A qualitative study exploring how pharmacist and nurse independent prescribers make clinical decisions.

Abstract

The aim of this study was to explore how secondary care pharmacist and nurse independent prescribers clinically reason when making prescribing decisions. Clinical reasoning is a central component of prescribers' competence and professional autonomy when reaching a clinically appropriate decision. Like doctors, pharmacist and nurse independent prescribers in the UK have extensive prescribing rights, but little is known about their clinical reasoning. A qualitative approach using a think-aloud methodology and semi-structured interviews. Eleven nurse and 10 pharmacist independent prescribers were asked to think-aloud about validated clinical vignettes prior to interview, between March - December 2015. Data were analysed using a constant-comparative approach. A strong link between clinical knowledge, grounded in previous experience and clinical reasoning was found. 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 with 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 decision-making model, encompassing case familiarization, generating hypotheses, case assessment, final hypotheses and decision-making stages, which oscillated throughout the model. This is the first study to explore the clinical reasoning processes of secondary care pharmacist and nurse independent prescribers. The resultant decision-making model shows clinical reasoning as a complex and dynamic process. This model can inform the training of independent prescribers to become accurate problem solvers and continue making clinically appropriate decisions.