Fifteen focus groups were conducted between July 2020 and April 2021 (Table 1). In total 67 staff participated in the focus groups including nursing (64%), doctors (12%), managers (12%), allied health (6%) and pharmacy (6%). While no one declined consent, some staff were unable to complete the entire focus group session due to competing clinical duties (n=5). One focus group was conducted over the phone owing to telehealth equipment being used for clinical work.
Table 1
Staff who participated in Virtual Clinical Pharmacy Service focus groups
Focus Group Number | Hospital Location | Nurse n (%) | Manager n (%) | Doctor n (%) | Pharmacist n (%) | Allied Health n (%) | Entered late or left early n (%) | Number of participants n (%) |
1 | Site 1 | 6 | 2 | | | | 1 | 8 |
2 & 3 | Site 2 | 6 | | 1 | | | | 7 |
4 & 5 | Site 3 | 9 | | 1 | | | 1 | 10 |
6 & 7 | Site 4 | 4 | 1 | 2 | | | 2 | 7 |
8 & 9 | Site 5 | | 2 | 1 | | | | 3 |
10 | Site 6 | 8 | | | | | | 8 |
11 & 12 | Site 7 | 5 | | 3 | | | 1 | 8 |
13 | Site 8 | 4 | 2 | | | | | 6 |
14 | VCPS providers | | | | 4 | | | 4 |
15 | Allied Health/ Other | 1 | 1 | | | 4 | | 6 |
Total | 43 (64) | 8 (12) | 8 (12) | 4 (6) | 4 (6) | 5 (7) | 67 |
Themes reflect the influence of Appreciative Inquiry. The first section describes staff perceptions of the value of the Virtual Clinical Pharmacy Service to patients, to staff and to the health service. These themes encapsulate the current strengths of the virtual service (summarised in Figure 1). The second section is focussed on identifying enhancements to build on the strengths and maximise potential of the VCPS (summarised in Figure 2). The initials FG refer to the focus group the quotation comes from.
Value to patient “...not every patient requires another allied health service, but they all require a pharmacist” FG8
Staff perceived patients were very accepting of the virtual pharmacy service and were comfortable using it. Staff described most patients as being able to engage with the virtual pharmacist in a similar way to in-person engagement.
“I wondered how some of the older generation would go but they've spoke nothing but high praise of it… I think because [virtual pharmacist] does such a brilliant job of interacting with them and talking to them about their medications, they've just embraced it.” FG 8
The technology was reliable, and most patients could see and hear the consultation.
“The patients are really receptive to it. The whole model. They really – because the screens are so big on the Wallie [telehealth cart] usually, and it’s really good. They can turn it up loud and go for it.” FG15
The interpersonal skills of the virtual pharmacist was critical in establishing rapport with the patient. Patients and carers were receptive to medication education they received and felt comfortable asking questions of the virtual pharmacist.
“I was watching a consult just earlier today, and [virtual pharmacist] said, okay, I'm going to quiz you- to the partner - because she's in charge of the medication. So she did - it's just a very nice and fun, free kind of thing.” FG4
Staff reported how valuable it was for virtual pharmacy staff to have local knowledge as this helped build rapport with patients and grasp nuances which were important for discharge planning such as the size of the town the patient was from and the distance from a major centre.
“Actually, that’s been one of the good things is that some of the pharmacists involved in our project were based in Dubbo. So, they knew our hospital and probably some of the others [hospitals] really well. So, if the patients said, oh, I’m from, say, Eumungerie, if you’ve got a doctor from the middle of Canada saying, I have no idea where that is, but the pharmacist did know where that was. So that’s actually been a positive thing.” FG13
Staff noted the more informed the patient (and their carer) was about their medications, the more likely they were to take the medications. Staff described the proactive role virtual pharmacists took in discharge planning such as organising or updating dose administration aids and ensuring the patient received a patient friendly medication list prior to discharge. Patient safety was seen to be enhanced by these improvements in communication between the hospital staff, patient, community pharmacy and general practice.
“...it was all just word of mouth; the doctor would tell the patients and us at the handover what the [medication] changes were [on discharge] and then he'd do the scripts and then they'd leave with the scripts even if we don't do it [medication list] - but at least this way, if there's something lost in that, if they've actually got a physical piece of paper that says, this is the medications you're meant to be on, it's much safer.” FG13
Staff identified the positive value to the patient by pharmacist involvement in the multidisciplinary team ward round. Staff felt all patients benefitted from the pharmacist involvement and identified that this was the first time they had been able to offer holistic patient care.
“… the MDT [multidisciplinary team ward round] is just the icing on a beautiful cake because for the only time in my 24 years of working at [remote] Hospital we actually do have a proper multidisciplinary round with the patients in the centre… So, for once I can actually say that holistic approach to patient care is 100 per cent...” FG8
Value to staff “I can't say how well we've embraced it and how much we love having this service. Not only just for us but for the patients, for the doctors, it's been great.” FG8
Staff viewed the virtual pharmacist as an additional team member who was trusted and approachable. They valued the double checking, reminders, back-up and guidance provided as they felt it led to safer practice, fewer medication errors and improvements in patient safety. Their experience of interacting with the service was efficient, but they also described efficiencies it brought to their own work.
“Easier, accessible, because they do medication reconciliations, they can see everyone, so there's efficiencies there, scanning what the orders are and any drug interactions. So it's quite, well, I think, useful and efficient and there's a patient safety focus as well” FG13
The VCPS provided regular formal education sessions to each site. However, focus group participants described numerous occasions where ‘just in time’ medication education relevant to current patient was extremely valuable. For example;
“I wanted to know why and what could we do better and what could we do differently, like was this appropriate for this patient, and they were really, really helpful. One [virtual pharmacist] was able to have a quick chat with me and explain it and I felt I had a much better understanding of what was going on and why the patient - why we were doing what we were doing.” FG10
Learning more about medications made clinicians more interested in how medications might be relevant to the care of a patient.
“… just getting that bit of education as we’re going, going “What does that drug do?” or “What’s that indication?”.... Because I mean pharmacy sort of stuff… – the names of different medications, all the different things. I can’t keep up with all those changes... It’s good.” FG15
Participating in ward rounds or patient medication reviews was also an education opportunity for nursing staff;
“Listening to them give the patients education. We’re learning at the same time as everyone else”. FG15
In spite of some having initial misgivings, focus group participants unanimously reported benefits from pharmacist involvement.
“I actually thought maybe it was going to be a bit intrusive, and… it didn’t take very long to see that it was a great help… well it is both educational and shall we use the word collegiate?" FG 9
Some nursing staff reported pharmacist communications also had a positive effect on their communication with medical staff as it had removed the perception nurses were challenging a doctor’s authority.
“…but the conversation between [virtual pharmacist] and clinician is very much a professional, informative conversation. But it always brings it back to the patients. Whereas I'm going to say before with not having that input from pharmacy it was very much seen as a challenge between doctor and nurse.” FG8
Virtual pharmacists reported less distractions from providing clinical services, time saved by not needing to change work locations within hospitals, improved continuity of care for patients and overall high job satisfaction.
“…I think that like as a job this is much more rewarding and much more – like I feel more satisfied doing this job. …I probably have had a like reinvigoration of what we can do and how we can benefit our patients. So I think it's a rewarding job… FG14
Value to health service “ I can see this is streets ahead of what we used to do” FG13
Staff reported the VCPS brought a positive culture about medications and were excited about the potential to improve hospital audit results, enhance compliance with key performance indicators and meet accreditation gaps.
“From a management side, when I'm doing my audits it's very, very helpful to have the pharmacist that's been in there and done the initial medication, best medication history…and yeah, the reconciliation then at the end. It has improved our audit results a lot…” FG1
A key aim of the VCPS to improve antibiotic prescribing was also noted.
“The other thing that has really improved is the antibiotic prescribing… it's far more in line with the therapeutic guidelines.” FG1
Staff were convinced of the potential of the virtual service to improve patient safety. For example a doctor stated; “I think it’s brilliant for its safety. It does improve safety. It has to. I mean how can it not?”(FG7). However, some participants identified medication errors had increased because more errors were being identified;
“I wouldn’t necessarily say the medication error rate is going up, just that the detection of the errors is going up.” FG9
Because of the VCPS, responsibility for identifying medication errors was shared between nursing and pharmacy staff;
We’re having a higher incident of reporting… I don’t see it as a negative aspect. The pharmacists also are picking up on errors and IIMSing them [reporting] and putting them through too. So that’s been a good thing and creates a safer culture here.” FG4
Investment by the health service in effective technology was critical to the success of the VCPS. Not only was there ease of use and accessibility for patients but the electronic medical record and the electronic medication management (eMeds) system facilitated timely communication between doctors, nurses, pharmacists and patients. For example;
“The virtual pharmacist suggestions, comments, et cetera, are there [in electronic medical record], and it’s pretty hard to miss. I mean – so, the degree of interaction is much more than I’ve [doctor] had previously with hospital-based pharmacists. FG9
Suggestions for improvements
Focus group participants were asked to suggest improvements to the VCPS that would make it easier to use for patients, staff and the health service. Suggestions included having the VCPS available to more patients, for longer hours including weekends, and continuing to work on communication including maintaining investment in training and in-services for staff to improve knowledge and understanding of the VCPS (Figure 2).
Expansion
Focus group participants were asked about how the virtual pharmacy service could be improved. Access to the VCPS was limited to hospital inpatients Monday to Friday 8am to 4.30pm during the trial. Staff felt the service would also be beneficial for other patients attached to the facility such as residential aged care patients or those getting hospital services at home.
“I think if they were going to look for improvements, they would be looking at all patients, whether they're TACP [Transitional Aged Care Package] or subacute or acute for that matter”. FG3
Extending the hours of operation would also make the VCPS more accessible for Visiting Medical Officers who also work in their own general practices. General practitioners tended to conduct hospital rounds early in the morning and late in the evening as well as on weekends. This resulted in less synchronous communications with the pharmacist instead relying on the eMeds system and medical records to share information and recommendations without the opportunity to clarify via phone or video call.
“We’re contractors [Visiting Medical Officers]. We’re not employees. That’s the other thing. I felt we were treated like employees not contractors. We run - in solo rural practice I’ve got commitments - a lot of external commitments independent of the hospital” FG7
Communication and processes
Participants placed high value on relationships and trust they had with other service providers and with patients. Some local doctors had ongoing relationships with many patients outside the hospital and perceived their knowledge of patient’s history including community pharmacy support was not taken into account with the VCPS;
“There are community patients who are going to go back into the community and then be community patients again which I will then manage myself again. There was a lot of double handling in that [instance].” FG7
Nursing staff also noted that communication between doctors and pharmacists could be improved to ensure optimal patient care;
“I just find that me personally I have just run today from either the [virtual] pharmacist to the doctor, to the phone and back again.” FG11
Implementing new procedures invariably changes tasks and potentially impacts staff roles in different ways. Some staff described challenges during the start-up phase of the VCPS when they were not sure how to use the equipment including when and why to call the pharmacist. Because many staff in small hospitals work part time they had missed the initial information and education sessions about the VCPS or did not always get an opportunity to interact with the pharmacists if they worked weekends and nights most of the time;
“Well, I didn't do the education, so I don't know if it was covered but up until now it had never occurred to me that I could use a virtual pharmacist to get answers to questions about medication.” FG13
While processes were mostly perceived as user friendly and effective some focus groups suggested refining procedures and systems;
“But that is the helpline number which takes a lot of time. A direct number it will be a bit quicker.”FG3
Some participants suggested improving the timeliness of medication lists on discharge because of how quickly patients wanted to leave the hospital;
“It's nothing actually to do with the actual pharmacy per se it's just they [patients] just want to go home, and they're not being held up anymore. Take the cannula out, I'm going home” FG6
Equipment
Some staff perceived the task of taking the equipment to the patient’s bedside to be an administrative responsibility not a nursing one and described resenting the ‘interference” with their usual duties.
“So, it very much relies on the nursing staff on the ground to have to, you know, take the VC to the patient and talk to the doctor” FG 6.
However, without exception all focus groups reported these implementation challenges had been resolved or worked around although one group suggested making the Wallie [telehealth cart] easier to move would improve their experience of the VCPS.
System software
One group reported some ongoing difficulties with the electronic medical record and the eMeds system. Improvements in the software so that it was consistent across different wards (intensive care unit to emergency department/general wards) would make for a safer system. The work of the virtual pharmacist picked up errors between these systems but staff felt improvements in the systems would deliver benefits to the health service in terms of more efficient use of time and improvements to patient care.
“When their meds were charted the [admitting] doctor looked at the medication list but that was actually one from April. This was to do with a patient being in ICU [Intensive Care Unit] and when they're in ICU they're on a different software system. Like in the general ward they're on power chart and so that's how we find their medication through power chart. But when they're in ICU it's called something else. So, we actually don't have access to it. We can't even see it”FG6