear to influence nurses’ views.
Introduction
Methods
Chronic kidney disease is a health problem of growing magnitude worldwide,[1] for which pharmacists show a potential contribution in improving clinical and economic outcomes.[2] Even though professional synergy between pharmacy and nursing has been advocated,[3] reports on the collaboration between these two professions in dialysis centres are scarce.[4] As nurses play a key role in caring for dialysis patients, exploring their receptivity is critical when planning the implementation of clinical pharmacy services in this setting. The aim of this study was to explore the differences in the views of Australian and Portuguese renal nurses on the provision of clinical pharmacy services in outpatient dialysis centres. We selected these two countries for the following reason: both have limited participation of pharmacists in patient clinical activities in dialysis centres; however, Australia is noted for its high implementation of other pharmacy services in community and hospital settings, while this implementation is lacking in Portugal.
An exploratory qualitative descriptive study employing semistructured interviews was conducted between February and December 2010 with a purposeful sample of Australian and Portuguese renal nurses. In Australia, dialysis centres are often affiliated with hospitals, hence they are serviced by hospital pharmacists who usually participate on the request of the outpatient dialysis staff and for specific patient needs. In Portugal, a new reimbursement regulation in 2008 established that medications are to be provided free-of-charge to patients in privately owned outpatient dialysis centres. As a result, pharmacists were specifically employed to perform logistical activities, such as managing medicines stocks, checking expiry dates, ensuring appropriate storing conditions and keeping a recording system for psychotropic drugs within the dialysis centre. Pharmacists, however, are not currently remunerated to perform any clinical activities with patients. Topics covered in the interview guide included dialysis patients’ needs, current role of pharmacists and potential clinical roles for pharmacists. The interviews were recorded
© 2013 Royal Pharmaceutical Society
International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Teresa M. Salgado et al.
301
and transcribed verbatim. A thematic content analysis was performed inductively for each transcript using N-Vivo 8 (QSR International Pty Ltd., Doncaster, Victoria, Australia). Attitudes or opinions of renal nurses towards pharmacists’ role were coded. Codes were then ordered by thematic similarity and clustered to reduce data to the main themes. Ethics approval was granted by two Boards in Australia and one in Portugal. Written consent was obtained from all participants.
Results Face-to-face interviews were conducted with 13 Portuguese and five Australian renal nurses (Table 1). Three main themes were derived from the analysis.
Nurses’ opinions towards pharmacists’ current role Australian nurses perceived a lack of hospital pharmacists’ involvement in outpatient dialysis centres because they were mostly dedicated to providing services to inpatients. Nevertheless, they viewed pharmacists as very helpful, accessible, reliable sources of information and knowledgeable about the correct dosages of renally excreted drugs. Nurses recognised pharmacists as the professionals who are better suited to provide drug information to patients. . . . even though there’s usually a little bit of general knowledge [about medicines] from the nurses . . . it’s maybe not always the right information. I think the pharmacist should always have the right information for the patient. (Australia 1) While some Portuguese nurses highlighted the importance of pharmacists in performing logistics roles, others viewed this Table 1
Characteristics of interview respondents
Participant demographics (n = 18) Age group 35–44 45–54 ≥55 Gender Male Female Country of origin Australia (AU) Portugal (PT) Years in clinical practice 5–14 15–24 ≥25
© 2013 Royal Pharmaceutical Society
function as an inspection role. In either case, pharmacists were perceived as external to the team because they were not physically present on a daily basis. Hence, clinical roles and contact with patients were thought to be unpractical and medications provision was undertaken by nurses. . . . the role of the pharmacist is at present only logistic . . . there is no chance for pharmacists to work closely with patients because that’s not how it is structured. (Portugal 10)
Nurses’ opinions towards pharmacists’ future role Australian nurses showed receptiveness towards pharmacists in dialysis centres and reflected that they should be more proactive and involved in dialysis patients’ care. Portuguese nurses commented that patients’ medication regimen was rarely modified and that pharmacists providing medications education would not be beneficial for patients, as physicians and nurses were already providing this service. Additionally, the presence of the pharmacist in Portugal was not perceived to be cost-effective. I don’t know if there would be benefits, I mean, having one more person explaining the medication, if they have the physician who prescribes and who explains what the medicine is, and the nurse who . . . delivers the medicines . . . (Portugal 3)
Future clinical pharmacy services to be provided Australian nurses appeared to be well aware of pharmacists’ competencies and mentioned several clinical pharmacy services that could be provided in the dialysis clinic, including taking comprehensive medication histories, eliciting medication lists, conducting medication reviews, managing anaemia and calcium/phosphate parameters, improving adherence and educating patients and staff.
No. of participants (%)
6 (33.3) 9 (50.0) 3 (16.7) 4 (22.2) 14 (77.8) 5 (27.8) 13 (72.2) 3 (16.7) 6 (33.3) 9 (50.0)
All those things [anaemia, calcium and phosphate levels] could be monitored by a pharmacist, yeah, and sort of discussed about what would be changed or increased or decreased . . . (Australia 5) Conversely, Portuguese nurses generally seemed to have little knowledge of pharmacists’ competencies. When questioned about potential roles for pharmacists, nurses showed hesitancy and stated ‘it is hard to answer that question’ (Portugal 6), admitting to have never thought of pharmacists as members of the multidisciplinary team. Potential future activities indicated by Portuguese nurses composed of participating in medicines provision, patient education and medication adherence monitoring. International Journal of Pharmacy Practice 2014, 22, pp. 300–303
302
Nurses’ views of pharmacists in dialysis
Discussion
Funding
Australian and Portuguese renal nurses showed disparate attitudes towards the inclusion of pharmacists in outpatient dialysis centres. In particular, Portuguese nurses were not aware of pharmacists’ expertise and had low expectations towards their contribution. This agrees with opinions of Portuguese nephrologists.[5] The main strength of this study is the differences identified in nurses’ opinions about the potential role of pharmacists in dialysis centres, apparently related to previous acquaintance with pharmacists’ clinical role. As in any qualitative study, the theoretical concept of data saturation can be a limitation. Two factors that may account for the divergent opinions of nurses from Australia and Portugal are as follows: (1) different exposures of nurses to pharmacists, arising from different histories of interprofessional collaboration; and (2) different collaborative practice regulations, with Australia being more active at this level.[6] Previous studies reported that nurses who worked with clinical pharmacists in the past were more likely to endorse having clinical pharmacists assigned to hospital wards and were more aware of their contribution to nursing practice.[7] The contributions of each professional working within a dialysis centre should be regarded as complementary rather than intrusive, while the roles of each need to be well defined to ensure effective teamwork.[8] It has been demonstrated that having pharmacists work directly with nursing staff on the wards fosters collaboration[9] and increases the frequency of pharmacist consultation by nurses,[9] as expected in dialysis centres.
This work was supported by Fundaçao para a Ciencia e a Tecnologia, Ministry of Education and Science, Portugal (Grant Number SFRH/BD/43999/2008).
Conclusions Different perspectives were given by Australian and Portuguese renal nurses, which might be the result of different exposures to pharmacists’ clinical skills, different healthcare systems and different health policies of interprofessional collaborative practice. Co-location and role definition appear crucial for an effective integration of the pharmacist within the dialysis centre team.
Declarations Conflict of interest The Authors declare that they have no conflicts of interest to disclose.
© 2013 Royal Pharmaceutical Society
Acknowledgements We acknowledge the invaluable contribution of Fresenius Medical Care in providing access to healthcare professionals working at their outpatient haemodialysis centres and to Baxter Portugal in supporting the cost of the transcription of the Portuguese interviews. We would also like to thank all the renal nurses who participated in this study and for sharing their views and experiences.
Authors’ contributions Teresa M. Salgado: Conception and design, acquisition of data, analysis and interpretation of data; drafting the article; final approval of the version to be published. Rebekah Moles: Analysis and interpretation of data; revising the article, providing intellectual content of critical importance to the work described; final approval of the version to be published. Shalom I. Benrimoj: Analysis and interpretation of data; revising the article, providing intellectual content of critical importance to the work described; final approval of the version to be published. Fernando Fernandez-Llimos: Conception and design, analysis and interpretation of data; revising the article, providing intellectual content of critical importance to the work described; final approval of the version to be published. All Authors state that they had complete access to the study data that support the publication.
Ethics approval The study was approved in Australia by the Human Research Ethics Committee at the University of Sydney (Protocol No. 13057) in September 2010 and by the Research Development Office at the Royal Prince Alfred Hospital, Sydney in November 2010 (Protocol No. X10-0282). In Portugal, approval was obtained from the Ethics Committee of Fresenius Medical Care in November 2009.
International Journal of Pharmacy Practice 2014, 22, pp. 300–303
Teresa M. Salgado et al.
References 1. Atkins RC. The epidemiology of chronic kidney disease. Kidney Int Suppl 2005; 94: S14–S18. 2. Salgado TM et al. Pharmacists’ interventions in the management of patients with chronic kidney disease: a systematic review. Nephrol Dial Transplant 2012; 27: 276–292. 3. Gouveia WA, Shane R. Establishing professional synergy between pharmacy and nursing. Am J Health Syst Pharm 2001; 58: 2031. 4. Rizkala AR et al. Impact of a pharmacy/ nursing-driven anemia management program on hemodialysis patients of a
© 2013 Royal Pharmaceutical Society
303
hospital-based dialysis unit. Pharmacotherapy 2000; 20: 366. 5. Salgado TM et al. Exploring the role of pharmacists in outpatient dialysis centers: a qualitative study of nephrologist views. Nephrol Dial Transplant 2013; 28: 397–404. 6. Commonwealth of Australia, The Pharmacy Guild of Australia. The fifth community pharmacy agreement between the Commonwealth of Australia and the Pharmacy Guild of Australia. 2010. http://www.health.gov.au/internet/ main/publishing.nsf/Content/8D21C5 E188499A03CA257BF0001C963A/ $File/5CPA%20Agreement%2005%20
August%202010.pdf (accessed 7 September 2011). 7. Chevalier B, Neville HL. Evaluating clinical pharmacy services on a surgical patient-care area: a nurses’ satisfaction survey. Int J Pharm Pract 2011; 19: 61–69. 8. Makowsky MJ et al. Collaboration between pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient medical setting. J Interprof Care 2009; 23: 169–184. 9. Fairbanks RJ et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emerg Med J 2007; 24: 716–718.
International Journal of Pharmacy Practice 2014, 22, pp. 300–303
