Challenges homecare nurses face in patient encounters when promoting safe medication use for older adults: a qualitative study

Technical Summary: Challenges Homecare Nurses Face in Patient Encounters When Promoting Safe Medication Use for Older Adults

Problem Statement
Medication management in municipal home care (HC) represents a critical intersection of patient safety, professional responsibility, and the complexities of delivering healthcare within private residences. While up to 30% of patients in home care may be exposed to potential medication errors, research specific to this sector remains limited. Older adults (65+) living at home are particularly vulnerable due to multimorbidity, frailty, and polypharmacy. Although homecare nurses (HCNs) play a central role in ensuring safe practices, they operate under significant constraints, including high workloads, time pressure, and fragmented information systems. Existing literature highlights the need for communication and collaboration but offers limited insight into how HCNs experience and navigate the conditions that challenge safe medication use during day-to-day encounters with older patients in their homes.

Methodology
This study employed a qualitative exploratory design using semi-structured interviews to investigate HCNs' perceptions of conditions challenging safe medication use.

• Setting: Three rural municipalities in Norway, ranging from 5,000 to 12,000 inhabitants.
• Participants: A heterogeneous sample of 14 HCNs (6 Registered Nurses and 8 Nurse Assistants) with 2–37 years of experience. Participants were recruited via purposive sampling between January 2024 and April 2025.
• Data Collection: Interviews were conducted between March 2024 and May 2025, lasting 45–70 minutes. The interview guide included questions on medication management situations, challenges in patient encounters, and the experience of ensuring safety in home settings. To enrich dialogue, researchers utilized photos illustrating medication situations, pillboxes, and handouts.
• Analysis: Data were analyzed using qualitative latent content analysis. Meaning units were condensed, coded, and organized into categories, which were subsequently synthesized into four overarching themes. Trustworthiness was ensured through rigorous coding discussions, member checking, and adherence to COREQ guidelines.

Key Results
The analysis identified four distinct themes describing the conditions that challenge HCNs' ability to promote safe medication use:

1. Balancing Patient Autonomy with Medication Safety: HCNs navigate a persistent tension between respecting a patient's right to self-determination and their professional duty to prevent harm. Entering the private sphere of a patient's home often feels intrusive, and patients frequently resist relinquishing control over their medications. HCNs report difficulties in intervening when patients hide medication, pretend to take it, or refuse regimens, requiring them to negotiate trust and motivation without coercion.
2. Grappling with the Complexity of Patients' Needs: The clinical complexity of the patient population, characterized by cognitive impairments (e.g., dementia) and physical limitations, creates significant uncertainty. Cognitive decline affects memory and decision-making, leading to unpredictable dosing (e.g., taking too much or nothing). Physical limitations hinder the ability to open packaging or handle tablets. HCNs must continuously assess whether patients possess the capacity to manage medications independently, often relying on patients to self-report errors—a strategy that fails when cognitive capacity is diminished.
3. Navigating Varying Expectations in an Intermediary Position: HCNs function as intermediaries between patients, relatives, physicians, and pharmacies. This role involves coordinating fragmented information flows, often acting as a "middleman" for medication changes. HCNs report frustration when their clinical observations are not fully acknowledged by physicians and face ethical dilemmas when relatives and patients hold conflicting views on who should manage medications. They bear the responsibility for safety without always possessing the formal authority to influence prescribing or dispensing decisions.
4. Struggling with Organizational Constraints Shaping the Patient Encounter: Structural conditions, including fluctuating staffing, high workloads, and a lack of continuity, undermine safe practices. Frequent changes in caregivers prevent the development of trust and a coherent understanding of patient needs. Time pressure limits the ability to observe side effects or engage in meaningful dialogue. Furthermore, a lack of shared understanding and consistent practices among colleagues, combined with an absence of structured forums for reflection, leads to inconsistent care and potential breaches of trust.

Significance and Claims
The study claims to provide novel insights into the "situated accomplishment" of medication safety in home care. Rather than viewing safety as a result of standardized procedures alone, the findings suggest that safe medication management is a dynamic, negotiated process heavily dependent on the HCN's ability to adapt to relational, clinical, and organizational constraints.

• Theoretical Contribution: The paper frames these challenges through the lens of Resilient Health Care (RHC), specifically a "Safety II" approach. It argues that safety emerges from the capacity of professionals to anticipate, monitor, and respond to varying conditions, rather than merely avoiding errors (Safety I).
• Practical Implications: The authors assert that addressing these challenges requires more than individual competence. They call for organizational and management-level support to strengthen the HCN's intermediary role. This includes creating structures for reflection, shared decision-making, and interprofessional collaboration.
• Policy Implications: The study concludes that medication safety in home care must be understood as a relational and organizational responsibility. Policy and management structures need to recognize the invisible coordination and ethical deliberation embedded in nursing practice, moving away from task-centered models toward those that support person-centered, autonomous care.

The authors maintain a modest stance, noting that the findings are exploratory and based on rural Norwegian contexts, and therefore may not be directly transferable to urban settings or different organizational structures. The study does not measure error rates or clinical outcomes but offers contextual insights into how safety is negotiated in everyday practice.