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Mertens JF, Kempen TGH, Koster ES, Deneer VHM, Bouvy ML, van Gelder T. Cognitive processes in pharmacists' clinical decision-making. Res Social Adm Pharm 2024; 20:105-114. [PMID: 37945418 DOI: 10.1016/j.sapharm.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/06/2023] [Accepted: 10/20/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Pharmacists' clinical decision-making is a core process in pharmaceutical care. However, the practical aspects and effective teaching methods of this process remain largely unexplored. OBJECTIVE To examine the cognitive processes involved in pharmacists' perceptions of how they make clinical decisions in pharmacy practice. METHODS Semi-structured, face-to-face interviews were conducted with pharmacists working in community, outpatient, and hospital care in the Netherlands between August and December 2021. Participants were explicitly asked for examples when asked how they make clinical decisions in practice and how they teach this to others. After transcribing audio-recorded interviews, an inductive thematic analysis was conducted to identify cognitive processes. A theoretical model of clinical decision-making was then used and adapted to structure the identified processes. RESULTS In total, 21 cognitive processes were identified from interviews with 16 pharmacists working in community (n = 5), outpatient (n = 2), and hospital care (n = 9). These cognitive processes were organized into 8 steps of the adapted theoretical model, i.e. problem and demand for care consideration, information collection, clinical reasoning, clinical judgment, shared decision-making, implementation, outcomes evaluation, and reflection. Pharmacists struggled to articulate their clinical decision-making and went back-and-forth in their explanations of this process. All pharmacists emphasized the importance of identifying the problem and described how they collect information through reviewing, gathering, recalling, and investigating. Clinical reasoning entailed various cognitive processes, of which comprehending the problem in the patient's context was deemed challenging at times. Pharmacists seemed least active in evaluating patient outcomes and reflecting on these outcomes. CONCLUSIONS Pharmacists use multiple cognitive processes when making clinical decisions in pharmacy practice, and their back-and-forth explanations emphasize its dynamic nature. This study adds to a greater understanding of how pharmacists make clinical decisions and to the development of a theoretical model that describes this process, which can be used in pharmacy practice and education.
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Affiliation(s)
- J F Mertens
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - T G H Kempen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - E S Koster
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - V H M Deneer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - T van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
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Kallis TJ, Allinson M. Factors affecting clinical pharmacist decision-making when reviewing and prescribing z-drugs in primary care: a qualitative interview study. Int J Clin Pharm 2023; 45:1176-1183. [PMID: 37454026 DOI: 10.1007/s11096-023-01617-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Z-drugs (zopiclone, zolpidem and zaleplon) are drugs with dependence forming characteristics licensed for the short-term management of insomnia. Patients regularly prescribed z-drugs are candidates for 'structured medication reviews', routinely delivered by pharmacists employed in general practice or primary care networks in England. AIM To understand the factors that affect pharmacist decision-making when reviewing and prescribing z-drugs in primary care. METHOD Qualitative semi-structured interviews with general practice based pharmacists were conducted using MS Teams®. Clinical vignettes to simulate real-world practice were sent to participants and then discussed at interview, followed by structured interview questions. Interview transcripts were thematically analysed to identify themes and sub-themes expressed by participants. RESULTS Three over-arching themes emerged over the course of qualitative interviews with 10 clinical pharmacists: the perceived role of the pharmacist in deprescribing, the decision-making process, and perceptions of best practice. Pharmacists highlighted that relationships with patients were an important foundation for medication reviews regarding z-drugs and that at times they felt pressure to continue prescribing z-drugs beyond their licensed use. Participants explored rule-based reasoning and compassionate care when rationalising their decision-making for reviewing and prescribing z-drugs. CONCLUSION Patient factors, time pressures, 'rule-based' beliefs and pharmacist self-efficacy were key practice aspects which can influence the pharmacist decision-making process when reviewing or prescribing z-drugs. Pharmacists believed z-drugs should be short-term interventions for insomnia, with non-pharmacological, holistic treatment being more appropriate for long term management.
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Affiliation(s)
| | - Maria Allinson
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
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Mertens JF, Koster ES, Deneer VHM, Bouvy ML, van Gelder T. Factors influencing pharmacists' clinical decision making in pharmacy practice. Res Social Adm Pharm 2023; 19:1267-1277. [PMID: 37236847 DOI: 10.1016/j.sapharm.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Pharmacists' clinical decision-making is considered a core process of pharmaceutical care in pharmacy practice, but little is known about the factors influencing this process. OBJECTIVE To identify factors influencing clinical decision-making among pharmacists working in pharmacy practice. METHODS Semi-structured interviews were conducted with pharmacists working in primary, secondary, and tertiary care settings in the Netherlands between August and December 2021. A thematic analysis was conducted using an inductive approach. The emerged themes were categorized into the Capability-Opportunity-Motivation-Behaviour (COM-B) model domains. RESULTS In total, 16 pharmacists working in primary care (n = 7), secondary care (n = 4) or tertiary care (n = 5) were interviewed. Factors influencing pharmacists' capability to make clinical decisions are a broad theoretical knowledge base, clinical experience, and skills, including contextualizing data, clinical reasoning, and clinical judgment. The pharmacy setting, data availability, rules and regulations, intra- and interprofessional collaboration, education, patient perspectives, and time are mentioned as factors influencing their opportunity. Factors influencing pharmacists' motivation are confidence, curiosity, critical thinking, and responsibility. CONCLUSIONS The reported factors covered all domains of the COM-B model, implying that clinical decision-making is influenced by a combination of pharmacists' capability, opportunity, and motivation. Addressing these different factors in pharmacy practice and education may improve pharmacists' clinical decision-making, thereby improving patient outcomes.
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Affiliation(s)
- J F Mertens
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - E S Koster
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - V H M Deneer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - T van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
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Charrois TL, Sewell HD. Clinical decision-making by fourth-year pharmacy students: Towards an understanding of their uncertainty. CURRENTS IN PHARMACY TEACHING & LEARNING 2023; 15:779-786. [PMID: 37537008 DOI: 10.1016/j.cptl.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/11/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Clinical decision-making is a critical process underpinning much of a pharmacist's daily activities. While it is known that pharmacists hesitate to make decisions, it remains unclear whether pharmacy students experience similar hesitancy. The objective of this study was to better understand the phenomenon of decision-making in pharmacy students. METHODS This study was designed from a social constructivist paradigm using qualitative case study methodology. The purpose was to investigate issues related to hesitancy in clinical decision-making by fourth-year pharmacy students. Data were collected through observation of students engaging in simulations, post-simulation interviews, and written reflections. Data analysis included multiple stages of coding, followed by pattern identification and discovery of interrelationships. RESULTS The primary themes relating to issues in pharmacy student clinical decision-making were relational factors, teaching and learning, degree of certainty, and personal characteristics. Relational factors include elements of relationships with patients and physicians as well as a sense of autonomy. The theme of teaching and learning included the sub-themes of formal education and learning in the real world. Degree of certainty included patient complexity, weighing risks and benefits, comfort in ambiguity, and a lack of information. Finally, personal characteristics associated with decision-making include personal experiences, leadership skills, and confidence. CONCLUSIONS Pharmacy education needs to focus on ensuring preceptors can help model comfort in ambiguity, that assessments include the reality of practice, and ensuring ample practice of decision-making in a simulated environment.
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Affiliation(s)
- Theresa L Charrois
- Faculty of Pharmaceutical Sciences, University of British Columbia, Office 3323, 2405 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada.
| | - H Douglas Sewell
- Werklund School of Education, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada.
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Meijvis VAM, Heringa M, Kwint HF, de Wit NJ, Bouvy ML. Barriers and facilitators for the implementation of the CombiConsultation by general practitioners, pharmacists and practice nurses: a qualitative interview study. Int J Clin Pharm 2023:10.1007/s11096-023-01597-7. [PMID: 37253951 PMCID: PMC10366006 DOI: 10.1007/s11096-023-01597-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/23/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND The CombiConsultation is a consultation with the pharmacist for patients with a chronic condition, aligned with the periodic consultation with the practice nurse or general practitioner. Implementation requires adjustments in the working methods of these healthcare providers and therefore behavioural changes. AIM The aim of this study was to identify the barriers and facilitators that determine the behavioural changes by pharmacists, general practitioners and practice nurses required for the implementation of the CombiConsultation. METHOD Ten community pharmacists, 5 practice nurses and 5 general practitioners were sampled from practices enrolled in the CombiConsultation study. Their views regarding the implementation of this clinical pharmacy service were explored using interviews based on the 14 domains of the Theoretical Domains Framework (TDF), which are linked to the Capability-Opportunity-Motivation-Behaviour-model. Barriers and facilitators in the domains were assessed by content analysis. RESULTS Twelve barriers and 23 facilitators were found within 13 TDF domains with high agreement between the healthcare providers. Important facilitators for implementation were the pharmacists' expertise in pharmacotherapy (capability), access to medical data and physical proximity between professional practices (opportunity). Barriers were pharmacists' insufficient consultation- and clinical-reasoning skills (capability), insufficient staff (opportunity) and reimbursement and lack of coordination among all involved healthcare providers (motivation). CONCLUSION All healthcare providers are motivated to implement the CombiConsultation. An existing collaborative practice, with a clear and accepted professional role of the pharmacist is essential. Training of pharmacists in consultation and clinical-reasoning skills can be beneficial, as well as arrangements on the consultation logistics, and reimbursement.
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Affiliation(s)
- Valérie A M Meijvis
- SIR Institute for Pharmacy Practice and Policy, 2331 JE, Leiden, The Netherlands.
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, 2331 JE, Leiden, The Netherlands
| | - Henk-Frans Kwint
- SIR Institute for Pharmacy Practice and Policy, 2331 JE, Leiden, The Netherlands
| | - Niek J de Wit
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marcel L Bouvy
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Lelie-van der Zande R, Koster ES, Teichert M, Bouvy ML. Barriers and facilitators for providing self-care advice in community pharmacies: a qualitative study. Int J Clin Pharm 2023:10.1007/s11096-023-01571-3. [PMID: 37029859 PMCID: PMC10082626 DOI: 10.1007/s11096-023-01571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 03/03/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Community pharmacies are easily accessible for self-care advice. Guidelines for providing self-care advice were introduced in several countries, including the Netherlands in the 1990s. Previous studies have indicated room for improvement in self-care advice in daily pharmacy practice. AIM To identify barriers and facilitators for providing self-care advice. METHOD Semi-structured interviews were conducted face-to-face or online with pharmacists and pharmacy assistants using a topic guide based on the Theoretical Domains Framework. The interviews were audio-recorded and transcribed verbatim. The transcripts were deductively analysed to identify barriers and facilitators for self-care counselling. COREQ guidelines were followed. RESULTS In total, 13 pharmacists and 12 pharmacy assistants were interviewed to reach data saturation. In general, most themes addressed by pharmacists and pharmacy assistants belonged to similar domains. The following domains were frequently mentioned: environmental context and resources (e.g. priority for prescription drugs, privacy, collaboration with general practitioners, access to patients' records), intentions (providing reliable advice), skills (communication, decision-making), knowledge (ready guideline knowledge), beliefs about consequences (patient safety), social influences (patient awareness of pharmacist role), reinforcement (lack of reimbursement for relatively time-consuming advice). CONCLUSION This study identifies barriers and facilitators for evidence-based self-care advice. Pharmacists should first support pharmacy assistants by helping them keep their knowledge and skills up to date and creating suitable pharmacy preconditions to facilitate improvements in self-care counselling. Second, collaboration with general practitioners regarding minor ailments should be improved.
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Affiliation(s)
- Rian Lelie-van der Zande
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
| | - Ellen S Koster
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Martina Teichert
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcel L Bouvy
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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