Educational and support needs of hospital prescribers on cardiology and respiratory wards

Educational and support needs of hospital prescribers on cardiology and respiratory wards

Abstract: (Please refer to instructions to authors and example abstract) Focal Points • This study explores the personal prescribing support mechanisms used by medical and non-medical prescribers of varying levels of experience. • The findings suggest that prescribing decisions are dependent upon experience and made within a ‘continuum of knowledge’ – first degree, second degree and third degree. • The value of pharmacists perceived by medical prescribers in offering clinical, as opposed to technical, prescribing support is likely to vary and cannot be assumed. • Support should be tailored to take into account an individual prescriber’s position within the ‘continuum of knowledge’. Introduction It is estimated that UK prescribers make errors on about 1.5% of all prescriptions in hospitals, of which a quarter are potentially serious and likely to result in patient harm.1 Recent research suggests there is a lack of safety culture and that errors caused by lack of knowledge would be prevented by better support in the working environment.2 The aim of this study was, therefore, to explore how knowledge and experience of prescribing might relate to personal support mechanisms that influence prescribing decisions. The specific objectives were to explore: 1) factors that shape individual prescribing patterns, especially taking experience and seniority into account; 2) level of confidence in personal ability to prescribe safely and accurately; 3) perceptions of the current role and value of ward pharmacists in supporting clinical decisions and the prescribing process. Method From approximately 80 medical staff, in-depth interviews were conducted lasting between 10 and 20 minutes with a purposive sample of 19 prescribing clinicians based at an East Midlands hospital: three respiratory and two cardiology medical consultants, three respiratory registrars, two respiratory and two cardiology FY2s, two respiratory and two cardiology FY1s, one pharmacist and two nurse (non-medical) prescribers. Interviews were transcribed verbatim and subjected to constant comparison qualitative thematic analysis adopting a phenomenological approach. The University Ethics Committee approved the protocol. Results The analysis identified ‘continuum of knowledge’ as a key theme relating to support mechanisms based upon ‘first-degree’, ‘second-degree’, and ‘third-degree’ knowledge. First-degree knowledge related to raw information or simply being told something – which was characteristic of junior FY1 and FY2 prescribers. Second-degree knowledge involved developing a rational basis for prescribing such as by utilising teaching workshops, discussions with a colleague or evidence-based research acquired from literature. Third-degree knowledge was more personal and acquired through experience associated with a higher degree of self-confidence. The continuum of knowledge was associated with the following factors: 1) Perceived role and value of national (e.g. NICE) and local guidelines; 2) Value of medical or clinical peers in supporting prescribing decisions; and 3) Value of pharmacists in supporting the technical process of writing correct prescriptions or making independent clinical decisions leading to a prescription. Discussion Prescribers who utilised first-degree knowledge (FY1s and, to some extent, FY2s and non-medical prescribers) followed local guidelines as ‘rote’ and relied upon peers, especially senior colleagues, as educators to help apply this knowledge in different circumstances and develop their confidence. They valued pharmacists in terms of minimising errors, checking doses and interactions, legal technicalities, and to help identify gaps in knowledge. Those utilising second or third degrees of knowledge (registrars, consultants and, to some extent, FY2s) took more account of cost in the decision process and developed a ‘self-education’ approach. All of the medical prescribers valued a potential role for pharmacists to ensure prescriptions were written correctly but varied in perceived need for clinical support from pharmacists such as taking independent responsibility for prescribing or completing discharge letters. Further research is required to explore support issues more specifically relating to non-medical prescribers who were under-represented in this study. References

1. Dean B, Schachter M, Vincent C and Barber N (2002) Causes of prescribing errors in hospital inpatients: a prospective study. The Lancet, 359, 1373-1378.
2. Dornan T, Ashcroft D, Heathfield H et al (2010). An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf (Accessed 30/5/2012).