This qualitative study is part of a larger study with focus group and individual interviews performed between October 2014 and February 2016 in Norway. The Regional Committees for Medical and Health Research Ethics in Central Norway approved the study (2014/1140).
Setting, training and practice
In Norway the municipalities are responsible for social welfare and health care for all its inhabitants, including home based health and social care and nursing homes [
15]. Part-time contracted general practitioners (GPs) most commonly provide the medical services in nursing homes [
16] and the home dwelling elderly with home based health and social care receive their medical service from their GP with assistance from home care nurses [
17]. The nurses in home care services often work alone as nurses, supported by staff with less or no formal nursing education [
18]. The majority of Norwegian pharmacists work in privately owned community pharmacies or hospital pharmacies. The municipalities have contracts with a hospital or community pharmacy to provide services to inspect drug management or to perform medication reviews [
19].
Interprofessional medication reviews is not established in primary health care in Norway, but since 2013 the GP legislation states that patients prescribed four or more drugs, the GP should perform medication reviews if this is necessary from a medical point of view [
20]. There is yet no such legislation for patients in nursing homes. In 2011–13 the Norwegian Patient Safety Programme “In safe hands” was implemented throughout Norway. Two of the 12 focus areas were to establish interprofessional teams on medication reviews in nursing homes and home based health and social care services [
21]. The centres for Development of Institutional and Home Care Services [
22] in each of Norway’s 19 counties were responsible for spreading the program to municipalities in their own county, following a national guideline based on the Intergrated Medicines Management (IMM-model) [
23].
The IMM-model consists of four main steps [
23] and is based upon the original version from Northern Ireland [
24]. In the first step, the nurses interview and go through a checklist with the patient, order blood samples and construct a drug list based on the available information. In the second step, the nurses pass this information to the pharmacist who identifies potential drug-related problems and checks if the prescribing is according to national guidelines. In the third step, the drug review is performed at a case conference where the responsible physician, nurse and the pharmacist meet and perform medication reconciliations and reviews where they discuss the best drug regime for that specific patient. The physician is responsible for the overall treatment. Finally, the nurse updates information of the drug regime agreed upon in the patient’s journal. They also observe how the patient responds to any changes and give feed back to the GP when necessary [
21]. The drug reviews require consent from the patient that allows health information to be shared in between the three professions involved.
The municipalities were encouraged to form interprofessional teams, consisting of at least one representative from the three professions; physician, nurse and pharmacist. In a course consisting of three structured learning meetings throughout one year the interprofessional teams of health professionals, were introduced to the methodology in the IMM-model, introduction to why IMRs are useful for the elderly patient, encouraged to initiate interprofessional cooperation and to establish interprofessional medication reviews (IMRs) [
25]. The interprofessional teams were encouraged to start practicing medication reconciliations and IMRs after the first meeting in the course [
21]. The nurses within each team were charged with developing local routines for the selection of eligible patients, routines for how to organize IMR-tasks on top of everyday tasks, and how to book case conferences. They were also responsible for spreading of knowledge on IMR to their colleagues. Only two physicians from the 11 participating municipalities attended the implementation course and only at the first meeting. It was therefore up to the team leaders, who were nurses, to recruit an appropriate physician from their municipality to their team. In some of the municipalities no physician was recruited and the IMRs were performed with only nurse and pharmacist present. In these teams the pharmacist first presented her findings to the nurse who then gave her input before she later was responsible of presenting the revised results from the discussion to the physician.
We aimed to recruit physicians, nurses and pharmacists who had participated in the patient safety program and who had experience of performing IMR. To ensure a representative sample, we wanted to have teams representing different municipality size, different length of experience with IMR and from both nursing homes and home based health and social care. The reports given by the different teams after the course were used to select teams based on these criteria.
To recruit informants, the appointed team leaders in 11 municipalities in Central Norway were contacted by e-mail and then by phone. They were told that they could volunteer teams even though not all team members in each team wanted to participate. This approach only lead to the recruitment of two pharmacists participating in several teams each and therefore additional two pharmacists were recruited through the hospital pharmacies in the county.
The semi-structured focus group interviews were conducted with representatives from all included teams 1–2 years after initiation of the course in their county. Focus group is particularly useful for exploring people’s common experiences, attitudes and views in environments where people interact. The use of group interaction is an explicit part of the method [
26]. The focus group interviews were either conducted at a nursing home or at the city hall in the municipality. An interview guide with open-ended questions focused on the following themes was used; perceived learning and gained knowledge in addition to perceived facilitators and barriers to be able to perform interprofessional medication reviews in primary health care [
27] (Additional file
1). The focus group interviews lasted approximately one and a half hour, were digitally recorded and led by the first author (HTB). The telephone interviews lasted approximately 20 min performed by the first author using the same interview guide. Participants were provided with written and oral information about the study and informed that they could withdraw at any time. Written informed consent was obtained from the participants before the interviews were conducted.
Data analysis
The interviews were digitally recorded and transcribed verbatim. They were analysed using the method of systematic text condensation [
28], according to an iterative four-step process. In the first step, all authors read a selection of the transcripts to identify preliminary themes, which were discussed. In the second step, the transcripts were searched in detail by the first author to identify meaning units, which were sorted under the preliminary themes and these were presented to the other authors. In the third step, the meaning units were arranged into subthemes. In all these steps the preliminary themes were adjusted. Then a narrative condensate was made of the meaning units sorted under each theme and subtheme. In the last step, an analytic text was produced based upon each theme and subtheme. The themes and the analysis were discussed among the authors several times and also in an extended research group to ensure validity. During the whole process, the authors went back to the original transcripts to ensure that the analysis was based upon them.