A qualitative study exploring the clinical reasoning processes of pharmacist and nurse independent prescribers in the United Kingdom

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A qualitative study exploring the clinical reasoning processes of pharmacist and nurse independent prescribers in the United Kingdom

Clinical reasoning is a central component of prescribers’ competence when reaching a clinically appropriate decision. Like doctors, pharmacist and nurse independent prescribers in the United Kingdom have extensive prescribing rights, but little is known about their clinical reasoning. This study explores the process and influences of clinical reasoning by secondary care pharmacist and nurse independent prescribers in the United Kingdom. A constructivist approach using think-aloud methodology immediately followed by semi-structured interviews was conducted with 11 nurse and 10 pharmacist independent prescribers working in secondary care between March and December 2015. Each participant was presented with validated clinical vignettes for the think-aloud stage, based on clinical therapeutic areas they chose. Data were analysed using a constant-comparative approach. Clinical knowledge and experience heavily influenced the process of clinical reasoning. Despite prescribers approaching the clinical vignettes holistically, their focus varied according to professional background and job role. Nurses were more likely to describe interacting with patients, compared to pharmacists who were more focused on medical notes and laboratory results. Think-aloud protocol analysis revealed a distinct pattern in the process undertaken to reach a clinical decision. This is presented as a prescribing model, encompassing case familiarisation, generating hypotheses, case assessment, final hypotheses and decision-making stages. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic and contextual factors. For example, prescribers were aware of treatment pathways but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour revealed that experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. The resultant prescribing model shows clinical reasoning as a complex and dynamic process. Findings from this study could inform the training of independent prescribers to improve their professional development, clinical reasoning skills and subsequently improve patient care.

Presenter:

Aseel Abuzour