Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic.

The new structured medication review (SMR) service was introduced into the National Health Service in England during the COVID-19 pandemic, following a major expansion of clinical pharmacists within new formations known as primary care networks (PCNs). The aim of the SMR is to tackle problematic polypharmacy through comprehensive, personalised medication reviews involving shared decision-making. Investigation of clinical pharmacists' perceptions of training needs and skills acquisition issues for person-centred consultation practice will help better understand their readiness for these new roles. A longitudinal interview and observational study in general practice. A longitudinal study of 10 newly recruited clinical pharmacists interviewed three times, plus a single interview with 10 pharmacists recruited earlier and already established in general practice, across 20 newly forming PCNs in England. Observation of a compulsory 2-day history taking and consultation skills workshop. A modified framework method supported a constructionist thematic analysis. Remote working during the pandemic limited opportunities for patient-facing contact. Pharmacists new to their role in general practice were predominantly concerned with improving clinical knowledge and competence. Most said they already practiced person-centred care, using this terminology to describe transactional medicines-focused practice. Pharmacists rarely received direct feedback on consultation practice to calibrate perceptions of their own competence in person-centred communication, including shared decision-making skills. Training thus provided knowledge delivery with limited opportunities for actual skills acquisition. Pharmacists had difficulty translating abstract consultation principles into specific consultation practices. SMRs were introduced when the dedicated workforce was largely new and being trained. Addressing problematic polypharmacy requires structural and organisational interventions to enhance the communication skills of clinical pharmacists (and other health professionals), and their use in practice. The development of person-centred consultation skills requires much more substantial support than has so far been provided for clinical pharmacists. [Abstract copyright: © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Alcohol, the overlooked drug: clinical pharmacist perspectives on addressing alcohol in primary care.

Attempts to routinely embed brief interventions in health systems have long been challenging, with healthcare professionals concerned about role adequacy, legitimacy, and support. This is the first study to explore clinical pharmacists' experiences of discussing alcohol with patients in their new role in UK primary care, in developing a novel approach to brief intervention. It investigates their confidence with the subject of alcohol in routine practice and explores views on a new approach, integrating alcohol into the medication review as another drug directly linked to the patient's health conditions and medicines, rather than a separated 'healthy living' issue. The study forms part of wider efforts to repurpose and reimagine the potential application of brief interventions and to rework their contents. Longitudinal qualitative study of 10 recruits to the new clinical pharmacist role in English primary care, involving three semi-structured interviews over approximately 16 months, supplemented by 10 one-off interviews with pharmacists already established in general practice. When raised at all, enquiring about alcohol in medication reviews was described in terms of calculating dose and level of consumption, leading to crude advice to reduce drinking. The idea was that those who appeared dependent should be referred to specialist services, though few such referrals were recalled. Pharmacists acknowledged that they were not currently considering alcohol as a drug in their practice and were interested in learning more about this concept and the approach it entailed, particularly in relation to polypharmacy. Some recognised a linked need to enhance consultation skills. Alcohol complicates routine clinical care and adversely impacts patient outcomes, even for those drinking at seemingly unremarkable levels. Changing clinical practice on alcohol requires engaging with, and supportively challenging, routine practices and entrenched ideas of different kinds. Framing alcohol as a drug may help shift the focus from patients with alcohol problems to problems caused for patients by alcohol. This is less stigmatising and provides role legitimacy for pharmacists to address alcohol clinically in medication reviews, thus providing one element in the formation of a new prevention paradigm. This approach invites further innovations tailored to other healthcare professional roles. [Abstract copyright: © 2023. The Author(s).

NetworkFleming Symposium: Update on Quality, Patient Safety and Wellness

Objective: Examine how provider wellness is foundational to providing high-quality and safe care

Effects of study design and allocation on participant behaviour-ESDA: study protocol for a randomized controlled trial

Background: What study participants think about the nature of a study has been hypothesised to affect subsequent behaviour and to potentially bias study findings. In this trial we examine the impact of awareness of study design and allocation on participant drinking behaviour. Methods/Design: A three-arm parallel group randomised controlled trial design will be used. All recruitment, screening, randomisation, and follow-up will be conducted on-line among university students. Participants who indicate a hazardous level of alcohol consumption will be randomly assigned to one of three groups. Group A will be informed their drinking will be assessed at baseline and again in one month (as in a cohort study design). Group B will be told the study is an intervention trial and they are in the control group. Group C will be told the study is an intervention trial and they are in the intervention group. All will receive exactly the same brief educational material to read. After one month, alcohol intake for the past 4 weeks will be assessed. Discussion: The experimental manipulations address subtle and previously unexplored ways in which participant behaviour may be unwittingly influenced by standard practice in trials. Given the necessity of relying on self-reported outcome, it will not be possible to distinguish true behaviour change from reporting artefact. This does not matter in the present study, as any effects of awareness of study design or allocation involve bias that is not well understood. There has been little research on awareness effects, and our outcomes will provide an indication of the possible value of further studies of this type and inform hypothesis generation

Integration of a clinical pharmacist workforce into newly forming primary care networks: a qualitatively driven, complex systems analysis

Objective The introduction of a new clinical pharmacist workforce via Primary Care Networks (PCNs) is a recent national policy development in the National Health Service in England. This study elicits the perspectives of people with responsibility for local implementation of this national policy package. Attention to local delivery is necessary to understand the contextual factors shaping the integration of the new clinical pharmacy workforce, and thus can be expected to influence future role development. Design A qualitative, interview study Setting and participants PCN Clinical Directors and senior pharmacists across 17 PCNs in England (n=28) Analysis Interviews were transcribed, coded and organised using the framework method. Thematic analysis and complex systems modelling were then undertaken iteratively to develop the themes. Results Findings were organised into two overarching themes: (1) local organisational innovations of a national policy under conditions of uncertainty; and (2) local multiprofessional decision-making on clinical pharmacy workforce integration and initial task assignment. Although a phased implementation of the PCN package was planned, the findings suggest that processes of PCN formation and clinical pharmacist workforce integration were closely intertwined, with underpinning decisions taking place under conditions of considerable uncertainty and workforce pressures. Conclusions National policy decisions that required General Practitioners to form PCNs at the same time as they integrated a new workforce risked undermining the potential of both PCNs and the new workforce. PCNs require time and support to fully form and integrate clinical pharmacists if successful role development is to occur. Efforts to incentivise delivery of PCN pharmacy services in future must be responsive to local capacity

Incidence of Secondary Hemophagocytic Lymphohistiocytosis in Critically-Ill COVID-19 Patients.

Objective Coronavirus disease 2019 (COVID-19) is associated with diffuse lung injury that can progress to acute respiratory distress syndrome, multisystem-organ failure, and death. The inflammatory storm seen in many COVID-19 patients closely resembles secondary hemophagocytic lymphohistiocytosis (sHLH) which has been described in other virus-associated severe sepsis. We sought to describe the incidence of sHLH in COVID-19 infected patients. Design In this retrospective study, we reviewed the records of critically ill COVID-19 positive patients to determine the incidence of sHLH. An H-score for sHLH diagnosis was determined for each study participant, with a score greater than 169 points needed for diagnosis. Setting A quaternary referral center in suburban Pennsylvania, USA. Patients All study participants had a positive COVID-19 test, and were deemed critically ill defined as receiving invasive mechanical ventilation and/or who expired. Measurements and Main Results Of the 246 records identified, 242 records met inclusion criteria and were reviewed. Eighty five patients were excluded from analysis due to missing H-score data parameters. Overall, 32 of 157 (20.38%, 95% CI:14.38-27.54%) patients met diagnostic criteria for sHLH. The average age was 69.42 years (standard deviation (SD) 14.81). Patients diagnosed with sHLH were more likely to be younger (61.09 years vs 69.38 years

Patient perspectives on discussing alcohol as part of medicines review in community pharmacies.

BACKGROUND: This paper reports on a qualitative study which formed part of the intervention development phase of a five year research programme (Community pharmacy: Highlighting Alcohol use in Medication aPpointments; CHAMP-1). OBJECTIVES: To better understand patient views on the appropriateness of alcohol as a subject for discussion in medication reviews in community pharmacy. METHODS: Semi-structured interviews were conducted with a sample of 25 people eligible for medication reviews whose AUDIT-C screening scores identified them as likely risky drinkers. Transcripts were analysed using a modified framework method with a constructionist thematic analysis approach. RESULTS: Most patients interviewed said they were open to the idea of a medication and alcohol linked discussion with a pharmacist if this was routine, well-conducted and confidential. Such a discussion was thought less personally relevant for those who viewed the proposed intervention through the prism of a particular set of ideas about the nature of alcohol problems, which distanced them from thinking about alcohol in terms of their everyday life and possible impacts on their health. Study findings attest to some of the sensitivities involved in discussion of alcohol, and the complexities inherent in helping people to talk about their own drinking, medicine use and health. CONCLUSIONS: Patients were open to the idea of discussing alcohol with community pharmacists in the context of a medicines review if this was sensitively done and the relevance was clear to them