Decision-Making Process in Comprehensive Medication Management Services: From the Understanding to the Development of a Theoretical Model

Decision-making about changing medications across transitions of care: Opportunities for enhanced patient and family engagement

BACKGROUND

Older patients often have complex medication regimens, which change as they move across transitions of care. Engagement of older patients and families in making medication decisions across transitions of care is important for safe and high-quality medication management.

AIMS

To explore decision-making between health professionals, older patients and families about medication changes across transitions of care, and to examine how patient and family engagement is enacted in the process of decision-making in relation to these medication changes.

METHODS

A focused ethnographic design was undertaken with semi-structured interviews, observations, and reflective focus groups or interviews. Reflexive thematic analysis was conducted on transcribed data. The study was undertaken at a public teaching acute care hospital and a public teaching community hospital in Australia.

RESULTS

In all, 182 older patients, 44 family members and 94 health professionals participated. Four themes were conceptualised from the data: different customs and routines, medication challenges, health professional interactions, and patient and family involvement. Environments had differences in their customs and routines, which increased the potential for medication delays or the substitution of unintended medications. Medication challenges included health professionals assuming that patients and families did not need information about regularly prescribed medications. Patients and families were informed about new medications after health professionals had already made decisions to prescribe these medications. Health professionals tended to work in disciplinary silos, and they had views about their role in interacting with patients and families. Patients and families were expected to take the initiative to participate in decision-making about medication changes.

CONCLUSIONS

Patient movements across transitions of care can create complex and chaotic medication management situations, which lacks transparency, especially for older patients and their families. A greater focus on pre-emptive and planned discussions about medication changes will contribute to improving patient and family involvement in medication decision-making.

Cognitive processes in pharmacists' clinical decision-making

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.

Comprehensive Medication Management Services with a Holistic Point of View, a Scoping Review

Implementing Comprehensive Medication Management (CMM) services uncovered the importance of the totality of the patient's perspective in this process. The holistic approach takes into account the physical, mental and emotional well-being of individuals, as well as their socioeconomic circumstances. The aim of this study was to characterize the scientific evidence associated with CMM services that included this holistic approach. A scoping review was conducted based on Arksey and O'Malley's method. Searches were performed in Google Scholar for papers published between 2010 and 2020 in English, Spanish and Portuguese. Study design, health contexts, sample of patients, results obtained, barriers and facilitators, and the integration of a holistic approach were determined. Two hundred and eighteen papers were evaluated, most of which focused on the implementation of this service through prospective observational studies. A minority of studies reported on a holistic approach, a smaller number examined the effect of social determinants of health, the patient's medication experiences and the pharmacotherapy outcomes from the patient's perspective. Despite the progress achieved, most of the referents do not yet reflect a broader view of the patient's life situation and its relationship to pharmacotherapy and the ways in which the pharmacist implements holistic elements to solve or prevent drug-related problems.

Clinical reasoning by pharmacists: A scoping review

BACKGROUND

Clinical reasoning is considered a core competency for pharmacists, but there is a lack of conceptual clarity that complicates teaching and assessment. This scoping review was conducted to identify, map, and examine evidence on used cognitive processes and their conceptualization of clinical reasoning by pharmacists.

METHODS

In March 2021, seven databases were searched for relevant primary research studies. Included were studies that examined cognitive processes in pharmacists while addressing a clinical scenario in a pharmacy-related setting. Using descriptive analysis, study characteristics, conceptualizations, operationalizations, and key findings were mapped, summarized, and examined. Results were reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

RESULTS

From 2252 abstracts, 17 studies were included that examined clinical reasoning in the context of forming a diagnosis (n = 9) or determining medication appropriateness (n = 4). Most studies conceptualized clinical reasoning as a context-dependent cognitive process whereby pharmacists apply and integrate knowledge and clinical experience to interpret available clinical data. Different terms labelled pharmacists' reasoning that showed analytical and intuitive approaches to clinical scenarios, either separately or combined. Medication review studies reported a predominance of analytical reasoning. The majority of diagnosis-forming studies in primary care identified no distinct cognitive reasoning pattern when addressing self-care scenarios.

IMPLICATIONS

This overview reflects a small but growing body of research on clinical reasoning by pharmacists. It is recommended that this competence be taught by explicating and reflecting on clinical reasoning as separate stage of the clinical decision-making process with transparent cognitive processes.

Assessing Job Satisfaction and Stress among Pharmacists in Cyprus

Background: Inadequate staffing, increased responsibilities and a high workload are some of the factors that are directly related to stress levels experienced by pharmacists, which in turn affect job satisfaction. Objective: The aim of this study was to assess job satisfaction and stress levels of pharmacists in Cyprus, involving those working in the public and private sector. Materials and Methods: A cross-sectional study was performed which involved the completion of the Job Satisfaction Survey (JSS) questionnaire to estimate job satisfaction, and the Perceived Stress Scale-14 (PSS-14) questionnaire to evaluate perceived stress. Data collection took place between January and March 2020 and the participation rate was 71.6% (n = 585). Results: Employees in private pharmacies overall reported higher levels of job satisfaction compared to public sector pharmacists. Public sector pharmacists were found to have stronger self-efficacy beliefs compared to other groups (p < 0.001). Female pharmacists had a higher average level of perceived helplessness than male pharmacists (p = 0.001). Regarding public sector pharmacists, it was generally observed that pharmacists working under the management of the Ministry of Health (MoH) had reduced job satisfaction than those working for other organizations. Additionally, pharmacists working under the management of the State Health Services Organization (SHSO) had the least overall perceived stress levels (p = 0.008), high self-efficacy beliefs (p = 0.006) and low perceived helplessness (p = 0.031) compared to pharmacists in other workplaces. Employees of private pharmacies were found to have higher levels of job satisfaction (p < 0.001) than SHSO pharmacists. However, those employees demonstrated increased perceived stress levels (p < 0.001) in comparison with SHSO pharmacists. Conclusions: Pharmacists’ job satisfaction is negatively correlated with perceived stress levels and helplessness, and positively correlated with self-efficacy beliefs. In the public sector, it seems that a re-evaluation is critical regarding the determinants that adversely influence job satisfaction amongst pharmacists.

Emergency Preparedness for the COVID-19 Pandemic: Social Determinants Predicting the Community Pharmacists’ Preparedness and Perceived Response in Malaysia

Background: Pandemic preparedness of healthcare providers helps to mitigate future threats such as spread and fatality rates, as well as the management of the disease. Pharmacists are key partners with public health agencies, and the role of community pharmacists is becoming increasingly recognised in this COVID-19 pandemic. The study aimed to explore the emergency preparedness of community pharmacists (CPs) for COVID-19. Methods: A cross-sectional study was performed among community pharmacists using cluster sampling followed by convenient sampling. A self-administered questionnaire was formulated using references from the previous literature and the WHO preparedness checklist. Descriptive analysis was undertaken for the participants’ socio-demographic characteristics. All the data collected were entered into the Statistical Package for Social Sciences version 24 (SPSS V.24), (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.) for analysis. Results: Most of the CPs had five or fewer years of practice experience, and they had all the mandatory information relating to the needs of their communities regarding the disease. The participants knew where to acquire these resources whenever needed. They were able to recognise the signs and symptoms of the disease. Most participants felt that they were confident to provide patient education and carry out their duties during these challenging times. There was a strong position correlation between preparedness and the perceived response of the participants. Conclusion: The community pharmacists in Malaysia are prepared enough for COVID-19 pandemic management and perceive that they can respond during any unprecedented situations, such as COVID-19. Community pharmacists were aware of the challenges that they need to face in their community regarding COVID-19.

Theoretical model and measurement of shared decision making in web-based pharmaceutical care consultation

Objectives

We aimed to construct a theoretical model and an observer-based measurement of shared decision making (SDM) in web-based pharmaceutical care consultation.

Methods

We first constructed a theoretical model through analysis of SDM models and interviews with 24 key informants. Then, the initial measurement was formulated, and the content was evaluated by 16 key informants alone. A cross-sectional study was executed, where 300 provider-patient encounters were collected at the online platform ‘Good Doctor Website’, for reliability and validity assessment. Content validity was evaluated by appropriateness score, that is the median of 7–9 and without disagreement. Interrater reliability was evaluated by Spearman correlation coefficient using 30 out of 300 samples. Single indicator validity was tested by Pearson correlation analysis, and convergent validity was evaluated by the Multiple Indicators Multiple Causes (MIMIC) model using 300 samples.

Results

Theoretical model constructed included four elements: ‘comprehensive understanding of the patient's condition’, ‘exchanging ideas on medication options’, ‘achieving a medication plan’, and ‘providing decision support’. Measurement constructed included four dimensions and 19 items, and four dimensions were in accordance with four elements of the theoretical model. We found median scores of these dimensions and items were 7–9 and without disagreement, indicating good content validity. Spearman correlation coefficients of 19 items were greater than 0.750, suggesting good interrater reliability. Pearson coefficients between 19 items and their external variables were significant (p < 0.001), and MIMIC model results showed that the R² values of dimensions 1–4 were over 0.5, indicating good single indicator validity and convergent validity.

Conclusions

Characteristics of web-based pharmaceutical care consultation, highlighting the importance of medication history, medication regimen, and detailed medication plan, were observed in the theoretical model. Measurement constructed had good reliability and validity and may be used by health policymakers to improve the quality of pharmaceutical care consultation online.

Medication reviews in community pharmacy: a scoping review of policy, practice and research in Canada

Objectives

This scoping review aims to systematically map the empirical evidence on publicly funded medication reviews provided by community pharmacists in Canada and identify gaps that could inform future research directions.

Methods

We used a scoping review framework and PRISMA guidelines for Scoping Reviews to conduct the study. Three electronic databases were searched for papers published between January 2000 until August 2020. Data was charted on study characteristics, and a thematic synthesis was performed.

Key findings

Of 41 original studies included, most were conducted in Ontario (n = 21). Majority of the studies employed quantitative designs (70%). Five major themes identified were program uptake, patient health outcomes, stakeholder beliefs and attitudes, processes and collaboration and pharmacy workplace culture, which varied considerably. At the individual, organizational and policy levels, many factors were interrelated and influenced the implementation of reimbursed medication reviews by community pharmacists. Gaps in eligibility policy highlighted some patients who may have complex needs are excluded. Variation in clinical outcomes may relate to different types of medication review and pharmacist practice across Canada. Few researchers evaluated eligibility criteria, the impact of policy changes, strategies to engage patients and healthcare professionals, patient–pharmacist communication or compared practice models of medication reviews. About 12% of the research applied a theoretical framework.

Summary

Publicly funded medication reviews in Canadian community pharmacies reduce medication-related problems and potentially improve patient health outcomes. Future research and policies could consider addressing barriers and exploring models for sustainable delivery of high-quality medication reviews internationally.

The Medication Experience: A Concept Analysis

This is a concept analysis of the medication experience with a focus on how it applies to the pharmaceutical care practice framework used by pharmacist practitioners. The medication experience is a vital component of pharmaceutical care practice and of patient-centered care. Although the experience of taking medication has been studied across disciplines for decades, a concept analysis of the medication experience is lacking. Rodgers’ evolutionary concept analysis method was utilized. Ovid Medline, CINAHL, PsycINFO, Sociological Abstracts and Google Scholar databases, references and hand searches were used to compile an international dataset of 66 papers published from 1982 to 2020. As a result of the available literature, the medication experience is defined as one of ambivalence and vulnerability in which the patient is actively engaged in an ongoing process or negotiation, which is pragmatic to the ways in which they live and experience life, contextualized and nuanced within the social construction of their individual realities. The concept of medication experience is an important addition to the scientific literature. The definition of medication experience from the perspective of the patient will help to better explain the concept for future research and theory development to move the discipline of pharmaceutical care practice forward.