In total, 19 physicians and nurses were invited, and 14 agreed to participate. Non-participation in the study was referred to lack of time, busy schedules and transfers to other hospitals. Nine medical physicians, five nurses and three pharmacists were interviewed. Interviews typically lasted between 20 and 40 min for the physicians and nurses, and between 45 and 60 min for the pharmacists. Five of the eight physicians were male; all nurses and pharmacists were females. Four of the physicians were consultants.
All physicians (n = 9) who interacted with the clinical pharmacists during the introduction of a clinical pharmacy service completed the Physician-Pharmacist Collaboration Index (PPCI) survey. The mean total PPCI score was 78.6 ± 4.7, total 92 (higher scores represent a more advanced relationship). Mean domain scores were highest for relationship initiation (13.0 ± 1.3, total 15), and trustworthiness (38.9 ± 3.4, total 42), followed by role specification (26.3 ± 2.6, total 30). A summary of PPCI domain and total scores is provided in Table 1.
The interviews were used to further explore the relationships between physicians, nurses and pharmacists. The CWR domains were used to initially describe the interactions. Three broad themes were identified. Within the first theme, Initiating relationships, two subthemes emerged: (1) Initial expectations and apprehensions, and (2) Learning to collaborate. Within the second theme, Role specification, three subthemes were identified: (1) Value added, (2) Accessibility and, (3) Patient care and safety. The third theme comprised Barriers and enablers. To allow the reader to judge the veracity of the interpretation, quotations have been used to illustrate the themes presented.
In this study, the pharmacists first visited the hospital to introduce themselves and the intervention. Hence, they initiated the relationship with both the physicians and nurses through this presentation.
Initial expectations and apprehensions
Pharmacists described the apprehensiveness of physicians and nurses before the intervention: “A little curiosity mixed with a little skepticism” (Pharmacist 1). It was difficult to explain their role: “We noticed that they looked confused. They wondered, what exactly we were going to do?” (Pharmacist 1). Both physicians and nurses commented on an expected focus on drug knowledge. Physicians had concerns about being told what to do. However, these concerns dissipated, being instead described as “a very humble … discussion” (Physician 3).
Learning to collaborate
Relationships were built over time and developed through understanding the pharmacists’ contributions to the team. One physician reflected on “bringing in knowledge from different roles into the work on the rounds … so that you can have good teamwork” (Physician 7). Physicians, nurses and pharmacists built collaborative relations consistent with the CRW model; the more providers worked and communicated with each other, the more providers relied on the pharmacists’ knowledge and greater collaboration. The pharmacists reported the climate as “open-minded” (Pharmacist 2). However, relationship initiation takes time: “It takes a while before you get to know each other” (Pharmacist 1). Some physicians commented on the importance of the pharmacists’ personal traits for team collaboration as “having the right people in the position” (Physician 1).
Relationships were built over time; proximity and visibility allowed both physicians and nurses to interact and understand the pharmacists’ professional ability. Words such as joint knowledge and collegiality were used. Mutual respect developed through understanding the role and capabilities of the pharmacists as “a professional relationship in which I have great respect for their knowledge” (Physician 2).
Something to add
Most participants mentioned that pharmacists had something to add for physicians and nurses as well as patients. One physician noted: “You continually receive education through their comments on the rounds” (Physician 6). These issues were discussed collaboratively in the team as “a joint exchange of knowledge” (Nurse 1) in which nurses and physicians could “ask questions and discuss things” (Pharmacist 1). One physician explained: “The work with drugs is a big piece in some way, and it is missing in the teamwork” (Physician 4).
The pharmacists, nurses, and physicians exchanged information directly on the rounds “about drugs which don’t work together” (Nurse 1), which “saved us time” (Physician 4). One physician noted the pharmacists’ expertise: “We physicians have relatively little drug knowledge” (Physician 4). The professional relationships initially built during the ward rounds, continued with individual contacts with the pharmacists. These results are consistent with the relatively high score in the PCCI relationship initiation trustworthiness.
The pharmacists reported being based in the ward as positive. One pharmacist mentioned a physician who often came by to ask questions: “It takes a while before you understand what we [pharmacists] know” (Pharmacist 2). Nurses also took advantage of the pharmacists being nearby: “Nurses could come occasionally and ask something” (Pharmacist 1). One physician noted: “You could always knock on the door and ask. I have thought about this [drug]. Is this [drug] good or is there another alternative?” (Physician 4).
Patient care and safety
The pharmacists’ expert knowledge on side effects, speaking to patients and reviewing patients’ medication lists were seen as important. According to one physician: “They know more about drugs and we can actually help out together, this helps the patient mainly” (Physician 5). Physicians and nurses were positive about the pharmacists speaking to patients, being as “especially good if you can explain an interaction” (Physician 8). For the pharmacists, patients provided reliable information as they were “a little more open” (Pharmacist 2).
Regarding patient safety, one pharmacist reported a patient on an unsuitable drug: “With her state of illness, she really shouldn’t have been taking this” (Pharmacist 2). Another pharmacist discovered an error when a patient switched wards: “They had taken drug levels of a drug that was very neurotoxic … and the patient had already been discharged” (Pharmacist 3).
Barriers and enablers
Overall pharmacists, physicians and nurses only identified a few barriers to the implementation of the intervention. Funding was noted: “If it is taken from the nurses’ budget, then it’s a direct no” (Nurse 5). Another barrier was time, as the rounds took longer: “Surely you can find good forms for how to do this” (Physician 6). Disagreement in decision-making was noted as a potential barrier: “In these cases I have the mandate to decide” (Physician 1). Another barrier was medication review documentation, for seeing that “the medication review has been reviewed relatively recently” (Physician 2). For the pharmacists, being based and employed at another hospital, 127 km from this rural hospital, distance was a barrier. One pharmacist reflected: “You could have been on site [at the hospital in TOWN] even more if you lived in TOWN” (Pharmacist 2).
Enablers were also reported, such as a climate at the ward which was “accepting” (Nurse 3). Another enabler was the size of the hospital: “It is smaller in [name of the place], and it is easier for you to get hold of a physician” (Pharmacist 1).