Study design

This study was conducted and reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [16].

We explored nurses’, physicians’ and pharmacists’ expectations about nurses’ role in PC, and related strengths, weaknesses, opportunities and threats through a qualitative descriptive research design with a phenomenological case study approach. Case study as a research method has been widely used for preliminary and exploratory stages of research [17–19]. Multiple case studies allow cross-case comparisons and the identification of themes across cases. A phenomenological approach using in-depth semi-structured interviews within the case studies support high quality data collection [20–22]. Phenomenology is well suited for exploring perspectives of healthcare professionals [23]. This research approach was chosen as an appropriate way to describe the essence of the phenomenon “nurses’ role in interprofessional PC”, by exploring it from the perspective of those who have experienced it, namely pharmacists, physicians and nurses themselves. Interviewing this study population enables studying and understanding healthcare professionals’ lived experiences in interprofessional PC. Only by understanding their personal experiences and perceptions of nurses’ responsibilities and tasks, and interprofessional collaboration and communication, we will be able to provide detailed examination of the current strengths and weaknesses, together with the future opportunities and threats from nurses’ involvement in PC [23].

Setting

The study took place in 14 European countries: Belgium, Czech Republic, Germany, Greece, Hungary, Italy, the Republic of North Macedonia, the Netherlands, Norway, Portugal, Slovakia, Slovenia, Spain and the United Kingdom (England and Wales). In each country in-depth interviews were conducted in four different settings: hospitals, community care, long-term residential care, and mental health care.

Participants

‘Key informant’ pharmacists, physicians and nurses were purposively sampled [24]. They could only be selected on the condition that they were named as expert in PC by at least two other healthcare professionals, with local knowledge of PC, and insights into the nature of problems and possible solutions. This allowed us to get information about nurses’ roles in interprofessional PC and to understand the motivations and beliefs of a large number of healthcare professionals with diverse backgrounds and opinions. Representatives of professional associations for nurses, physicians and pharmacists, and healthcare providers in different healthcare institutions were asked to identify key informants. Researchers contacted the persons identified as potential participants by email or telephone, informed them about the study, and about being named as a key informant on nurses’ role in interprofessional PC. If they agreed with being able to serve as a key informant, written information was provided to fully inform the potential participants about the study details.

We aimed for at least two interviews per profession (n = 3) per healthcare setting (n = 4), per country (n = 14), resulting in 24 in-depth face-to-face interviews per country. These numbers were aimed for in order to compile a sample with perspectives as diverse as possible. Data saturation was reached in each participating country. There were no restrictions as to gender or age. No reimbursement was provided for participation. Exact numbers of those approached and declining were not registered in all countries.

Interview guide development

An interview guide (S1 Appendix) was developed in English based on literature and the results of a previous quantitative study about nurses’ practices in interprofessional PC (Fig 1, step 1) [13]. During a meeting with all European partners, the interview guide was adjusted until consensus was reached (Fig 1, step 2).

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Fig 1. International approach to increase methodological quality.

https://doi.org/10.1371/journal.pone.0251982.g001

To ensure conformity across twelve languages, the concept of PC was described at the beginning of the interview: “healthcare professionals’ contribution to the care of individuals in order to optimize medicines use and improve health outcomes”. This description was derived from the Pharmaceutical Care Network Europe definition of 2013, taking into account the interprofessional aspect of PC [8, 14].

Responsibilities and tasks were defined based on the literature, together with discussions with an expert in health law, liability law and ethics and an expert in legal philosophy and ethics: “The role of nurses involves several responsibilities. A responsibility for nurses is an obligation that they have by virtue of their role as a nurse. Their central responsibility is to be the patient’s health advocate and to provide high quality care, using sound professional judgement and taking into account the relevant legal and moral considerations. The other responsibilities of nurses derive from this central responsibility. Nurses can be made to answer for failing in their responsibilities, which could result in disciplinary, civil, and criminal liability. Specific tasks may have to be performed in order to fulfill a responsibility.” [25, 26].

The interview guide consisted of four main topics.

1. Topic 1: Responsibilities. Respondents were asked what responsibilities would be part of the ideal role of nurses in PC and what these responsibilities would imply. Preparation and administration of medicines by nurses was considered as an obvious part of PC and therefore outside the study’s scope. After open reflections, four responsibilities were presented: 1) monitoring and following-up of therapeutic and adverse effects of medicines; 2) monitoring and following-up medicines adherence; 3) decision making on medicines use, including prescribing medicines, excluding preparation and administration; 4) providing patient education and information about medicines. Respondents were asked what they would like to change, add, or remove. This structuring ensured uniformity across 14 countries and 12 languages.
2. Topic 2: Tasks. Specific tasks within the previously defined responsibilities were elicited. A similar strategy as above, with open and then more guided reflections, was used. The predefined tasks for reflection were: 1) detecting clinical change, healthcare problems or assessing patient needs; 2) registration; 3) interprofessional communication (including reporting, alerting and discussion); 4) patient communication; 5) intervention in emergency cases; 6) follow-up; 7) self-care support; 8) ‘dependent’ nurse prescribing; 9) ‘independent’ nurse prescribing; 10) reporting medication errors and safety issues.
3. Topic 3: Interprofessional team working. Ideal communication and collaboration between pharmacists, physicians and nurses, when aiming for high quality PC and predefined interactions were suggested: 1) nurses reporting observations to physicians and pharmacists; 2) physicians providing information and instruction to nurses; 3) pharmacists giving advice to nurses.
4. Topic 4: SWOT analysis. Finally, respondents were asked to reflect on strengths, weaknesses, opportunities and threats (SWOT) of nurses’ current and ideal roles.

Data collection

Nurse researchers in each country were trained in qualitative research and in-depth interviewing during a joint one-week training program at University of Antwerp in November 2019 (Fig 1, step 3). When agreed, the interview guide was translated into all national languages and pilot tested in each country by at least one pharmacist, physician and nurse (Fig 1, step 4–5). The test interviews were not included in the data analysis. No significant adjustments were made after the pilot interviews. Between December 2018 and October 2019 interviews were conducted by two to four interviewers per country (Fig 1, step 6). Participants were mostly interviewed at their workplace, or another location, such as participant’s home or the researcher’s workplace. Regardless of location, confidentiality was maintained. Only the interviewer and the interviewee were present during the interview. Interviews lasted from 30 to 90 minutes, and were audio recorded. Field notes were taken. No interviews were repeated. Audio recordings were transcribed verbatim by the interviewer or a professional transcriber (Fig 1, step 7). They were not returned to participants for member checking.

Data analysis

The qualitative analysis started after the first interview [27]. The transcripts were coded by labelling lines of text in order to group and compare similar or related data segments. To create an international code book for data analysis, 12 interviews were fully translated into English and coded by the local researchers from 4 countries (one pharmacist, one physician, one nurse per country) (Fig 1, step 8). The English codes were then collected to create a common first code book, to be used as a guide for analysing subsequent interviews (Fig 1, step 9). Consensus was achieved within the consortium, and the next 30 interviews were analysed (Fig 1, step 10–11). Extra codes and themes could be added if new content arose. The final code book consisted of 11 themes, combined with 49 sub-themes, addressing nurses’ roles and the related SWOT analysis (S2 Appendix; Fig 1, step 12).

To improve the confirmability of the study, every first interview per professional group per country was analysed by two researchers [28–30]. In that way, at least three interviews per country (one nurse, one physician, one pharmacist) were analysed by two researchers. All other transcripts and coding were at least checked by a colleague. After the data were analysed at national level, by coding the transcripts, researchers in each country selected quotations for each theme and sub-theme (Fig 1, step 14). To store the quotations, add labels and arrange the data, Microsoft Excel^® tables were created. To accomplish an overall view on the data, the preselected citations were reviewed by two researchers (first and second author) to reassess the code labels for accuracy and to compare the different opinions throughout Europe. All assumptions were taken into account, regardless the number of times they occurred (Fig 1, step 16). The national data per country, as well as the overall international data, were presented at an international meeting with all partners to discuss the completeness and interpretation of the results per country, and achieve international consensus (Fig 1, step 17).

Ethics approval

The Ethics Committee for Social Sciences and Humanities of the University of Antwerp approved the study design (reference SHW_19_30). Depending on local regulations in Slovenia, the UK and Portugal, additional approval was obtained from the Medical Ethics Committee of the Republic of Slovenia (reference 0120-516/2018/6), Health and Care Research Wales (reference 19/HCRW/00) and the Ethics Committee of the Escola Superior de Enfermagem in Coimbra (reference 543/12-2018). National regulations and laws applying to the other countries didn’t require additional permits or approvals. All respondents received information on the purpose, design and execution of the study. Written informed consent was given by all study participants.

Responsibility 1: Monitoring therapeutic and adverse effects of medicines

Some respondents considered monitoring patients for the benefits and harms of medicines administered as part of basic nursing care, whereas others disagreed.

“I think pharmacists are better placed to report about unwanted effects, since we are committed to report on pharmacovigilance. Pharmaceutical care is pharmacists’ work, and nobody else’s”

(Pharmacist-05, Slovenia)

“The clinical evaluation and follow-up is something nurses currently do on a daily basis and which is often the trigger of alarm to physicians. It is already part of nurses’ skills and it is being done well.”

(Physician-01, Portugal)

Within monitoring, nurses’ tasks were defined as medication anamnesis, detecting clinical change and healthcare problems and assessing patient needs. Early recognition of signals and linking with medicines was seen as vital to patients’ safety. Reporting observations to the team (physician and pharmacist) and to patients or their informal caregivers and family, as well as registration and follow-up of medicines’ desirable and undesirable effects were recognized as nurses’ tasks. Follow-up was suggested as either a nursing or shared responsibility or solely a medical task.

“Pharmacists won’t notice side effects, only one person will–it’s the nurse.”

(Pharmacist-20, Hungary)

“Nurses don’t only distribute medicines like a trained monkey. They are able to realize that somehow a problem could arise and preventive interventions might be necessary.”

(Nurse-04, Germany)

To monitor therapeutic and adverse effects of medicines, respondents perceived a certain level of knowledge about medication to be needed, and therefore high quality nurse education must be provided. In addition, some felt clear legal frameworks, policies and regulations, allocating nurses clear roles in monitoring, are necessary.

Responsibility 2: Monitoring medicines adherence

Many respondents considered adherence monitoring to be a clear and obvious aspect of nurses’ roles, while some were convinced that this was a physician-only responsibility or even the sole responsibility of the patient.

“Monitoring and following-up medication adherence, this is probably clear. This is an area which is the least controversial, I see no problem in it.”

(Nurse-12, Czech Republic)

Within monitoring medication adherence, one important nursing task was to detect and alert the interprofessional team of any non-adherence. Nurses may also motivate patients to adhere to their prescribed regimen. Motivational interviewing of patients with targeted open questions would identify reasons of non-adherence, determine patients’ needs, and support self-care.

“When the nurse is with the patient, she realizes whether the pill is too big for the patient and he would prefer to take two smaller ones twice a day.”

(Pharmacist-02, Italy)

Prerequisites of adherence monitoring by nurses included: clear guidelines about the responsibilities of nurses, pharmacists and physicians in monitoring adherence within a legal framework; open, blame-free culture; open dialogue between pharmacists, physicians and nurses; appropriate nurse training in PC; and a manageable workload, resulting in time to care and explore issues with patients.

Responsibility 3: Decision making on medicines use, including (de)prescribing, medication reconciliation and medication review

A wide variation in opinions was reported, with more positive views in countries with existing nurse prescribing. Differences in opinion were not confined to any one profession. A small number of respondents considered nurses already possessed the required competences, and advocated nurse-prescribing for a wide range of medicines, usually within their specialist fields.

“Doctors, especially in hospitals, got used to giving their stamps to the head nurse to write prescriptions.”

(Pharmacist-01, Greece)

“We have an internal deal with the nurses on my ward, that they are allowed to give some medicines to patients on their own, under specific circumstances and specific medicines that we agreed on.”

(Physician-06, Slovenia)

Others favoured nurse prescribing, but only after extra training and under specific conditions, e.g. emergencies, low risk medicines (often those that can be purchased without a prescription) or confined to nurses with high levels of nursing education. A further group would never–under any circumstances—give nurses a role in decision making or prescribing. They considered this responsibility to be too complex and a medical responsibility, in which collaboration with nurses was not desirable.

“Experiences with nurse prescribing in other countries are not of that kind, that we need to be scared of it.”

(Pharmacist-02, Belgium)

“It scares me… it is probably just my feeling… I cannot imagine nurse prescribing.”

(Pharmacist-10, Czech Republic)

Respondents considering decision making on medicines to be a part of nurses’ ideal roles described possible tasks within this responsibility: nurses could decide on the route, formulation and brand; add or deprescribe treatments; adjust and titrate doses; prepare prescriptions (to be validated by a physician); and prescribe repeat prescriptions. Respondents predominantly reflected on the selection of products, the level of autonomy and the level of emergency: local and low-risk medicines from a limited list were preferred to systemic and high-risk medicines; supervision by physicians or pharmacists and shared responsibility were favoured above full autonomy for nurses; and life-threatening emergencies warranted increased autonomy. Others felt that more complex thinking is required in these situations, arguing against more responsibility for nurses. There were calls for flexible practice guidelines. Knowledge was mentioned as a crucial prerequisite for decision-making in PC. As an initial step, more pharmacology is needed in pre- and post-registration nurse education. Level 6 (Bachelor) nurses [31], nurse specialists and nurse practitioners were suggested as having the minimum level of education to prescribe.

“Nurse prescriptions should be very limited. I would understand nurse prescribing, but only in very specific restricted situations.”

(Pharmacist-03, Spain)

“What responsibilities would be part of the ideal role of a nurse in interprofessional pharmaceutical care? In my ambulatory practice I think nurses can prescribe ‘repeating prescriptions’ within control consultations. I think nurses can decide about routine medicines, within a certain spectrum, within their specialization in the field.”

(Physician-22, Slovakia)

“Nurses could have autonomy on the renewal of chronic therapies, previously prescribed by a doctor.”

(Nurse-10, Italy)

“Nurses have the right to give emergency therapy when the patient’s life is endangered, e.g. in case of major bleeding.”

(Nurse-02, Republic of North-Macedonia)

“I would increase the level of knowledge, because if we don’t have the proper level of knowledge, we can’t prove to doctors and pharmacists that we are competent to prescribe and right now they don’t trust us enough to prescribe.”

(Nurse-07, Slovenia)

Responsibility 4: Providing patient education and information about medicines

Some respondents were convinced that responsibilities for educating and informing patients were the professional territory of physicians or pharmacists, while others believed these responsibilities should be shared with nurses. Opinions were based on the very limited content in pharmacotherapeutics in nurse education.

“Patient education about medicines would be better done by a pharmacist, they go to school for 5 years and learn everything about medicines, while nurses have only one course in school.”

(Pharmacist-01, Slovenia)

With improved education, nurses could: explain medical diagnoses; inform patients and their caregivers about short- and long-term advantages and disadvantages of their medicines; support self-care; counsel patients at discharge; encourage and empower patients to take their medicines.

“A nurse has a responsibility to the patient to keep the patient fully informed about what has been prescribed, the risks associated, side effects associated and benefits likewise.”

(Physician-04, UK)

“I think patient education and providing information is already done, it is common that nurses educate patients. We can discuss about the quality and the way, but I think, the role of nurses should be enhanced here.”

(Nurse-12, Czech Republic)

“Nurses should provide patient education and information on drugs, because doctors are too complicated for patients.”

(Nurse-02, Slovakia)

Interactions between nurses, physicians and pharmacists in an ideal interprofessional collaboration

Interprofessional communication, including reporting, advising, informing, alerting and discussing was considered of major importance in interprofessional PC. Collaboration, coaching and supervising within the nursing team was also reported as important.

“Multidisciplinary communication works, nurses are irreplaceable, they ensure that information and documentation is effectively passed between team members.”

(Nurse-03, Slovakia)

“Three-dimensional communication is missing. Clinical pharmacists have been collaborating mainly with physicians, discussion with nurses is missing.”

(Physician-10, Czech Republic)

Contextual factors allowed nurses to have a role in interprofessional collaboration, e.g. confidence in nurses’ knowledge, self-confidence of nurses, an open blame-free culture, clear roles and responsibilities, availability of team members, involvement of nurses in PC team meetings, absence of hierarchic attitudes, and equality between professionals. Written communication was recommended to ensure proper communication.

“The working atmosphere is crucial. This must ensure openness and honesty and give room for clear feedback to each other.”

(Physician-08, the Netherlands)

“I don’t know who my nurses are in my two local surgeries. It would be nice to know their names, I don’t think that’s the nurses’ fault I think it’s the way we get used to working.”

(Pharmacist-24, UK)

Strengths, weaknesses, opportunities and threats of nurses’ role in interprofessional PC

Strengths and limitations

To our knowledge, this is the first pan-European qualitative interview study about PC by nurses. The quality of the research can be demonstrated based on the qualitative research quality criteria of Lincloln and Guba [28]. Firstly, triangulation of sources and analyst triangulaton indicate credibility. Secondly, the extensive focus on the PC context of the participants resulting in thick descriptions will facilitate transferability of the study findings. Thirdly, the dependability is confirmed by investigator triangulation: coding of the first interviews by multiple researchers within one country, plus a non-country specific reassessment of the code labels linked to preselected citations by a team of researchers.

The confirmability of this research could only be partially achieved. Researchers from all countries were trained in qualitative research, in-depth interviewing, and ‘bracketing’ their own beliefs about nurses’ role in PC during a joint one-week training program. However, since interviewers and respondents often shared work environments, contextual intersecting relationships between the participants and the researchers cannot be ignored. As we wanted to avoid the profession of the researchers influencing the responses from physicians, pharmacists, and other nurses, interviewers were asked not to inform interviewies about their profession unless directly questioned [54].

Another limitation is the absence of structured integration of the field notes, that have been made during the process of transcribing, critical reflecting and coding. Therefore, the researchers might have missed important non-verbal indicators, such as participants’ body language and tone of voice.

The selected participants were ‘key informant’ experts in PC, who knew best what was happening in PC in clinical practice. However, findings cannot be generalised to more junior clinicians or managerial staff. No reimbursement was provided for participation, leading to occasional refusal to participate. Exact numbers of those declining to participate were not registered, leading to an unknown selection bias. Despite the limited number of participants per professional group at national level, no new themes were generated in the last interviews reviewed, suggesting sufficient information power [55]. Socio-cultural influences, mainly in terms of attitudes towards other professions might affect perspectives related to interprofessional collaboration, as was demonstrated in several studies [43, 56]. In this research, no information was sought on cultural and/or ethnic identities of respondents. We wished to avoid sensitive questions and any possibility that respondents might be identified by local readers. Diversity should be taken into account in future research.

Implications for clinical practice and future research

Our results offer opportunities to create a framework for discussion in clinical practice, collaboration in research, and labour mobility. Nurses, pharmacists and physicians should openly discuss allocation of specific responsibilities and tasks. Our list of responsibilities and tasks is not exhaustive. Medication safety management [57], care coordination [58], overseeing patient medication self-management [59, 60], assessing patients’ competences [61], coaching and training patients [62], discharge planning [63] and interprofessional referrals [64] are additional nursing responsibilities and tasks identified in the literature. A scoping review of research about PC by nurses would be useful to confirm the completeness of the role described or supplement with additional responsibilities and tasks. Further research should also address the differences in nurses’ roles within different levels of nurse education.

Exploring nurses’ ideal role in PC is not intended to remove responsibilities from other professional groups. On the contrary, the benefits of interprofessional collaboration and communication between pharmacists, physicians and nurses and its major impact on care quality and patient outcomes have already been amply demonstrated [48, 49, 65–69]. Yet, healthcare systems are historically hierarchical in nature with physicians regularly assuming leadership positions and decision-making roles. Frustrations, lack of confidence, lack of organization and structural hierarchies hinder interprofessional relationships and communication [41]. Power imbalance between professions is an important factor in nurses’ professional roles when discussing PC and its formalisation. To address this source of conflict, it may be helpful for team members to discuss and agree roles and responsibilities [40]. Increasing the awareness of all team members’ potential roles would allow pharmacists, nurses and physicians to benefit from teamwork [65]. Also, educators hesitate to address the reality of hierarchies in healthcare [70]. The training of healthcare professionals remains largely single discipline, which may reduce the ability to collaborate interprofessionally [71]. Therefore, we call for more interprofessional education, as well as rigorous research on interprofessional PC to tackle the remaining barriers.