Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study

Abstract

Transitional medication management, in which individual needs are balanced against organizational priorities, is crucial for safe discharge processes. The aim of this study was to explore hospital nurses’ transitional medication management in the discharge of older patients with multi-morbidity. Using an ethnographic approach the data were collected through participant observations at a mixed medical ward at a Danish university hospital for two weeks. The participants were five registered nurses, responsible for nursing care of 23 patients with multi-morbidity and planned for discharge. The data comprised field notes that were analysed using iterative processes of domain, taxonomic and component analysis. The reporting adhered to the COREQ checklist. Hospital nurses’ transitional medication management was characterized by unpredictability and inconsistency in patient situations, fragmentation and discontinuity in working processes and complexity in communication systems. Special attention to nurses’ needs assessment skills and clinical decision making in caring for patients with multi-morbidity in a single focused healthcare system is required.

Introduction

Medication management is identified as the most challenging component of a patient's transition from the hospital to the home ¹ and is prominent in recommendations for safe discharge procedures.^2,3 Multi-morbidity and polypharmacy are common in the ageing population, ⁴ and inadequate transitional medication management places patients at risk of adverse events and an increased need for health professional assistance. ⁵ Hospital nurses’ transitional medication management is crucial to ensure that patients receive medications adjusted to their actual needs both during and after hospitalization.^6,7

Background

Patients’ readiness for discharge is found to include physical stability, psychosocial ability as well as adequate information, support and knowledge. ⁸ However it also requires health professionals to balance the patients’ needs against organizational priorities. ⁹ Discharge planning starts at the time of admission, and as the average length of stay decreases, less time is available for the coordination of services across settings and preparing the patients for their situation at home. ¹⁰ A consequence for the patients might be that efficient care trajectories control the discharge processes, and that the final notification of discharge turns up unexpectedly. ¹⁰ This may contradict the patients’ expectations of discharge as an important point for information on the management of their diseases. ⁹

Medication errors related to hospital discharge are well documented, and discrepancies are found in up to 95% of patients’ medication lists at hospital discharge,^1,11 which may have serious consequences for the patients. ⁵ Beside the increasingly accelerated and specialized hospital treatment plans, new and innovative treatment possibilities, as well as an ageing population, have added to the problem. ¹² This means that many patients are discharged from the hospital with a complex set of instructions for their medication regimen to be continued in the home,^12,13 which further increases the risk of medication errors. Risk factors for medication errors are the patient's age, polypharmacy, irregular medication schedules, high-risk medications^6,14 as well as inadequate interdisciplinary teamwork and inconsistent medication review. ⁵ Hence, the possible solutions to well-documented international challenges in transitional medication management may depend on health professionals’ management of medications in specific healthcare contexts.

Transitional medication management is a complex intervention with multiple actors and processes involved as well as the recipients’ being in varying and unstable health conditions. ¹⁵ Hospital nurses’ responsibility for dispensing and administering patients’ medications covers the in-hospital stay and the preparation for post-hospital medication management, which is also shown to pose challenges.^16,17 In hospital nurses’ medication management, they contextualize actual prescriptions to the patient's complex and changing needs. ¹⁸ However, specific challenges in transitional medication management are not identified.

Older persons in need of hospitalization in general medical wards often suffer from multi-morbidity, which may hamper the possibility of strictly following standardized care and treatment plans. ¹⁹ Polypharmacy and hyper-polypharmacy are common in patients with multi-morbidity. ⁴ If high-risk medications are incorrectly administered, it can result in bleeding, falls, pain and infections,^6,20 which will further complicate the patients’ situations. Patients with multiple chronic conditions and/or cognitive impairments are the most vulnerable to medication errors.^4,13 These patients are in need of health professional assistance in transitional medication management, which encompasses continuous observation and adjustments of care and treatment.^7,16 This might be mediated by hospital nurses’ clinical decision making, in which they combine clinical knowledge, nursing experience, knowledge of the patient's preferences and available resources. ²¹

The existing electronic communication systems do not provide sufficient knowledge for the professionals to perform safe medication management during discharge processes.^22–24 Identified reasons are limitations in the electronic communication systems, hospital nurses’ missing knowledge of home care nurses’ knowledge needs, and missing access to the patient's medication list before hospital admission. ²⁴ Likewise, hospital nurses’ ‘short-term perspective’ and home care nurses’ ‘long-term perspective’ may influence the problems. ²⁵

Transitional medication management is crucial in the discharge of older persons with multi-morbidity and polypharmacy. Discrepancies in medication lists at hospital discharge are common, and place patients at risk of adverse events and an increased need of health services. Transitional medication management is a context-specific complex intervention characterized by multiple actors and processes, as well as by the recipients’ varying and increasingly complex healthcare needs. ¹⁵ Hence, an in-depth exploration of hospital nurses’ transitional medication management can add to the knowledge of possible areas for change. The aim of this study was to explore hospital nurses’ transitional medication management for older patients with multi-morbidity.

Methods

An ethnographic approach inspired by Spradley was applied. This approach is suitable for exploring social situations encompassing specific actors (hospital nurses), activities (transitional medication management) and settings (medical ward). ²⁶ The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used in this research. ²⁷

Setting and participants

The setting was a general medical ward dimensioned to 19 patients with mixed medical diseases at a Danish university hospital. Participants were registered nurses (RNs) (Table 1) who collaborated with nursing assistants and specialized medical doctors within nephrology, cardiology, pulmonary diseases and internal medicine.

Table 1.

Work experience of registered nurses (RNs) each observation day.

Observation day	Participant (registered nurse number)	Work experience
Day 1	RN1	Experience as RN: 1 year. Experience from this from this ward: 1 year. Previously worked as nursing assistant in the primary healthcare sector.
Day 2	RN1	As day 1
Day 3	RN2	Experience as RN: 1 year. Experience from this ward: 1 year. Previously worked as nursing assistant at another medical ward for 9 years.
Day 4	RN3	Experience as RN: 3 years. Experience from this ward: 3 years.
Day 5	RN4	Experience as RN: 3 months. Experience from this ward: 3 months.
Day 6	RN2	As day 3
Day 7	RN5	Experience as RN: 1 year. Experience from this ward: 1 year.

Note. Two nurses are observed on two days each (RN1 and RN2).

Each day, both patients and health professionals were divided into three groups. In each group, one nurse was responsible for the patients’ care trajectories, care plans, ward rounds and medication management in collaboration with one or two nursing assistants or students, who maintained direct caring for the patients. Because discharge planning started at admission, a number of patients each day were planned to be discharged (Table 2).

Table 2.

Planned and completed number of discharges on each observation day.

Day	Number of patients in the group	Number of patients planned for discharge	Number of patients that were discharged
1	6	4	1
2	6	3	2
3	5	3	1
4	7	2	2
5	5	3	0
6	6	4	1
7	6	4	1

Data collection and analysis

Participant observations of registered nurses’ transitional medication management by 23 patients were carried out for seven days. The observer (first author) was a female nurse and PhD, experienced in ethnographic approaches, and employed as a researcher at the university hospital. The nurse-manager initiated the study and acted as gate keeper. The observer and the participants did not know each other before the study. The relation was established based on a common interest in safe transitional medication management. The participating RNs were chosen based on the number of planned patient discharges in their group. Five different RNs were observed. During the observations, field notes were produced based on observations and informal interviews with the RNs as well as with other health professionals. During observations, the RNs cared for 41 patients, of whom 23 patients were planned to be discharged on the observation day. The field notes covered all the RN's work on the day for observations. However, after each observation, the field notes were sorted and expanded regarding situations in which the RN's work concerned medication management by the patients that were planned to be discharged. Data consisted of 41 pages of expanded field notes.

The analysis was carried out by both authors in three steps inspired by Spradley. ²⁶ First, domain analysis, in which the data material was read and scrutinized for semantic relations, resulted in 32 domains. Second, taxonomic analysis served to group and structure domains in hierarchies. Third, contrast analysis further sharpened similarities and differences and resulted in the communication of findings. During each step the authors discussed the analysis and assessed the saturation without involving the participants.

Ethical considerations

The nurse-manager enabled the researcher's access to the field and established contact with the health professionals at the ward. ²⁶ The participating RNs provided written informed consent to participate in the study. To minimize harm and do good, ²⁸ the researcher informed the participants of the interest in transitional medication management to enhance beneficence for the patients. The participants were assured of the voluntary nature of participation, anonymity and confidentiality. ²⁹ The study was approved and registered by the responsible local authority (reg nr. 2019–52).

Findings

Transitional medication management in the hospital context was characterized by unpredictability, inconsistency, fragmentation, discontinuity and complexity. Of the 23 patients who were scheduled for discharge on the observation days, only eight were discharged as planned. In 15 situations, the patients’ unstable health condition or lack of remedies or preparation of home conditions hindered the discharge. Hospital nurses’ transitional medication management was embedded in multiple caring activities because the nurse was responsible for the care of 6–8 patients together with 1–2 nursing assistants and/or students. In discharge planning, transitional medication management was one of several care activities that had to be aligned with assessment of the patients’ needs and capacities. Although several characteristics might be at stake simultaneously in data extracts, the findings are, for clarity, presented in three themes: unpredictability and inconsistency in patient situations, fragmentation and discontinuity in working processes, and complexity in communication systems.

Unpredictability and inconsistency in patient situations influenced discharge planning

Unpredictability and inconsistency in patients’ health situations were prominent and influenced medication administration on the day of planned discharge, and they often caused cancellation of planned discharges. In the following example, a patient planned to go to a surgical appliance maker on his way home from the hospital. An unforeseen decreased saturation and removal of an IV line caused changes in discharge planning:

A man 84 years old was planned for discharge today. He suffers from diabetes, which has caused reduced renal function, and he has had a crus amputation four months ago. The plan for his hospital admission was draining of accumulated fluids in his legs in order to enable preparation of a leg prosthesis. A visit by the surgical appliance maker is planned for today on his way from the hospital to the home, in order to prepare for this. Today his weight loss is 4 kilos; he still needs oxygen supply and has decreased saturation to 83% despite supply of 3 litres of oxygen. In preparing the medication administration this morning, the nursing assistant tells the nurse that the patient's peripheral venous catheter is removed. The nurse considers whether a new peripheral venous catheter should be established, or the intravenous diuretic treatment should be changed to oral treatment. At the same time, the daughter calls the nurse and asks if it is possible to provide the patient with a lunch packet on his way home to stabilise the blood glucose level. (Day 6)

Unpredictable components in this patient situation were removal of the IV line and low saturation, indicating an unforeseen need for oxygen supply. This led the nurse to consider whether a new IV line should be established on the day of planned discharge, and whether oxygen supply for transportation and for the home should be arranged. Other examples of unpredictable health situations were recurrent pneumonia due to tube feeding, raised temperature despite treatment with antibiotics, or minor effects of diuretics in cases of impaired heart functioning/fluid accumulation.

The patients’ unpredictable health situations often caused changes in medication administration on the day of planned discharge. For example, a terminally ill patient suffered from stomach pain on the day of planned discharge:

During the nurse's preparation of morning medications, the nursing assistant tells that a terminally ill patient, a woman 74 years old suffering from lung cancer, has stomach pain. While preparing the medications, the nurse observed that prescribed painkillers were not sustained release medications. She considers if this is the reason for the patient's stomach pain. In her further reflections, she notes that both morphine and iron supply will reduce the peristaltic movements in the patient's bowel, which might cause pain due to obstipation. Eventually, she decides to bring laxatives, according to a delegated prescription rule at the ward, to the patient together with the morning medications. Due to the patient's nausea, she also chose to select the most important tablets, such as painkillers and antiemetics, and store the rest for later administration and consider asking the medical doctor for rationalisation of the prescribed medications. (Day 5)

This patient's unpredictable stomach pain led the nurse to reflect on possible adjustments of medications. The reflection implied knowledge of diseases, physiology and pharmacology, which should be combined with knowledge of the patient's situation, needs and preferences. In this case, the nurse relied on a delegated prescription rule at the ward. In other cases, the adjustment of prescribed medications required contact with the medical doctor, who was responsible for prescriptions. Unpredictability caused deviations from care and treatment plans. This inconsistency of care trajectories with care plans implies supplemental working processes. For example, in the case of deviations from prescriptions, this should be noted in the medication system connected to the electronic patient record. This system was surprisingly complicated for the observer. Different colour codes were applied for each tablet at each administration time. A tablet at eight o’clock in the morning marked green indicated that this tablet was dispensed but not administered. Likewise, yellow, purple, brown and other colours indicated other actions (patients’ self-administered medications, administered medications and the like). On one occasion a nurse dispensed a tablet for hypertension. During the administration round, she decided not to deliver the tablet to the patient because the morning examinations showed unpredictable low blood pressure. Subsequently she had to note that in the medication system by clicking several boxes, writing notes and saving notes. After consultation with the responsible medical doctor, it was decided that the hypertension medication should be administered despite the low blood pressure – and the nurse was reversing the notes again.

Patients’ unpredictable health situations caused deviations from care and treatment plans. This implied inconsistency in discharge planning, in which transitional medication management should be aligned to the patients’ actual and future needs and competencies.

Fragmentation and discontinuity in working processes influenced medication needs assessment

Fragmentation of tasks and discontinuity in responsible health professionals impeded the assessment and fulfilment of the patients’ medication needs. Fragmentation in working tasks implied that several actors were involved in planning and fulfilling the patients’ medication needs after hospital discharge, such as general practitioner, physiotherapist and drug store:

This patient was hospitalised after a fall incident in the home. At the hospital, low levels of serum Natrium were found due to anti depressive medications. At discharge, he was asked to go to his general practitioner after one week for adjustment of medications and to stop eye treatment in two days. The nurse asked the patient how he normally got his medications. He normally went to the drugstore to pick medications up himself. They discussed whether he was able to walk to the drugstore after hospital discharge and the possibility for physiotherapy. The patient was not sure. Eventually they decided that medications could be delivered to the home for a supplemental cost, which the patient accepted. (Day 6)

In this case, both the patient and the health professionals strived to assess the patient's physical ability and self-care capacity after hospital discharge. This was difficult, partly because the foundation for assessment was the nurse's knowledge of the ill patient in a hospital environment and partly due to discontinuity in the nurse's knowledge of the patient.

Assessment of the patient's medication needs during an in-hospital stay could be challenging because the health status was also affected by hospitalization. For example, the adjustment of diuretics due to leg oedema was dependent on the patient's mobility, such as walking and sitting habits, which could differ at the hospital and in the home. In addition, patients’ respiratory functioning may be difficult to assess due to their varied ability and possibility to manage inhalation medication. Discharge planning could require assessment of the patient's ability to order protein drinks by telephone or to manage portable oxygen supply until permanent oxygen supply is established in the home. This assessment was hampered by inadequate knowledge of the patient due to discontinuity in responsible health professionals because of working schemes and division of tasks, which meant that the responsible nurse was occupied with administrative working tasks, while other health professionals provided direct patient care.

Discharge planning encompassed an assessment of the patient's capacity to dispense and administer medications after hospital discharge, which might differ from their capacity before hospital admission due to decreased health status or due to medication changes. The nurses made efforts to assess these self-management capacities by listening carefully to the patients’ questions and statements regarding medication administration in the home. A patient who had administered medications independently before hospital admission asked if she should continue the new hypertension medication after hospital discharge and whether it should be added to her usual hypertension medication. In this case, the nurse considered the patient to be able to manage the changes after hospital discharge.

Assessment of the patient's needs and capacities required knowledge of the patient, which was hampered by fragmentation and discontinuity. Missing knowledge of the patient's needs could cause cancellation of discharges. In the following example, a patient's need for walking aides and oxygen supply was unclarified:

A woman 93 years old suffers from pneumonia and cystitis, which is treated with intravenous antibiotics. She is planned for discharge to the home today. The nurse observes that the patient uses walking aides and that she still needs oxygen supply. (Day 2)

The nurse considers that the patient's mobility and respiratory functioning must be clarified, which includes the arrangement of appropriate assistance, walking aides and potentially oxygen supply. Hence, fragmentation implied that the nurse was not aware of the patient's needs, and discontinuity implied that the nurse missed knowledge of already performed discharge planning activities. Fragmentation and discontinuity put demands on cross-sectional patient care and assessment of patients’ needs. For example, a patient's unstable health condition means that a new inhalation medication is prescribed on the day of planned discharge:

A woman 66 years old suffers from chronic obstructive pulmonary disease. She is planned for discharge to the home today. A new inhalation mediation is prescribed; this type of medication is not available at the ward. Before the discharge, her need for oxygen supply in the home must be considered based on a blood test and the prescribed medication must be in place. (Day 7)

In this situation, the patient's reactions to the prescribed treatment, as well as adjustment of treatment, will have to be evaluated after hospital discharge. This situation illustrates the need for continuous assessment of the patient's needs from the hospital to the home, which requires continuity. This puts demands on communication with the patient and/or the home care services, which might alleviate fragmentation and discontinuity.

Complexity in communication systems influences medication administration

Complexity in communication systems could hamper the intended alleviation of fragmentation and discontinuity. In discharge planning, the nurses strived to assess the patients’ competencies in managing medication administration in the home or the need for health professional assistance. This implied that the medication plans were communicated properly to the patient or to the municipal healthcare services. The complexity in this process was evident in nurses’ considerations concerning the patients’ ability to read and understand medication lists, to assess when, which and how medications should be administered, and to manage necessary adjustments. If the patient needed help from municipal healthcare services, these instructions should be visible and available among different health professionals in the home.

At discharge, the nurses prepared medications for one or two days to send home with the patient. The preparation implied several considerations, which showed the complexity in the communication. For example, different drugs might be listed in different ways in the electronic mediation list. For some the dosage said, ‘one tablet two times a day’ for others ‘50 mg morning and midday’ or for some drugs it said, ‘two tablets Monday and one tablet Friday’. These differences implied considerations such as: ‘Does the patient know that in this case two times a day is morning and evening?’, ‘That 50 mg is dispensed as two tablets of each 25 mgs?’ or ‘Which dosette box to start with?’ Beside the dispensed medications in dosette boxes, the patient usually needed p.n. (pro necessitate) medications or drugs, which could not be dispensed, such as powder, patches, inhalations, drops or mixtures. During the preparation of medications to send home with the patient, a nurse considered:

For this patient, antibiotics are prescribed for 8 am and 8 pm. The latter is in-between the dosette box's four possibilities, which are usually used as: 8 am, 12 am, 17 pm and 22 pm. The nurse considers if the 8 pm antibiotics are better placed in the ‘night’ room or in a separate envelope beside the dosette box. There are pros and cons. She knows that it is important for the effect of antibiotics that it is administered with 12 h continuity and consider the chance for the patient to administer the drugs in the best possible way. (Day 2)

The nurses considered how to communicate these plans to the patient and whether the patient was able to follow these instructions after returning home. If the nurse wanted to communicate these uncertainties to secure proper administration, this resulted in handwritten notes on the medication list, which would increase the complexity of communication. Another patient, who was blind, wanted temporary treatment with antibiotics dispensed beside her usual medications, which were dispensed in plastic bags from the drug store. This was against the regulations, and the nurse considered how to act. Eventually the nurse decided to follow the patient's wishes because it would increase her ability to administer the medications.

The patients’ private medications that they had brought with them to the hospital were sent to the patients’ homes. Sometimes these medications should not be administered after hospital discharge, and the nurse considered the patients’ understanding and the risk of administration of both actual and previous medications, which was exemplified in the following extract:

After preparing the medications that the patient should bring to the home, the nurse finds the bag with the patient's private medications in a drawer. She observes a pill bottle with beta-blocker and wonders why the patient has these; they had not figured on the patient's previous or actual medication lists. The nurse considers the potential medication errors if the patient doesn't understand which drugs to administer. (Day 4)

Communication was an essential part of the assessment of the patient's ability to administer medications after hospital discharge. When the nurse handed over the prepared medications at discharge, this was, on a few occasions, accompanied by a verbal communication. In these cases, the conversation took place in a living room while the patient was dining; the television made noise and a taxi driver was waiting in the doorway to take the patient home. Nevertheless, the patient posed questions about the medications. In one situation, laxatives were prescribed and prepared, but the patient had never used these. In another situation, the patient used to have an injection on Monday mornings. He went home on a Monday afternoon and wondered whether he should take this injection. In most situations, the nurses handed over medications at the patient's bed or wheelchair simultaneously with the patient leaving the hospital ward. This offered no possibility for clarifying questions or communicating about medication administration in the home. Instead, the patient went home with a bundle of papers, dosette boxes and separate medications. As such, the complexity in verbal communication encompassed disturbing activities, uncertainty of the patient's abilities and inconsistency in medication plans. If the patient needs health professional assistance in the home, the communication should be shared with municipal healthcare services.

Messages and notes in the electronic patient journal sent from hospital to home were intended to be available and visible for municipal healthcare professionals. However, the complexity of communication systems meant that the patient journal might be hard to survey. The nurses’ discharge planning notes seldom specified medication changes or plans for adjustments. Instead, this information was sent from the hospital to the patient's general practitioner a few days after hospital discharge. Electronic care trajectory plans constituted the written communication between the hospital and the municipal healthcare services. They were intended to summarize the performed care and treatment during the in-hospital stay and provide an overview of the patients’ post-hospital care needs. In the predefined boxes in the patient trajectory plan, two boxes regarding medications were marked: ‘New medications? Yes/No’, and ‘Medications ordered? Yes/No’. Thus, information about which specific drugs were skipped, added or changed as well as which specific drugs were ordered and where to pick them up was not provided. Often, nurses considered the drugs for which the patient would need a new prescription. This is exemplified in the extract regarding a terminally ill patient:

In preparing the medications for the patient in the home, the nurse wonders why iron supply, antihypertensive drugs and osteoporosis drugs are prescribed and ordered at the drug store. The nurse does not appreciate that the patient pays for these drugs, if they are not necessary and appropriate in this situation. (Day 7)

In this case, the nurse wanted to avoid a situation where medications in the home might be missing; at the same time she did not want the patient to pay for medications that were not needed. As such, complexity in written communication encompassed inadequate information regarding medication changes, observations and plans for adjustment as well as doubt about the need for prescriptions.

Discussion

Patients’ unstable health conditions challenged discharge planning

Unclarified medication needs, caused by patients’ unstable health conditions, hindered patients’ discharge from the hospital to the home. The unpredictability was influenced by patients’ multi-morbidity and fragile health situations, which are known to challenge care trajectories.^19,30 Multi-morbidity and polypharmacy are common in older persons and present a fundamental challenge of the single-disease focus in healthcare systems. ¹⁹ This means that traditional disease-oriented guidelines often seem inadequate, which complicates clinical decision making ³⁰ and thus discharge planning. The actual incentives for specialized and accelerated care trajectories imply activity-based financing, which encourages hospitals to rapidly diagnose and initiate treatment. ³¹ This results in intensified care trajectories, shorter in-hospital stays, and increasing ambulatory care. These incentives are not tailored to fragile patients with multi-morbidity, ¹⁹ who do not necessarily fit into standards for rapid diagnosis and prescription of treatment. ³² The specialized and accelerated care trajectories may be a barrier for transitional medication management. ² As such, hospital nurses may feel overloaded with tasks and unable to maintain an overview of patients’ medication. ²⁴ The incentives for accelerated hospital treatment plans ³¹ imply that the patient's discharge should be planned at admission. ³² This results in fictive discharge dates, which can be changed during the in-hospital stay. This was evident in multiple events and problem solving during the day of planned discharges as well as high rates of cancelled discharges. This raises the discussion of when a patient is ‘ready for discharge’, ⁸ which is also dependent on the organization and resources in the municipal healthcare sector. Diversity in culture, focus and approaches to nursing care are found in the hospital and home-care sectors^25,33 as well as inadequate knowledge of cross-sectional collaborators’ knowledge needs. ³³ Unpredictability in patient situations might hamper the nurses’ ability to secure appropriate assistance after hospital discharge. Hence, the existing organization of discharge processes ² does not necessarily benefit patients with multi-morbidity and fragile health conditions. These patients may need additional nursing care due to continuous changes of plans, which was also evident in the massive work involved in documenting medication changes in the electronic medication administration system. This could indicate that systems, rules and regulations were developed to fit patients in stable and predictable trajectories. Hence, it could point at challenges in caring for patients with multi-morbidity in a single-disease-focused healthcare system. ¹⁹

Working processes required competent nurses

Fragmentation and discontinuity in working processes could stress the need for hospital nurses’ competencies in clinical decision making. The nurses should be able to simultaneously assess the patients’ actual needs and estimate how these needs would align to conditions at home. Multiple changes and problem solving during the day of planned discharge required clinical decision making based on different knowledge sources. ²¹ For example, laxative treatment was changed based on knowledge of physiology, pharmacology, patient preferences and life situation, as well as of regulations and remits. This highlighted the importance of nurses’ clinical decision making in in-hospital medication management, ¹⁸ which required a sound knowledge base, clinical experience and competent analyses of patients’ health situations. This further stressed the importance of nurses’ generalist knowledge in caring for patients with multi-morbidity in a specialized healthcare context.

Assessing a patient's needs requires knowledge of the patient's actual and habitual health, medical and caring knowledge, as well as knowledge of the patient's history and home conditions. ³⁴ This assessment could be challenged by the organization of care, which in this ward was ‘team-care’ with a single nurse responsible for the care of a group of 6–8 patients. In team-care, the nurse primarily maintains administrative tasks, medication management and ward rounds, while a nursing assistant maintains direct patient care. ³⁵ This means that the nurse relies on second-hand information in clinical decision making, which could hamper inclusion of patients’ preferences, and add to the patients’ experiences of lack of personalized care in transitional medication management. ² As opposed to this, the primary nursing care model in which a single nurse handles the whole of the patient's trajectory ensures that the nurse's preparation of individual care plans and discharge plans rely on first-hand assessment of the patient's needs. ³⁶ However, primary nursing care could reduce peer learning and competence development among nurses. ³⁵

Although the data material did not allow for a comparison of nurses’ clinical experience with the rate of discharges, there was a tendency for more patients to be discharged when more experienced nurses were responsible for the care. This might indicate that discharge ratios could depend on the nurses’ competencies, which are shown to develop from novice to expert during clinical experience. ³⁷ Competent nurses apply an in-depth understanding of the whole patient situation, which guides nursing practice prior to rules and principles. ³⁷ Experienced nurses are able to combine intuition with evidence for best patient care, ³³ whereas inexperienced nurses employ an analytic approach in decision making. ²¹ This improves expert nurses’ decisions, especially in more complicated patient situations, ³⁸ such as transitional medication management for patients with multi-morbidity. As such, the working processes challenged clinical decision making both due to the nurses’ level of experience and due to the organization of care.

Communication systems challenge patient safety

Communication systems encompassed the sharing of electronic communication within and across different sectors with separate IT systems in which multiple health professionals each contributed to the documentation of a minor part of the patient's trajectory from the hospital to home. Although communication is well known as crucial for safe discharge practices, ³ complexity in communication systems and the impact on cross-sectional collaboration is also well documented.^2,24,30,33 Discharge planning at admission implied massive documentation and changes during the in-hospital stay, which could blur the overview. This was further worsened because the electronic health records were designed for information storage rather than to enable an overview of the patient's situation. ³⁹ This is underpinned by findings of one-way electronic communication regarding patient discharges being less optimal and mistrusted by the receiver. ²⁴ Whether fragmentation of care and clinical decisions based on second-hand knowledge add to this mistrust could be questioned. However, the organization of nursing care has been found to impact communication. ³⁶ Electronic communication systems were not designed to encompass changes, deviations and individual solutions which were subsequently added by handwriting ²⁴ on the printed lists and documents. This meant that information could be lost or misunderstood, which might challenge patient safety.

Verbal communication about medications at the patient's discharge could challenge patient safety due to the noisy and disorderly environment. This could challenge the recommendation of teaching patients how to properly use discharge medications ³ and add to patients’ experienced confusion about new and ceased medications, substitutions and side effects.^2,30 Patients’ engagement with and preferences for involvement in medication management could vary,^30,40 and the nurses’ fragmented knowledge of the patient situation could hamper clear communication, which might have serious consequences for the patient's health.^6,20

Methodological considerations

The participants’ relatively short professional experience could have affected the findings. Nevertheless, shortage of registered nurses as well as high proportions of newly graduated nurses characterize medical wards in general. Although a small-scale study allows for in-depth analysis and descriptions of situations, it may also limit the transferability of findings. However, patients with multi-morbidity and specialized accelerated hospital treatment plans are international tendencies in healthcare systems, which may be recognizable. Likewise, detailed description of the context and participants will enable judgement of transferability to other contexts.

Conclusion

Hospital nurses’ transitional medication management is characterized by unpredictability and inconsistency in patients’ health situations which challenge discharge planning in a specialized and accelerated hospital context. Fragmentation and discontinuity in working processes stress the need for nurses’ competencies in clinical decision making. This requires competent nurses with the ability to assess patients’ actual and future medication needs. Complexity in communication systems may indicate challenges in caring for patients with multi-morbidity in a single-disease-focused healthcare system.

Supplemental Material

sj-docx-1-njn-10.1177_20571585211061735 - Supplemental material for Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study

Supplemental material, sj-docx-1-njn-10.1177_20571585211061735 for Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study by Mette Geil Kollerup and Birgitte Schantz Laursen in Nordic Journal of Nursing Research

Supplemental Material

sj-docx-2-njn-10.1177_20571585211061735 - Supplemental material for Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study

Supplemental material, sj-docx-2-njn-10.1177_20571585211061735 for Exploring hospital nurses’ transitional medication management for older patients with multi-morbidity: An ethnographic study by Mette Geil Kollerup and Birgitte Schantz Laursen in Nordic Journal of Nursing Research