Manchester Pharmacy School, University of Manchester, Manchester, UK.
J Adv Nurs. 2018 Jan;74(1):65-74. doi: 10.1111/jan.13375. Epub 2017 Aug 1.
The aim of this study was to explore how secondary care pharmacist and nurse independent prescribers clinically reason when making prescribing decisions.
Clinical reasoning is a central component of prescribers' competence and professional autonomy when reaching a clinically appropriate decision. Like doctors, pharmacist and nurse independent prescribers in the UK have extensive prescribing rights, but little is known about their clinical reasoning.
A qualitative approach using a think-aloud methodology and semi-structured interviews.
Eleven nurse and 10 pharmacist independent prescribers were asked to think-aloud about validated clinical vignettes prior to interview, between March - December 2015. Data were analysed using a constant-comparative approach.
A strong link between clinical knowledge, grounded in previous experience and clinical reasoning was found. Despite prescribers approaching the clinical vignettes holistically, their focus varied according to professional background and job role. Nurses were more likely to describe interacting with patients, compared with pharmacists who were more focused on medical notes and laboratory results. Think-aloud protocol analysis revealed a distinct pattern in the process undertaken to reach a clinical decision. This is presented as a decision-making model, encompassing case familiarization, generating hypotheses, case assessment, final hypotheses and decision-making stages, which oscillated throughout the model.
This is the first study to explore the clinical reasoning processes of secondary care pharmacist and nurse independent prescribers. The resultant decision-making model shows clinical reasoning as a complex and dynamic process. This model can inform the training of independent prescribers to become accurate problem solvers and continue making clinically appropriate decisions.
本研究旨在探讨二级保健药剂师和护士独立开方者在做出开方决策时的临床推理过程。
临床推理是开方者在做出临床适当决策时的能力和专业自主权的核心组成部分。与医生一样，英国的药剂师和护士独立开方者拥有广泛的开方权，但对他们的临床推理知之甚少。
采用出声思维法和半结构化访谈的定性方法。
2015 年 3 月至 12 月，11 名护士和 10 名药剂师独立开方者在接受访谈前被要求对经过验证的临床病例进行出声思维。使用恒定比较法对数据进行分析。
发现临床知识与临床推理之间存在很强的联系，而临床知识则根植于以往的经验。尽管开方者整体上对临床病例进行了综合考虑，但他们的关注点根据专业背景和工作角色而有所不同。护士更有可能描述与患者的互动，而药剂师则更关注医疗记录和实验室结果。出声思维方案分析揭示了一个在做出临床决策过程中所采用的独特模式。该模式以决策模型呈现，包括病例熟悉、假设生成、病例评估、最终假设和决策制定阶段，这些阶段在整个模型中不断波动。
这是第一项探索二级保健药剂师和护士独立开方者临床推理过程的研究。由此产生的决策模型表明，临床推理是一个复杂而动态的过程。该模型可以为独立开方者的培训提供信息，使其成为准确的问题解决者，并继续做出临床适当的决策。
