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.