Person-centred interactions between nurses and patients duringmedication activities in an acute hospital setting:Qualitative observation and interview study

Danielle Bolster a,*, Elizabeth Manias b

a The Alfred Hospital, Melbourne 3181, Australiab The University of Melbourne, School of Nursing and Social Work, Australia

International Journal of Nursing Studies 47 (2010) 154–165

A R T I C L E I N F O

Article history:

Received 14 February 2009

Received in revised form 24 May 2009

Accepted 31 May 2009

Keywords:

Medication management

Nursing interactions

Observational study

Person-centred care

A B S T R A C T

Background: There is increasing emphasis on person-centred care within the literature and

the health care context. It is suggested that a person-centred approach to medication

activities has the potential to improve patient experiences and outcomes.

Objectives: This study set out to examine how nurses and patients interact with each other

during medication activities in an acute care environment with an underlying philosophy

of person-centred care.

Design: A qualitative approach was used comprising naturalistic observation and semi-

structured interviews.

Setting: The study setting was an acute care ward with a collaboratively developed

philosophy of person-centre care, in an Australian metropolitan hospital.

Participants: Eleven nurses of varying levels of experience were recruited to participate in

observations and interviews. Nurses were eligible to participate if they were employed on

the study ward in a role that incorporated direct patient care, including medication

activities. A stratified sampling technique ensured that nurses with a range of years of

clinical experience were represented. Patients who were being cared for by participating

nurses during the observation period were recruited to participate unless they met the

following exclusion criteria: those less than 18 years of age, non-English speaking patients,

and those who were unable to give informed consent. Twenty-five patients were observed

and 16 of those agreed to be interviewed.

Results: The results of the study generated insights into the nature of interactions between

nurses and patients where person-centred care is the underlying philosophy of care. Three

major themes emerged from the findings: provision of individualised care, patient

participation and contextual barriers to providing person-centred care. While the

participating nurses valued a person-centred approach and perceived that they were

conducting medication activities in a person-centred way, some nurse–patient interac-

tions during medication activities were centred on routines rather than individualised

patient assessment and management. These interactions were based on nurses’

perceptions of what was important for the patient and did not provide opportunities

for patient participation. Two main contextual barriers in relation to a person-centred

approach to medication activities were identified as multidisciplinary communication and

time constraints.

Conclusions: While some nurse–patient interactions during medication activities were

consistent with the principles of person-centred care, the study results highlighted factors

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

* Corresponding author. Tel.: +61 3 90763399.

E-mail address: d.bolster@alfred.org.au (D. Bolster).

0020-7489/$ – see front matter . Crown Copyright � 2009 Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijnurstu.2009.05.021

that influence the nature of these interactions, and identified opportunities to improve

nursing practice. To ensure person-centred care is applied to medication activities, nurses

should undertake ongoing assessment of patients’ needs in relation to their medications

and encourage opportunities for increased patient participation.

Crown Copyright � 2009 Published by Elsevier Ltd. All rights reserved.

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165 155

What is already known about the topic?

� A

person-centred approach to health care delivery iseffective and efficient, and leads to improved patientoutcomes. � N urses’ interactions with patients during medication

activities are often not based upon assessment ofindividual patient requirements and can be determinedby task-orientated routines.

� P ast research has shown that nurses’ interactions with

patients during medication activities in communitymental health and rehabilitation settings with a philo-sophy of person-centred care are individualised anddriven by patients needs and preferences.

What this paper adds

� S

ome interactions between nurses and patients duringmedication activities in an acute care setting with aphilosophy of person-centred care are individualised andprovide opportunities for patient participation. � S ome nursing interventions remain centred on routine,

and the nurses’ perception of what is important for thepatient, despite a philosophy of person-centred care.

� M ultidisciplinary communication and the demands of

the clinical context provide challenges for nurses inrelation to providing person-centred care.

1. Introduction

The provision of person-centred care is commonlyregarded as a crucial component of delivering high qualityhealth care, and features prominently in the literature andphilosophy statements of health care organisations (Coyleand Williams, 2001; Mead and Bower, 2000; Sheard, 2004).An emergent focus on a person-centred approach hasoccurred as a result of the increasing emphasis onimproving processes and outcomes of care- and a growingawareness of consumer rights and expectations (Dawood,2005; McCormack, 2003; Manley, 2004). A person-centredapproach to health care delivery is purported to beeffective and efficient, and result in improved patientoutcomes (Holman and Lorig, 2000).

Despite the emphasis on person-centred care andclaims that it leads to improvements in patient experienceand outcomes, there are multiple interpretations ofperson-centred care across nursing and other health caredisciplines (Cahill, 1996; Lutz and Bowers, 2000). How-ever, within the varying definitions and conceptual views,key attributes of person-centred care can be identified andare intrinsically linked: the existence of a therapeuticrelationship between nurses and patients, the provision ofindividualised care and evidence of patient participation

(Cahill, 1996; McCormack and Titchen, 2001; Redman andLynn, 2004). The person-centred nursing frameworkdeveloped by McCormack and McCance (2006) emphasisesthe importance of these key factors being underpinned bythe nurses’ understanding of the patients’ beliefs andvalues. In addition, the person-centred nursing frameworkarticulates the attributes and skills of nurses and thecharacteristics of the care environment that are required inorder to achieve person-centred processes. The complexityof providing person-centred care is highlighted, thussupporting the view that establishing and maintaining aperson-centred approach across an organisation or in aclinical unit is complex and challenging. Some authorsassert that very few services can truly claim to deliverperson-centred care (Baker et al., 2003; Lutz and Bowers,2000).

Medication activities provide an opportunity to exam-ine nursing practice for evidence of a person-centredapproach, due to the high level of interactions occurringbetween nurses and patients during these activities.Medication administration and education are aspects ofpatient care that are performed by nurses and mostpatients have some form of medication administered tothem by a nurse during a hospital admission (Osborneet al., 1999). Previous research has shown that therelationship between health professionals and patientsand the ways in which information is provided is critical inenhancing medication concordance and management(Manias et al., 2007; Pound et al., 2005; Williams et al.,2008). Worthington (2003) states that a partnershipbetween the nurse and the patient consistent withperson-centred care can have a significant influence onpatients’ understandings and attitudes towards theirmedications and on the degree of compliance with theirmedication regimens. An individualised person-centredapproach to medication activities also has the potential toimprove patient experiences and outcomes including:increased opportunities for patient education aboutmedications, administration of medications at a time thatis most appropriate for the patient and a decreased risk ofmedication error (Reid et al., 2002).

Despite the purported benefits of a person-centredapproach to medication activities, there is scant literaturewhich seeks to describe or examine the nature ofinteractions between nurses and patients during medica-tion activities. The studies that have been undertaken inthis area demonstrate that the interactions betweennurses and patients during medication activities are rarelyconsistent with the principles of person-centred care.Previous research has demonstrated that nurses’approaches to medication activities are often not basedon an assessment of patients’ individual requirements, andcan be determined by task-orientated routines (Martens,

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165156

1998; Haglund et al., 2004; Manias et al., 2005). Each ofthese three studies examining interactions between nursesand patients during medication activities had a differentfocus; medication discharge education provided by nursesto patients, medication administration in an inpatientpsychiatric setting and protocol use by graduate nurses,respectively. It is a potential limitation that theseresearchers did not utilise person-centred care as aframework to examine their findings, however, the out-comes of each study demonstrated significant similaritiesrelated to routinised nursing practice lacking individua-lised patient assessment. This task-based approach isincongruent with a person-centred philosophy, where theemphasis is on providing individualised care, which valuesand respects the patient as a person (Radwin, 1996;Suhonen et al., 2002). An individualised approach tomedication activities involves a dialogue between nursesand patients, where the needs and preferences of thepatient are identified and an ongoing plan is developedcollaboratively to meet these needs. Nurses’ assessment ofthe needs and preferences of individual patients were notevident in these studies (Martens, 1998; Haglund et al.,2004; Manias et al., 2005).

It is readily apparent that an approach to medicationactivities that is based on routine and tradition is unlikelyto meet the needs of individual patients. Reid et al. (2002)evaluated a pilot program on a surgical unit in the UnitedKingdom, utilising multiple methods of evaluation includ-ing observation of practice, documentation audits and staffquestionnaires. The aim of the program was to implementa less regimented and more individualised, person-centredapproach to medication activities. The findings revealedthat despite the new program, patient assessmentremained separate from the process of medicationactivities and the assessment data was not used to informmedication decisions. The incongruence between a per-son-centred philosophy and task-orientated patient care,suggests that implementing an individualised, person-centred approach to medication activities is more complexthan merely changing systems and processes related tomedication administration for patients. However, thefindings of the study were limited in that patients’ viewswere not directly sought as part of the evaluation, whichwould appear to be contradictory in a project designed toevaluate person-centred care.

The complexity of implementing a sustainable person-centred approach is supported by the work of Rycroft-Malone et al. (2001), which is also reported by Latter et al.(2000). This work involved a multiple case study approachto investigate the contribution of nurses to medicationeducation for patients- across an area trust in the UnitedKingdom. Seven different clinical areas were chosen fortheir significance in relation to medication education andrepresented adult, care of the older person, mental healthand community nursing contexts. Consistent with thefindings of related studies, the results demonstrated that amajority of nurse–patient interactions were dominatedand led by nurses, and contained relatively simpleinformation which is incongruent with person-centredcare (Cahill, 1996). Overall, the case study approachemployed by researchers generated very rich data.

However, the study focuses on medication education asa discrete component of medication activities undertakenby nurses and the findings may not be able to be applied tomedication management more broadly.

Significantly, the findings of Rycroft-Malone et al.(2001) revealed some atypical interactions between nursesand patients in both the community mental health contextand the rehabilitation ward (Rycroft-Malone et al., 2001).The interactions in these settings were less dominated bynursing staff in comparison to other clinical areas such asacute medical wards and surgery-based clinics. There wasevidence of nurses providing a broad range of informationabout medications, such as monitoring medication out-comes and side effects, which was driven by identificationof patient needs and preferences. In contrast to otherclinical settings, both the community mental health andrehabilitation units had a person-centred philosophy ofcare. The nurses from these settings emphasised anindividualised, holistic approach, with respect and part-nership being central to nurse–patient interactions. Thisengagement of clinical nurses in application of thephilosophy of care was notably absent in the implementa-tion of a person-centred medication model evaluated byReid et al. (2002). However, it could be argued that therehabilitation and community mental health areas identi-fied in the Rycroft-Malone et al. (2001) study may havedifferent challenges to acute care settings in relation toindividual workload and time constraints, which may alsohave impacted on the nature of nurse–patient interactions.

1.1. Aim

The aim of this study was to examine the nature ofinteractions between nurses and patients during medica-tion activities in an acute care setting with an underlyingphilosophy of person-centred care. The study sought toanswer the following research question: How do nursesand patients interact with each other during medicationactivities in an acute care environment with an underlyingphilosophy of person-centred care? Two further subsidiaryquestions were also explored:

� W

hat are nurse and patient perceptions of theirexperience relating to medication activities? � W hat factors influence the nature of these interactions?

In the context of this study, medication activities weredefined as the following processes: communication with thepatient about medications, patient assessment and evalua-tion in relation to medications administered, patient educa-tion, and communication with multidisciplinary team(Manias et al., 2005).

2. Methods

2.1. Design

A naturalistic observational research design wasutilised for this study. Naturalistic observation drawsthe researcher into the real-world context and generatesrich data that are unlikely to be captured from a survey or arandomised controlled trial (Barker et al., 2002; Johnstone

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165 157

and Kanitsaki, 2006). To increase the completeness of thedata, semi-structured interviews were also undertakenwith participants following the observation periods.Seeking the views of the participating nurses and patientswas also consistent with the person-centred theoreticalframework of the study.

2.2. Study setting and participants

The study was conducted in an acute care ward in anAustralian metropolitan tertiary referral teaching hospi-tal. The 20-bed ward was chosen as the study setting dueto their philosophy of person-centred care. A shared visionstatement articulating person-centred care had beencollaboratively developed by the nursing and medicalteam of the ward, in concordance with the organisationalphilosophy. This vision statement was displayed in theunit and was utilised by the nursing team when employ-ing and orientating new staff members, and to guidediscussions and decision-making in ward and teammeetings. Data collection occurred between July andSeptember 2007.

Informal information sessions were held to recruitnurse participants, and interested nurses were asked toleave their contact details with the researcher. Nurses wereeligible to participate if they were employed on the studyward in a role that incorporated direct patient care,including medication activities. A stratified samplingtechnique was utilised to ensure that nurses with a rangeof years of clinical experience were represented. Of thenurses who volunteered, participants were randomlyselected from the following categories of years ofexperience: less than 2 years, between 2 and 4 yearsand greater than 4 years.

Patients who were being cared for by participatingnurses during the observation period were also invited tobe part of the study, unless they met the followingexclusion criteria: patients who were under 18 years ofage, patients who could not speak English where a familyor staff member could not be accessed to act as aninterpreter, patients who were unable to give informedconsent, for example, in situations involving confusion,

Table 1

Observation schedule.

Observation notes

Note the time the nurse enters and exits the patients’ bedside area (including

Describe the patients’ appearance including non-verbal communication.

Describe the nurse’s appearance including non-verbal communication.

Record the presence of other elements in the environment that may be impact

noise

presence of other people

the physical condition of the patient.

Note any other task the nurse is undertaking at the same time that the medica

patient assessment

attending to the request of another patient

responding to another health professional

other.

Note any ways that the nurse responds to the individual needs of the patient:

following up a request

taking into consideration hearing deficit, speech or swallowing difficulties

other, e.g. consideration of patients’ pain/discomfort.

sedation or impaired state of consciousness, and patientswho were not well enough to participate in the interviewprocess.

2.3. Participant observation

Nurse–patient interactions during medication activitieswere observed and audio recorded by the observer (firstnamed author), who followed the participating nurseduring each observation period. Each participating nursewas observed for one, 2-h observation period. These timeintervals represented rich data episodes for medicationactivities including medication administration, patienteducation and communication with multidisciplinaryteam members, as validated by the Nurse Manager ofthe participating ward. Probability sampling wasemployed to select the observation periods across thetimes and days of the week, through the use of a randomnumbers table. The observer adopted an ‘‘observer asparticipant’’ approach, interacting only with participants ifit was necessary to clarify a particular situation orinteraction, or to make a participant feel more at easewith the observation process (Gold, 1958; Manias andStreet, 2000; Spradley, 1980). Field notes were alsorecorded during the period of observation according tothe observation schedule as detailed in Table 1.

2.4. Semi-structured interviews

Following the observation component of the research,semi-structured interviews were conducted individuallywith participating nurses and patients. Interviews withnurses and patients were conducted separately from eachother to increase the likelihood of honest and frankresponses from participants. Demographic data werecollected from both the nurse and patient participants atthis time. Nurse participants were interviewed at amutually convenient time as soon as possible followingthe observation period, for approximately 30 min. Theinterviews were audio recorded to assist with dataanalysis. Open-ended questions were used to explorenurses’ views on person-centred care relating to medica-

bed number).

ing on the interaction between the nurse and the patient:

tion activity is occurring:

Table 2

Interview schedules.

Nurse participants Patient participants

How would you define person-centred care in relation

to medication activities?

How do you feel about the type and amount of information you have been

given about your medications while you have been in hospital?

Can you please comment on the extent to which you think that

you deliver person-centred care in relation to medication activities?

Could you please comment on the extent to which you have been

encouraged to make decisions or choices about the medications you are

taking, or the way in which you are taking them?If you think about the medication activities that took place during

the period of observation, could you highlight anything that you

think demonstrated person-centred care?

Was there anything you would have liked the nurse to have done

differently while you were having your medications given to

you/explained to you?Was there anything that you do not think was consistent with your

beliefs about person-centred care?What factors influenced the interactions you had with your patients

regarding their medications during the observation period.

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165158

tion activities, and perceived influences on nurse–patientinteractions during the period of observation.

A semi-structured interview with participating patientswas also conducted shortly after the observation period, toexplore patients’ experiences of interactions with nursesrelated to medication activities occurring during theperiod of observation. Interviews were conducted pri-vately but within the ward setting. Interview schedulesused with nurses and patients are shown in Table 2. At theend of observations, the histories of the participatingpatients were accessed to gain information about theirreason for hospital admission, length of stay, and medica-tions prescribed at the time of admission in addition tothose prescribed at the time of observation.

2.5. Data analysis

Descriptive statistics were used to summarise thedemographic data collected from nurse and patientparticipants. Audio-tapes of the observation periods andthe semi-structured interviews were transcribed verbatim.Data analysis of the transcripts and field notes wasconducted using the framework process described byRitchie and Spencer (1994). The approach involves asystematic process of sorting and categorisation ofmaterial according to identified issues and themes, whileretaining detail from the original accounts and observa-tions from which it has originated. The five steps aredistinct but interrelated and include: familiarisation,conceptualisation of themes, application of themes tothe data, rearranging the data according to themes, andfinally mapping which enables the data to be interpretedas a whole (Ritchie and Spencer, 1994). Transcripts fromobservations, field notes and interviews with nurses andpatients in addition to the demographic data werecompared and contrasted through all stages of the dataanalysis. The data were also considered in relation to thedefinition of person-centred care utilised for this study.

2.6. Rigour of the study

The multiple methods of data collection used withinthis study increase the richness of the data and improvethe validity of study findings. The observation andinterview schedules were designed based upon theliterature and therefore drew on the strengths of pastresearch (Brown and McCormack, 2006; Manias et al.,

2005, 2002). Two researchers examined the data inde-pendently and agreement was obtained regarding theidentified themes, with an audit trail being evidentthrough all stages of data analysis. A number of strategiesidentified by previous researchers were employed todecrease the possibility of nurse participants demonstrat-ing an increased awareness of their behaviours, andsubsequent potential modification of behaviour duringthe observation period. These strategies included:

� m

eeting with the participants on two occasions prior tothe commencement of data collection to enable parti-cipants to feel comfortable with the observer and theobservation process; � t he use of unobtrusive positioning and avoidance of eye

contact by the observer during the observation periods toensure that participants were not distracted or promptedduring their interactions;

� c onducting observations over a 2-h period, to allow time

for the participants to become less aware of the presenceof the researcher (Manias et al., 2005; Manias and Street,2000).

2.7. Ethical considerations

Ethics approval from the hospital and university ethicscommittees was granted prior to the commencement ofthe study. Consent was obtained from patient and nurseparticipants prior to the commencement of each observa-tion period. Confidentiality was maintained through allstages of data collection and analysis through theallocation of a code for each participant. Individuals whointeracted with the participants during the observationperiod were informed of the research project and its aimsduring- or immediately after the observation, and weregiven the option of their conversation being withdrawnfrom the research data. The hospital ethics committeerequired the observer (an experienced registered nurse) tobring any unsafe practice that may have put patients at riskto the attention of the participating nurse. However, thissituation did not arise during observations.

3. Results

A total of 11 nurses were observed throughout 11observation periods. The observer ceased recruitment after11 observations as saturation of themes occurred at this

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165 159

point. Observations were conducted over 2-h periodsacross most days of the week as shown in Table 3. Two ofthe 11 nurses were male, and the average age of theparticipating nurses was 27. The full demographic profileof the nurses was similar to that of the population of nursesemployed in the unit, and is detailed in Table 4. All of theobserved nurses participated in a subsequent interview.

During the observations, 29 patients were allocated tonurses participating in the study. A total of 25 patients metthe inclusion criterion and were observed, and 16 of thosepatients consented to participate in subsequent inter-views. The majority of the patients were male (n = 19) andthe mean age of the participants was 59 years (SD = 22).The youngest participants were 18 years-of-age, and theoldest participant was 91 years old. The mean number ofdays since the patients were admitted was 8, with a rangeof 37. The patient demographics were consistent with thatof the participating ward.

Table 3

Characteristics of the observation periods.

Observation period Number of

observations conducted

Day of the week

Monday 3

Tuesday 1

Wednesday 0

Thursday 2

Friday 3

Saturday 0

Sunday 2

Observation time

07:00–09:00 h 4

11:30–13:30 h 3

19:00–21:00 h 4

Table 4

Demographic profile of nurse participants (n = 11).

Characteristics n

Gender

Male 2

Female 9

Age group (years)

20–30 8

31–40 3

Years of nursing experience

<2 3

2–4 5

>4 3

Years employed on the ward

<2 4

2–4 4

>4 3

Nursing qualification

Certificate of Nursing 1

Bachelor of Nursing 8

Post-Graduate Diploma 2

Hours worked per week

8 3

32 2

38 6

Patient participants had a diverse range of pre-existingmedical conditions, in addition to their admission diag-nosis. The mean number of pre-existing medical condi-tions per patient was 4 (SD = 3) with a range of 12. Twopatients had no pre-existing medical conditions. Patientsusually had a greater number of medications prescribed atthe time of observation than when they were admitted tohospital. The mean number of medications prescribed perpatient on admission was 6, which increased to a mean of12 medications prescribed per patient at the time ofobservation. Changes to medications occurring duringpatients’ hospital stay included an alteration in the type ofmedication prescribed, dose, frequency or time of medica-tion administration.

Three major themes were identified from observationand interview data: provision of individualised care,patient participation and contextual barriers to providingperson-centred care. When quotes from the data havebeen provided to illustrate the themes, ‘‘O’’ indicates thatthe quote has originated from an observation period,while ‘‘I’’ indicates the quote has originated from aninterview.

3.1. Provision of individualised care

During interviews, all of the participating nursesemphasised that person-centred care was about providingindividualised care to patients, which relied upon ‘‘gettingto know’’ patients and establishing a relationship withthem. One nurse, with 2 years of experience commented:

Sometimes it can be your relationship that you haveactually established with them. And I think also that it isquite different when you have just met a patient for thefirst time. As to when you’ve known them for a few daysand when you’ve established a more stronger [sic]relationship with them. Then I think there is quite a bigdifference and they put quite a lot of trust in you. (N5 - I)

Patients made broad comments about their relationshipswith the nursing staff, such as: ‘‘they’ve all been fantastic,really’’ (P12 - I), ‘‘they are all really nice girls’’ (P4 - I) and‘‘they’ve been wonderful’’ (P2 - I), though none of thepatients made any statements indicating they hadestablished a relationship with an individual nurse.

Nurses emphasised that getting to know the patientthrough the therapeutic relationship was crucial in termsof understanding patient needs, expectations and prefer-ences, and the subsequent provision of individualised care.One nurse who had over 4 years of experience stated:

. . . making sure it’s patient-centred is making sure youdo have that discussion first thing in the morning aboutwhat they like and how their day is structured, and thethings that you might have to do for them and what sortof suits them best as well. (N 9 - I)

In relation to medication activities, the provision ofindividualised care was described in terms of flexibleapproaches to medication activities. In practice, nurseswere observed to identify and meet simple patientpreferences in relation to their medications, such as

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165160

crushing tablets or breaking them in half. Patients’ viewson the provision of care that met their needs werevaried. One patient, who had a long period of hospita-lisation and very specific needs about his medications,expressed that his preferences had been met by thenursing staff:

Well, the potassium is definitely the worst [for gutirritation]. Now they’ve [the nurses] got it in the liquidform and that is not as bad as the tablets. The tablets aretwo little tablets like that, round ones; they take abouttwo hours to get them down. Two hours for two tablets.The liquid is not bad; it [a burning sensation] goes awayafter 30 or 40 seconds. It has been pretty good really.Definitely they’ve [the nursing staff] done everythingthey can. Now in the liquid form so it is not quite so bad.They’ve done everything. (P6 - I)

However, another patient described not having hisneeds met in relation to the times that his blood sugar wasbeing tested and the subsequent consequences associatedwith his medications for diabetes:

At home I’ve got more time in between to keep thesugar readings down. I’ve got a lot more time inbetween taking pills, because I’ve got all day. I doreadings at different times to what they do here. I meanif you’ve just had breakfast and then you take a reading,well it is going to be up. (P1 - I)

3.2. Patient participation

Over a third of the participating nurses highlighted theimportance they placed upon involving patients in theircare and encouraging them to take part in medicationactivities, in relation to a person-centred approach. Theyaccentuated the notion of participation and collaboration,as indicated by the following comment:

I mean just empowering as much as you can, educatingthem so that they can make choices about what theywant and what they don’t want. (N7 - I)

Three nurses further articulated the potential, positiveoutcomes of patient participation especially in relation tothe safe administration of medications. During interview, aminority of patients described being involved in theirmedication activities. However, two patients discussedhow their active participation in medication activitiesresulted in identifying errors or anomalies related to themedications that were administered to them. This wasobserved in the following interaction between an experi-enced nurse and a patient with multiple, complex drugallergies.

Nurse:

‘‘Epilum. [sodium valproate] 300 mg bd. Twicea day, sorry.’’

Patient:

‘‘No. What are you doing? What’s the purpleone?’’

Nurse:

‘‘That’s the Epilum [sodium valproate].’’

Patient:

‘‘Oh dear, they are different.’’

Nurse:

‘‘Oh, OK. These are yours [holds up a differentmedication box]. Right. So you take three100 mg tablets.’’

Patient:

‘‘Yes, I can’t take the others [a differentbrand of the medication] because I am allergicto the dyes. I did say that at the start.’’

Nurse:

‘‘That’s why I’m here with them in front of you,so that we get it right.’’ (N11, P24 - O)

Observation also revealed that sometimes opportunitiesfor patient participation were missed, such as involvementin decision making or ascertaining preferences and in theprocess of preparing for discharge.

In terms of defining person-centred care in relation tomedication activities, most nurses (n = 9) emphasised theimportance of providing information about medications tothe patients they were caring for and ‘‘keeping theminformed’’ (N6 - I). Nurses thought that the informationconveyed to patients should include what medications werebeing administered and their purpose, and should preparethem for discharge. This was expressed typically as, ‘‘makingsure that the patient understands what they’re getting, andwhy they’re getting it’’ (N8 - I). Most patients felt that theinformation they had been provided with regarding theirmedications was ‘‘very thorough’’ (P1 - I) and they feltinformed about what medications were being administeredand for what purpose, as evident in this patient’s comments:

I feel satisfied that they’ve explained everything andwhat it is for and why. So that you are not in the darkabout anything and you know what to expect. (P3 - I)

Observations revealed that the majority of nurses didprovide patients with information about what medicationsthey were administering and why the medications wereprescribed. In most instances, this information consisted ofrelatively simple statements about individual medicationssuch as; ‘‘This is your amiodarone for controlling yourheart rate’’ (N3 - O) and ‘‘This is some anginine [glyceryltrinitrate] to help with your chest pain. It sits under yourtongue and dissolves’’ (N6 - O). The discussions weregenerally initiated and dominated by nurses.

Slightly less than half the nurse participants (n = 5)identified at interview that providing information topatients could be supported by involving the patient inthe interaction and establishing how much patientsalready knew and understood about their medications.Observations revealed that it was not common practice fornurses to assess patients’ knowledge of the medicationsthey were administering to them. Two nurses wereobserved to undertake simple assessments such as, ‘‘Doyou know what these tablets are for?’’ or, ‘‘Why do youthink you are taking the aspirin?’’ (N5 - O). One nurse wasobserved to consistently and thoroughly assess patients’knowledge of their medications throughout the observa-tion period, as demonstrated by the following example:

Nurse:

‘‘I’ll give you your Lasix [frusemide]. Do youknow what it is for?’’

Patient:

‘‘Yes.’’

Nurse:

‘‘What is it for?’’

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165 161

Patient:

‘‘For the fluid in the blood.’’

Nurse:

‘‘Yes. It is for getting rid of extra fluid. Now,do you take a co-enzyme tablet at home?

Patient:

‘‘No, never did.’’

Nurse:

‘‘It is a vitamin tablet. You’ve been having itwhile you’ve been in here. Do you know whatthis one is for?’’

Patient:

‘‘Yes, it is for stomach ulcers’’

Nurse:

‘‘And what about this? This one is aspirin’’

Patient:

‘‘Oh, well I take aspirin, but a different one’’

Nurse:

‘‘This one. . .which one do you take at home?’’

Patient:

‘‘The regular one.’’

Nurse

‘‘Is it a little white tablet like that, but it iswhite? Yeah, I’ll ask the doctors about it.This one is just coated. You know what thatone is [nurse shows the patient a metoprololtablet]. That is just 30 milligrams. And,because your blood sugar is 11 [millimol/litre]this morning, the doctors want you to havea little bit of insulin as well. Is it O.K. if I givethat to you now?’’ (N7, P13 - O)

The patient being cared for by this particular nurseidentified that this nurse’s approach to the provision ofeducation about medications was not the same as othernurses: ‘‘In fact. . . [N7] was quite an exceptional person, inthis regard.’’ (P13 - I)

3.3. Contextual barriers to person-centred care in relation to

medication activities

A number of contextual barriers in relation to a person-centred approach to medication activities emergedthroughout the study. The two main sub-themes high-lighted by nurses and patients were communicationchallenges with the health care team and time constraints.

3.3.1. Communication challenges with the health care team

Six nurses identified that an important component ofperson-centred care was ensuring that patients had beenprescribed the correct medications. This emphasis on thecorrect prescription of medications required nurses tocommunicate with the health care team, in particular withthe medical staff. Communication with the medical staffoccurred during the daily medical rounds, and outside ofthose times. This communication between nurses andmedical staff related to confirming or altering medicationdoses and nurses requesting the prescription of additionalmedications to meet identified patient needs. Patientsseemed to be largely unaware of the role that the nursesassumed in ensuring that they were prescribed the correctmedications, and presumed that nurses played a passive rolein this relationship, as evident in the following statements:

The nurses tell me that the doctor has put me off so-and-so, and I’m now on so-and-so. (P1 - I)

. . . the doctor tells the nurse and then the nurse tells me(P4 - I)

Nurses highlighted that there were challenges involvedin communication with the medical team. It could be atime-consuming process, particularly in relation to acces-sing and contacting medical staff. Nurses also identifiedthe role of the pharmacist within the health care team inrelation to medication activities for patients. The nursesperceived that the role of the pharmacist was importantspecifically in establishing the medications that patientshad been taking prior to admission, and then in terms ofpreparing patients for discharge. However, no commu-nication between nurses and pharmacists was observedduring any of the observations. The two disciplinesappeared to work quite independently of each other.The observer noted many missed opportunities for nursesand pharmacists to communicate concerning informationabout medications and to ensure the patient wasadequately informed and educated. Occasionally, the nursewould refer to information that they assumed had beenprovided by the pharmacist. For instance, N4 was observedwhile preparing a patient for discharge. The dischargemedications had been provided earlier to the patient by thepharmacist, while the nurse was absent. The nurse madereference to the medications:

Nurse:

‘‘So you’ve had all of your medicationsexplained to you, and you are happy with that.’’

Patient:

‘‘Yeah.’’ (N4, P8 - O)

No other communication occurred between the nurseand the patient regarding the patient’s discharge medica-tions. When questioned about this during interview, N4commented:

To be honest, I hadn’t actually given that a lot ofthought. I know that the pharmacist does explain themedications quite thoroughly with the patient, so I wasalways under the impression that it was their role to doso. . .it might have been a good opportunity to say, ‘‘Thepharmacist has been through the medications with you,do you understand everything that they have told you,is [sic] there any questions you have about any of yourmedications.’’ That is probably something I could do forthe future I think. (N4 - I)

This particular nurse had less than 1 year of clinicalexperience; however, other nurses with a greater numberof years of experience also commented on the lack ofcommunication and collaboration between themselvesand the pharmacists, especially in relation to preparingpatients for discharge.

3.3.2. Time constraints

All participating nurses identified a lack of time as afactor that limited the interactions they were able to havewith their patients, in relation to their medications.

Nurses viewed a lack of time restricted their ability toengage with the patients to establish a relationship withthem, and to facilitating lengthy discussions aboutmedications. Nurses understood the factors that contrib-uted to a lack of time to include general work pressures andcaring for patients who were acutely unwell. Somepatients also commented on the busyness of the nurses

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165162

and the potential implications of this, for both the nursesand themselves.

Sometimes they [the medications] weren’t on time, butI understand that. They’ve got so much running about[the nurses]. It’s not just me. (P22 - I)

During the observation periods, nurses appearedrushed and they spent little time with patients in relationto medication activities. The longest continuous interac-tion between a nurse and a patient in relation tomedication activities throughout the observation periodswas 20 min. Two nurses were observed to sit down withpatients during medication activities. However, nursesusually stood at the end of the bed to administer or discussmedications and generally made little eye contact withpatients. During some of the observations, the environ-ment did appear to be hectic and demanding for thenursing staff. However, nurses themselves recognised thatthere were fluctuations in the level of busyness theyexperienced, both from day-to-day and across differenttime periods of the same day. Five nurses made commentsduring the observation periods that they were not verybusy or they were having a ‘‘nice’’ shift. During quietertimes, nurses were usually located in the nurses’ stationreading and documenting in patient histories.

4. Discussion

This study provides new knowledge about the extent towhich nurses provide person-centred care in their inter-actions with patients during medication activities. Find-ings highlighted that some nurse–patient interactions inthis setting were consistent with person-centred care;providing an individualised approach to care and oppor-tunities for patient participation. This type of interaction israrely reported in previous literature and should beacknowledged. However, the findings also highlighteddiscrepancies between what nurses say they do and whatthey actually do (Caldwell and Atwal, 2005; Farley andMcLafferty, 2003; Patton, 2002). In this study, while nursesvalued a person-centred approach and perceived that theywere conducting medication activities in a person-centredway, observation revealed that activities were largelycentred on the nurses’ understanding of what wasimportant for patients.

Previous research about medication activities hasshown that care provided by nurses did not build uponassessment or knowledge of the patient (Haglund et al.,2004; Manias et al., 2004b, 2005; Martens, 1998).Similarly, observations revealed that nurses did notroutinely assess patients’ prior knowledge or preferencesabout their medications. This finding was contradictory toviews articulated by nurses during interview. Nursesstated that getting to know patients and understand theirparticular needs was an important component of person-centred care. While they generally spoke highly of thenursing staff, none of the patients mentioned key relation-ships they had established with particular nurses inreference to medication activities, which may haveimpacted on the provision of individualised care.

The provision of individualised nursing care movesaway from task-centred routines to tailored care based onknowledge of the person (Binnie and Titchen, 1999;Manley, 2004; Suhonen et al., 2002). In this study, littlevariation was evident between interactions involvingnurses and different patients throughout medicationactivities. Nurses articulated during interview that theyplaced priority on providing information to patients toensure they knew what medications they were prescribed,and for what purpose. There were some instances observedwhere nurses provided comprehensive information topatients about their medications based on an assessmentof their needs and preferences. These interactions werecharacterised by two-way dialogue between patients andnurses. However, in most instances, nurses appeared to usea standard process or mental ‘‘check-list’’ rather thanspecific knowledge of patients’ situations and theirpreferences, to guide the provision of information. Thisuse of a standard process is consistent with previousresearch, which demonstrated that nurses providedinformation about medications to patients that waslimited, generalised and lacked an individualised approach(Rycroft-Malone et al., 2001).

Previous studies by Haglund et al. (2004) and Maniaset al. (2005) also demonstrated that nursing care inrelation to medication activities was based on rituals androutines, rather than the provision of individualised care.In this study, some nurses were observed to provide aflexible approach to meet the requirements of individualpatients, such as the timing of medications or the crushingof tablets for ease of swallowing. However, medicationadministration was largely determined by the routinemedication times and processes.

The implementation of an individualised approach tocare requires shared decision-making and negotiationbetween patients and nurses, and facilitates patientparticipation (McCormack and McCance, 2006; Redmanand Lynn, 2004). A partnership-based relationshipbetween nurses and patients can have a significantinfluence on patients’ understanding and attitudestowards their medications (Worthington, 2003). In thisstudy, there was some evidence of nurses and patientsworking collaboratively. These interactions were oftenfocused on medication education, or clarifying theprescription or dose of certain medications prescribedfor the patient. However, it was also observed that therewere many missed opportunities for nurses to activelyengage patients in their medication activities. Often theinteractions and decision-making was dominated bynurses. These findings are consistent with previousresearch where observation of practice revealed thatnurses did not create opportunities for patient participa-tion (Haglund et al., 2004; Penney and Wellard, 2007;Rycroft-Malone et al., 2001).

A number of potential barriers in relation to theprovision of person-centred care were highlighted throughthis study. Notably, the potential barriers identified bynurses related to the clinical context. In addition, theliterature identifies nurse attributes that are essential forthe provision of person-centred care. These attributesinclude: professional competence, highly developed inter-

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165 163

personal skills and an ability to demonstrate clarity ofbeliefs and values (Binnie and Titchen, 1999; McCormackand McCance, 2006; Price, 2006).

Previous research suggests that the experience leveland professional competence of nurses influence theirclinical decision-making and capacity to individualisenursing care (Eisenhauer et al., 2007; Manias et al.,2004a). However, in this study there was not a consistentfinding between nurses’ level of experience, or length oftime employed on the ward, and the nature of theinteractions between themselves and patients. Forinstance, some relatively inexperienced nurses wereobserved to establish relationships with patients basedon generating knowledge of their preferences and level ofunderstanding of their medications, while other experi-enced nurses were observed to have interactions withpatients in which they dominated the decision-makingbased on limited knowledge of the patient. These diversefindings highlight the influence of additional nurseattributes on a person-centred approach to care, such asinterpersonal skills and an ability to demonstrate clarity ofbeliefs and values.

In addition to the attributes of individual nurses,aspects of the clinical context that impacted on theinteractions between nurses and patients emergedthrough the study. A lack of time was identified by everyparticipating nurse as a factor that potentially inhibits aperson-centred approach. Factors that contributed to timeconstraints included general workload pressures andcaring for patients who were acutely unwell. These factorsare similar to those identified in previous research (Daviset al., 2005; Henderson et al., 2007; Radwin, 1996; Redmanand Lynn, 2004; West et al., 2005; Willson, 2000). Nursesperceived that a lack of time restricted their ability toengage with patients to establish a relationship with themand limited interactions in relation to medications, whichare findings consistent with the literature (Radwin, 1996).

Nurses were observed to look busy throughout the datacollection period. They appeared rushed, and spent littletime with patients. They usually stood at the end of the bedto conduct medication activities, rarely sat with patientsand generally made little eye contact throughout interac-tions. Consequently, patients revealed that they perceivedthe nurses to be busy. However, nurses themselvesidentified that there were fluctuations in the levels ofbusyness that they experienced. Despite expressing thatthey wished they had more time to spend with patients inrelation to their medications, this was not observed duringany of the quieter periods throughout this research. Duringthese times nurses were usually located in the nurses’station reading and documenting in patient histories.

A number of challenges in relation to nurses’ commu-nication with the multidisciplinary team regarding person-centred medication activities were also highlighted. Similarto the findings of Willson (2000), observation and inter-views with nurses revealed that nurses initiated a great dealof communication with the medical team, to ensure thecorrect prescription of medications for individual patients.This communication was often time-consuming, particu-larly in relation to nurses accessing and contacting medicalstaff via a paging system when they were not located on the

ward. This lack of access was noted to lead to potentiallysignificant delays in patient treatment and was a source offrustration for the nursing staff.

Of additional significance, was that no communicationbetween nurses and pharmacists was observed. While itwas clear that both disciplines were interacting individu-ally with patients about their medications, nurses workedquite independently of pharmacists. For instance, therewere occasions where it was evident that the pharmacisthad recently had contact with patients regarding theirmedications; however, nurses and pharmacists were notobserved to communicate with each other about theseinteractions. This lack of communication is consistent withthe findings of Martens (1998), who found that medicationeducation was an uncoordinated and disjointed inter-disciplinary process. In addition, the lack of time spentbetween nurses and pharmacists shown in this studysupports the observational work of Ampt and Westbrook(2007) who found that communication between thesediscipline groups was virtually non-existent.

4.1. Limitations

The main limitation of this study is recruitment fromone acute care setting, which may limit the transferabilityof the findings. However, the diverse demographiccharacteristics of nurses and patients and the conduct ofobservations at different times and days of the weekensured a variety of experiences and perceptions werecaptured. Consequently, the results provide valuableinsights into the experience of patients and the beliefsand behaviour of nurses, which can be used to inform andpotentially challenge the practice of nurses more broadly.

Participating nurses may also have demonstrated anincreased awareness in communicating with patientsabout their medications as a result of being observed.However, a number of strategies identified by previousresearchers were employed to decrease the discomfortlevels of participating nurses (Manias et al., 2005; Maniasand Street, 2000). It has also been demonstrated previouslythat it is difficult for individuals to sustain behaviour that isdramatically different from normal for any length of timein a busy health care environment (Mulhall, 2003).

4.2. Relevance to clinical practice

Given the evidence that a person-centred approach isessential for enhanced quality of patient care andimproved outcomes, it is crucial for nurses to pursueopportunities to ensure that person-centred interactionsare more consistently evident in practice. The findingshave a number of implications for clinical practiceincluding the importance of establishing patients’ needsand preferences about their medications. Changes tonursing practice are therefore required to promotepossibilities for patients to participate more actively inmedication activities. To ensure active patient participa-tion, nurses need to employ the use of more open-endedquestions to elicit information regarding patients’ needsand preferences, and encourage patients to ask questionsabout their medications (Rycroft-Malone et al., 2001).

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165164

Significantly, this study also demonstrated that nurseswere not aware of, or did not value the skills they requiredto practice in a person-centred way. Helping nursesdevelop their own person-centredness through discussingliterature and reflecting on their practice would be a usefulstrategy to identify individual and collective learning anddevelopment needs (McCormack and McCance, 2006).Enhancement of required skills such as effective listeningand communication could occur through mentorship ormore formalised nursing education and practice develop-ment programs.

The discrepancy between how nurses thought theydelivered person-centred care and how they actuallydelivered care, reveals that the presence of a person-centred philosophy of care does not guarantee a consistentperson-centred approach. It has been recognised that theimplementation of person-centred care is complex andchallenging (Cahill, 1996). The findings of this studysuggest that clinical areas working towards deliveringperson-centred care need to critique and reflect upon theirpractice. Regular evaluation is required to determine ifclinical practice is consistent with nurses’ beliefs and theirphilosophy of care, and to make subsequent practicechanges and develop new ways of working if required(McCormack and Garbett, 2003).

Finally, the study findings also highlight the value ofobservation in addition to patient and staff interviews aspotentially powerful feedback mechanisms, which couldbe utilised in many clinical units. These strategies need tobe considered by both nursing management and nursingeducation teams as approaches for implementing sustain-able practice change. Importantly, these forms of datarevealed challenges present in the clinical environment,which are potential barriers to person-centred interac-tions. Collaborative work with nursing staff in relation tolocal barriers would result in the development ofcontextually relevant and effective systems and processesto address these challenges.

5. Conclusions

This study revealed that in an acute care environmentwith a philosophy of person-centred care, some nurse–patient interactions during medication activities werecentred on routines rather than individualised patientassessment and management. These interactions werebased on nurses’ perceptions of what was important forthe patient and did not provide opportunities for patientparticipation. This approach was incongruent withnurses’ understanding of how they practised person-centred care. Multidisciplinary communication emergedas a challenging aspect of person-centred care in relationto medication activities. The nature of these challengesrequires further investigation involving the variousmultidisciplinary teams and should be the focus offuture research in this area. Given that a person-centredapproach is essential for enhanced quality of patient careand improved outcomes, it is crucial for nurses tocollaboratively pursue opportunities to ensure thatperson-centred interactions are more consistently evi-dent in practice.

Acknowledgements

We are indebted to the individuals and health profes-sionals who generously gave up their time to participate inthis research. Contributions: DB and EM were involved inthe study design, data collection and analysis and manu-script preparation.

Conflict of interest: None declared.Funding: There was no funding provided for this

research.Ethical approval: The Alfred Hospital, Melbourne,

Victoria, Australia (Project 101/07); University of Mel-bourne (Ethics ID: 0715937).

References

Ampt, A., Westbrook, J.I., 2007. Measuring nurses’ time in medicationrelated tasks prior to the implementation of an electronic medicationmanagement system. In: Studies in health technology and infor-matics (3rd International Conference on Information Technology inHealth Care: Socio-Technical Approaches), vol. 130. IOS Press,Amsterdam, pp. 157–168.

Baker, C., Edwards, P., Packer, T., 2003. You say you deliver person-centred-care? Prove it!. Journal of Dementia Care 12 (1), 18–20.

Barker, K., Flynn, E., Pepper, G., 2002. Observation method of detectingmedication errors. American Journal of Health-System Pharmacy 59,2314–2316.

Binnie, A., Titchen, A., 1999. Freedom to Practice: The Development ofPatient Centred Nursing. Butterworth, Oxford.

Brown, D., McCormack, B., 2006. Determining factors that have an impacton effective evidence-based pain management with older people,following colorectal surgery: an ethnographic study. Journal of Clin-ical Nursing 15, 1287–1298.

Cahill, J., 1996. Patient participation: a concept analysis. Journal ofAdvanced Nursing 24, 561–571.

Caldwell, K., Atwal, A., 2005. Non-participant observation: using videotapes to collect data in nursing research. Nurse Researcher 13 (2),42–54.

Coyle, J., Williams, B., 2001. Valuing people as individuals: developmentof an instrument through a survey of person-centredness in second-ary care. Journal of Advanced Nursing 36 (3), 450–459.

Davis, L., Keogh, S., Watson, K., McCann, D., 2005. Dishing the drugs: aqualitative study to explore paediatric nurses’ attitudes and practicerelated to medication administration. Collegian 12 (4), 15–20.

Dawood, M., 2005. Patient-centred care: lessons from the medical profes-sion. Emergency Nurse 13 (1), 22–28.

Eisenhauer, L., Hurley, A., Dolan, N., 2007. Nurses’ reported thinkingduring medication administration. Journal of Nursing Scholarship,First Quarter 82–87.

Farley, A., McLafferty, E., 2003. An introduction to qualitative researchconcepts for nurses. Professional Nurse 19 (3), 159–163.

Gold, R., 1958. Roles in sociological field observations. Social Forces 36 (3),217–223.

Haglund, K., von Essen, L., von Knorring, L., Sidenvall, B., 2004. Medica-tion administration in inpatient psychiatric care—get control andleave control. Journal of Psychiatric and Mental Health Nursing 11,229–234.

Henderson, A., Van Eps, M., Pearson, K., James, C., Henderson, P., Osborne,Y., 2007. ‘Caring for’ behaviours that indicate to patients that nurses‘care about’ them. Journal of Advanced Nursing 60 (2), 146–153.

Holman, H., Lorig, K., 2000. Patients as partners in managing chronicdisease. Partnership is a pre-requisite for effective and efficient healthcare. British Medical Journal 320 (7234), 526–527.

Johnstone, M., Kanitsaki, O., 2006. The moral imperative of designatingpatient safety and quality care as a national nursing research priority.Collegian 13 (1), 5–9.

Latter, S., Yerrell, P., Rycroft-Malone, J., Shaw, D., 2000. Nursing, medica-tion education and the new policy agenda: the evidence base. Inter-national Journal of Nursing Studies 37, 469–479.

Lutz, B., Bowers, B., 2000. Patient-centred care: understanding its inter-pretation and implementation in health care. Scholarly Inquiry forNursing Practice: An International Journal 14 (2), 165–182.

McCormack, B., 2003. A conceptual framework for person-centred prac-tice with older people. International Journal of Nursing Practice 9,202–209.

D. Bolster, E. Manias / International Journal of Nursing Studies 47 (2010) 154–165 165

McCormack, B., Garbett, R., 2003. The meaning of practice development:evidence from the field. Collegian 10 (3), 13–16.

McCormack, B., McCance, T., 2006. Development of a framework for person-centred nursing. Journal of Advanced Nursing 56 (5), 472–479.

McCormack, B., Titchen, A., 2001. Patient-centred practice: an emergingfocus for nursing expertise. In: Higgs, J., Titchen, A. (Eds.), PracticeKnowledge and Expertise in the Health Professions. ButterworthHeinemann, Oxford, pp. 96–101.

Manias, E., Aitken, R., Dunning, T., 2004a. Medication management bygraduate nurses: before, during and following medication adminis-tration. Nursing and Health Sciences 6, 83–91.

Manias, E., Aitken, R., Dunning, T., 2005. How graduate nurses use pro-tocols to manage patient’s medications. Journal of Clinical Nursing 14,935–944.

Manias, E., Beanland, C., Riley, R., Baker, L., 2004b. Self-administration ofmedication in hospital: patients’ perspectives. Journal of AdvancedNursing 46 (2), 194–203.

Manias, E., Botti, M., Bucknall, T., 2002. Observation of pain assessmentand management—the complexities of clinical practice. Journal ofClinical Nursing 11, 724–733.

Manias, E., Claydon-Platt, K., McColl, G., Bucknall, T., Brand, C., 2007.Managing complex medication regimens: perspectives of consumerswith osteoarthritis and healthcare professionals. The Annals of Phar-macotherapy 41, 764–771.

Manias, E., Street, A., 2000. Legitimisation of nurses’ knowledge throughpolicies and protocols in clinical practice. Journal of Advanced Nur-sing 32 (6), 1467–1475.

Manley, K., 2004. Workplace culture: is your workplace effective? Howwould you know?. Nursing in Critical Care 9 (1), 1–3.

Martens, K., 1998. An ethnographic study of the process of medicationdischarge education. Journal of Advanced Nursing 27, 341–348.

Mead, N., Bower, P., 2000. Patient-centredness: a conceptual frameworkand review of the empirical literature. Social Science and Medicine 51(7), 1087–1110.

Mulhall, A., 2003. In the field: notes on observation in qualitativeresearch. Journal of Advanced Nursing 41 (3), 306–313.

Osborne, J., Blais, K., Haynes, J., 1999. Nurses’ perceptions: when is it amedication error? Journal of Nursing Administration 29 (4), 33–38.

Patton, M., 2002. Qualitative Research and Evaluation Methods, 3rd ed.Sage, Thousand Oaks.

Penney, W., Wellard, S., 2007. Hearing what older consumers say aboutparticipation in their care. International Journal of Nursing Practice13, 61–68.

Pound, P., Britten, N., Myfanwy, M., Yardley, L., Pope, C., Daker-White,G., Campbell, R., 2005. Resisting medicines: a synthesis of quali-tative studies of medicine taking. Social Science & Medicine 61,133–155.

Price, B., 2006. Exploring person-centred care. Nursing Standard 20 (50),49–56.

Radwin, L., 1996. ‘Knowing the patient’: a review of research on anemerging concept. Journal of Advanced Nursing 23 (6), 1142–1146.

Redman, R., Lynn, M., 2004. Advancing patient care through knowl-edge development. Canadian Journal of Nursing Research 36 (3),116–129.

Reid, B., Townson, R., Renton, H., Shiel, A., 2002. A trial of patient-centreddrug administration. Nursing Times 98 (37), 36–38.

Ritchie, J., Spencer, L., 1994. Qualitative data analysis for applied policyresearch. In: Bryman, A., Burgess, R. (Eds.), Analyzing QualitativeData. Routledge, London, pp. 173–194.

Rycroft-Malone, J., Latter, S., Yerrell, P., Shaw, D., 2001. Consumerism inhealth care: the case of medication education. Journal of NursingManagement 9, 221–230.

Sheard, D., 2004. Person-centered care: the emperor’s new clothes?Journal of Dementia Care 12 (2), 22–25.

Suhonen, R., Valimaki, M., Leino-Kilpi, H., 2002. ‘‘Individualised care’’from patients’, nurses’ and relatives’ perspective—a review of theliterature. International Journal of Nursing Studies 39, 645–654.

Spradley, J., 1980. Participant Observation. Holt, Rinehart and Winston,New York.

West, E., Barron, D., Reeves, R., 2005. Overcoming the barriers to patient-centred care: time, tools and training. Journal of Clinical Nursing 14,435–443.

Williams, A., Manias, E., Walker, R., 2008. Interventions to improvemedication adherence in people with multiple chronic conditions:a systematic review. Journal of Advanced Nursing 63 (2), 132–143.

Willson, H., 2000. Factors affecting the administration of analgesia topatients following repair of a fractured hip. Journal of AdvancedNursing 31 (5), 1145–1154.

Worthington, B., 2003. The nurse’s role in patient-centred medicinesmanagement. Professional Nurse 19 (3), 142–144.