Prevalence of opioid use in adults with spinal cord injury: A systematic review and meta-analysis.

OBJECTIVE: To determine the prevalence, reported harms and factors associated with opioid use among adults with spinal cord injury (SCI) living in the community. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Comprehensive literature searches were conducted in PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Scopus for articles published between 2000 and 2023. Risk of bias was assessed using a prevalence-specific tool. Random-effects meta-analyses were conducted to pool prevalence data for any context of opioids. Sensitivity and subgroup analyses were also performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study protocol was registered via Prospero (CRD42022350768). RESULTS: Of the 4969 potential studies, 38 were included in the review. Fifty-three percent of studies had a low risk of bias, with a high risk of bias in 5% of studies. The pooled prevalence for the 38 studies included in the meta-analysis (total cohort size of 50,473) across any opioid context was 39% (95% confidence interval [CI], 32-47). High heterogeneity was evident, with a prediction interval twice as wide as the 95% CI (prediction interval, 7-84%). Mean or median opioid dose was unreported in 95% of studies. Opioid dose and factors related to opioids were also rarely explored in the SCI populations. CONCLUSIONS: Results should be interpreted with caution based on the high heterogeneity and imprecise pooled prevalence of opioids. Contextual details including pain, cohort-specific injury characteristics and opioid dosage were inconsistently reported, indicating a clear need for additional studies in a population at greater risk of experiencing opioid-related adverse effects.

Resilience and empathy in pharmacy interns: Insights from a three-year cohort study.

Background: Resilience and empathy are important attributes for healthcare professionals to navigate challenging work environments and providing patient-centred care. Knowledge about pharmacists' levels of resilience and empathy, particularly during the early stages of their careers, is limited. Objectives: To explore pharmacy interns' levels of resilience and empathy using the Connor-Davidson-Resilience-Scale-25 (CD-RISC-25) and the Kiersma-Chen-Empathy-Scale (KCES), examine potential associations with demographic characteristics and ascertain what challenges interns' resilience and which support mechanisms they identify. Methods: Hard copies of the surveys were distributed to three cohorts during face-to-face intern pharmacy workshops from 2020 to 2022. Additionally, a qualitative questionnaire explored interns' experiences while completing an accredited internship program during the COVID-19 pandemic. Data were analysed using descriptive and inferential statistics, open-ended questions were analysed through qualitative and quantitative content analysis. Results: Among 134 completed surveys, most respondents were female, aged 18-22, and worked in hospitals. The CD-RISC-25 mean score was 66.6 (SD 11.7) and the KCES mean was 84.3 (SD 9.23) indicative of intermediate levels of resilience and empathy. Resilience and empathy scores did not significantly differ between the three cohorts (p-value > 0.05), and both were not consistently correlated with each other (p-value > 0.05). No significant associations were found between demographic characteristics and resilience scores. However, age and pre-internship employment history showed a statistically significant association with empathy scores (p-value < 0.05), with younger age groups and those who worked part-time during undergraduate studies demonstrating higher levels of empathy. Challenges undermining interns' resilience included the COVID-19 pandemic, internship requirements, and feelings of inadequacy and inexperience. Conclusions: This study showed that resilience and empathy scores among interns were at what can be regarded as intermediate levels, largely unaffected by the COVID-19 pandemic or cohort demographics. It highlights professional aspects and strategies which are professionally sustaining and may assist interns in navigating challenges to their resilience and empathy.

A realist synthesis of educational outreach visiting and integrated academic detailing to influence prescribing in ambulatory care: why relationships and dialogue matter.

BACKGROUND: Many quality improvement initiatives in healthcare employ educational outreach visits, integrating academic detailing to bridge evidence-practice gaps and accelerate knowledge translation. Replicability of their outcomes in different contexts varies, and what makes some visiting programmes more successful than others is unclear. OBJECTIVE: We conducted a realist synthesis to develop theories of what makes educational outreach visiting integrating academic detailing work, for whom, under which circumstances and why, focusing on the clinician-visitor interaction when influencing prescribing of medicines in ambulatory care settings. METHODS: The realist review was performed in accordance with RAMESES standards. An initial programme theory was generated, academic databases and grey literature were screened for documents with detail on contexts, intervention and outcomes. Using realist logic of analysis, data from 43 documents were synthesised in the generation of a refined programme theory, supported by additional theoretical frameworks of learning and communication. RESULTS: Twenty-seven interdependent context-mechanism-outcome configurations explain how clinicians engage with educational outreach visits integrating academic detailing through programme design, what matters in programme design and the educational visitor-clinician interaction and how influence extends beyond the visit. They suggest that in addition to relevance, credibility and trustworthiness of a visit's contents, communication and clinical skills of educational visitors, the relationship between the educational visitor and clinician, built on a dialogue of learning from and sense-making with each other, creates conditions of critical thinking which are conducive to facilitating prescribing practice change when necessary. CONCLUSION: This realist synthesis elucidates that the quality of clinician-educational visitor interactions is pivotal to educational outreach visiting programmes. Building and sustaining relationships, and establishing an open dialogue are important; neglecting these undermines the impact of visits. Educational visitors can facilitate clinicians' reflection on practice and influence their prescribing. Clinicians value the discussion of individualised, tailored information and advice they can translate into their practice. PROSPERO REGISTRATION NUMBER: CRD42021258199.

How early career pharmacists understand resilience - A qualitative study of experiences, challenges and strategies.

INTRODUCTION: Resilience assists healthcare professionals in negotiating challenges, remaining positive when experiencing adversity, and in constructively dealing with difficult work situations and environments. There is increasing research about how early career healthcare professionals, understand and maintain resilience but little is known about support early career pharmacists may need and value. AIMS: To explore early career pharmacists' understanding of resilience, their strategies to enhance and maintain resilience as healthcare professionals and to identify resilience-fostering programmes they perceive could be implemented to support them. METHODS: Three focus groups and 12 semi-structured interviews with a total of 15 hospital pharmacists and 10 community pharmacists (both less than 3 years post-registration) were conducted. An inductive thematic analysis of transcripts was performed to identify main themes and subthemes. RESULTS: Pharmacists understood resilience as the capability to adapt to and learn from challenges and setbacks, which they can build through experience and exposure. Resilience in the workplace was challenged by their working environment and workload, which could lead to ego depletion, the transition from intern to registered pharmacist and working during the COVID-19 pandemic, which both added pressure and uncertainty to their role. Professional resilience was supported on individual, social and organisational levels and through self-care strategies. Pharmacists perceived mentorship and sharing experiences, experiential placements and constructive but challenging role play as potentially beneficial in building resilience during undergraduate studies and internship. DISCUSSION: Pharmacists defined resilience constructively and identified challenges testing but also strategies supporting their resilience in the workplace. Workplaces can support pharmacists by monitoring workload and workplace relationships, creating opportunities for peer and mentor support and by allowing pharmacists to implement their personal, individualised resilience maintaining strategies. Early career pharmacists' experiences and insights would be valuable when considering the design and implementation of resilience-fostering programmes.

Learning on the run - a qualitative, longitudinal study of pharmacy educators' experiences implementing a hospital pharmacy residency program.

BACKGROUND: A hospital pharmacy foundation residency training program has been introduced in Australia, modelled on residency programs established in other countries. The program aims to support the professional development of early-career hospital pharmacists, in both clinical and non-clinical roles. Pharmacy educators are usually tasked with the implementation and maintenance of this program. This qualitative, longitudinal study aimed to investigate hospital pharmacy educators' expectations, perceptions and experiences with implementing and developing their residency program. METHODS: Qualitative data were collected at two timepoints, approximately 24 months apart, using either focus groups or interviews with pharmacy educators who were directly involved in the implementation of the residency program at their respective hospitals. During the early phases of implementation, and approximately 24 months later, participants were asked about their experiences and expectations of the residency program as well as any changes that had occurred within the residency program over time. RESULTS: Four focus groups and three semi-structured interviews were held with pharmacy educators and senior pharmacists from different hospital settings. These were audio recorded and transcribed verbatim. Transcripts were inductively analysed via thematic analysis. Fifteen hospital pharmacy educators and senior hospital pharmacists participated in the initial focus groups and interviews, and seven educators were retained for follow-up. Four main themes were established from the discussions: participants had great expectations of a positive impact of the residency on their workplace and residents' professional development; substantial effort, support and resources were needed to implement and maintain a residency program; self-motivation and engagement is needed by residents to succeed and experience timely completion and career acceleration; and lastly a balance between standardisation, consistency and flexibility in delivering the residency needs to be found. The role of educators changed with the implementation of a residency, with the addition of more managerial and supervisory aspects. CONCLUSION: The Australian hospital pharmacy foundation residency program is a complex workplace training program with multiple factors and prerequisites influencing its implementation, development and outcomes. Pharmacy educators are central to the successful implementation and ongoing sustainability of a residency program. They may benefit from formal training and qualifications to support their role.

Realist research to inform pharmacy practice and policy.

Theory-driven implementation and evaluation of pharmacy services can enhance their contribution to overall healthcare. As complex interventions most pharmacy practice programmes and services will be adopted and modified during their implementation into various healthcare contexts and systems. Realist approaches to theory-driven evaluation consider these variations in programmes, interventions and the contexts of their implementation and establish theories on how they work best, for whom and why. This paper illustrates the practical application of the realist philosophy of science to pharmacy practice relevant areas of healthcare using two case studies, a realist synthesis of existing literature on medication reviews and a realist review and evaluation related to medicines management. Applying realist logic establishes causative explanations of what could be essential factors in the success of programmes, enabling policy makers in their decision-making and pharmacy practice researchers as well as practitioners in optimising service design.

The implementation of a pharmacy residency program - A qualitative study on the diffusion of an innovation.

Background: Structured workplace training supports pharmacists in achieving individual career goals as well as health services to meet workforce development goals. Hospital pharmacy residency programs offer structured training pathways for early career pharmacists. A residency program was introduced in Australia, modelled on formal programs already established in other countries. Objective: This qualitative study explored key stakeholders' expectations and early experiences with the implementation of a pharmacy residency program using an analytical framework derived from implementation science. Methods: Three focus groups and seven semi-structured interviews were conducted over a 24-months period with pharmacy managers, senior pharmacists and resident and non-resident pharmacists from different Australian State and hospital settings. They were audio recorded and transcribed verbatim. Transcripts were analysed via thematic analysis using Diffusion of Innovation Theory as a categorising framework. Results: Thirty stakeholders participated in focus groups and interviews. Three of the five main factors that influenced the adoption of an innovation according to Diffusion of Innovation Theory were identified as prominent, two as weaker themes. The relative or perceived advantage of adopting or participating in a residency program was identified as a major theme. Pharmacy managers and resident pharmacists regarded individual and workforce advancement as creating a potential advantage for them. The complexity of the program's implementation, with concerns about its resourcing requirements and sustainability, influenced uptake. The compatibility of the program with already existing training pathways was explored, with the residency sharing similar objectives with current pharmacy education and workforce development goals. Observability and trialability played lesser roles in facilitating program uptake. Conclusion: The implementation and diffusion of the pharmacy residency program can be interpreted by referring to key principles of Diffusion of Innovation Theory. Findings from this study and consideration of theory can inform the diffusion and ongoing maintenance of pharmacy workplace training and education programs.

Cancer patients' perspectives on participating in a community pharmacy-based hyperglycaemia screening service - A qualitative exploration of enablers and barriers.

BACKGROUND: Patients diagnosed with cancer are often treated with high dose glucocorticosteroids, increasing their risk of developing hyperglycaemia or steroid-induced diabetes, which can be reduced by regular monitoring of blood glucose levels. Community pharmacies can provide easily accessible monitoring services to patients, but may not be convenient or acceptable for people with a cancer diagnosis. OBJECTIVES: To explore patients' motivations, perceptions of benefits and barriers influencing their decisions to participate in a novel community pharmacy-based hyperglycaemia screening and monitoring program. METHODS: Patients initiated on high-dose-glucocorticosteroids at a quaternary cancer centre, who were meeting risk factor-based inclusion criteria and offered participation in a community-based blood glucose monitoring program, were purposively recruited to semi-structured interviews. Interview transcripts were analysed using content analysis and the Framework Method. RESULTS: Twenty-four patients participated in the interviews, of whom eighteen enrolled into the monitoring program and six declined participation. Interview analysis identified themes of motivators and barriers which were interpreted within the Health Belief Model. Patients individually balanced perceptions of risk and susceptibility to hyperglycaemia with the illness and treatment burden of a cancer diagnosis and the ability to access the program. Health concerns, accessibility of the community pharmacy, trust in healthcare professionals and altruism of patients (giving back) were identified as enablers to enrol. Barriers were inaccessibility of the community pharmacy, extra burden to deal with monitoring appointments, and initial misunderstandings about the screening and monitoring program. CONCLUSION: Ascertaining individual tipping points based on motivators or enablers and barriers with subsequent tailoring of supportive care programs will be more likely to meet patients' individual needs and may increase the likelihood of delivering appropriate care via community pharmacies.

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

BACKGROUND: Medication reviews for people transitioning from one healthcare setting to another potentially improve health outcomes, although evidence for outcome benefits varies. It is unclear when and why medication reviews performed by pharmacists in primary care for people who return from hospital to the community lead to beneficial outcomes. OBJECTIVE: A realist synthesis was undertaken to develop a theory of what works, for whom, why and under which circumstances when pharmacists conduct medication reviews in primary care for people leaving hospital. METHODS: The realist synthesis was performed in accordance with Realist And MEta-narrative Evidence Syntheses: Evolving Standards reporting standards. An initial programme theory informed a systematic literature search of databases (PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts, OpenGrey, Trove), augmented by agency and government sources of information. Documents were synthesised by exploring interactions between contexts, intervention, outcomes and causal mechanisms. RESULTS: The synthesis identified 9 contexts in which 10 mechanisms can be activated to influence outcomes of pharmacist medication reviews conducted in primary care postdischarge. For a medication review to take place these include trust patients have in healthcare professionals, their healthcare priorities postdischarge, capacity to participate, perceptions of benefit and effort, and awareness required by all involved. For the medication review process, mechanisms which issue an invitation to collaborate between healthcare professionals, enable pharmacists employing clinical skills and taking responsibility for medication review outcomes were linked to more positive outcomes for patients. CONCLUSIONS: Medication reviews after hospital discharge seem to work successfully when conducted according to patient preferences, programmes promote coordination and collaboration between healthcare professionals and establish trust, and pharmacists take responsibility for outcomes. Findings of this realist synthesis can inform postdischarge medication review service models.

In search for gold - The relevance of realist reviews and evaluations to pharmacy research and policy development.

Pharmacy services and programs can be regarded as complex interventions which are developed and implemented within the open, complex system of overall healthcare. Realist research considers matters of complexity and provides insights into what programs and interventions work, why and in which contexts. Based on the philosophy of science of critical realism, realist evaluations and realist reviews generate causative explanations which inform pharmacy practitioners, educators and policy makers in which context programs and services achieve particular outcomes. This more nuanced understanding of how pharmacy services contribute to overall healthcare provides guidance for the refinement and targeting of programs, interventions and practice models. This article outlines key aspects of realist research approaches and provides insight into how realism can contribute to research in and the practice of pharmacy.

Experiences of medical dominance in pharmacist-doctor interactions - An elephant in the room?

BACKGROUND: The development of new roles by pharmacists supports the delivery of healthcare services but potentially also encroaches into other healthcare professions' domains of practice. Some novel pharmacy services are only reluctantly accepted by the medical profession and are surrounded by a discourse which expresses medical dominance, with pharmacists facing resistance to their closer involvement in patient care. OBJECTIVE: To investigate whether and how pharmacists may experience medical dominance in their practice. METHODS: For this qualitative study, pharmacists working in primary care settings were introduced to concepts of sociology in healthcare and medical dominance, then asked to reflect on personal experiences of potential medical dominance, and their emotional and behavioural response. The reflective texts were thematically analysed using a framework based on theories of medical dominance, self-regulation and the influence of emotions on cognition to interpret themes. RESULTS: Twenty-five pharmacists provided detailed reflective accounts. Most worked in a community pharmacy when they experienced medical dominance in interactions with doctors. They described how doctors demarcated territory, evaded scrutiny or disparaged pharmacists' professional expertise. Pharmacists perceived limited options in negotiating these experiences and often employed patients in resolving issues which were left unaddressed. They felt frustrated, undervalued and angry after their experiences and described apprehensiveness in future interactions with doctors. CONCLUSION: Although experiences of medical dominance by pharmacists working in primary care seem to be an infrequent though regular occurrence pharmacists do not seem to be well prepared to counter or negotiate around it. Perceived and actual dominance in interprofessional interactions with doctors are stressors which may affect pharmacists' ability to problem-solve, their role effectiveness and satisfaction.

Pharmacists' advice and clinical reasoning in relation to cardiovascular disease risk factors - A vignette case study.

BACKGROUND: Pharmacists are increasingly providing public health services like the screening and monitoring for cardiovascular disease risk factors. Information on risk factors should be integrated into an assessment of absolute cardiovascular disease risk. Limited information is available on how pharmacists interpret test results and information related to cardiovascular disease risk factors. OBJECTIVE: To investigate the potential advice to clients featured in vignette case studies and reasoning of pharmacists in relation to multiple cardiovascular disease risk factors. METHODS: Three vignette case studies representing clients with varying degrees of absolute cardiovascular disease risk who requested blood pressure and cholesterol level testing and related advice were designed and distributed to practicing pharmacists. Vignettes contained all necessary information for absolute cardiovascular disease risk assessment. Two open ended questions asked what advice pharmacists would provide and what influenced their decisions to give specific advice. Responses were analysed using content analysis and assessed for appropriateness in relation to cardiovascular guidelines. RESULTS: Replies of twenty-nine pharmacists were analysed. Advice to hypothetical clients was mainly appropriate when it concentrated on lifestyle modifications. Pharmacists' reasoning indicated a focus on individual risk factors in their decision making on advice rather than consideration of absolute cardiovascular disease risk, which resulted in inappropriate recommendations of referral and follow up. CONCLUSION: Advice provided in relation to case studies and underlying clinical reasoning indicate potential knowledge gaps, anchoring bias and a framing effect in how pharmacists interpret multiple cardiovascular disease risk factors.

The influence of mobile health applications on patient - healthcare provider relationships: A systematic, narrative review.

OBJECTIVE: To explore the influence of mobile health applications on various dimensions of patient and healthcare provider relationships. METHODS: A systematic, narrative review of English literature reporting experiences and outcomes of using mobile health applications was performed, evaluating communication and relationships between patients and healthcare professionals. Findings were framed thematically within the four dimensions of relationship-centred care. The methodological quality of included articles was appraised. RESULTS: Thirty-seven articles were included, all of them meeting tenets of relationship-centred care. After adopting mobile health applications patients perceived an overall positive impact on their relationship with healthcare providers, indicating they are ready to transition from traditional clinical ecounters to a different modality. Use of the applications supported patients in assuming active roles in the management of their health in collaboration with health professionals. Reluctance of providers to using mobile health needs to be acknowledged and addressed when encouraging wider use of applications in clinical practice. CONCLUSION: The use of mobile health applications can influence communication and relationships between patients and providers positively, facilitating relationship-centered healthcare. PRACTICE IMPLICATION: Implementation of mobile health can support patients' self-efficacy, improve access to healthcare services and improve relationships between patients and providers in ambulatory and hospital settings.

From enforcement to advocacy - Developing a Foucauldian perspective of pharmacists' reflections on interactions with complex patients.

BACKGROUND: Pharmacists are extending their engagement in health care beyond the supply and monitoring of medicines. Extended roles for pharmacists propose participation in health promotion, disease monitoring and other health surveillance activities, involving them more closely in the lives of patients. OBJECTIVES: To explore pharmacists' written reflections on patient-centred practice after interactions with people who experience complexity and difficulties to participate in their health care, using a Foucauldian approach. METHODS: For this qualitative study, pharmacists enrolled in a postgraduate program first watched a video introducing them to the concept of complexity and conflicting patient priorities in health care. They then interacted with patients and reflected on these encounters, their understanding and practice of patient-centeredness. The reflective texts were thematically analysed, using the constant comparison method. Foucault's method of problematisation was used to construct and interpret themes. RESULTS: Sixty-six pharmacists provided reflective accounts of their patient interaction. Main themes showed how pharmacists emphasised adherence to prescribed medicines, disease monitoring and other desirable health behaviours over tailoring advice to patients' priorities. The Foucauldian analysis elucidated how they prioritised supporting individual patient responsibility over addressing complexity in medication regimens and prescribed health care, risking normalisation of an enforcing role. Pharmacists acknowledged a discrepancy in their patient-centred practice when taking responsibility for patients' medication taking behaviour while encouraging the adoption of certain disciplines to achieve compliance. When pharmacists respected patients' agency and tailored advice and professional support to the needs, wishes and capacities of patients, they developed opportunities for advocacy via increased patient-centeredness. CONCLUSION: Pharmacists' discursive practices as described in their reflections raise questions of how they employ their sociological and professional roles in negotiating the relatively best outcomes for patients. Pharmacists increasing their awareness of how they conduct themselves may enhance their patient-centeredness when extending participation in disease monitoring and surveillance.

Doctor-pharmacist communication in hospitals: strategies, perceptions, limitations and opportunities.

Background Effective communication between health professionals contributes to safe and efficient patient care, whereas communication breakdown can lead to adverse patient outcomes and increased healthcare expenditure. Information on how pharmacists and doctors communicate with each other in hospitals is limited. Objective To explore usage and perceptions of communication methods by doctors and pharmacists in hospital settings. Setting Four public hospitals in Australia. Method A mixed method study utilising a pilot questionnaire, semi-structured interviews, and electronic survey was designed. Frequentist statistics and logistic regression were used to analyse survey data. Thematic analysis was conducted to evaluate semi-structured interview data and free-text survey comments. MAIN OUTCOME MEASURES: Frequency of use of communication methods, perceptions of the convenience, time taken to use, accuracy and effectiveness of each method. Results More than 95% of doctors and pharmacists combined used face-to-face and phone calls to communicate with each other, 70% used a medication management plan, and 62% used progress notes. A preference for oral communication was confirmed with the expressed need for building professional rapport and receiving responses. Perceptions regarding effectiveness of oral communication methods were related to perceptions of their convenience and accuracy. Professional groups described differences in perceived ownership of various modes of communication. Conclusions Preferences for oral communication create potential issues with recall and comprehension. Integrating oral communication features into written communication methods, e.g. creating responses, conversations, building rapport, may change doctors' and pharmacists' perceptions of effectiveness. Communication receipt and response functionality in electronic medication and record management systems may improve communication.

From transitions to transformation - A study of pharmacists developing patient-centered communication skills.

BACKGROUND: Pharmacists' communication with patients often focuses on technical aspects of advice giving, while limiting socio-emotional content. To develop pharmacists' patient-centered communication a learning and practice module integrating motivational interviewing (MI) was designed for an online postgraduate program, and its impact on their self-described practice evaluated. OBJECTIVES: To investigate whether training in patient-centered communication changes pharmacists' perceptions of communicating with patients, and how any changes in their communication style influenced interactions and relationships with patients. METHODS: A descriptive, qualitative study analyzing reflective journal entries detailing pharmacists' experiences of implementing patient-centered communication in practice was designed, evaluating reflections on initial patient interactions after training and 9-12 weeks later. Using the framework method of content and thematic analysis, an evaluation framework was devised that integrated communication, change and learning theories. Reflections were categorized within the framework as transitional (e.g. using good communication skills), transactional (e.g. using MI techniques, achieving reciprocity) or transformational (e.g. describing transformative learning, changing frames of reference in understanding of patient-centeredness). Differences between the first and last journal entries were evaluated and analyzed using descriptive statistics. RESULTS: Eighty-nine pharmacists provided two reflective journal entries for evaluation. Over 9-12 weeks, pharmacists described a change in their perspective of patient-centeredness, how they expanded the socio-emotional aspects of communication and succeeded in difficult conversations. When applying the thematic evaluation framework to initial journal entries, 38 (42%) of reflections fell within the transitional category, 51 (58%) were deemed transactional and none transformational. This changed to 10 (11%) transitional, 45 (51%) transactional and 34 (38%) transformational. Differences were observed between journal entries from pharmacists who studied completely online and those who also attended a workshop. CONCLUSION: Learning and practicing techniques of MI and person-focused communication changed many pharmacists' frames of reference in regards to patient-centeredness and their self-reported communication style with patients.

Negotiating "Unmeasurable Harm and Benefit": Perspectives of General Practitioners and Consultant Pharmacists on Deprescribing in the Primary Care Setting.

The use of multiple medicines, known as polypharmacy, poses a risk of harm that is greatest in older adults with multimorbidity. Deprescribing aims to improve health outcomes through ceasing medicines that are no longer necessary or appropriate due to changing clinical circumstances and patient priorities. General practitioners (GPs) and consultant pharmacists (CPs) are well positioned to facilitate deprescribing in primary care in partnership with older adults who present with inappropriate polypharmacy. In this article, we explore GPs' and CPs' views about inappropriate polypharmacy, the reasoning they apply to deprescribing in primary care, and identify factors that support or inhibit this process. Using focus group methodology and the Framework Method for thematic analysis, two major themes were discerned from the data-working through uncertainty and risk perception as a frame of reference. The findings provide important insights when devising methods for advancing and supporting deprescribing in primary care.

Enablers and barriers to the use of antibiotic guidelines in the assessment and treatment of community-acquired pneumonia-A qualitative study of clinicians' perspectives.

BACKGROUND: Community-acquired pneumonia (CAP) is a common condition and a number of guidelines have been developed for its assessment and treatment. Adherence to guidelines by clinicians varies and particularly the prescribing of antibiotics often remains suboptimal. OBJECTIVE: The aim of this study was to elucidate potential barriers and enablers to the adherence to antibiotic guidelines by clinicians treating CAP in an Australian hospital. METHODS: Semi-structured interviews were conducted with purposively recruited senior prescribers who regularly treat CAP in an Australian hospital. Thematic analysis identified a number of themes and subthemes related to their knowledge, attitudes and behaviours associated with the use of CAP guidelines. RESULTS: Thematic saturation was reached after 10 in-depth interviews. Although similar barriers to the use of guidelines as previously described in the literature were confirmed, a number of novel, potential enablers were drawn from the interviews. Clinicians' acceptance and accessibility of guidelines emerged as enabling factors. Generally positive attitudes towards antimicrobial stewardship services invite leveraging what was described as the relationship-based and hierarchical nature of medical practice to provide personalised feedback and updates to clinicians. CONCLUSIONS: Adding a social and personalised approach of antimicrobial stewardship to policy- and systems-based strategies may lead to incremental improvements in guideline adherent practice when assessing and treating CAP.

Attitudes and attributes of pharmacists in relation to practice change - A scoping review and discussion.

BACKGROUND: Multiple barriers and facilitators to the uptake of cognitive services in pharmacy practice have been identified. Pharmacists' attitudes and attributes have been described as barriers and facilitators in relation to the uptake of extended pharmacy services, in addition to those of a more systemic nature. OBJECTIVES: To systematically scope and review the literature describing pharmacists' attitudes and attributes in relation to the implementation of cognitive services or role extension and to critically analyze and discuss their relevance as barriers or facilitators. METHOD: A scoping review of the literature on attitudes and attributes of pharmacists in relation to pharmacy practice was performed, including 47 articles on attitudes and 12 on attributes, forming the basis for a critical analysis within theoretical frameworks. RESULTS: Pharmacists' attitudes toward role extensions and new pharmacy service models are generally positive and their personal attributes and personality traits appear favorable for roles as health professionals. Pharmacists perceived a number of barriers to the uptake of extended roles. CONCLUSION: Pharmacists' attributes, including personality traits, and attitudes favor the implementation of cognitive and patient-focused health care services and should not be regarded as major barriers to the uptake of extended pharmacy practice roles. Framing their attitudes and attributes within the theories of planned behavior and personality trait theories indicates that individual motivation needs to be underscored by systemic support for pharmacy practice change to succeed on a wide scale.