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.

Clinical Judgement Analysis: An innovative approach to explore the individual decision-making processes of pharmacists.

BACKGROUND: Pharmacy stands increasingly on the frontline of patient care, yet current studies of clinical decision-making by pharmacists only capture deliberative processes that can be stated explicitly. Decision-making incorporates both deliberative and intuitive processes. Clinical Judgement Analysis (CJA) is a method novel to pharmacy that uncovers intuitive decision-making and may provide a more comprehensive understanding of the decision-making processes of pharmacists. OBJECTIVES: This paper describes how CJA potentially uncovers the intuitive clinical decision-making processes of pharmacists. Using an illustrative decision-making example, the application of CJA will be described, including: METHOD: An illustrative study was used, applying an established method for CJA. The decision to initiate anticoagulation, alongside appropriate risk judgements, was chosen as the context. Expert anticoagulation pharmacists were interviewed to define and then refine variables (cues) involved in this decision. Decision tasks with sixty scenarios were developed to explore the effect of these cues on pharmacists' decision-making processes and distributed to participants for completion. Descriptive statistical and regression analyses were conducted for each participant. RESULTS: The method produced individual judgement models for each participant, for example, demonstrating that when judging stroke risk each participant's judgements could be accurately predicted using only 3 or 4 out of the possible 11 cues given. The method also demonstrated that participants appeared to consider multiple cues when making risk judgements but used an algorithmic approach based on one or two cues when making the clinical decision. CONCLUSION: CJA generates insights into the clinical decision-making processes of pharmacists not uncovered by the current literature. This provides a springboard for more in-depth explorations; explorations that are vital to the understanding and ongoing development of the role of pharmacists.

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.

How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience.

BACKGROUND: Patients often carry medication lists to mitigate information loss across healthcare settings. We aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use. METHODS: We used a mixed-methods design comprising two focus groups with patients and carers, 16 semistructured interviews with healthcare professionals, 60 semistructured interviews with people carrying medication lists, a quantitative features analysis of tools available for patients to record their medicines and usability testing of four tools. Findings were triangulated using thematic analysis. Distributed cognition for teamwork models were used as sensitising concepts. RESULTS: We identified a wide range of mechanisms through which carrying medication lists can improve medication safety. These included improving the accuracy of medicines reconciliation, allowing identification of potential drug interactions, facilitating communication about medicines, acting as an aide-mémoire to patients during appointments, allowing patients to check their medicines for errors and reminding patients to take and reorder their medicines. Different tools for recording medicines met different needs. Of 103 tools examined, none met the core needs of all users. A key barrier to use was lack of awareness by patients and carers that healthcare information systems can be fragmented, a key facilitator was encouragement from healthcare professionals. CONCLUSION: Our findings suggest that patients and healthcare professionals perceive patient-held medication lists to have a wide variety of benefits. Interventions are needed to raise awareness of the potential role of these lists in enhancing patient safety. Such interventions should empower patients and carers to identify a method that suits them best from a range of options and avoid a 'one size fits all' approach.

Improving Pharmacists' Targeting of Patients for Medication Review and Deprescription.

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults' medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily "hold" medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.

Deprescribing medicines in the acute setting to reduce the risk of falls.

BACKGROUND: Falls are a common cause of morbidity and hospitalisation in older people. Inappropriate prescribing and polypharmacy contribute to falls risk in elderly patients. This study's aim was to quantify the problem and find out if medication review in the hospital setting led to deprescribing of medicines associated with falls risk. METHODS: Admissions records for elderly patients were examined to identify those whose presenting complaint included a fall. Inpatient medication charts, pharmaceutical care notes, medical notes and discharge summaries were examined to identify any falls-risk medicines from admission histories and to determine if any medication review took place, and whether or not changes were made as a result. In particular deprescribing and dose reduction details were analysed. RESULTS: 100 patients over 70 years old were admitted following a fall during the 2 months study period. The mean number of medicines on admission was 6.8 per patient with polypharmacy found in 62/100 (62%). One or more falls-risk medicine was found in 65/100 (65%) patients. Medicines review was carried out in 86/100 (86%) of patients, and 59/697 (8.5%) medicines were deprescribed. Pharmacist involvement in medication review led to a significant reduction in the number of falls-risk medicines per patient (p=0.002). CONCLUSIONS: Inappropriate prescribing and polypharmacy are found frequently in elderly patients at admission following a fall. Comprehensive medicines reviews should be carried out in all such patients with the objective of deprescribing or reducing doses to minimise risk of harm. Involvement of a pharmacist improves the rate of reduction of falls-risk medicines.

The Acute Care Assessment Tool: 'Pharmacy ACAT'.

BACKGROUND: The Acute Care Assessment Tool (ACAT) was developed as a workplace-based assessment (WPBA) for trainee performance whilst working in acute medicine. Here, we discuss the multi-professional potential of ACAT through a pilot with foundation and senior hospital pharmacists. CONTEXT: The pharmacy profession is engaging meaningfully with foundation training for pharmacists akin to doctor foundation training, and has launched a post-foundation recognition scheme as a route to advanced generalist or specialist practice. Foundation training has included the adoption of familiar WPBA, such as the mini-clinical evaluation exercise (mini-CEX) and case-based discussion (CbD). However, mini-CEX and CbD are 'snapshot' assessments, and we identified a need for the assessment of practice over a short period of time. A local director of medical education suggested ACAT. We identified a need for the assessment of practice over a short period of time INNOVATION: Permission was gained from the Joint Royal Colleges of Physicians to adapt the ACAT to form the 'Pharmacy ACAT'. Adaptations were based on the two current Royal Pharmaceutical Society competency frameworks used for foundation and post-foundation practice. The 'Pharmacy ACAT' was piloted across three acute hospitals (known as 'Trusts') in London for foundation trainees, and was found to be broadly acceptable in terms of time and was valued for feedback, particularly for foundation pharmacy trainees. Senior pharmacists at the single pilot site were more sceptical. IMPLICATIONS: We believe that the 'Pharmacy ACAT' should be considered for routine use in pharmacy foundation training in hospital and community practice as it 'plugs a gap' in the current scheme of WPBA, by allowing the assessment of a short period of practice as opposed to a snapshot. It also has potential for use at undergraduate level.

Why we should understand the patient experience: clinical empathy and medicines optimisation.

OBJECTIVES: To critically discuss the need for pharmacists to underpin their consultations with appropriate 'clinical empathy' as part of effective medicines optimisation. METHODS: Use of literature around empathy, consultation and pharmacy practice to develop a case for greater clinical empathy in pharmacy consultations. KEY FINDINGS: Clinical empathy is defined from the literature and applied to pharmacy consultations, with a comparison to empathy in other clinical professions. Historical barriers to the embedding of clinical empathy into pharmacy consultations are also explored. CONCLUSIONS: We challenge the pharmacy profession to consider how clinical empathy should underpin consultations with a series of introspective questions and provide some sample questions to support pharmacy consultations. We also make the case for appropriate education and professional development of consultation skills at undergraduate and postgraduate level. We contend that patients' relationships with practitioners are critical, and a lack of empathy can impact the effectiveness of care.

A pilot survey of junior doctors' attitudes and awareness around medication review: time to change our educational approach?

OBJECTIVES: Our aim was to explore junior doctors' attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. METHOD: An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. RESULTS: Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacist's duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. CONCLUSIONS: Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a 'bottom-up' educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.

Use of a medication passport in a disabled child seen across many care settings.

Written information for patients about their medicines has demonstrable benefits for their understanding and adherence. In the UK, no single, complete record of medications for individual patients can be guaranteed. Therefore, patients and carers are often relied on to recall the complete medication list, which can be a challenge given multiple and potentially stressful appointments. Wide-ranging feedback suggests that a medication 'passport' developed by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North West London (NIHR CLAHRC NWL) has benefited elderly patients, who often attend many appointments where the current medication list may not be available. We describe the use of this passport (known as 'My Medication Passport'--MMP) in a child with multiple disabilities. The practical advantages are explored, including the potential for a paediatric version to facilitate discussions around the administration of medicines. MMP is an early example of a useful tool to help children and young people, parents and carers to manage medicines more effectively.

Use of a multisource feedback tool to develop pharmacists in a postgraduate training program.

OBJECTIVES. To evaluate use of a peer-assessment tool as a performance indicator for junior pharmacists in a formal postgraduate training program in London. METHODS. A 4-year retrospective analysis of data gathered using the pharmacy mini-PAT (peer-assessment tool) was undertaken. Assessments, including junior pharmacist self-evaluations, were conducted every 6 months. Overall performance and performance for clustered items were analyzed to determine changes. Assessments by healthcare professionals were then compared between professional groupings, which included pharmacists, physicians, and nurses. RESULTS. There was a significant improvement over time in both self-assessment scores and scores on assessments conducted by others using the mini-PAT. Junior pharmacists rated themselves significantly lower than did their assessors (p<0.001); pharmacist assessors rated the performance of junior pharmacists significantly lower than did other healthcare professionals (p<0.001). Validity, ease of use, and relevance of the pharmacy mini-PAT were demonstrated. CONCLUSIONS. As part of a range of formative evaluations involving assessors from across various health professions, the mini-PAT is a valuable instrument for developing junior pharmacists. A cohort's mini-PAT result provides a snapshot of his/her performance that can be used to identify key areas requiring further training.