Whether or not health practitioners, rather than doctors, should prescribe medicines is no longer a debate, it is now embedded with good outcomes (i5, 2018). However, the challenge is to ensure that the education and training of increasing number of non-medical prescribers (NMPs) promotes competence and safe prescribing. As this responsibility falls to both employing organisations and individual NMPs, a supportive structure where supervision, governance and a clear role is set out for the novice prescriber are needed (Hemingway and Ely, 2009). Individually, the NMP needs to work within their scope of practice and develop as per their role specification, incorporating all the determinants of safe prescribing (Royal Pharmaceutical Society (RPS), 2016). One such determinant is establishing successful interprofessional working appropriate to the context of care and prescribing focus (Hemingway et al, 2019).
The broader facilitation of prescribing and medicines optimisation by interprofessional working is now embedded both clinically (RPS, 2016) and educationally (Davies and Gidman, 2011). The University of Huddersfield has a recent history of facilitating interprofessional education involving medicines (Hemingway et al, 2019). The aim of these workshops is to cultivate collaborative working to improving patient care in prescribing, in line with the The Centre for the Advancement of Interprofessional Education (CAIPE) guidelines (2016). Students work alongside each other to problem-solve simulated patient cases, where the expertise and input of each profession is required to achieve a favourable outcome for the patient. Students are given the opportunity to learn with, from and about each other, and are exposed early on to the multidisciplinary environment in which they will be working.
This paper presents a follow-up appraisal of an interprofessional safe prescribing workshop (Hemingway et al, 2019) measured by two instruments. A more in-depth rational, including a literature review is available in Hemingway et al, 2019. Further motivation for this study was to assess reliability of an internally-produced workshop evaluation (Hemingway et al, 2019), and to determine whether the workshop increased student readiness for interprofessional learning.
Methods
Effective interprofessional education is instrumental in facilitating communication and collaboration between practitioners who can work in partnership to resolve problems and provide effective care. With this in mind, joint working between student NMPs (nurses, podiatrists and physiotherapists) and fourth year MPharm students (in the final year of an undergraduate pharmacy degree) was introduced in the form of an interprofessional workshop centred around the issue of prescriptions, and determinants of competence and safety. The university now include paramedic and pharmacy students on the NMP course, but did not at the time of this evaluation. The two groups had a major focus on safety; as the future experience of one group (student NMPs) would involve prescribing medication, and the other group (pharmacy students) would be dispensing and supplying medication in the near future after successful completion of their courses.
The workshop was underpinned by the process, knowledge and relationships aspects of prescribing medicines optimally (Hemingway et al, 2019). Process refers to the fact that safe and effective prescribers and pharmacists, as dispensers, need to understand the processes by which medicines are prescribed, supplied and administered; thus a collaborative approach is needed (Cooke et al, 2017). Knowledge refers to the fact that the NMP as prescriber and pharmacist in their dispensing role must be able to identify and understand the patient's condition and the use of their chosen agent. The drug chosen has to have a suitable dose, formulation and dose regime, and must include safety considerations and contra-indications in their choice (Greenwood, 2016). Relationships refer to the fact that evidence exists that the best outcomes for patients are achieved by effective interprofessional working. Improved understanding leads to mutual respect and increases the likelihood of inter-professional referral and shared working (Davies and Gidman, 2011). These three domains corresponded to the domains of one of the instruments utilised to assess the workshop; the internally-produced Workshop Evaluation Questionnaire (Hemingway et al, 2019).
A second instrument, the Readiness for Inter-Professional Learning (RIPLS) questionnaire (Parsell and Bligh, 1999), was also utilised in the assessment of the workshop. This instrument included the following domains:
- Teamwork and collaboration
- Professional identity
- Roles responsibilities.
The RIPLS scale has had various adaptions to suit the sample and context needed, but it was decided to retain the original iteration (Parsell and Bligh, 1999), as undergraduate (MPharm) and graduate (NMP) students together or as a contrasting sample had yet to be evaluated.
Both instruments were distributed after the workshop was completed. Respondents were asked to put each one in an assigned box. There was no identifying content on the questionnaire.
The aim of this study was to assess the perceptions of an inter-professional workshop and attitudes toward working interprofessionally for NMPs and MPharm students. The following objectives were set to fulfil this aim:
- To assess workshop outcomes for the safe prescription of medicines and interprofessional working, using cross-sectional questionnaires; evaluating aspects of inter-professional working and readiness for interprofessional working
- To evaluate the reliability of the internal workshop evaluation as an instrument for interprofessional medicines safety workshops
- To determine whether the workshops have given any new insights into the development of medicines safety workshops.
Statistical methods
Data was collected by NMP and MPharm students attending the workshop. Respondents were requested to complete both the RIPLS questionnaire (Parsell and Bligh, 1999) and the Workshop Evaluation Questionnaire (Hemingway et al, 2019). The RIPLS questionnaire consisted of nineteen 5-point Likert items, with the teamwork and collaboration domain comprising nine items; the Professional Identity domain comprising seven items and the roles and responsibilities domain comprising three items. Each domain score was calculated as the sum of the scores of individual items in that domain. The professional identity domain included components of negative and positive professional identity; comprising three and four items respectively. For this domain, items relating to negative professional identity were reverse coded to calculate a meaningful domain score.
The internally-produced Workshop Evaluation Questionnaire consisted of nine 6-point Likert items with each of the domains of knowledge, process and relationships comprising three items. Each domain score was calculated as the sum of the scores of individual items in that domain. This questionnaire also elicited respondents' status as either NMP or pharmacy student (pharmacist).
Data were checked to assess the extent and pattern of any missing data and the requirement for imputation. The internal consistency of responses associated with each domain in both questionnaires was assessed using Cronbach's alpha coefficient. The scores on each item were summarised descriptively and compared against theoretical maxima, minima and neutral scores. The correlation of measures was also assessed. The significance of the difference in scores obtained by the two groups of participants (where recorded) was assessed using independent sample t-tests (under the assumption of unequal variances); with informally applied Bonferroni corrections where appropriate.
Results
RIPLS questionnaire
The RIPLS questionnaire was fully completed by 114 respondents. Reliability analysis revealed good internal consistency between items on the teamwork and collaboration domain (α=0.922); good internal consistency between items on the professional identity domain (α=0.770) and moderate internal consistency between items on the roles and responsibilities domain (α=0.569).
Results from this questionnaire are summarised in Table 1.
Table 1. Summary of domain scores (RIPLS instrument)
| Domain | Mean (SD; range) |
|---|---|
| Teamwork and collaboration | 41.0 (4.26; 27 to 45) |
| Professional identity | 31.1 (3.39; 22 to 35) |
| Roles and responsibilities | 5.34 (1.96; 3 to 13). |
Scores in the Team-work and Collaboration domain could vary from 9-45, with a uniformly neutral response of 27 and high scores representing positive opinions. Hence the reported scores represented very positive opinions.
Scores in the Professional Identity domain could vary from 7-35, with a uniformly neutral response of 21 and high scores representing positive opinions. Hence the reported scores represented very positive opinions.
Scores in the roles and responsibilities domain could vary from 3-15, with a uniformly neutral response of nine. Hence the reported scores represented somewhat mixed opinions.
Correlation analyses conducted on the data revealed a strong positive correlation between teamwork and collaboration and professional identity which was statistically significant (r=0.711; 95% bootstrapped confidence interval (0.580-0.833); p<0.001). No correlation was revealed to exist between the roles and responsibilities domain and either of the other two domains.
Workshop evaluation questionnaire
The workshop evaluation questionnaire was completed by 126 respondents, comprising 58 NMPs, 30 pharmacy students and 38 respondents who did not specify their status. Two items in the relationships domain were worded so as to be applicable only to one group of respondents each: Profession shares common skills/attitudes with pharmacists and Profession shares common skills/attitudes with NMPs. A new item, profession shares common skills/attitudes with interdisciplinary colleagues, was created for analysis from a combination of these items, which included no missing data. Very low amounts of missing data on other items were recorded, including three missing responses to one of the items contributing to the knowledge domain, and two missing responses to one of the items contributing to the process domain. Scores on these missing items were imputed using mean substitution.
Reliability analysis revealed very good internal consistency between items in the knowledge domain (α=0.792); items in the process domain (α=0.792); and items in the relationships domain (α=0.941).
Results from the workshop evaluation are summarised in Table 2.
Table 2. Summary of workshop evaluation scores
| Domain | Mean (SD; range) |
|---|---|
| Knowledge | 14.8 (2.90; 3 to 18) |
| Process | 14.8 (3.12; 3 to 18) |
| Relationships | 15.7 (3.26; 3 to 18) |
In all domains, scores could vary between three (most negative responses) and 18 (most positive responses), with scores of 10.5 representing a respondent with neutral feelings in a particular domain. Hence, mean respondent scores were indicative of positive responses in all domains. However, the full range of scores, from completely positive to completely negative, was recorded in all domains.
Correlation analyses conducted on the data revealed strong positive correlations between the knowledge and process domains (r=0.880, 95% bootstrapped confidence interval 0.795 to 0.928); between the knowledge and relationships domains (r=0.880; 95% bootstrapped confidence interval 0.780 to 0.930) and between the process and Relationships domains (r=0.884; 95% bootstrapped confidence interval 0.794 to 0.936). All correlations were statistically significant (P<0.001 in all cases).
Some substantive difference between the groups was revealed on the Relationships domain, in which the MPharm students scored 1.2 points more than NMPs, on average. However, no significant differences between the responses of NMPs and those of pharmacy students were revealed in any domain. Independent sample t-tests (under the assumption of unequal variances) found the (NMP – pharmacy student) difference in means to be 0.113 (95% confidence interval -1.02-1.25; P=0.843) for knowledge scores; -0.319 (95% confidence interval -1.61 to 0.970; p=0.623) for process scores; and -1.20 (95% confidence interval -2.48-0.087; p=0.067) for relationships scores. No Bonferroni corrections were required for these results due to lack of significance in any domain.
Discussion
The Workshop Evaluation Questionnaire elicited generally positive responses, only a small number of participants gave negative feedback. This effect was observed in all three domains of knowledge, process and relationships. However, consistency of any observed effect was to be expected, given the high correlations observed within each pair of domains. This was consistent with results obtained from a previous, similar workshop evaluation at Huddersfield (Hemingway et al, 2019).
Participant scores on the RIPLS questionnaire were positive in the teamwork and collaboration and professional identity domains, but not in the roles and responsibilities domain, which elicited mixed responses.
In general, it appears that the workshops are positively rated by students who see them as valuable in their development to become prescribers. Across participant groups, MPharm students scored slightly higher, albeit not significantly so, on the relationships domain than NMPs, in contrast to the previous evaluation, in which NMPs scored slightly higher. This may be related to the distinct perceptions of the sample in this study, or may show some limitations with the workshop evaluation. Nevertheless, this paper provides further evidence that interprofessional education workshops based on prescribing medicines competently can prepare students to work collaboratively within a culture of safety (Hardisty et al, 2014; Paterson et al, 2015).
Any scale used to assess inter-professional learning needs to be verified to be suitable for use. The internal consistency of most domains on both questionnaires was good, but less so for the roles and responsibilities domain of the RIPLS questionnaire. This may be because although the initial RIPLS questionnaire was designed for use with undergraduate rather than postgraduate sample, in the current study it was administered to a combination of postgraduate and experienced clinicians (NMPs); whose experience may contrast with MPharm students with little clinical experience. This mismatch between study groups may have introduced some bias into the results. However, Reid et al (2006) validated the RIPLS for postgraduate students and hence the scope of its applicability may include student NMPs. An alternative view by Mahler et al (2015) cautioned that the RIPLS as an evaluative scale is problematic, and suggested there are different scales available that may be less prone to the reliability issues identified in the current analysis.
Conclusions
The statistical analysis revealed the workshop to be evaluated well by participants in most domains using both instruments. However, the RIPLS instrument revealed that participants have some negative responses in the roles and responsibilities domain. The internal consistency of items of the internally-produced instrument was found to be good in all domains; all of which were also shown to be strongly associated with each other. No evidence was revealed that NMPs and MPharm students rated the workshop significantly differently from each other.
Further evaluations are planned and these findings will be used to further develop the internal workshop questionnaire. The effectiveness of the RIPLS instrument used by other participants with different backgrounds, such as experienced clinicians and undergraduate pharmacy students will also be investigated.
Key Points
- Interprofessional education (IPE) can play an important part role toward safe prescribing practice
- Students value IPE workshops focused on their learning and prescribing safety
- Further evaluations are necessary to establish evidence of IPE in NMP educaton
CPD reflective questions
- Reflect on what other professions are involved in your prescription decision?
- What is the pharmacy role in the prescribing process?
- Is IPE the way forward to maintain safe and competent prescribing?