Learning to prescribe - pharmacists' experiences of supplementary prescribing training in England

Background: The introduction of non-medical prescribing for professions such as pharmacy and nursing in recent years offers additional responsibilities and opportunities but attendant training issues. In the UK and in contrast to some international models, becoming a non-medical prescriber involves the completion of an accredited training course offered by many higher education institutions, where the skills and knowledge necessary for prescribing are learnt. Aims: to explore pharmacists' perceptions and experiences of learning to prescribe on supplementary prescribing (SP) courses, particularly in relation to inter-professional learning, course content and subsequent use of prescribing in practice. Methods: A postal questionnaire survey was sent to all 808 SP registered pharmacists in England in April 2007, exploring demographic, training, prescribing, safety culture and general perceptions of SP. Results: After one follow-up, 411 (51%) of pharmacists responded. 82% agreed SP training was useful, 58% agreed courses provided appropriate knowledge and 62% agreed that the necessary prescribing skills were gained. Clinical examination, consultation skills training and practical experience with doctors were valued highly; pharmacology training and some aspects of course delivery were criticised. Mixed views on inter-professional learning were reported – insights into other professions being valued but knowledge and skills differences considered problematic. 67% believed SP and recent independent prescribing (IP) should be taught together, with more diagnostic training wanted; few pharmacists trained in IP, but many were training or intending to train. There was no association between pharmacists' attitudes towards prescribing training and when they undertook training between 2004 and 2007 but earlier cohorts were more likely to be using supplementary prescribing in practice. Conclusion: Pharmacists appeared to value their SP training and suggested improvements that could inform future courses. The benefits of inter-professional learning, however, may conflict with providing professionspecific training. SP training may be perceived to be an instrumental 'stepping stone' in pharmacists' professional project of gaining full IP status

A national cross sectional survey of heads of midwifery services of uptake, benefits and barriers to use of obstetric early warning systems (EWS) by midwives

Objective to identify the extent to which Early Warning Systems (EWS) are used by midwives in the United Kingdom (UK), the maternity settings they are used in, physiological parameters used to ‘trigger’ referral, training provision, barriers to implementation and role in preventing maternal morbidity. Design cross-sectional survey of heads of midwifery services. An email questionnaire was sent in September 2012. Setting UK NHS secondary care organisations providing maternity care. Findings heads of midwifery from 107 (68%) of 157 NHS organisations responded, with 108 questionnaires returned as two organisations had recently merged. All organisations, apart from one which only had a free-standing midwifery unit, had introduced EWS. Nearly all respondents (99%) reported EWS were used by midwives antenatally, 76% in labour and 100% on the postnatal ward. All EWS charts included body temperature, heart rate, respiratory rate, systolic blood pressure and oxygen saturation although parameters for escalation varied widely. Barriers to use of EWS by midwives included overlap with the partogram in labour, and staff shortages and delays obtaining clinical review when referral was triggered. Two-thirds considered EWS prevented maternal morbidity although few could provide supporting evidence, for example, audit findings. Training for midwives in use of EWS was available in 83% of organisations. Conclusion most UK midwives are using EWS, with the highest use in obstetric units. The heterogeneity of EWS currently used potentially limits collation of evidence to inform appropriate system level responses. Research is needed to evaluate the role of EWS to prevent maternal morbidity during and after pregnancy in different maternity settings

How Can I Drink Safely?; Perception Versus the Reality of Alcohol Consumption

This article investigates differences between perception and actual consumption of alcohol in young adults within the UK, suggesting that inaccurate information in the public domain may hamper those seeking to drink safely plus the development of moderate drinking cultures. Results confirm that inaccurate information may be preventing the development of safe drinking behaviours among certain groups. In addition, they indicate that some groups choose to ignore safe consumption limits in particular circumstances. Results indicate that many government strategies aimed at reducing unsafe drinking behaviour are inaccurately targeted; changing male public consumption behaviour may trigger changes in female behaviour

Prognostic model for patient survival in primary anorectal mucosal melanoma:stage at presentation determines relevance of histopathologic features

Pathological staging of primary anorectal mucosal melanoma is often performed according to the American Joint Commission on Cancer (AJCC) guidelines for cutaneous melanoma, as an anorectal melanoma-specific staging system does not exist. However, it remains unknown whether prognostic factors derived for cutaneous melanoma also stratify risk in anorectal melanoma. We retrospectively determined correlations between clinicopathological parameters and disease-specific survival in 160 patients. Patients were grouped by clinical stage at presentation (localized disease, regional or distant metastases). Cox proportional hazards regression models determined associations with disease-specific survival. We also summarized the somatic mutations identified in a subset of tumors analyzed for hotspot mutations in cancer-associated gene panels. Most of the patients were white (82%) and female (61%). The median age was 62 years. With a median follow-up of 1.63 years, median disease-specific survival was 1.75 years, and 121 patients (76%) died of anorectal melanoma. Patients presenting with regional (34%) or distant metastases (24%) had significantly shorter disease-specific survival compared to those with disease localized to the anorectum (42%). Of the 71 anorectal melanoma tumors analyzed for hotspot genetic alterations, somatic mutations involving the KIT gene (24%) were most common followed by NRAS (19%). Increasing primary tumor thickness, lymphovascular invasion, and absence of regression also correlated with shorter disease-specific survival. Primary tumor parameters correlated with shorter disease-specific survival in patients presenting with localized disease (tumor thickness) or regional metastases (tumor thickness, absence of regression, and lymphovascular invasion), but not in patients presenting with distant metastases. Grouping of patients according to a schema based on modifications of the 8th edition AJCC cutaneous melanoma staging system stratified survival in anorectal melanoma. Our findings support stage-specific associations between primary tumor parameters and disease-specific survival in anorectal melanoma. Moreover, the AJCC cutaneous melanoma staging system and minor modifications of it predicted survival among anorectal melanoma patients

Engineers and planners: Sustainable water management alliances

Copyright © 2011 ICE Publishing Ltd. Permission is granted by ICE Publishing to print one copy for personal use. Any other use of these PDF files is subject to reprint fees.In the future, increasing pressure will inevitably be placed on the spatial planning system to improve its consideration of water management issues. Emerging challenges include designing for climatic extremes, reducing flood risk, managing increasingly scarce water resources and improving water quality. These issues need to be balanced with a range of other spatial planning priorities and objectives, including meeting new housing needs, facilitating economic growth, and creating and maintaining quality places. The sheer complexity of the issues surrounding water management and the impacts upon spatial planning mean that partnership working is essential to achieve an integrated approach. Planners need the expertise, and crucially the understanding, of engineers and hydrologists. However, there can be considerable misunderstanding and miscommunication between disciplines, often concerning the institutional context in which the various parties operate. A plethora of policies, tools and assessments exist, which can make integrated water management an overwhelming prospect for the planner. This paper attempts to identify and address some of the issues faced, as well as examining how planners embed hydrological issues in decision making and how engineers could better facilitate this

Increase in computed tomography in Australia driven mainly by practice change: A decomposition analysis

Background: Publicly funded computed tomography (CT) procedure descriptions in Australia often specify the body site, rather than indication for use. This study aimed to evaluate the relative contribution of demographic versus non-demographic factors in driving the increase in CT services in Australia. Methods: A decomposition analysis was conducted to assess the proportion of additional CT attributable to changing population structure, CT use on a per capita basis (CPC, a proxy for change in practice) and/or cost of CT. Aggregated Medicare usage and billing data were obtained for selected years between 1993/4 and 2012/3. Results: The number of billed CT scans rose from 33 per annum per 1000 of population in 1993/94 (total 572,925) to 112 per 1000 by 2012/13 (total 2,540,546). The respective cost to Medicare rose from $145.7 million to$790.7 million. Change in CPC was the most important factor accounting for changes in CT services (88%) and cost (65%) over the study period. Conclusions: While this study cannot conclude if the increase is appropriate, it does represent a shift in how CT is used, relative to when many CT services were listed for public funding. This ‘scope shift’ poses questions as to need for and frequency of retrospective/ongoing review of publicly funded services, as medical advances and other demand- or supply-side factors change the way health services are used

Pain relief in labour: a qualitative study to determine how to support women to make decisions about pain relief in labour

Background Engagement in decision making is a key priority of modern healthcare. Women are encouraged to make decisions about pain relief in labour in the ante-natal period based upon their expectations of what labour pain will be like. Many women find this planning difficult. The aim of this qualitative study was to explore how women can be better supported in preparing for, and making, decisions during pregnancy and labour regarding pain management. Methods Semi-structured interviews were conducted with 13 primiparous and 10 multiparous women at 36 weeks of pregnancy and again within six weeks postnatally. Data collection and analysis occurred concurrently to identify key themes. Results Three main themes emerged from the data. Firstly, during pregnancy women expressed a degree of uncertainty about the level of pain they would experience in labour and the effect of different methods of pain relief. Secondly, women reflected on how decisions had been made regarding pain management in labour and the degree to which they had felt comfortable making these decisions. Finally, women discussed their perceived levels of control, both desired and experienced, over both their bodies and the decisions they were making. Conclusion This study suggests that the current approach of antenatal preparation in the NHS, of asking women to make decisions antenatally for pain relief in labour, needs reviewing. It would be more beneficial to concentrate efforts on better informing women and on engaging them in discussions around their values, expectations and preferences and how these affect each specific choice rather than expecting them to make to make firm decisions in advance of such an unpredictable event as labour