Supporting recently qualified hospital pharmacists: advice for the first few years

The main difference between being a trainee pharmacist and a newly qualified pharmacist within the NHS is an increase in responsibility. A newly qualified pharmacist’s main responsibilities are:

• Documenting an accurate medication history;
• Screening drug charts;
• Ensuring that the correct medicine and dose is dispensed at the right time to the right patient. 

Newly qualified pharmacists play a big role in the multidisciplinary team (MDT). A structured hospital pharmacy training programme can support junior pharmacists, lightening the load by providing appropriate support and helping pharmacists achieve the skills and knowledge detailed in the Royal Pharmaceutical Society Foundation Pharmacy Framework​[1]​.

Within a structured hospital pharmacy training programme, there are different levels and types of support available. For example, junior pharmacists are usually assigned a supervisor for any support associated with their training, alongside a separate supervisor to provide support relating to the diploma, and they can rely on band 7 and 8 pharmacists within their clinical team should anything need to be escalated. One of the benefits of belonging to a MDT is that team members each provide different wisdom and contribute specific knowledge to different scenarios. 

As well as experience in clinical and patient services (e.g. on a general medical or surgical ward), where fundamental skills are developed and learnt, experience can be gained within the technical services where practical pharmaceutical knowledge is gained.

Making use of the multidisciplinary team

Within a structured training programme, it is possible to make full use of the complementary skillsets that exist within the MDT. Different colleagues can support the development of junior pharmacists in various ways. 

The pharmacy department

Medicines management pharmacy technicians (MMPTs) are experienced and skilled members of the pharmacy department. From day one, it is important that junior pharmacists are introduced to them. Perhaps the MMPTs could lead on aspects of teaching in inductions, supporting newly qualified pharmacists with developing medication history and prioritisation skills. MMPTs working on wards know how to prioritise new patients, so encourage them to share how they do this with newly qualified pharmacists. Their experience will be particularly valuable for pharmacists who may not have previously trained in a hospital setting.

Dispensary technicians, checkers, assistants and dispensers are often seen to be in the background; however, their contribution to shared objectives is very important, beyond just dispensing medicines. As experts in the sourcing and supply of medicines, they contribute hugely towards ensuring that patients receive their medicines in a timely and efficient manner. They are also important in communicating any supply issues so that any delays can be mitigated as soon as possible. A thorough induction and rotations with these teams allows newly qualified pharmacists to see there is more to timely patient care than safely screening a drug chart.

Senior pharmacists may be team leaders, or they may be highly specialised pharmacists. A patient and understanding team leader who exemplifies the standards expected of all pharmacists ensures that newly qualified pharmacists have a role model to look up to, and someone to turn to should they need that. Highly specialised pharmacists, and even consultant pharmacists, are experts that junior pharmacists can learn from, shadow, or seek guidance from.

Do not overlook the experience held by non-clinical senior pharmacists, including those working in education and training, technical services and managerial roles. These senior pharmacists all help ensure that the care given is patient-centred, highly specific and from a position of best practice. Including junior pharmacists within clinical research (led by a consultant pharmacist) also helps develop the next generation of clinical researchers.

The wider multidisciplinary team

Nurses provide pharmacists with important information about patient care, from patient-specific observation parameters to details of drug administration. They spend high proportions of their time with patients and will have valuable insights into their individual needs. They might pre-empt the unexpected discharge of a patient or notice an issue developing with their patient; for example, a change in their patient’s swallowing function, important information needed for administering drugs. Nurse–pharmacist and pharmacist–nurse teaching can encourage the improvement of individual skills and allow relationships to grow and develop, fostering positive and efficient teamwork. 

Occupational therapists help assess how a patient will be cared for practically at home. This information is important because it can help pharmacists make decisions regarding medication administration. In geriatric medicine, MDTs and ward rounds (where the pharmacist and occupational therapist are both equal contributors) can help develop respect and understanding of each other’s roles and mitigate delays in discharge. 

Physiotherapists help pharmacists understand how a patient will function at home. This can alert pharmacists to any changes that might need to be made for the safe administration of medicines. For example, there might be a need to contact a local pharmacy to set up a dosette box for a patient who struggles to remember which medicines to take when. 

Other members of the MDT have valuable knowledge and experience, such as speech and language therapists, dietitians and of course doctors. Ensuring that junior pharmacists have appropriate access and adequate opportunity to learn from the full MDT is an important element of a structured support programme.

How to support newly qualified colleagues 

As junior pharmacists develop, they will slowly transition from a consciously incompetent (with a sense of awareness) pharmacist, whose every decision is checked over, to a consciously competent (learning) pharmacist. It is important as a supervisor to support junior pharmacists to be precise and safe and promote optimal therapies for patients. Regular teaching can help newly qualified pharmacists understand the background evidence and rationale behind every clinical decision. As their knowledge and confidence grows, they will also find that the guidelines they frequently checked earlier in their career become embedded knowledge, making their clinical decisions quicker and more efficient. Take it a step further by encouraging junior pharmacists to get involved in redrafting guidelines and shaping the development of the skills we want to encourage in future generations of pharmacists.

Solidify the basics and provide opportunities to upskill

Medicines optimisation is a significant part of a pharmacist’s contribution to patient care. A pharmacist’s input should lead to improved patient outcomes ensuring that patients receive appropriate medication in the safest way possible with medicines optimisation forming a routine component of practice. 

Case-based presentations can provide good learning opportunities, allowing the junior pharmacist to reflect and discuss cases with colleagues. Regular teaching by specialist pharmacists is also important.

Clear documentation on discharge ensures that colleagues in primary care can continue supporting patients and implement secondary-care recommendations. Verbal and non-verbal counselling of medicines on discharge also empowers patients to be aware of their medication changes and how to take any new medicines prescribed. Support pharmacists with this by assessing their ability to perform these fundamental tasks.

Empower junior colleagues

As junior pharmacists practise and gain more experience, they will become more confident in their decisions. Ensure support is always available and let them know that many people have gone through what they’re going through. Show your trust in them, your team and the programme. 

Speak up

Within the NHS, there are national speak-up policies that encourage staff to feel safe and confident speaking up when they have concerns, whether about patient care or the workplace. Junior hospital pharmacists play an integral role in patient care, so it is important that they feel able to speak up when something is not right. It is important for supervisors to support and encourage this as well as to listen and respond as necessary. Everyone has a responsibility to ensure that the NHS and other pharmacy settings are providing the best care to patients and are safe, supportive and encouraging places to work. Supporting junior pharmacists in this encourages the confidence to verbalise and act on concerns.

A structured training programme can enable junior pharmacists to gain experience with governance and medication safety teams early on in their careers, which is to be encouraged also.

Scenarios

Below are four scenarios that a junior hospital pharmacist (‘you’) may experience and some suggestions for support in these situations.

1. It is the morning; you are on an older person’s ward, managing 20 beds. You are the sole pharmacist for the ward, but your band 7 colleague is managing the ward next door and you have their extension number so you can contact them if you have any questions. You have a trainee pharmacist working with you on the ward. When you come in, the nurse in charge lets you know that two of your patients are going home today, and they need to be home by 17:00 (when their package of care starts). One of these patients uses a dosette box at home. The procedure in your dispensary states that dosette boxes must be sent by 13:00 if they are to be dispensed that day. You also notice that you have two new patients who need their medication history completed. How do you handle these tasks?

This is a classic example of the tasks expected of a junior hospital pharmacist on a ward. The main considerations are learning how to prioritise the different tasks, such as the new patients and the patients being discharged. A ward-based assessment tool, completed by a senior pharmacist within the clinical team at the start of rotation, would ensure that supervisors can identify a newly qualified pharmacist’s work practice and provide practical tips on how to approach managing the workload of a ward. It also allows for progress to be tracked across time, providing a helpful overview of a junior hospital pharmacist’s progress at the end of each rotation. A thorough induction with exposure to the non-clinical teams also ensures that work processes are understood to aid newly qualified pharmacists with their decision making.

2. It is the afternoon; you are with a band 7 pharmacist managing a busy admissions ward. You have seen all your new patients but are waiting for the doctors’ ward round to finish so you know the plans for patients being discharged. One patient assigned to be discharged was admitted with an infective exacerbation of chronic obstructive pulmonary disease. The patient has been rude to the nurses, and you are now being put under pressure to prepare the medication for discharge quickly. You have also been asked by the doctors to identify an appropriate dose of enoxaparin for a patient with suspected pulmonary embolism with stage four chronic kidney disease. You also need to review a patient you haven’t seen in a couple of days who is being treated for hospital-acquired pneumonia with gentamicin and amoxicillin. How do you handle these tasks?

As is often the case, barriers appear that are out of the pharmacist’s control. Remember, the priority is ensuring patients are safe. It is important that newly qualified pharmacists are aware of their position within the MDT. Senior members of the team should be available to support junior pharmacists, especially with complex clinical decisions (e.g. the enoxaparin dose or reviewing the therapeutic drug monitoring for high-risk drugs), and these can be turned into teaching and learning opportunities.

Likewise, if a colleague is uncomfortable speaking to members of the MDT, why not perform a ‘direct observation of practical skills’ evaluation so that they can learn where they can improve. It will also benefit the newly qualified pharmacist as it will provide them with assessments to be used in their diploma portfolio of evidence. 

3. You are the on-call pharmacist, working remotely from home, and you receive a phone call at 02:00. It is a nurse calling from the intensive care unit (ICU), requesting levosimendan for a patient in ICU; their supply has run out. You take the patient’s details, and the nurse’s contact details and explain you will ring them back after clinically screening the drug and will provide instructions for supply.

It is easy to see why this scenario could be worrying — levosimendan is not even in the BNF — but a competency assessment prior to the new colleague beginning their on-call shifts should encourage them to trust their normal working processes, and if they still can’t find the information they need, they should be reminded that they can always contact the appropriate senior for support. Within a structured hospital pharmacy training programme, there is always support, even at 02:00. Safety of the patient and appropriate supply of medicines are always the most important factors.

4. One morning, before starting work, one of the senior pharmacists asks to speak to you. There has been a medication-related incident: a patient you had clinically screened had received two doses of gentamicin within a four-hour window. Unfortunately, you did not pick up the two prescriptions and the patient therefore received two doses and has suffered some harm. The error was reported by one of the nurses. 

How can reflection on this situation be encouraged? It may be productive to work with relevant colleagues to complete a root cause analysis method to understand how the error happened. This would also identify ways to improve their work process. How can they be best supported to deal with this personally? Are newly qualified team members aware of who they can speak to?

Mistakes happen to everyone — the most important thing is how we deal with the outcome to minimise harm where possible and learn from errors going forwards. In a structured programme, there is no shortage of support available, or people to speak to, and junior pharmacists should be regularly reminded of this.

Summary

Newly qualified pharmacists are learning on job in their first few years and need guidance and support to fully develop their knowledge and skills. All members of a MDT can offer such support, from nurses and pharmacy technicians to physical and speech therapists. It is important to have patience and encourage confidence in newly qualified pharmacists, build competence in the basics, give opportunities to upskill and provide a safe working environment.

The ‘Structured Training and Experience for Pharmacists’ (STEP) programme is one of a variety of different training programmes for newly qualified pharmacists across the UK, equipping hospital pharmacists to provide the best care for their patients (see Box). The future for pharmacists is exciting as we gain more advanced skills and responsibilities, contributing to a more patient-centred NHS.