Interprofessional learning
Interprofessional learning for medication safety Jessica Hardisty and Lesley Scott, Department of Pharmacy, Health and Wellbeing, University of Sunderland, UK Sarah Chandler, Clinical Pharmacy Department, Northumbria Healthcare Trust, North Tyneside General Hospital, North Shields, Tyne and Wear, UK Pauline Pearson, Faculty of Health & Life Sciences, Northumbria University, Newcastle, UK Suzanne Powell, CETL4HealthNE, School of Medical Sciences Education Development, Newcastle University, Newcastle-upon-Tyne, UK Interprofessional education should be encouraged
SUMMARY Background: Patient safety is a worldwide priority. Recommendations have been made that doctors, nurses and pharmacists could interact more effectively to improve patient outcomes, and that interprofessional education should be encouraged. In 2009, the North East Strategic Health Authority awarded Workforce Development Initiative funding to Northumbria Healthcare National Health Service (NHS) Foundation Trust to develop an undergraduate interprofessional training activity in medication safety for medicine, pharmacy and nursing students. Context: Interprofessional seminars for medication safety
and therapeutics were developed that were delivered across the North East of England. The initial seminars took place between January and April 2011 at 10 teaching hospitals, and were attended by over 400 students (from medicine, pharmacy and nursing). Innovation: The majority of the workshops were facilitated by an interprofessional team comprised of pharmacists, doctors and nurses, with all students working in small groups with participants from each of the professional groups, where possible. All seminars had standardised materials, but it was up to individual facilitators to choose which of the five case
studies were used within the seminar. The seminars lasted between 2 and 3 hours, and depending on which case studies were used, two or three cases could be discussed. Student feedback showed that the seminar was particularly successful in highlighting and improving the students’ understanding of each other’s roles and responsibilities in relation to medication safety. There are considerable organisational challenges in arranging interprofessional groups. Scenarios need to provide tasks that engage and challenge all of the professions involved. Facilitation is an important element.
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INTRODUCTION
K
eeping patients safe is a priority for most health care systems worldwide.1 Policy over the past decade has moved to recognise key areas of risk, including moving and handling, communication, infection control and medication.2 Errors around the prescribing and administration of medication contribute disproportionately to patient harm.3 A recent study exploring UK medical graduates’ preparedness for prescribing in practice showed that lack of preparedness is related to lack of exposure to, and preparation for, clinical practice.4 Bradley et al. showed that for UK pharmacy students, voluntary work experience compensated for limited practice exposure and aspects of patient safety not adequately addressed in the formal curriculum.5 Other work has indicated the importance of the wider team, and of interprofessional working in the effective administration of medicines.6–8 The multi-agency Medical School Councils report recommended prescribing competences for all foundation doctors from day 1.9 Building on this, a study commissioned by the General Medical Council to quantify the problem of medication and prescribing error, and explore causative factors, found that 8.9 per cent of prescription orders made by junior medical staff in 19 UK hospitals contained errors, but few of these caused patient harm as they were intercepted by other doctors, pharmacists or nurses.10 A recommendation from this study was that doctors, nurses and pharmacists could interact more effectively to improve patient outcomes, and that interprofessional education should be encouraged. The work described here represents a response to this recommendation.
CONTEXT IN NORTH EAST ENGLAND Undergraduate medicine, nursing and pharmacy education are
established in the North East of England, based at universities spread across a wide geographical area. Although all institutions deliver training around prescribing and therapeutics to these groups using a variety of teaching and learning strategies, interprofessional education is rare. In 2009 a grant was awarded by the North East Strategic Health Authority (SHA) to Northumbria Healthcare National Health Service (NHS) Foundation Trust to deliver a project to develop undergraduate interprofessional training in medication safety for medicine, pharmacy and nursing students. The project aimed to: • address inequalities in education provision around therapeutics;
designed the format and content of the training. The seminar used five case scenarios covering a variety of acute and chronic conditions, including exacerbation of chronic obstructive pulmonary disease, diabetic complications, gastrointestinal bleeding, atrial fibrillation, pain, depression, hypertension and Parkinson’s disease. As a result, students were exposed to the prescribing and administration of a wide range of commonly used medications, as well as those associated with high risks. Specific learning outcomes were based on the prescribing competencies developed by the Medical Schools Council. These included: • establishing an accurate drug history;
• encourage interprofessional learning and working to promote patient-focused attitudes to medicines use;
• planning appropriate therapy for common indications;
• develop students’ knowledge and skills to ensure safe and effective medicine-management practices;
• deducing appropriate treatment for acute illness based on symptoms, signs and investigations;
• offer a variety of accessible and valuable resources around prescribing to students;
• reviewing a patient’s existing medication in the light of their current condition and appraising previous prescribing;
• give students the opportunity to simulate multidisciplinary teamwork in preparation for entering the clinical workforce. All final-year undergraduate pharmacy and medical students, and a proportion of nursing students, in the region were invited to attend a half-day interprofessional medication safety seminar. These seminars took place between January and April 2011 at 10 teaching hospitals, and were attended by over 400 students.
LEARNING OUTCOMES The project team (comprising two pharmacists, one doctor and invited external experts)
Lack of preparedness [for prescribing in practice] is related to lack of exposure to, and preparation for, clinical practice
• writing safe and legal prescriptions; • accessing information about prescribing and calculating appropriate doses; • critically appraising the prescribing of others; • ensuring prescriptions are legible, unambiguous and complete.
ENCOURAGING A TEAM APPROACH To achieve these learning outcomes, students worked through cases in interprofessional groups, following the stages of a hospital admission
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Cases and associated teaching materials provided acknowledged the complexity of prescribing decision-making
SIMULATING THE COMPLEXITY OF PRESCRIBING DECISION-MAKING
Figure 1. Seminar resources (per small group), including mini flipchart
and the associated therapeutic interventions (including drug history-taking, review of regular medication, investigations and diagnosis, treatment choice, monitoring and complication of a discharge prescription; see Figure 1). Table 1 presents an example case and the expected student contributions, by profession. Each seminar was attended by between 25 and 30 students working in small groups of five or six, including nursing, medical and pharmacy students, where possible, the ratio of which varied at different teaching sites, reflecting the students’ availability to attend. Seminars were facilitated by clinical lecturers from medical, nursing and pharmacy backgrounds, to reflect the dynamics of the student groups. Facilitators selected how many and which cases to use at each seminar. This ensured that they were able to match the knowledge and clinical expertise of the facilitation team with the complexities of the cases being delivered. The majority of seminars were delivered using two or three cases within the allotted time frame of 2–3 hours. Seminar tasks were designed to engage students from different professional groups to use and apply their knowledge and skill to contribute to group discussion and decision-making. Table 2 outlines how tasks are presented to students, expected learning
outcomes and the facilitator’s role in supporting students to achieve the outcomes.
RESOURCES FOR SELF-STUDY In addition to attending a seminar, each student received a resource pack containing the material outlined in Figure 2 for self-study. In providing study materials, students were encouraged to access the content of the cases they had not engaged with during the seminar. Students were also able to assess their own performance during the seminar against the correct responses outlined in the resource pack. The resource pack offered a significant reserve of information for students to use in preparation for exams and future clinical practice.
EVALUATION OVERVIEW Both quantitative and qualitative data were collected (see Figure 3). Quantitative data were derived from students completing pre- and postseminar questionnaires, which contained a modified Readiness for Interprofessional Learning Scale.11,12 Qualitative data were derived from observations, semistructured interviews and focus groups.
The primary innovative feature of the project was the development of cases and associated teaching materials that acknowledged the complexity of prescribing decision-making. Seminar tasks allowed students to develop and practise generic prescribing skills (such as dose calculation, identifying interactions and dosage adjustment), whilst also offering students the opportunity to experience the simulated pressures of a clinical environment. Time for decision-making and team problem solving was purposely limited and inadequate, or incomplete information was provided about the patient’s medical history and other parameters, creating a difficult, realistic working environment. This allowed facilitators to discuss with students how safe prescribing decisions can be made in these circumstances, when to take advice from senior colleagues and which other measures to undertake to avoid error. ‘Grey’ areas of prescribing practice were also discussed, for example when a variety of approaches to a problem or practical points are not given in resources, such as the British National Formulary, but are instead gained through clinical experience. Students from all professional disciplines were generally positive about the learning experience offered by the seminar, valuing time spent working alongside other roles, particularly with pharmacy students, and exploring collaboration around specific cases. At three sites there were no nursing students present, and this gap was acknowledged by the other students, recognising that they could have contributed to the seminar, and was filled instead by the facilitators in some cases. The cases and
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Table 1. An example case illustrating tasks, materials and expected contributions, by profession Clinical scenario A patient was visited by her GP after morning surgery. On examination she has distressed breathing, is coughing up purulent sputum and is unable to speak in sentences. She has no social support and the GP decides admission to hospital is necessary. Past medical history: diabetes, COPD, osteoarthritis, previous MI 1998, hypertension, depression. Medication: Mrs Wilson has brought a bag of medication from home. Task 1: Attempt to compile a drug history for this patient. Task 2: Plan and write an in-patient treatment chart. Consider this patient’s existing medications and how you would manage her current acute episode. Analyse the results of the investigations presented (see below) to help you complete this task.
The seminar was particularly successful in improving students’ understanding of one another’s roles and responsibilities
Results of the investigations Blood pressure = 108/77 mmHg Weight = 58 kg Sodium = 132 mmol/L (135–145 mmol/L) Potassium = 4.1 mmol/L (3.5–5 mmol/L) Urea = 11.3 mmol/L (2.5–6.7 mmol/L) Creatinine = 200 µmol/L (70–150 µmol/L)
Pharmacy contribution
Nursing contribution
Medical contribution
Pharmacy student clarifies medication Interpret information received from patient and determine implications of this for the classes prescribed. administration of medications. Review and interpretation of the summary of medication regimen received Advise the group on the correct prescribing of antibiotics, steroids and other from GP. medications, including when required, to Calculate the patient’s renal function give ward nursing staff adequate informa(creatinine clearance) and assess tion to ensure safe administration upon the implications of this, along with admission. their blood pressure for the patient’s medication regimen; communicate this information to the group. Advise the group on antibiotic choice and other guideline-led therapeutic interventions. Advise the group on other prescribing issues, such as venous thromboembolism prophylaxis.
Discuss patient’s past medical history, and work with nursing and pharmacy students to link these to the medications prescribed. Interpret the chest X–ray and communicate the findings, and therefore a diagnosis, to the group.
Abbreviations: COPD, chronic obstructive pulmonary disease; GP, general practitioner; MI, myocardial infarction.
tasks were designed and facilitated to encourage all students to contribute to group discussion and decision-making: for example, medical students interpreted the results of investigations to determine a diagnosis; pharmacy students gave advice on the most appropriate, evidence-based therapeutic intervention; and nursing students provided
information on the practicalities of administering therapy to patients. Student feedback showed the seminar was particularly successful in improving the students’ understanding of one another’s roles and responsibilities in relation to medication safety.
I feel I have gained an understanding of the other
roles that are involved in patient care. It was great to spend some time with pharmacy students and discuss with them additional questions I had about their role, which is something I have not had a previous opportunity to do. Nursing Student
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Facilitators can discuss with students how to determine the appropriate treatment for the patient
Table 2. An example of case content, expected student learning outcomes and the role of the facilitator
Task 1: take a medication history 10 minutes to complete this task
Students are provided with details of:
Learning objectives
Facilitator feedback to students
The ability to establish an accurate drug history
Facilitators can highlight the common pitfalls of medication history-taking, such as:
• the presenting complaint; • This is achieved by collat• patients supplying inaccurate ing information from a • brief details of past or inadequate information, collection of medicines, medical history; unable to recall names of from the patient and from • information about the pamedication, referring to inhaled other people (carers, GP, tient’s current medication medication by colour etc.; old prescriptions). (this may be incomplete). • patients receiving medication • Information should also Students may request from different sources; be recorded about drug additional information allergies, adverse drug from the facilitators of • out-of-date or contradicting reactions and drug interthe seminar, but they information provided from actions. are not prompted to do other sources (carers, GP); so and must be specific • patient non-compliance. about the information they require, why they need it and where they would obtain it in a ward situation.
Task 2: plan and The investigations provided The ability to plan write an in–pa- to the student are depend- appropriate therapy for tient treatment ent on the presenting common indications plan by analys- complaint. They include: Deduce appropriate treatchest X–ray, urea and ing the results ment for acute illness of the patient’s electrolytes, liver function based on symptoms, signs tests, Helicobacter pylori investigations and investigations results, endoscopy report, Review patients’ existing 15 minutes to ECG report, blood pressure. medication in the light complete this task of current condition, appraise previous prescribing The ability to write safe and legal prescriptions Access information about prescribing and calculate appropriate doses Detect and manage adverse drug reactions
Facilitators can discuss with students how to determine the appropriate treatment for the patient based on signs, symptoms, examinations and investigations: • the analysis of the investigations and their relevance to prescribing decision-making; • how to write safe prescriptions and communicate information to the rest of the team; • reviewing patient’s existing medication in light of the patient’s current clinical condition; • how to make decisions to discontinue medication; • other prescribing issues such as fluids and venous thromboembolism prophylaxis.
Task 3: check the discharge prescription 5 minutes to complete this task
A discharge prescription is prepared for the patient (several days after the acute admission), and the student is asked to check it in their capacity as a doctor, clinical pharmacist or ward sister.
The ability to critically appraise the prescribing of others Ensure prescriptions meet appropriate standards: are legible, unambiguous and complete Ability to review prescribing and cancel prescriptions if appropriate
Facilitators can highlight to students common errors made on discharge: • medication omitted that the patient received prior to admission; • inadequate information given about medication stopped or started during admission; • no information given about duration of treatment course or monitoring needed after discharge.
Abbreviations: ECG, electrocardiogram; GP, general practitioner.
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It was really good being able to discuss with the pharmacy students about drug interactions. I will definitely use that on the ward where I have a query about [medications]. Medical Student It’s important that we sort of know, you know, the different roles of each other and liaise together… we probably need more of these sessions so that we know what we do and sort of collaborate. Pharmacy Student IMPLICATIONS Effective prescribing and medicines management is complex. Preparing professionals to deliver safe and effective practice requires education that addresses the complexity and facilitates them in developing and rehearsing the appropriate skills in a safe environment. The programme described here has
Five detailed scenarios Each follows a paent journey from hospital admission to discharge, with full discussion and feedback
Summaries of the 10 most prescribed drug classes Outlining main indicaons, dosages, interacons, adverse drug reacons and praccal prescribing points
A series of short tasks covering prescribing skills Including: dosage calculaons, medicaon ming and administraon, paediatric prescribing and management of drug interacons, monitoring drug therapy and adverse drug reacons.
Safe and effective practice requires education that addresses the complexity of prescribing and managing medicines
Figure 2. Contents of student resource pack
used classroom-based work in an interprofessional context (in NHS trusts) to prepare more than 400 students. To date we have not been able to explore the continuing impact in practice. There are three key implications that arise for those implementing similar initiatives. Firstly, there are considerable organisational challenges in arranging interprofessional groups when students come from different organisations with different placement arrangements in practice. We have found that building local relationships with course directors is helpful, but curricular demands sometimes act as a barrier. Secondly, it is clear from this work that the scenarios
that are set for groups need to be developed by interprofessional groups, and specifically provide tasks that engage and challenge all of the professions involved. Funding to produce high-quality materials is also beneficial (as in this case, from the SHA’s workforce development fund). Finally, this work has shown that facilitation is an important element, and that facilitators need to come from across the professions involved, and to be trained and confident in facilitating interprofessional, rather than uniprofessional, learning. Facilitators in the pilot were experienced, but did not receive specific training for interprofessional
Data collection at 11 sites
Pre-RIPL Questionnaire (students = 418)
Pre-RIPL (students = 318) (cleaned)
Observations (students = 233; facilitators = 41)
Students by profession (Medical = 190; Pharmacy = 76; Nursing = 52
Semi-structured interview (facilitators = 3; organisers = 3)
Focus groups (facilitators = 10; students = 76)
Student Focus Groups (Medical = 47; Pharmacy = 24; Nursing = 5)
Facilitator Focus Groups (at 4 different sites)
Post-RIPL Questionnaire (students = 416)
Post-RIPL Questionnaire (students = 318) (cleaned)
Previous IPL (Yes = 129; N=181)
Figure 3. Overview of the evaluation of the medication prescribing seminars, including data on the professions of the participating students. RIPL, Readiness for Interprofessional Learning
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Facilitators need to come from across the professions involved, and to be trained and confident in facilitating interprofessional learning
learning (IPL) facilitation. This has subsequently been provided. When these areas are adequately addressed, interprofessional education should ensure that doctors, nurses and pharmacists work together more effectively to improve medicine management and patient outcomes. REFERENCES 1. Andermann A, Ginsburg L, Norton P, Arora N, Bates D, Wu A, Larizgoitia I. Core competencies for patient safety research: a cornerstone for gobal capacity strengthening. BMJ Qual Saf 2011;20:96–101. 2. National Reporting and Learning System (NRLS). Patient Safety Topics 2012. Available at http:// www.nrls.npsa.nhs.uk/resources/ patient-safety-topics. Accessed on 17 June 2012. 3. Barber N, Rawlins M, Franklin BD. Reducing prescribing error: competence, control, and culture. Qual Saf Health Care 2003;12:i29–i32. 4. Rothwell C, Burford B, Morrison J, Morrow G, Allen M, Davies C,
Baldauf B, Spencer J, Johnson N, Peile E, Illing J. Junior doctors prescribing: enhancing their learning in practice. Br J Clin Pharmacol 2011;73:194–202. 5. Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf 2011;20:826–831. 6. Bertsche T, Bertsche A, Krieg EM, Kunz N, Bergmann K, Hanke G, Hoppe-Tichy T, Ebinger F, Haefeli WE. Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents. BMJ Qual Saf 2010;19:1–5. 7. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit. JAMA 1999;281:267–270. 8. World Health Organisation. WHO Patient Safety Curriculum Guide: Multi-Professional Patient Safety Curriculum Guide. Available at http://www.who.int/patientsafety/
education/curriculum/tools-download/en/index.html. Accessed on 17 June 2012. 9. Medical Schools Council. Outcomes of the Medical Schools Council Safe Prescribing Working Group. London: Medical Schools Council; 2007. 10. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP Study. London: General Medical Council; 2009. 11. McFadyen AK, Webster V, Strachan K, Figgins E, Brown H, McKecknie J. The Readiness for Interprofessional Learning Scale: A possible more stable sub-scale model for the original version of RIPLS. J Interprof Care 2005;19:595–603. 12. Reid R, Bruce D, Allstaff K, McLernon D. Validating the Readiness for Interprofessional Learning Scale (RIPLS) in the postgraduate context: are health care professionals ready for IPL? Med Educ 2006;40:415–422.
Corresponding author’s contact details: Mrs Lesley Scott, (formerly CETL4HealthNE), Department of Pharmacy, Health and Wellbeing, Sciences Complex, University of Sunderland, SR1 3SD, Tyne and Wear, UK. E-mail: [email protected]
Funding: The project was originally funded by a Workforce Development Initiative Fund (WDIF) from NHS North East (Strategic Health Authority), and the further development and writing of this article has been supported by CETL4HealthNE. Conflict of interest: None to declare. Ethical approval: Full ethical approval was gained from Newcastle University, with permission from the Universities of Northumbria, Sunderland and Teesside. The proposal was sent to the chair of the Newcastle and North Tyneside 1 Research Ethics Committee (REC), who confirmed that it was service evaluation and full ethical approval from the REC was not necessary. In order to have permission to observe the sessions and carry out focus groups with attendees and staff within the host NHS trusts, service evaluation forms were submitted alongside the proposal in all of the trusts. Approval from all trusts was gained. doi: 10.1111/tct.12148
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Interprofessional learning for medication safety Jessica Hardisty and Lesley Scott, Department of Pharmacy, Health and Wellbeing, University of Sunderland, UK Sarah Chandler, Clinical Pharmacy Department, Northumbria Healthcare Trust, North Tyneside General Hospital, North Shields, Tyne and Wear, UK Pauline Pearson, Faculty of Health & Life Sciences, Northumbria University, Newcastle, UK Suzanne Powell, CETL4HealthNE, School of Medical Sciences Education Development, Newcastle University, Newcastle-upon-Tyne, UK Interprofessional education should be encouraged
SUMMARY Background: Patient safety is a worldwide priority. Recommendations have been made that doctors, nurses and pharmacists could interact more effectively to improve patient outcomes, and that interprofessional education should be encouraged. In 2009, the North East Strategic Health Authority awarded Workforce Development Initiative funding to Northumbria Healthcare National Health Service (NHS) Foundation Trust to develop an undergraduate interprofessional training activity in medication safety for medicine, pharmacy and nursing students. Context: Interprofessional seminars for medication safety
and therapeutics were developed that were delivered across the North East of England. The initial seminars took place between January and April 2011 at 10 teaching hospitals, and were attended by over 400 students (from medicine, pharmacy and nursing). Innovation: The majority of the workshops were facilitated by an interprofessional team comprised of pharmacists, doctors and nurses, with all students working in small groups with participants from each of the professional groups, where possible. All seminars had standardised materials, but it was up to individual facilitators to choose which of the five case
studies were used within the seminar. The seminars lasted between 2 and 3 hours, and depending on which case studies were used, two or three cases could be discussed. Student feedback showed that the seminar was particularly successful in highlighting and improving the students’ understanding of each other’s roles and responsibilities in relation to medication safety. There are considerable organisational challenges in arranging interprofessional groups. Scenarios need to provide tasks that engage and challenge all of the professions involved. Facilitation is an important element.
290 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 290–296
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INTRODUCTION
K
eeping patients safe is a priority for most health care systems worldwide.1 Policy over the past decade has moved to recognise key areas of risk, including moving and handling, communication, infection control and medication.2 Errors around the prescribing and administration of medication contribute disproportionately to patient harm.3 A recent study exploring UK medical graduates’ preparedness for prescribing in practice showed that lack of preparedness is related to lack of exposure to, and preparation for, clinical practice.4 Bradley et al. showed that for UK pharmacy students, voluntary work experience compensated for limited practice exposure and aspects of patient safety not adequately addressed in the formal curriculum.5 Other work has indicated the importance of the wider team, and of interprofessional working in the effective administration of medicines.6–8 The multi-agency Medical School Councils report recommended prescribing competences for all foundation doctors from day 1.9 Building on this, a study commissioned by the General Medical Council to quantify the problem of medication and prescribing error, and explore causative factors, found that 8.9 per cent of prescription orders made by junior medical staff in 19 UK hospitals contained errors, but few of these caused patient harm as they were intercepted by other doctors, pharmacists or nurses.10 A recommendation from this study was that doctors, nurses and pharmacists could interact more effectively to improve patient outcomes, and that interprofessional education should be encouraged. The work described here represents a response to this recommendation.
CONTEXT IN NORTH EAST ENGLAND Undergraduate medicine, nursing and pharmacy education are
established in the North East of England, based at universities spread across a wide geographical area. Although all institutions deliver training around prescribing and therapeutics to these groups using a variety of teaching and learning strategies, interprofessional education is rare. In 2009 a grant was awarded by the North East Strategic Health Authority (SHA) to Northumbria Healthcare National Health Service (NHS) Foundation Trust to deliver a project to develop undergraduate interprofessional training in medication safety for medicine, pharmacy and nursing students. The project aimed to: • address inequalities in education provision around therapeutics;
designed the format and content of the training. The seminar used five case scenarios covering a variety of acute and chronic conditions, including exacerbation of chronic obstructive pulmonary disease, diabetic complications, gastrointestinal bleeding, atrial fibrillation, pain, depression, hypertension and Parkinson’s disease. As a result, students were exposed to the prescribing and administration of a wide range of commonly used medications, as well as those associated with high risks. Specific learning outcomes were based on the prescribing competencies developed by the Medical Schools Council. These included: • establishing an accurate drug history;
• encourage interprofessional learning and working to promote patient-focused attitudes to medicines use;
• planning appropriate therapy for common indications;
• develop students’ knowledge and skills to ensure safe and effective medicine-management practices;
• deducing appropriate treatment for acute illness based on symptoms, signs and investigations;
• offer a variety of accessible and valuable resources around prescribing to students;
• reviewing a patient’s existing medication in the light of their current condition and appraising previous prescribing;
• give students the opportunity to simulate multidisciplinary teamwork in preparation for entering the clinical workforce. All final-year undergraduate pharmacy and medical students, and a proportion of nursing students, in the region were invited to attend a half-day interprofessional medication safety seminar. These seminars took place between January and April 2011 at 10 teaching hospitals, and were attended by over 400 students.
LEARNING OUTCOMES The project team (comprising two pharmacists, one doctor and invited external experts)
Lack of preparedness [for prescribing in practice] is related to lack of exposure to, and preparation for, clinical practice
• writing safe and legal prescriptions; • accessing information about prescribing and calculating appropriate doses; • critically appraising the prescribing of others; • ensuring prescriptions are legible, unambiguous and complete.
ENCOURAGING A TEAM APPROACH To achieve these learning outcomes, students worked through cases in interprofessional groups, following the stages of a hospital admission
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 290–296 291
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Cases and associated teaching materials provided acknowledged the complexity of prescribing decision-making
SIMULATING THE COMPLEXITY OF PRESCRIBING DECISION-MAKING
Figure 1. Seminar resources (per small group), including mini flipchart
and the associated therapeutic interventions (including drug history-taking, review of regular medication, investigations and diagnosis, treatment choice, monitoring and complication of a discharge prescription; see Figure 1). Table 1 presents an example case and the expected student contributions, by profession. Each seminar was attended by between 25 and 30 students working in small groups of five or six, including nursing, medical and pharmacy students, where possible, the ratio of which varied at different teaching sites, reflecting the students’ availability to attend. Seminars were facilitated by clinical lecturers from medical, nursing and pharmacy backgrounds, to reflect the dynamics of the student groups. Facilitators selected how many and which cases to use at each seminar. This ensured that they were able to match the knowledge and clinical expertise of the facilitation team with the complexities of the cases being delivered. The majority of seminars were delivered using two or three cases within the allotted time frame of 2–3 hours. Seminar tasks were designed to engage students from different professional groups to use and apply their knowledge and skill to contribute to group discussion and decision-making. Table 2 outlines how tasks are presented to students, expected learning
outcomes and the facilitator’s role in supporting students to achieve the outcomes.
RESOURCES FOR SELF-STUDY In addition to attending a seminar, each student received a resource pack containing the material outlined in Figure 2 for self-study. In providing study materials, students were encouraged to access the content of the cases they had not engaged with during the seminar. Students were also able to assess their own performance during the seminar against the correct responses outlined in the resource pack. The resource pack offered a significant reserve of information for students to use in preparation for exams and future clinical practice.
EVALUATION OVERVIEW Both quantitative and qualitative data were collected (see Figure 3). Quantitative data were derived from students completing pre- and postseminar questionnaires, which contained a modified Readiness for Interprofessional Learning Scale.11,12 Qualitative data were derived from observations, semistructured interviews and focus groups.
The primary innovative feature of the project was the development of cases and associated teaching materials that acknowledged the complexity of prescribing decision-making. Seminar tasks allowed students to develop and practise generic prescribing skills (such as dose calculation, identifying interactions and dosage adjustment), whilst also offering students the opportunity to experience the simulated pressures of a clinical environment. Time for decision-making and team problem solving was purposely limited and inadequate, or incomplete information was provided about the patient’s medical history and other parameters, creating a difficult, realistic working environment. This allowed facilitators to discuss with students how safe prescribing decisions can be made in these circumstances, when to take advice from senior colleagues and which other measures to undertake to avoid error. ‘Grey’ areas of prescribing practice were also discussed, for example when a variety of approaches to a problem or practical points are not given in resources, such as the British National Formulary, but are instead gained through clinical experience. Students from all professional disciplines were generally positive about the learning experience offered by the seminar, valuing time spent working alongside other roles, particularly with pharmacy students, and exploring collaboration around specific cases. At three sites there were no nursing students present, and this gap was acknowledged by the other students, recognising that they could have contributed to the seminar, and was filled instead by the facilitators in some cases. The cases and
292 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 290–296
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Table 1. An example case illustrating tasks, materials and expected contributions, by profession Clinical scenario A patient was visited by her GP after morning surgery. On examination she has distressed breathing, is coughing up purulent sputum and is unable to speak in sentences. She has no social support and the GP decides admission to hospital is necessary. Past medical history: diabetes, COPD, osteoarthritis, previous MI 1998, hypertension, depression. Medication: Mrs Wilson has brought a bag of medication from home. Task 1: Attempt to compile a drug history for this patient. Task 2: Plan and write an in-patient treatment chart. Consider this patient’s existing medications and how you would manage her current acute episode. Analyse the results of the investigations presented (see below) to help you complete this task.
The seminar was particularly successful in improving students’ understanding of one another’s roles and responsibilities
Results of the investigations Blood pressure = 108/77 mmHg Weight = 58 kg Sodium = 132 mmol/L (135–145 mmol/L) Potassium = 4.1 mmol/L (3.5–5 mmol/L) Urea = 11.3 mmol/L (2.5–6.7 mmol/L) Creatinine = 200 µmol/L (70–150 µmol/L)
Pharmacy contribution
Nursing contribution
Medical contribution
Pharmacy student clarifies medication Interpret information received from patient and determine implications of this for the classes prescribed. administration of medications. Review and interpretation of the summary of medication regimen received Advise the group on the correct prescribing of antibiotics, steroids and other from GP. medications, including when required, to Calculate the patient’s renal function give ward nursing staff adequate informa(creatinine clearance) and assess tion to ensure safe administration upon the implications of this, along with admission. their blood pressure for the patient’s medication regimen; communicate this information to the group. Advise the group on antibiotic choice and other guideline-led therapeutic interventions. Advise the group on other prescribing issues, such as venous thromboembolism prophylaxis.
Discuss patient’s past medical history, and work with nursing and pharmacy students to link these to the medications prescribed. Interpret the chest X–ray and communicate the findings, and therefore a diagnosis, to the group.
Abbreviations: COPD, chronic obstructive pulmonary disease; GP, general practitioner; MI, myocardial infarction.
tasks were designed and facilitated to encourage all students to contribute to group discussion and decision-making: for example, medical students interpreted the results of investigations to determine a diagnosis; pharmacy students gave advice on the most appropriate, evidence-based therapeutic intervention; and nursing students provided
information on the practicalities of administering therapy to patients. Student feedback showed the seminar was particularly successful in improving the students’ understanding of one another’s roles and responsibilities in relation to medication safety.
I feel I have gained an understanding of the other
roles that are involved in patient care. It was great to spend some time with pharmacy students and discuss with them additional questions I had about their role, which is something I have not had a previous opportunity to do. Nursing Student
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Facilitators can discuss with students how to determine the appropriate treatment for the patient
Table 2. An example of case content, expected student learning outcomes and the role of the facilitator
Task 1: take a medication history 10 minutes to complete this task
Students are provided with details of:
Learning objectives
Facilitator feedback to students
The ability to establish an accurate drug history
Facilitators can highlight the common pitfalls of medication history-taking, such as:
• the presenting complaint; • This is achieved by collat• patients supplying inaccurate ing information from a • brief details of past or inadequate information, collection of medicines, medical history; unable to recall names of from the patient and from • information about the pamedication, referring to inhaled other people (carers, GP, tient’s current medication medication by colour etc.; old prescriptions). (this may be incomplete). • patients receiving medication • Information should also Students may request from different sources; be recorded about drug additional information allergies, adverse drug from the facilitators of • out-of-date or contradicting reactions and drug interthe seminar, but they information provided from actions. are not prompted to do other sources (carers, GP); so and must be specific • patient non-compliance. about the information they require, why they need it and where they would obtain it in a ward situation.
Task 2: plan and The investigations provided The ability to plan write an in–pa- to the student are depend- appropriate therapy for tient treatment ent on the presenting common indications plan by analys- complaint. They include: Deduce appropriate treatchest X–ray, urea and ing the results ment for acute illness of the patient’s electrolytes, liver function based on symptoms, signs tests, Helicobacter pylori investigations and investigations results, endoscopy report, Review patients’ existing 15 minutes to ECG report, blood pressure. medication in the light complete this task of current condition, appraise previous prescribing The ability to write safe and legal prescriptions Access information about prescribing and calculate appropriate doses Detect and manage adverse drug reactions
Facilitators can discuss with students how to determine the appropriate treatment for the patient based on signs, symptoms, examinations and investigations: • the analysis of the investigations and their relevance to prescribing decision-making; • how to write safe prescriptions and communicate information to the rest of the team; • reviewing patient’s existing medication in light of the patient’s current clinical condition; • how to make decisions to discontinue medication; • other prescribing issues such as fluids and venous thromboembolism prophylaxis.
Task 3: check the discharge prescription 5 minutes to complete this task
A discharge prescription is prepared for the patient (several days after the acute admission), and the student is asked to check it in their capacity as a doctor, clinical pharmacist or ward sister.
The ability to critically appraise the prescribing of others Ensure prescriptions meet appropriate standards: are legible, unambiguous and complete Ability to review prescribing and cancel prescriptions if appropriate
Facilitators can highlight to students common errors made on discharge: • medication omitted that the patient received prior to admission; • inadequate information given about medication stopped or started during admission; • no information given about duration of treatment course or monitoring needed after discharge.
Abbreviations: ECG, electrocardiogram; GP, general practitioner.
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It was really good being able to discuss with the pharmacy students about drug interactions. I will definitely use that on the ward where I have a query about [medications]. Medical Student It’s important that we sort of know, you know, the different roles of each other and liaise together… we probably need more of these sessions so that we know what we do and sort of collaborate. Pharmacy Student IMPLICATIONS Effective prescribing and medicines management is complex. Preparing professionals to deliver safe and effective practice requires education that addresses the complexity and facilitates them in developing and rehearsing the appropriate skills in a safe environment. The programme described here has
Five detailed scenarios Each follows a paent journey from hospital admission to discharge, with full discussion and feedback
Summaries of the 10 most prescribed drug classes Outlining main indicaons, dosages, interacons, adverse drug reacons and praccal prescribing points
A series of short tasks covering prescribing skills Including: dosage calculaons, medicaon ming and administraon, paediatric prescribing and management of drug interacons, monitoring drug therapy and adverse drug reacons.
Safe and effective practice requires education that addresses the complexity of prescribing and managing medicines
Figure 2. Contents of student resource pack
used classroom-based work in an interprofessional context (in NHS trusts) to prepare more than 400 students. To date we have not been able to explore the continuing impact in practice. There are three key implications that arise for those implementing similar initiatives. Firstly, there are considerable organisational challenges in arranging interprofessional groups when students come from different organisations with different placement arrangements in practice. We have found that building local relationships with course directors is helpful, but curricular demands sometimes act as a barrier. Secondly, it is clear from this work that the scenarios
that are set for groups need to be developed by interprofessional groups, and specifically provide tasks that engage and challenge all of the professions involved. Funding to produce high-quality materials is also beneficial (as in this case, from the SHA’s workforce development fund). Finally, this work has shown that facilitation is an important element, and that facilitators need to come from across the professions involved, and to be trained and confident in facilitating interprofessional, rather than uniprofessional, learning. Facilitators in the pilot were experienced, but did not receive specific training for interprofessional
Data collection at 11 sites
Pre-RIPL Questionnaire (students = 418)
Pre-RIPL (students = 318) (cleaned)
Observations (students = 233; facilitators = 41)
Students by profession (Medical = 190; Pharmacy = 76; Nursing = 52
Semi-structured interview (facilitators = 3; organisers = 3)
Focus groups (facilitators = 10; students = 76)
Student Focus Groups (Medical = 47; Pharmacy = 24; Nursing = 5)
Facilitator Focus Groups (at 4 different sites)
Post-RIPL Questionnaire (students = 416)
Post-RIPL Questionnaire (students = 318) (cleaned)
Previous IPL (Yes = 129; N=181)
Figure 3. Overview of the evaluation of the medication prescribing seminars, including data on the professions of the participating students. RIPL, Readiness for Interprofessional Learning
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Facilitators need to come from across the professions involved, and to be trained and confident in facilitating interprofessional learning
learning (IPL) facilitation. This has subsequently been provided. When these areas are adequately addressed, interprofessional education should ensure that doctors, nurses and pharmacists work together more effectively to improve medicine management and patient outcomes. REFERENCES 1. Andermann A, Ginsburg L, Norton P, Arora N, Bates D, Wu A, Larizgoitia I. Core competencies for patient safety research: a cornerstone for gobal capacity strengthening. BMJ Qual Saf 2011;20:96–101. 2. National Reporting and Learning System (NRLS). Patient Safety Topics 2012. Available at http:// www.nrls.npsa.nhs.uk/resources/ patient-safety-topics. Accessed on 17 June 2012. 3. Barber N, Rawlins M, Franklin BD. Reducing prescribing error: competence, control, and culture. Qual Saf Health Care 2003;12:i29–i32. 4. Rothwell C, Burford B, Morrison J, Morrow G, Allen M, Davies C,
Baldauf B, Spencer J, Johnson N, Peile E, Illing J. Junior doctors prescribing: enhancing their learning in practice. Br J Clin Pharmacol 2011;73:194–202. 5. Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf 2011;20:826–831. 6. Bertsche T, Bertsche A, Krieg EM, Kunz N, Bergmann K, Hanke G, Hoppe-Tichy T, Ebinger F, Haefeli WE. Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents. BMJ Qual Saf 2010;19:1–5. 7. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit. JAMA 1999;281:267–270. 8. World Health Organisation. WHO Patient Safety Curriculum Guide: Multi-Professional Patient Safety Curriculum Guide. Available at http://www.who.int/patientsafety/
education/curriculum/tools-download/en/index.html. Accessed on 17 June 2012. 9. Medical Schools Council. Outcomes of the Medical Schools Council Safe Prescribing Working Group. London: Medical Schools Council; 2007. 10. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP Study. London: General Medical Council; 2009. 11. McFadyen AK, Webster V, Strachan K, Figgins E, Brown H, McKecknie J. The Readiness for Interprofessional Learning Scale: A possible more stable sub-scale model for the original version of RIPLS. J Interprof Care 2005;19:595–603. 12. Reid R, Bruce D, Allstaff K, McLernon D. Validating the Readiness for Interprofessional Learning Scale (RIPLS) in the postgraduate context: are health care professionals ready for IPL? Med Educ 2006;40:415–422.
Corresponding author’s contact details: Mrs Lesley Scott, (formerly CETL4HealthNE), Department of Pharmacy, Health and Wellbeing, Sciences Complex, University of Sunderland, SR1 3SD, Tyne and Wear, UK. E-mail: [email protected]
Funding: The project was originally funded by a Workforce Development Initiative Fund (WDIF) from NHS North East (Strategic Health Authority), and the further development and writing of this article has been supported by CETL4HealthNE. Conflict of interest: None to declare. Ethical approval: Full ethical approval was gained from Newcastle University, with permission from the Universities of Northumbria, Sunderland and Teesside. The proposal was sent to the chair of the Newcastle and North Tyneside 1 Research Ethics Committee (REC), who confirmed that it was service evaluation and full ethical approval from the REC was not necessary. In order to have permission to observe the sessions and carry out focus groups with attendees and staff within the host NHS trusts, service evaluation forms were submitted alongside the proposal in all of the trusts. Approval from all trusts was gained. doi: 10.1111/tct.12148
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