Innovations in education and training to enable development of pharmacists as clinicians.

The NHS is in urgent need of clinical healthcare capacity in terms of front-line clinician staff, to deal with the burgeoning complexity and volume of care being delivered. These clinicians need to be accountable for the delivery of direct clinical care to patients, meeting the demands of clinical services and patients. In the UK, from 2026 onwards, all new pharmacists will be independent prescribers at point of registration. There is an opportunity for pharmacists to evolve their traditional role - from that of medicines governance, supply and ancillary advice - to one in which they have a central role within the NHS as a clinician. The aim of this programme of research was to explore innovations in education and training that would enable development of pharmacists as clinicians. The programme is comprised of six public outputs investigating four separate educational interventions, including: a pharmacy longitudinal clerkship (PLC) and interprofessional education (IPE) placements at undergraduate level, and the use of simulation-based education (SBE) and an Advanced Clinical Examination & Assessment (ACE) course within the advanced pharmacist space. Output 1 used Donabedian's conceptual model to characterise the development and implementation of the first cohort of a PLC model for student pharmacists (SPs). It used interpretivist philosophy and qualitative semistructured interviews of SPs and tutors, informed by the Theoretical Domains Framework (TDF), to undertake an initial evaluation. Seven themes were identified and mapped to seven TDF domains. These reported increased levels of student confidence, enthusiasm for a pharmacy career, and general practitioner (GP) positivity about the PLC. Output 2 reported on two further cohorts of the PLC model. Qualitative semi-structured interviews of SP and GP tutors were used to explore stakeholder perceptions of influences of behavioural determinants on SP development. Interview design and analysis were informed by the TDF. Seven SPs and five GPs were interviewed. Key themes included: knowledge – utilisation and practical application; skills – triangulation of skills under supervision; beliefs about capabilities – confidence building with clinical and patient contact; professional role and identify. The evaluation showed the benefits of the PLC model by embedding SPs in clinical teams and the clinical environment over a prolonged period. It was expected that this training would translate into a more confident transition to postgraduate professional practice. Output 3 reported on the evaluation of a separate week-long innovative hospital-based IPE placement involving SPs and medical students. Evaluation focused on level 1 and 2 of the Kirkpatrick Four-Level Training Evaluation Model. Focus groups were used to explore the students' views and experiences. Thematic analysis was undertaken using the TDF. Three key categories with multiple sub-themes were identified: Category 1, overall perception of experience; Category 2, student interactions; Category 3, suggestions for improvement. Overall, students valued their participation in the week and reported many benefits of learning with and from other students. Output 4 was a commentary giving some critical thought on the current state of advanced pharmacist practice within the UK, as well as giving primary thinking on how UK pharmacists, service models, and pharmacist education systems need to adapt to meet the demands of advanced pharmacist practice. It challenges pharmacy's historic dogma, discusses a requirement for teaching to transcend simplistic concepts of medicines-harm, considers the need for the standardisation of clinical skills and discusses the necessity for formal advanced practice programmes and preceptorship models. It finally proposes a model for Advanced Pharmacist Practitioners and the ultimate future vision of autonomous practice. Output 5 reported on the implementation of innovative SBE to support the development of advanced general practice clinical pharmacists (GPCPs). An interpretivist philosophy was applied where pre and post simulation questionnaires were used to support an evaluation focused on level 1 and 2 of the Kirkpatrick Four-Level Training Evaluation Model. Increased confidence and self-reported competence were reported in all areas pertaining to application of consultation and clinical skills. Qualitative comments from the participants regarding the training course were also favourable, highlighting the value of the training in developing clinical competence and confidence when dealing with a variety of general practice scenarios. Output 6 explores the potential behavioural determinants influencing the implementation of skills gained from ACE courses by GPCPs. The work used an interpretivist philosophy and qualitative methodology, with theoretical underpinning using the TDF. Seven dyadic (paired) interviews were conducted. Three main themes were identified: 1. Factors influencing implementation of advanced clinical skills by pharmacists; 2. Social and environmental influences affecting opportunities for pharmacists in advanced clinical roles; 3. Perceptions of pharmacist professional identify for advance practice roles. The work identified numerous behavioural determinants related to the implementation of advanced clinical skills including: the course supporting clinically autonomous practice; frustration around social and environmental factors limiting implementation causing alienation; need for clarification of professional identity/roles. This programme of research identified numerous innovations in education and training which would allow pharmacists to develop as clinicians over a variety of career stages and healthcare settings. There is commonality between PLC and IPE placements in terms of affording SPs exposure to clinical environments as part of undergraduate education. The benefits observed during individual placements are also likely to be synergistic if combined into a longitudinal IPE placement. SBE was used effectively in both undergraduate and advanced pharmacist education, and can be expected to augment clinical teaching at all levels of pharmacist education. ACE courses would make a suitable component of a competency-based training programme for advanced pharmacist practitioners, where skills learned on the course can be integrated into practice in a preceptored and supervised environment. This is similar to how clinical skills were implemented and practiced during PLC placements. Recommendations included the need to develop education and training across the continuum of pharmacist practice, and should be linked to an accepted career structure. Clinically supervised, curriculum-based training programmes delivered in clinical practice should contain elements of IPE and SBE to augment the learning experience for any career level. Review of current education and training pathways are urgently needed such that exposures to the beneficial innovations described in this thesis might be utilised to expeditiously create pharmacist clinicians with these skills, to enhance healthcare capacity in support of clinical care delivery to patients

Aspirin desensitization in patients undergoing percutaneous coronary intervention: A survey of current practice

Background: Aspirin remains the mainstay of anti-platelet therapy in cardiac patients.However, if a patient is allergic to aspirin and dual anti-platelet therapy is indicated — suchas with percutaneous coronary intervention (PCI), then there is no clear guidance. Onepossibility is aspirin desensitization. A variety of protocols exist for the rapid desensitization ofpatients with aspirin allergy. The aim of this survey was to assess current knowledge andpractice regarding aspirin desensitization in the UK.Methods and results: We conducted a UK wide survey of all UK 116 PCI centers andobtained complete responses from 40 (35.4%) centers. Of these, just 7 (17.5%) centers hadpreviously desensitised patients; 29 (87.9%) centers suggested a lack of a local protocolprevented them from desensitizing, with 10 (30.3%) unsure of how to conduct desensitization.Only 5 (12.5%) centers had a local policy for aspirin desensitization although 25 (64.1%)units had a clinical strategy for dealing with aspirin allergy; the majority (72%) giving higherdoses of thienopyridine class drugs.Conclusions: In the UK, there appears to be no consistent approach to patients with aspirinallergy. Patients undergoing PCI benefit from dual anti-platelet therapy (including aspirin),and aspirin desensitization in those with known allergy may facilitate this. Sustained effortshould be placed on encouraging UK centers to use desensitization as a treatment modalityprior to PCI rather than avoiding aspirin altogether

General practitioner views of an electronic high-risk medicine proforma to facilitate information transfer.

Background The potential of warfarin related harm is increased if clinicians lack the full patient specific information to make informed decisions—an e-proforma has been developed to communicate this information on hospital discharge. Objective To determine the views of general practitioners (GPs) on a warfarin discharge e-proforma. Method A cross-sectional survey of all GPs (n=272) within the Raigmore Hospital catchment area of NHS Highland, Scotland. Results The response rate was 39.3% (107/272). 84 (78.5%) noticed recent changes to information supplied on discharge for warfarin patients. 64 (59.8%) respondents thought this would result in more informed prescribing with regards to dosing, while 65 (60.7%) felt this would improve safety. Accurate completion, timely receipt of the e-proforma and a realistic date for subsequent INR tests were considered important by GPs. Conclusion This study suggests the use of an e-proforma to communicate information about a high-risk medication, warfarin, to GPs on discharge optimises safe, informed prescribing and monitoring in primary care. The development of a discharge e-proforma for other high-risk medication as a patient safety improvement measure should be explored

Urban vs rural STEMI patients; is there a difference?

Background: Timely access to reperfusion therapy for ST elevation myocardial infarction (STEMI) is vital. Every minute of delay costs 10 days of patient's life. Patients living in the rural Scottish highlands face a lot of challenges to optimum reperfusion therapy (ORT), due to geographical and environmental barriers that influence receiving pharmacological or interventional therapy timeously. Aims: looking at ORT comparing remote vs urban patients. Methods: Patients admitted, between March 2014 and April 2015, were selected from Raigmore hospital STEMI electronic database. A data collection form was developed by the research team and piloted. Clinical details were collected retrospectively from patient's discharge letters. 132 patients who suffered STEMI were included. Data collected included; patients' treatment location, date of admission, distance to the nearest cardiac-unit (CU), MI location, route of access to health, LV function and reperfusion therapy received. Results: 132 patients were identified, 73% received percutaneous coronary intervention, 31.7% received pre-hospital thrombolysis, 24.8% received in-hospital thrombolysis while 13% didn't receive any treatment. From this cohort 51% lived more than 50 miles from the nearest CU. Further analysis is ongoing to identify who received ORT and in the remaining cases what barriers limited ORT. These barriers will be divided into modifiable and non-modifiable. Conclusion: From initial analysis of the results it seems that there is a differential in patients' care, with more rural patients potentially receiving sub-optimal reperfusion therapy. This is likely to have an adverse mortality outcome. More research required to determine if addressing barriers to ORT is achievable and cost effective

Using the theoretical domains framework to explore behavioural determinants for medication taking in patients following percutaneous coronary intervention.

The aim of this study was to investigate relationships between factors influencing medication taking and behavioural determinants in patients who have undergone percutaneous coronary intervention (PCI). A cross-sectional survey was undertaken, using a postal questionnaire distributed to PCI patients. The questionnaire was iteratively developed by the research team, with reference to the Theoretical Domains Framework (TDF) of behavioural determinants, reviewed for face and content validity, and piloted. Data were analysed using descriptive and Principal Component Analysis (PCA). Inferential analysis explored relationships between PCA component scores and factors influencing medicating taking behaviour. The adjusted response rate was 62.4% (325/521). PCA gave 3 components: (C1) Self-perceptions of knowledge and abilities in relation to medication taking; (C2) Aspects relating to activities and support in medication taking; (C3) Emotional aspects in taking medication. Generally, respondents held very positive views. Statistically significant relationships between all three components and self-reported chest pain/discomfort indicated patients with ongoing chest pain/discomfort post-PCI are more likely to have behavioural determinants and beliefs which make medication-taking challenging. Respondents who were on 10 or more medications had lower levels of agreement to the C2 and C3 statements indicating challenges associated with their activities / support and anxieties in medication taking. The study concluded that PCI patients show links between TDF behavioural determinants and factors influencing medication taking for those reporting chest pain or polypharmacy. Further research needs to explore the effective design and implementation of behavioural change interventions to reduce the challenge of medication-taking

A qualitative study of the perspectives of older people in remote Scotland on accessibility to healthcare, medicines and medicines-taking

Acknowledgements The authors wish to acknowledge the input of: Melissa Davidson, Lucie Donaldson, Katie Milne and Samantha Moodie to data collection; Anna Marie McGregor, Katie MacLure, Alpana Mair, Gary Todd, Martin Wilson and Kay Wood to interview schedule review; and all interviewees.Peer reviewedPublisher PD

Prescribers’ perceptions of benefits and limitations of direct acting oral anticoagulants in non-valvular atrial fibrillation.

Background: There is an acknowledged lack of robust and rigorous research focusing on the perspectives of those prescribing direct acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). Objective: The objective was to describe prescribers’ experiences of using DOACs in the management of non-valvular AF, including perceptions of benefits and limitations. Methods: A cross-sectional survey of prescribers in a remote and rural area of Scotland. Among other items, the questionnaire invited free-text description of positive and negative experiences of DOACs, and benefits and limitations. Responses were independently analysed by two researchers using a summative content analysis approach. This involved counting and comparison, via keywords and content, followed by interpretation and coding of the underlying context into themes. Results: One hundred and fifty-four responses were received, 120 (77.9%) from physicians, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 unidentified professions). Not having to monitor INR was the most cited benefit, particularly for prescribers and patients in remote and rural settings, followed by potentially improved patient adherence. These benefits were reflected in respondents’ descriptions of positive experiences and patient feedback. The main limitations were the lack of reversal agents, cost and inability to monitor anticoagulation status. Many described their experiences of adverse effects of DOACs including fatal and non-fatal bleeding, and upper gastrointestinal disturbances. Conclusions: While prescribers have positive experiences and perceive benefits of DOACs, issues such as adverse effects and inability to monitor anticoagulation status merit further monitoring and investigation. These issues are particularly relevant given the trajectory of increased prescribing of DOACs

Prescribers' views and experiences of using direct acting oral anticoagulants in the management of nonvalvular atrial fibrillation: a survey in remote and rural Scotland.

A recent systematic review highlighted the lack of robust studies on prescribers' perspectives of direct-acting oral anticoagulants (DOACs) for non-valvular atrial fibrillation (AF). The aim was to determine prescribers' views and experiences of prescribing DOACs. A cross-sectional survey of prescribers in a remote and rural area of Scotland. Survey items were: demographics; prescribing of DOACs; views of potential influences on DOAC prescribing; knowledge of prescribing guidelines; and experiences. Items on potential influences were based on the Theoretical Domains Framework (TDF). Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis (PCA) was performed on the items of potential influences. One hundred and fifty-four responses were received, 120 (77.9%) from doctors, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 missing). PCA of the TDF items of potential influences gave four components. Component scores for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing were positive. Those for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness were more neutral. There were low levels of agreement for statements relating to DOACs being more effective, safer and cost-effective than warfarin. There were similar responses around the complexity of bleeding management and detection of over and under-anticoagulation. This study has identified several key issues of DOAC prescribing (e.g. bleeding management) hence further emphasis is required in continuing professional development and during guideline implementation and evaluation