Use of cross-sector apprenticeships in pharmacy: is it a sustainable quality education model for pharmacy assistants?

OBJECTIVES: To establish whether undertaking cross-sector pharmacy apprenticeship training to become a pharmacy assistant equally split across the two main pharmacy sectors improves training experience and cross-sector understanding. METHODS: A mixed method approach was utilised to explore the experiences of 10 pharmacy apprentices, their employers and education provider. Questionnaires were used to explore apprentices' experiences and views following each 6-month placement. Seven pharmacy employers and the education provider were invited to take part in telephone interviews. Questionnaires were analysed using simple frequencies; qualitative data were analysed thematically. KEY FINDINGS: Ten apprentices were recruited, and nine apprentices returned questionnaires from at least one placement. Three hospital-based employers, four community employers and one education provider were interviewed. All participants had found the pilot positive and the cross-sector training to have been a useful experience. Employers noted that the pilot provided the apprentice with valuable insight into the patient's journey and the opportunity to share learning across sectors. Employers also commented that more information regarding the nature of the training would have been useful to help better structure the placement for the apprentice. CONCLUSIONS: This paper explores the benefits and challenges of employing a pharmacy apprentice and utilising a novel cross-sector training model. Findings have potential relevance to the training of other pharmacy staff, including pharmacy technicians and pharmacists. They offer early insights into the potential value of pharmacy apprenticeships for training pharmacy assistants, particularly if these are set up across the two main sectors hospital and community pharmacy.

Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies.

BACKGROUND: While efforts have been made to bring about quality and safety improvement in healthcare, it remains by no means certain that an improvement project will succeed. This suggests a need to better understand the process and conditions of improvement. The current study addresses this question by examining English community pharmacies attempting to undertake improvement activities. METHOD: The study used a longitudinal qualitative design, involving a sample of ten community pharmacies. Each pharmacy took part in a series of improvement workshops, involving use of the Manchester Patient Safety Framework (MaPSaF), over a twelve-month period. Qualitative data were collected from the workshops, from follow-up focus groups and from field notes. Template analysis was used to identify themes in the data. RESULTS: The progress made by pharmacies in improving their practice can be described in terms of a behavioural change framework, consisting of contemplation (resolving to make changes if they are required), planning (deciding how to carry out change) and execution (carrying out and reflecting on change). Organizational conditions supporting change were identified; these included the prioritisation of improvement, a commitment to change, a trusting and collaborative relationship between staff and managers, and knowledge about quality and safety issues to work on. CONCLUSIONS: Our study suggests a process by which healthcare work units might undergo improvement. In addition to recognising and providing support for this process, it is important to establish an environment that fosters improvement, and for work units to ensure that they are prepared for undergoing improvement activities.

Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies.

OBJECTIVE: Procedural violations are known to occur in a range of work settings, and are an important topic of interest with regard to safety management. A Safety-I perspective sees violations as undesirable digressions from standardised procedures, while a Safety-II perspective sees violations as adaptations to a complex work system. This study aimed to apply both perspectives to the examination of violations in community pharmacies. DESIGN: Twenty-four participants (13 pharmacists and 11 pharmacy support staff) were purposively sampled to participate in semi-structured interviews using the critical incident technique. Participants described violations they made during the course of their work. Interviews were digitally recorded, transcribed verbatim and analysed using template analysis. SETTING: Community pharmacies located in England and Wales. RESULTS: 31 procedural violations were described during the interviews revealing multiple reasons for violations in this setting. Our findings suggest that from a Safety-II perspective, staff violated to adapt to situations and to manage safety. However, participants also violated procedures in order to maintain productivity which was found to increase risk in some, but not all situations. Procedural violations often relied on the context in which staff were working, resulting in the violation being deemed rational to the individual making the violation, yet the behaviour may be difficult to justify from an outside perspective. CONCLUSIONS: Combining Safety-I and Safety-II perspectives provided a detailed understanding of the underlying reasons for procedural violations. Our findings identify aspects of practice that could benefit from targeted interventions to help support staff in providing safe patient care.

When procedures meet practice in community pharmacies: qualitative insights from pharmacists and pharmacy support staff.

OBJECTIVES: Our aim was to explore how members of community pharmacy staff perceive and experience the role of procedures within the workplace in community pharmacies. SETTING: Community pharmacies in England and Wales. PARTICIPANTS: 24 community pharmacy staff including pharmacists and pharmacy support staff were interviewed regarding their view of procedures in community pharmacy. Transcripts were analysed using thematic analysis. RESULTS: 3 main themes were identified. According to the 'dissemination and creation of standard operating procedures' theme, community pharmacy staff were required to follow a large amount of procedures as part of their work. At times, complying with all procedures was not possible. According to the 'complying with procedures' theme, there are several factors that influenced compliance with procedures, including work demands, the high workload and the social norm within the pharmacy. Lack of staff, pressure to hit targets and poor communication also affected how able staff felt to follow procedures. The third theme 'procedural compliance versus using professional judgement' highlighted tensions between the standardisation of practice and the professional autonomy of pharmacists. Pharmacists feared being unsupported by their employer for working outside of procedures, even when acting for patient benefit. Some support staff believed that strictly following procedures would keep patients and themselves safe. Dispensers described following the guidance of the pharmacist which sometimes meant working outside of procedures, but occasionally felt unable to voice concerns about not working to rule. CONCLUSIONS: Organisational resilience in community pharmacy was apparent and findings from this study should help to inform policymakers and practitioners regarding factors likely to influence the implementation of procedures in community pharmacy settings. Future research should focus on exploring community pharmacy employees' intentions and attitudes towards rule-breaking behaviour and the impact this may have on patient safety.

Strength and endurance training of an individual with left upper and lower limb amputations.

PURPOSE: The purpose of this article is to describe the development of a strength and endurance training programme designed to prepare an individual with a left glenohumeral disarticulation and transtibial amputation for a bike trip across the USA. METHOD: The subject was scheduled for training three times per week over a two-month period followed by two times per week for an additional two months. Training consisted of a resistance training circuit using variable resistance machines, cycling using a recumbent stationary bike, and core stability training using stability ball exercises. Changes in strength were assessed using 10 RM tests on the resistance machines and changes in peak VO(2) were monitored utilizing the Cosmed K4b pulmonary function tester. RESULTS: The subject demonstrated a 30.3% gain in peak VO(2). The subject's 10 RM for left single limb leg press increased 36.8% and gains of at least 7.7% were seen for all other muscle groups tested. CONCLUSION: The strength and endurance training programme adapted to compensate for this subject's limb losses was effective in increasing both strength and peak VO(2). Adapting exercise programmes to compensate for limb loss may allow individuals with amputations to participate in physically challenging activities that otherwise may not be available to them.

Helix P4 is a divalent metal ion binding site in the conserved core of the ribonuclease P ribozyme.

The ribonuclease P ribozyme (RNase P RNA), like other large ribozymes, requires magnesium ions for folding and catalytic function; however, specific sites of metal ion coordination in RNase P RNA are not well defined. To identify and characterize individual nucleotide functional groups in the RNase P ribozyme that participate in catalytic function, we employed self-cleaving ribozyme-substrate conjugates that facilitate measurement of the effects of individual functional group modifications. The self-cleavage rates and pH dependence of two different ribozyme-substrate conjugates were determined and found to be similar to the single turnover kinetics of the native ribozyme. Using site-specific phosphorothioate substitutions, we provide evidence for metal ion coordination at the pro-Rp phosphate oxygen of A67, in the highly conserved helix P4, that was previously suggested by modification-interference experiments. In addition, we detect a new metal ion coordination site at the pro-Sp phosphate oxygen of A67. These findings, in combination with the proximity of A67 to the pre-tRNA cleavage site, support the conclusion that an important role of helix P4 in the RNase P ribozyme is to position divalent metal ions that are required for catalysis.

The track of the pre-tRNA 5' leader in the ribonuclease P ribozyme-substrate complex.

The ribonuclease P (RNase P) ribozyme is an endonuclease that binds precursor tRNAs and catalyzes the removal of 5' leader nucleotides. Biochemical and photo-cross-linking studies have identified sites of contact between the mature tRNA domain of pre-tRNA and the ribozyme; however, relatively little is known about the location of the 5' leader in the ribozyme-substrate complex. To investigate the local three-dimensional environment of the 5' leader, we employed the short-range photo-cross-linking agent 4-thiouridine (s(4)U). The s(4)U photoagent was incorporated into a series of pre-tRNA substrates containing unique uridine residues in the 5' leader sequence at positions -1, -3, -5, -7, or -10. The modified substrates formed high-affinity complexes with the ribozyme and produced discrete intermolecular cross-links to RNase P RNA from Bacillus subtilis. Locations of the cross-linked nucleotides in the ribozyme and pre-tRNA were determined by reverse transcriptase primer extension. Photoagents incorporated into the 5' leader detected discrete elements of ribozyme structure in a progression from J18/2 to L15 to P3. Importantly, all of the cross-linked species retained the ability to cleave the covalently attached pre-tRNA, indicating that the cross-links reflect the native structure of the ribozyme-substrate complex. Together with available structural and biochemical data, the cross-linking results suggest a model for the position of the 5' leader within the ground-state ribozyme-substrate complex.

Use of circular permutation and end modification to position photoaffinity probes for analysis of RNA structure.

Photocrosslinking allows first-order structural analysis with relatively small amounts of biological material and can be applied in complex in vitro systems. In this article we describe methods for positioning both arylazide and thionucleotide photoagents within an RNA of interest by end modification of circularly permuted RNAs. Application of this technique provided a library of constraints that, together with biochemical and phylogenetic comparative data, were used to develop a structure model of the bacterial ribonuclease P ribozyme-substrate complex. Circularly permuted genes for in vitro transcription are generated by PCR from tandem genes. Circularly permuted RNA transcripts can be modified with high efficiency at both the 5' and 3' termini with arylazide crosslinking reagents, or transcription can be primed with photoactive nucleotide analog monophosphates such as 6-thioguanosine. These crosslinking agents can be used over a wide range of experimental conditions but remain inert until they are activated by UV light. Crosslinked sites are subsequently mapped by reverse transcriptase primer extension of gel-purified crosslinked species. In addition to providing basic protocols for these methods, we discuss approaches for establishing the relevance of crosslinking data to native RNA structure.

Identification of individual nucleotides in the bacterial ribonuclease P ribozyme adjacent to the pre-tRNA cleavage site by short-range photo-cross-linking.

The bacterial RNase P ribozyme is a site-specific endonuclease that catalyzes the removal of pre-tRNA leader sequences to form the 5' end of mature tRNA. While several specific interactions between enzyme and substrate that direct this process have been determined, nucleotides on the ribozyme that interact directly with functional groups at the cleavage site are not well-defined. To identify individual nucleotides in the ribozyme that are in close proximity to the pre-tRNA cleavage site, we introduced the short-range photoaffinity cross-linking reagent 6-thioguanosine (s6G) at position +1 of tRNA and position -1 in a tRNA bearing a one-nucleotide leader sequence [tRNA(G-1)] and examined cross-linking in representatives of the two structural classes of bacterial RNase P RNA (from Escherichia coli and Bacillus subtilis). These photoagent-modified tRNAs bind with similar high affinity to both ribozymes, and the substrate bearing a single s6G upstream of the cleavage (-1) site is cleaved accurately. Interestingly, s6G at position +1 of tRNA cross-links with high efficiency to homologous positions in J5/15 in both E. coli and B. subtilis RNase P RNAs, while s6G at position -1 of tRNA(G-1) cross-links to homologous nucleotides in J18/2. Both cross-links are detected over a range of ribozyme and substrate concentrations, and importantly, ribozymes cross-linked to position -1 of tRNA(G-1) accurately cleave the covalently attached substrate. These data indicate that the conserved guanosine at the 5' end of tRNA is adjacent to A248 (E. coli) of J5/15, while the base upstream of the substrate phosphate is adjacent to G332 (E. coli) of J18/2 and, along with available biochemical data, suggest that these nucleotides play a direct role in binding the substrate at the cleavage site.

Differential chemical probing of a group II self-splicing intron identifies bases involved in tertiary interactions and supports an alternative secondary structure model of domain V.

Dimethyl sulfate modification was used to probe for tertiary structural elements in the group II intron PI.LSU/2 from the mitochondrial pre-ribosomal RNA of the brown alga Pylaiella littoralis. Modification of the lariat form of the intron under conditions that allow both native folding and conformational homogeneity is found to be generally consistent with secondary and tertiary structural features identified previously for group II ribozymes. A comparison of chemical probing at temperatures just below and above the first melting transition illustrates the cooperative unfolding of tertiary structure and identifies novel candidates for tertiary interactions in addition to defining elements of secondary structure. Substitution of the GAAA terminal loop of domain V is shown to be compatible with retention of conformational homogeneity (despite the loss of an important tertiary interaction), but produces a concise methylation footprint in domain I at the site previously shown to harbor the receptor for that loop. The analysis also identified two nucleotide positions in domain V with novel secondary and potential tertiary structural roles. The proposed refinement of domain V secondary structure is supported by an expanded comparative analysis of group II sequences and bears increased resemblance to U2:U6 snRNA pairing in the spliceosome.

Utilization of cofactors expands metabolism in a new RNA world.

RNA has been hypothesized to have preceded proteins as the major catalysts of the biosphere, yet there are only a very limited number of chemical reactions that are known to be catalyzed by modern RNA. Cofactors are used by the majority of protein enzymes to supply additional functional groups to the active site. RNA should also be able to utilize some of these same cofactors to extend its own catalytic potential. We describe here how it could be possible to use selection--amplification from a population of random RNA to obtain a coenzyme A mediated RNA transacylase. Exploitation of some of the sulphur chemistry mediated by coenzyme A could have significantly expanded a prebiotic RNA directed metabolism.

Metal coordination sites that contribute to structure and catalysis in the group I intron from Tetrahymena.

We have used nucleoside phosphorothioates (NTP alpha S) and a substitution-interference method to identify phosphate oxygens that appear to be important to guanosine cofactor addition in the self-splicing group I intron from Tetrahymena thermophila. For the majority of these phosphate oxygens, however, the effect of NTP alpha S substitution is significantly reduced in reactions containing the added presence of manganese ion (Mn2+) relative to magnesium ion (Mg2+) alone. The observed "rescue" of the NTP alpha S effect at these positions is thought to be due to the larger affinity of Mn2+ for sulfur. These data suggest the direct coordination of divalent metal ions within the highly conserved catalytic core of the Tetrahymena intron. Because many of these metal binding sites appear to be in positions of close backbone-backbone approach, and adjacent to the guanosine binding site the splice junction, we suggest roles for the corresponding ions in stabilizing tertiary structure and substrate recognition and as participants in catalysis.

Analysis of the role of phosphate oxygens in the group I intron from Tetrahymena.

We have developed a quantitative substitution interference technique to examine the role of Pro-Rp oxygens in the phosphodiester backbone of RNA, using phosphorothioates as a structural probe. This approach is generally applicable to any reaction involving RNA in which the precursor and reaction products can be separated. We have applied the technique to identity structural requirements in the group I intron from Tetrahymena thermophila for catalysis of hydrolysis at the 3' splice site; 44 phosphate oxygens are important in 3' splice site hydrolysis. These include four or five oxygens previously observed to be important in exon ligation. Although phosphate oxygens having a functional significance can be found throughout the intron, the strongest phosphorothioate effects are closely associated with positions in the highly conserved intron core, which are likely to be involved in tertiary interactions, substrate recognition and catalysis.

Stereoselective arginine binding is a phylogenetically conserved property of group I self-splicing RNAs.

We have examined the reaction of GTP with RNA polymerase transcripts containing the self-splicing RNA precursors from the Neurospora crassa Cob1 intron, and from introns in the sunY, nrdB and td genes of bacteriophage T4. In each case, we find a low Km for GTP (between 0.8 and 11 microM), accompanied by competitive inhibition of the GTP reaction by L-arginine, as was found for the previously examined Tetrahymena nuclear pre-rRNA intron. Trials with the 20 standard amino acids show that inhibition in all cases is specific to the arginine side-chain. L-arginine binds with similar affinity to all introns studied, the Ki's ranging from 4.3 to 21 mM. Strikingly, the relative binding preference of the RNAs for L- versus D-arginine is highly conserved: the ratio of L-arg Ki/D-arg Ki, the stereoselectivity, is always close to 2. Because of the conservation of GTP and arginine binding constants and particularly because of the conserved stereoselectivity, we conclude that the evolution of an effective group I RNA transesterification catalyst necessarily produces a specific and stereoselective RNA binding site for a single amino acid. This suggests that selection for an ancient group I RNA could have fortuitously initiated the specific association of RNA sequences with amino acids, a first step toward the genetic code.

Epidermal growth factor immunoreactive material in the rat brain. Localization and identification of multiple species.

Brains of adult male rats were dissected into five distinct regions: brainstem, cerebellum, hippocampus, diencephalon, and telencephalon. Epidermal growth factor-like immunoreactivity was isolated and characterized by radioimmunoassay and nondenaturing polyacrylamide gel electrophoresis. Radioimmunoassay indicated levels of standard rat epidermal growth factor equivalents ranging from 0.99 to 0.33 ng/g wet weight of brain tissue. Competition curves were not parallel to those generated with standard rat epidermal growth factor, indicating a lack of structural identity between the immunoreactive material in the brain and standard rat epidermal growth factor. Extracts of submandibular gland and blood did, however, produce parallel competition curves. Electrophoresis indicated the presence of multiple bands of immunoreactive material in each of the regions of the brain. The major bands of activity migrated to positions distinct from that of standard rat epidermal growth factor. This is the first demonstration of multiple forms of epidermal growth factor-like immunoreactive material in the central nervous system.