Nurse-pharmacist collaborations for promoting medication safety among community-dwelling adults: A scoping review

Abstract

Background

Despite good evidence that supports improved clinical health outcomes and the cost effectiveness of nurse-pharmacist collaboration for promoting medication safety among adults in acute care settings, there is limited research in community settings.

Objective

This scoping review examines, maps, and identifies gaps in the existing literature on nurse-pharmacist collaboration to augment medication safety among community-dwelling adults.

Design

Setting(s): Community setting

Participants

This review consists of 3,464 participants across 23 studies

Methods

We used the enhanced Arksey and O'Malley framework by Levac and colleagues. Studies from MEDLINE, CINAHL, ProQuest, Scopus, and PubMed databases implementing medication safety through nurse-pharmacist collaboration for community-dwelling adults were included. We extracted data according to country of origin, intervention, and relevance to the current review.

Results

Twenty-three studies were included in this review. Nurse-pharmacist collaborations in community settings are still evolving and are in a nascent form. Five sub-themes emerged from literature review of collaboration between nurses and pharmacists in community settings for medication safety. They are creating new opportunities to address gaps in community medication safety, enabling complementary interprofessional roles in medication safety, facilitating of efficient and cost-effective measures for medication safety, diverse nature of assessments done by nurses and pharmacists, and incohesive teams due to poor collaborative practices.

Conclusions

Nurse-pharmacist collaborations in community settings improved disease management, prevented adverse drug events, and reduced hospitalizations. They resulted in early identification and correction of medication safety related issues, reduced wait periods to see general practitioners, and enhanced chronic disease self-management skills among community-dwelling adults. There is a need to improve existing systems and policies through research for sustaining such collaborations especially in community settings.

Registration: number (& date of first recruitment): Not applicable.

What is already known

• •There is a high prevalence of medication errors in the community due to polypharmacy and multimorbidity.
• •Complexity of disease management, adverse drug events, and hospitalizations can be reduced through interprofessional collaborations in community settings.

What this paper adds

• •Nurse-pharmacist collaborations in community settings can improve disease management, prevent adverse drug events, reduce hospitalizations, and wait periods to see physicians.
• •Nurse-pharmacist collaborations can improve medication safety among community-dwelling adults with chronic conditions through safer medication use processes, early identification, and correction of medication safety related issues, and enhanced chronic disease self-management.
• •Collaboration between community nurses and community pharmacists is still evolving and there is a need to eliminate task duplication and develop strategies to improve communication and role clarity for effective nurse-pharmacist collaboration.

1. Background

The rise in chronic conditions has led to increased complexity in disease process management among community-dwelling adults (The Joint Commission, 2020). Polypharmacy, involvement of multiple healthcare providers, frequent transitions between care facilities, and changes to medication regimens, complicate chronic disease process management (Alper et al., 2020; LeBlanc and Choi, 2015; Lyson et al., 2019). These situations result in medication discrepancies that may compromise the safety, health, and well-being of the community-dwelling adults (Foubert et al., 2019). Interprofessional collaborative approaches that encourage patient engagement through assessment, education, and monitoring (Engel and Prentice, 2013) enhance medication safety (Flynn and Anderson, 2012).

Medication safety is defined as the freedom from preventable harm with medication use (Institute for Safe Medication Practices Canada, 2007). According to Lyson et al. patient-related factors, provider-related factors, and healthcare system related factors influence medication safety (2019). Patient-related factors include aging, limited health literacy, medication regimen changes due to transition between care facilities, polypharmacy, non-compliance / medication adherence, erroneous use of high-risk medications, and socioeconomic factors such as low income and low English proficiency (Lyson et al., 2019; Taylor et al., 2018). Provider-related factors include the skill levels of caregivers, number of caregivers, errors / discrepancies in medication use process, drug-drug interactions, potentially inappropriate prescriptions, inadequate monitoring of clinical indicators result in duplicate medications, non-therapeutic dosing, and adverse drug events (Banning, 2005; Lyson et al., 2019). A lack of universal guidelines and mandatory reporting systems, variances in funding, the differences in scopes of practice and skill mix of providers, and the availability of community resources influence risk factors within the healthcare system (Lyson et al., 2019). Medication safety might affect patient safety at any stage: assessment, prescription, transcription, dispensing, administering, and monitoring of medications (C.M. Godfrey et al., 2013). Addressing adverse events, reviewing best possible medication histories, monitoring clinical indicators, proper handoffs during care transitions, and medication reconciliation can address the factors that compromise medication safety (Alper et al., 2020; Foubert et al., 2019).

Collaborative interprofessional strategies, such as follow-up appointments, home visits, and counselling on medication adherence by providers working in community settings improve medication safety (Alper et al., 2020; The Joint Commission, 2020; Willis et al., 2011). Within the context of the healthcare system, interprofessional collaboration is a process of problem-solving, with shared responsibility for decision making, and the ability to carry out care plans while working towards a common goal (D'Amour et al., 2005). Healthcare conceptualizes collaboration as a complex dynamic process that addresses the perspectives of both the providers and the patients (D'Amour et al., 2005). Good team dynamics, shared goals, open communication, knowledge sharing, and mutual engagement to integrate professional roles promote interprofessional collaboration (Celio et al., 2018; Engel and Prentice, 2013). Such collective action engages patients in decision-making and care (Jones et al., 2017).

1.1. Key definitions

• Community-dwelling Adults. People aged 18 or older living at home including retirement homes where they live independently and use community nursing services for chronic healthcare conditions.

• Nurse-Pharmacist Collaborations. A collaboration between nurses and pharmacists working either as part of an interprofessional team with a physician, or as an independent dyad within community care settings. According to Saint-Pierre et al. these collaborations can be co-located collaborations, non-hierarchical collaborations, collaborations through shared consultation, and collaborations via referral and counter-referral (2018).

• Medication Safety Related Issues. Medication use processes that result in medication error, drug-to-drug interaction, drug-disease interaction, non-compliance / medication adherence, medication discrepancy, duplicate medication, non-therapeutic dosing, adverse events, potentially inappropriate prescriptions, polypharmacy, and inadequate monitoring of clinical indicators.

1.2. A call for improved medication safety in the community

According to the Canadian Patient Safety Institute (2017), in the next 30 years, there could be an enormous increase in the number of patient safety incidents in homecare settings resulting in greater treatment expenditures. To improve medication safety, the World Health Organization launched “Medication Without Harm” in 2017 as a global patient safety challenge with the intent to engage patients and providers for improved medication safety through education, research, and innovation. Similarly, a Joint Commission national patient safety goal is to improve the safe use of medications in homecare (The Joint Commission, 2020). Despite these measures, and variation in community-based health services, community-dwelling adults with chronic conditions, still have unmet needs regarding medication safety (Ploeg et al., 2019). Medication safety within the context of community care has not received the same focus as acute care (C.M. Godfrey et al., 2013). With the global movement in the healthcare paradigm to keep people at home, homecare services have seen a major shift in the way they provide services (Dennis et al., 2009; Hohl et al., 2019). The goal is to provide care efficiently and effectively through interprofessional collaborative practices (D'Amour et al., 2005; Shade et al., 2014). These services enable people to live at home and prevent hospitalizations (Ellenbecker et al., n.d.).

1.3. Community nursing and pharmacy collaboration

In community-based care, clients live in their natural or home environments with chronic disease an aspect of everyday life and goals of care focus on maximizing quality of life, encouraging self-care, illness prevention, and continuity of care (Hunt, 2012). Community nursing services include case management and disease management for health promotion, with nurses delivering care in multiple settings, like client homes, nursing homes, assisted living, and community health centers (Hunt, 2012). Community clients take more active roles in their medication management for chronic disease compared to hospitalized patients (Foubert et al., 2019). They monitor for side effects like changes in cognition, vision, mood, and behavior patterns that can negatively influence their psychosocial well-being, ability to perform activities of daily living, and potentially impact their overall safety at home (Foubert et al., 2019).

Community nursing teams can collaborate with physicians and other providers to provide client care and support (Hunt, 2012). The presence of a community pharmacist might fortify such care teams by addressing medication safety (Tasai et al., 2019). The pharmacist can provide medication reconciliation, identify, and rectify medication errors, and counsel clients on medications to achieve medication safety (Banning, 2005; Tasai et al., 2019). Community nurses working in collaboration with pharmacists can reduce adverse events and the hospitalization of community-dwelling adults by simplifying medication regimens, ensuring clear and accurate medication treatment orders, helping to monitor high-risk medications, answering medication-related questions, and highlighting concerns regarding non-adherence in community settings (Lee et al., 2018a; While, 2019). Moreover, such collaborations can reduce workload and wait periods to see physicians to improve chronic disease self-management skills of community-dwelling adults (Celio et al., 2018; Hadi et al., 2012).

There is very limited research on nurse-pharmacist collaborations in community settings (Celio et al., 2018; Hohl et al., 2019; Pherson et al., 2018). Where present, the literature focuses on chronic conditions such as diabetes, heart failure, and dementia, and without a focus on medication safety (McLean et al., 2008; Omboni and Caserini, 2018; Santschi et al., 2017). Given the rise in chronic disease, the complexity of disease management, and medication safety issues, it is important to understand how nurse-pharmacist collaborations might promote medication safety among community-dwelling adult populations.

2. Methods

A scoping review method was purposefully selected for this review to aid in knowledge synthesis for informing practice, future research direction, and policy by providing a comprehensive summary of various studies (Noble and Smith, 2018). This scoping review uses the enhanced Arksey and O'Malley framework by Levac et al. (2010) to examine the extent, range, and type of research activity, as well as the gaps in existing literature in this area (Arksey and O'Malley, 2005; Noble and Smith, 2018). The enhanced framework clarified and expanded all stages of the original framework with recommendations that support review process consistency (Levac et al., 2010). To provide a comprehensive overview of the literature, an iterative search strategy was used to include a variety of study designs in this review (Peters et al., 2015).

2.1. Stage one: Identifying the research question

With the high prevalence of medication errors at home (Lee et al., 2018a) related to polypharmacy from multiple comorbidities (Bell et al., 2017), developing roles and scopes of practice of community nurses and pharmacists, and limited evidence of nurse-pharmacist collaboration in community settings (Celio et al., 2018), it is important to understand how nurses and pharmacists can collaborate for medication safety. We identified no reviews in the current literature related to nurse-pharmacist collaboration in community settings with a focus on promoting medication safety for community-dwelling adults to guide research and practice. Therefore, the purpose of this scoping review was to examine, map, and identify gaps in the existing literature on nurse-pharmacist collaboration in community-dwelling adults in relation to medication safety. The research question guiding this scoping review was: How can nurse-pharmacist collaborations promote medication safety among community-dwelling adult populations?

2.1.1. Protocol and registration

A review protocol does not exist for this scoping review.

2.2. Stage two: Identifying the relevant studies

2.2.1. Eligibility criteria

The eligibility criteria were published or in-press English language, peer-reviewed articles with full text availability. Eligible articles include articles addressing any aspect of medication safety through nurse-pharmacist collaboration within community settings. Focus was on community services provided either at clients' homes or at community clinics run and managed by nurses. Period of search ranged from the inception of the database to 2021 to prevent loss of any historic/relevant studies. We conducted the final search on August 30, 2021, with monitoring of ongoing alerts for saved search terms.

2.2.2. Information sources

Studies from MEDLINE, CINAHL, ProQuest, Scopus, and PubMed were analyzed.

2.3. Stage three: Study selection process

An iterative search strategy was done in consultation with nursing librarian trained in Joanna Briggs Institute's Scoping Review methodology. The search was done in three stages by lead author and search results were confirmed by the librarian. Search I was conducted to identify the relevant studies in MEDLINE and CINAHL databases. Search II involved using the identified keywords and index terms across MEDLINE, CINAHL, ProQuest, Scopus, and PubMed databases. Search III was conducted for additional studies to access the primary sources. In addition, Google Scholar was used to identify gray literature, including guidelines, glossaries, and statistics. A search of Theses and Dissertations in ProQuest for existing studies in this area was also done. Appendix A has the list of the detailed search strategy employed for the MEDLINE database. Figure 1 in Appendix A shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-Scr) 2020 flow diagram depicting the details of the study selection process. Table 1

Table 1.

Keywords and subject headings used in search.

MEDLINE
I	Nurses and pharmacists
II	Medication adherence
III	Medication errors
IV	Medication reconciliation
V	Medication therapy management
VI	II or II or IV or V
VII	I and VI
CINAHL
I	(Major heading “nurses”) + (Major / minor heading “medication compliance” or “medication history” or “medication reconciliation” or “medication management” or “medication errors”)
II	(Major heading “pharmacists”) + Major / minor heading “medication compliance” or “medication history” or “medication reconciliation” or “medication management” or “medication errors”)
III	(Major heading “collaboration”) + Major / minor heading “medication compliance” or “medication history” or “medication reconciliation” or “medication management” or “medication errors”)
IV	Keywords used in combination to the above – “community dwelling adults”, “community”, “medication safety”

2.3.1. Inclusion criteria

• Types of Participants. Community-dwelling adults, with one or more chronic conditions, receiving guidance on medication safety in community settings from a nurse-pharmacist collaboration were included.

• Types of Interventions or Phenomena of Interest. Nurse-pharmacist collaborations within community care settings.

• Comparator. The interventions incorporating a nurse-pharmacist collaboration in various settings across different geographic locations were compared.

• Context. The context of this review is medication safety through a nurse-pharmacist collaboration within community settings for community-dwelling adults.

• Types of Studies. Qualitative, quantitative studies, reviews, and mixed method studies have been included in this review.

• Types of Outcomes. Outcomes regarding medication safety aspects such as hospitalization/readmission because of potentially inappropriate prescriptions, drug-to-drug interactions, medication errors, adverse events, medication adherence, self-management ability, and medication compliance in the community-dwelling adults.

2.3.2. Exclusion criteria

This review excludes nurse-pharmacist collaboration in community hospitals, long-term care homes, or assisted-living facilities where formal nursing care is provided and medication management is done completely by formal caregivers with no active participation by the client. Articles in languages other than English are also excluded in this review.

The final search yielded 297 results which were categorized using Zotero. The elimination of duplicates resulted in a total of 229 articles. All collaborations apart from nurse-pharmacist within the community context were removed from the final list. A total of 114 articles were left in the final list. These were further scrutinized using the inclusion criteria of nurse-pharmacist collaborations, aspect of medication safety within community settings in community-dwelling adults. This resulted in 23 articles that became the core of the scoping review. The lead author initiated the screening process which was repeated by two research assistants all arriving at the same conclusion. There were no discrepancies identified after initial clarification of the “community-dwelling adults” and “nurse-pharmacist collaboration”.

2.4. Stage four: Data charting and item extraction

To answer the research question, the following variables were deemed pertinent: (a) medication safety related issues, (b) nurse-pharmacist collaboration type, (c) strategies/interventions, (d) outcomes measured, and (e) results/findings.

The data extraction was an iterative process (Peters et al., 2015). A data chart was created with the following variables for data extraction: author(s), year of publication, source origin/country of origin, setting, population, study design, kind of collaboration, component of medication safety addressed, strategy used, outcomes measured, and findings relevant to the current scoping review. The scoping review process and key findings are elaborated in Appendix B.

Details of extracted fields from selected studies

Author(s), Year, Country	Setting + Sample Study design	Medication safety aspect(s) addressed	Nurse-pharmacist collaboration type	Intervention / Strategy	Outcomes measured	Findings
Hadi et al., 2016, UK	Community Clinic 79 Adult chronic pain (non-malignant) patients. Mixed methods design	Non-malignant pain management	Co-located collaboration	Education, medication review, and development of self-management skills	Pain intensity, physical functioning, emotional functioning, quality of life, and chronic pain grade	Nurse-pharmacist collaboration can effectively manage chronic pain in a community setting. Lack of referrals and funding biggest hurdles to sustain nurse-pharmacist collaborations
McLean et al., 2008, Canada	Community Pharmacy 14 community pharmacies with 227 eligible patients. Randomized control trial	Screen, assess, and measure BP in patients with Diabetes	Co-located collaboration	Community nurses and community pharmacists trained with BP guidelines and developed competencies to assess, screen, and measure BP in patients with Diabetes	The difference in change in systolic BP between the control and intervention groups at 6 months	Nurse-pharmacist collaboration intervention resulted in a clinically important improvement in BP. Policies needed to renumerate nurse-pharmacist collaborations for chronic disease management
Setter et al., 2009, USA	Home Health Care 220 adults aged 50 years or older discharged from hospital and referred to a home health care agency. Prospective longitudinal study	Assessing medication discrepancies during transition from hospital to homecare	Collaboration through shared consultation	Patients discharged from hospital into homecare in the community are assessed by nurses and pharmacists for identification and resolution of medication discrepancies	Improved percentage of medication discrepancies resolved and reduction in the numbers of planned and emergent physician visits and repeat hospitalizations	Nurse-pharmacist collaborations effective in resolving medication discrepancies in patients transitioning from the hospital setting to a home health care nursing agency. Medication discrepancies identified were due to two reasons – System level: Inaccurate or incomplete discharge instructions. Patient level: non-intentional and non-adherence to medication use
Pherson et al., 2018, USA	Nurse-pharmacist collaboration within the Community Aging in Place, Advancing Better Living for Elders program. 59 participants of age 65 and older on low income and functional limitations. Retrospective chart review	Identification of medication related problems	Collaboration through shared consultation	Facilitating aging in place. In-person medication review, patient education, assess for falls, pain, mood, and sexual health. Assist with medication adherence, medication side effects, readability of medication labels, resolve medication discrepancies and affordability of medications for patients	Identify opportunities to simplify complex medication regimens and improve medication safety	The nurse-pharmacist dyad resulted in the identification of numerous opportunities to simplify and improve the safety of the medications taken by older people living in the community with functional limitations. Transfer of knowledge for similar cases, improved knowledge, and ability to provide better patient education
Smith, 2016, Scotland	Community pharmacists and community nurses providing services to people living with dementia. Seven community pharmacists, two accuracy checking technicians and one community nurse Qualitative study	Communication and information sharing between providers	Collaboration via referral and counter-referral	Examining the situation of interaction between community pharmacists and community nurse when delivering services to people with dementia with nurses prescribing and pharmacists fulfilling the prescriptions	Identify facilitators and barriers to services based on interactions between community nurses and community pharmacists	Lack of collaboration and integrated teamwork between community pharmacists and community nurses due to limited communication has been noted. With nurses prescribing pharmacists felt a part of their work was taken on by nurses leaving them feel less integrated. To increase information sharing and communication, it was recommended to consider use of technology
While et al., 2005, UK	Community pharmacists 166 pharmacies in three metropolitan boroughs identified via a Health Authority website Questionnaire survey	Changing professional roles with Nurse prescribing	Collaboration via referral and counter-referral	The process of collaboration between nurses and pharmacists in the context of nurse prescribing are evaluated	Contact rates between the pharmacists and their local prescribing nurses	This study suggests that there is a readiness and willingness among community pharmacists to engage in interprofessional working with nurse prescribers. This changing role of nurses allows for maximizing the skills and resources of the existing workforce. There needs to be a greater understanding of roles to build cohesive teams
Bell et al., 2017, Norway	Interprofessional medication reviews in primary health care. Thirteen nurses and four pharmacists Qualitative study	Interprofessional medication reviews to prevent medication discrepancies	Collaboration via referral and counter-referral	Based on the Integrated Medication Management model, the experiences of nurses and pharmacists are examined	Knowledge improvement of participating nurses and pharmacists during medication reviews	Greater role clarity of the other profession and individual role in medication review, and the benefit of working in teams collaboratively identified. Nurses and pharmacists learned to be mutually interdependent. They were able to build on their combined knowledge of linking patient's symptoms to their medication use and challenge physician's prescription when presenting the case for physician approval. A need for common physical base to improve interprofessional collaborations, better funding, access to complete medical history and accessibility to monitoring data of a patient were seen as few future recommendations
Celio et al., 2018, Switzerland	Literature review 21 reference articles Review	Various interventions that address medication safety in terms of continuity of care and medication adherence	N/A	Articles evaluating medication adherence enhancing interventions with nurse-pharmacist collaboration in adult patients were included	Medication adherence enhancing interventions with a pharmacist and nurse collaborating with/without other healthcare professionals	Nurse-pharmacist medication adherence enhancing interventions are rare and often in a nascent phase. Nurse-pharmacist collaboration has professionals who provide different skills and expertise to patient care that complements the skill set of one another. Three risks associated with interprofessional collaborations – decline in responsibilities, loss of professional identity, and interprofessional conflicts. There is a need for more rigorous and high-quality methodological studies that focus on collaboration and interprofessional education of providers
Foubert et al., 2019, Belgium	Interprofessional collaboration with home care nurses, community pharmacists, and Physicians Convenience sample of 7 community pharmacists, 12 home care nurses and 12 physicians. Cross-sectional observational study	Shared medication schemes for medication safety with regards to dosing frequency, Inappropriate prescriptions, medication regimen complexity	Collaboration via referral and counter-referral	Develop a shared medication scheme for community-dwelling adults	Inventory the number of times pharmacists altered the medication scheme completed by nurses along with areas where improvements were made	This study showed that the community pharmacists could work in collaboration with home care nurses to improve patient safety while removing task duplication and using nursing resources efficiently. Need for better collaborative agreements between providers on medication management and a need to implement electronic health services for improved communication between providers
Lee et al., 2018, (a) Australia	Community pharmacists. 84 home nursing clients receiving support with medication management. Prospective study	Explore number and type of medication related processes, medication treatment authorization discrepancies	Collaboration through shared consultation	An integrated home nursing clinical pharmacy service. Community nurses referred patients to pharmacists with medication regimen/management concerns (as identified by pre-defined conditions in the study design). Pharmacists completed medication reconciliation and comprehensive medication review at the patient's home	Identify medication related processes and prescriber's uptake of recommendations, accuracy of the medication orders and number of patients receiving and updated medication order	The home nursing clinical pharmacy model can aid nurses to optimize medication safety and thereby prevent adverse events in frail elderly in community. The most common actions physicians took based on recommendations of pharmacist were dose reduction and stopping medications
Lee et al. (b) Australia	Community nurses, community pharmacists and Physicians involved in the provision of medication management services for home nursing clients. Convenience sample of 55 community nurses, 17 physicians, 10 community pharmacists and 4 nurse managers who provided medication management services to homecare clients. Qualitative exploratory study	Medication management processes with regards to medication errors and adverse events	Collaboration through shared consultation	Focus groups, in-depth interviews and stakeholder consultations were conducted to understand barriers to the medication management processes	Issues affecting the delivery of medication management services	Collaboration can lead to efficient use of resources provided there is role clarity and responsibilities are defined for the team members. Strategies are needed to improve interprofessional medication management and medication safety in the home nursing setting
T. Toivo et al., 2018, Finland	Home care clients ≥ 65 years in primary care, community nurses, community pharmacists and physicians. 191 participants from various health care units. Participatory action research	Medication reconciliation and medication risk assessment	Collaboration through shared consultation	Nurses identify clinically significant drug-related problems during home visits and report to the clinical pharmacist. The community pharmacists conduct medication reviews and patients’ physician makes final decisions on medication changes needed	general health status, functional ability of the older adults, and symptoms suggestive of adverse effects of medications	This study protocol shows how increased role clarity can lead to better collaboration. nurse-pharmacist collaboration can facilitate and innovate processes of medication management of homecare clients
Toivo et al., 2019, Finland	Older home care clients. 129 participants aged 65 and over who are home care clients of five home care units, a public health care center and a private community pharmacy. Two-arm, parallel, cluster randomized controlled trial	Medication risks associated with polypharmacy and drug regimens	Co-located collaboration	Nurses made preliminary assessments on medication risks and reported the findings to pharmacists. Pharmacists triaged cases for review	Number of approved changes in medication risks	Care coordination indicated a tendency for effectiveness when the agreed upon suggested recommendations were implemented by Physicians and nurses as planned
Taylor et al., 2018, USA	An outpatient, interprofessional telehealth chronic care management pilot program. 69 patients with three or more chronic conditions or took at least five medications. Retrospective review	Medication review regarding medication safety, vaccinations, adherence, cost savings for prescriptions by recommending alternatives and addressing care gaps related to medication management	Non-hierarchical collaboration	A physician referred patients at risk for medicine-related problems to the tele pharmacist where nurses coordinated with patients to facilitate the virtual visits. The pharmacist provided coaching, medication safety surveillance, prevention, and wellness services to the patients	The number of interventions per patient, telepharmacist recommendations made, prescriber acceptance of pharmacist recommendations of medication safety issues, resolution, and pharmacist related costs	Integrating the tele pharmacist and registered nurse improved the effectiveness of telehealth services in reaching underserved populations, improving patient care, and decreasing health care costs. There is need for legislation for telehealth and medicine remuneration
Meyer-Massetti et al., 2018, Switzerland	Patients transferring from hospital to home care in Switzerland. 100 patients aged 64 years and over and receiving 4 or more medications at the time of discharge to a home care organization. Prospective observational study	Medication management with regards to discharge process, prescription quality and clarity, post discharge medication supply and availability	Collaboration through shared consultation	Prescription quality was analyzed assessed for ambiguity by nurses and pharmacists	The quality of the transfer process was measured comparing agreed-upon with reported parameters	In addition to the known risk factors in patients transferring from hospital to home care (age, polypharmacy, multiple providers), three major problems impacted upon medication safety: fragmented communication, unreliable medication availability and a poor prescription quality. Presence of pharmacist in medication reconciliation process provided greater support to nurses within the clinical decision support system. Need for a robust and proactive reporting system to address medication mismanagement
Perraudin et al., 2016, Switzerland	Patients on an interprofessional home-based subcutaneous immunoglobulin therapy within the Swiss healthcare system. Patients needing treatment for primary immunodeficiency diseases with home-based subcutaneous immunoglobulin therapy. Quantitative study (Cost minimization analysis)	Medication safety, adherence, and patient coaching	Co-located collaboration	The interprofessional drug therapy management consist of inclusion (participant recruitment), training (three sessions with nurses and pharmacists) and long-term follow-up (an annual appointment with nurse-pharmacist dyad)	Cost efficiency	Home-based subcutaneous immunoglobulin therapy with an interprofessional team be an efficient alternative to hospital-based therapy. More autonomy and patient empowerment as patient can stay home for the therapy. Need to address the systemic barriers and have a remuneration plan for continuity and availability of this collaboration
Elliott et al., 2017, Australia	A collaborative, person-centered model of clinical pharmacy support for community nurses and their clients to do medication management. Three groups: Participants - Older people referred to the home nursing service for medication management, their caregivers, community nurses, physicians, and pharmacists. Reference group - a interprofessional stakeholders – nurses, pharmacists, physicians, community advocates, community nurse managers, government officials and representatives from nursing and pharmacy societies Project team – nursing and pharmacy academics, nurse managers and sociologist Qualitative participatory action research	Medication management – activities pertaining to medication administration, dose administration aids, medication lists, medication review, and medication risk management	Two kinds of collaborative interactions noted: 1) Collaboration through shared consultation – Collaboration between participants and reference group. 2) Collaboration via referral and counter-referral – collaboration between participants	Nurses communicated with pharmacist about medication management problems and sent referrals to address them. Pharmacists provided home visits, medication reconciliation, medication review, medication regimen simplification, preparation of medication lists for clients and nurses, liaison and information sharing with prescribers and pharmacies and patient/caregiver education	Range of clinical pharmacy services such as medication review and simplifying medication regimens for high-risk community-dwelling adults	Resulted in a collaborative, person-centered clinical pharmacy model that addressed the needs of clients, caregivers, nurses, and other stakeholders. The result of collaboration between nurse and pharmacists led to simplifying medication regimes and sharing of work thus leading to a decrease in number of home visits a nurse paid in the past
Porter et al., 2015, USA	Patient-Centered Medical Home for hemodialysis patients. 240 patients will be recruited from two dialysis centers. Nonrandomized quasi experimental trial	Medication management as part of hemodialysis care coordination	Collaboration through shared consultation	The program extends the existing dialysis care team (comprised of a nephrologist, dialysis nurse, dialysis technician, social worker, and dietitian) by adding a general internist, pharmacist, nurse coordinator, and a community health worker, all of whom will see the patients together, and separately, as needed	Quality of Life and satisfaction, blood pressure and diet; and healthcare use like emergency room visits and hospitalizations; and staff perceptions on care coordination	The model can be tried to other chronic conditions to enhance care coordination for safer patient care. May provide insight into things like interdependence, integration, role clarity for professions within the team for improved nurse-pharmacist collaboration
Santschi et al., 2017, Switzerland	The Team-Based Care for improving Hypertension management involving nurses, community pharmacists, and physicians on blood pressure control of hypertensive outpatients. 110 Outpatients from two ambulatory clinics and seven community pharmacies. Pragmatic randomized control study	Monitoring of clinical indicator – blood pressure	Collaboration via referral and counter-referral	Patients allocated to the intervention group receive the intervention. Nurses and pharmacists are trained per protocol and once they meet the competencies, they provide structured individual sessions at baseline, 6, 12 and 18 weeks	The primary outcome is the difference in daytime ambulatory blood pressure between the two group patients at 6-month of follow-up. Secondary outcomes include patients’ and healthcare professionals’ satisfaction with the intervention and blood pressure control at 12 months (6 months after the end of the intervention)	The results of this study protocol can inform policymakers on implementable strategies for routine clinical practice in terms of utilizing existing community resources. Inform policy makers about ways to improve efficacy and possible implementation and dissemination of a collaborative approach for hypertension management
Verweij et al., 2018, Netherlands	Cardiac Care Bridge transitional care program. 500 eligible patients aged 70 years or older and at high risk of readmission and mortality will be enrolled in six hospitals in the Netherlands. Randomized trial	Medication management in all three components of the intervention namely case management, disease management, and home-based rehabilitation	Collaboration via referral and counter-referral	Multiphase intervention Community Care Registered Nurse and Physiotherapist take over care of patients being discharged. The nurse performs medication reconciliation, identifies medication discrepancies, drug related problems, side effects, adherence and addresses them with physicians / pharmacists, and evaluates functional state of patient in collaboration with physiotherapist	Primary outcome: Incidences of unplanned readmission or mortality within 6 months post- randomization. Secondary outcomes: physical functioning, functional capacity, depression, anxiety, medication adherence, health-related quality of life, healthcare utilization and care giver burden	This study protocol when implemented will provide new knowledge on the effectiveness of the integration of geriatric and cardiac care
Bayraktar-Ekincioglu and Kucuk, 2018, Turkey	An oncology outpatient clinic. 43 patients were evaluated during their 204 clinic visits between October 2015 to March 2016 period. The study was conducted in an oncology outpatient clinic. Prospective study	The assessment and the interpretation of the severity of medication side effects	Collaboration through shared consultation	The assessment of side effects was conducted by a pharmacist and nurse independently using the National Cancer Institute Common Terminology Criteria for Adverse Events version 2	Comparison of the difference in the severity assessments of side effects between a clinical pharmacist and nurses	The care provided had a holistic approach. This may indicate that by allocating tasks based on professional skills, the resources can be used more efficiently by removing redundancies. The need for a new care model with increased interprofessional communication, and collaboration to improve care in oncology outpatient clinics. Need for objective measurement tools to eliminate subjective discrepancies depending on patient self-report and provider interpretation
Braungart et al., 2018, USA	A nurse- run warfarin clinic 50 Patients who are on Warfarin during the study timeframe, and clients of the clinic, and Warfarin was managed by the clinic. Outpatient clinic settings. Retrospective analysis	Monitoring of a high-risk medication (Anticoagulant therapy)	Collaboration via referral and counter-referral	Nurses in an Internal Medicine Practice received competency-based education regarding management of Warfarin from an embedded clinical pharmacist	Difference in the quality of patient management and maintenance of Time in Therapeutic Range for provider managed or nurse managed cohort	While the study did not show improvement of Time in Therapeutic Range by the nursing staff, quality of care was maintained and a new opportunity for interprofessional collaboration was created
Hamano et al., 2015, Japan	Older patients living at home. 78 of the 430 patients enrolled (1/5th) used both the nurse and pharmacist home visit programs in homecare setting. Cross-sectional study	Inappropriate prescriptions and the associated drug costs	Collaboration via referral and counter-referral	Identifying PIMs with the Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria and estimating the drug costs based on actual pharmaceutical prices and measured against either nurse or pharmacist home visits with both nurse and pharmacist home visits	Estimate the relations of either nurse or pharmacist home visit program to drug costs of inappropriate prescriptions	Complex patients’ needs were met better Need for longitudinal intervention study to assess the effectiveness of nurse-pharmacist collaboration to Inappropriate prescriptions drug costs

2.4.1. Methodological quality appraisal

The studies included are either from peer-reviewed journals or from reputable evidence-based sources such as government agencies, regulatory, or research facilities. For methodological quality appraisal, we checked for indexing of these articles in CINAHL as well as Scopus.

2.5. Stage five: Collating, summarizing, and reporting the results

2.5.1. Analysis

The sum of all participants across the 23 studies resulted in 3464 participants. The mean average age of the participants was between 46.5 to 86 years. The chronic conditions studied ranged from 1 to 9 illnesses like non-malignant pain, hypertension, diabetes, dementia, oncology, end stage renal disease, primary immunodeficiency diseases, anticoagulation therapy, functional limitations resulting from falls, mood, pain, and sexual health with clients taking up to 13 medications. Analgesics, anticoagulants, and antihypertensives were the top three categories of medications explored. The studies focused on different nurse-pharmacist collaboration types in the context of medication safety factors (Celio et al. (2018) and strategies to address them (Lee et al., 2018a; Meyer-Massetti et al., 2018; Porter et al., 2015; Setter et al., 2009; Taylor et al., 2018). The number of care providers was not always implicitly conveyed. The outcomes vary from the creation of new workflows for nurse-pharmacist collaborations (Foubert et al., 2019), adoption of systemic changes to improve medication safety (Lee et al., 2018a), and allow for changes to or expansion of scopes of practice (Smith, 2016).

2.5.2. An overview of the findings

Nurse-pharmacist collaborations can support medication safety in community settings through interventions like patient education, task allocation, utilizing existing community resources, expanding the care teams, creating new opportunities, simplifying medication regimens, and counselling patients on medication adherence (Porter et al., 2015; Santschi et al., 2017; Taylor et al., 2018; Verweij et al., 2018). These collaborative interactions are successful when the team members have longitudinal relationships (Pherson et al., 2018), access to all members of the team (Verweij et al., 2018), and use innovative technologies to achieve the medication safety outcomes (Taylor et al., 2018). On the contrary, nurse-pharmacist collaborations failed when there is lack of cohesiveness (Toivo et al., 2019), low contact rate, lack of reciprocity, limited communication, lack of defined roles, and responsibilities between the dyads (Smith, 2016; While et al., 2005). This can lead to an increase in interprofessional conflicts, feelings of marginalization, and lack of integration among team members (Celio et al., 2018; Smith, 2016). It is observed that team members especially physicians show reluctance to either refer (Hadi et al., 2016) or use the recommendations suggested by the nurse-pharmacist dyads (Toivo et al., 2019) in community settings. This hesitancy is attributed to limited clarity on roles, responsibilities, and remuneration structure within the teams (Taylor et al., 2018; Toivo et al., 2019).

Making recommendations to physicians. Nurse-pharmacist collaborations frequently recommended monitoring of changes to clients’ medications (Pherson et al., 2018). The nurse-pharmacist collaboration resulted in either nurse (Pherson et al., 2018), pharmacist (Hadi et al., 2016; Lee et al., 2018a) or both (Hamano et al., 2015) making referrals or recommendations regarding medication safety to physicians. The number of recommendations to physicians was as high as 97.1% (Hadi et al., 2016). Nurses worked in collaboration with pharmacists to provide client education (Foubert et al., 2019; McLean et al., 2008; Porter et al., 2015; Santschi et al., 2017). They identified medication discrepancies during medication reviews (Lee et al., 2018a; Meyer-Massetti et al., 2018; Porter et al., 2015; Setter et al., 2009; Taylor et al., 2018). Such collaborations identified need to secure medication supply (Meyer-Massetti et al., 2018), observe medication administration techniques (Perraudin et al., 2016), and measure clinical indicators (Braungart et al., 2018; Foubert et al., 2019; Meyer-Massetti et al., 2018). Nurse-pharmacist collaborations addressed client education by informing clients about the modifiable risk factors, their consequences on overall health and well-being, medication side effects, importance of medication adherence, and lifestyle choices to aid self-management of chronic diseases (McLean et al., 2008). Lee et al. (2018a) reported how the pharmacist prepared and assisted physicians to update treatment authorizations for 81% of the clients based on the review and recommendation of the community nurse.

Completing medication reconciliation and counselling on safe medication practices.Foubert et al. (2019) helped improve medication safety by studying the efficacy of pharmacist-generated standardized medication schemes after medication review and medication reconciliation were completed by a community nurse. These schemes addressed factors like medication indicators (61%), moment of intake (9%), name of medication (18%), instructions for use (6.6%), and frequency of dosing (0%). These factors not only aid detection of potential adverse events and inappropriate prescriptions, but also recommend appropriate therapies (Foubert et al., 2019). Nurses used these changed schemes in client education and monitoring of clinical indicators for self-management of chronic conditions (Foubert et al., 2019). In other studies, nurses directly promoted medication safety in nurse-pharmacist collaborations. For example, nurses sent referrals to pharmacists upon identifying discrepancies during medication reconciliation and worked towards their resolution (Setter et al., 2009). Nurse-pharmacist collaborations also assessed prescription quality for ambiguity, contraindications, duplicate medications, inappropriate prescriptions, medication supply (Meyer-Massetti et al., 2018). This helped identify and prevent adverse events and hospitalizations. Setter et al. (2009) identified the resolution of 67% of medication discrepancies through nurse-pharmacist collaboration. According to Pherson et al. (2018), we can prevent adverse events by assessing medication regimens for polypharmacy. The most common medication regimens involved antihypertensives (23%), analgesics (14%), and anticoagulation therapies (13%) (Pherson et al., 2018). According to Lee et al. (2018a) nurse-pharmacist collaborations provided counselling on medication management to 41.2% of the referrals and got rid of disused or expired medications in 16.7% cases. There were 71.4% recommendations for medication changes, of which 52.5% were adopted by physicians (Lee et al., 2018a). Taylor et al. (2018) found that through telepharmacy, over 200 client-specific interventions were provided based on their medication review. The interventions addressed safety (49%), immunizations (24.5%), care gaps (13.5%), adherence (10%), and cost savings (3%). The recommendations made were for monitoring clinical indicators (35.9%), contraindications (4%), inappropriate prescriptions (25%), and drug-disease interactions (14%) (Taylor et al., 2018). Proper medication administration techniques are less frequently discussed in the literature. In only one study, nurses coached and corrected the technique of injection administration in a cost-minimizing analysis study (Perraudin et al., 2016). In this study, the community nurse and pharmacist visited the client at home for training and follow-up under the guidance of the physician prescribing the dosage (Perraudin et al., 2016).

Monitoring clinical indicators. A few nurse-pharmacist collaborations have monitored clinical indicators such as blood pressure (McLean et al., 2008), international normalized ratio (INR) (Braungart et al., 2018), and serum panels (Porter et al., 2015) for chronic disease management. Through client education and follow-up, McLean et al. (2008) demonstrated a drop in systolic blood pressure by 5.6 at the 6-month period from baseline BP of 141.2 (13.9)/77.3 (8.9) mm Hg. In a pretest-posttest measure of baseline international normalized ratio results for warfarin management by nurses (with pretest mean baseline at 69.6% and posttest mean baseline after collaboration at 68.4%), Braungart et al. (2018) noted no significant difference between nurse-led versus physician-led care in monitoring INR for anticoagulation goals thus, generating a new opportunity for nurse-pharmacist collaboration (Braungart et al., 2018).

2.5.3. Qualitative thematic analysis

Five sub-themes emerged from literature review of collaboration between nurses and pharmacists in community settings for medication safety.

Create new opportunities to fill the gaps in community medication safety. The professional roles of nurses and pharmacists complement each other within the collaborative dyad and provide opportunities to fill the gaps in medication safety within the community care system (Bell et al., 2017; Hadi et al., 2016; Santschi et al., 2017; T. Toivo et al., 2018). In a non-hierarchical collaboration, Taylor et al. (2018) incorporated a telepharmacist for medication safety to perform medication review and provide recommendations with a nurse coordinating the meetings. Nurse-led care in a co-located collaborative model by Braungart et al. (2018) was able to maintain goals of care in anticoagulant therapy management. This created a new opportunity where nurses were trained by a clinical pharmacist (Braungart et al., 2018).

To address medication safety through collaboration, there is an inclination towards the need for new shared referral models of care with pharmacist house calls after receiving referrals from community nurses (Lee et al., 2018b; Elliott et al., 2017; T. Toivo et al., 2018). Similarly, to address complex medication needs of people on hemodialysis, the need for a collaboration through shared consult consisting of a pharmacist has been proposed (Porter et al., 2015). Creation of these new opportunities and care models has added additional dimensions to filling gaps in the current community health care system.

Enable complementary interprofessional roles in medication safety. Nurse-pharmacist dyads allow for integration of care by closing the gap between the professions (Santschi et al., 2017; Smith, 2016; Verweij et al., 2018). Lee et al. (2018b), described collaboration through shared consultation where nurses reviewed medications and provided support to clients by liaising with pharmacists for medication supply, packaging, dosing, and medication administration aids. Shared referral collaboration showed resolution of medication discrepancies following transition from hospital to home (Setter et al., 2009). In a co-located collaboration, nurses as team leaders performed medication reviews while pharmacists provided services for medication management to deliver education and lower BP in people with diabetes (McLean et al., 2008). Such nurse-pharmacist collaborations also enabled nurses and pharmacists to improve their clients’ physical functionality and allow aging at home by addressing limiting factors like pain, mood, incontinence, smoking cessation, and falls risk assessment (Pherson et al., 2018).

Facilitate efficient and cost-effective measures for medication safety. The shift in payment incentives has resulted in integrated services that focus on delivering value-based services globally (Lee et al., 2018b; Taylor et al., 2018). One nurse-pharmacist collaboration addressed drug costs of inappropriate prescriptions for complex clients (Hamano et al., 2015). Studies propose removing redundant practices by utilization of existing community resources to address medication discrepancy management through various nurse-pharmacist collaborations for efficiency and economy (T. Toivo et al., 2018). They address medication adherence through client education, treatment options, lifestyle modifications (Santschi et al., 2017), and coach on medication administration (Perraudin et al., 2016).

Diverse client assessments by nurses and pharmacists. In a nurse-pharmacist collaboration via referral and counter-referral between nurses and pharmacists, medication schemes designed by nurses were subjected to modifications by pharmacists for the same medication reviews (Foubert et al., 2019). In another nurse-pharmacist collaboration through shared consultation for addressing prescription clarity, nurses’ evaluation of the discharge process and medication discrepancies was deemed incomplete due to focus on procurement, prescription, and administration only while the pharmacist evaluation was deemed more comprehensive as they included clarifications addressing transcription, dispensing, monitoring of clinical indicators, and inappropriate prescriptions (Meyer-Massetti et al., 2018). Similarly, in a nurse-pharmacist collaboration, to assess the side effects resulting from chemotherapy agents, despite using the same tool, pharmacists graded differently than their nursing colleagues due to the difference in their scopes of practice (Bayraktar-Ekincioglu and Kucuk, 2018). Such differences in assessments may influence the course of medication management.

Incohesive teams from poor collaboration.Toivo et al. (2019) noted failure of a collaboration through shared consultation model due to lack of cohesiveness among team members. In this collaboration, nurses did medication reconciliation and medication risk assessment, while the community pharmacist made recommendations for medication changes based on medication review and monitored outcomes. The physicians, however, did not follow through with implementing the formally agreed upon pharmacist recommendations (Toivo et al., 2019).

Lack of referrals from physicians is another factor that influences the success or failure of a nurse-pharmacist collaboration (Hadi et al., 2016). Celio et al. (2018) noted that in community settings, nurses and pharmacists are strategically placed to implement multifactorial interventions that can simplify medication regimens and motivate clients to make lifestyle modifications. The dyads bring different expertise and skills to the team. However, due to lack of defined roles and responsibilities within the team, client care, and professional identities can suffer, resulting in interpersonal conflicts (Celio et al., 2018). Another study observed a lack of integration in nurse-pharmacist collaboration via referral and counter-referral when nurses undertook prescribing (Smith, 2016). This occurs because of limited reciprocity, weak community networking (Smith, 2016), and a low contact rate between the nurses and pharmacists (While et al., 2005).

2.6. Stage six: Consultation

2.6.1. Purpose for the consultation

Consultation will take place for the purpose of knowledge translation and exchange activities that involve disseminating the review results and engaging nurses and pharmacists in research that builds and sustains nurse-pharmacist collaborations for enhancing medication safety among community-dwelling adults. The researchers will engage in consultation with educators, policy makers, and other researchers at a future date to test and build sustainable nurse-pharmacist collaborations in community settings to address medication safety in community-dwelling adults within an existing health system.

2.6.2. Stakeholders and data integration and opportunities for knowledge transfer and exchange

Stakeholders will include both researchers and users such as academics, clinical educators, patients, nurses, and pharmacists working in community, as well as policy makers. The activities will include dissemination and active research (Chapman et al., 2020). Presentations and publications will be part of knowledge translation activities that disseminate the preliminary findings and recommendations to overcome the shortcomings. Active research with integrated knowledge translation will be undertaken to improve the current tools, methods and processes through designing, auditing, and testing them for validity and reliability.

3. Discussion

Collaboration is the action of working with someone to produce/create something (D' Amour et al., 2005). In the context of healthcare, interprofessional collaboration, implies a process of problem-solving, shared responsibility for decision making, and the ability to carry out a care plan while working towards a common goal (O’ Daniel and Rosenstein, 2008). To advance medication safety in community settings, there is a need for collaborative teamwork with a shared goal of improving the medication use process and addressing factors that affect medication safety (Meyer-Massetti et al., 2018). This scoping review identified the need for open communication, knowledge sharing, and improved engagement of nurses and pharmacists to collectively address client needs of medication safety and management of chronic conditions. The key dimensions for nurse-pharmacist collaborations are interdependence, creation of new opportunities, role flexibility with little or no hierarchy, shared responsibility and awareness of team strengths and limitations (Saint-Pierre et al., 2018). For creating sustainable nurse-pharmacist collaborations these aspects need to be addressed and integrated into routine practice.

Moreover, system factors such as lack of guidelines for standardizing processes of medication management, lack of mandatory reporting policies, and sub-optimal MUP also impact nurse-pharmacist collaboration (Lee et al., 2018b; Meyer-Massetti et al., 2018). Further research is needed so that policies can be developed and implemented to standardize medication management. Current systems have task duplication, ineffective workflow processes, lack of remuneration models, and suboptimal healthcare resource use. In addition, it has been noted that certain proposals designed for achieving nurse-pharmacist collaborations when tested in real-world settings are not as successful as the theoretical expectations (Lee et al., 2018b; Toivo et al., 2019). As new knowledge is being developed, optimization of processes, engaging longitudinal interventions, and larger sample sizes are needed. Community setting factors that require more exploration include medication supply, procurement, availability, storage (Lee et al., 2018a; Meyer-Massetti et al., 2018), safe medication administration techniques (Perraudin et al., 2016), and medication error auditing / reporting systems (Meyer-Massetti et al., 2018). In terms of collaboration, a need for better communication channels, skill mix within varying scopes of practice, community resource availability, and variances in funding still need to be further examined (Lee et al., 2018b; Toivo et al., 2019). These are dependent on the specific contexts of health care systems that are localized to a country (Smith, 2016; Taylor et al., 2018).

3.1. Implications for practice

Efficient use of existing community resources, information sharing and collaboration between nurses and pharmacists is vital for medication safety (Celio et al., 2018; T. Toivo et al., 2018); however, there is reluctance to share information between nurses and pharmacists leading to inconsistent (Lee et al., 2018b; Smith, 2016), or limited communication (Meyer-Massetti et al., 2018; T. Toivo et al., 2018; While et al., 2005), and task duplication (Foubert et al., 2019). According to Smith (2016), due to weak networking between nurses and pharmacists, the information shared varied and was inconsistent and this led to less optimal client care. When scopes of practice are expanded then partners in the collaboration may feel marginalized This was a noted when nurses started to prescribe pharmacists felt excluded in the collaboration (Smith, 2016). By providing interprofessional education and encouraging interactions through interprofessional medication reviews (Bell et al., 2017), facilitating centralized information (Foubert et al., 2019), and improving team member engagement (Verweij et al., 2018), it is possible to create high functioning, cohesive nurse-pharmacist collaboration teams. Such changes in practice may improve client care coordination, early identification of problems, development of interventions, and define shared goals (Bell et al., 2017). Role clarity is also vital according to Smith (2016). The lack of role clarity, and hierarchical nature of collaboration, nurse-pharmacist collaborations suffer as members feel that their scope of practice is encroached by the other profession (Celio et al., 2018; D'Amour et al., 2005; Smith, 2016).

3.2. Implications for future research

Of the four collaborative models suggested by Saint-Pierre et al. (2018), no single collaborative model can achieve all the above stated goals. For collaborative teams to work in a cohesive fashion, all dimensions of collaboration such as interdependence, role flexibility, collective ownership of goals, newly created professional activities for role clarification and reflection need to be addressed (Saint-Pierre et al., 2018). A combination of non-hierarchical collaboration and collaboration via referral and counter referral may improve trust, co-ordination, team competence, and collaborative practices. Regular meetings can enable sharing of patient information, care goals, coordination of care, feedback on the interventions (Saint-Pierre et al., 2018). Such collaboration needs leadership from nursing, pharmacy, and policy makers (Celio et al., 2018).

Further investigation is needed in the following areas: optimizing medication management (Foubert et al., 2019; Pherson et al., 2018; Lee et al., 2018a, 2018b), using technology for electronic prescribing and auditing, telepharmacy, implementation of electronic health services (Foubert et al., 2019; Meyer-Massetti et al., 2018; Taylor et al., 2018), longitudinal interventions to study service knowledge and accessibility (Hamano et al., 2015), studies to test potential replicability of patient care goals (Braungart et al., 2018), and improving patient education (Pherson et al., 2018). This may support collaboration between nurses and pharmacists (Foubert et al., 2019) and the development of innovative strategies for task shifting interventions (C.M. Toivo et al., 2018). There is also a need to development better tools to improve communication (Bayraktar-Ekincioglu and Kucuk, 2018), interprofessional medication reviews (Foubert et al., 2019), reporting systems (Meyer-Massetti et al., 2018) and new care models for specific health conditions (Porter et al., 2015) and/or healthcare settings (Verweij et al., 2018). Current systems have suboptimal interprofessional communication rendering them less efficient and ineffective (Lee et al., 2018b). By researching process improvement in localized community settings with a larger range of participants (Smith, 2016), workplace policies and processes systems can be improved (Lee et al., 2018b). With increasing chronic conditions, such systems will also help understand the economic impact of expanded interprofessional healthcare teams (Porter et al., 2015).

3.3. Implications for policy

Nurse-pharmacist collaborations provide holistic care by enabling consultation time with a focus on upstream factors that avoid preventable medication errors, inappropriate prescriptions, and adverse events (Hadi et al., 2016). These collaborations can make primary physician visits more efficient and optimize client care by improving long-term adherence in a cost-effective manner (Setter et al., 2009). However, due to improper remuneration policies (Perraudin et al., 2016), and lack of legislation for innovative care models (Taylor et al., 2018), such collaborations are not widely explored and clients who need such services cannot access them (McLean et al., 2008). At a system level, there is a need for reliable processes for assessment of medication availability, prescription quality, and care innovation to improve medication safety (Meyer-Massetti et al., 2018). We can achieve this only by high stakeholder support (Elliott et al., 2017). According to While et al. (2005), when designing and implementing policies, policymakers must pay equal attention to people issues and policies for organization changes so that the resulting policy may set mandatory conditions for interprofessional working. Therefore, policies are needed for mandatory discrepancy reporting systems (Meyer-Massetti et al., 2018), reliable processes for sharing medication information, and enhanced interprofessional medication management (Lee et al., 2018b). Inaccurate or incomplete or ambiguous care instructions lead to delayed patient care (Meyer-Massetti et al., 2018; Lee et al., 2018b; Hamano et al., 2015). Healthcare is a high-risk organization (HRO). Like other HROs, such as the airline industry, it needs to step up in terms of quality control, updating measures, eliminating redundant practices to improve safety outcomes especially in community care settings (Setter et al., 2009).

4. Limitations

This scoping review maps the current existing literature to provide insights into the area of nurse-pharmacist collaboration in community settings for the purpose of enhancing medication safety. The strength of this scoping review is that included studies focus on very specific nurse-pharmacist collaborations. It includes the most recent peer-reviewed articles. Upon analysis, the evidence highlights the various aspects of medication safety that these dyads address through different collaborative practices. It also identifies gaps that need further exploration. nurse-pharmacist collaborations are still in their nascent form. This can be seen in the form of study protocols and proposals for new models of care in the included literature. These models are hypothetical and are currently being evaluated or still in the hypothetical phase. Some of the interventions described in the studies need larger longitudinal participation to test for replicability and generalization. Another limiting factor is the challenge of comparing the strength of similar strategies due to the variances in the healthcare systems globally. Since articles written in English only are reviewed, there is a possibility of missing literature published in other languages. The databases and search terms used, and lack of full text availability, may have limited other potential sources that could have informed this review.

5. Conclusions

This scoping review has consolidated the reality that nurse-pharmacist collaborations have positive outcomes on medication safety among community-dwelling adults. nurse-pharmacist collaborations can address medication safety issues pertaining to patient related factors, provider related factors, and system related factors (Fields; Hamano et al., 2015; Porter et al., 2015). Strategies for medication safety by these collaborative efforts can result in assessment and resolution of inappropriateness of medications, assessment of adherence, functional ability, education about treatment options, and lifestyle management (Elliott et al., 2017; Foubert et al., 2019; Meyer-Massetti et al., 2018); however, these processes need to be further explored as newer models are being proposed (Santschi et al., 2017; T. Toivo et al., 2018). There is a tremendous potential for adopting these collaborative practices to inform practice, future research options, policy change, and large-scale implementation. Due to variation in healthcare systems globally, further research is warranted for encouraging and implementing systemic changes.

Funding sources

No external funding.

Declaration of Competing Interest

All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version. This manuscript has not been submitted to, nor is under review at, another journal or other publishing venue. The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript.