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REVIEW

The Role of the Nurse in the Management of

Medicines During Transitional Care: A Systematic
Review
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Journal of Multidisciplinary Healthcare

Abbas Mardani 1 Purpose: To synthesise knowledge and to explore the role of the nurse in medicines
Pauline Griffiths 2 management during transitional care.
3 Methods: An integrative systematic review was conducted. Electronic databases such as
Mojtaba Vaismoradi
1
PubMed [including Medline], Web of Knowledge, Scopus, and Cinahl from January 2010 to
Nursing Care Research Center, School
For personal use only.

of Nursing and Midwifery, Iran University April 2020 were searched. Original qualitative and quantitative studies written in English that
of Medical Sciences, Tehran, Iran; focused on the role of the nurse in medicines management during transitional care, which
2
Department of Nursing, College of included movement between short-term, long-term, and community healthcare settings were
Human and Health Sciences, Swansea
University, Swansea, Wales, UK; 3Faculty included.
of Nursing and Health Sciences, Nord Results: The search process led to the retrieval of 10 studies, which were published in
University, Bodø, Norway
English from 2014 to 2020. They focused on the role of the nurse in patients' medicines
management during transitional care in various healthcare settings. Given variations in the
aims and methods of selected studies, the review findings were presented narratively utilizing
three categories developed by the authors. In the first category as ‘medication reconciliation
process’ the nurse participated in obtaining medication history, performing medication
review, identifying medication discrepancies, joint medication reconciliation and adjustment.
The second category as ‘collaboration with other healthcare providers’ highlighted the
nurses' role in clarifying medicines' concerns, interdisciplinary communication and consulta­
tion, discharge planning and monitoring. In the third category as ‘provision of support to
healthcare recipients’, the nurse was responsible for interpersonal communication with
patients, education about medicines, and simplification of medication regimens, and symp­
toms management during transitional care.
Conclusion: Nurses play a crucial role in the safety of medicines management during transi­
tional care. Therefore, they should be empowered and more involved in medicines management
initiatives in the healthcare system. Patient safety and avoidance of medication errors during
transitional care require that medicines management becomes a multidisciplinary collaboration
with effective communication between healthcare providers.
Keywords: continuity of care, multidisciplinary collaboration, medicines management,
nurse, patient safety, systematic review, transitional care

Introduction
Transitional care has become an important aspect of patient care in the healthcare system
Correspondence: Mojtaba Vaismoradi
Faculty of Nursing and Health Sciences, due to shorter lengths of hospital stay and the increased requirements of post-discharge
Nord University, Bodø 8049, Norway care.1 Given the association between patient handovers during transitional care and
Tel + 47 75517813
Email [email protected] incidences of adverse events, transitional care has been identified as a high-risk stage

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of the patient care journey.2–4 Transitional care has been family caregivers in medicines management.18 Preventable
defined as a set of developed measures to ensure the continuity adverse drug events in transitional care account for
and coordination of health care when the patient is transferred 46%–56% of all medication errors.19 A systematic review
between various levels of health care in the same or to other reported that 11%-59% of the medication history errors at
healthcare settings.5,6 The transfer of necessary information admission and discharge had the potential to harm the
and the liability of patient care from one healthcare setting to patient.20 Redmond et al21 in a Cochrane review on 20
another is the fundamental and essential element of quality and studies reported that 559 out of 1000 patients were at the
safety in healthcare facilities.7 Factors that can disrupt effec­ risk of one or more medication discrepancies during standard
tive transitional care across healthcare settings include inade­ transitional care programmes. Points of care transition in the
quate patient or caregiver training, inappropriate healthcare system where patients are at the danger of medi­
communication between healthcare providers, insufficient cation-related harm include hospital to home transition;22
evaluation of access to medication, and low health literacy admission to the hospital;23 hospital admission, transfer and
levels.8 Therefore, transitional care has become a concentrated discharge;24 discharge from the hospital and post-
area of research and practice in medical sciences.9 discharge;25 and admission to the emergency department.26
Effective medicines management is a complex undertak­
ing in both short-term and long-term healthcare settings
Transitional Care: Medicines Management including hospitals and nursing homes and requires collabora­
and Patient Safety tion by healthcare providers such as nurses, physicians and
Achieving optimal transitional care between healthcare pharmacists to maximize positive healthcare consequences
settings is essential to ensure patient safety and prevent and to minimize practice errors.14 Medicines management is
hospital readmissions.10 It has been suggested that effec­ one of the most complex interdependent clinical challenges in
tive transitional care can reduce by 50% the relative risk of health care and each healthcare provider involved in transi­
readmission within 30 days of discharge and save $2 for tional care has independent, joint and overlapping
every $1 spent in the healthcare system.11 In general, responsibilities.27,28 Nurses are considered to be key members
transitional care programmes work as the bridge between of the transitional care team.29,30 Their crucial role encom­
pre-discharge and post-discharge caring interventions at passes evaluating the transitional care plan, recognizing poten­
multiple points in time. Patient engagement, as well as tial problems and then resolving them in order to improve
collaboration and communication between healthcare patient safety.31 Involvement of nurses in medicines manage­
staff,12 is encouraged from admission to the primary care ment of transitional care helps with the provision of access to
setting to the return to the patient's own home.13 care for patients with fragmented care or those at high risk of
Medicines management is an essential component of the readmission. Their role has been suggested to be an alternative
provision of high-quality care and patient safety in transi­ to the use of emergency services because it improves the
tional care.14 One of the primary solutions for patient safety workflow for referring physicians and supports care naviga­
from the perspective of the World Health Organization tion back to community healthcare providers through patient
(WHO) is to ensure medication safety in transitional care.15 education and medication self-management.32
Also, medication-related issues have been considered to be Despite the importance of nurse participation in the
substantial components of high-quality care in transitional safety of medication practice and the success of transi­
care,16 in particular, that the medication regimen be trans­ tional care, there is no integrated knowledge of the nurse
ferred as safely as possible.17 Transitional care programmes role in medicines management of transitional care in the
can help with reducing medication-related problems, international literature. Therefore, this systematic review
improving access to medication therapy, providing compre­ of the international literature aimed to find an answer to
hensive medication counselling, and bridging gaps in medi­ the following question: What is the role of the nurse in
cation care following hospital discharge.10 However, patients medicines management during transitional care?
in transitional care between healthcare settings are prone to
medication errors due to the lack of appropriate communica­ Aim
tion between healthcare providers, insufficient education and This review aimed to synthesise knowledge and explore
training, inappropriate follow-up, inadequate medication the role of the nurse in medicines management during
reconciliation, and lack of engagement of patients and their transitional care.

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Methods Study Selection

Protocol and Registration Each step of the systematic review process was performed
This integrated systematic review of international literature independently by the authors (AM, PG and MV). They
involved both qualitative and quantitative studies.33–35 It undertook online conversations to share the search results
allowed the authors to combine individuals' understandings and decide on the next steps of the study. The studies'
obtained from statistical findings of quantitative research and titles, abstracts and full-texts were obtained during the
narrative findings of qualitative studies in order to develop search process and were screened by the authors. The
a comprehensive understanding of the study phenomenon.36 authors held discussions to resolve controversies and
This systematic review was informed of the Preferred reach a consensus over the inclusion of selected studies.
Reporting Items Systematic Reviews and Meta-analysis
(PRISMA) Statement35 and has been registered on the Quality Appraisal
PROSPERO under the code of CRD42020163046: https:// For the overall quality appraisal of selected studies in
www.crd.york.ac.uk/prospero/display_record.php? terms of the appropriateness of the research process and
RecordID=163046. structure, the Enhancing the Quality and Transparency of
Health Research (EQUATOR) was used.37 Tools for the
appraisal of selected studies were as follows: the Standards
Search Process and Eligibility Criteria
for Reporting Qualitative Research (SRQR) for qualitative
To identify appropriate keywords, the research team
research; the Strengthening the Reporting of Observational
undertook discussions amongst themselves and also drew
Studies in Epidemiology (STROBE) for observational,
upon their experiences in the field of transitional care and
cross-sectional and cohort studies; the Good Reporting of
medicines management. They also conducted a pilot
A Mixed Methods Study (GRAMMS) for Mixed-methods
search in general and specialized databases to find relevant
designs; Consolidated Standards of Reporting Trials
keywords. To identify papers on the role of the nurse in
(CONSORT) for experimental and quasi-experimental stu­
medicines management during transitional care, the
dies. Also, the Hawker et al38 criteria regarding the
Boolean search method was applied using the following
research aim, scientific structure, quality of the research
keywords: (nurs* AND (participation OR involvement OR
process and methodology, conclusion and references were
engagement OR role) AND (“transitional care” OR “tran­
specially considered for appraising the studies. In addition
sition of care” OR “care transition” OR “healthcare transi­
to the consideration of scores given by the appraisal tools
tion” OR “continuity of patient care”) AND (“medicines
for making a final decision on the inclusion or exclusion of
management” OR medication OR medicines OR drug OR
studies, the authors discussed and made appropriate deci­
“pharmaceutical preparations” OR pharmaceuticals)).
sions on the significance and the methodological quality of
Guidance and support were received from an expert librar­
each study for data analysis and synthesis.
ian during the search process. Accordingly, the online
databases of PubMed [including Medline], Web of
Knowledge, Scopus and Cinahl were searched to extract Data Collection Process and Synthesis of
studies published in online peer-reviewed scientific jour­ Results
nals from January 2010 to April 2020. Grey literature A data extraction table, containing the first author surname,
search encompassed policy documents, clinical guidelines publication year, the country where the study was con­
and cross-references from bibliographies for improving the ducted, design, sample size and setting, and data relating to
search coverage. Inclusion criteria for selecting relevant the role of the nurse in medicines management of transi­
studies were: qualitative and quantitative studies, focus on tional care were developed and pilot-tested to ensure that it
the role of the nurse, medicines management of transi­ could collect required data on the characteristics of selected
tional care in short-term and long-term healthcare settings studies. The review findings were presented narratively due
as well as community healthcare settings, and publication to variations within the selected studies in terms of aims and
in peer-reviewed scientific journals. Articles without exact methods that hindered performing a meta-analysis. The
relevance to the nurse’s role or concentration on the role of results of the selected studies were then reviewed and appro­
other healthcare professionals involved in medicines man­ priate categories were developed based on differences and
agement were excluded. similarities in their findings. The authors undertook frequent

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discussions to reach agreements on assigning the studies’ a retrospective cohort,41 one used a mixed-method study,42
findings into the categories. and one was a retrospective review of medical records.40

Results Transitional Point of Care in the Selected

Search Outcome and Selection of Studies Studies
The results of our search in the databases have been The selected studies focused on medicines management
presented in Table 1. The search process using the pre­ during the transition of care in various settings as follows:
from the emergency department to the medical ward,39
determined keywords led to retrieving 4037 articles. After
from the hospital to the long-term care facilities and
deleting unrelated and duplicate titles, and performing
home,42 from the hospital to home,40,41 between different
abstract and full-text reading, ten studies were selected
wards in the hospital,46 from the skilled nursing facility to
finally for data analysis and synthesis. The methodological
home,43 from the admission to discharge at the hospital,47
quality of the selected studies was evaluated during the
from the emergency department to discharge,48 to a home
full-text appraisal phase. No study was excluded as it was
hospice,44 and to a nursing home.45
judged that they had an acceptable level of quality in terms
of presentation and research design, theoretical and con­
ceptual framework, and their findings could inform our
The Role of the Nurse in Medicines
review. No more studies were discovered for inclusion Management During Transition of Care
during the grey literature search and from reviewing the Since there were heterogeneities in the studies' methods,
reference lists of the selected studies. objectives and results, a meta-analysis could not be con­
The study flow diagram according to the Preferred ducted and our review findings were presented narratively.
Reporting Items for Systematic Reviews and Meta- Three categories concerning the role of the nurse in the
Analyses (PRISMA) has been presented in Figure 1. safety of medicines management of transitional care were
identified: “medication reconciliation process”, “collabora­
tion with other healthcare providers”, and “provision of
General Characteristics of the Selected support to healthcare recipients”. These categories were
Studies identified after an analysis of the studies' findings (Figure 2).
An overview of the selected studies (n = 10) has been
demonstrated in Table 2. They were all published in Medication Reconciliation Process
English from 2014 to 2020, seven studies were from the This category discusses the role of the nurse in the med­
USA,39–45 one from Canada,46 one from Oman,47 and one icines' assessment process during transitional care at var­
from Australia.48 ious healthcare levels. Nurses were noted to play a crucial
Regarding the studies' methodologies, two studies used role in medicines management through the reconciliation
a qualitative design,45,48 one was a secondary qualitative process, where an accurate list of a patient's current med­
analysis,44 one was a survey,47 one used an experimental icines was assessed and was compared with the current list
design,43 two used a prospective cohort,39,46 one was in use. Accordingly, the nurses had three main

Table 1 Results of Different Phases of the Search Process

Database Total in Each Selection Based Selection Based Selection Based
Database on Title Reading on Abstract on Full-Text
Reading Reading/Appraisal

CINAHL 1012 14 4 2
PubMed [including Medline] 2283 13 4 3
Scopus 570 6 2 1
Web of Science 172 11 4 4
Manual search/backtracking 0 0 0 0
references
Total of databases 4037 44 14 10

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The role of the nurse in medicines management during transitional care

Identification

Records identified through database Additional records identified through

searching grey literature search and cross
(n = 4037) referencing from bibliographies
(n = 0)

Excluded based on titles and duplication (n = 3993)

Screening

Reading abstract to check for inclusion

criteria
(n = 44)
Excluded based on abstracts
(n = 30), reasons:
No focus on medicines
Eligibility

management of transitional
care (n=22);
Reading full-text articles to check for No focus on nurses (n=8)
inclusion criteria
(n = 14)

Excluded based on full-text

reading
(n = 4), reason:
Included

No exact focus on nurses'

Full-text appraisal for inclusion in data involvement (n=4)
analysis and synthesis
(n = 10)

Figure 1 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Note: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement. PLoS Med 6(7): e1000097. Available from: http://prisma-statement.org/PRISMAStatement/FlowDiagram.aspx. The PRISMA Statement distributed under the terms
of the Creative Commons Attribution License.65

responsibilities as “assessment of medication history”, that clinical nurses were involved in the medication reconci­
“identification of medicines discrepancies”, and “joint liation process at admission. Accordingly, emergency nurses
role in medicines reconciliation” that were described as collected medication history, and admitting floor (ward) nurses
follows. collected additional medication history and sent the report
about medication reconciliation to admitting physicians. The
Assessment of Medication History mean time spent by admitting floor nurses collecting medica­
Nurses were involved in obtaining medication history from tion history prior to (11 minutes) or after (16.6 minutes)
patients in the admission time to healthcare centres or at the placing the admission orders were not significantly different,
transition between healthcare levels.39,46 Chhabra et al39 noted but time spent per medication after placing admission orders

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Table 2 Characteristics of the Studies Selected for Data Analysis and Synthesis
Authors, Aim Method/Full- Sample and Setting The Role of the Nurse Main Finding
Year, Text in Medicines
Country Appraisal Management During
Score Transitional Care

Vogelsmeier, To explore the Qualitative/17 18 leaders, 13 registered Primary role in Nursing home physicians
2014, USA45 perceptions of leaders out of 21 nurses, and 28 licensed medication rely on nurses to know
and staff nurses of practical nurses in 8 mid- reconciliations and about medicines; active
nursing homes western nursing homes a main role in identifying vs passive information
concerning the process discrepancies in the seeking in medication
of medication medication order history and diagnosis of
reconciliation, with discrepancies; making
a focus on recognizing sense of medication
the medication order orders to recognize
discrepancies discrepancies

Chan et al, To compare the Prospective 84 patients up to 18 Transfer of medication No differences between
2015, completeness and cohort years admitted to and/or reconciliation through the nurse and/or
Canada46 accuracy of best possible comparison/25 transferred between the obtaining best possible pharmacist and pharmacy
medication histories and out of 34 cardiac critical care unit medication histories technician in terms of
reconciliation performed and cardiology unit of the completion of best
by a pharmacy technician a paediatric tertiary care possible medication
(pilot study) and by teaching hospital histories or completion
nurses and/or of reconciliation within
pharmacists (baseline) 24h of admission;
transfer reconciliation
completeness was higher
in the pharmacy
technician than nurse
and/or pharmacist

Manias et al, To explore how Qualitative/18 10 patients, 10 family Clarifying medicines’ Major themes:
2015, healthcare providers, out of 21 members, 27 nurses, 15 concerns and patients' contextual environment
Australia48 patients, and their family pharmacists and 11 clinical parameters with of care, competing
members communicate physicians from two doctors; nurses situated responsibilities of care,
about managing public hospitals in the nursing home awareness of
medicines across organize medicines' responsibility for safety,
transitional care points changes with a phone call and interprofessional
to a general practitioner communication
in the hospital when
a patient transfers to the
nursing home;
performing interpersonal
communication with
patients and
interdisciplinary
communication was
crucial for medicines
management

(Continued)

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Table 2 (Continued).

Authors, Aim Method/Full- Sample and Setting The Role of the Nurse Main Finding
Year, Text in Medicines
Country Appraisal Management During
Score Transitional Care

Lovelace To investigate the impact Retrospective 346 veterans from the An initial assessment Veterans who received
et al, 2016, of the McGuire veterans review of Richmond, VA Hunter including an extensive transitional care program
USA40 administration medical medical Holmes McGuire VAMC medication review, services had a 67%
centre transitional care records/24 out as a 399-bed facility collaboration with the reduction in hospital
program on veteran of 34 pharmacist to provide an admissions and a 61%
emergency department accurate discharge reduction in emergency
and hospital utilization medication chart, making department visits in the
and costs medication adjustments 90 days after
and order medications' participation in the
renewals program

Reidt et al, To describe the Experimental/24 87 participants in the Provision of consultation There was no difference
2016, USA43 interprofessional out of 37 intervention group to the pharmacist when in hospitalizations 30
collaborative practice received care based on unexplained changes days after discharge from
model and compare the the model, and 189 occurred in the the skilled nursing
outcomes of participants individuals in the effectiveness of and facility; participants
who received care based comparison group safety of all prescriptions, receiving the
on the model and those received routine care at collaborating with the intervention according to
individuals who received a non-profit skilled pharmacist to determine the model had a lower
routine care from the nursing facility with 60 the discharge medication risk of emergency
geriatrician and nurse transitional care unit regimen, and department visits
practitioner in transition beds recommending items to
from the skilled nursing the pharmacist to
facility to home address at follow-ups

Al-Hashar To investigate beliefs, Survey/18 out 143 physicians, 47 Nurses had a joint role A lack of clearness of
et al, 2017, responsibilities and of 32 pharmacists and assistant with physicians and current practices of
Oman47 perceived roles of pharmacists and 274 pharmacists in medication reconciliation
nurses, pharmacists and nurses from a university medication reconciliation and a lack of agreement
physicians about the tertiary care hospital in transitional care about other providers'
medication reconciliation with 450 beds role in medication
process reconciliation between
the three healthcare
professions

Chhabra To compare time spent Prospective, 72 patients were Collecting medication Pharmacists and nurses
et al, 2019, by nurses and unblinded, randomized based on the history and performing spent a mean of 10
USA39 pharmacists according to cohort location of pharmacist to medication reconciliation minutes less per patient
the location of observational/ be interviewed in the with admitting physicians in the emergency
a medication-focused 26 out of 34 emergency department department than patients
interview or on the floor in a 435- on the medical floor for
bed community hospital collecting medication
history. The discrepancy
in the transcript was
found by the rate of 1 in
4 medications

(Continued)

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Table 2 (Continued).

Authors, Aim Method/Full- Sample and Setting The Role of the Nurse Main Finding
Year, Text in Medicines
Country Appraisal Management During
Score Transitional Care

Otsuka et al, To examine the effect of Retrospective 660 patients were in the Performing the follow-up 30-day hospital
2019, USA41 an interprofessional cohort/28 out interprofessional post- phone call to the patient readmission was lower in
transition of care facility of 34 acute care clinic as in the or caregiver to begin the the intervention group,
on 30-day hospital intervention group and process of medication but for emergency
reutilization the comparison group reconciliation by department visits no
from two outpatient determining if patients difference between the
clinics within an were capable to fill their groups was found
academic medical centre. new prescriptions

Tjia et al, To identify nurses' Secondary 6 home hospice nurses, 3 Performing medication Education, skill-building,
2019, USA44 viewpoints about their qualitative inpatient hospice nurses, review as the key support and counselling
role in hospice family analysis/15 out and 1 medical home component of for family caregivers;
caregivers' medication of 21 nurse coordinator for medication support and need to an intervention
management primary care from three deprescribing process, to standardize patient-
hospice agencies and providing education to cantered medication
their referring hospital increase medication review
systems knowledge to family
caregivers, simplifying
medication regimens as
support to patient and
family caregivers

Prusaczyk To discover the Mixed methods/ 9 healthcare providers in Primary provision of Healthcare providers at
et al, 2020, transitional care 5 out of 6 the qualitative phase and education about the hospital had
USA42 measures provided to reviewing 126 patients medications, medication distinguished roles in the
older adults with and with dementia and 84 safety and being highly provision of transitional
without dementia without dementia from involved in medication care to patients with
an urban, large academic reconciliation and different roles for
medical centre with 9000 medication review patients with and
employees without dementia

(2 minutes) was higher than before it (0.94 minute). In the from the hospital. The outpatient nurse practitioner then
study by Chan et al46 the nurses' role in the medication collaborated with the case management nurse during home
reconciliation process was to obtain the best possible medica­ visits. They reviewed medications according to the assess­
tion history and perform medication reconciliation for those ment provided by the case management nurse, made
patients who were admitted to the cardiology ward or the adjustments, and ordered medications renewals if the
critical care unit or those who were transferred between wards. case management nurse faced difficulties in access to
primary healthcare providers. Prusaczyk et al42 described
Identification of Medicines Discrepancies transitional care measures being provided to older adults
Reviewing medications overall,40,42 collecting information with and without dementia in the transition from the hos­
for identifying medication discrepancy,45 and medication pital to long-term care facilities and home, and noted that
support and deprescribing process44 were reported as roles registered nurses and advanced practice registered nurses
of nurse. In the transitional care programme devised by delivered medication safely to 99% and 37% of patients,
Lovelace et al40 the case management nurse performed an respectively. Advanced practice registered nurses were
initial assessment and extensive medication review during described as being highly involved in medication review
the first home visit or telephone follow-up after discharge and medication reconciliation.

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Medication reconciliation Collaboration with other Provision of support to

process healthcare providers healthcare recipients

Clarification of medicines’
Joint role in medicines
concerns and patients’ clinical Interpersonal
reconciliation;
parameters; communication with
Identification of medicines Interdisciplinary patients;
discrepancies; communication;
Education about
Assessment of medication Provision of an accurate medicines;
history; discharge medicines chart;
Simplification of
Review of medicines for Consultation in case of medicines regimens;
adjustment and renewal; unexplained changes;
Symptom management
Medicines reconciliation based on Discharge planning for the and monitoring after
capabilities to fill new medicines regimen; discharge
prescriptions
Monitoring and follow-up of
medicines regimens;
Change of medicines

Figure 2 The nurse role in medicines management of transitional care.

In the study by Tjia et al,44 nurses' perspectives on their engage in a cognitive process called “sense-making” where
role in family caregivers' medicines management and support tried to identify medication discrepancies. In this respect,
in transition to home hospice were addressed. Nurses consid­ rules/regulations, specific medications and the experience of
ered that medication review was a key component of medica­ errors and adverse events were cues to consider potential
tion support and the deprescribing process. The nurse was discrepancies.
responsible for checking the medication list to find essential
and nonessential medicines, describing them to the family Joint Role in Medicines Reconciliation
caregiver and discussing with the physician to receive recom­ In the study by Otsuka et al41 nurses were the members of
mendations on discontinuing nonessential ones to prevent side interprofessional post-acute care clinics and were involved
effects, adverse drug reactions (ADRs), and polypharmacy. in medicines management for those patients who were
The nurse would also monitor the process of medication by the transferred from the hospital to their own homes. The
patient and the family caregiver before making any decision process of medication reconciliation was started through
regarding changes to essential medicines. assessing patients' capabilities to fill out their new pre­
Vogelsmeier45 reports that nurses in nursing homes had scriptions via telephone calls to the patient or the caregiver
a primary role in performing medication reconciliations and within two business days post discharge.
they assessed medication history and identified medication Al-Hashar et al47 reported that nurses had a supportive role
order discrepancies during transition to nursing homes. Some working with pharmacists and physicians in medication recon­
nurses performed “active information seeking” through ciliation from hospital admission to discharge. Nurses consid­
reviewing transfer documents and talked with residents and ered themselves to be second only to physicians in medication
families in order to understand the medication history and reconciliation since they: obtain an accurate medication his­
reasons behind ordering medications. Others performed “pas­ tory on admission, verify and reconcile discrepancies between
sive information seeking” as they assumed that medication the medication history list, those ordered on admission and at
orders at transfer were correct and that time challenges and transition, and send the discharge medication list to the next
heavy workloads hindered deciphering clinical information to healthcare provider. Nurses considered that they were second
discover medication order discrepancies. Many nurses did only to the pharmacist in the provision of instructions and

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counselling for patients about medications upon discharge. and sent the list and information to the case management
From the pharmacists' perspective, the nurses' role in the nurse who then contacted the patients or their caregiver to
process of medication reconciliation was of less importance schedule a home visit. Following the home visit, case
than that of pharmacists and physicians as nurses were not management nurses would then report medication discre­
involved in sending the patients' discharge medication list to pancies to the members of the transition care programme
the next healthcare provider. Physicians described the nurse team and the patients' primary care provider and care
playing a supportive role in the medication reconciliation manager. The case management nurse would also collabo­
process with key roles being played by themselves and the rate with a pharmacist to provide a precise discharge
pharmacist in the medication reconciliation in transitional medication chart with print size adjustments for those
care. patients suffering from impaired vision.
Vogelsmeier’s45 study found that nursing home physi­
cians relied on information and recommendations provided
Collaboration with Other Healthcare
by the nurse to know what medications the resident was
Providers supposed to be taking because they provided care to resi­
This category describes the role of the nurse in the med­
dents only in the nursing home. The physicians were
icines management of transitional care at various health­
unfamiliar with residents' medical care prior to transfer,
care levels in collaboration with other healthcare
rarely communicated with other healthcare providers and
providers. In the study by Manias et al48 regarding com­
were not present at the time of transfer. Therefore, nurses
munication about medicines management during the tran­
were the prime source of information on medicines man­
sition point between emergency departments and medical
agement and would request that the physician perform
wards, the nurses' proactive stance in medical wards was
required assessments and review laboratory values. The
evident as nurses clarified concerns over medicines with
nurse would then consult with the physician prior to med­
doctors. Nurses in the medical ward evaluated the clinical
icines being prescribed.
parameters of transferred patients from the emergency
Reidt et al43 focussed on a model for interprofessional
department and alerted doctors about gathered information
collaboration that improved discharge from a skilled nur­
leading to rational medicine changes. When the patient
sing facility to home. Nurses played the main role in
was transferred to the nursing home, those nurses then
discharge planning from the skilled nursing facility. The
organized medicines' changes via a phone call to the gen­
pharmacist a few days before discharge would review the
eral practitioner.48
electronic health record to evaluate dietary supplement
Various synchronous and asynchronous forms of inter­
prescriptions and over-the-counter medications in terms
disciplinary communication among healthcare profes­
of indication, effectiveness and safety and would ensure
sionals including nurses, physicians, and pharmacists
that changes of medications made during the hospital and
influenced medicines management between the transition
skilled nursing facility stays were still appropriate. The
points of care.48 While nurses considered verbal commu­
pharmacist resolved unexplained changes by consulting
nication essential so as to be equipped quickly to provide
with the nurse practitioner and shared recommendations
suitable care, asynchronous communication, such as dis­
such as starting or ceasing medicines, adjusting doses, or
charge summaries and referral letters, was also valued.
ensuring that necessary laboratory work was ordered for
The accuracy and readability of the documented content
the discharge medication regimen. In addition, the phar­
of communication were significant requirements to avoid
macist and nurse determined collaboratively the discharge
medication discrepancies at transitional points of care.
medication regimen. The nurse also monitored particular
Nurses acknowledged that written communication was
medicines' side effects and reminded patients about fol­
essential to face the challenge of working in a quickly
low-up appointments.
changing environment.48
In the study by Lovelace et al40 some patients were
transferred to nursing homes for short-term rehabilitation Provision of Support to Healthcare
following their hospitalizations based on the devised tran­ Recipients
sitional care programme. The pharmacist contacted the This category discusses the nurses' provision of support to
nursing home to obtain a list of discharge medications healthcare recipients in the medicines management of

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transitional care at various healthcare levels. Tjia et al44 doctors, pharmacists, patients and their families as well as
explored nurses' perspectives on their role in family caregivers' applying fundamental nursing interventions to relieve poten­
medicines management and support in the transition to home tially negative consequences on patient wellbeing.50,51
hospice. Nurses provided education and skill building for This review discovered that nurses actively played various
family caregivers, and emphasized increasing knowledge roles in the medication reconciliation process such as collect­
and education regarding symptoms. To enable skill-building, ing medication history, reviewing medications, collecting
they focused on symptom management and less on medicines information to identify medication discrepancies, coordinating
organization and administration. The medication regimen was medication support, and supporting the deprescribing process.
simplified for patients' and family caregivers by eliminating as They started the medication reconciliation process by asses­
many medications as possible.44 Nurses also improved trust sing patients' capabilities to comply with their new prescrip­
and communication through paying attention to patients and tions and engaging in their joint role with pharmacists and
their family caregivers and understanding the concerns of the physicians in medicines management from admission to the
family caregiving when deprescribing medications.44 hospital until discharge. The nurse was the key health profes­
Prusaczyk et al42 evaluated transitional care interventions sional in performing medication reconciliation in nursing
provided by various healthcare providers to older adults with homes. Nurses raised concerns over medicines prescribed by
and without dementia in transition from the hospital to long- doctors, provided medication consultation to the pharmacist,
term care facilities and home. Nurses were the primary provi­ assisted in collaboratively determined discharge medication
ders of patient education regarding medication education and regimes, and had interdisciplinary communication with phy­
how to manage and monitor symptoms after discharge.
sicians and pharmacists to ensure medication safety. They
Advanced practitioner registered nurses also helped with edu­
provided medication education, consultation and symptoms
cation about the management and monitoring of symptoms. In
management associated with medications, helped with simpli­
the Al-Hashar et al47 study, nurses described their key role in
fying the medication regimen, and established interpersonal
the provision of instructions and counselling to patients about
communication to ensure medication safety and support to
medications upon discharge. Manias et al48 described inter­
healthcare recipients. The nurses' integral role in the medica­
personal communication between health professionals, includ­
tion reconciliation process in various transitional points of care
ing nurses, and patients being the key ingredient of
has been supported by current international literature.1,52,53
maintaining medication safety. Provision of medicines'
Medication reconciliation is defined as an official process in
instructions for patients when moved between their homes
which healthcare providers work with patients to ensure the
and the hospital meant patients could take a more active stance
exact and complete transfer of medication information at the
in managing their medicines.
interfaces of care.54 Several international patient safety orga­
nizations including the Institute for Health Improvement (IHI),
Discussion
This systematic review integrated the findings of qualitative the Joint Commission (TJC), and the World Health
and quantitative studies and synthesised knowledge regarding Organization (WHO) have acknowledged that medication
the role of the nurse in the safety of medicines management of reconciliation is pivotal to achieve medication safety through
transitional care. Findings from this review indicate that the identifying medication discrepancies, particularly at transition
nurse's role in medicines management of transitional encom­ care points.55 Achieving optimal medication reconciliation
passes: medication reconciliation, collaboration with other requires the recognition of responsibilities and roles, interdis­
healthcare providers, and provision of support to healthcare ciplinary teamwork, proper communication, and better track­
recipients. According to the international literature, all health­ ing and reporting of information to successfully incorporate
care professionals should collaborate together to ensure patient the stages of medication reconciliation and ensure patient
safety. Moreover, nurses should take more responsibility and safety.54,56 On the other hand, healthcare professionals' insuf­
become more involved in patient safety initiatives and act ficient knowledge of medicines management is one of the
proactively in order to protect and maintain the safety of important barriers to achieving optimal medication
medicines' management through disclosing and reporting reconciliation.57 Sufficient education and training are not pro­
errors.49 In addition, nurses are able to be involved in the vided to nursing students to practice medication reconciliation.
reduction of medicines' side effects and ADRs through mon­ Therefore, there is an evident need for training on the full
itoring medicines and providing informational support to medication reconciliation process and policy in clinical

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settings and the medication reconciliation process should be and long-term healthcare settings might have impacted the
covered in the degree education curriculum of nurses.58 synthesis and integration of the review findings. Also, studies
As highlighted in the findings of this review, two of the were limited to English language. However, performing our
main roles of the nurse in medicines management during search using multidimensional keywords and in international
transitional care are communication and collaboration with databases provided a comprehensive overview of the current
other healthcare providers. As a part of an interdisciplinary international knowledge about the role of the nurse in medi­
team, nurses along with physicians and pharmacists can play cines management safety during transitional care. Also, bias in
a crucial role in medicines management during transitions the process of data collection and synthesis was reduced as
from one setting to another. The findings of Albert's59 sys­ much as possible through close cooperation and discussion
tematic review on transition-of-care models in patients with between the authors. The role of nurses in medicines manage­
heart failure suggested that multi-professional teamwork, ment during transitional care is closely related to the type of
communication, and collaboration had key roles in ensuring healthcare settings and type of transitional point of care. Given
patient safety. Another recent systematic review by Bethishou the limited number of studies that met the inclusion criteria for
et al60 investigating the effectiveness of pharmacy-led conti­ this review prevented the full exploration of the role of the
nuity of care programmes indicated that the collaboration of nurse in medicines management at different transitional points
the pharmacist with nurses in undertaking phone calls to of care including transition within the hospital, from hospital
patients after discharge improved the quality and safety of to home and other healthcare facilities, which needs considera­
care. Ensing et al's52 suggested that in the transition point of tion in future studies.
care and post-discharge, pharmacists were most likely to col­
laborate closely with nurses to improve patient care outcomes.
Conclusion
Lack of communication and collaboration between healthcare
This systematic review focused on the role of the nurse in
providers, including nurses, is an important barrier to medi­
medicines management during transitional care and iden­
cines management at the transitional point of care.57
tified how it impacted on patient safety. Both qualitative
Therefore, nurses should develop communication skills and
and quantitative research findings through an integrative
effectively be invited to collaborate with the interprofessional
review design were included in order to provide
team in order to improve the continuity and coordination of
a comprehensive image of the study phenomenon.
care.61,62
Considering the critical role of nurses in medicines man­
Our review findings indicate that the nurses' role in the
agement during the transitional care process requires adequate
provision of education and support about medications and
attention to degree level education and in-service training for
symptoms management to patients and their family care­
nurses. Successful medicines management and reducing med­
givers requires optimal communication to ensure medica­
ication errors require the recognition of responsibilities and
tion safety. Provision of patient support and education at
roles, a multidisciplinary collaboration and communication
the transition points of care can reduce the risk of adverse
between various healthcare professions including nurses, doc­
medication-related events.16 Ozavci et al63 showed that
tors and pharmacists. Healthcare professionals through inter­
medication discrepancies at transitional care of older
disciplinary collaboration and communication share
patients were associated with nurses' communication with
objectives, display shared responsibility and power, make
patients. A systematic review by Tobiano et al64 on how
decisions collectively, and work together to improve medica­
patients engaged in medication communication during
tion safety during transitional care. Also, health professionals
admission and discharge demonstrated that nurses per­
should be aware of the role of the nurse in medicines manage­
formed counselling and education about medication,
ment to ensure medication safety during transitional care.
instructed patients about the medication discharge plan,
Future studies using qualitative and quantitative research
and conducted telephone calls for post-hospital discharge
methods should explore how nurses can be more actively
follow-ups about medications.
involved in medicines management of transitional care affect­
ing on patient care outcomes including adherence to medica­
Limitations tion regimens, visits to the emergency department, and
The heterogeneity of the selected studies' methods and varia­ reduction of the readmission rate to long-term healthcare
tions in their focus including being conducted in short-term settings.

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Data Sharing Statement 9. Storm M, Schulz J, Aase K. Patient safety in transitional care of the
elderly: effects of a quasi-experimental interorganisational educa­
All data pertinent to this study are contained in the article. tional intervention. BMJ Open. 2018;8(1):e017852. doi:10.1136/
bmjopen-2017-017852
10. Cole J, Wilkins N, Moss M, Fu D, Carson P, Xiong L. Impact of
Acknowledgments pharmacist involvement on Telehealth Transitional Care Management
Nord University, Bodø, Norway has supported the publication (TCM) for high medication risk patients. Pharmacy (Basel).
2019;7:4.
of this manuscript through coverage of publication charges.
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reported, whether that is in the conception, study design, home: a review for the neurohospitalist. Neurohospitalist. 2015;5
(1):35–42. doi:10.1177/1941874414540683
execution, acquisition of data, analysis and interpretation, 13. Lee KH, Low LL, Allen J, et al. Transitional care for the highest risk
or in all these areas; took part in drafting, revising or patients: findings of a randomised control study. Int J Integr Care.
2015;15:e039. doi:10.5334/ijic.2003
critically reviewing the article; gave final approval of the
14. Vogelsmeier A, Pepper GA, Oderda L, Weir C. Medication reconci­
version to be published; have agreed on the journal to liation: a qualitative analysis of clinicians’ perceptions. Res Social
which the article has been submitted; and agree to be Adm Pharm. 2013;9(4):419–430. doi:10.1016/j.sapharm.2012.08.002
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patientsafety/Preamble.pdf?ua=1. Accessed May 28, 2020.
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This research received no external funding.
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The authors have no conflicts of interest to declare. 823aa8c8
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