The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health.

Pharmacists have traditionally supported the prescribing process, arguably in reactive or corrective roles. The advent of pharmacist prescribing in 2004 represented a major shift in practice, leading to greater responsibility for making clinical decisions with and for patients. Prescribing rights require pharmacists to take a more prescriptive role that will allow them to contribute to long-standing prescribing challenges such as poor medication adherence, overprescribing, and the need for shared decision-making and person-centered care. Central to these endeavors are the development and possession of effective consultation skills. University schools of pharmacists in the UK now routinely include consultation skills training, which is also provided by national education bodies. These challenges remain difficult to overcome, even though it is understood, for example, that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments. More recently, a concerted effort has been made to tackle overprescribing and the harm that may occur through the inappropriate use of medication. In routine pharmacy work, these priorities may linger at the bottom of the list due to the busy and complex nature of the work. Solutions to these problems of adherence, optimizing benefits of medication, and overprescribing have typically been pragmatic and structured. However, an arguably reductionist approach to implementation fails to address the complex patient interactions around prescribing and taking medication, and the heterogeneity of the patient's experience, leaving the answers elusive. We suggest that it is essential to explore how person-centered care is perceived and to emphasize the relational aspects of clinical consultations. The development of routine pharmacist prescribing demands building on the core values of person-centered care and shared decision making by introducing the concepts of "relational prescribing" and "open dialogue" to cultivate an essential pharmacotherapeutic alliance to deliver concrete positive patient outcomes. We provide a vignette of how a clinical case can be approached using principles of relational prescribing and open dialogue. We believe these are solutions that are not additional tasks but must be embedded into pharmacy practice. This will improve professional satisfaction and resilience, and encourage curiosity and creativity, particularly with the advent of all pharmacists in Great Britain becoming prescribers at graduation from 2026.

A qualitative evaluation of weekly reflective practice sessions for the intensive care unit pharmacy team during the COVID-19 pandemic.

Despite well-being initially being high on the agenda for UK health organisations, the COVID-19 pandemic has highlighted significant gaps around provision for well-being of pharmacists in the UK. The COVID-19 intensive care unit (ICU) environment exposed pharmacists to mental, physical and emotional challenges, including high levels of patient mortality. OBJECTIVES: To provide an account of the experience of pharmacists working within an ICU at a large National Health Service hospital who attended reflective practice sessions throughout the first wave of the pandemic. METHOD: A retrospective, cross-sectional design was used to gather information from eight participants who had attended nine, 30-minute weekly reflective practice sessions. Participants were invited to complete a 10-item online self-report questionnaire. The responses from the questionnaire were analysed using theoretical thematic analysis. RESULTS: Seven participants completed the self-report questionnaire. Thematic analysis of responses identified four themes: (1) permission: both professional and personal 'permission' was necessary for participants to be present for the reflective practice sessions and to attend to their own well-being; (2) containing safe space: reflective practice sessions offered a consistently secure environment from which to explore topics which created challenge, personally and/or professionally; (3) connectedness: the impact of these sessions on participants' relationships with other attendees, as individuals and the group as a whole; and (4) emotional experience: increased awareness of developments around their expression, processing and management of emotion as a result of attending the sessions. CONCLUSIONS: This study provides new and important insights into the use of reflective practice for pharmacists working in an ICU during the COVID-19 pandemic. Findings demonstrate heterogeneity in the experience of distress, the need to support the pharmacy profession, and the need to provide opportunities for staff to connect safely with colleagues during such crises. The impact of organisation-led support for the pharmacy profession is discussed as a future direction of research.

Improving shared decision-making in pharmacist-led haematology clinics: a 'Plan Do Study Act' approach.

INTRODUCTION: The concept of person-centred care is regarded as an essential approach to healthcare. A core component of person-centred care is the shared decision-making process. There is evidence that effective shared decision-making can improve people's satisfaction with their care. This quality improvement project used the 'Plan Do Study Act' (PDSA) cycles to test the small changes made and to assess their impact on shared decision-making in clinic consultations. OBJECTIVE: To enhance patient satisfaction in pharmacist-led haematology clinics by improving shared decision-making. METHODS: Patients from a haematology clinic participated in a survey based on the validated 'Benefit, Risk, Alternatives, do Nothing' (BRAN) questions, which encourage patients' involvement in shared decision-making conversations with clinicians. Data were collected from 142 consultations over 3 months, using three PDSA cycles, which provided the structure to implement changes, evaluate their impact, and build on the learning from previous cycles. The first cycle analysed the shared decision-making in the clinic. The second cycle involved shared decision-making training for pharmacists. On the third cycle, decision-making aid leaflets were implemented. RESULTS: First cycle results showed patients were mostly satisfied with the 'Benefit' statement. The second cycle revealed satisfaction improvements on 'Risk'. On the third cycle, satisfaction increased on the 'do Nothing' statement. The baseline mean of the patient satisfaction score increased from 3.25/5 at the start to 3.75/5 by the end of the study. CONCLUSIONS: The results show that each cycle had a positive effect, suggesting that training specialist pharmacists in person-centred care and shared decision-making led to an improvement in patient satisfaction. Encouraging patients to be involved in shared decision-making enabled them to ask questions in consultations and led to improved satisfaction. The project highlighted the importance of developing the skills and knowledge of the pharmacy workforce to support the needs of an expanding and ageing cancer population.

Goal attainment scaling to facilitate person-centred, medicines-related consultations.

Goal attainment scaling (GAS) is a method of setting and evaluating goal achievement across different patient groups. In the rehabilitation setting, this measure helps patients to identify personalised goals and evaluate their achievement over time. This report will focus on how GAS, currently embedded in clinical practice in the rehabilitation setting, may be used in pharmacy practice. The use of a coaching approach to consultations, which includes goal setting, provides an opportunity to integrate the GAS methodology into medicines-related consultations. Using examples from pharmacy practice, the report will outline methods of measuring goal attainment as part of person-centred pharmacy conversations to support medicines optimisation.​.

Guide to undertaking person-centred inpatient (ward) outpatient (clinic) and dispensary-based pharmacy consultations.

WHO uses the internationally accepted term 'person-centred care', also usedby the Royal Pharmaceutical Society in the UK, to highlight the importance of considering that patients are people first; they have families, communities and are living with conditions for which they receive healthcare. The challenge that faces pharmacy professionals is embedding a person-centred approach to pharmacy practice. In a hospital setting, there are specific processes that must be completed to optimise safe, efficient and effective practice, however thesetend to be professionally focused. The coaching model, GROW, supports more person-centred conversations and has been used successfully in health in the National Health Service (NHS) in the UK . Inin pharmacy, practitioners were challenged with the task of integratingperson-centred consultation techniques as part of the pharmacy processes they were required to complete within their everyday activities. Therefore, a set of person-centred questions were developed, using concepts from GROW and the Four E's, to create guides for practitioners to use within each of the pharmacy processes they commonly undertook. The guides were piloted with three pre-registration pharmacists and, following modification, were included in the skill development sessions described in a related publication in this issue 'A pilot study to evaluate knowledge of person-centred care (PCC), before and after a skill development programme, in a cohort of pre-registration pharmacists (PRPs) within a large London Hospital'. These guides are used by pharmacy staff in the author's organisation to support a person-centred approach to pharmacy practice.

Pilot study to evaluate knowledge of person-centred care, before and after a skill development programme, in a cohort of preregistration pharmacists within a large London hospital.

INTRODUCTION: Aperson-centred approach to healthcare encompasses personalised care, supporting the individual to recognise their strengths and promote their independence. Preregistration pharmacists , who arenew pharmacy graduates undertaking their training year of practice before qualification,may need support embedding this in practice. OBJECTIVE: To explore the knowledge and confidence in person-centred care (PCC) in a cohort of 12 preregistration pharmacists before and after receipt of an inhouse pharmacy-focused skill development programme using qualitative and quantitative measures. METHODS: Two half-day skill development sessions were delivered to 12 preregistration pharmacists. Assessment forms were completed before and after the skill development sessions, including quantitative data gathered via Likert scales and qualitative, narrative responses. Responses were coded and classified into themes. Participants submitted one written reflective account demonstrating the use of PCC in medicines-related patient consultations following completion of the skill development programme. RESULTS: Assessment forms were received from all participants. Self-reported knowledge of PCC improved from the start of the first session to the end of the second session. The average score for the understanding of PCC rose from 6.5 to 9.6 (Likert scale of 0-10) to the end of the second session. Qualitative analysis identified five person-centred themes, including active listening, using open questions, supporting and empowering patients, developing a shared agenda, and encouraging patients to take ownership of their medicines. CONCLUSIONS: Confidence and knowledge increased from the start of session 1 to the end of session 2. and analysis of the reflective accounts and themes also identified increased knowledge of PCC. This work aligns with previous hospital trust work, which identified that a training programme increased awareness and provided foundation knowledge. A short programme to develop PCC skills was effective in improving the PCC knowledge of 12 preregistration pharmacists. A review of pharmacists' written accounts of their consultations suggests that these skills were integrated into practice.

Education around medication review and deprescribing: a survey of medical and pharmacy students' perspectives.

Research into the practice of medication review is developing across the world in response to the ever-increasing burden of inappropriate polypharmacy. Education, training and support of undergraduates and novice practitioners to equip them to participate in the medication review process could lead to long-term shifts in practice. The purpose of this study was to explore the awareness of pharmacy and medical undergraduates about medication review, deprescribing and polypharmacy, in order to inform improvement strategies. In November 2016, all final-year medical and pharmacy students at a London (UK) university were invited to complete a short questionnaire survey. Qualitative analysis inductively themed free-text comments and quantitative analysis used descriptive statistics to summarize responses, with chi-square tests used to indicate differences between the groups. The overall response rate was 34% (171/500). The terms 'medication review' and 'polypharmacy' were known to the students, whilst the term 'deprescribing' was unfamiliar with no difference between the groups. The term 'medication review' meant different things to the groups: pharmacy students suggested a focus on adherence and patient understanding, whilst medical students focused on interactions and whether medicines were still indicated. The groups differed in their perceptions of who they thought undertook reviews, who identifies potentially inappropriate medicines, who makes the final decision to deprescribe and the frequency of medication reviews. Both groups reported that on qualification they would not be comfortable stopping a medicine without discussion with a senior colleague, but would be comfortable prompting a senior colleague to review. Both groups had some awareness of medication review tools. The meaning of the term 'medication review' differed between the student groups. While medical students focused on clinical aspects, pharmacy students emphasized patient experience. Both groups anticipated a lack of confidence in deprescribing without senior support, highlighting the need for alignment between education and professional development syllabi in a way that combines the variety of professional perspectives. Prompts by juniors could lead to more medication reviews within existing practice, and may give them invaluable experience in reviewing medicines in their future careers as seniors.

Shared decision making in chronic medication use: Scenarios depicting exemplary care.

Patient-centred care includes patients and their values in the healthcare decision-making process. Shared decision-making is essential for patient satisfaction, medication adherence, and positive clinical outcomes. It also empowers patients to play an active role in managing their health condition by improving their sense of agency, allowing them to personalise their care. Long-term prescriptions are an unexplored area where shared decision-making could be impactful. This paper provides 5 common clinical prescription scenarios pertaining to route of administration, medication timing, side effects, and length of prescription. Minor tailoring of treatment plans could significantly improve clinical outcomes. These serve as exemplars as to how to personalise prescriptions through shared decision making in accordance with patient values.

Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing.

Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual's history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice.

Person-Centred Care Including Deprescribing for Older People.

There is concern internationally that many older people are using an inappropriate number of medicines, and that complex combinations of medicines may cause more harm than good. This article discusses how person-centred medicines optimisation for older people can be conducted in clinical practice, including the process of deprescribing. The evidence supports that if clinicians actively include people in decision making, it leads to better outcomes. We share techniques, frameworks, and tools that can be used to deprescribe safely whilst placing the person's views, values, and beliefs about their medicines at the heart of any deprescribing discussions. This includes the person-centred approach to deprescribing (seven steps), which incorporates the identification of the person's priorities and the clinician's priorities in relation to treatment with medication and promotes shared decision making, agreed goals, good communication, and follow up. The authors believe that delivering deprescribing consultations in this manner is effective, as the person is integral to the deprescribing decision-making process, and we illustrate how this approach can be applied in real-life case studies.

Developing person-centred consultation skills within a UK hospital pharmacy service: evaluation of a pilot practice-based support package for pharmacy staff.

A person-centred approach to care is central to NHS England's health policy agenda and a standard for pharmacy practice from the General Pharmaceutical Council. Health coaching is a method of delivering person-centred care. A pilot of a health coaching support package, including a 2-day course and practice-based follow-up, was delivered to 70 London North West Healthcare NHS Trust pharmacy staff between December 2015 and July 2017. OBJECTIVES: To evaluate the support package, identifying key themes from course feedback, evaluating staff perception and evidence of application in practice. To identify key benefits of the support package. METHODS: Qualitative analysis of written course feedback was undertaken to identify staff learning themes about person-centred care. The themes were used to design a survey, administered to support package recipients (staff), exploring staff perception of the package. Qualitative review of written examples highlighted use of person-centred themes in practice. RESULTS: Twelve person-centred themes emerged from 49 course evaluations forms, describing what participants learnt about patient-centred care. Of 24 surveys completed, respondents reported increased awareness of themes; however, use in practice varied between themes. Overall, respondents valued the support package and rated practice-support more highly than the course for ongoing development. Patient examples described the use of themes in practice. CONCLUSIONS: The support package increased awareness of person-centred themes, portrayed within the practice examples submitted. While the course provided a foundation for use of a person-centred approach, continuing practice-based support is desired by staff to embed learning into day-to-day practice.

Opportunities for collaboration between pharmacists and clinical pharmacologists to support medicines optimisation in the UK.

Medicines optimisation is a clinician-driven, person-centred ongoing process. Pharmacists and clinical pharmacologists have medicines-related expertise to deliver medication review which optimises clinical and cost-effective use of medication, aligned with patient preferences, contributing to improved health outcomes. There is a large pharmacy workforce, directly accessible to patients, who can provide expert medicines-related care on the high street, and increasingly in general practice and care homes settings. There are a small number of clinical pharmacologists in practice, mainly working in a hospital setting. Potential opportunities for collaboration are extensive, including local initiatives in collaborative education, formulary/medicines management, electronic prescribing, service evaluation, research, direct clinical services as well as strategic planning through the Regional Medicines Optimisation Committees. Pharmacists and clinical pharmacologists have complementary skill sets and through acknowledging the differences in their approaches and valuing their unique skills, health services can ensure that patients are signposted to appropriate services.

Person-centred care and HIV: challenges and solutions.

Person-centred consultations (PCCs) are fundamental to effective healthcare communication, and its use is embedded within key clinical guidance. There are three aspects to PCC: use of the best available research evidence, clinical expertise of the clinician and the patient's circumstances, goals, values and wishes. Balancing theses three aspects in the context of HIV prevention and management can be challenging, and we use three case examples to highlight these.

Using Theory to Explore the Determinants of Medication Adherence; Moving Away from a One-Size-Fits-All Approach.

Non-adherence to prescribed medicines has been described as "a worldwide problem of striking magnitude", diminishing treatment effects and wasting resources. Evidence syntheses report current adherence interventions achieve modest improvements at best, and highlight the poor progress toward the longstanding aim of a gold-standard intervention, tailored to meet individual need. Techniques such as motivational interviewing and health coaching, which aim to facilitate patient-centred care and improve patient resourcefulness, have shown promise in supporting adherence, especially in patients with psychological barriers to medicine-taking, such as illness perceptions and health beliefs. Despite a plethora of research, there is little recognition that the nature and complexity of non-adherence is such that a one-size-fits-all approach to interventions is never likely to suffice. This commentary re-visits the call for adherence interventions to be tailored to meet individual need, by considering what this means for day-to-day practice and how this can be achieved. It provides an update on advances in psychological theory to identify the root cause of an individual's non-adherence to encourage matching of provided adherence support. It also provides a practical perspective by considering exemplars of innovative practice and evaluating the day-to-day practicalities of taking a novel approach.

Deprescribing: is the law on your side?

Deprescribing can feel risky: prescribers need to consider the consequence of stopping a medication medicolegally, particularly where there may be a guideline or accepted practice that suggests its use. This review aims to provide reassurance and encouragement to safely deprescribe. Experience suggests that for many patients the prescribing of multiple medicines is the norm. In the right setting and at the right time, deprescribing provides a real opportunity to minimise side effects and unwanted interactions through patient-centred conversations. How does the prescriber stand if they stop a medication for which there is an evidence-based guideline to use it? This review explores the concepts of clinical negligence and informed patient consent in the context of deprescribing. Using examples from UK case law, the review discusses the legal tests which are applied to establish an action based on clinical negligence and lack of informed consent. It describes the recent changes in law which reinforce the importance of providing information focused on what is material to individual patients. The use of prescribing tools to support safe deprescribing and informed consent are also discussed. When deprescribing is undertaken in partnership with patients, supported by the knowledge, skills and experience of both patient and clinicians and the patient's values and preferences based on clinical skill, judgement and evidence-based medicine, law presents no barriers to deprescribing.