Clinical Judgement Analysis: An innovative approach to explore the individual decision-making processes of pharmacists

Background: Pharmacy stands increasingly on the frontline of patient care, yet current studies of clinical decision-making by pharmacists only capture deliberative processes that can be stated explicitly. Decision-making incorporates both deliberative and intuitive processes. Clinical Judgement Analysis (CJA) is a method novel to pharmacy that uncovers intuitive decision-making and may provide a more comprehensive understanding of the decision-making processes of pharmacists. / Objectives: This paper describes how CJA potentially uncovers the intuitive clinical decision-making processes of pharmacists. Using an illustrative decision-making example, the application of CJA will be described, including: Scenario and associated task development around a defined judgement / Capture of pharmacists' decision-making processes and analysis using appropriate statistical methods / Method: An illustrative study was used, applying an established method for CJA. The decision to initiate anticoagulation, alongside appropriate risk judgements, was chosen as the context. Expert anticoagulation pharmacists were interviewed to define and then refine variables (cues) involved in this decision. Decision tasks with sixty scenarios were developed to explore the effect of these cues on pharmacists’ decision-making processes and distributed to participants for completion. Descriptive statistical and regression analyses were conducted for each participant. / Results: The method produced individual judgement models for each participant, for example, demonstrating that when judging stroke risk each participant’s judgements could be accurately predicted using only 3 or 4 out of the possible 11 cues given. The method also demonstrated that participants appeared to consider multiple cues when making risk judgements but used an algorithmic approach based on one or two cues when making the clinical decision. / Conclusion: CJA generates insights into the clinical decision-making processes of pharmacists not uncovered by the current literature. This provides a springboard for more in-depth explorations; explorations that are vital to the understanding and ongoing development of the role of pharmacists

A Randomised controlled trial of Energetic Activity for Depression in Young people (READY): A multi-site feasibility trial protocol

Background: Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery. Methods: The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13–17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a ‘healthy living’ behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness. Discussion: UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression. Trial registration: ISRCTN, ISRCTN66452702. Registered 9 April 2020

Medicines Optimisation and Patient Safety NIHR CLAHRC Learning Event, held 16th January 2017

This article presents independent research in part funded by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London (NWL). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Use of a medication passport in a disabled child seen across many care settings

Written information for patients about their medicines has demonstrable benefits for their understanding and adherence. In the UK, no single, complete record of medications for individual patients can be guaranteed. Therefore, patients and carers are often relied on to recall the complete medication list, which can be a challenge given multiple and potentially stressful appointments. Wide-ranging feedback suggests that a medication 'passport' developed by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North West London (NIHR CLAHRC NWL) has benefited elderly patients, who often attend many appointments where the current medication list may not be available. We describe the use of this passport (known as 'My Medication Passport'-MMP) in a child with multiple disabilities. The practical advantages are explored, including the potential for a paediatric version to facilitate discussions around the administration of medicines. MMP is an early example of a useful tool to help children and young people, parents and carers to manage medicines more effectively.</p

The role of patients and carers in diffusing a health-care innovation: A case study of "My Medication Passport"

BACKGROUND: Patients are increasingly recognized as playing important roles in improving health services. Little is known about the mechanisms by which patients develop and diffuse local innovations in a complex health-care system. OBJECTIVE: To ascertain how diffusion of an innovation, My Medication Passport, occurred and roles played by patients in it. DESIGN: Case study: quantitative mapping of innovation's diffusion and analysis of the routes and occupations of those through whom the innovation spread; documentary analysis; reflective assessment of patient's roles. SETTING AND PARTICIPANTS: NHS Trusts, third sector organizations, patients and health-care professionals. INTERVENTIONS STUDIED: Co-produced action to raise awareness and influence use of the innovation; order database which enabled ease of access to the innovation. MAIN OUTCOME MEASURES: Geographical spread of innovation; occupations of individuals; types of organizations using the innovation. RESULTS: The innovation spread from initial development and use in Northwest London across the UK and beyond. Key roles played by patients were as follows: co-producer; advocate; relationship builder; relationship broker; planner; presenter; awareness raiser; trainer; networker. Patients identified and introduced potential audiences and users to MMP, using social, organizational, sectoral, lay and professional networks to do so. They organized a range of awareness-raising and communication activities, monitored feedback, evaluated the impact and responded to new interest. DISCUSSION AND CONCLUSIONS: The roles of patients in diffusing innovations are under-recognized. Collaborative working between patients, carers and health-care professionals in planning and progressing the use and supporting diffusion of the innovation was important. Principles described in this study are relevant to progressing other patient-led ideas for innovative changes relating to health service development

How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience

Background Patients often carry medication lists to mitigate information loss across healthcare settings. We aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use. Methods We used a mixed-methods design comprising two focus groups with patients and carers, 16 semistructured interviews with healthcare professionals, 60 semistructured interviews with people carrying medication lists, a quantitative features analysis of tools available for patients to record their medicines and usability testing of four tools. Findings were triangulated using thematic analysis. Distributed cognition for teamwork models were used as sensitising concepts. Results We identified a wide range of mechanisms through which carrying medication lists can improve medication safety. These included improving the accuracy of medicines reconciliation, allowing identification of potential drug interactions, facilitating communication about medicines, acting as an aide-mémoire to patients during appointments, allowing patients to check their medicines for errors and reminding patients to take and reorder their medicines. Different tools for recording medicines met different needs. Of 103 tools examined, none met the core needs of all users. A key barrier to use was lack of awareness by patients and carers that healthcare information systems can be fragmented, a key facilitator was encouragement from healthcare professionals. Conclusion Our findings suggest that patients and healthcare professionals perceive patient-held medication lists to have a wide variety of benefits. Interventions are needed to raise awareness of the potential role of these lists in enhancing patient safety. Such interventions should empower patients and carers to identify a method that suits them best from a range of options and avoid a ‘one size fits all’ approach

Community nursing and antibiotic stewardship: the importance of communication and training

Antimicrobial stewardship (using antimicrobials responsibly) can reduce the risk of antimicrobial resistance (AMR). Many health professionals identify themselves as ‘antibiotic guardians’, but patient expectations, time constraints, and a lack of confidence or underdeveloped communication skills can influence decisions to prescribe. Nurse prescribers have an important role to play in antibiotic stewardship, and their numbers continue to grow. While nurse prescribers welcome this extension to their traditional role, they are often faced with barriers to antibiotic stewardship activities. These barriers may relate to their Capability (knowledge/skill), Opportunity (norms of practice, influence of patients, environmental factors), and Motivation (attitudes and beliefs, concern over outcome, emotion and habit) [COM-B]. Education, training and enablement can help to overcome these barriers, and the development of knowledge, confidence and effective communication skills should be of priority. Further, communication skills can help nurse prescribers understand patient expectations, with the use of open-ended questions, active listening and creation of a patient-centred consultation that leads to a mutually agreed end goal and way forward