Christy Noble

Becoming a pharmacist: the role of curriculum in professional identity formation

Objective To understand how the formal curriculum experience of an Australian undergraduate pharmacy program supports students’ professional identity formation. Methods A qualitative ethnographic study was conducted over four weeks using participant observation and examined the ‘typical’ student experience from the perspective of a pharmacist. A one-week period of observation was undertaken with each of the four year groups (that is, for years one to four) comprising the undergraduate curriculum. Data were collected through observation of the formal curriculum experience using field notes, a reflective journal and informal interviews with 38 pharmacy students. Data were analyzed thematically using an a priori analytical framework. Results Our findings showed that the observed curriculum was a conventional curricular experience which focused on the provision of technical knowledge and provided some opportunities for practical engagement. There were some opportunities for students to imagine themselves as pharmacists, for example, when the lecture content related to practice or teaching staff described their approach to practice problems. However, there were limited opportunities for students to observe pharmacist role models, experiment with being a pharmacist or evaluate their professional identities. While curricular learning activities were available for students to develop as pharmacists e.g. patient counseling, there was no contact with patients and pharmacist academic staff tended to role model as educators with little evidence of their pharmacist selves. Conclusions These findings suggest that the current conventional approach to the curriculum design may not be fully enabling learning experiences which support students in successfully negotiating their professional identities. Instead it appeared to reinforce their identities as students with a naïve understanding of professional practice, making their future transition to professional practice challenging.

Learning to prescribe through co-working: junior doctors, pharmacists and consultants

Learning to prescribe is challenging for junior doctors. Significant efforts have been made to improve prescribing education, especially in view of the high rates of prescribing errors made by junior doctors. However, considerations of educational options often overlook the fact that learning to prescribe and prescribing practices rely on practice‐based interactions with informed practitioners, such as pharmacists and consultants. Pharmacists have long made important contributions to developing prescribing capacities.

Developing junior doctors’ prescribing practices through collaborative practice: Sustaining and transforming the practice of communities

ABSTRACT Prescribing in acute healthcare settings is a complex interprofessional process with a high incidence of medication errors. Opportunities exist to improve prescribing learning through collaborative practice. This qualitative interview-based study aimed to investigate the development of junior doctors’ prescribing capacity and how pharmacists contribute interprofessionally to this development and the prescribing practices of a medical community. The setting for this study was a large teaching hospital in Australia where ethical approval was gained before commencing the study. A constructionist approach was adopted and the interviews were held with a purposive sample of 34 participants including junior doctors (n = 11), clinical supervisors (medical; n = 10), and pharmacists (n = 13). Informed by workplace learning theory, interview data were thematically analysed. Three key themes related to pharmacists’ contributions to prescribing practices emerged: building prescribing capacities of junior doctors through guidance and instruction; sustaining safe prescribing practices of the community in response to junior doctor rotations; and transforming prescribing practices of the community through workplace learning facilitation and team integration. These findings emphasize the important contributions made by pharmacists to building junior doctors’ prescribing capacities that also assist in transforming the practices of that community. These findings suggest that rather than developing more conventional education programs for prescribing, further consideration should be given to interprofessional collaboration in everyday activities and interactions as a means to promote both effective learning for individuals and advancing the enactment of effective prescribing practice.

Individuals’ Mediation of Learning Professional Practice: Co-working and Learning to Prescribe

The role of workers’ agency and intentionality in mediating their work-life learning is key basis for understanding how that learning occurs through and across their working lives. This proposition arises, in part, from the realisation that much of individuals’ learning and development across working life required for effective work and employability occurs through workers’ engagement in everyday work activities and interactions, that is, outside of the circumstances of intentional education or training interludes and being taught, instructed or guided by co-workers. It is individuals’ agency and intentionality that mediates learning in these circumstances, as it also does in close interactions with others (i.e. more experienced workers, trainers, teachers). There is nothing particularly new here. Personal mediation has probably been the key means of learning across human history for most workers and across their working lives. Interactions with more informed others are, however, necessary for learning not able to be secured through individual discovery alone. Indeed, there are clear limits to what can be realised solely through this agency and intentionality. The mediation of other workers is often required for learning concepts to be understood, procedural capacities to be developed and when dispositional aspects of work practice require to be made accessible and appropriated. Co-working and learning, however, also requires individuals’ mediation of what they experience interpersonally. Rather than being the unidirectional passage of knowledge from the expert to novice, these processes are bidirectional and interdependent. Understanding how this interdependent means of learning might be supported through everyday co-working activities and interaction offers ways to promote the potency of work settings as learning environments. This chapter sets out how the development of occupational capacities can be supported in, through and across working lives through co-working. These processes are illuminated and discussed through considering how co-working between novice doctors and pharmacists promotes this learning. This illustrative example is used to offer some initial considerations about the kinds of practice curriculum and pedagogies that can support learning through co-working. Conceptual considerations are also advanced to capture and explain this process of learning as being agentic.

Informal learning in the workplace: what are the environmental barriers for junior hospital pharmacists?

Objective To determine the environmental barriers to informal learning in the workplace of junior hospital pharmacists.

Strategies for research engagement of clinicians in allied health (STRETCH): a mixed methods research protocol

Introduction Allied health professionals (AHPs) report positive attitudes to using research evidence in clinical practice, yet often lack time, confidence and skills to use, participate in and conduct research. A range of multifaceted strategies including education, mentoring and guidance have been implemented to increase AHPs’ use of and participation in research. Emerging evidence suggests that knowledge brokering activities have the potential to support research engagement, but it is not clear which knowledge brokering strategies are most effective and in what contexts they work best to support and maintain clinicians’ research engagement. Methods and analysis This protocol describes an exploratory concurrent mixed methods study that is designed to understand how allied health research fellows use knowledge brokering strategies within tailored evidence-based interventions, to facilitate research engagement by allied health clinicians. Simultaneously, a realist approach will guide a systematic process evaluation of the research fellows’ pattern of use of knowledge brokering strategies within each case study to build a programme theory explaining which knowledge brokering strategies work best, in what contexts and why. Learning and behavioural theories will inform this critical explanation. Ethics and dissemination An explanation of how locally tailored evidence-based interventions improve AHPs use of, participation in and leadership of research projects will be summarised and shared with all participating clinicians and within each case study. It is expected that local recommendations will be developed and shared with medical and nursing professionals in and beyond the health service, to facilitate building research capacity in a systematic and effective way.

The service/teaching tension: a window into the soul of a hospital

Editor – Cleland and colleagues are to be applauded for their elegant qualitative study of responses to tensions between service delivery and training in general surgery.1 The study is elegant because the authors’ use of management theory helps to unravel the complexities of the tension. Management theories, such as paradox theory, hold much promise if they are used as lenses through which to explore the cultural barriers that stifle medical education delivery.

Not enough time for research? Use of supported funding to promote allied health research activity

Purpose The current project evaluated the impact of a short-term, supported funding initiative that allowed staff from allied health (AH) professions to undertake research activity within rostered employment time. Specifically, the project will report on outcomes pertaining to individual research capacity, research output, and overall satisfaction with the initiative. Participants and methods Sixteen AH clinicians (n=16) from six AH professions participated in the evaluation of the initiative, with data being collected within a service improvement framework. Clinicians received up to 4 weeks of protected time relieved from their clinical duties to undertake research activities, including writing for publication, undertaking a systematic review, data analysis, and preparation of ethics applications. An AH Research Fellow provided additional support and mentorship, including the development of an implementation plan. Evaluation included pre–post measures of individual research capacity using a 15-item self-report Research Capacity and Culture (RCC) survey, a post-implementation satisfaction survey, and monitoring of research output achieved. Results Statistically significant improvements (p<0.05) were found on 14 out of 15 items on the RCC tool, with meaningful improvements in securing funding, analyzing qualitative data, writing for publication, literature searching skills, and providing advice to less experienced researchers. Overall satisfaction with the initiative was high, with positive comments from AH professionals (AHPs) regarding the initiative. Research output arising from the initiative included eleven manuscripts being submitted, with six currently in publication and others under review. Conclusion The preliminary findings support the feasibility of implementing a local, clinical funding model to promote individual research capacity and research output for AHPs. The short-term funding should be supported by local mentorship and guidance. Local barriers and suggestions to optimize implementation, including integrating within existing research infrastructure and using flexible “backfill” options, will also be described.

Implementing an integrated pathway to care for the dying: is your organisation ready?

BACKGROUND Integrated pathways for care of the dying aim to promote the delivery of high-quality palliative care, regardless of access to specialist services. AIM To produce a heuristic technique to assist with planning and evaluating the integration of the care of the dying pathway into everyday work. METHODS Electronic databases were searched to identify research papers focused on the implementation of integrated pathways for care of the dying in acute hospital settings. RESULTS A total of 13 articles were reviewed using the four elements of normalisation process theory-coherence, cognitive participation, collective action and reflexive monitoring. These results informed the development of a heuristic for organisational readiness. CONCLUSION The organisational readiness heuristic provides an evidence-based checklist for organisational leaders who are planning to introduce new, or evaluate current, integrated pathways for care of the dying. The next step is to trial the heuristic for feasibility in practice.

How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study

BackgroundThere is a pressing need to improve end-of-life care in acute settings. This requires meeting the learning needs of all acute care healthcare professionals to develop broader clinical expertise and bring about positive change. The UK experience with the Liverpool Care of the Dying Pathway (LCP), also demonstrates a greater focus on implementation processes and daily working practices is necessary.MethodsThis qualitative study, informed by Normalisation Process Theory (NPT), investigates how a tool for end-of-life care was embedded in a large Australian teaching hospital. The study identified contextual barriers and facilitators captured in real time, as the ‘Clinical Guidelines for Dying Patients’ (CgDp) were implemented. A purposive sample of 28 acute ward (allied health 7 [including occupational therapist, pharmacists, physiotherapist, psychologist, speech pathologist], nursing 10, medical 8) and palliative care (medical 2, nursing 1) staff participated. Interviews (n = 18) and focus groups (n = 2), were audio-recorded and transcribed verbatim. Data were analysed using an a priori framework of NPT constructs; coherence, cognitive participation, collective action and reflexive monitoring.ResultsThe CgDp afforded staff support, but the reality of the clinical process was invariably perceived as more complex than the guidelines suggested. The CgDp ‘made sense’ to nursing and medical staff, but, because allied health staff were not ward-based, they were not as engaged (coherence). Implementation was challenged by competing concerns in the acute setting where most patients required a different care approach (cognitive participation). The CgDp is designed to start when a patient is dying, yet staff found it difficult to diagnose dying. Staff were concerned that they lacked ready access to experts (collective action) to support this. Participants believed using CgDp improved patient care, but there was an absence of participation in real time monitoring or quality improvement activity.ConclusionsWe propose a model, which addresses the risks and barriers identified, to guide implementation of end-of-life care tools in acute settings. The model promotes interprofessional and interdisciplinary working and learning strategies to develop capabilities for embedding end of life (EOL) care excellence whilst guided by experienced palliative care teams. Further research is needed to determine if this model can be prospectively applied to positively influence EOL practices.