Table 3.

Selection of quotes

Categories	Quotations
Laboratory tests are the “gold standard” for assessing adherence	“If their blood tests or their blood pressure are normal, I assume that they are taking it [medication]. Or if their phosphate is ok. Then I assume they are taking the medication” (Physician site 1) “It is very much the blood tests. Whether you are a physician or nurse. The way a dialysis department works, we look at blood samples and relate them to the prescribed medications” (Nurse site 2)
Varying practices for supporting adherence	“No, it [medication adherence] is not something we regularly inquire about. I don’t think we [the department] have any focus on it” (Nurse site 1) “There is no time for you to sit down and say; Well, let’s talk about medication [..] Unless there is something wrong [..]You might say that there isn’t any real system (Nurse site 4) We can’t say that it does not take place. Because it does, of course, sometimes. But it is often a resource problem, when there is time to discuss and review the medication [..] it is not structured in a systematic way. In principle yes. But due to lack of resources, the systematic approach goes haywire. Having a dialog to uncover the extent of the problem in detail for each patient is virtually non-existent. It is sporadic and relates to individual medications” (Physician site 3)
Exploring patients’ reasons for non-adherence	“if there is a problem with the blood tests, then we talk to them about; Are you taking your phosphate binder? If it’s the one we can see is a problem, right? But I don’t talk to them about their medicine intake, if I can see that everything is running as it should and there is nothing to see in the blood tests” (Nurse site 1) “I ask the patient; How many do you take? If I say: It says here that you have to take 2 × 3 calcium tablets, then they usually just say; Yes!” (Physician Site 4)
Reviewing medication lists	“When I talk to the patient, it is important to try and explain to them why we do something about this [prescribe medication] It has to be on an informed basis that the patient make decisions” (Physician site 3) “I have made it a routine to put an arrow up or down or write “NEW” with a pen next to the new prescriptions or where I have made changes. Because when they come home and the spouse or someone else helps them with their medicine, then they can also see where I have made changes” (Physician Site 4)
Deprescribing or adding on	“As doctors we have a great responsibility to ensure that they get the medicine they need and certainly no more than that. However, there is a lot of it [prescribing medication] that runs completely unconsciously, with only modest documentation” (Physician Site 3) “Well, it is a question of clarity. If we have to get somewhere, then it is simply a matter of simplifying the patient’s medication regimens. You will be able to get really far with that. We spend a lot of time on this in the hemodialysis department. It takes time to sit down with the patient and simply get the medication lists reconciled. What are you taking? Are you taking what we think you are taking? Why don’t you take this? And then we negotiate what the patient wants to be involved in and what we need to remove in order for us to reach a common goal. It is simply a matter of getting it [medication regime] fitted so that patients can comprehend it” (Physician Site 1) “I often say; If this gives you side effects or does not work, then we have another one we can try. So that’s our way of working. And just make it clear to them, that if something bothers them, then we will try something else [medication]. Because it is of no use to us, to put them on lifelong treatment with something [medication] and that something doesn’t work for them “(Physician Site 1)
Motivational interviewing	“It [motivational interviewing] is one of the most effective tools I have been able to use so far. Instead of using our time on small talk or overwhelming the patients with too much information. You’ll find out…. Well, are they at all ready to make a change in their behavior? Where are they in their lives? Is there room for anything [information] today? Should I keep quiet or” (Nurse Site 2) If we can meet them in a way, so that they also hear from us; Well you are not the only one in the world who finds it difficult [adhering to medication regimes]. I think that it would have a very big influence on how they would tackle it” (Nurse site 1)
Unclear allocation of roles and responsibility	“It is also about how we prioritize our tasks. Because I almost always talk to my patients about fluid or elevated potassium” It’s about resources and time. It is not incorporated in the way you conduct nursing with the patient. Maybe it is also because it [talking to patients about medication] is more a physician thing - that it is just s not prioritized much among nurses” (Nurse site 1) “My patient was here today, so I should go straight in and check up on his medication intake and so on. Meanwhile also having to attend to the other three / four patients I have been assigned today? You barely have time to take care of the patients you have been assigned today. There it is, it does not happen at all!” (Nurse site 4) “But it is the law that describes who is responsible for what things. When you prescribe any medicine, you are obliged to tell how it works, side effects, how to take it, etc.” (Physician site 2) “But often it is the nurses who talk to the patients. Because they sit right beside the patients, when they start them up on dialysis. They sit and talk [..] and of course then it is often natural that you address; Do you remember to take your medicine?” (Physician site 2)
Navigating time and resource limitations	“We find that they do not take it [medication], but we do not actually find out why. Because it takes a long time” (Nurse site 2) “We actually have so much staff turnover and we are missing so many hands [nurses] at the moment. So right know there is not much control over it [who is responsible for talking to patients about medication]” (nurse site 4) “In 10 min, we have to take care of the initial problem patients come with and go through 30 pharmaceuticals; What do they take? Why and how? And so on. That is what we are asked to do, right? But then there is just something that is not adding up. [..] Yes, you try to run as fast as possible through the medication; are there any changes? and quickly ask; Do you get this medicine? but there is. You can’t manage to go through all the patient’s medications in terms of side effects, what they take, if they take one or the other. That is simply not possible” (Physician site 3) “Not that we had super much time before, but now we spend even more time at the computers. You do not have any time to talk to them [patients] about the medication, unfortunately. We don’t even have the time to tell them why you prescribe new medication anymore”. (Physician site 1)
Suggestions for future strategies	“There is no doubt about it. Those who have few resources, they are the ones who have the most difficulty. They are the ones we lose the most. Whereas the well-educated and well-off. It is clearly the ones with poor resources. It would help if we could focus on them” (Physician site 1) “We could have a check list [..] and do a monthly screening [medication adherence] [..] And then you will probably discover along the way that it is not relevant for all patients” (Nurse site 1) ” I think it is important that you regularly talk to patients about “how is it going with your medicine” and it should be scheduled how often it should be done” (Nurse site 4) “I would really like to sit down and spend an extra half hour on reviewing the medication list and make sure that they understand why they are getting the medicine and how they should take it [..]” (Physician site 1) “Social workers were amazing when they worked here. They could really help with many different things [..] Then you knew where to refer patients to [if they had difficulties paying for medication]. I think it is difficult in the framework we are subject to now, and I think we lose patients because of it” (Nurse site 1) “There is no doubt about it. If we made the regimes more individually. At least that’s my opinion. If it was the same person, they saw every time [..] So, she could continue where she left off last time. Because then she will have the opportunity to assess; Is it today I have to go all in, is the patient ready for this and that today, or should I wait until next time? The problem is that there is no overall consensus or system” (Physician site 3)