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Embedding the Clinician-Researcher Pharmacist in Healthcare

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Embedding the Clinician-Researcher Pharmacist in Healthcare Embedding the clinician-researcher pharmacist in healthcare Alice Victoria Gilbert Bachelor of Pharmacy A thesis submitted for the degree of Doctor of Philosophy at The University of Queensland in 2016 School of Medicine Abstract Background: This thesis presents work from a clinical pharmacist practicing as an Embedded Researcher. The majority of the research presented was conducted within the Mental Health Service of the Northern Territory (NT). The NT is unique in terms of its demographics; it has a small, culturally diverse population which is dispersed over a large geographic area. Over one third of the NT population live in remote areas and 71% of those living remotely identify as Aboriginal or Torres Strait Islanders. This poses unique challenges in regards to the delivery of health-services to individuals and communities, particularly those living in remote areas. Prior to the employment of a pharmacist within the Mental Health Service, there were high risk medication practices occurring. Following an initial observation period completed by the pharmacist, significant evidence-practice gaps in care for patients with mental illness were identified. Due to the large number of these evidence- practice gaps, the pharmacist undertook a multitude of change management and quality improvement activities by adopting the Embedded Researcher technique. The studies within this thesis include all aspects of the medication management cycle. The studies include assessments of prescribing practices, medication management, electronic medication management systems, risk minimisation, medication safety and quality, medicines information and hospital discharge. Aim: The aim of this thesis is to investigate the effectiveness of an Embedded Pharmacist Researcher (EPhR) and their impact on the Quality Use of Medicines. This thesis is designed to demonstrate how a clinical pharmacist, embedded within a team, can identify problems, develop innovative interventions, and implement sustainable solutions. Method: All research was conducted using the Embedded Researcher technique and targeted areas which were identified during clinical work as a translation gap between literature and practice. The National Medicines Policy, coupled with the Quality Use of Medicine principles, provided a foundation that supported the development, implementation and evaluation of the interventions within each healthcare setting. The applications of well-known theoretical models were used to develop a conceptual framework for Alice Victoria Gilbert | 2016 Page | ii each intervention and are detailed in the introduction to each section or study. Each framework uses an extensive selection of behaviour change theories developed in areas such as education, social marketing, public health and health promotion. Models such as Social Cognitive Theory, The Transtheoretical Model, PRECEDE- PROCEED were used to develop the key building blocks and processes needed to facilitate behaviour change and to achieve high quality medicines use which has been sustained. Using the Embedded Researcher technique lends itself to incorporating both Qualitative and Quantitative Evaluation for each intervention. This enables each study to achieve a depth of understanding due to the ability to add descriptive data. For many of the studies presented, examples of mixed methodology are applied to demonstrate a robust analysis of each intervention. Results: Outcomes for all interventions within this thesis were successful. Results for each intervention were evaluated using the Clinical Value Compass targeting a multifaceted assessment of clinical outcomes, functionality of the service, patient satisfaction and costs due to direct medical or indirect social expenditure. There are over twenty studies presented within this thesis, all of which demonstrate the variety and depth of research that can be conducted using the Embedded Researcher Technique. The quality improvement and practice changes reported include; Clinical Outcomes; review of the impact of prescribing a new medicine promoted by the pharmaceutical industry on patient outcomes. This was evaluated by assessing tolerability of medicine, treatment failure and total number of patients who remained on the new therapy. Functionality of the Service; Multiple studies demonstrated quality improvement activities required to meet National Accreditation Standards. Examples include reviewing prescribing practices and targeted education to improve adherence to best practice, design and implementation of a Mental Health Community Medication Chart to meet legal requirements and to improve continuity, and safety initiatives such as an evaluation of a rapid implementation quality improvement program for medicine security. Alice Victoria Gilbert | 2016 Page | iii Patient Satisfaction; Implementation of an independent non-biased medication information website for Mental Health patients, targeted patient surveys to provide feedback on medication management within Mental Health, and demonstrating that a ward based clinical pharmacist can help to meet patient’s needs in regards to medicines information. Costs due to Direct or Indirect Social Expenditure; Changing medication management systems in both the inpatient and community based Mental Health facilities resulted in an ongoing annual cost savings of greater than $35 000 to the NT government, and seeking funding for a technician to help with medication co- ordination for a high-risk population group to potentially reduce the financial expenditure associated with re-admission which accounted for $601 772 to the Mental Health service. Utilising the Embedded Researcher Technique gives each intervention a greater likelihood of success due to the Embedded Researcher’s understanding of the importance of the culture, the potential resistance and lines of communication available for each stage of change. Conclusion: This thesis indicates the abundance of opportunities available for Embedded Pharmacist Researchers within a practice based setting. Providing these studies demonstrates how an Embedded Pharmacist Researcher can develop research questions from clinical practice, conduct appropriate evaluations using scientific methodology, and put forward a translation of the results to practice development. The outcomes of these change management projects gave the Embedded Pharmacist Researcher the opportunity to expand the pharmacy workforce, extend current roles of pharmacists, improve patient outcomes and determine ways to reduce expenditure for the Northern Territory Government. This work of an Embedded Researcher has demonstrated what can be offered by a pharmacist to a healthcare system, and this work can be seen as an example of a response that can be replicated by any pharmacist, in any position, as long as key methodology and insights are utilised, and the specialist skills of a pharmacist are executed. Alice Victoria Gilbert | 2016 Page | iv Declaration by Author This thesis is composed of my original work, and contains no material previously published or written by another person except where due reference has been made in the text. I have clearly stated the contribution by others to jointly-authored works that I have included in my thesis. I have clearly stated the contribution of others to my thesis as a whole, including statistical assistance, survey design, data analysis, significant technical procedures, professional editorial advice, and any other original research work used or reported in my thesis. The content of my thesis is the result of work I have carried out since the commencement of my research higher degree candidature and does not include a substantial part of work that has been submitted to qualify for the award of any other degree or diploma in any university or other tertiary institution. I have clearly stated which parts of my thesis, if any, have been submitted to qualify for another award. I acknowledge that an electronic copy of my thesis must be lodged with the University Library and, subject to the policy and procedures of The University of Queensland, the thesis be made available for research and study in accordance with the Copyright Act 1968 unless a period of embargo has been approved by the Dean of the Graduate School. I acknowledge that copyright of all material contained in my thesis resides with the copyright holder(s) of that material. Where appropriate I have obtained copyright permission from the copyright holder to reproduce material in this thesis. Alice Victoria Gilbert | 2016 Page | v Publications during candidature Peer-reviewed papers Published Gilbert AV, Clinical Pharmacists Help Prescribers and Patients Make Informed Decisions. BMJ. 2015; 350: h2960. Gilbert AV, Patel BK, Roberts MS, Williams DB, Crofton JH, Morris NM, Wallace J, Gilbert AL. An Audit of Medicines Information Quality in Electronically Generated Discharge Summaries - Evidence to Meet the Australian National Safety and Quality Health Service Standards. J Pharm Pract Res. 2016. Accepted for publication 16 June 2016 (JPPR-2015-Dec-125). Gilbert AV, Patel BK, Morrow M, Williams DB, Roberts MS, Gilbert AL. Providing Community-Based Health Practitioners with Timely and Accurate Discharge Medicines Information. BMC health services research. 2012; 12(1): 453. McLain SE, Pogue TL, Richardson KL, Westcoast P, Gilbert AV, Heywood MJ, Welch SA, Keily J, Patel BK. Applying the National Inpatient Medication Chart audit to electronic medication management systems: what does it tell us? J Pharm Pract Res. 2016.
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