Research article
Communicating with patients, families and health professionals about managing medications in intensive care: A qualitative observational study

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Abstract

Objectives

To explore communication between patients, families, and health professionals about managing medications in intensive care.

Design

A qualitative exploratory study was undertaken using participant observations. A thematic analysis of the data was performed.

Setting

The setting comprised an intensive care unit at a public, teaching hospital in Melbourne, Australia.

Findings

Three themes were identified: provision of information, therapeutic relationships, and patient and family centred care. Nurses and pharmacists communicated regularly about medications with patients and family members. Doctors were occasionally present at the bedside during medical ward rounds or in undertaking medical procedures and subsequently their patient and family interactions about managing medications tended to be minimal. Pharmacists spent time in clarifying patients’ medication history prior to their admission to the intensive care unit. Nurses were at the forefront of communication with patients and their family members. However, nurses sometimes missed cues and valuable opportunities to respond to families’ concerns during their interactions. Communication was commonly hampered by time constraints and competing responsibilities of health professionals.

Conclusion

Communication tended to involve clarification of patients’ medication history and the ways in which medications affected patients’ clinical status or medical condition. Attention is needed in attending to cues from families in communicating about medications.

Introduction

Communication about managing medications involves conveying information about treatment regimens and understanding patients’ and family members’ needs and preferences. Through communication, there are opportunities for health professionals to inform patients and families about medications, to examine why these medications are prescribed, to determine reasons for medication discontinuation and to accurately clarify the patients’ medication history. In the intensive care setting, communication about medications is extremely challenging. Patients generally have an impaired ability to interact due to the presence of an artificial airway or assisted ventilation, and they are usually affected by sedation, fatigue and delirium (Bell et al., 2018). However, towards the end of their intensive care stay when plans are being made for patient discharge to a general ward environment, most patients are in a conscious state and are therefore able to participate in communication. For the most part; however, while critically ill patients are not able to communicate in intensive care (Happ et al., 2011), family members are in a position to be the voice or advocate for these patients (Brown et al., 2015, Hetland et al., 2018).

A dearth of research exists on how patients and family members communicate about medication management in the intensive care unit (ICU). In a retrospective clinical audit of intensive care medical records, generalised linear mixed modelling identified the odds of a prescribing incident increased 5.96 times for each additional ward transfer (95% CI 3.52, 9.99; P < 0.001) (Manias et al., 2014). This result demonstrates the importance of communication about medication decisions in relation to patients’ movements across transitions of care from the intensive care environment. Interviews with families of critically ill patients conducted by Wong et al. (2015) indicated that health professionals interacted in supportive ways but families also experienced unsupportive interactions because of poor communication. In a scoping review, Olding et al. (2016) examined patient and family involvement in intensive care. Interview-based exploratory study designs were the most common approach used. Only three articles specifically explored relationships between health professionals, patients and family members in interpreting patterns of communication. Major areas of patient and family involvement comprised end-of-life care and palliative care decisions. No work was identified in relation to communication about medications.

Observational methods can provide useful information about the complexities involving social, environmental and organisational contexts that impact on communication processes (Moser and Korstjens, 2018). These methods can elicit novel understandings of interconnections between medication management and communication practices. New knowledge can be therefore illuminated on how communication occurs in real-life clinical situations, to generate strategies for improving patient care.

Section snippets

Aim

The aim of the study was to explore how communication occurs between patients, families and health professionals about managing medications in the intensive care unit.

Research design and ethical considerations

A qualitative exploratory research design was chosen comprising participant observations. The strength of this research design lies in its facilitation of providing insights through inductive discovery into key issues surrounding medication communication. This facilitation enables understandings of the social aspects of

Sample and observation characteristics

A total of 50 hours of observations were undertaken. Observations were carried out at different days from Monday to Friday and at various times during the day, ranging from 8 am to 6 pm. Each observation was approximately four hours in duration. Twenty health professionals comprising 18 nurses and 2 pharmacists were shadowed as they interacted with patients and family members and with other health professionals. Their years of experience as a health professional ranged from 4 to 25 years.

Discussion

This observational study provided new knowledge about communicating about medications in intensive care. Themes identified were the provision of information by family members regarding patients’ medications and their clinical condition; the therapeutic relationships between health professionals, patients and family members; and the environmental characteristics of intensive care. Patients and families influenced medication management by making important links with the patients’ treatment

Limitations

This study was conducted at an Australian single-site ICU in a metropolitan tertiary referral hospital that may not have appropriately reflected the practices of other healthcare facilities, those in regional areas, or in other countries. As observations were undertaken at the patients’ bedside, there was relatively little involvement from doctors. Doctors were noted to discuss patient information at the central computer station. They undertook medication prescribing activities in this central

Conclusion

Family members played an important role in communicating about patients’ medication regimen before admission to intensive care, which helped to prevent and resolve medication problems in intensive care. While patients had complex medication regimens, family members sought out clarification about the changing dynamics of how medications affected patients. However, there was only limited inclusion of families or of conscious patients in decision making. Communication was commonly hampered by time

Ethical statement

Appropriate ethical approval for the conduction and dissemination of this study was obtained from the ethics committee of the participating hospital in Melbourne, Australia. The reference number is: H2010/03995.

Financial support

This publication was made possible by funding from an Australian Research Council (ARC) Discovery Project Grant, project no. DP1093038. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the ARC.

Declaration of Competing Interest

None declared.

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