Evaluation Report to MPC 090617 - HEIW Pharmacy · graduate preparedness for the pre-registration...

Evaluatinganintegratedpre-registrationtrainingprogrammeinNorthWales:perceptionsofpre-registrationpharmacistsandtheirtutors

ReporttoMPCprogrammeboard-July2017

ExecutiveSummary

BackgroundSixpre-registrationpharmacists(pre-reg)arecurrentlyexperiencingtrainingthroughanintegratedprogrammeinBetsiCadwaladerUniversityHealthBoard(BCUHB)wherebytheyareexposedtohospital,communityandprimarycarepharmacyenvironments.ThisprogrammeisthefirstofitskindinWales.MethodsFollowingethicscommitteeapprovalsemi-structuredonetooneinterviewsandfocusgroupswereundertakenwitharangeofstakeholdersinordertoevaluatetheprogramme.Abroadtopicguidewithpromptsandprobeswasdevelopedandincludedsectionsexploringparticipantdemographicdetails,experiencesofpre-registrationtraining/supervisingpre-registrationtrainingandopinionstowardsrespectivepre-registrationtrainingprogrammes.Interviewswereconductedatthesixmonthandtenmonthtimepoints,thesewereaudiorecorded,transcribedverbatimandthematicallyanalysed.ResultsTwentytwoparticipantswereinterviewed(sixintegratedpre-reg,fivetutors,sixhospitalpre-regandfivecommunitypre-reg)atthesixmonthtimepoint.Allbutthreeparticipantswerefollowedupattenmonths.Fourthemeswereidentified,namely1)programmevaluetointegratedpre-reg2)programmevaluetootherstakeholders(includinghospitalandcommunitypharmaciesaswellaspatientsthemselves)3)valueofcross-sectorexperiencetohospitalandcommunitypre-reg4)suggestionsforchange.Intervieweesexpressedoverwhelminglypositiveviewstowardstheintegratedprogramme.Itsperceivedbenefitsincludeproducing“rounded”pharmacistswithanabilitytoworkinmorethanonesectoruponregistration,aswellasimprovingpre-regconfidenceincommunicatingandallowingpre-regtotakeownershipfortheirtrainingyear.ConclusionThisstudyprovidesaninsightintotheperceptionsofintegratedpre-regandtheirtutorstowardsthepilotprogrammeaswellascomparisonswithothersonatraditionalhospitalorcommunitypharmacyonlyprogramme.Participantswereabletoreflectupontheknowledge,skills,attitudesandvaluesdevelopedaspartoftheintegratedprogrammeandsuggestwaysinwhichtheprogrammemaybeimprovedforfuturetrainees.Thosereviewingorconsideringimplementinganintegratedpre-registrationprogrammemaywishtopaycarefulconsiderationtothestructureofthetimetable,stakeholderexpectationsofintegratedpre-reg,theimportanceofcommunicationbetweenstakeholders(hospitalandcommunitypharmacytutorsandtutorswithtrainees)andthegeographicallocationoftrainingsitesinvolved.

FullReportResearcherThisstudywasconductedbyWCPPEeducationprojectmanagerandPhDcandidate,BethanBroad.Theresearcherwasnewtothejobpositionandowingtotheinductivenatureoftheresearchhadnosignificantpriorknowledgeoftheintegratedpre-registrationprogramme.Theresearcherdidhoweverhaveexperienceofqualitativeinterviewinginaseparatestudyexploringpharmacygraduatepreparednessforthepre-registrationyear.

BackgroundSinceAugust2016sixpre-registrationpharmacists(pre-reg)inBetsiCadwaladerUniversityHealthBoard(BCUHB)haveexperiencedpre-registrationtrainingthroughamulti-sectorprogrammewherebytheyspendtimeinhospital,communityandprimarycarepharmacyenvironments.Forthepurposeofthisreporttheschemehasbeenreferredtoastheintegratedpre-registrationprogramme,inlinewithwhattheschemeisreferredtolocally.Inordertoevaluatetheeffectivenessofthisnewprogrammeinpreparingtraineesfordayonepharmacypracticetheresearcherwascommissionedtoconductaqualitativeserviceevaluation.Thestudyincludedtheviewsofintegratedpre-regthemselvesaswellastheperceptionsoftheirtutors.Pre-regcompletingahospitalonlyorcommunityonlytrainingprogrammewerealsoincludedasameansofcomparison.

AimsThisstudyaimedtoexploretheopinionsofintegratedpre-regtutorsandpre-regfromarangeofsectors(hospital,communityandintegratedprogrammetrainees)towardspreparednessfordayonepharmacypracticeaswellastheirperceptionstowardstheirrespectivetrainingprogrammes.

MethodsQualitativemethodswereemployedforthisstudyowingtotheexploratorynatureoftheresearch.Stakeholderviewsweregatheredviasemi-structuredonetooneinterviewsorfocusgroupsbythesameresearcher.Opinionswereexploredattwotimepoints,firstlyatapproximatelysixmonthsintotheprogramme,thenagainapproximatelyfourmonthslater.Repeatinterviewingallowedtheresearchertoexplorewhetheropinionschangeaspre-regprogressthroughthetrainingyear,gainmoreexperienceandvariedresponsibilities.Topicguideswithpredeterminedtopicsandquestionsweredrafted,howevertheorderandexactwordingofthesequestionswerenotcraftedpriortointerviews.Topicguidesfirstlyexploredparticipantfactors(forpre-regthisincludedtheirgraduatingSchoolofPharmacy,priorworkexperiences,andwhethertheirprogrammewastheirfirstchoiceofpre-reg.Forsupervisingtutorsthisincludedtheirsectorofpractice,timespentintheircurrentroleand

experiencewithsupervisingpre-reg).Thesecondtopicguidesectionexploredthetaskspre-regwerecurrentlyworkingon,howtheywerefindingtheseandhowpreparedtheyfelt/wereperceivedtobefordayoneofpracticeuponregistration(includingcomparisonswithotherpre-reg).Finallyparticipantswereaskedtoreflectontheirrespectivepre-registrationprogrammesandsuggestwhatworkswell,whatcouldbeimprovedandhowthismaybeimproved.ThestudywasapprovedbyCardiffSchoolofPharmacyResearchEthicsCommitteeandBCUHB.Potentialinterviewees(n=36;allintegratedpre-regandtheirtutorsinBCUHB;allhospitalpre-reginBCUHBandaconvenience/purposivesampleofcommunitypre-regfromSouthWales)wereinvitedbye-mailandgiventwoweeksinwhichtorespondbeforearemindere-mailwassent.Respondents(n=22)wereprovidedwithaninformationsheetandconsentformbeforeinformedwrittenconsenttotakepartinthestudywasobtained.Interviewswereaudiorecorded,transcribedverbatim,anonymisedandthematicallyanalysed(BraunandClarke,2006).InterviewswereconductedfacetofaceinavarietyoflocationsincludingatrainingroomwithinCardiffUniversityandanoff-sitetrainingfacility.Wheretheselocationswerenotconvenientfortheparticipantinterviewswereconductedoverthetelephone.Analysis

BraunandClarke’sthematicanalysiswascarriedoutbyfirstlyreadingandre-readingthetranscriptstoachievefamiliaritywiththedata.Codeswerethenassignedsentencebysentencewherethedatarepresentedsomethingsignificantinrelationtotheresearchquestion.Repeatedpatternsofmeaningwereidentifiedandcodessortedintooverarchingthemesandsubthemes.Themesandcodeswerethencheckedforconsistencytoensuretheyaccuratelyrepresentedthedata.ResultsAtthesixmonthtimepointinterviewswereconductedwithfiveintegratedpre-regtutors,fivecommunitypre-reg,sixhospitalpre-regandsixintegratedpre-reg.Atthetenmonthtimepointfollowupinterviewswereconductedwithallbutonetutorandtwohospitalpre-reg,whowerelosttofollow-up.

Table1DepictionofintervieweesincludedinthestudysampleandmechanismofdatagenerationInterviewsatsixmonthtimepointParticipant Methodofdata

generationNumberofparticipants

Meaninterviewduration(minutes)

Integratedpre-registrationpharmacists

Facetofacefocusgroup

5 60

Telephoneonetooneinterview

1 28

Hospitalpre-registrationpharmacists

Facetofacefocusgroup

6 27

Communitypre-registrationpharmacists

FacetofaceInterviews

3 43

Telephoneonetooneinterviews

2 15

Integratedpre-registrationtutors

Telephoneonetooneinterviews

5 20

InterviewsattenmonthtimepointParticipant Methodofdata

generationNumberofparticipants

Meaninterviewduration(minutes)

Integratedpre-registrationpharmacists

Facetofacefocusgroup

6 42

Hospitalpre-registrationpharmacists

Facetofacefocusgroup

4 27

Communitypre-registrationpharmacists

FacetofaceFocusgroup

4 32

Facetofaceonetooneinterview

1 21

Integratedpre-registrationtutors

Telephoneonetooneinterviews

4 19

Analysisofthedataidentifiedfourthemes,namely1)programmevaluetointegratedpre-registrationpharmacists2)programmevaluetootherstakeholders3)valueofcross-sectorexperiencetohospitalandcommunitypre-registrationpharmacists4)suggestionsforchange.

Table2:Themesandsubthemesidentifiedfromthedata

Theme 1)Programmevalue

tointegratedpre-registrationpharmacists

2)Programmevaluetootherstakeholders

3)Valueofcross-sectorexperiencetohospitalandcommunitypre-registrationpharmacists

4)Suggestionsforchange

Subthemes Pre-registrationpharmacistknowledgePre-registrationpharmacistskillsPre-registrationpharmacistattitudesandvaluesPreparednesstopracticeinmultiplesectorsA“wellrounded”pharmacist

CommunitypharmacyHospitalpharmacyPatientsCross-sectorworking

AnunderstandingofpracticewithinsectorsOpportunitiesforexperiencesnotencounteredinpredominantsectorSuggestedchangestocross-sectorexperiencesPositiveattitudestowardsintegratedpre-registrationprogramme

ImprovetimetablestructureImprovestakeholdercommunicationManagementofstakeholderexpectationsEnhanceprimarycareexperienceAddressgeographicalchallenges

Theme1:Programmevaluetointegratedpre-registrationpharmacistsParticipantswereoverwhelminglypositiveintheiropinionstowardstheintegratedpre-registrationprogramme.Integratedpre-regthemselvesstatedthatitwasn’teveryone’sfirstchoicewhenapplyingforpre-regplaceshoweveruponfollowupattenmonthstherewasconsensusthattheywouldallchoosetodotheprogrammeagainasfirstchoice.Pre-registrationpharmacistknowledgeInterviewsrevealedthatbothtutorsandintegratedpre-regthemselvesperceivedpre-regknowledgetobeimprovingastheprogrammeprogressed.InparticulartheyweresaidtohaveasuperiorknowledgeofOverTheCounter(OTC)productsandfinanceincomparisonwiththeirhospitalpre-regpeers.

Integratedpre-reg5:“…thehospitalcolleaguesIfindoftenifIhaveadiscussionwiththemtheyarestrugglingwiththeirOTCknowledge…” Pre-regtutor3:“…theyknowabitmoreaboutfinance…understandingthegenericsandbrandsandwhattheycanandcan’tdo” However,integratedpre-regweresaidtopotentiallylackclinicalknowledgeincomparisonwithhospitalpre-regpharmacistpeers,owingtorelativelylesstimespentonthewards.Boththeintegratedpre-regthemselvesandtheirtutorsexpressedconfidencethatclinicalknowledgewouldimproveinthefinalmonthsoftheprogrammewhengreatertimeisspentinthewardenvironment.Spendingtimewithpositiverolemodelsinprimarycareinthelatterpartoftheprogragmmewasdeemedaneffectivewayofdevelopingclinicalknowledge. Pre-regtutor5:“…whenthey’vefinishedtheirprocesseswhichtheynowallhavedonetheycanjustspendtheirtimeonthewardssoIthinkatthispointthisiswhentheyaregoingtogaintheirclinicalknowledgewhereasmaybethetraditionalonesareslightlyahead.They’vehadtheotherdaysoftheweekwheretheygainit.” Pre-regtutor5:“…shehassomegreatrolemodelssorecentlywehaveseenherclinicalknowledgeincreasebecausetheyarereallyspendingsomegoodqualitytimewithherinprimarycare…”Pre-registrationpharmacistskillsIntegratedpre-regwerepraisedforthetransferrableskillstheyweredevelopingattributedtotheprogrammenamelysignpostinganddecisionmaking. Pre-regtutor2:“…itmakesthemmuchmoreintelligentaboutthedecisions…maybetheywillhavebettersignpostingskills,betterresources,tomakebetterclinicaldecisions”

Pre-regtutor4:“…Ithinkthere’ssometransferrableskillsthatshehasgainedfromthere[community]inherworkethicandmaybeherumdispensing…”Whileallpre-reginterviewedexpressedconfidenceincommunicationskillstutorsnotedthatintegratedpre-regcommunicationwithpatientsappearedsuperiorowingtotheirexperienceincommunitypharmacy.Indeed,communitypre-regthemselvesattributedtheircommunicationskillstotheconstantpatientexposureencounteredinthecommunitypharmacyenvironment. Pre-regtutor5:“Ithinkthebenefitofdoingthathasstoodoutinacommunicationway,theyarelessafraidcertainlywhatIsee,togetinvolvedinthings.Um,there’stwo[Anonymoushospitalpre-reg]arealittlemorestandoffish.[Anonymousintegratedpre-reg]whentheycomeintohospitaltheywanttogetinvolvedinthings.Ithinkthat’sbecausetheyareusedtogettinginvolvedincommunity.Thereisnohiding…theirgetupandgoattitudeisadefinitepositive…the[Anonymoushospitalpre-reg]arealittlemorehesitantinpickingupthephoneandinpickingupthepatientsatthehatch…” BB:“…howdoyoufindpatientcontactandyourpreparednessforthatelement… Communitypre-reg5:absolutelyfine,Ispeaktopatientsmostofmyday.ThepharmacistnormallysendsmeoutandthenifIcan’tanswerthequeryhe’llanswerit”Obtainingexposuretocommunitypracticewasalsosaidtoplayaroleinintegratedpre-regachievingcompetenciesandhavingthesesignedoffquickerthanhospitalpre-reg. Pre-regtutor5:“…shehasbeengettingalotofcompetenciessooner.Youknowcommunitysectorthingsthatyoujustfindincommunity,thedocumentationwithprivateprescriptions…overthecounterthingsshecanpickupveryquicklyaswell.”Integratedpre-regthemselvesreportedfeelingpreparedforproblemsolving.Acommunitypre-regalsocommentedthattheyperceivedanunderstandingofsectorsenhancestheabilitytofindsolutionstoproblems. Integratedpre-reg4:“Ithinkintermsofproblemsolvingyouaremorepreparedifanythingisthrownatyoubecauseyou’vebeeninthedifferentsectors”Theintegratedprogrammewasnotedasbeingparticularlybeneficialtopre-reginallowingthemtodevelopbothknowledgeandskillsinanumberofsectorssimultaneously. Integratedpre-reg5:“Icandevelopmyskillssidebyside:theOTCandtheclinicalatthesametime.Ithinkit’squitenicetohaveabreakfromonetodotheotheraswell,itkeepseverythingfresh.”

Pre-registrationpharmacistattitudesandvaluesConfidencewasanattributerepeatedlymentionedwhendiscussingtheintegratedprogramme.Inparticulartutorsnotedintegratedpre-regconfidenceineachsectortobeincreasingsuchthatthey’llhavegreaterconfidenceondayoneofpracticeincomparisonwiththeirpeers.Integratedpre-regthemselvesattributedthisconfidencetohavingexposureofallsectors,being“thrownin”andreceivinggreaterresponsibilityinprimarycare. Integratedpre-reg2:“Ifeellikealotmorebecauseyouarethrowninthere…youcangotoeachsiteandstayquietlyoryoucanbeconfident,interactandyou’llgainthemostoutofit” Incontrastcommunitypre-regdidnotalwaysexpressthesamelevelofconfidenceforday1ofpractice. Communitypre-reg2:“Ithinki’llbenervouslikedoublecheckingthings…youknowwhenyouworryabouteverythingbecauseit’syourfirstdayandsuddenlyyouaregoingfromhavingallthatbackup…”Tutorscommentedontheirperceptionsofintegratedpre-regworkethicandtheirproactivenature.Incomparisonhospitalpre-regweresaidtobelesslikelytogetinvolvedintasks.Bothtutorsandintegratedtraineesalikeacknowledgedhowtheprogrammehadallowedthemtobecomemoremature,requirelessspoon-feedingandtoleave“studentmode”.Integratedpre-regappearedtohavedevelopedasenseofindependence,anabilitytoself-directtheirlearningandtakegreaterownershipfortheirpre-registrationyear. Pre-regtutor3:“…theintegratedhavegotmoreownershipoftheirpre-registrationyear.Theyseemtodoalotmorebackgroundreadingandthey’renotspoonfedasmuchasthehospitalonesandIdon’tthinktheywanttobespoonfedeither…thereisadifferencewheretheyareinawayabitmoremature.” Integratedpre-reg1:“Ithastaughtustostandonourowntwofeetandbeorganisedandproactiveandyoucan’tjusttakeabackseatandexpecteverythingtojusthappenforyoubecauseit’snotgoingtohappen”PreparednesstopracticeinmultiplesectorsPerceivedpreparednessforday1practicevariedbetweenparticipantsatthehalfwaystageyettherewasconsensusthatbytheendoftheirtrainingprogrammespre-regfelttheywouldbereadytopracticeintheirrespectivesectors.However,integratedpre-regwereuniqueinexpressingconfidencetopracticeinmorethanonesectoruponregistration. IntegratedPre-reg1:“…ItgivesyoumoreconfidencetosayIcangointoanysectorandI’dbecomfortable…havingworkedinbothIdon’tfeelthere’dbeaproblemgoingintoeither”

Hospitalpre-reg6:“…onday1Icouldn’twalkintoacommunitypharmacyanddotheirjobbutviceversaIdon’tthinktheycouldwalkintoahospitalonday1anddoourjob” Pre-regtutor5:“…she[integratedpre-reg]couldgointoeithersectorattheendofthepre-regyearreallyandIthinkshewouldbe,she’dfitintoeachsectorreally”Communitypre-regheldreservationsabouttheirabilitytotransfertohospitalpractice.Itwasperceivedthatitwouldbeeasiertomovefromahospitalpre-regtocommunitypracticethanviceversa.Inparticularcommunitypre-regweresaidtobeanxiousaboutinterpretingbloodresultsandspeakingwithwarddoctors.Similarlyhospitalpre-regnotedalackofOTCknowledgeandabilitytoprovidecommunitypharmacyservicesincomparisonwiththeircommunitypharmacypeers. Communitypre-reg1:“…ifIhadtogointohospitalpharmacynowIwouldbeterrified…Iwouldprobablyfinditmoredifficulttoaddressconsultantsandjuniordoctors.Um,interpretingumLFT’sandU&E’sandgivingmyprofessionaljudgment.” Hospitalpre-reg2:“…thegeneraloverthecounterandthatkindofstuff,myknowledgeislackingthere.Paracetamoldosinginchildren,Idon’tknow.”Itwasalsodeemedpositivethatintegratedpre-reghavingexperienceindifferentsectorswouldallowaninformedcareerchoicetobemade. Integratedpre-reg4:“…itsmademerealisewhereexactlyIwanttoendup,afteruniyouthinkohmygodhospital,hospital,community,communitybutthisthingthenmakesyoureallythinkaboutwhereyouwanttoendupbecauseyouseeeverything.”A“wellrounded”pharmacistTheterm“wellrounded”wasusedonmultipleoccasionsbytutorsthroughoutinterviewingtodescribeintegratedpre-regandtheintegratedpre-regexperienceitself. Pre-regtutor2:“I’mquitejealousIdidn’tgettheopportunitytodoit.BecauseIthinktheyarehavingaverybroadroundedexperience.WhateverpaththeywanttotakeatleasttheycansaytheyknowwhatgoesonintheotherandthatisgoodforthewholepharmacyprofessionIthink”Itissaidthattheabilitytoseethingsfromarangeofperspectivesandhavingcontactwithhealthcareprofessionalstoseehowthingsfittogethergivesaholisticapproach. Integratedpre-reg5:“itdefinitelybroadensyourmindsetforwhoisactuallyworkingintheentireteamthatcaresafterpatientsthatyousee.Yousee

nurses,youseedistrictnurses,youseeGPs,thereceptionstaff…youseepeoplelikedeliverydriversandthingsyougettoseehowallofitfitstogetherandlikehowthathelpsthentowardspatientcare.”Theabilityoftheintegratedpre-regtoseepatientsinarangeofsectorswasalsosaidtogiveanappreciationofthewholepatientjourneyandlinksbetweensectors.Ultimatelyatutorstatedthatthiswillmakeintegratedpre-regbetterpharmacists. Pre-regtutor2:“…theyhaveinsightintothewholeprofessionandthatcanopenavenuesthen,theymightspecialiseinhospitalinthefutureorincommunitybutthey’llhavethatnetworkofcontacttoknowwheretoapproachforthatextrainformation.They’llbeummuchimprovedpharmacistsIthink”Theme2:ProgrammevaluetootherstakeholdersCommunitypharmacyCommunitypre-regtutorsstatedhowtheintegratedprogrammehadgiventhemandtheirstaffagreaterinsightintoothersectors. Pre-regtutor1:“Ithinkithasgivenusallaninsightintotheotherside…

BB:Whenyousayithasgivenyouallaninsight,whospecificallydoyoumean?

Pre-regtutor1:Myselfandthedispensaryteam”Issuespickedupbyintegratedpre-reginprimarycarepracticehavealsobeenrelayedintothecommunitybyintegratedpre-regthemselves. Integratedpre-reg4:“…wehadaprimarycaredayandthetechniciangaveusanMIenquiry…apatientbroughtit[decapeptylinjection]insayingtheexpirydatesweredifferent…Ihadmycommunitydaythenextday…andIcameacrossthesamesortofprescriptions,IrememberedfromthepreviousdayIthoughohI’veseenthisbefore…IphonedthecompanytoverifyandtheysaidyesitsgotdifferentexpirydatessoIwasthenabletoinformthepharmacyteamincaseapatientcameandraisedthesameissueandthenIinformedprimarycarethatwastheissue”Integratedpre-regwerealsoparticularlykeentoprovidedetaileddischargesummariestopatientsleavinghospital,astheyhadgainedanappreciationoftheirusefulnesstocommunitypractice. Integratedpre-reg2:“…wedohavelittleenvelopesthatyou’remeanttoputintheirbagstogivebutnobodygivesittothemsolikenowjustbecauseI’mdoingthis…ifIhaveaTTO(takehomeprescription)that’sforpharmacyI’mlikefoldingitupquickly,putitinthebag[laughs]justbecauseitmakeslifesomucheasier…youappreciateeachsectoralotmore”

HospitalpharmacyThehospitalsectorwasalsosaidtobenefitfromtheattitudesintegratedpre-reghadbeenperceivedtodevelopwhileincommunitypractice.Atutorbelievedthatconfidencebuiltinthisenvironmenthadbeenbroughtintothehospitalworkplace. Pre-regtutor5:“…shehasbroughtthatmentalityovertohospitalwhichwearenotalwaysusedto.WearealittlemoresoftIwouldsay.ShehasbroughtthekindofnononsenseapproachintothehospitalwhichIthinkisgoodtohaveadifferentideaabouthowtodealwithcertainsituations…”Integratedpre-regthemselvesalsocommentedonhowhospitalpracticecouldbetterutiliseapatients’communitypharmacyrecordswhileconductingmedicinesreconciliation. Integratedpre-reg3:“…youareabletocomeupwithrecommendations…IfthepatientcomestothehospitalandwepicktheGPrecordswhydon’twepickthecommunityrecords…”PatientsAsaconsequenceoftheintegratedprogrammetutorsperceivedthatpatientsmaybenefitfromcloserworkingbetweensectors.Integratedpre-regthemselvesagreedwiththissentimentandfelttheprogrammeallowedthemtodomoreforpatients. Pre-regtutor3:“…beingabletoworkcloselywillmakemuchmoresensewithpatientcaretobeabletoprioritisethepatientsandtomakethingseasiersothatthecareisnotcompromised” Integratedpre-reg1:“Ithinkitgivesyoualmostanotherlevelofskilltobeabletosortofdomoreforthepatient…”Cross-sectorworkingIntegratedpre-regthemselveshavebeenabletoseehowcommunicationbetweensectorscanbeimproved,wherefrustrationsandmisconceptionslieandidentifyopportunitiesforsectorstoworkmoreclosely. Integratedpre-reg6:“…itmakesyouseethingsthatdifferentsectorsdowrongornotsomuchdowrongbutthingsthatirritatetheotherbecausethere’salotofirritabilitybetweenthesectorswheretheydon’tthinkveryhighlyofeachotherandyouseewherethatcomesfrombutyoualsoseethemisconceptions…whenwegointopracticeIthinkwe’llbebetteratnotdoingthat”

Theme3:Valueofcross-sectorexperiencetohospitalandcommunitypre-registrationpharmacistsThroughoutinterviewswithcommunityandhospitalpre-regreferencewasmadetotheirexperiencesinothersectorsthroughtheirpre-regtrainingprogramme.Commentswereonthewholepositivewithcross-sectorexperiencesbeingseenasimportantandenjoyable,evenifthepre-reghadnointerestinworkinginthatsector.AnunderstandingofpracticewithinsectorsPre-regperceivedthatspendingtimeinothersectorsallowedthemtounderstandtheprocessesanddifficultiesfacedwithinthatsector.Itwasalsoperceivedtobebeneficialinallowingbarrierstocommunicationandtransferofpatientsbetweensectorstobeseen. Communitypre-reg1:“…beingabletoworkinbothsectorswithinyourpre-regwouldgiveyouanunderstandingonhoweachsortofsideaddressesissuesandgoesaboutcommunicationandgoesaboutdecisionmakingreally”OpportunitiesforexperiencesnotencounteredinpredominantsectorForhospitalpre-regcross-sectorexperienceswereseenasanopportunitytoberemindedoftherulesandregulationsgoverningcommunitypharmacy,practiceOTCconsultationsandgainexposuretotheadditionalservicesprovided. Hospitalpre-reg3:“…someoftheareaswewerelackingbeforegoingintocommunitygothighlighted.Wehadachancetodomoreofthecommunityandoverthecounterstuffthatwedon’tgettodealwithinhospital”Communitypre-regtoofoundtheircross-sectorexperiencesbeneficialinachievingcompetenciestheywereunabletomeetincommunity,practicingdrughistorytakingandwritingpatientprofiles. Communitypre-reg2:“Ididpatientprofilesonnewpatients…Ididasepticsandthingswhichisreallygoodbecausesomeofthecompetenciesyoucantreallygetincommunityproperly”Forbothhospitalandcommunitypre-regitwasacknowledgedthatthey“didn’tknowwhattheydidn’tknow”beforedoingtheircross-sectorplacements.Suggestedchangestocross-sectorexperiencesDespitetheoverwhelminglypositiveviewstowardscross-sectorplacementsacommunitypre-regparticipantwasdissatisfiedwiththehospitalexperiencetheyreceived.Thishighlightedtheimportanceofwardexposureandcarefulplanningtothesuccessofcross-sectorexperiences.

Communitypre-reg2:“…maybebeingleftinadispensaryinahospitalprobablyisn’tideal

[CommunityPre-reg4laughs]BB:Wasthatthecaseforyou?Communitypre-reg4:yeahCommunitypre-reg2:…it’sthesameprocessasbeingincommunity.I

thinkthethingisyouneedtobeonthewardsandseeingdifferentthings…”Thedurationofcross-sectorplacementswereperceivedtooftenbetooshort,inparticularahospitalpre-regfeltthattimewasspentatthestartoftheircommunityexperience“settlingin”.Suggestionsweremadethatrepeatexposurethroughoutthepre-regprogrammemaybemorebeneficial. Hospitalpre-reg2:…thefirsthalfaweekorsoisactuallymoreacclimitisingandfindingwherethingsare…” Communitypre-reg4:“…thereisnowayoftrulyexperiencingtheothersectorunlessyouaredoingacross-sectorplacementwhereyouaretherethroughouttheyearforalongerperiod.”Onecommunitypre-regsuggestedthatcross-sectorplacementsshouldformacompulsorypartofthepre-regyear. Communitypre-reg1:“…ratherthanadvisoryIdothinkitshouldbeacompulsorycomponentthatwegointohospital…”Positiveattitudestowardsintegratedpre-registrationprogrammeCommunitypre-reginparticularexpressedsupportfortheintegratedprogrammenotingbenefitssuchasmakingtheexperiencestandardisedforallpre-regandallowingthemtoseethingstheywouldn’totherwiseseeincommunitypracticealone.Onecommunitypre-regevencommentedthattheywouldhaveconsideredanintegratedposthadonebeenavailable. Communitypre-reg5:“…Ithinkallpre-reg’sshouldbeintegrated.Idon’twanttoworkinhospitalbutIfeellikepeoplewouldbemoreroundedpharmacistsiftheyworkedinajointpre-reg…

BB:soifyoudidhavetheopportunitytodoonewhatwouldyourthoughtsbetowardsthat?

Communitypre-reg5:umIprobablywouldhavethoughtaboutit,yeahBB:yousaidyouthinkallpre-regshouldbeintegrated,whyisthat?Communitypre-reg5:becausetheneverybodygetsthesameexperience,

obviouslyinhospitalyouseethingsyoudon’tseeincommunity,incommunityyouseethingsyoudon’tseeinhospital.Everybodyhas,andeverybodyseeseverything.”Theme4:SuggestionsforchangeWhileopinionstowardstheintegratedpre-regprogrammewereoverwhelminglypositiveitwasnotedthatsomeissueshavealreadybeen

identifiedandaddressedforthecurrentcohort.Manyofthechallengesoutlinedwerealsosaidtobenotexclusivetotheintegratedprogramme.ImprovetimetablestructureWhileintegratedpre-regwereinitiallysupportiveofthecurrentweeklystructure(wherebytwodaysarespentincommunity,twoinhospitalandonedayinprimarycarepractice)theproposaltochangethetimetablesuchthattraineesspendawholeweekinonesectorwithadayofprimarycareinbetweenwaswelcomed.Benefitsweresaidtoincludegivinganopportunityforintegratedpre-regtosettlebetter,tofollowupproblemsineachsector,allowingthemtotakegreaterresponsibilityineachsiteandalsoreducingconfusion. Integratedpre-reg4:“…thefirstfewweeksIwasallovertheplace.I’dgotocommunityandbetaughtthis,hospitaldifferentsystem,sometimesyouactlikeyou’reabitconfused.” Pre-regtutor1:“They’llcertainlyhavetofollowupproblemsmorewhichyoucansometimesmakeoneandnotrealiseyou’vecreatedonebecauseyou’vegone” Pre-regtutor3:“…bygivingthemsnapshots,justtwodayshereandthereittookthemlongertosettleinandtodoliketheirdispensinglogsandcheckingsoweareadjustingitnextyear.Hopefullythatwouldworkbetter…” Integratedpre-reg6:“…blockweekswouldbebetterforcontinuityespeciallyinthehospital,likeIwassayingfeelinglikeIwasmissingoutontheresponsibilityofmanagingaward.You’dgetthatifyouhadblockweeks…”Theflexibilityoftheprimarycaredaywasalsocommentedupon,withpositiveattitudesexpressedtowardsmakingthisdaya“floating”dayinwhichthetraineecanvisitwheneverisbestforthesector(i.e.ifthereisanimportantmeetingforthemtoattendorsimilar). Pre-regtutor2:“…thatonespecificdayprimarycarehasbeenabittoorestricted…sometimesitcouldbethatthereisacliniconaTuesdaymorningandtheyneedtobetheretoseeitbutitcouldbeonThursdaythefollowingtimethattheyneedtobethereforsomethingelse…”Integratedpre-regmadenumerouscommentssurroundingdisparitiesbetweenwardexposureandcommunitypharmacyexperienceswithsomeperceivingtheyhavelessstructurethanothers.Whilesomeappreciatedtheflexibilityinbeingabletoidentifyandorganiseexperienceswhichtheydeemedbeneficial,otherswouldpreferamorestructuredapproach.However,toomuchstructureinthetimetablewasalsodeemedtocausepre-regstresswherechangesneededtobemade. Integratedpre-reg6:“…wejusthavetolooktoawardandaskifanyoneneedsahand…whichiskindofabadthingbecauseitfeelslessstructuredandum

youarenotdevelopingthatresponsibilitythatyouhaveifyouweretoworkonaward…butit’skindofalsoagoodthingbecauseitgivesyoufreedomtogoanddothethingsyouneedtodolikelastweekIknowtheonlyspecialtyIhaven’tmanagedtoseemuchofisrespiratorysolastweek…Ijustwenttotherespiratorywardanddidstuffthere.” Integratedpre-reg1:“…ifonethingfallsbehindtheneverythingelsefallsbehind…ifyoudon’tsticktoit[thetimetable]itreallydoescausealotofstress Integratedpre-reg2:andIdon’tthinkthestaffrealisethat.They’llbelikeohyeahwe’llswitchthatoveritslike-pleasedon’ttouchmyschedule[laughs]”Whileintegratedpre-regcurrentlyenjoy“supernumerary”statusattributedtotheirtwodaysaweekinhospitalandcommunitysectorapotentialproblemhasbeenidentifiedinthattheswitchtofullweeksineachsitemayleadtointegratedpre-reg“replacing”otherstaffmembers. Integratedpre-reg2:“…becauseI’monlytheretwodaysaweekit’skindoflikeI’mastudentsotheyarealwaystryingtoteachmebutIdon’tgetabusedinthewholebusydispensingenvironment…” Pre-regtutor1:“…theworryisyouwilllookatitandthinkohgoodIcangiveamemberofstaffoffasanegative,becausewhenyouknowtheyaregoingtobehereforafullweekyousortofthinkwhoopee,thoughwetrynotto,butIknowyouinstinctivelydo…”ImprovestakeholdercommunicationBothtutor-tutorandtutor-traineecommunicationwassaidtobeachallenge.Tutorcommunicationwithtraineescanoftenbead-hocowingtotheperiodsoftimespentoffsite. Pre-regtutor5:“Umhavingtimetomeettheactualtutorofthecommunityonehasbeenaslightissue.Youeithercatchthemovertheirlunchperiodoryouprobablyneedabigmeetingbecausetheyneedtogetbackfilled…soIhadn’tquiterealisedhowmuchloneworkingtherewasincommunity…thecommunicationbetweenhospitalandtheothermaintutorincommunityhasbeenrestrictedprobably.”RecommendationsforovercomingthesechallengesincludebetteruseofITsolutionssuchase-mailoranonlinediaryandtelephonecommunication.Meetingsmayalsoneedtobescheduledfurtherinadvance. Pre-regtutor5:“Iwouldliketoputsomedatesindiariessothattheyaretakenaccountofwhentherotasaredonetwoweeksorwhateverinadvance” Pre-regtutor2:“whatwewantedwasanonlinediarythatwecouldinput-thisiswhatthey’llbedoingforthenextfortnightincommunityandit’sjustmakingthemawareinhospital…wehaveovercomeitinthatwearee-mailingeachother…”

ManagementofstakeholderexpectationsIntegratedpre-regpharmacistsfeltthatpharmacystaffwouldbenefitfromreceivingcommunicationthatintegratedpre-regareuniqueintheirtrainingneeds.Inparticularunduepressuremaybeplaceduponthestudentstoprogressatthesamerateashospitalonlypre-reg.Whilesometutorsstressedthatintegratedpre-regshouldnotcomparethemselvestohospitalonlytrainees,integratedpre-regoftenbenchmarkedtheirprogresstothem. Pre-regtutor2:“…thehospitalpre-regstudentsandtheintegratedpre-regstudentsarealwaystryingtobenchmarkeachotheragainsteachother…andtheyshouldn’tbecausetheyarenotthesamepackage…I’vegotafeelingthatthehospitalsectorisstilltryingtocramafullhospitalsectorpre-regprogrammeintotheintegratedprogrammeandIthinkthatisamistake.” Integratedpre-reg6:“Maybethetutorsandthepharmacistsbothinthehospitalandcommunityneedto,needmore,trainingortounderstandthatwearedifferentfromafulltime”Integratedpre-regalsofeltthatthetimescalesgiventothemtocompleteproceduralcompetencies(i.e.dispensing)wereunrealistic,astheywereinlinewithwhathospitalpre-regwereexpectedtoachieveyettheyspendlesstimeonsiteinwhichtocompletethesecompetencies. Integratedpre-reg5:“…oftenyoucanfeellikesomeofthestaffthinkthatyouarefallingbehindbutitisbecausewe’vehadhalfthetimecomparedwithwhotheyarecomparingustowhichisthehospitalpre-reg’s.Ithinkit’simportantforeveryonetobeawareofthefactthatwedohavehalfthetimeandmaybethatshouldbeincorporatedintotheschedule…giveusalittlebitlongertoachievethesamethings.”Integratedpre-regandtheirtutorsexpressedtheconcernthatpre-regmaybeusedtodispenseinparticularincommunitypharmacyenvironments.Indeed,acommunitypre-regsharedthissentimentwheretheyfelttheytooaresometimesusedasanextrapairofhands. Integratedpre-reg6:“...incommunitywithpharmacistsmaybeexpectingyoutodoloadsofdispensingandloadsofotherstuffandyounotgettingtimetolearn…” Communitypre-reg1:“…Ithinkparticularlytheyseeyouascheaplabour….Ifeelyouoftenfallintotheroleofdispenser” Pre-regtutor1:“Havinganextrapairofhandsisalwaysbeneficial.Eventhoughyouaren’tsupposedtousethemasanextrabody…”

EnhanceprimarycareexperiencePrimarycareexposureaspartoftheintegratedprogrammewassaidtobeanattractivefeature.Gainingexperienceinthissectorearlyintheircareerswassaidtobebeneficialtointegratedpre-reg. Integratedpre-reg1:“…nobodyelsegetsit[primarycareexposure]thisearlyinyourcareer…Ithoughtifyoucandoitaspartofyourpre-regthenwhynot?”Howeverthiscouldbeimprovedbyprovidinggreaterexposuretopharmacistsasopposedtootherstaff(i.e.technicians)inprimarycare. Pre-regtutor5:“Ithinkthey’vespenttoomuchtimeinmyopinionwithtechnicians,umdoingprocessstuff.IthinknowhavingseenlearningwhenattachedtothepharmacistthatIthinkisverymuchthefuture.”Atutoralsoperceivedthatwhilecompletingtheauditelementofthetrainingyearinprimarycarewasbeneficialtothepre-reg,completingitacrosssectorswouldallowmoretimeforpre-regtocompleteprimarycarerelatedtasks. Pre-regtutor5:“…theyputtheaudit,orserviceimprovementproject,inprimarycarewhichwhentheyonlyhaveonedayaweek…Ithinkitwouldbebettertosomehowcrossthoseboundaries…soitwouldn’tdraintheirtimeinprimarycareentirely.”Integratedpre-regsuggestedthattheywouldbeinterestedinaprimarycarecareeruponregistrationhowevernotedlimitedopportunitiesfordevelopmentofthiscareerpathwayimmediatelypost-registration.Integratedpre-regsuggestedthatofferinganintegrateddiplomatoprovidecontinuitywouldbebeneficial. Integratedpre-reg3:“Iftheysetupanintegratedpre-regtheyshouldsetupanintegrateddiploma”AddressgeographicalchallengesOwingtothedistancebetweenhospitalandcommunitytrainingsitescommunicationwassaidtobedifficult.Thisalsoledtopre-reghavinglesstimetowriteevidencesanddoadditionalworkduetotravelcommitments. Pre-regtutor3:“…Ithinkeventhoughwecommunicateviatelephoneandemailwiththetutorsumitisdifficult…itmightworkabitbetterifwesawthemmoreregularlybutthegeographicalareait’sdifficult…that[commute]sometimescanimpactontheirstudieswheretheyaretootiredtogohomeanddosomework”.

DiscussionTwentytwoparticipantsweresuccessfullyrecruitedandinterviewedatthesixmonthtimepoint.Nineteenofthesewerefollowedupattenmonths.TheinterviewerwasapharmacistandmemberofstaffatWCPPE.Participantsmayhaveagreedtotakepartinlightofthisalternativelytheymayhavewishedtocontributetothedevelopmentoftheprogramme,indeedmanyintegratedpre-reginparticularcommentedthattheirviewscouldbeusedtoshapethefutureoftheprogramme.Whileengagementwiththeliteratureanddetailsurroundingtheintegratedprogrammewaslimitedinterviewerbiascannotberuledout(NewmanandBenz,1998).ThisprogrammeisthefirstofitskindinWalestoofferpre-regtheopportunitytoexperiencetrainingincommunity,hospitalandprimarycarepharmacyenvironments.IndoingsosatisfyingtheGeneralPharmaceuticalCouncilrequirementforpre-regonsplitorjointprogrammestospend“forexample,six(orperhapsnine)monthsspentincommunitypharmacyandsix(orperhapsthree)monthsinhospitalpharmacy”or“six(orperhapsnine)monthsspentinapatient-facingsectorandsix(orperhapsthree)monthsinanon-patient-facingsector”(GeneralPharmaceuticalCouncil,2017).Whileothercross-sectorprogrammesareavailableinEnglandandScotland,there’scurrentlynopublishedworkontheireffectiveness.ApilotschemeestablishedinEnglandin2015offerspre-regtheopportunitytospendonedayaweekfor8weeksinaGPenvironment(PharmacistSupport,2017)aimingtoprovidethe“greatercollaboration”betweenhealthcareprofessionalscalledforinNHSEngland’s“FiveYearForward”document(NHS,2014).Theschemehasreceivedpositivefeedbackandhassincebeenrolledoutfurther(PharmacistSupport,2017).Thepilotaimedtogivepre-rega“deepunderstanding”ofhowGPsurgeriesoperate(Collins,2015).Whileanevaluationontheprogrammehasnotbeenpublished,resultsfromthisstudyshowthatthoseontheintegratedpre-reginNorthWaleshavebenefittedfromgaininganunderstandingofhowGPpracticeswork,anelementwhichcommunitypre-regstatedtheywouldliketogainfurtherunderstandingofthroughvisitstoGPsurgeries.InScotland,pre-regrecruitedthroughthePre-registrationPharmacistScheme(PRPS)followacoretrainingprogrammewheretheytooareprovidedtheopportunityforcross-sectorplacements(NHSEducationforScotland,2017).Furtherresearchintotheeffectivenessofsuchprogrammesisneeded.Participantsinthisstudyhadvariedexperiencesdependingontheirsectorofpractice,consistentwiththefindingsofa2016study;whichshowedthatexperiencesdifferedbetweensettingswhere“servicesprovidedandpatientmixvaried”(Jeeetal.2016).Arecommendationwasmadethatstandardisationacrosssitesmayreducevariationinexperienceandpre-regprofessionalsocialisation(Jeeetal.2016).Inthisstudyitwasperceivedthattheintegratedprogrammemaybeawayinwhichpre-regcouldobtainthe“sameexperience”byseeingthingsinothersectorswhichtheyotherwisewouldn’thavetheopportunitytosee,thuspotentiallyachievinggreaterstandardisation.

Limitationsofthestudyincludetherelativelysmallsamplesize,astherearecurrentlyonlysixpre-regundertakingtheintegratedprogramme.Theeffectofself-reporterbiascannotberuledoutaspre-regweremakingcommentsrelatingtotheirownpreparedness(Gordon,1999;Daviesetal2006).Triangulationofintegratedpre-regviewswiththoseoftheirtutorsaimedtominimisethiseffectaspreviousstudieshaveshownthatemployerperceptionsofgraduatepreparednessinpharmacyhavebeenlessfavourablethanthoseofgraduatesthemselves(Kairuzetal,2010).Thisstudydidnotobservethiseffectandagreementwasseenonmanyofthekeyareasexplored.Theopinionsofhospitalandcommunitypre-regtutorswerehowevernotincludedinthisstudy.Twofurtherthemes(‘tasksundertakenbypre-registrationpharmacists’and‘desiredqualitiesofintegratedpre-registrationpharmacists’)wereidentifiedfromthedatabutarenotdiscussedhereastheyarelessrelevanttotheresearchaims.ConclusionThisstudyprovidesaninsightintostakeholderperceptionsoftheintegratedpre-registrationtrainingprogrammeinNorthWales.Ithasidentifiedthatbothintegratedpre-regandtheirtutorsalikehavepositiveperceptionsoftheprogramme.Itsbenefitsinpreparingpre-regforpracticeandwiderbenefitswithinthepharmacycommunityhavebeensuggested,aswellaswaysinwhichtheprogrammemayberefinedforfuturecohorts.Thestudyalsoidentifiedthatthoseconsideringimplementingorreviewinganintegratedpre-registrationprogrammemaywishtoconsider:

- Thebalanceofprovidingbothstructureandflexibilitywithinthetimetable

- Carefulmanagementofstakeholderexpectationssuchthatindividualsinvolvedintheintegratedprogrammearewellinformedoftheroles,responsibilitiesanduniqueneedsofintegratedpre-regpharmacists

- Theimportanceofcommunicationinintegratedprogrammes(particularlybetweentutorsindifferentsectorsandbetweentutorsandpre-regpharmaciststhemselves)

- Geographicallocationoftrainingsites,suchthatpre-regareabletotravelwithrelativeconveniencebetweensectors

FutureWorkEthicalapprovalhasbeenobtainedinordertoconducttelephoneinterviewswiththeintegratedpre-regcohortuptosixmonthspostcoursecompletion,inordertoexploretheiropinionspostregistration.

AcknowledgementsTheresearcherwouldliketothankalltheparticipantswhotookthetimetosharetheiropinionsandhelpinthedevelopmentoftheintegratedpre-registrationprogrammeinNorthWalesandpotentiallyelsewhere.

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