Exploration of an On-Site Pharmacist Intervention within Australian Residential Aged Care Facilities Using Normalisation Process Theory: A Mixed-Methods Study

mixed-methods


Introduction
Medication-related harm remains an ongoing problem for residents living in residential aged care facilities (RACFs) [1,2].It is well established that residents living in RACFs are at high risk of medication-related harm arising from high rates of inappropriate medication use [3] which can lead to unplanned hospital admissions and higher health care costs [1,4].Tis problem may be partially attributed to the complex nature of medication management processes within RACFs [5].Broadly consistent with RACF practice internationally, Australia's Guiding Principles for Medication Management in Residential Aged Care Facilities describes how general practitioners (GPs) coordinate the health care of residents.Complexity exists as multiple health care professionals (specialist in palliative care, geriatricians, and other specialists), RACF staf (registered nurses), and allied health professionals (pharmacists) are involved in the prescribing, dispensing, administration, and supply of medications to residents living in RACFs [6].In addition, it is widely accepted that healthcare system, facility, and/or health professional level factors may also impact medication management within RACFs, including but not limited to information communicated at care transitions and irregular resident medication reconciliation and review upon returning to RACFs, e.g., from the hospital or at RACF admission [6].
To address the multifactorial nature of RACF medication management processes, complex health interventions are required.A "complex intervention" is characterised as an intervention with numerous components which interact with each other to contribute to intended outcomes [7].To ensure positive patient outcomes, it is essential that complex health interventions be evaluated.Quality evaluation of complex interventions can support the dissemination and adoption of evidence-based interventions in the real world [8].
Te Pharmacists in Residential Aged Care Facilities (PiRACF) study was a cluster randomised controlled trial which investigated whether OSPs directly employed parttime by RACFs could improve medication management [9].Te OSP intervention was complex given its focus on improving medication management at both the resident and RACF levels, requiring collaboration and communication with multiple stakeholders, thereby also supporting resident-centred care.
In a recent scoping review, we highlighted that the use of theory to frame evaluations of pharmacist interventions in RACFs is sparse [10].Tis is despite some evidence that public health interventions underpinned by theory are more likely to demonstrate positive health outcomes [11].Nested within the PiRACF study, this mixed-methods study used normalisation process theory (NPT) to explore whether and how having OSPs in RACFs became part of routine practice, i.e., "normalised" in Australian RACFs.
NPT was considered suitable for this study a priori given that it can provide an understanding of how new practices in health and other settings can become normal practice at both the individual and collective levels [12].NPT has been employed in implementation, feasibility, and process evaluation studies to evaluate complex interventions across various settings [12][13][14].NPT has also been previously utilised in complex intervention studies undertaken in RACFs [15][16][17].NPT consists of four constructs (coherence, cognitive participation, collective action, and refexive monitoring) [18] with further descriptions of each construct described in Table 1.More recently, a 23-item normalisation measure development questionnaire (NoMAD) instrument was developed based upon the four NPT constructs, which has demonstrated good construct validity and face validity [19].
Tis topic is important because the OSP role is relatively new and gaining an understanding of the workability and integration of OSPs within RACFs could help inform the anticipated rollout of OSPs within Australian RACFs from 2023 [20].An underlying premise of NPT is that if a complex intervention is fully workable and is integrated entirely into routine practice, this will support the overall success of the intervention [21].Tus, if OSPs are considered as part of routine practice, this would increase the likelihood of their impact on improving medication management within RACFs.To date, there is sparse literature available on the workability and integration of OSPs within RACFs in Australia and internationally.Tis study addresses this research gap, and moreover, it has helped to identify future OSP research studies as well as policy and practice implications which could inform OSP rollout within Australian RACFs.
Te aims of this study were to understand the extent to which OSPs became part of routine practice, i.e., "normalised" and how OSPs were normalised (or not) within these RACFs from the perspectives of residents, family members, OSPs, and health care team members (specifcally prescribers, managers, and nursing staf).

Methods
Tis study employed an embedded mixed-methods study design.A qualitative-dominant approach was taken with a smaller quantitative component to enhance this study's methodology [22,23].An important element of reducing medication-related harm relates to collaboration among GPs, RACF nursing staf, and pharmacists [24].As such, the perspectives of these health care professionals were sought in this study.Consistent with other pharmacist interventions in RACF studies, the manager perspective was also sought [16,25].Resident and family member insights were sought, as their end-user perspective is an important evaluation component when assessing care provision [26].Te use of an adapted survey based upon the NoMAD instrument was also consistent with the approach taken by the Care Home Independent Prescribing Pharmacist Study (CHIPPS) study team whose process evaluation study protocol included the use of the NoMAD instrument [27].Given the objectives of this mixed-methods qualitative dominant study, survey data reliability and construct validity tests were neither planned a priori nor undertaken for this study.However, for this study, the adapted survey was piloted by a prescriber and nurse who provided feedback to help establish face validity.
For this study, data were collected from semistructured interviews and an adapted survey from April 2021 to January 2022.Tis timeframe meant that participant feedback was sought from at least nine months after the OSP's commencement within their respective RACF.A prescriber and nurse piloted the interview guide and adapted the survey to establish face validity.A family member of a resident living in an RACF also piloted the interview guide.For the purposes of this study, specifc interview questions were underpinned by NPT as well as seeking insights for the PiRACF study evaluation.A range of stakeholder perspectives were obtained using a purposive (stratifed) sample approach [28].Health care team members (prescribers, RACF managers, and nursing staf), OSPs, residents, and Health & Social Care in the Community family members were invited to participate in the semistructured interviews.
Health care team members were invited to complete the adapted survey, informed by the NoMAD instrument to obtain their individual and collective perspectives.It was estimated that the total number of prescribers, RACF managers, and nursing staf in the seven RACFs would be approximately 127 given available RACF stafng data.Te estimated survey response size required was 46 noting previous mixed methods studies which have employed the NoMAD instrument with a mean response rate of 36% [29,30].

Data Collection.
For the health care team member interviews and surveys, RACF managers facilitated e-mail recruitment.E-mail reminders and individual invitations were also sent to prescribers, RACF staf, and OSPs.Hard copy surveys and a locked survey box were distributed to RACFs to facilitate survey completion.
For the resident and family member interviews, OSPs and/or RACF managers contacted those who had interacted with the RACF OSPs.Only participants with the capacity to consent were eligible to be interviewed.Residents and family members were provided a $20 gift card for their involvement.
Te lead author (MB) conducted audio-recorded interviews.Tese interviews were transcribed, checked, and deidentifed to ensure participant anonymity and confdentiality [31].

Data Analysis and Reporting.
Ritchie and Spencer's framework analysis approach was used to analyse the qualitative data [32].Tis approach consists of the following steps: (1) familiarisation; (2) constructing a thematic framework; (3) indexing; (4) charting; (5) mapping; and interpretation [32].Tis approach was chosen in recognition of the anticipated large volume of qualitative data associated with this study [33].Te qualitative data was deductively coded and analysed based on the NPT constructs.Regular ongoing discussions with coauthors informed the development of an initial coding framework, along with the analysis and interpretation of the data [34].NVivo was utilised to aid in data management and maintain a clear audit trail [35].
All quantitative data (inclusive of hard copy survey results entered by the study team) were downloaded from Qualtrics and cleaned in Microsoft Excel.Consistent with Lewis et al. mixed-methods study which employed the NoMAD instrument, survey responses for this study were described and summarised at the group level [30].
Te qualitative data in this study was reported according to the Consolidated Criteria for Reporting Qualitative Research Checklist [36].Te mixed-methods data were integrated at the interpretation stage [37], with qualitative fndings reported followed by quantitative and integrated data fndings, consistent with the dominant qualitative approach of this study.Tis mixed-methods study was also reported according to Hadi et al.'s recommendations to improve mixed-methods research reporting for pharmacy practice researchers [38].
Te Human Research Ethics Committees at the University of Canberra (HREC-2007), ACT Health (2019/ ETH13453), and Calvary Public Hospital Bruce  approved this study.Written consent from participants was obtained prior to interviews and survey commencement.

Coherence
Te frst NPT construct of coherence (making sense of the intervention) relates to how participants make sense of the intervention at the individual and team level.Making sense of the intervention includes having an understanding of how the new practice compares to usual practice and the perceived value of the new practice [18] Cognitive participation Te second NPT construct of cognitive participation (investment in the intervention) relates to the engagement of participants in operationalising the new practice.Investment in the intervention includes key people driving the new practice and perceiving the intervention as being a legitimate part of their new practice, as well as being willing to adopt the new practice [18] Collective action Te third NPT construct of collective action (enacting the intervention) relates to the work which participants undertake to operationalise a new practice.Enactment of the intervention includes the ease of intervention integration into existing work, the impact on working relationships, confdence of others participating, and adequate management support of the new practice [18] Refexive monitoring Te fourth NPT construct of refexive monitoring (appraising the intervention) relates to the work which participants undertake when assessing a new practice at the individual and team level.Appraisal of the intervention includes awareness of the new practice, perception of the new practice's impact, potential to modify work to incorporate the new practice, and support future improvements [18] and family members (n = 4) from seven RACFs participating in the PiRACF study.Te interview length ranged from 14 minutes to 163 minutes.Te median duration of interviews for health care team members, residents, and family members was 38 minutes.Te OSP interview median duration was 148 minutes.Semi-structured interview participant characteristics are described in Table 2.
Sixteen completed surveys (n = 16) were returned between April 2021 and January 2022 from 10 RACF nursing staf, 3 RACF managers, and 3 prescribers, with a survey response rate of 13%.A contributing factor to the low survey response may have been the ACT COVID-19 lockdown which commenced in August 2021 and resulted in an increased workload for health care professionals, including RACF staf [39].Te adapted survey fndings are displayed in Table 3. Te qualitative, quantitative, and integrated fndings for this study have been reported according to the NPT constructs.
3.1.Coherence.Overall, most participants interviewed considered that having the OSP at their respective RACF was diferent from usual practice and was benefcial, particularly with regards to the provision of more timely medicationrelated information for residents and family members.
Te qualitative fndings suggested that most participants across the seven RACFs agreed that OSPs working within their respective RACFs difered from usual practice.Some residents and family members across the RACFs considered that the OSP was more available compared to RACF staf and visiting GPs (usual practice).As described by one resident, who valued knowing what medications they were being prescribed, their GP "combined one particular tablet with another particular tablet.[ In addition, one manager described a reduction in management complaints at their RACF, namely, that "it's really gone from you know six or seven [complaints] in a month to zero" [M6.1], which the RACF manager considered was a "a big refection" [M6.1] of having the OSP at their RACF.Tis RACF manager indicated that by "having OSP here on-site. . .we can give the [requested medication] information straightaway to the family instead of them stewing for a week while we're trying to gather the information" [M6.1].Tis was then contrasted with usual practice wherein a registered nurse sometimes "spent hours trying to fnd that [medication] information" [M6.1] and instances where family members were not satisfed with the medication information provided "because it's not quite what they're after" [M6.1], resulting in "quite a lot of complaints about medication, why they are put on this, "I'm not getting the correct information," that type of thing" [M6.1].
Another powerful example of how having OSPs in RACFs difered from usual practice was during family member admission into an RACF.One family member described this as a time "full of misgivings. . .You always think you'd done the wrong thing.You think of how others are judging you" [FM3.1].Tis family member considered that this time was "such a crucial time for a pharmacist to be here when someone, a loved one, has just been placed into care and changes are being made to medication" [FM3.1].Usual practice, without the OSP, would have meant that this family member would not have had access to a pharmacist on-site to talk to about "the medication side of things" [FM3.1].
Most health care team members at both the individual and team level described the OSP's role as benefcial.According to one manager, it was benefcial that their OSP was "able to take a long-term interest in residents and follow up medication-related matters for them over many weeks and months" [M5.1].Tis continuity and its value were also mentioned by two OSPs, culminating in some OSPs being able to have a deeper understanding of the resident and sometimes being able to "build a really good history and a relationship with them" [OSP 1] through ongoing interactions.Prescribers were also generally positive in their appraisal of the OSP's benefts.However, three prescribers did not consider that the OSP was substantially benefcial within the context of their respective RACFs.One of these prescribers noted that the OSP may have been underutilised by the RACF; a second acknowledged that the OSP could have added value for less experienced prescribers; and the other prescriber indicated their full support of OSPs in the RACF but that they did not have a working relationship with that particular OSP as they only communicated with each other electronically on medication-related matters.In addition, relevant quotes which further support the NPT construct fndings reported in this study are provided in Table 4.

Quantitative Finding.
Most health care team member survey respondents positively reported on the adapted survey questions which related to the NPT coherence construct.In particular, all survey respondents (100%, n � 16) considered that they saw the potential benefcial impact of the OSPs at their RACF.Te quantitative fndings indicated that having the OSP made sense to health care team member survey respondents.Te qualitative fndings tended to suggest that most participants perceived that having the OSP in their respective RACF was benefcial.Te positive quantitative fndings strongly complement these fndings from the health care team member perspective.

Cognitive Participation.
Overall, participants interviewed were positively invested in having the OSP at their respective RACF with managers often being key people helping to drive normalisation of OSPs within RACFs.Health care team members across the seven RACFs also tended to perceive that working with OSPs was now part of their usual role.

4
Health & Social Care in the Community OSPs interviewed indicated that their managers were often key people to help drive having the OSP to become a part of routine practice.One OSP indicated that "Te general manager introduced me and said, "Tis is our on-site pharmacist.We're so happy and lucky to have her here.We wanna make the most of having [the OSP] here, and please involve [the OSP] in stuf,"" [OSP 1].Tis OSP considered that their manager was key to helping drive RACF staf to realise and accept that the OSP was to be "integrated into their systems" [OSP 1].Te OSP themselves also often needed to drive normalisation of their role by identifying and volunteering their involvement in additional activities and saying, "Look, I can actually help you with that."[OSP6].
Across the seven RACFs, most health care team members interviewed considered that working with the OSP was a legitimate part of their role and were invested in working with the OSP.However, they were more likely to work collaboratively with the OSP after the OSP established a trusted relationship with them.As described by one OSP, establishing these relationships was "the foundation for anything else" [OSP 6] they did within the RACF.Tis then helped increase the likelihood of prescribers listening to them and being "far more likely to act" [OSP 6] when medication recommendations were made.Tis is mirrored by a prescriber who indicated an openness to medication recommendations made by the OSP, "Obviously if [OSP 1] made recommendations, it would be very sensible for me to listen to them and generally and act on them" [GP1.2].In addition, relevant quotes which further support the NPT construct fndings reported in this study are provided in Table 4.

Quantitative Findings.
Health care team member survey respondents positively reported on the adapted survey questions which focussed on the NPT cognitive participation construct.All survey respondents (100%, n � 16) considered that they were open to working collaboratively with their OSP and would continue to support their OSP.Tese quantitative fndings suggested that there were high levels of investment amongst survey respondents.Te qualitative fndings which indicated that there was good investment in having OSPs in their respective RACFs are reinforced by the positive health care team member survey fndings.

Collective Action.
Most health care team members interviewed had varying perspectives on the OSP's impact on their respective workloads, but the majority considered that it was easy for them to work with OSPs.Furthermore, the qualitative fndings suggested that OSPs were more likely to enhance as opposed to disrupt existing relationships.
Most managers and nursing staf considered that having the OSP undertake medication management activities reduced their workload.As described by a nurse, the "workload for us will be crazy now that OSP 1 is leaving" [RN1.1].Tere were, however, divergent views of the OSPs impact on prescriber workload ranging from a noticeable reduction in workload and "shorten[ing] our time spent on-site" [GP1.1]through to contributing to a slight increase "because OSP 6 will be scrutinising a lot of the medication, a lot more than I would" [GP 6.1].Tese varying views were not unexpected given the OSP's focus on medication management,    Health & Social Care in the Community Health & Social Care in the Community "Empowering the residents to make some of their decisions has been helpful as well, I think.For example, one resident, really wanted to self-medicate his inhaler and so I advocated for him, and I checked his technique and I said, "Well, I think he can," and so because of my input, he's now able to self-medicate that and he's a lot happier" [OSP6] 14 Health & Social Care in the Community including more medication reviews and audits of high-risk medications compared to usual practice.Most health care team members seemed to fnd it easy to integrate the new way of working with the OSP into routine practice.Nursing staf consistently found it "quite easy to adapt" [RN4.1] to having OSPs at their respective RACFs.Likewise, a manager described how "we just worked together and I can't see any of it being difcult" [M1.1] refective of the ease of OSP normalisation at that RACF.Some GPs also considered that it was easy to integrate working with the OSP, as illustrated by this quote, "I think it just happened.I don't think we tried to engineer it" [GP1.2] when describing how they worked with an OSP.As we might expect, the time it took for health care team members to integrate working with OSPs varied across RACFs.However, overall, at the time of the interview, most health care team members seemed to consider that the OSP at their respective RACF had become part of their team.Residents and family members tended to fnd it easy to interact with OSPs once they became aware of their presence.
Participants interviewed did not appear to perceive that OSPs disrupted any existing relationships.Instead, examples were provided wherein the OSP was seen as facilitating communication amongst health care team members.One nurse indicated that "when OSP 5 is there. . .we ask [the OSP] to, you know, "Can you please help us talk to the GP?". . .having [the OSP] there, it's very easy to interact with [the GP] because you've got that extra support" [RN5.1].Tat is, the OSP sometimes helped nursing staf have improved interactions with prescribers within RACFs.In addition, relevant quotes which further support the NPT construct fndings reported in this study are provided in Table 4.

Quantitative Findings.
Health care team member survey respondents positively reported on the adapted survey questions relating to the NPT collective action construct.Most survey respondents (94%, n � 15) strongly agreed that it was easy to integrate working with the OSP into their existing work and that OSPs were adequately supported by management.Importantly, a high proportion of survey respondents either strongly disagreed (50%, n � 8) or disagreed (38%, n � 6) that the OSPs disrupted existing relationships.As with the previous NPT constructs, the qualitative fndings appear to be complemented by the positive quantitative fndings.

Refexive Monitoring.
Overall, the qualitative fndings indicated that most participants considered that OSPs were worthwhile and valued across the seven RACFs.Furthermore, residents, family members, nursing staf, and managers were able to describe examples where the OSP was able to provide specifc medication management support.Te ongoing worth and value of OSPs was actively demonstrated by two RACFs continuing to self-fund their OSPs once the PiRACF study concluded.
Most residents and family members considered that OSPs were accepted with "everybody know [ing]  Residents and family members who had regular interactions with OSPs were the most supportive of OSPs.Health care team members interviewed were also broadly accepting of OSPs in RACFs, as articulated by one manager, who stated that they felt that the OSP was "invaluable" [M4.1].While fve managers mentioned lack of funding as a barrier to having OSPs continue beyond the trial, two RACFs elected to continue self-funding the part-time OSPs within their respective RACFs.
One potentially invaluable role of OSPs is related to how some family members considered that the OSPs provided a "broker" role within the RACF.One family member described how the OSP "had an in to the role of the RN, the role of the doctors, [the OSP] had access to these people" [FM3.1].Tis family member perceived that as the OSP "knew about them.[Te OSP] knew their roles, what the full nature of their roles" which meant that "I just felt that [the OSP] was able to often tell me, "Look, check [with] so and so"" [FM3.1].For this family member, it seemed that the OSP made it easier for them to navigate and connect with relevant health care team members to facilitate the provision of quality care to their family member.
When refecting on this complex intervention, residents and family members described examples where the OSP's impact was valued.For instance, one family member described the importance of speaking with the OSP which helped to increase their medication knowledge thereby making them more empowered to have "proper discussions with doctors and my husband's specialists" [FM 3.1].Tat is, discussions with an OSP helped this family member feel "more confdent to have those [

medication management decision making] discussions [with doctors and specialists] and know what sorts of questions I need to ask and know what
I should be aiming for" [FM 3.1].Tis sentiment is echoed by a manager who considered that "we've gone from residents who have just left everything in our hands to them actually questioning the doctors, "Why do I need this?"" [M6.1].Tat is, some OSPs were able to help empower residents at times, thereby helping to give "them back control [over] their own medications" [M6.1].However, to be expected, this perspective was not universal with a family member at a different RACF describing conversations with the OSP about potential medication changes for their family member as "it's all pretty much gobbledygook to me.Tey explain the diferent drugs and that, I but I don't know what they are" [FM1.1].Instead, this family member relied upon "the fact that mum is happy and she had no incidents and everything is going well" [FM1.1] when it came to accepting suggested medication changes.
When refecting upon where the OSP's impact was valued, a nurse described that the OSP "helped us with the psychotropic register a lot.So I feel like if [the OSP] wasn't there, it would have taken us a lot of time and a lot of manpower to do that, but having [the OSP] there, it really helped us getting things on track" [RN 5.1].Tat is, the OSP undertook activities which could be used to support medication management in the future.In addition, relevant quotes which further support the NPT construct fndings reported in this study are provided in Table 4.

Quantitative Findings.
Health care team member survey respondents positively reported on the adapted survey questions relating to the NPT refexive monitoring construct.All survey respondents (100%, n � 16) strongly agreed that they valued the OSP's impact, and most survey respondents (75%, n � 12) strongly agreed that they and their colleagues believed that working with the OSP was worthwhile.Tese quantitative fndings illustrate that health care team member survey respondents positively appraised having OSPs at their respective RACFs.Tese quantitative fndings reafrm the qualitative fndings which suggested that residents, family members, and health care team members positively perceived OSPs within RACFs.

Discussion
Tis mixed-methods study explored the extent of OSP normalisation and how OSPs were normalised within the context of the PiRACF study.Te qualitative fndings indicated that overall OSPs within RACFs made sense, with generally good levels of investment and support for OSP normalisation across the RACFs.Overall, having OSPs within RACFs was positively perceived by health care team members, residents, and family members.Tese positive fndings were complemented by the positive quantitative study fndings which were refective of health care team member survey responses.Te survey responses should be interpreted with caution given that the response rate was 13% (compared to this study's mean response target of 36%).Tis study's fndings demonstrated that OSPs can be normalised within Australian RACFs and illustrated some important insights which could help inform the future role of OSPs working within Australian RACFs.
Te positive appraisal of OSPs by health care team members, residents, and family members was informed by the perception that OSPs were able to assist in reducing nursing, manager, and some prescriber workloads, that OSPs were easy to integrate into existing work, and that OSPs added value and were (or could be) benefcial within RACFs.By contrast, a qualitative study using NPT conducted within a German RACF identifed that barriers to implementing their complex intervention, which sought to reduce antipsychotic prescribing, related to staf experiencing higher workloads due to their intervention along with uncertainty about that intervention's feasibility and impact [15].It is possible that those barriers were not identifed in this study due to a range of varying intervention and contextual factors, in particular, having OSPs within RACFs in the PiRACF study context.
Consistent with a mixed methods study conducted within an Australian operating room department which utilised the NoMAD instrument [29], health care team member survey respondents in this study were also positive with regards to the value, ease of integration, and support of the intervention, i.e., having OSPs at their respective RACFs.Similar to a qualitative study conducted in Australian primary health care which was underpinned by NPT [40], this study also identifed funding as a perceived barrier to intervention continuation.It is anticipated that this barrier will be addressed, to some extent, through anticipated Australian Government funding to expand the role of pharmacists, inclusive of OSPs, in RACFs from January 2023.It is suggested that future OSP studies could consider survey data reliability and validity testing and include further in-depth data analysis of survey data results.Future research on the sustainability of OSP normalisation within RACFs in other geographical and socio-economic settings may also be benefcial.
Some previous NPT studies have tended to focus on the perspective of health care professionals with limited exploration of resident and family perspectives in studies which have employed NPT [13].Informed by the literature [13,27], this study incorporated insights from multiple stakeholders, including residents and family members, to understand OSP normalisation from a system-wide as opposed to a professionally-focussed perspective.A contribution of this study is that the qualitative fndings yielded important insights from the perspectives of residents and family members, particularly with respect to OSPs potentially providing a "broker" role and empowering residents and family members in relation to medication management decision-making.
A novel fnding of this study was that some family members perceived that the OSP could assist them in connecting and communicating more efectively with health care team members.As such, it appeared that some OSPs were able to act as a "broker" to support increased communication and connection so that these family members were supported to navigate care for their loved one within their respective RACFs [41].While the potential role of pharmacists in a "knowledge broker" role as part of the Evidence-Based Medication Knowledge Brokers in Residential Aged CarE (EMBRACE) study currently underway includes facilitating collaboration between all stakeholders in medication management [42], the fndings of this study shed light on the potential role of OSPs to explicitly support residents and family members in a new and novel way.Ongoing exploration of this potential "broker" role provided by OSPs within Australian RACFs is strongly encouraged.
Previous studies conducted in Northern Ireland and Malaysia have identifed that residents living in RACFs are seldom empowered with respect to medication management [43,44].Residents who are not empowered may be described as passively accepting care provided by health care team members and not questioning any aspects of the care provided [44].A necessary prerequisite for empowered residents and family members would likely include good levels of health literacy.Health literacy can be defned as individuals having the necessary skills, knowledge and motivation to access, and understand and apply health information when making decisions about their (or their family member's) care [45].In addition, discussions among health care professionals, residents, and family members about medications, particularly during transitions of care, e.g., admission to an RACF, are an important mechanism to support residents and family members in having the necessary information to make informed medication management decisions [46].16 Health & Social Care in the Community Te qualitative fndings of this study suggested that some OSPs were able to increase the medication knowledge of and empower some residents and family members with regards to medication management decision-making by being onsite and discussing medication-related matters with them.While not all residents and family members may wish to increase their medication knowledge and discuss specifc medication-related matters, these opportunities should nevertheless be available.Te fndings of this study have real-world implications with more empowered residents and family members more likely to be actively involved in decision-making discussions, asking questions, and initiating conversations (such as deprescribing conversations) [47] in relation to medication management.Further exploration of how OSPs within Australian RACFs can support resident and family member health literacy, as well as empower residents and family members to participate in medication management decision-making discussions, particularly during transitions of care, should be considered.
Tis study provided unique insights into the extent of OSP normalisation and how OSPs were normalised from the perspectives of residents, family members, health care team members, and OSPs in RACFs.Tis study builds upon the previous literature which has employed NPT to explore complex interventions within RACFs [15,16].It also demonstrated the viability of evaluating a pharmacist intervention within Australian RACFs through the lens of NPT.Critically, this study helped to address a potential gap identifed in the evaluated pharmacist intervention in the RACF literature wherein there is sparse utilisation of theory help guide evaluation.Te limitations of this study relate to its limited generalisability, low survey response rate, as well as the possibility that health care team member interview participants may not have been survey respondents and vice versa.In addition, the perspectives of care staf and allied health professionals were not obtained in this study.A fnal limitation was that this study was designed and conducted prior to the publication of a recently developed coding NPT qualitative coding manual which includes guidance on how to map NPT fndings to the realist evaluation contextmechanism-outcome confguration [18].Future OSP research could beneft from the use of this qualitative coding manual.Key strengths of this study were its use of mixedmethods design and incorporation of multiple stakeholder perspectives, including those of residents and family members.

Conclusions
Tis study provided insights into the extent of OSP normalisation and how OSPs were normalised within Australian RACFs from the perspectives of prescribers, RACF managers, RACF nursing staf, OSPs, residents, and family members.Tis study demonstrated that OSPs were generally positively appraised and could be normalised (i.e., become part of routine practice) in real-world RACFs.Tis study has policy and practice implications for the rollout of the relatively new OSP role within Australian RACFs, particularly in relation to the potential role of OSPs to provide a potential "broker" role and increase resident and family member knowledge and empowerment with regards to medication management decision-making.Furthermore, this study has identifed future OSP research directions, particularly in relation to the sustainability of OSP normalisation and illustrated the value of using theory to guide the evaluation of a pharmacist intervention in RACFs.

13 I 14 I 13 I 14 I 16 I 1 I 9 I 16 IFeedback
colleagues (e.g., RACF staf, visiting general practitioners) and I have a shared understanding of the on-site pharmacist's purpose at this facility understand how the on-site pharmacist's role afects my work can see the potential benefcial impact of having the on-site pharmacist at this facility Tere are key people who drive working alongside the on-site pharmacist at this facility and get others involved believe that working with the on-site pharmacist is a legitimate part of my role am open to working collaboratively with the on-site pharmacist at this facility will continue to support the on-site pharmacist working at this facility easily integrate working with the on-site pharmacist into my work on-site pharmacist disrupts existing relationships (item score reversed) have confdence in my colleagues' ability to work with the on-site pharmacist aware of reports about the work undertaken by the on-site pharmacist and I believe that having the on-site pharmacist working at this facility is that having the on-site pharmacist working at this facility is worthwhile value the on-site pharmacist's impact at this facility can modify how I work with the on-site pharmacist to improve resident care which relates to about the activities undertaken by the on-site pharmacist can be used to improve resident medication care in the future N � total number of responses to each survey question.6Health& Social Care in the Community who [the OSP] is.[Te OSP]'s not on the outside looking in" [R3.1].

Table 4 :
Additional, relevant quotes from semistructured interview participants.

Table 4 :
Continued.Like the thing is it [the OSP at the RACF] didn't make much diference to my work...I felt like [OSP2] tried [their] best.Like I'm not a part of RACF 2 and I just think the role could be [more] developed there though that's all" [GP2.1]"It was particularly valuable in the team and made my job easier [having the OSP at RACF 4], though it wasn't necessarily educational [for me]" [GP4.1]"So the interaction has mostly been -well, in fact, I think all of it has been asynchronous through some form of electronic communication. . ."So basically, I had to inject myself and say, "Look, I can take that workload from you.I can do that for you.I can help with that," and really push a little bit at the beginning to say, "Look, I am actually here to help you and make your life easier.""[OSP 1] "I've been on outings with the residents when they were short-staf to help -for example, we took four residents to the RAAF. . .

Table 4 :
Continued."SoI went to see a patient at one of the facilities when the [OSP] was there . . .

Table 4 :
Continued."Allwecan do is try and manage it as best as we can and I guess having OSP 5 there is also useful in that respect because[OSP5]'s probably able to make changes or talk to the doctor a little bit more easily than we can, at the moment, the doctor and the nurses who are on staf at the time" [FM5.1]"Oh,I just feel that if I was unsure of anything, I certainly -I think I would ask to see OSP 6 rather than the nurse, to tell you the truth. . .

Table 4 :
Continued."[OSP3] is somebody that you can go to regarding the type of medications, the role of the diferent medications that your mum might be taking.If you've got any questions regarding medications or if you feel that something is needed to be added, make an appointment and talk to OSP 3 frst and just get some understanding and then you can take it further if you need to, or OSP 3 can take it further" [FM3.1]

Table 4 :
Continued."So, I personally would like to be involved, if I have capacity to be, I would -or someone that has the capacity on my behalf, I would like them to be involved because it afects me, and medication is something that we take -potentially they're taking multiple medications daily.If they're informed, they know what they're taking, why are they taking it, how it can beneft them, they would -I assume would feel empowered and then it would encourage them to want the best of their health care."Oh, I should take this because it's for my heart and it will provide this beneft.""You feel more in control.If you have a problem, you want to feel "Oh, yeah.I can do this.Tis is within my grasp here.""[FM3.1]"then [OSP1] has explained, and then when [OSP1] goes, that's when I start to think.And I think, "Well, maybe I should ask [OSP1] or I should ask that."So the idea is growing.It's like putting a seed in your brain.It's growing that, you know, the more I ask and the more I talk, the more I'll understand it" [R1.3]