Factors influencing secondary care pharmacist and nurse independent prescribers’ clinical reasoning: An interprofessional analysis

Factors influencing pharmacists' clinical decision making in pharmacy practice

BACKGROUND

Pharmacists' clinical decision-making is considered a core process of pharmaceutical care in pharmacy practice, but little is known about the factors influencing this process.

OBJECTIVE

To identify factors influencing clinical decision-making among pharmacists working in pharmacy practice.

METHODS

Semi-structured interviews were conducted with pharmacists working in primary, secondary, and tertiary care settings in the Netherlands between August and December 2021. A thematic analysis was conducted using an inductive approach. The emerged themes were categorized into the Capability-Opportunity-Motivation-Behaviour (COM-B) model domains.

RESULTS

In total, 16 pharmacists working in primary care (n = 7), secondary care (n = 4) or tertiary care (n = 5) were interviewed. Factors influencing pharmacists' capability to make clinical decisions are a broad theoretical knowledge base, clinical experience, and skills, including contextualizing data, clinical reasoning, and clinical judgment. The pharmacy setting, data availability, rules and regulations, intra- and interprofessional collaboration, education, patient perspectives, and time are mentioned as factors influencing their opportunity. Factors influencing pharmacists' motivation are confidence, curiosity, critical thinking, and responsibility.

CONCLUSIONS

The reported factors covered all domains of the COM-B model, implying that clinical decision-making is influenced by a combination of pharmacists' capability, opportunity, and motivation. Addressing these different factors in pharmacy practice and education may improve pharmacists' clinical decision-making, thereby improving patient outcomes.

Collaborative clinical reasoning learning using an integrated care pathway in undergraduate interprofessional education: An explorative study

Collaborative clinical reasoning (CCR) is part of interprofessional collaborative practice and aims to negotiate and manage patient problems. An integrated care pathway (ICP) can be used as a framework for developing comprehensive patient care, typically in a clinical setting. This study aims to explore the CCR process in undergraduate interprofessional teams and the use of ICP as guidance in discussing a patient's problem and its comprehensive management. This is a qualitative study following phenomenology and was performed in an interprofessional education (IPE) program held by Health Science Cluster Universitas Indonesia. A total of four observations involving 40 students and four focus-group discussions involving 18 students from different health professions backgrounds were conducted to explore the CCR process using the ICP framework. In-depth interviews with four tutors from different health professions backgrounds and document analysis were also conducted as triangulation processes. This study shows that CCR was held in two stages - individual and group. The ICP framework could be used as a guiding tool in the CCR process to discuss the patient's management and discharge plan. This study also demonstrates that there are several challenges in this learning process, including the clinical case used in the discussion, the need for prior knowledge and previous exposure to IPE and the ICP framework, and health professions' dominance during the discussion. This study provides evidence on learning of CCR using the ICP framework as a guiding tool in a pre-licensure IPE program. This approach is useful for preparing students to develop an interprofessional, comprehensive, and holistic health care plan and to help them understand the roles of each profession.

What patient assessment skills do pharmacist independent prescribers require to prescribe immunomodulators in myeloma?

AIM

To gain consensus on the patient assessment skills required by pharmacist independent prescribers prescribing immunomodulators in myeloma across National Health Service Scotland.

METHODS

This was a two-phase study which used nominal group technique to gain local consensus followed by a two-round eDelphi questionnaire to gain national consensus across all cancer networks.

SETTING

This project was conducted across the three cancer networks within NHS Scotland: South East Scotland Cancer Network; West of Scotland Cancer Network and North Cancer Alliance.

SUBJECTS

Participants were invited from each cancer network (South East Scotland Cancer Network, West of Scotland Cancer Network and North Cancer Alliance) and included haematology consultants, haematology specialist registrars, haematology advanced nurse practitioners and haematology pharmacists.

RESULTS

There were five participants in the nominal group technique. Twenty-two out of 31 patient assessment skills gained local consensus, seven patient assessment skills did not gain consensus and two patient assessment skills were deemed irrelevant. There were 12 and 14 participants in round one and two of the eDelphi questionnaire, respectively. Twenty-nine patient assessment skills were included in the first-round questionnaire and 21 gained consensus. The remaining eight patient assessment skills were included in round two where seven did not achieve consensus and one achieved disagreement consensus.

CONCLUSION

This research outlines 21 patient assessment skills required for pharmacist independent prescribers to prescribe immunomodulators for myeloma patients according to haematology specialists in Scotland. Discussion on patient assessment skills without consensus showed that the pharmacist independent prescribers would have a shared responsibility with the consultant. This work should inform the development of a competency framework to allow training of pharmacist independent prescribers in Scotland. Some patient assessment skills could be transferrable for pharmacist independent prescribers prescribing systemic anti-cancer therapy for other haematological malignancies.

A realist synthesis of staff-based primary health care interventions addressing universal health coverage

Background

Methods

Results

Conclusions

Developing a competence framework for nurses in pharmaceutical care: A Delphi study

BACKGROUND

Nurses play an important role in pharmaceutical care. They are involved in: detecting clinical change; communicating/discussing pharmacotherapy with patients, their advocates, and other healthcare professionals; proposing and implementing medication-related interventions; and ensuring follow-up of patients and medication regimens. To date, a framework of nurses' competences on knowledge, skills, and attitudes as to interprofessional pharmaceutical care tasks is missing.

OBJECTIVES

To reach agreement with experts about nurses' competences for tasks in interprofessional pharmaceutical care.

METHODS

A two-phase study starting with a scoping review followed by five Delphi rounds was performed. Competences extracted from the literature were assessed by an expert panel on relevance by using the RAND/UCLA method. The experts (n = 22) involved were healthcare professionals, nurse researchers, and educators from 14 European countries with a specific interest in nurses' roles in interprofessional pharmaceutical care. Descriptive statistics supported the data analysis.

RESULTS

The expert panel reached consensus on the relevance of 60 competences for 22 nursing tasks. Forty-one competences were related to 15 generic nursing tasks and 33 competences were related to seven specific nursing tasks.

CONCLUSIONS

This study resulted in a competence framework for competency-based nurse education. Future research should focus on imbedding these competences in nurse education. A structured instrument should be developed to assess students' readiness to achieve competence in interprofessional pharmaceutical care in clinical practice.

Time for change? A qualitative exploration of the educational preparation and subsequent continuing professional development needs of nurse and midwife prescribers

AIM/OBJECTIVE

The aim of this study was to explore nurse and midwife prescribers' perception of their educational preparation for the role and identify continuing professional development (CPD) requirements to generate practitioner-based knowledge with the potential to inform education and research, policy and practice.

BACKGROUND

Educational preparation for the nurse and midwife prescribing role has remained relatively unchanged since its introduction and follows a model whereby practitioners engage in theoretical learning and learning situated within the clinical environment, facilitated by a dedicated medical mentor. No significant examination of this preparation has been undertaken in Ireland since 2009.

DESIGN

This was a qualitative study, guided by elements associated with hermeneutic phenomenology.

METHODS

Following research ethics approval and informed consent, 16 participants from 2 maternity hospitals participated in one-to-one audio recorded semi-structured interviews.

RESULTS

Participants experience of the education programme varied with some acknowledging the importance of a broad pharmacological module whereas others believed it to be irrelevant given their prescribing scope was in many instances quiet narrow. The experience of being mentored by a medical doctor ranged from a positive learning experience to one which did not contribute to learning. Barriers to engaging with CPD were identified along with advancements in the practice arena which identify additional CPD requirements.

CONCLUSIONS

This study has generated practitioner-based knowledge which provides direction for future developments in the educational preparation of nurse and midwife prescribers, particularly around pharmacology and mentorship and outlines specific CPD requirements for practitioners.

Competence and confidence with prescribing in pharmacy and medicine: a scoping review

Objectives

Prescribing is a growing scope of practice for pharmacists. The objective of this scoping review is to explore themes within the literature related to prescribing competence and confidence in the disciplines of pharmacy and medicine.

Methods

Online databases MEDLINE, EMBASE and Global Health were used to identify articles from inception to October 2018. Articles describing either the competence or confidence of physician, pharmacist or student prescribing, including inappropriate prescribing and prescribing errors were included.

Key findings

After applying the inclusion and exclusion criteria, 33 eligible articles remained. Many studies demonstrate that medical students and junior doctors are not competent in prescribing when they enter practice, and their perceived confidence is often higher than their assessed competence. There were fewer studies about pharmacist competence and confidence with prescribing; however, they described pharmacists that felt competent to prescribe but lacked confidence. Themes from the review included self-awareness, lack of education and educational improvements, prescribing errors and resources, prescribing culture and barriers to prescribing, gender differences and benefits to prescribing.

Conclusions

There is little consensus from the outcomes of these studies related to prescribing competence or confidence. While some reflect positively on prescribing competence and confidence, others show major deficits in competence and lack of confidence. Further research needs to be done to evaluate pharmacist competence and confidence with respect to prescribing.

Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams

The objectives of this paper are to: (1) identify contextual factors such as policy that impacted the implementation of community-based primary health care (CBPHC) innovations among 12 Canadian research teams and (2) describe strategies used by the teams to address contextual factors influencing implementation of CBPHC innovations. In primary care settings, consideration of contextual factors when implementing change has been recognized as critically important to success. However, contextual factors are rarely recorded, analyzed or considered when implementing change. The lack of consideration of contextual factors has negative implications not only for successfully implementing primary health care (PHC) innovations, but also for their sustainability and scalability. For this evaluation, data collection was conducted using self-administered questionnaires and follow-up telephone interviews with team representatives. We used a combination of directed and conventional content analysis approaches to analyze the questionnaire and interview data. Representatives from all 12 teams completed the questionnaire and 11 teams participated in the interviews; 40 individuals participated in this evaluation. Four themes representing contextual factors that impacted the implementation of CBPHC innovations were identified: (I) diversity of jurisdictions (II) complexity of interactions and collaborations (III) policy, and (IV) the multifaceted nature of PHC. The teams used six strategies to address these contextual factors including: (1) conduct an environmental scan at the beginning (2) maintaining engagement among partners and stakeholders by encouraging open and inclusive communication; (3) contextualizing the innovation for different settings; (4) anticipating and addressing changes, delays, and the need for additional resources; (5) fostering a culture of research and innovation among partners and stakeholders; and (6) ensuring information about the innovation is widely available. Implementing CBPHC innovations across jurisdictions is complex and involves navigating through multiple contextual factors. Awareness of the dynamic nature of context should be considered when implementing innovations.

Prescribing in 2019: what are the safety concerns?

INTRODUCTION

Unintended harm from prescribing errors remains a prevalent concern in healthcare leading to significant morbidity and mortality around the world. Prescribers face new challenges to their practice in modern times such as increasingly complex health-care systems, an aging population with increasing multimorbidity, and rapid growth in the number of novel medicines. Areas covered: Prescribing concerns in modern practice are outlined based on seminal literature in this area and the author's continual academic oversight of this topic. Major UK and international reports have been used to highlight the important emerging issues in prescribing, and focused literature searches performed to highlight key papers supporting this review. Expert opinion: Whilst there are many ways to consider mitigating the risk of harm from prescribing, it is suggested that a tripartite approach is required. Patients and carers are essential partners in the process and shared decision-making has replaced paternalistic practice in achieving joint prescribing decisions. Comprehensive and coordinated care is critical to avoid fragmented care and poor transfer of prescribing information. Lastly, a whole systems approach is crucial to ensure that all prescribers are supported (and not overwhelmed) when making safe, effective and timely prescribing decisions.

Providing medicines in emergency and urgent care: a survey of specialist paramedics' experiences of medication supply and views on paramedic independent prescribing

Introduction:

Specialist paramedics in the United Kingdom are able to undertake additional training and education in the assessment and treatment of minor illness and injuries. The provision of medication often forms a part of specialist paramedic care, but there is currently no research into the perceived usefulness or impact of the use of patient group directions or on their preparedness to undertake paramedic independent and supplementary prescribing. The aim of this study was to (a) investigate the ways in which medicines are currently supplied by specialist paramedics and (b) establish views on the introduction of paramedic independent and supplementary prescribing, including practitioner preparedness and potential impact on practice.

Methods:

An online questionnaire was sent to 268 specialist paramedics employed by two NHS ambulance Trusts in England who jointly employed 54% of the national population (n = 495) of specialist paramedics. Data were analysed using descriptive statistics and a framework analysis approach.

Results:

Patient group directions were reported to be used regularly and infections, pain and exacerbations of respiratory conditions were the most frequently treated conditions by specialist paramedics.

Although just over half of participants reported that patient group directions did not restrict their ability to supply medication to patients, a significant minority found them too restrictive. Examples of restrictions included contradictions to local antimicrobial guidance and being unable to supply sufficiently strong analgesia.

The majority of participants (66/78, 84.6%) felt confident to undertake paramedic independent and supplementary prescribing and that it would enhance both their scope of practice (70/72, 97.2%) and patient care (67/72, 93.0%). However, participants had concerns regarding organisational readiness for paramedic independent and supplementary prescribing (50/72, 69.4%), including provision of paramedic access to patient records (65/72, 90.2%) and obtaining sufficient clinical support (39/72, 54.1%).

Conclusions:

Patient group directions do enable specialist paramedics to supply medication to patients in order to treat a range of conditions, but at times the paramedics felt that the patient group directions restricted autonomous practice. The majority of participants felt confident to undertake paramedic independent and supplementary prescribing and anticipated that it would enhance patient care.