Draft a memo outlining the readiness of the organization to implement the change strategy: SWOT analysis, discussion of challenges see attached, recommendation.

RESEARCH ARTICLE

The challenge of involving old patients with

polypharmacy in their medication during

hospitalization in a medical emergency

department: An ethnographic study

Pia Keinicke FabriciusID 1,2*, Ove Andersen1,2,3, Karina Dahl Steffensen4,5,6, Jeanette

Wassar KirkID 1,7

1 Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Copenhagen,

Denmark, 2 Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,

3 Emergency Department, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark, 4 Department of

Oncology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark, 5 Institute of

Regional Health Research, University of Southern Denmark, Odense, Denmark, 6 Center for Shared

Decision Making, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark,

7 Department of Public Health, Nursing, Aarhus University, Aarhus C, Denmark

* [email protected]

Abstract

Background

More than 70% of patients admitted to emergency departments (EDs) in Denmark are older

patients with multimorbidity and polypharmacy vulnerable to adverse events and poor out-

comes. Research suggests that patient involvement and shared decision-making (SDM)

could optimize the treatment of older patients with polypharmacy. The patients become

more aware of potential outcomes and, therefore, often tend to choose less medication.

However, implementing SDM in clinical practice is challenging if it does not fit into existing

workflows and healthcare systems.

Aim

The aim was to explore the determinants of patient involvement in decisions made in the ED

about the patient’s medication.

Methods

The design was a qualitative ethnographic study. We observed forty-eight multidisciplinary

healthcare professionals in two medical EDs focusing on medication processes and patient

involvement in medication. Based on field notes, we developed a semi-structured interview

guide. We conducted 20 semi-structured interviews with healthcare professionals to elabo-

rate on the findings. Data were analyzed with thematic analyses.

Findings

We found five themes (determinants) which affected patient involvement in decisions about

medicine in the ED: 1) blurred roles among multidisciplinary healthcare professionals, 2)

PLOS ONE

PLOS ONE | https://doi.org/10.1371/journal.pone.0261525 December 30, 2021 1 / 20

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OPEN ACCESS

Citation: Fabricius PK, Andersen O, Steffensen KD,

Kirk JW (2021) The challenge of involving old

patients with polypharmacy in their medication

during hospitalization in a medical emergency

department: An ethnographic study. PLoS ONE

16(12): e0261525. https://doi.org/10.1371/journal.

pone.0261525

Editor: Adam Todd, Newcastle University, UNITED

KINGDOM

Received: April 12, 2021

Accepted: December 3, 2021

Published: December 30, 2021

Peer Review History: PLOS recognizes the

benefits of transparency in the peer review

process; therefore, we enable the publication of

all of the content of peer review and author

responses alongside final, published articles. The

editorial history of this article is available here:

https://doi.org/10.1371/journal.pone.0261525

Copyright: © 2021 Fabricius et al. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: The data that support

the findings of this study contain potentially

identifying or sensitive information about

older patients with polypharmacy increase complexity, 3) time pressure, 4) faulty IT- sys-

tems, and 5) the medicine list as a missed enabler of patient involvement.

Conclusion

There are several barriers to patient involvement in decisions about medicine in the ED and

some facilitators. A tailored medication conversation guide based on the SDM methodology

combined with the patient’s printed medicine list and well-functioning IT- systems can func-

tion as a boundary object, ensuring the treatment is optimized and aligned with the patient’s

preferences and goals.

Introduction

Globally the prevalence of patients with polypharmacy is set to rise as the population ages and

more people suffer from multiple long-term conditions taking numerous medicines. Conse-

quently, it makes more people prone to drug-related events and frequently acute admissions in

emergency departments [1, 2]. More than 1,000,000 out of 1,300,000 yearly hospital admis-

sions in Denmark are acute admissions in emergency departments (EDs), and more than 70%

of these admissions are older patients (65 + years) with comorbidity conditions and polyphar-

macy [3, 4], defined as taking five or more medications [5]. We have earlier identified that the

use of potentially inappropriate use of medicine (so-called PIMS) in older patients (65 + years)

admitted to our ED was very common (a prevalence of 85%). Furthermore, the use of PIMS

was associated with low functional status and reduced health-related quality of life [6].

In recent years, there has been an increasing focus on dealing with patients with polyphar-

macy, as treatment is getting more and more complex [1]. This complexity is also seen inside hos-

pitals, where historically, the medication process has been a simple task performed mainly by

physicians and nurses [7], but in recent years, more healthcare professionals with different roles

and responsibilities for medication have been introduced into hospitals; e.g., pharmacists have

been introduced into ED departments to optimize rational use of medication, and ensure patient

safety [8]. Polypharmacy represents a global patient safety risk, but according to the World

Health Organization (WHO), patients can play a key role in the early detection of inappropriate

polypharmacy if they are involved and invited to tell more about their symptoms and side-effects

[1]. Inappropriate polypharmacy is defined as when medicines are no longer needed, cause

adverse drug reactions, or the patient is not willing or able to take medicines as intended [1].

Another problem with polypharmacy is that most clinical guidelines typically have a strong

focus on starting medication with limited guidance about not starting, reducing, or stopping

medication (known as deprescribing) [9]. Furthermore, most clinical guidelines do not offer

specific guidance to how “decisions” about medicine should be made with polymedicated

patients, reflecting the patient’s preferences, needs, and values to support patient involvement

optimally and shared decision making [10]. The term “Patient involvement” is often used

interchangeably and covers a diverse range of possibilities, emphases, models, and practices,

with Shared decision Making (SDM) being one of the leading concepts within [10]. SDM is

cited to be the pinnacle of patient-centered care [11] and is a specific approach where health-

care professionals and patients build a partnership, where the healthcare professionals share

the best available evidence, and the patients express their values and preferences and partici-

pate in decisions about their medical treatment [9]. Research shows that involving patients in

their care and listening to their views improves knowledge, decision outcomes, compliance

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healthcare professionals, managers and their

departments. The data are not publicly available

due to ethical restrictions. The research Data

Protection Agency of the Capital Region of

Denmark can be contacted for further requests:

E-mail: videnscenterfordataanmeldelser.

[email protected] or Phone: +45 35 45 52

11.

Funding: Ove Andersen received funding provided

by Velux Foundation grant number (00021736):

https://veluxfoundations.dk/da/forskning/

aldringsforskning. The funders had no role in the

study design, data collection and analysis, decision

to publish, or preparation of the manuscript.

Competing interests: The authors have declared

that no competing interests exist.

with treatments [12]. However, there is still a lack of solid studies investigating the impact of

patient involvement of older multimorbidity patients with polypharmacy.

Ideally, SDM with older polymedicated patients in the ED would be a process where the

older patients are “active” partners. The patient works in partnership with the healthcare pro-

fessionals about treatment choices. The healthcare professional presents different options

using risk communication, and the patient’s preferences are explored and supported, and deci-

sions about changes (or no changes) to the patient’s medicine are reached jointly [10].

Patient-centered healthcare and patient involvement is a quality goal in many countries’

healthcare policies, including Denmark’s [10, 13]. Nevertheless, the gap between healthcare

policy and routine clinical practice is persistent. Studies indicate that although there have been

some promising signs of improvement, patients do not always feel as involved in their treat-

ment as they would like to be, and patients do not always receive as much information about

their medicine as they would like to have [10].

The healthcare professionals’ attitude towards patient involvement is also cited as a barrier

while some healthcare professionals may have the assumptions that the older patients cannot

contribute to decisions about their medicine, or the healthcare professionals think that they

know their patient’s preferences already, so they do not need to ask the patient [14]. Addition-

ally, older patients may have different preferences for involvement, low health literacy, diffi-

culty hearing, or cognitive impairment, which makes it more challenging to become involved

in decisions about medicines [15].

Furthermore, several studies highlight the influence of contextual factors influencing the

implementation of patient involvement and SDM in routine practice, which could fail if it is

not implemented in a way that fits into existing workflows, organizations, and health systems

[16]. Although the general principles of SDM have been used partly by emergency physicians

ad hoc for decades, the systematic use and evaluation of SDM in the Emergency Department

(ED) still remains in its infancy [14]. Therefore the aim of this study was to explore the deter-

minants of patient involvement in decisions made in the ED about the patient’s medication.

Materials and methods

This study was the first in a program called OPTICARE. OPTICARE’s aim is to develop a

“Medication Conversation Guide” that uses an SDM methodology tailored to involve polyme-

dicated 75+-year-old patients in the ED in their medication (age 75 + year was put in place

due to the wording in the Velux Foundation, the fund achieved).

This study was a baseline study with the aim of exploring the determinants of patient

involvement in decisions about their medication before implementing SDM. Determinants

are defined as “Factors of practice which either prevent or enable improvements in profes-

sional healthcare practice” [17]. Because implementation studies recognize the importance of

culture and organizational context [18], we conducted an ethnographic study with a focus on

the healthcare professionals who treat patients in the specific context of the ED. We did not

expect to observe SDM in the ED as SDM has not yet, been implemented in our medical EDs.

We, therefore, focused on patient involvement, which is more broadly defined by Cribb [10]

as “active rather than passive patients.” When exploring patient involvement in decisions

about medicine in the ED, we focused on the patient’s active role in decisions about their med-

icine in the medical ED and determinants influencing this active involvement.

Study setting

The study was conducted at a university hospital in the capital region of Denmark, where the

healthcare system is publicly funded by taxes. The Danish welfare state provides free treatment

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for all citizens requiring medical care, as well as free hospital and home-based care services.

The acute medical patients are referred to the hospital either by the general practitioners

(GPs), emergency medical helplines, after-hours GP services, or ambulances.

The university hospital is divided into three different locations which each houses a medical

emergency department to cover the catchment area of 517,00 people. The context in this study

includes two of the medical emergency departments, which are named (Department X and

Department Y) (see Table 1).

The EDs have an average daily intake of approximately 30–45 patients with hospitalization

of up to 48 hours in the ED.

For over a decade, emergency services across Denmark have changed due to health policy

reforms with the implementation of new EDs (so-called Acute Medical Units) with the aim of

improving the quality and efficiency of emergency care [19]. The new EDs offer a single point

of hospital entry for all emergency care (except children and women in labor), 24/7 for effec-

tive emergency diagnostics and treatment with the continuous presence of skilled senior physi-

cians, which covers ED physicians and senior physicians from the medical specialties.

Several other countries as the UK, Australia, the Netherlands, Germany, and France, have

introduced similar reforms to secure safe and efficient pathways for patients in need of emer-

gency care [20].

The new Danish EDs treat patients for up to 48 hours before discharge to home or a spe-

cialty department. It is an overall goal that 70% of all acute patients are discharged directly

from the new ED without further hospitalization to a medical ward. This also includes the

acute admitted older patients with multimorbidity and polypharmacy.

As the new ED is expected to be implemented in 2023, this baseline study serves as explor-

ing new ways to improve the future patient pathways in the new EDs for older patients with

polypharmacy.

Since 2014, Department X has had clinical pharmacy technicians (in Denmark called pharma-

conomists) employed who are responsible for the administration of medication during dayshift.

The pharmaconomists hold a three-year degree and are comparable to most pharmacy technicians

in other countries [21]. In Denmark, pharmaconomists work at their own private pharmacies, and

in hospital pharmacies, where they often are responsible for the daily clinical management of

Table 1. Setting characteristics.

Setting: Department X

• Department X is one of the largest EDs in Denmark and is located in a hospital that is classified as an acute

hospital receiving critically ill patients into its Intensive Care Unit (ICU).

• The department has 29 beds.

• There are approximately 4–5 ED senior physicians.

• There are approximately 8–11 physicians are employed in one of the hospital’s medical specialty wards covering

shifts in the ED.

• There is a geriatric team with geriatric doctors and nurses.

• Pharmacists and pharmaconomists administer medication during the dayshift on weekdays.

Setting: Department Y

• Department Y is a smaller ED than X, and its location is not classified as an acute hospital and does not have an

ICU.

• The department has 19 beds.

• There are 2 ED senior physicians.

• 9 senior physicians are employed in one of the hospital’s medical specialty wards and cover shifts in the ED,

where they treat all hospitalized patients regardless of their medical specialty.

• Nurses manage medication with minor involvement from a pharmacist.

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medicine in the wards. Their work includes administering medicine to the hospitalized patients in

the ward. Like the pharmacy technicians in the UK, the pharmaconomists in Denmark practice

dispensing medicine without the supervision of a pharmacist. In September 2018, pharmacists

were introduced into the ED with the aim of supporting ED physicians with the implementation

of an e-health platform, which is used while the patient is hospitalized. When the patient is not hos-

pitalized, the prescribed medicine is registered in the patient’s Shared Medication Card (SMC),

which is housed in a central database that contains electronic data on all Danish citizens’ prescrip-

tions and medicine [22]. The Pharmacists and the geriatric physician do structured medication

reviews on a daily basis for selected older polymedicated patients in the ED.

Study design

The design was a qualitative ethnographic study [23] carried out in three steps. First, we con-

ducted field observations. Based on the observations, we developed a semi-structured inter-

view guide attached in the S1 File. Then, we conducted semi-structured interviews with

healthcare professionals [24] from both EDs. The study was structured according to the stan-

dards for reporting qualitative research (SRQR) [25].

Participants

Nonprobability purposeful sampling with maximum variation [26] resulted in the recruitment

of 48 different healthcare professionals (see Table 2) representing a broadly mixed multidisci-

plinary team who were observed for 58 days.

Data collection and analysis

Field observations

Initially, a field study was carried out in Department X from October 2018 to February 2019,

in which the researcher (P.F.) acted as a nonparticipant observer [23] for 33 days. Influenced

Table 2. Participant characteristics.

Data Department X (n) Department Y (n) Total (n)

Field observations

ED physicians 8 15 23

Nurses 7 7 14

Pharmacists 5 - 5

Pharmaconomists 5 - 5

Geriatric physicians 5 - 5

Secretaries 2 1 3

Geriatric nurses 2 - 2

Consulting physicians from the hospital’s medical specialties 1 - 1

Total 35 23 58

Semi structured interviews

ED physicians 4 4 8

Nurses 4 2 6

Pharmacists 1 - 1

Pharmaconomists 2 - 2

Geriatric physicians 1 - 1

Secretaries 1 - 1

Geriatric nurses 1 - 1

Total 14 6 20

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by J. Spradley’s participant observation approach [23], an observation guide was developed as

a broad, descriptive guide to observation to locate social situations in which medication prac-

tices occurred. The focus points were as follows: What is going on, and who is participating in

the medication process? What do people do and say about medication? Who makes decisions

regarding medication? What or who is involved in those decisions? What do the patients say

about medication? What role do patients or their relatives have? The observation approach

was in accordance with Spradley’s description of the “mini-tour,” as from the start, we had

chosen a narrow focus on medication practices [25] which during the field observations

became even more focused and selective. We chose Spradley’s participant observation

approach while Spradley is a classic within ethnographic fieldwork. Furthermore, Spradley

offers a structured stepwise approach to participant observations, which is helpful for ethnog-

raphers. Identical field studies were conducted by the same researcher in Department Y from

August 2019 to September 2019 for 23 days. In total, 48 different healthcare professionals were

followed in their daily work rounds for three hours on average. Researcher P.F. observed the

healthcare professionals for 58 days in 144 hours.

The healthcare professionals were followed during day and evening shifts. The recruitment

of participants was planned in advance with the managing nurses, who helped to locate partici-

pants according to our selection criteria. These criteria included participants from different

healthcare professions involved in the patient’s medicine and with the most diverse years of

clinical competencies to get as nuanced insight as possible of factors influencing patient

involvement in decisions about their medicine. From the start, we had the assumption that all

healthcare professionals in the ED (except the physiotherapists and secretaries) were involved

in the medication process and therefore were relevant informants who were included based on

their profession (ED physicians, geriatric physicians, consulting physicians from the medical

specialties, nurses, pharmacists, and pharmaconomists).

The observational approach was nonparticipatory [23]. Sometimes asking clarifying questions

in go-along interviews allow the healthcare professional to clarify what was going on and to

express reflexive aspects of their experience in situ. Detailed field notes were taken, documenting,

as close as possible, what was said and done by whom. Verbal and nonverbal reactions, e.g.,

bodily reactions, facial expressions, moods, and sounds, were documented on a paper block with

a pen. Immediately after the observation, the written field notes were further expanded in a word

document. Data from the field observations consist of 221 A4 pages of rich text material.

To capture the researcher’s thoughts and how her readings of other SDM studies affected

the ongoing investigation, the researcher’s thoughts were documented in a research diary [25]

which was frequently discussed with co-author J.K.

Interview guide

We developed a semi-structured interview guide [24] from an initial analysis of the field notes.

The overall aim of the interview guide was to let the healthcare professionals elaborate on their

perspective on the determinants of patient involvement in medication that had been identified

through the field observations. The interview guide was designed in collaboration with J.K.

Before the semi-structured interviews were carried out, the interview guide was pilot tested

for comprehensibility with two non-clinical colleagues. The pilot test resulted in minor

changes, e.g., how questions were worded before the interviews were carried out.

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Semi-structured interviews

To strengthen the plausibility and credibility of the findings, which is a validity criterion in

ethnographic research [25], semi-structured interviews were also conducted to test the

researcher’s interpretations of the field observations.

Twenty ED healthcare professionals were interviewed by the first author in January 2020.

The selection of respondents was based on two inclusion criteria. Ten healthcare professionals

who were followed during the field study and ten healthcare professionals who were not fol-

lowed were selected in order to achieve as much nuance in the perspectives as possible. The

interviews took place in a room closely connected to the two EDs and lasted from 25 to 45

minutes. Each interview was tape-recorded and later transcribed verbatim by P.F. (n = 7) and

three research secretaries (n = 13). In total, the data material consisted of 183 A4 pages.

Data analysis

A thematic analysis was carried out, which is a qualitative analytic method that offers reflexiv-

ity unconstrained by a pre-existing theoretical frame [27].

The analysis was carried out in two steps. The first author, P.F., read and reread the

field notes to become familiar with the material [25], The field notes were initially ana-

lyzed with an open, inductive, thematic approach [27]. Text pieces were coded and

recoded in an ongoing iterative interpretation process [29] using the software program

NVIVO 11 [28]. The coding process was frequently read and discussed with J.K. and later

discussed with the rest of the research team to ensure the credibility of the analysis [29].

The initial analysis of the field notes resulted in the themes that informed the questions in

the semi-structured interview guide. The themes’ primary focus was on the healthcare

professionals’ perspectives on barriers and facilitators (the determinants) of patient

involvement in decisions about medicine in the ED.

In the second step, the transcribed text from the interviews was initially coded and

merged deductively into the existing themes from the interview guide. See Table 3. Data

saturation was reached after 20 interviews, as no further issues were identified in the data

material [29]. During an iterative interpretation process with J.K., some themes were

merged while others were divided into new themes [29] as it became apparent that some

themes appeared to be more important for patient involvement in decisions about medi-

cation than others.

During the analysis and interpretation process, it became clear to us that medication (and

especially polypharmacy) crosses boundaries between different healthcare sectors, different

departments, medical specialists, and medication has similarities with the sociological theory

of boundary objects. Boundary objects has the ability to transmit knowledge and meaning

between different group of people [30, 31] and our results will be discussed through this theo-

retical lens in the discussion section.

Table 3. Analysis example from interview transcription to theme.

Interview Transskription Code Sub-theme Theme

“. . . but it’s obvious that there are two IT- systems that don’twork well together, and that theydonotworkwell together doesnot make the situation concerning the patient’smedicationany easier . . . if just . . . if just all ITworkedwell, and itwas possible to figure outwhat patients actually tookat home. Oftendifferentmedication is registered in the systems, and the larger the background issues, suchas ITand such, then focus is on those issues insteadof the patient.” (Interview, Pharmacist, Department X)

Poor integration between the e-health platform and

SMC took time and attention away from direct contact

between the physician and patient.

• Poorly integrated IT

systems lead to less patient

involvement

Faulty IT-

systems

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Ethical issues

The Danish Data Protection Agency (file number VD-2019-264) approved this study. Under

Danish law, no further formal approval from the Ethics Committee is necessary for studies

that do not involve biomedical issues. Written consent was obtained from the departmental

management of both EDs. Written and oral informed consent was also collected from the

healthcare professionals who were observed and interviewed. All participants were guaranteed

anonymity and the opportunity to withdraw their consent to the study at any time. With this,

our study complies with the World Medical Associations´ ethical principles for medical

research involving human subjects (The Declaration of Helsinki) [32]. In the field observa-

tions, P.F. acted in line with situational ethics, balancing intuition, sense, morality, and respon-

sibility [33], constantly judging if the researchers’ presence could violate the patient’s integrity.

Occasionally, P.F. judged a patient to be too vulnerable and in too severe a condition that it

would have been unethical to continue the observation. The researcher, P.F., has worked as a

nurse and consultant at the hospital for 20 years, which led to a position in which it was rela-

tively easy to obtain access and insights into the healthcare professionals’ thoughts on medica-

tion and patient involvement.

Results

The observations and interviews revealed that managing medication to- and communication

with the patients in the medical ED is a fragmented process involving various healthcare pro-

fessionals, medical specialties, time pressure, and faulty IT- systems, which influence patient

involvement in medication decisions and may impede medication optimization. Further, the

study revealed that the patients’ printed medicine list could facilitate more communication

about medicine and increase patient involvement in decisions about medicine in the ED if the

healthcare professionals were more aware of this opportunity.

We identified five themes (determinants) which affected patient involvement in decisions

about medicine in the ED:

1. Blurred roles among multidisciplinary healthcare professionals,

2. Older patients with polypharmacy increase complexity,

3. Time pressure,

4. Faulty IT- systems, and

5. The medicine list as a missed enabler of patient involvement.

Four of the themes identified issues that prevented patient involvement in decisions about

medication, while one of the themes identified a solution that could enable patient involve-

ment if healthcare professionals were aware of this opportunity. The five themes include eight

sub-themes illustrating how the themes influence patient involvement in decisions about med-

icine in the ED (See Table 4).

Theme 1: Blurred roles among multidisciplinary healthcare professionals

The observations and interviews revealed that managing medication in the ED is a fragmented

process that involves different healthcare professionals: physicians, pharmacists, pharmacono-

mists, and nurses with different competencies, which influenced patient involvement.

Unlike the physicians and nurses, the pharmacists and pharmaconomists were only focused

on medication, and according to the pharmacists and pharmaconomists themselves, they

therefore had the resources to help the physicians, who often had difficulty obtaining an

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overview of patient medication from the e-health platform and the Shared Medication Card

(SMC). In addition, the observations revealed that the pharmacists and the pharmaconomists

had found several faulty medication prescriptions that were corrected before medication was

administered.

One pharmaconomist stated:

"Weonly focuson themedicine. Wedonothave to findoutwhen they [thepatient]will be dischargedor if they shouldgo toanursinghomeor someoutpatient clinic." (Interview, Pharma- conomist, Department X).

Sub-theme: Invisible roles. In contrast, some professionals were not aware of their role in

the medication process, even though they often had significant roles in decisions about the

patient’s medicine. Several nurses and some medical secretaries stated that they had little to do

with the patients’ medication. However, the observations showed the opposite. The nurses had

frequent conversations with the patients about medicine, and often it was the nurses who

knew why a patient did not take their medicine as intended. The nurses passed on the informa-

tion to the physicians, who made the medication changes based on the information from the

nurses. Therefore, nurses often had a decisively significant influence in decisions about their

patient’s medication in the ED, even though many nurses were unaware of it.

Similarly, the observations revealed that the secretaries often had the time-consuming work

of following up on loose ends related to a medication when patients called the ward after

discharge.

One of the secretaries said: "Weare like intermediaries spendinga lot of timeon thingswe havenotbeen involved in earlier." (Observation, Secretary, Department X).

The interview revealed that the secretaries often had the task of follow-up communication

about medicine with patients calling the ED after discharge and were unaware of why their

medication had been changed. It happened quite often, according to the secretaries.

Sub-theme: Responsibility for polypharmacy. The physicians often preferred not to

evaluate a polymedicated patient’s usual medications as they did not always perceive that it

was their job but the patient’s GPs job. In these situations, very limited patient communication

about medicine was observed. Only when it was suspected that the medicine caused the

patient’s acute situation, the ED physicians had many questions to the patient about the medi-

cine. However, some ED physicians felt bad about not evaluating the patient’s polypharmacy,

and they were aware that some GPs expected the same as the physician responsible for treat-

ment in the acute care setting. One chief physician said:

Table 4. Themes and subthemes.

No. Themes Sub-themes

1. Blurred roles among multidisciplinary healthcare

professionals

• Invisible roles

• Responsibility for polypharmacy

2. Older patients with polypharmacy increased

complexity

• Trust

3. Time pressure • A revolving door

• Time-consuming communication

4. Faulty IT-systems • Poorly integrated IT systems lead to less patient

involvement

• Challenging discharge

5. The medicine list as a missed enabler of patient

involvement

• Inconsistently use of medicine lists

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"Unfortunately, that’s the culture. Everyone thinks that somebodyelse shoulddo it." (Obser- vation, Chief physician, Department Y).

During the observations, some pharmacists and pharmaconiomists raised the concern that

polymedicated patients are more frequently acute hospitalized than patients without polyphar-

macy. The pharmacists emphasized the possibility of a structured medication review with

patient involvement and SDM in the ED, for all, and not only a few older polymedicated

patients.

Nevertheless, the observations and the interviews revealed that the pharmacists, pharmaco-

nomists, nurses, physicians, and secretaries all had important roles in ensuring patient safety

and patient involvement in decisions about medication, even though there were different per-

spectives on their efforts and responsibilities for patient involvement in decisions about medi-

cine in the ED.

Theme 2: Older patients with polypharmacy increased complexity

The observations and interviews revealed that the complexity, fragmentation, and communi-

cation were exacerbated in older patients with polypharmacy. In addition, the observations

and the interviews revealed that older patients’ polypharmacy is challenging in the ED because

the’ medication registrations in the SMC could not be trusted, which complicated patient

involvement.

Sub-theme: Trust. Physicians had to take the patients’ SMC medication records at face

value, and most assumed that the patients took the medications as registered. However, the obser-

vations showed that very few older patients knew what was registered on their SMC, and often

the SMC had not been updated by the patient’s GP for a long time. This resulted in ambiguities

and complications in communication about medication, which was also time-consuming.

The ED physicians found themselves in a dilemma regarding whether they should rely on

the SMC or the older patients’ own account of their medication, and the observations showed

that there could be errors either way, as the older patients sometimes had a hard time remem-

bering their actual medicine. In the following situation, an older patient informed the physi-

cian that she was not given any medication, and when the physician subsequently read about

five fixed drugs in the SMC, the physician spontaneously said to P.F.:

"Look, andshe said shedidnot getanymedication!" (Observation, Physician, Department Y).

In the interview, a younger physician explained that he deliberately did not involve older

patients with polypharmacy in decisions about their medicine because he had experienced that

older patients often did not know about their medicine or did not care about it, and therefore

he did not try.

The observation revealed that the ED physicians were often reluctant to trust the older

patients’ accounts of their own medications, as the older patients were in an acute condition

when admitted to the ED. This acute situation affected how much dialogue and patient

involvement about medication was observed because many physicians were reluctant to

involve the older patients. One physician, before seeing a patient with polypharmacy for the

first time, exclaimed:

“What canyouexpect froman87-year-old?” (Observation, Physician, Department Y).

However, some physicians made a great effort to involve the older patients with polyphar-

macy at the physicians round. Sometimes it seemed to be a success, and there was dialogue,

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and the patient had an influence on decisions about which medicine should be deprescribed

before being discharged. The observations revealed that older polymedicated patients who were

active asking questions about their medicine seemed to have high health literacy were easier to

involve because they often involved themselves. This highlights that older patients have different

preconditions for involvement in decisions about their own medicine. To secure a good relation-

ship between the patient and the healthcare professional are the key to an agreement on shared

decisions about the patient’s medicine. When healthcare professionals choose not to involve

patients, they also deselect their patients’ possibility to optimize their own health.

Theme 3: Time pressure

Time constraints were a determinant that influenced patient involvement in decisions about

medication in the ED. Time can be understood as both physical time (clock time) and mental

time (the health professionals’ experience of time) [34]. The results have shown that both clock

time and mental time stressed the healthcare professionals, and lack of time was a constant

focus both in the observations and during the interviews.

Sub-theme: A revolving door. Several healthcare professionals explained that it was chal-

lenging to make time for medication conversations with patients in the ED due to the short

admission periods and the fast patient flow, which often meant that patients were discharged

or referred to other departments before decisions about the patients’ medication were dis-

cussed with or even communicated to the patient. For example, a pharmaconomist described

it this way:

"It’s likea revolvingdoor. Either thepatient leaves theEDor ismoved toanotherward. So, thepatientwill probablybe gonewhenyouget back if you leave theEDto talk toaphysician about themedication." (Interview, Pharmaconomist, Department X).

Sub-theme: Time consuming communication. Patient involvement includes more than

patient information. A young physician stated during the interview:

“Thephysiciansneed to encourage thepatient because thepatientswill not speakupunlesswe ask them." (Interview, young physician, Department Y).

However, it takes time to establish a dialogue, and the healthcare professionals had the

mental pressure that time was often not available because of the high patient flow. Therefore,

asking patients questions, which is essential for patient involvement, was seen as a challenge.

In the interviews, several healthcare professionals explained that they intentionally avoided

asking the patients questions, as it could be time-consuming. For example, a nurse explained

the dilemma: "There is alwayspressure to see thenextpatient, so if they talk toomuch, westart wishing for themto finishbecauseweknowthenextpatient is alreadywaiting." (Interview Nurse, Department X).

However, due to the healthcare professionals’ mental focus on lack of time, it seemed this

influenced the medication process and fragmented communication about medicine, which

resulted in less effort to involve the patients.

Theme 4: Faulty IT- systems

The observations revealed that the physicians spent noticeably more time on their computers

than with their patients, which fragmented the medication process and communication about

medicine and, hence patient involvement.

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Sub-theme: Poorly integrated IT systems lead to less patient involvement. Poor inte-

gration between the SMC and the e-health platform made it difficult to obtain an overview of

the patients’ medication. In the interviews, several healthcare professionals explained that

medication had become more complex and unmanageable after introducing the e-health plat-

form. A pharmacist explained:

“. . . but it’s obvious, that thereare two IT- systems thatdon’tworkwell together, and that theydonotworkwell togetherdoesnotmake the situation concerning thepatient’smedica- tionanyeasier . . . if just . . . if just all ITworkedwell, and itwaspossible to figureoutwhat patients actually tookathome. Oftendifferentmedication is registered in the systems, and the larger thebackground issues, suchas ITand such, . . . then focus is on those issues insteadof thepatient.” (Interview, Pharmacist, Department X).

This quote highlights how patient communication was often postponed due to IT issues in

the office, and the observations revealed that medication decisions were often made by the

physician in front of a computer before the patient was involved. This led to apparent frag-

mentation between medication decision-making and how patients were informed or involved

in their medications.

The observations showed cultural differences in the two wards regarding how quickly phy-

sicians left the office to talk to patients. In Department Y, the chief physician acted as a role

model and encouraged the other physicians to spend time with the patients rather than in

front of the computer. The observations showed that the chief physician did so himself. In con-

trast, no chief physicians were observed encouraging patient interaction in Department X dur-

ing the time of observation.

Sub-theme: Challenging discharge. The observations also showed that the challenges with

IT- systems were most evident at discharge when the physicians, after reviewing the medications,

should have re-entered the patient’s medication from the e-health platform back onto their SMC.

It was time-consuming, and physicians often expressed their frustration loudly. The physicians

did not understand why they could not re-enter the medicine and the patient’s usual medication

in the SMC as prescribed and registered in the SMC by the GP before admission. This problem

often made the physicians distinguish between medications concerning acute issues, which they

were responsible for, and medicines prescribed by GPs, which they would not interfere.

However, one nurse explained in the interview that the problems were partly caused by

themselves. They often forgot to decide the patient’s medications registered in the SMC at the

time of admission; thus, the problem was postponed to discharge. In addition, the nurse

explained that this was not an isolated event:

"Nobodymakesadecisionaboutmedicineanymore. Many just go fromSMCto the e-health platform." (Interview, Nurse, Department X).

This shows that decisions about the patients’ prior medications are not made at the time of

admission and are therefore disconnected from the decisions made about medication in the

ED, resulting in the patients risk of being discharged with a list of prescribed medications that

have not been evaluated as a whole.

Theme 5: The medicine list as a missed enabler of patient involvement

The observations showed that the patients’ medicine lists as registered in the SMC or on the e-

health platform were used inconsistently, but when they were used during ward rounds or dur-

ing discharge, it created more dialogue, thereby enabling patient involvement.

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Sub-theme: Inconsistently use of medicine lists

The physicians’ only way to use the medicine list in conversations with the patient was by

printing a copy of the medicine list. The interviews revealed that healthcare professionals val-

ued the printed medicine list differentially. It was sometimes unclear who was responsible for

printing and reviewing the medication list together with the patients. Several physicians stated

that it was the nurses’ or secretaries’ job to print the medication list from the e-health platform

and hand it to the patients at discharge. In contrast, several nurses believed this to be the physi-

cians’ responsibility.

Several physicians stated that they always printed the patient’s SMC medicine list at admis-

sion and used it in conversations with the patients. However, the observations showed that the

patients’ printed medication lists were rarely present during ward rounds. The observations

showed that in only a few cases did the physicians printed and used the e-health platform med-

ication list at discharge. A nurse said:

"I ask thephysician toprint it [medication list], but it oftenannoys them, and theydonot have theprinter login." (Observation, Nurse, Department X).

In this, the observation revealed that the responsibility for printing the patient’s medicine

list was also fragmented and shared between the ED physicians and the nurses.

The interviews revealed that healthcare professionals had different explanations for why the

medicine list was not used more frequently in medication conversations during ward rounds

and discharge. One reason was that medication prescriptions had become electronic and

paperless, so printing the patient’s medicine list was obsolete. In addition, the observations

showed that in contrast to the physicians, the pharmaconomists and nurses, when administer-

ing medications, frequently used a handheld rover (PDA) to show the patient a digital version

of the medicine list to involve the patient visually.

In the interviews, several healthcare professionals elaborated that the lists were not used

due to bad habits, a lack of attention, and a subculture in which healthcare professionals think

others should involve the patient and review the medicine list with them. Asked why the medi-

cation lists were not used more often, an experienced chief physician answered:

"I agree, but it is due tobusynessand someverybadhabits." (Interview, Physician, Depart- ment X).

Nevertheless, the observations showed that the few times a printed medicine list was used

to support medication conversations, the patient had several specific questions about the medi-

cations, resulting in more dialogue about medications, which is a prerequisite for patient

involvement.

Discussion

This study aimed to gain deeper insight into the determinants of patient involvement in deci-

sions made in the ED about the patient’s medication.

We found five themes (determinants) which affected patient involvement in decisions

about their medication in the ED, which might hinder medication optimization. The five

themes were: 1) blurred roles among multidisciplinary healthcare professionals, 2) older

patients with polypharmacy increased complexity, 3) time pressure, 4) Faulty IT- systems, and

5) the medicine list as a missed enabler of patient involvement. In addition, four of the themes

identified issues that were a barrier to patient involvement. In contrast, one of the themes, the

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medicine list, identified a solution that could enable patient involvement if healthcare profes-

sionals were aware of this opportunity.

Other studies have also found that treating multimorbidity patients with polypharmacy is

fragmented and influences patient involvement. Sinnott et al. [35] found that care provided by

several medical specialists in the treatment of multimorbidity patients, compounded by poor

coordination and communication within the health service and with the GP, was a challenge

for patient-centered care and SDM. An Australian study [36] also found poorly defined indi-

vidual responsibility and challenges with coordinating the treatment of older multimorbid

patients with polypharmacy in community dwellings. As in our study, poorly defined respon-

sibilities and challenges to coordination contributed to the avoidance of ownership for older

patient’s polypharmacy among healthcare professionals. The Australian study suggested dele-

gating coordination and review responsibilities across healthcare sectors to care coordinators,

which could be useful in improving overall care [36]. This highlights the fact that involving

older patients with multimorbidity and polypharmacy in their medical treatment is not only a

challenge in EDs but also for GPs and in communities.

One of our main findings was the perceived lack of time for patient involvement in medica-

tion in the ED. Légaré et al. [37] similarly found that time constraints, in general, are amongst

the most frequently cited barrier to implementing SDM in clinical practice. However, one

study found that the length of consultations varied from 8 minutes less to 23 minutes more

(with a median of 2.5 minutes more) when the consultation was supported by a patient deci-

sion aid to facilitate SDM. This highlights the need for more research investigating whether

patient involvement and SDM consumes significant amounts of time or less time [37] in the

ED.

Probst et al. [14] also found that time is a core determinant of practicing SDM in the ED.

The authors highlight that SDM should only be employed when time allows it, when the medi-

cal situation is nonurgent, and when there is no risk of poor patient outcomes due to the time

taken to practice SDM. As our results revealed, the lack of physical (clock) time can make it

more difficult for the healthcare professionals in the ED to find mental capacity to involve

older polymedicated patients in decisions about their medicine if the patients are perceived

challenging to involve, in the first place.

The medication process and medication conversations can be understood as “boundary

objects” [30, 31]. According to the literature, a successful boundary object is able to transmit

meaning between groups and provide a shared language to enhance knowledge [31]. The con-

cept of “boundary objects” shares similarities with SDM and the aim of the medication conver-

sation guide we plan to develop in a future study. The medication conversation guide aim to

facilitate the sharing of information between patients and medical experts and the sharing of

that information with other healthcare services, thereby contributing to the assurance of

patient safety and patient involvement in medication, and hence medicine optimization. Our

SDM medication communication guide, therefore, may have the potential to become a suc-

cessful boundary object if it is well tailored to the ED context.

We did find one enabler for patient involvement in medication, which could also be charac-

terized as a boundary object, e.g., the patients’ printed medication list. When the printed medi-

cation list was actively used during medication conversations with the patient, we observed

more dialogue between the patient and the healthcare professional than when the list was not

used. We ascribe this dialogue to the use of the printed medication list. Unfortunately, the

medication list was used sparingly and was often not updated by the patient’s GP, which often

caused even more confusion about the patient’s medication even when the printed medication

list was used.

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Garfield et al. [38] also noted how the medication list has the ability to facilitate and change

the way in which information about medicine was shared between patients and professionals.

However, the study found significant barriers to the use of the medication list because patients

did not understand the usefulness of the list. Professionals either lacked access to an accurate

list or assumed that they had a good list, believing that different healthcare IT- systems com-

municated with each other, which—as in our findings—was not always the case.

Victoria Reay [39] highlights the so-called “productivity paradox”, which had been a conse-

quence of the digitalization of healthcare in the National Healthcare System (NHS) in the UK.

It has led to workarounds, both within the computer systems and alongside them. Doctors are

complaining about spending more time entering data than being with their patients [39]. Simi-

lar to results from our study, the physicians also spend a lot of time on faulty IT systems

instead of having direct patient interactions indicating that if IT- systems in healthcare do not

support clinical workarounds, it will become a barrier, rather than a facilitator for patient

involvement.

We found that older multimorbidity patients with polypharmacy represent a substantial

challenge in the ED. No one takes full responsibility for the patient’s polypharmacy. The

patients’ medications were not accurately updated in the SMC, and the patients’ medications

became more confused as medication was added in the ED. This uncertainty about patients’

medication made several ED physicians refrain from reviewing the patients’ SMC medications

and defer that review to the GP without involving the patient in this decision. This can be seen

as a dilemma for ED physicians. According to the physicians’ pledge, they have committed to

“practice with conscience and dignity and following good medical practice” [40].

Patient-centered healthcare builds on the ideology that patients should become active part-

ners in healthcare [41]. Furthermore, healthcare policies demand that healthcare professionals

involve patients in their medical treatment [10, 42]. Therefore, it is essential for our society

(and patients) that vulnerable patients with multimorbidity and polypharmacy be empowered

to better care for themselves. However, at the same time, Ecks’ recent study has shown that

socioeconomic hardship and inequality make it more difficult for people from disadvantaged

backgrounds to engage actively in treatment decision-making [43]. The importance of social

inequality in multimorbidity is emphasized further in Barrett et al.‘s study on multimorbidity,

which reveals that the onset of multimorbidity occurs ten to fifteen years earlier in socially

deprived areas, calling into question the existing single disease treatment approach in health-

care [44].

Nonetheless, a systematic review and meta-analysis indicate that SDM can improve out-

comes considerably for disadvantaged patients. SDM has shown to enhance patients’ knowl-

edge and involvement in decision-making, reduce uncertainty about the course of action, and

raise patients’ decision self-efficacy [12]. As a result, it is argued that SDM has the potential to

reduce health disparities significantly. Durand et al. [12] emphasize, however, the critical sig-

nificance of tailoring design and content to the need of disadvantaged individuals if the poten-

tial of SDM is to be achieved.

Implementing patient involvement and SDM in everyday clinical practice is challenging if

it is not applied to fit well into existing workflows and organizational systems [45]. Other SDM

studies have found that culture is one of the most frequent barriers to SDM implementation

[46]. According to Spradley, most ethnographers make use of what people say when trying to

describe a culture. However, Spradley focuses more on making inferences from what people

do (cultural behavior) and what they make and use (cultural artifacts), and the meaning they

ascribe to these artifacts [23]. From our perspective, Spradley’s methodology has been helpful

for our study, as it has made it clear to us that artifacts—such as poorly integrated medication

IT- systems and a lack of updated medicine lists—influence the culture surrounding patient

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involvement in medication in the ED. As a result, our findings contribute to existing SDM

research by looking beyond the direct interactions between patients and healthcare profession-

als and what people say about this and by highlighting the importance of exploring contextual

and organizational aspects before introducing SDM in clinical practice, as these aspects may

be strong determinants of patients’ and healthcare professionals’ ability to practice patient

involvement in a specific context.

Furthermore, an updated review from the International Patient Decision Aid Standard col-

laboration (IPDAS) [47] investigated what works when implementing patient decision aids in

routine clinical settings. The review found that patient decision aids are less likely to be used in

typically crisis-driven teams or deal with life-threatening issues. The ED settings in our study

often treat life-threatening conditions when the patient is admitted, but patients’ conditions

often stabilize within 24–48 hours after initial treatment, creating an opportunity for medica-

tion conversations with the patient. Additionally, it should be noted that 70% of all patients

admitted to the EDs in our study was expected to be discharged directly from the ED, making

this the best opportunity for medical conversations with the patient while hospitalized. Fur-

thermore, our results revealed that the nurses and secretaries had essential but often invisible

roles in the medication process even though the observations and interviews revealed that they

often had much patient communication about medicine, and the nurses influenced the final

decisions about the patient’s medicine. Olling et al. [48] have in similar to our findings, found

that oncology nurses play a crucial role in SDM as they support the patients’ basic needs and

help them navigate key decisions points as decision coaches, even though their work often is

“invisible” [48]. If nurses and the health care team were more aware of–and thought to

increase nurse’s role in SDM, patient care would become more patient-centered [48]. This

could also be relevant for the ED nurses and secretaries in the ED. Yet, it is relevant to explore

if it is possible and reasonable to practice patient involvement and SDM with older patients

with polypharmacy in the ED context and herby fulfil the healthcare policy goals of patient-

centered healthcare.

Methodological strength and limitations

This present study has several strengths and limitations. We have used the Standards for

Reporting Qualitative Research (SRQR) [25], which we believe strengthens the validity and

transparency of our ethnographic qualitative study. Our ethnographic approach is a strength.

It enabled us to investigate how patient involvement in medication in the ED cannot be seen

as an isolated phenomenon but is closely interrelated with context, healthcare technologies,

and organizational pathways [23]. A large part of culture consists of tacit knowledge, which is

most prominent in people’s actions and not always visible in interviews. Therefore, combining

field observations with semi-structured interviews with the healthcare professionals involved

in medication processes in the ED is a strength [49]. Another strength is that the ethnographic

fieldwork was performed by the same researcher, P.F., in two different ED settings with similar

patient populations, which increases the generalizability of our findings, as it was possible to

contrast the influence of local culture and influential key persons with more general findings

[26]. This may have strengthened the transferability of our study results [50] to other ED

settings.

There are also limitations. The purposeful sampling strategy [26] of the following healthcare

professionals might have made the medication process appear more fragmented than it would

have occurred had we chosen to instead follow a patient over time. On the other hand, our

results provide insights into how fragmented and stressful managing medication can be for

healthcare professionals in the ED. Furthermore, when performing ethnographic studies in a

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hospital setting, the researcher can follow the healthcare professionals, the patients, or the visi-

tors [51]. Most researchers choose to follow the staff (as we did)—a position that is well known

to P.F., who has a professional background as a nurse. P.F.’s background may be a strength,

but it may also be a limitation, as it may have shaped the focus on and the interpretations of

specific themes, which another researcher may not have prioritized. To enhance the trustwor-

thiness of our analysis, P.F. and J.K. frequently discussed the coding process and ethical issues

to align interpretations of the data.

Furthermore, it might be a limitation that our ethnographic focus was mainly on the health-

care professionals and the context in which they work without focusing (much) on interactions

with patients. However, patients are essential coproducers of patient involvement and influ-

ence how much (or little) involvement occurs, which may also have influenced our results.

Therefore, the patient perspective will be explored in our following study.

Conclusion

We found five themes (determinants) which affected patient involvement in decisions about

their medication in the ED, which may hinder the patient’s medication optimization. Four of

the themes identified issues that prevented patient involvement. In contrast, one of the themes,

the medicine list, identified a solution that could enable patient involvement if the healthcare

professionals in the ED were aware of this opportunity.

A tailored medication conversation guide based on the SDM methodology may potentially

function as a boundary object, supporting older polymedicated patients and healthcare profes-

sionals during medication reviews in the ED and across healthcare sectors to ensure that older

patients receive medication aligned with their preferences and goals.

Supporting information

S1 File.

(DOC)

Acknowledgments

The authors would like to thank the management of both EDs for providing us with the oppor-

tunity to conduct field studies in their departments and to conduct interviews. We also thank

all the healthcare professionals from both EDs for letting P.F. participate in their daily work.

Author Contributions

Data curation: Pia Keinicke Fabricius.

Formal analysis: Pia Keinicke Fabricius, Jeanette Wassar Kirk.

Funding acquisition: Pia Keinicke Fabricius, Ove Andersen, Jeanette Wassar Kirk.

Investigation: Pia Keinicke Fabricius.

Methodology: Pia Keinicke Fabricius, Jeanette Wassar Kirk.

Supervision: Ove Andersen, Karina Dahl Steffensen, Jeanette Wassar Kirk.

Validation: Jeanette Wassar Kirk.

Writing – original draft: Pia Keinicke Fabricius, Ove Andersen, Karina Dahl Steffensen, Jean-

ette Wassar Kirk.

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Writing – review & editing: Pia Keinicke Fabricius, Ove Andersen, Karina Dahl Steffensen,

Jeanette Wassar Kirk.

References 1. World Health Organisation. Medication Safety in Polypharmacy. Geneva: World Health Organization;

2019.

2. Ayalew MB, Tegegn HG, Abdela OA. Drug Related Hospital Admissions; A Systematic Review of the

Recent Literatures. Bull Emerg Trauma. 2019; 7: 339–346. https://doi.org/10.29252/beat-070401

PMID: 31857995

3. Schiøtz ML, Stockmarr A, Høst D, Glümer C, Frølich A. Social disparities in the prevalence of multimor- bidity–A register-based population study. BMC Public Health. 2017; 17: 422. https://doi.org/10.1186/

s12889-017-4314-8 PMID: 28486983

4. Frølich A, Ghith N, Schiøtz M, Jacobsen R, Stockmarr A. Multimorbidity, healthcare utilization and socioeconomic status: A register-based study in Denmark. PLOS ONE. 2019; 14: e0214183. https://

doi.org/10.1371/journal.pone.0214183 PMID: 31369580

5. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of

definitions. BMC Geriatr. 2017; 17: 230. https://doi.org/10.1186/s12877-017-0621-2 PMID: 29017448

6. Jensen LD, Andersen O, Hallin M, Petersen J. Potentially inappropriate medication related to weakness

in older acute medical patients. International Journal of Clinical Pharmacy. 2014; 36: 570–580. https://

doi.org/10.1007/s11096-014-9940-y PMID: 24723261

7. Aarts J. The Social Act of Electronic Medication Prescribing. Stud HealthTechnol Inform. 2013: 327–

331. PMID: 23388308

8. Cohen V. Safe and effective medication use in the emergency department. Bethesda, MD: American

Society of Health-System Pharmacists, 2014; ISBN: 1585283754, 9781585283750

9. Jansen J, Naganathan V, Carter SM, McLachlan AJ, Nickel B, Irwig L, et al. Too much medicine in older

people? Deprescribing through shared decision making. BMJ. 2016; 353: https://doi.org/10.1136/bmj.

i2893 PMID: 27260319

10. Cribb PA. Involvement, Shared Decision-Making and Medicines. Royal Pharmaceutical Society: Cen-

tre for Public Policy Research King’s College London; 2011 p. 60. Available: www.rpharms.com.

Assessed 25 of nov. 2021.

11. Barry MJ, Edgman-Levitan S. Shared Decision Making—The Pinnacle of Patient-Centered Care. N

Engl J Med. 2012; 366: 780–781. https://doi.org/10.1056/NEJMp1109283 PMID: 22375967

12. Durand M-A, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, et al. Do Interventions Designed to Sup-

port Shared Decision- Making Reduce Health Inequalities? A Systematic Review and Meta-Analysis.

PLOS ONE. 2014; 9: 13. https://doi.org/10.1371/journal.pone.0094670 PMID: 24736389

13. Dahl Steffensen K, Hjelholt Baker V, Vinter MM. Implementing shared decision making in Denmark:

First steps and future focus areas. Z Evid Fortbild Qual Gesundhwes. 2017; 123–124: 36–40. https://

doi.org/10.1016/j.zefq.2017.05.005 PMID: 28529123

14. Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, et al. Shared Decision-

making in the Emergency Department: A Guiding Framework for Clinicians. Ann Emerg Med. 2017; 70:

688–695. https://doi.org/10.1016/j.annemergmed.2017.03.063 PMID: 28559034

15. Belcher VN, Fried TR, Agostini JV, Tinetti ME. Views of Older Adults on Patient Participation in Medica-

tion-related Decision Making. J Gen Intern Med. 2006; 21: 298–303. https://doi.org/10.1111/j.1525-

1497.2006.00329.x PMID: 16686804

16. Scholl I, LaRussa A, Hahlweg P, Kobrin S, Elwyn G. Organizational- and system-level characteristics

that influence implementation of shared decision-making and strategies to address them—a scoping

review. Implementation Sci. 2018; 13: 40. https://doi.org/10.1186/s13012-018-0731-z PMID: 29523167

17. Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for iden-

tifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of

factors that prevent or enable improvements in healthcare professional practice. Implementation Sci-

ence. 2013; 8: 35. https://doi.org/10.1186/1748-5908-8-35 PMID: 23522377

18. Kirk JW, Haines ER. Ethnography. Handbook on Implementation Science. UK & Massachusetts USA:

Edward Elgar Publishing,; 2020. pp. 480–486.

19. Danmark, Sundhedsstyrelsen. Styrket akutberedskab: planlægningsgrundlag for det regionale sund-

hedsvæsen. Sundhedsstyrelsen; 2007. Downloaded from the Danish Health Authority. https://www.sst.

dk/da/udgivelser/2007/styrket-akutberedskab—planlaegningsgrundlag-for-det-regionale-

sundhedsvaesen, (in Danish) nov. 2021

PLOS ONE Determinants of patient involvement in medication in the context of an emergency department

PLOS ONE | https://doi.org/10.1371/journal.pone.0261525 December 30, 2021 18 / 20

20. Baier N, Geissler A, Bech M, Bernstein D, Cowling TE, Jackson T, et al. Emergency and urgent care

systems in Australia, Denmark, England, France, Germany and the Netherlands–Analyzing organiza-

tion, payment and reforms. Health Policy. 2019; 123: 1–10. https://doi.org/10.1016/j.healthpol.2018.11.

001 PMID: 30503764

21. European Association of Pharmacy Technicians. Community Pharmacy Technicians—European Sur-

vey. 2017. In: PHARMACY TECHNICIANS ACROSS EUROPE [Internet]. [cited 23 Jul 2021]. Avail-

able: https://www.eapt.info/resources/PDF-Downloads/EAPT-European-Survey-(2017)-Community-

Pharmacy-Technicians-(1).pdf

22. The Danish health Data Authority. Shared Medication Card (in danish Fælles Medicin Kort). Available:

https://sundhedsdatastyrelsen.dk/da/registre-og-services/om-faelles-medicinkort/fmk-

sundhedsprofessionelle. Accessed nov. 2021

23. Spradley JP. Participant Observation. Waveland Press; 2016.

24. Kvale S, Brinkmann S. Interview: introduktion til et håndværk. 2nd ed. Kbh.: Hans Reitzel; 2009. In danish

25. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research:

A Synthesis of Recommendations. Academic Medicine. 2014; 89: 1245–1251. https://doi.org/10.1097/

acm.0000000000000388 PMID: 24979285

26. Green J, Thorogood N. Qualitative Methods for Health Research. SAGE; 2018.

27. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;

3: 77–101. https://doi.org/10.1191/1478088706qp063oa

28. Qualitative Data Analysis Software | NVivo. [cited 22 Jun 2020]. Available: https://www.qsrinternational.

com/nvivo-qualitative-data-analysis-software/home

29. Guest G, Bunce A, Johnson L. How Many Interviews Are Enough?: An Experiment with Data Saturation

and Variability. Field Methods. 2006; 18: 59–82. https://doi.org/10.1177%2F1525822X05279903

30. Star SL, Griesemer JR. Institutional Ecology, “Translations” and Boundary Objects: Amateurs and Pro-

fessionals in Berkeley’s Museum of Vertebrate Zoology, 1907–39. Social Studies of Science. 1989; 19:

387–420. https://doi.org/10.1177%2F030631289019003001

31. Fox NJ. Boundary Objects, Social Meanings and the Success of New Technologies. Sociology. 2011;

45: 70–85. https://doi.org/10.1177%2F0038038510387196

32. World Medical Association Declaration of Helsinki: ethical principles for medical research involving

human subjects. JAMA. 2013; 310: 2191–4. https://doi.org/10.1001/jama.2013.281053 PMID:

24141714

33. Tjørnhøj-Thomsen T. Togetherness. Creation in time and space. 1. edition. In: Hastrup K, editor. Into the world: a primer in anthropological method (In Danish). 1. edition. Copenhagen: Hans Reitzel; 2003.

34. Berg Olsen J-K. Temporalitet og realisme. Norsk Filosofisk Tidsskrift. 2001; 36. (in Danish)

35. Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs’ perspectives on the management of patients with

multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013; 3: e003610.

http://dx.doi.org/10.1136/bmjopen-2013-003610 PMID: 24038011

36. Mc Namara KP, Breken BD, Alzubaidi HT, Bell JS, Dunbar JA, Walker C, et al. Health professional per-

spectives on the management of multimorbidity and polypharmacy for older patients in Australia. Age

Ageing. 2016; ageing;afw200v2. https://doi.org/10.1093/ageing/afw200

37. Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient Education and

Counseling. 2014; 96: 281–286. https://doi.org/10.1016/j.pec.2014.06.014 PMID: 25034637

38. Garfield S, Furniss D, Husson F, Etkind M, Williams M, Norton J, et al. How can patient-held lists of

medication enhance patient safety? A mixed-methods study with a focus on user experience. BMJ Qual

Saf. 2020; 29: 764–773. https://doi.org/10.1136/bmjqs-2019-010194 PMID: 31949006

39. Reay V. Why we won’t have a paperless NHS anytime soon. In: https://theconversation.com/profiles/

victoria-reay-473691/articles [Internet]. 16 May 2018 [cited 23 Jul 2021]. Available: https://

theconversation.com/profiles/victoria-reay-473691/articles

40. The World Medical Association. The Physician’s Pledge. In: WMA- The World Medical Association-

WMA Declaration of Geneva [Internet]. 2018 [cited 11 Feb 2021]. Available: https://www.wma.net/

policies-post/wma-declaration-of-geneva/

41. Coulter A. Engaging patients in healthcare. Maidenhead, Berkshire, England: McGraw Hill/Open Uni-

versity Press; 2011.

42. Person-centred care made simple | The Health Foundation. [cited 3 Jan 2021]. Available: https://www.

health.org.uk/publications/person-centred-care-made-simple

43. Ecks S. Depression, Deprivation, and Dysbiosis: Polyiatrogenesis in Multiple Chronic Illnesses. Cult

Med Psychiatry. 2021 [cited 17 Jun 2021]. https://doi.org/10.1007/s11013-020-09699-x

PLOS ONE Determinants of patient involvement in medication in the context of an emergency department

PLOS ONE | https://doi.org/10.1371/journal.pone.0261525 December 30, 2021 19 / 20

44. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and

implications for health care, research, and medical education: a cross-sectional study. The Lancet.

2012; 380: 37–43. https://doi.org/10.1016/s0140-6736(12)60240-2

45. Gravel K, Légaré F, Graham ID. Barriers and facilitators to implementing shared decision-making in

clinical practice: a systematic review of health professionals’ perceptions. Implementation Science.

2006; 1. https://doi.org/10.1186/1748-5908-1-16 PMID: 16899124

46. Frosch DL, Tietbohl C, Scholl I. Overcoming implementation challenges to advance shared decision

making in routine practice. In: Elwyn G, Edwards A, Thompson R, editors. Shared Decision Making in

Health Care: Achieving evidence-based patient choice. Oxford University Press; 2016.

47. Joseph-Williams N, Abhyankar P, Boland L, Bravo P, Brenner AT, Brodney S, et al. What Works in

Implementing Patient Decision Aids in Routine Clinical Settings? A Rapid Realist Review and Update

from the International Patient Decision Aid Standards Collaboration. Med Decis Making. 2020;

0272989X20978208. https://doi.org/10.1177/0272989X20978208 PMID: 33319621

48. Olling K, Steffensen KD, Berry L, Stacey D. The Invisible Roles of Oncology Nurses in Shared Decision

Making. Cancer Care Research Online. 2021; 1: e0007. https://doi.org/10.1097/CR9.

0000000000000007

49. Justesen L, Mik-Meyer N. Qualitative methods in organizational-and management studies (in Danish).

1. udgave. Kbh.: Hans Reitzel; 2010.

50. Malterud K. Qualitative research: standards, challenges, and guidelines. The Lancet. 2001; 358: 483–

488. https://doi.org/10.1016/s0140-6736(01)05627-6

51. van der Geest S, Finkler K. Hospital ethnography: introduction. Social Science & Medicine. 2004; 59:

1995–2001. https://doi.org/10.1016/j.socscimed.2004.03.004 PMID: 15351467

PLOS ONE Determinants of patient involvement in medication in the context of an emergency department

PLOS ONE | https://doi.org/10.1371/journal.pone.0261525 December 30, 2021 20 / 20

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