Nurses play a key role in medication review. This study explores nursing students' awareness and understanding of concepts (pharmacology, medication review, polypharmacy, and deprescribing) and gives insight into their preparedness to engage with these in clinical settings. This cross-sectional survey was conducted at a London higher education institution. The sample comprised 127 third-year undergraduate adult and paediatric nursing students. Data were collected using a structured questionnaire, which included free-text items to capture qualitative insights. Quantitative data were analyzed using descriptive statistics, while thematic analysis explored qualitative responses. Respondents were familiar with the terms medication review (94%, 118/125) and polypharmacy (76%, 96/126), but not deprescribing (37%, 46/125). Although respondents could identify triggers for initiating a medication review, their understanding of the collaborative nature of the process for healthcare professionals and patients was inconsistent. Respondents were able to identify medications that may warrant review and potential deprescribing. Core concepts related to medication review were generally understood by respondents. However, understanding of deprescribing, as well as the nurse's role in advocating for patients during medication review, was less consistent.

Despite well-being initially being high on the agenda for UK health organisations, the COVID-19 pandemic has highlighted significant gaps around provision for well-being of pharmacists in the UK. The COVID-19 intensive care unit (ICU) environment exposed pharmacists to mental, physical and emotional challenges, including high levels of patient mortality. Objectives To provide an account of the experience of pharmacists working within an ICU at a large National Health Service hospital who attended reflective practice sessions throughout the first wave of the pandemic. Method A retrospective, cross-sectional design was used to gather information from eight participants who had attended nine, 30-minute weekly reflective practice sessions. Participants were invited to complete a 10-item online self-report questionnaire. The responses from the questionnaire were analysed using theoretical thematic analysis. Results Seven participants completed the self-report questionnaire. Thematic analysis of responses identified four themes: (1) permission: both professional and personal 'permission' was necessary for participants to be present for the reflective practice sessions and to attend to their own well-being; (2) containing safe space: reflective practice sessions offered a consistently secure environment from which to explore topics which created challenge, personally and/or professionally; (3) connectedness: the impact of these sessions on participants' relationships with other attendees, as individuals and the group as a whole; and (4) emotional experience: increased awareness of developments around their expression, processing and management of emotion as a result of attending the sessions. Conclusions This study provides new and important insights into the use of reflective practice for pharmacists working in an ICU during the COVID-19 pandemic. Findings demonstrate heterogeneity in the experience of distress, the need to support the pharmacy profession, and the need to provide opportunities for staff to connect safely with colleagues during such crises. The impact of organisation-led support for the pharmacy profession is discussed as a future direction of research.

There are many factors that can impact the safety and effectiveness of medicines in people with a learning disability. As part of our series on medicines optimisation in people with additional needs, this article discusses the important issues to consider when prescribing for people with a learning disability.

Pharmacists have traditionally supported the prescribing process, arguably in reactive or corrective roles. The advent of pharmacist prescribing in 2004 represented a major shift in practice, leading to greater responsibility for making clinical decisions with and for patients. Prescribing rights require pharmacists to take a more prescriptive role that will allow them to contribute to long-standing prescribing challenges such as poor medication adherence, overprescribing, and the need for shared decision-making and person-centered care. Central to these endeavors are the development and possession of effective consultation skills. University schools of pharmacists in the UK now routinely include consultation skills training, which is also provided by national education bodies. These challenges remain difficult to overcome, even though it is understood, for example, that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments. More recently, a concerted effort has been made to tackle overprescribing and the harm that may occur through the inappropriate use of medication. In routine pharmacy work, these priorities may linger at the bottom of the list due to the busy and complex nature of the work. Solutions to these problems of adherence, optimizing benefits of medication, and overprescribing have typically been pragmatic and structured. However, an arguably reductionist approach to implementation fails to address the complex patient interactions around prescribing and taking medication, and the heterogeneity of the patient's experience, leaving the answers elusive. We suggest that it is essential to explore how person-centered care is perceived and to emphasize the relational aspects of clinical consultations. The development of routine pharmacist prescribing demands building on the core values of person-centered care and shared decision making by introducing the concepts of "relational prescribing" and "open dialogue" to cultivate an essential pharmacotherapeutic alliance to deliver concrete positive patient outcomes. We provide a vignette of how a clinical case can be approached using principles of relational prescribing and open dialogue. We believe these are solutions that are not additional tasks but must be embedded into pharmacy practice. This will improve professional satisfaction and resilience, and encourage curiosity and creativity, particularly with the advent of all pharmacists in Great Britain becoming prescribers at graduation from 2026.

As pharmacists become established in their roles within Primary Care Network (PCN) multidisciplinary teams, it is important that their wellbeing and self‐care needs are supported. Here, the authors describe how the process of ‘restorative clinical supervision’, which they reframe as ‘professional self‐care’, brings pharmacists together to help them manage the complex professional and personal challenges they are now faced with.

Background: As part of tackling polypharmacy, effective medication review and safe deprescribing are key to World Health Organisation's (WHO) 3rd Global Patient Safety Challenge. There is little information about whether this occurs consistently in pharmacy and medicine courses in England. Objective: To create a snapshot of medication review, polypharmacy and deprescribing educational activity in a small number of university courses for medicines, pharmacy and non-medical prescribing. Method: The authors undertook a pilot scoping exercise by emailing colleagues in schools of pharmacy and medicine across England about course inclusion of medication review and deprescribing. 11 universities, describing 17 programmes, responded (eight undergraduate pharmacy, four undergraduate medicine, four postgraduate medicine, one non-medical prescribing course). Data were categorised as: programme content, tools to support deprescribing, learning outcomes, and future intentions for deprescribing teaching. Results: The results suggested variation in what was being taught. Conclusion: In order to address both national and international agenda, the authors suggest that inclusion of training in this area and consistency of curricula are crucial to adequately equipping our future workforce to be fit for purpose.

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.

Research into the practice of medication review is developing across the world in response to the ever-increasing burden of inappropriate polypharmacy. Education, training and support of undergraduates and novice practitioners to equip them to participate in the medication review process could lead to long-term shifts in practice. The purpose of this study was to explore the awareness of pharmacy and medical undergraduates about medication review, deprescribing and polypharmacy, in order to inform improvement strategies. In November 2016, all final-year medical and pharmacy students at a London (UK) university were invited to complete a short questionnaire survey. Qualitative analysis inductively themed free-text comments and quantitative analysis used descriptive statistics to summarize responses, with chi-square tests used to indicate differences between the groups. The overall response rate was 34% (171/500). The terms 'medication review' and 'polypharmacy' were known to the students, whilst the term 'deprescribing' was unfamiliar with no difference between the groups. The term 'medication review' meant different things to the groups: pharmacy students suggested a focus on adherence and patient understanding, whilst medical students focused on interactions and whether medicines were still indicated. The groups differed in their perceptions of who they thought undertook reviews, who identifies potentially inappropriate medicines, who makes the final decision to deprescribe and the frequency of medication reviews. Both groups reported that on qualification they would not be comfortable stopping a medicine without discussion with a senior colleague, but would be comfortable prompting a senior colleague to review. Both groups had some awareness of medication review tools. The meaning of the term 'medication review' differed between the student groups. While medical students focused on clinical aspects, pharmacy students emphasized patient experience. Both groups anticipated a lack of confidence in deprescribing without senior support, highlighting the need for alignment between education and professional development syllabi in a way that combines the variety of professional perspectives. Prompts by juniors could lead to more medication reviews within existing practice, and may give them invaluable experience in reviewing medicines in their future careers as seniors.

Medication safety is a hot topic around the world but tends to focus on what professionals believe about prescribing, supply and safe administration of medicines.1 Historically, less attention has been paid to the patient or carer’s perspective, including how they take or give medicines at home. One key question that we ought to consider routinely is this: what does the patient or carer do with a medicine once they are away from the gaze of the healthcare professional? Emerging patient medication safety data from the home setting is raising concerns. For instance, in some studies it was estimated that 9 out of every 10 parents, carers or family members have administered a medicine incorrectly at some point.2 Such errors included dosage mistakes, wrong medication and wrong route of administration. We acknowledge that what health professionals deem to be ‘incorrect’ may be deliberate and reasoned by carers or patients, and this issue is beyond the scope of this article. However, legitimate concern about mistakes in using medicines is matched by an inertia within the healthcare system to identify and address such problems. More research is needed into medication administration errors in patients’ homes. Healthcare professionals may be more concerned about the administration of complex or high-risk medicines, such as oral anticancer agents, anticoagulants, insulins or biologics, and of course, it is critical that patients use these safely. However, our view is that we have neglected to check as part of our routine practice that administration of medicines is correct for lower risk or more commonly used tablets, capsules and …

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.

Background and importance Studies suggest that in the hospital setting, prescribing errors are most common at admission, largely due to challenges of medication reconciliation. Problems are also common following transfer from hospital into the community and when attending outpatient appointments. Many patients who take medications use patient held information about medication (PHIMed) to improve transfer of medication related information across care settings. However, it is not known how PHIMed is used in practice and the extent to which PHIMed tools available meet the needs of patients and healthcare professionals. Discussion with patients and carers highlighted this as a priority for research. Aim and objectives To identify how PHIMed is used in practice, barriers and facilitators to its use, and its role in supporting medication safety. Material and methods We used a mixed methods design comprising two focus groups with patients and carers, 16 semi-structured interviews with healthcare professionals, 60 semi-structured interviews with PHIMed users, a quantitative features analysis of PHIMed solutions available in the UK and usability testing of four PHIMed tools. Participants were identified and recruited in Greater London in 2018, using advertisements on social media, our professional networks and face to face recruitment in outpatient clinics. Findings were triangulated using thematic analysis using distributed cognition for teamwork (DiCoT) models as sensitising concepts. NHS ethics approval was obtained. Results We found that PHIMed was viewed positively by patients and carers using it and healthcare professionals. We identified a wide range of mechanisms through PHIMed improved medication safety, such as identification of potential drug interactions. However, a key barrier to use was lack of awareness by patients and carers that healthcare information systems are often fragmented, which meant that they had not identified a need for PHIMed. Different PHIMed tools met different needs, with no ‘one size fits all’ solution. No tools currently meet the core needs of all users. Conclusion and relevance Healthcare professionals should raise awareness among patients and carers of the potential safety benefits of carrying and using PHIMed, encourage its use during consultations and be able to signpost to some of the tools and features available. PHIMed tool developers should modify their tools in order to meet all core user requirements. References and/or acknowledgements No conflict of interest.

Introduction: Objective structured clinical examinations (OSCEs) are widely used as a competency-based assessment of clinical skills within M.Pharm. programmes of many United Kingdom (UK) pharmacy schools. Aim: To evaluate the clinical performance of final year M.Pharm. students and elicit their views and experiences of the OSCE assessment. Methods: Students were divided into 11 groups and completed an OSCE exam, comprising 11 stations of seven minutes in length, following a four-day placement in clinical practice. Students were asked to complete an acceptability questionnaire, and their OSCE performance was correlated with their final degree classification and their Oriel rank position. Results: Overall, the OSCE assessment is acceptable from the students’ perspective. Differences were found between the students’ performances at the individual OSCE stations. Students performed best on patient consultation stations and least on clinical-problem solving stations. There was no correlation between students OSCE marks and their Oriel rank position. There was however a strong correlation between the students OSCE mark and their final degree classification (r=0.528, n=119, p=0.000). Conclusion: Final year pharmacy undergraduates perform poorly in activities which demand an element of clinical problem identification. Further research is required on how clinical problem solving skills can be developed amongst undergraduates and the specific role placements have in achieving this.

AimTo establish the views of adolescent patients with learning disabilities and their carers, of the patient-held medication passport (My Medication Passport-MMP). MethodsA questionnaire was devised to find out if patients/carers thought a patient-held record of their medications (the MMP) was useful and to suggest improvements as appropriate. The MMP is a patient-held record of medicines use available as a passport sized booklet.1 MMPs were distributed to patients and carers for them to read and review at a patient focus group. Ethics approval was not required for this study.Results20 questionnaires were sent and a total of 17 completed questionnaires were returned (85% response rate). 70% (n=12) of the questionnaires were completed by carers, 24% (n=4) by family members and 1% (n=1) by a patient. 100% (n=17) of carers/patients who reviewed the MMP found it useful. When asked about features they liked about MMP; Seven carers noted the MMP was easy to use; four carers felt MMP was a good way to keep (personal) medicines information up to date; with three further clarifying that it could be used as a ‘concise way of keep track (of medicines)’ and two specified they liked that ‘all the information is in one book’. When Patients/carers were asked for ways MMP could be improved; two carers asked for more space to document past medication, including an area to ‘keep track of the behaviours and how it is exhibited because of the medication’; one carer noted that ‘some youngsters would benefit from more visual learning’ and one asked for a version to be made available via app on smart phone. Limitations included a small sample with limited exposure to MMP. The patient group sampled may not be representative.ConclusionPassports as tools aim to help patients better manage their medicines and have been successfully used in a patient with learning disability.2 It is encouraging to see that this small group of patients with learning disability find the MMP useful. Suggested adaptations to MMP for this patient group included it being more visual, and having areas for past medication. Other trials of MMP have suggested that it may require a section surrounding medicines administration. Patients have since been directed to the MMP app which can be downloaded onto a smartphone. There are many opportunities for future work including conducting an evaluation of the MMP in use over time and across different sectors, and to determine what patients actually record in the MMP.ReferencesBarber S, et al. Evaluation of My Medication Passport: a patient-completed aide-memoire designed by patients, for patients, to help towards medicines optimisation. BMJ Open4(8). https://bmjopen.bmj.com/content/4/8/e005608Jubraj B. Use of a medication passport in a disabled child seen across many care settings. BMJ Case Reports. 25 February 2015; http://casereports.bmj.com/content/2015/bcr-2014-208033Save

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults’ medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily “hold” medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.

Hospital pharmacists encounter polypharmacy increasingly frequently during a patient's journey from admission to discharge. Many older adults take several medicines regularly for long-term conditions or disease prevention and, because the prescribing of medicines is the most common healthcare intervention in acute settings, a patient's medication list will almost invariably be added to during a hospital episode. National guidelines have been written for the management of single-disease states (National Institute for Health and Care Excellence, 2016), although the increase in co-morbidities with increasing age (Guthrie, Makubate, Hernandez-Santiago, & Dreischulte, 2015) provides the potential for polypharmacy to occur even when best practices are followed. This is compounded when separate clinicians prescribe for each co-morbidity, the patient attends different pharmacies for dispensed items, or the patient also purchases over-the-counter or -Internet medicines. Therapies are not necessarily tested in older people, but nevertheless they should not be denied on the basis of age if the patient might benefit (Drugs and Therapeutics Bulletin, 2016). One leading physician describes prescribing for older people as an art, as it depends on knowing what is appropriate for an individual, particularly in the context of multimorbidity (O'Mahony, 2016), which refers to the presence of two or more long-term health conditions (National Institute for Health and Care Excellence , 2016).

We are delighted to present this themed issue on ‘deprescribing’, a subject that has gained increasing importance in prescribing practice across the world over the last decade. For example, at a recent European General Practitioner conference that attracted over 3000 participants, four symposia were devoted to medication appropriateness, polypharmacy and deprescribing. The appetite for safe deprescribing was clear, but clinicians (we consider pharmacists to be clinicians) voiced concerns including a lack of robust guidance, patient attitudes, and a fear of medicolegal consequences from deprescribing. Our themed issue provides an introduction to the deprescribing debate, with articles ranging from reviews by international experts on the current problems surrounding deprescribing, to a description of practical tools to support the process. We have also attempted to broaden the deprescribing debate by including articles on the patient view of deprescribing, a legal perspective, and the role of nurses working with patients, pharmacists and doctors to make deprescribing decisions collaboratively. Our themed issue also considers deprescribing in special populations such as older people with falls, patients in care homes, and, more briefly, in paediatrics and people with learning disabilities. In short, we hope to provide the reader with an accessible, practical overview of the emerging area of deprescribing. In the first of our review articles, Polly Duncan and colleagues outline key steps in the deprescribing process ( see page 37 ) and identify that while the harms of inappropriate polypharmacy are established, there is a paucity of evidence around the benefit of deprescribing in general practice settings. Focusing on the UK perspective, the authors suggest that doctors in general practice … Correspondence to Barry Jubraj, Institute of Pharmaceutical Sciences, King's College London, 150 Stamford Street, London SE1 9NH, UK; barry.jubraj{at}kcl.ac.uk

Background: The Acute Care Assessment Tool (ACAT) was developed as a workplace-based assessment (WPBA) for trainee performance whilst working in acute medicine. Here, we discuss the multi-professional potential of ACAT through a pilot with foundation and senior hospital pharmacists.Context: The pharmacy profession is engaging meaningfully with foundation training for pharmacists akin to doctor foundation training, and has launched a post-foundation recognition scheme as a route to advanced generalist or specialist practice. Foundation training has included the adoption of familiar WPBA, such as the mini-clinical evaluation exercise (mini-CEX) and case-based discussion (CbD). However, mini-CEX and CbD are snapshot' assessments, and we identified a need for the assessment of practice over a short period of time. A local director of medical education suggested ACAT.Innovationl: Permission was gained from the Joint Royal Colleges of Physicians to adapt the ACAT to form the Pharmacy ACAT'. Adaptations were based on the two current Royal Pharmaceutical Society competency frameworks used for foundation and post-foundation practice. The Pharmacy ACAT' was piloted across three acute hospitals (known as Trusts') in London for foundation trainees, and was found to be broadly acceptable in terms of time and was valued for feedback, particularly for foundation pharmacy trainees. Senior pharmacists at the single pilot site were more sceptical.Implications: We believe that the Pharmacy ACAT' should be considered for routine use in pharmacy foundation training in hospital and community practice as it plugs a gap' in the current scheme of WPBA, by allowing the assessment of a short period of practice as opposed to a snapshot. It also has potential for use at undergraduate level.

In the editorial of this deprescribing themed issue, we began by recognising that deprescribing is not easy. For many clinicians, the decision to deprescribe is hampered by the lack of evidence for safe methods of deprescribing. We identified the need for education to support clinicians in their deprescribing endeavours. Here, we describe our strategy to educate around deprescribing, which emerged from the medicines optimisation work stream at the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Northwest London (CLAHRC NWL). CLAHRC NWL is a research and implementation programme1 ,2 that uses the model for improvement3 as a central component of quality improvement (QI) initiatives. We contend that education about deprescribing should adopt both a ‘top down’ to include senior clinicians, and ‘bottom up’ to include junior staff and students. This is supported by a patient safety initiative that was found to be best facilitated by such a combination approach to change.4 We will focus on the latter (hereafter bottom-up approach): educating junior and undergraduate clinicians, so that they enter the workplace with the confidence and skill to at least consider the need for deprescribing both at the point of initial prescribing and when undertaking medication review. We are conscious that the term bottom-up approach can have a number of meanings, here we use it to refer to the capacity to lead to grass-roots changes that will grow and pervade practice, rather than ‘command and control’ regulations on actions. The theory and practice of education are, at this level, andragogy (the education of adults), thus the principles of adult learning should be used;5 yet the evaluation techniques used for child education may prove useful for long-term assessments of change, for instance, those studies seeking to address differentials in earnings. …