METHODS
Qualitative data were obtained as part of a wider quantitative study investigating the prescribing history of patients from the time of hospital admission until the day of discharge. Fieldwork was conducted by three cohorts of research assistants who were undertaking their final year of the MPharm pharmacy degree between January and March during 2015, 2016 and 2017. Ethical approval and honorary contracts were granted by UK University Hospitals of Leicester (UHL) and De Montfort University (DMU) for each cohort of students: 2015: UHL Reg. No. 7186e, 2016: DMU FREC 1679, 2017: DMU FREC 1866).
Each year, the research assistants selected a sample of clinical notes of patients who were being treated on the AMU at Leicester Royal Infirmary. The inclusion criteria for selection were: age 65+ years; admission during the previous week; having one or more of the following presentations, all of which are frequently associated with medication issues and polypharmacy:- fall, urinary tract infection, confusion or lower respiratory tract infection. From this sample, NL selected 6 case studies, of contrasting prescribing complexity, that were judged to be within the experience of participants and who would be expected to manage within their routine practice. These case studies were subsequently shown to medical staff and pharmacists during a focus group in the second phase of the study as a basis for stimulating discussion about prescribing decisions. The median number of medicines prescribed at the point of admission to hospital for patients who were included as case studies was seven (min 2, max 20).
After the quantitative survey had been completed, doctors working within the AMU were invited (by NL in his role as AMU consultant physician) to attend a focus group that was held during a normal regular clinical lunchtime meeting located within the hospital premises. Pharmacists were similarly invited to a single separate focus group in 2017. It was made clear that about one hour would be set aside for the focus group and that attendance was voluntary. Those who took part in the study gave written consent after having advance opportunity to read a participant information sheet and a verbal explanation immediately prior to commencement.
A total of forty-eight participants (39 doctors, nine pharmacists) attended the focus groups which included a minimum of nine and a maximum of 19 participants per group. The level of experience of the doctors ranged from the first foundation year up to consultant level. The names of the doctors who attended the focus groups were not recorded. Those who were in their first foundation year attended only one focus group and doctors in more senior grades attended between one and three groups according to their availability to attend. Those who attended the pharmacy focus group were all pharmacists ranging from ‘band 6’ (newly qualified) to ‘band 8A’ (specialist pharmacists). A semi-structured topic guide was used by an academic male, non-clinician, facilitator (PR) in order to encourage open and blame-free discussion relating to prescribing decisions arising from the case-studies. During the period of the study PR was employed as pharmacist final project supervisor, researcher, and evaluator at a local school of pharmacy and not previously known by the study participants. The facilitator had extensive previous experience in conducting focus groups in health contexts using unstructured and semi-structured techniques. His background as a pharmacist offered a broad understanding of the clinical use of medicine which facilitated development of rapport with the participants. However, the facilitator endeavoured to remain neutral with respect to his views of prescribing decisions while interacting with the group. Each focus group was also attended by up to three final year undergraduate pharmacy students primarily as non-participant observers although assisting the facilitator by intervening occasionally in order to seek clarification. The number of case studies presented to participants ranged from three to six per focus group depending upon the complexity of the cases and consequently the amount time available. The reason for showing the medical and medication histories was to provide context and to facilitate opening up discussion on prescribing decisions.
Upon commencement of the focus group, participants were invited to reflect upon what they aimed to achieve as prescribers and upon any difficulties that arise when assessing the medication needs of a newly admitted patient. The discussion emanating from these opening questions then provided context for the group to consider prescribing decisions that were shown within the case studies. The facilitator put each case study up on screen and paper copies of the case studies were made available. The facilitator read out, for each case study in turn, the presenting diagnoses and therapeutic actions including medication that was stopped, paused, or started during the period of stay. Then the group was invited to share their thoughts on the case study and to consider whether they would have acted in the same way with respect to prescribing decisions. There were no more set questions as such - the remainder of the focus group was conducted using an unstructured format where questions arose from the ensuing comments and discussion. The facilitator encouraged participants to make their own judgements and comments and, where appropriate, prompted respondents to expand or explain their thinking.