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Teaching students about the WHO Guide to Good Prescribing Abstract: Although the WHO Guide to Good Prescribing is widely used in medical education to teach rationale prescribing to physicians, this method is less known in graduate nursing education. The purpose of this article is to review the motivation behind this model and to discuss the incorporation of a P (personal) drug assignment into a graduate pharmacology course. Kristine Anne Scordo, PhD, RN, ACNP-BC, FAANP
hree reports from the Institute of Medicine, Too Err is Human, Crossing the Quality Chasm, and Health Professions Education: A Bridge to Quality, emphasized widespread problems related to patient safety and called for dramatic restructuring of traditional health professions education.1-3 Among these strategies is the need to safely prescribe appropriate medications. Advanced practice
T
registered nurses (APRNs), along with physicians and other healthcare providers, are under increased scrutiny to safely and effectively prescribe medications. Therefore, it is imperative that nursing educational programs prepare competent providers. National program accreditation reviews are competency based, and curricula outcome data are evaluated for the attainment of competencies.4
Keywords: graduate nursing students, pharmacology, WHO Guide to Good Prescribing
www.tnpj.com
The Nurse Practitioner • March 2014 51
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teaching students about the WHO Guide to Good Prescribing
improved by “implementing similar procedures that involve identifying a problem (the question), generating one or more hypotheses, collecting and processing reliable and valid data (the experiment), interpreting the results, drawing conclusions, and recommending further action.”7 The “experiment” starts when a patient seeks medical care. First, the provider defines the patient’s problem (the diagnosis). Next, the provider has to specify the therapeutic objective and choose a treatment of proven efficacy and safety from Incorporating P-drugs into an assignment different alternatives. The treatment is during pharmacology and clinical courses helps then started (for example, by writing an students understand rational prescribing. accurate prescription and providing the patient with clear information and instructions). To determine the success of the treatment, the provider monitors its results. If the problem adverse reactions of different drug categories and selected has been solved, the treatment can be stopped. If not, the drugs. However, patients who need drug therapy vary in age, process is repeated (see Normative model of scientific, medical, gender, size, and sociocultural characteristics, all of which and therapeutic problem solving). may affect treatment choices. Additionally, clinical training The specifics of each step are detailed in the World often deals with diagnostic rather than therapeutic skill Health Organization’s (WHO) Guide to Good Prescribing. development. Students may mimic the prescribing behavior This guide, along with the Teacher’s Guide to Good Prescribof their clinical preceptors without rationale as to why cering, is freely available from the WHO site: apps.who.int/ tain treatment regimens are chosen. The rationale for choosmedicinedocs/pdf/whozip23e/whozip23e.pdf and apps.who. ing drugs can be difficult to identify if pharmacology referint/medicinedocs/pdf/s2292e/s2292e.pdf. The Guide to Good ences are drug-centered and rarely discuss the rationales for Prescribing is based on 10 years of experience teaching the selection. Although students may learn pharmacology, their model at the University of Groningen (Netherlands) and is diagnostic reasoning for prescribing could remain weak. primarily intended for undergraduate medical students who This article will focus on pharmacotherapeutic safety. are about to begin clinical rotations. Prior to the compilation One means to increase safety is to discuss a systematic of the guide, the model was tested in various international approach to teaching prescribing skills, such as P (personal) medical schools.8-15 To date, these studies demonstrate that drugs. using the principles of rational prescribing may lead to safe, ■ P drugs cost-effective prescribing, a better understanding of pharIncorporating P-drugs into an assignment during pharmamacologic principles, and increased confidence in prescribcology and clinical courses gives students a step-by-step ing the appropriate medications. To apply this process to a guide to the process of rational prescribing. P-drug selection graduate pharmacology course, the substeps of the therateaches students to use impartial, objective information peutic and monitoring process detailed in the guide were obtained from appropriate literature to make prescribing modified. These modifications are discussed below. decisions. This is an important exercise to help reduce irrational prescribing and improve prescribing behavior. ■ P-drug analysis assignment The P-drugs approach was originally developed by the Graduate students at Wright State University, College of Department of Pharmacology and Clinical Pharmacology Nursing take a three-credit general pharmacology course. of the Faculty of Medicine, University of Groningen, NethThereafter, pharmacology topics specific to their concentraerlands in 1980 as part of a pharmacotherapy project.5 The tion are taught in the clinical courses. P-drugs are one of four assignments that include a multiple-choice midterm aim of the project was to improve medical students’ pharand final, and group web-case discussions. Over 10 years macotherapeutic teaching through a problem-solving apago, when the assignment was first developed, students were proach. A normative or prescriptive model that combined responsible for five P-drug assignments. Due to feedback medical problem solving and decision analysis along with and concerns regarding the amount of time each P-drug practical medical aspects and pharmacologic facts was used assignment takes—particularly from faculty who have takto promote rational drug choice and prescribing.6 The basic en the course—the assignment was reduced to four. tenet of the model is that medical decision making can be Provider education programs are faced with increased pressure to ensure graduates meet established competencies so that they are capable of providing safe patient care. Programs that prepare nurse practitioners (NPs) must develop curricula that maximize learning experiences. Graduate-level pharmacology courses often present “drug-centered” material and focus on indications and
52 The Nurse Practitioner • Vol. 39, No. 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.tnpj.com
Teaching students about the WHO Guide to Good Prescribing
During the course orientaNormative model of scientific, medical, and therapeutic problem solving tion, the students are given specific instructions as to the Scientific MEDICAL/ purpose and steps of the Ptherapeutic (1-7) drug assignment. The importance of the student’s ability to Patient’s problem Question obtain information specific to the medications, and not Diagnosis merely cut and paste the infor1. Determine the goal of treatment mation from various websites, 2. Choose a (drug) treatment Hypothesis 2.1 Take/choose a first-choice (drug) treatment is included in the instructions. 2.2 Verify appropriateness for the patient The university uses www.turnitin.com, a website that deTreatment tects academic plagiarism. Experiment 3 Start drug-treatment Students are told that in most 3.1 Write a prescription/administer the drug practices, there are a few diag3.2 Inform, instruct, and warn the patient noses for which APRNs will 3.3 Make next appointment repeatedly prescribe. ThereResults Results fore, students are instructed to 4. Monitor the results determine four common diag5. Draw conclusions noses that they will need to learn to treat during the course. Conclusions Conclusions They are encouraged to obtain 6. Determine further action ideas from graduate preceptors by reviewing the literature or RecommenFurther action recommendations made from dations 7. Stop/alter/continue treatment students who previously took the course and now are in their De Vries TP. Presenting clinical pharmacology and therapeutics: A problem based approach for choosing and clinical rotations. Students are prescribing drugs. Br J Clin Pharmacol. 1993;35(6):581-586. Reproduced with permission. encouraged to be as specific as possible when choosing and defining the diagnoses. For instance, diagnosis of systolic heart treatment of bacterial infections, students would need to list failure would mean the student would have to describe all the all classes of antibiotics. These drug classes are then put into a possible classifications of drugs used to treat this condition chart that compares them for efficacy, safety, and suitability. from diuretics to angiotensin-converting enzyme inhibitors Each drug classification must include both the generic and (ACEI). A diagnosis of hypertension in a patient with type I trade name of the medication. The pharmacodynamics and pharmacokinetics are briefly described under efficacy, adverse, diabetes with microalbuminuria is clearly more specific. After students formulate a diagnosis, they develop a ther- and/or life-threatening reactions listed under safety, and special apeutic objective or goal of treatment. The goal might be to considerations, including pregnancy category listed under cure the disease/disorder, relieve symptoms, prevent exacerba- suitability; students are expected to reference each section. Once students are aware of the potential medication tions, prevent complications, or a combination of these goals. The treatment objectives are based on current guidelines and/ classes that could be used to treat the disease, they choose one classification of medications. This choice is based on a or evidence from recent publications. Knowing the therapeutic objective, students must identify thorough review of the evidence, which includes current all possible classifications of medications that could be used— clinical trials and guidelines. After deciding on the appropriregardless of whether or not the class is appropriate for the ate classification, students then develop a chart that comdiagnosis. For instance, in a hypertensive patient with type I pares all medications in this classification for safety, suitdiabetes with microalbuminuria, the student would list all ability, and cost of treatment. From this, students learn classes of medications known to treat hypertension, such as specific differences in the medications, such as drug-drug ACEI, angiotensin II receptor blockers, renin inhibitors, beta- interaction (for example, which drugs inhibit or potentiate blockers, calcium channel blockers, and diuretics. For the CYP enzymes; the different half-lives of the drugs; which www.tnpj.com
The Nurse Practitioner • March 2014 53
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teaching students about the WHO Guide to Good Prescribing
drugs are generic; which drugs have been studied in clinical trials; and what specific recommendations are for each medication). The last step is to determine which medication they will use to treat the diagnosis. This decision requires the student to justify their choice based on current evidence and the cost to the patient. They must also include information on how long the treatment will last, what testing (if any) is required, how often, and what type. Thus, this is a five-step process that encourages students not only what to prescribe, but more important how to rationally choose and prescribe drugs. ■ Student feedback During the last 10 years, students have commented that although the assignment is quite tedious, it is worthwhile during their clinical practicums. Recently, an open-ended questionnaire was given to two classes of acute care NP students during their last clinical practicum and one recently graduated class (N = 60). Three open-ended questions were posed: What do you believe to be the best benefit from doing the P-drug assignment; what do you believe to be the negative aspects of the P-drug assignment; and do you believe the P-drug assignment assisted you in managing patients in your current or past clinical rotations: If so, how or how not? Of the 52 respondents who completed the questionnaire, all believed the assignment was beneficial. The following comments were very common: “The most beneficial aspect of this assignment is learning a diagnosis and grasping all of the potential drug classes that can be used”; “I learned so much about all the different classifications of drugs”; “the assignment was a vehicle to review current, evidence-based articles on how I should be thinking about prescribing—not just from what my preceptor said. I learned to challenge choices made by others.” With respect to the negative aspects, the timeconsuming nature of the assignment was a common theme. The following comment is noteworthy: “Students need to understand the magnitude of this assignment as well as the extreme benefit they will gain from allowing themselves the time to perform it correctly. This is an assignment that cannot be done last minute. Be certain to emphasize this over and over.” With respect to the third question, all students agreed that this is an invaluable assignment. One student commented that, “Doing the P-drug assignment is a love/hate relationship!” Others stated that the antibiotics were initially confusing, but remembering the P-drug assignment helped them to correctly prescribe for the patient. The assignment was useful when one student was able to teach his preceptor why a specific drug should not be prescribed due to a potential drug-drug interaction. ■ Conclusion Graduate students who are taught a systematic approach to choosing and prescribing drugs rationally have the po-
tential to develop behaviors that will lead to safe, costeffective healthcare. Knowing how to objectively select medications on the basis of well-defined criteria as opposed to irrational prescribing (for example, a demanding patient or a heavily promoted drug) may prevent suboptimal prescribing practices. Longitudinal research is needed to determine if the use of P-drugs in graduate educations can achieve its original intent—to develop sound prescribing behaviors. REFERENCES 1. Kohn LJ, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington: National Academies Press; 1999. 2. Wolfe A. Institute of Medicine Report: crossing the quality chasm: a new health care system for the 21st century. Policy, Politics & Nursing Practice. 2001;2(3). 3. Greiner A, Knebel E, eds. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003. 4. American Association of Colleges of Nursing. The Essentials of Master’s Education for Advanced Practice Nursing Education. Washington, DC: Author; 2011. 5. De Vries TP. Presenting clinical pharmacology and therapeutics: general introduction. Br J Clin Pharmacol. 1993;35(6):577-579. 6. De Vries TP. Presenting clinical pharmacology and therapeutics: a problem based approach for choosing and prescribing drugs. Br J Clin Pharmacol. 1993;35(6):581-586. 7. De Vries TP. Presenting clinical pharmacology and therapeutics: a problem based approach for choosing and prescribing drugs. Br J Clin Pharmacol. 1993;35(6):582. 8. Akici A, Kalaça S, Gören MZ, et al. Comparison of rational pharmacotherapy decision-making competence of general practitioners with intern doctors. Eur J Clin Pharmacol. 2004;60(2):75-82. doi:10.1007/s00228-0040751-2. 9. De Vries TP, Henning RH, Hogerzeil HV, et al. Impact of a short course in pharmacotherapy for undergraduate medical students: an international randomised controlled study. Lancet. 1995;346(8988):1454-1457. 10. Kawakami J, Mimura Y, Adachi I, Takeguchi N. Yakugaku Zasshi. Application of personal drug (P-drug) seminar to clinical pharmacy education in the graduate school of pharmaceutical sciences. 2002;122(10):819-829. 11. Mahajan R, Singh N, Singh J, Dixit A, Jain A, Gupta A. Assessment of awareness among clinicians about concepts in undergraduate pharmacology curriculum: a novel cross-sectional study. J Young Pharm. 2010;2(3):301-305. doi:10.4103/0975-1483.66797. 12. Meyer JC, Summers RS, Möller H. Randomized, controlled trial of prescribing training in a South African province. Med Educ. 2001;35(9):833-840. 13. O’Shaughnessy L, Haq I, Maxwell S, Llewelyn M. Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009. Br J Clin Pharmacol. 2010;70(1):143-148. doi:10.1111/j.1365-2125.2010.03665.x. 14. Akici A, Gören MZ, Aypak C, Terzio_lu B, Oktay S. Prescription audit adjunct to rational pharmacotherapy education improves prescribing skills of medical students. Eur J Clin Pharmacol. 2005;61(9):643-650. doi:10.1007/ s00228-005-0960-3. 15. Smith A, Hill S, Walkom E, Thambiran M. An evaluation of the World Health Organization problem-based pharmacotherapy teaching courses (based on the “Guide to Good Prescribing”), 1994-2001. Eur J Clin Pharmacol. 2005;61(10):785-786. Kristine Scordo is professor and director of the Adult-Gero Acute Care Nurse Practitioner Program at Wright State University, College of Nursing, Dayton, Ohio and is a Fellow of the American Academy of Nurse Practitioners. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NPR.0000443231.95228.e3
54 The Nurse Practitioner • Vol. 39, No. 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.tnpj.com
Teaching students about the WHO Guide to Good Prescribing Abstract: Although the WHO Guide to Good Prescribing is widely used in medical education to teach rationale prescribing to physicians, this method is less known in graduate nursing education. The purpose of this article is to review the motivation behind this model and to discuss the incorporation of a P (personal) drug assignment into a graduate pharmacology course. Kristine Anne Scordo, PhD, RN, ACNP-BC, FAANP
hree reports from the Institute of Medicine, Too Err is Human, Crossing the Quality Chasm, and Health Professions Education: A Bridge to Quality, emphasized widespread problems related to patient safety and called for dramatic restructuring of traditional health professions education.1-3 Among these strategies is the need to safely prescribe appropriate medications. Advanced practice
T
registered nurses (APRNs), along with physicians and other healthcare providers, are under increased scrutiny to safely and effectively prescribe medications. Therefore, it is imperative that nursing educational programs prepare competent providers. National program accreditation reviews are competency based, and curricula outcome data are evaluated for the attainment of competencies.4
Keywords: graduate nursing students, pharmacology, WHO Guide to Good Prescribing
www.tnpj.com
The Nurse Practitioner • March 2014 51
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teaching students about the WHO Guide to Good Prescribing
improved by “implementing similar procedures that involve identifying a problem (the question), generating one or more hypotheses, collecting and processing reliable and valid data (the experiment), interpreting the results, drawing conclusions, and recommending further action.”7 The “experiment” starts when a patient seeks medical care. First, the provider defines the patient’s problem (the diagnosis). Next, the provider has to specify the therapeutic objective and choose a treatment of proven efficacy and safety from Incorporating P-drugs into an assignment different alternatives. The treatment is during pharmacology and clinical courses helps then started (for example, by writing an students understand rational prescribing. accurate prescription and providing the patient with clear information and instructions). To determine the success of the treatment, the provider monitors its results. If the problem adverse reactions of different drug categories and selected has been solved, the treatment can be stopped. If not, the drugs. However, patients who need drug therapy vary in age, process is repeated (see Normative model of scientific, medical, gender, size, and sociocultural characteristics, all of which and therapeutic problem solving). may affect treatment choices. Additionally, clinical training The specifics of each step are detailed in the World often deals with diagnostic rather than therapeutic skill Health Organization’s (WHO) Guide to Good Prescribing. development. Students may mimic the prescribing behavior This guide, along with the Teacher’s Guide to Good Prescribof their clinical preceptors without rationale as to why cering, is freely available from the WHO site: apps.who.int/ tain treatment regimens are chosen. The rationale for choosmedicinedocs/pdf/whozip23e/whozip23e.pdf and apps.who. ing drugs can be difficult to identify if pharmacology referint/medicinedocs/pdf/s2292e/s2292e.pdf. The Guide to Good ences are drug-centered and rarely discuss the rationales for Prescribing is based on 10 years of experience teaching the selection. Although students may learn pharmacology, their model at the University of Groningen (Netherlands) and is diagnostic reasoning for prescribing could remain weak. primarily intended for undergraduate medical students who This article will focus on pharmacotherapeutic safety. are about to begin clinical rotations. Prior to the compilation One means to increase safety is to discuss a systematic of the guide, the model was tested in various international approach to teaching prescribing skills, such as P (personal) medical schools.8-15 To date, these studies demonstrate that drugs. using the principles of rational prescribing may lead to safe, ■ P drugs cost-effective prescribing, a better understanding of pharIncorporating P-drugs into an assignment during pharmamacologic principles, and increased confidence in prescribcology and clinical courses gives students a step-by-step ing the appropriate medications. To apply this process to a guide to the process of rational prescribing. P-drug selection graduate pharmacology course, the substeps of the therateaches students to use impartial, objective information peutic and monitoring process detailed in the guide were obtained from appropriate literature to make prescribing modified. These modifications are discussed below. decisions. This is an important exercise to help reduce irrational prescribing and improve prescribing behavior. ■ P-drug analysis assignment The P-drugs approach was originally developed by the Graduate students at Wright State University, College of Department of Pharmacology and Clinical Pharmacology Nursing take a three-credit general pharmacology course. of the Faculty of Medicine, University of Groningen, NethThereafter, pharmacology topics specific to their concentraerlands in 1980 as part of a pharmacotherapy project.5 The tion are taught in the clinical courses. P-drugs are one of four assignments that include a multiple-choice midterm aim of the project was to improve medical students’ pharand final, and group web-case discussions. Over 10 years macotherapeutic teaching through a problem-solving apago, when the assignment was first developed, students were proach. A normative or prescriptive model that combined responsible for five P-drug assignments. Due to feedback medical problem solving and decision analysis along with and concerns regarding the amount of time each P-drug practical medical aspects and pharmacologic facts was used assignment takes—particularly from faculty who have takto promote rational drug choice and prescribing.6 The basic en the course—the assignment was reduced to four. tenet of the model is that medical decision making can be Provider education programs are faced with increased pressure to ensure graduates meet established competencies so that they are capable of providing safe patient care. Programs that prepare nurse practitioners (NPs) must develop curricula that maximize learning experiences. Graduate-level pharmacology courses often present “drug-centered” material and focus on indications and
52 The Nurse Practitioner • Vol. 39, No. 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.tnpj.com
Teaching students about the WHO Guide to Good Prescribing
During the course orientaNormative model of scientific, medical, and therapeutic problem solving tion, the students are given specific instructions as to the Scientific MEDICAL/ purpose and steps of the Ptherapeutic (1-7) drug assignment. The importance of the student’s ability to Patient’s problem Question obtain information specific to the medications, and not Diagnosis merely cut and paste the infor1. Determine the goal of treatment mation from various websites, 2. Choose a (drug) treatment Hypothesis 2.1 Take/choose a first-choice (drug) treatment is included in the instructions. 2.2 Verify appropriateness for the patient The university uses www.turnitin.com, a website that deTreatment tects academic plagiarism. Experiment 3 Start drug-treatment Students are told that in most 3.1 Write a prescription/administer the drug practices, there are a few diag3.2 Inform, instruct, and warn the patient noses for which APRNs will 3.3 Make next appointment repeatedly prescribe. ThereResults Results fore, students are instructed to 4. Monitor the results determine four common diag5. Draw conclusions noses that they will need to learn to treat during the course. Conclusions Conclusions They are encouraged to obtain 6. Determine further action ideas from graduate preceptors by reviewing the literature or RecommenFurther action recommendations made from dations 7. Stop/alter/continue treatment students who previously took the course and now are in their De Vries TP. Presenting clinical pharmacology and therapeutics: A problem based approach for choosing and clinical rotations. Students are prescribing drugs. Br J Clin Pharmacol. 1993;35(6):581-586. Reproduced with permission. encouraged to be as specific as possible when choosing and defining the diagnoses. For instance, diagnosis of systolic heart treatment of bacterial infections, students would need to list failure would mean the student would have to describe all the all classes of antibiotics. These drug classes are then put into a possible classifications of drugs used to treat this condition chart that compares them for efficacy, safety, and suitability. from diuretics to angiotensin-converting enzyme inhibitors Each drug classification must include both the generic and (ACEI). A diagnosis of hypertension in a patient with type I trade name of the medication. The pharmacodynamics and pharmacokinetics are briefly described under efficacy, adverse, diabetes with microalbuminuria is clearly more specific. After students formulate a diagnosis, they develop a ther- and/or life-threatening reactions listed under safety, and special apeutic objective or goal of treatment. The goal might be to considerations, including pregnancy category listed under cure the disease/disorder, relieve symptoms, prevent exacerba- suitability; students are expected to reference each section. Once students are aware of the potential medication tions, prevent complications, or a combination of these goals. The treatment objectives are based on current guidelines and/ classes that could be used to treat the disease, they choose one classification of medications. This choice is based on a or evidence from recent publications. Knowing the therapeutic objective, students must identify thorough review of the evidence, which includes current all possible classifications of medications that could be used— clinical trials and guidelines. After deciding on the appropriregardless of whether or not the class is appropriate for the ate classification, students then develop a chart that comdiagnosis. For instance, in a hypertensive patient with type I pares all medications in this classification for safety, suitdiabetes with microalbuminuria, the student would list all ability, and cost of treatment. From this, students learn classes of medications known to treat hypertension, such as specific differences in the medications, such as drug-drug ACEI, angiotensin II receptor blockers, renin inhibitors, beta- interaction (for example, which drugs inhibit or potentiate blockers, calcium channel blockers, and diuretics. For the CYP enzymes; the different half-lives of the drugs; which www.tnpj.com
The Nurse Practitioner • March 2014 53
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Teaching students about the WHO Guide to Good Prescribing
drugs are generic; which drugs have been studied in clinical trials; and what specific recommendations are for each medication). The last step is to determine which medication they will use to treat the diagnosis. This decision requires the student to justify their choice based on current evidence and the cost to the patient. They must also include information on how long the treatment will last, what testing (if any) is required, how often, and what type. Thus, this is a five-step process that encourages students not only what to prescribe, but more important how to rationally choose and prescribe drugs. ■ Student feedback During the last 10 years, students have commented that although the assignment is quite tedious, it is worthwhile during their clinical practicums. Recently, an open-ended questionnaire was given to two classes of acute care NP students during their last clinical practicum and one recently graduated class (N = 60). Three open-ended questions were posed: What do you believe to be the best benefit from doing the P-drug assignment; what do you believe to be the negative aspects of the P-drug assignment; and do you believe the P-drug assignment assisted you in managing patients in your current or past clinical rotations: If so, how or how not? Of the 52 respondents who completed the questionnaire, all believed the assignment was beneficial. The following comments were very common: “The most beneficial aspect of this assignment is learning a diagnosis and grasping all of the potential drug classes that can be used”; “I learned so much about all the different classifications of drugs”; “the assignment was a vehicle to review current, evidence-based articles on how I should be thinking about prescribing—not just from what my preceptor said. I learned to challenge choices made by others.” With respect to the negative aspects, the timeconsuming nature of the assignment was a common theme. The following comment is noteworthy: “Students need to understand the magnitude of this assignment as well as the extreme benefit they will gain from allowing themselves the time to perform it correctly. This is an assignment that cannot be done last minute. Be certain to emphasize this over and over.” With respect to the third question, all students agreed that this is an invaluable assignment. One student commented that, “Doing the P-drug assignment is a love/hate relationship!” Others stated that the antibiotics were initially confusing, but remembering the P-drug assignment helped them to correctly prescribe for the patient. The assignment was useful when one student was able to teach his preceptor why a specific drug should not be prescribed due to a potential drug-drug interaction. ■ Conclusion Graduate students who are taught a systematic approach to choosing and prescribing drugs rationally have the po-
tential to develop behaviors that will lead to safe, costeffective healthcare. Knowing how to objectively select medications on the basis of well-defined criteria as opposed to irrational prescribing (for example, a demanding patient or a heavily promoted drug) may prevent suboptimal prescribing practices. Longitudinal research is needed to determine if the use of P-drugs in graduate educations can achieve its original intent—to develop sound prescribing behaviors. REFERENCES 1. Kohn LJ, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington: National Academies Press; 1999. 2. Wolfe A. Institute of Medicine Report: crossing the quality chasm: a new health care system for the 21st century. Policy, Politics & Nursing Practice. 2001;2(3). 3. Greiner A, Knebel E, eds. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003. 4. American Association of Colleges of Nursing. The Essentials of Master’s Education for Advanced Practice Nursing Education. Washington, DC: Author; 2011. 5. De Vries TP. Presenting clinical pharmacology and therapeutics: general introduction. Br J Clin Pharmacol. 1993;35(6):577-579. 6. De Vries TP. Presenting clinical pharmacology and therapeutics: a problem based approach for choosing and prescribing drugs. Br J Clin Pharmacol. 1993;35(6):581-586. 7. De Vries TP. Presenting clinical pharmacology and therapeutics: a problem based approach for choosing and prescribing drugs. Br J Clin Pharmacol. 1993;35(6):582. 8. Akici A, Kalaça S, Gören MZ, et al. Comparison of rational pharmacotherapy decision-making competence of general practitioners with intern doctors. Eur J Clin Pharmacol. 2004;60(2):75-82. doi:10.1007/s00228-0040751-2. 9. De Vries TP, Henning RH, Hogerzeil HV, et al. Impact of a short course in pharmacotherapy for undergraduate medical students: an international randomised controlled study. Lancet. 1995;346(8988):1454-1457. 10. Kawakami J, Mimura Y, Adachi I, Takeguchi N. Yakugaku Zasshi. Application of personal drug (P-drug) seminar to clinical pharmacy education in the graduate school of pharmaceutical sciences. 2002;122(10):819-829. 11. Mahajan R, Singh N, Singh J, Dixit A, Jain A, Gupta A. Assessment of awareness among clinicians about concepts in undergraduate pharmacology curriculum: a novel cross-sectional study. J Young Pharm. 2010;2(3):301-305. doi:10.4103/0975-1483.66797. 12. Meyer JC, Summers RS, Möller H. Randomized, controlled trial of prescribing training in a South African province. Med Educ. 2001;35(9):833-840. 13. O’Shaughnessy L, Haq I, Maxwell S, Llewelyn M. Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009. Br J Clin Pharmacol. 2010;70(1):143-148. doi:10.1111/j.1365-2125.2010.03665.x. 14. Akici A, Gören MZ, Aypak C, Terzio_lu B, Oktay S. Prescription audit adjunct to rational pharmacotherapy education improves prescribing skills of medical students. Eur J Clin Pharmacol. 2005;61(9):643-650. doi:10.1007/ s00228-005-0960-3. 15. Smith A, Hill S, Walkom E, Thambiran M. An evaluation of the World Health Organization problem-based pharmacotherapy teaching courses (based on the “Guide to Good Prescribing”), 1994-2001. Eur J Clin Pharmacol. 2005;61(10):785-786. Kristine Scordo is professor and director of the Adult-Gero Acute Care Nurse Practitioner Program at Wright State University, College of Nursing, Dayton, Ohio and is a Fellow of the American Academy of Nurse Practitioners. The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NPR.0000443231.95228.e3
54 The Nurse Practitioner • Vol. 39, No. 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.tnpj.com
