The prescribing team in secondary care – collaboration a hierarchy

By Olivia Timbs

By Mary Tully, Reader in Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of Manchester

This lecture gives an overview of how the attributes of teamwork could be applied to prescribing in secondary care. Xyrichis & Ream considered teamwork to be “a dynamic process involving two or more health professionals with complementary backgrounds and skills, sharing common health goals, and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care. This is accomplished through interdependent collaboration, open communication and shared decision-making”.¹  Although only two of the research studies that I described had teamwork as an explicit part of the data collection strategy, we have found teamwork recurring in a lot of our research.

On admission to hospital, the prescriber will initially attempt to identify what medication the patient was taking at home. Admission to hospital is the stage at which most prescribing errors were likely to occur, with 13.4% of medication orders containing an error.² The medicines reconciliation process, currently delivered by pharmacy staff as standard practice in NHS hospitals, ensures the preparation of an up-to-date and accurate medication list. Preliminary results from ongoing work with pharmacists and doctors suggest that there is only occasional teamwork in the medicines reconciliation process, involving pharmacists, pharmacy technicians and doctors. 

The European working Time directive had a huge impact on the hospital medical team. Previously, the medical team was a tight cohesive unit that worked together during the day and did on call together at night.  Now, the shift system means that doctors can be working with a different team of people each time they worked nights. Nonetheless, there are still many of the attributes of teams to be seen in the way that the doctors, and sometimes the pharmacists, describe what happens around prescribing and prescribing errors during the patients’ stay.

In a team we would expect to see two or more health professionals with complementary backgrounds and skills.  This is certainly the different grades of doctors, but can also include the pharmacist.  There was some evidence that pharmacists were seen as part of a team with the common goal of safe prescribing, with communication and some shared decision making.²  Pharmacist prescribers felt that their qualification had quite an impact on how they felt regarding membership of the team.  They were very positive about what the authority to prescribe meant for their own work.³  So there was certainly evidence in our results that pharmacists working on the ward were part of a team.

Factors such as prescribing to facilitate the wider team, and the influence of the medical hierarchy influences how the doctors choose to prescribe4.  In some cases, junior doctors were willing to break the rules, such as prescribing after a medication had already been administered, to ensure the interdependent functioning of the multidisciplinary team.  They were aware that such routine violations ensured the smooth running of the service for the patient. Although it frequently made the doctors feel uncomfortable, they still prescribed. 

Teams of doctors still operate within a hierarchal structure, with the junior doctor at the bottom and the consultant at the top.  Clearly this has a lot of advantages for junior doctors.  In our interviews about prescribing errors, they talked a lot about seeking advice from their seniors whenever they were unsure what to do.²  In our work about uncomfortable prescribing, when faced with a difficult prescribing decision or a difficult patient, they felt that they could pass the responsibility to senior doctors.⁴  Not all junior doctors could discuss problems with their seniors, however, when they wanted to share decision-making.  This could be because of the hierarchical issues or because their senior colleagues were rarely physically available, such as surgeons spending most of their time in theatre.

One of the important attributes of teamwork is that there is open communication between the members.  With shift working, face-to-face communication is reduced, so doctors depend upon the medical record.  However, the record isn’t a full description of absolutely everything that has happened.  The doctors consider the medical record to be primarily a tool to use to transfer information between health-care professionals responsible for the care of the patient.  They expect the other health-care professionals to know the ‘norm’ about what is going on in the ward5 and they do not necessarily record information they expect their colleagues to know. This can cause problems later, such as at the time of the patient’s discharge. At that point, junior doctors write the discharge summary, containing both the list of medicines to be dispensed and the instructions to the general practitioner as to what needs to be done for the future care of the patient.  At this point, the prescribing team broadens out to include primary care and initially we would want to see open communication and shared decision making.

Unfortunately, the doctor writing the discharge summary may have just returned to working days, after a week of nights, and therefore is totally dependent on what is written in the medical records to know what to write in that discharge prescription.  If it isn’t in the medical records, and the doctor wasn’t present during the decision-making, information is unlikely to be written in the discharge prescription.⁵ In addition, the doctors who are writing those discharge summaries or discharge letters also expect the GPs to be able to “read between the lines”, in the same way as they do their ward-based colleagues.  However, GPs actually much more explicit instructions about what to do – they don’t have that knowledge of what is common practice on the ward that the hospital doctors think they do.⁶

Some people need regular care by both hospital doctors and general practitioners, because of their condition.  Shared care arrangements have been set up in some areas to try to improve the way that this works. Therefore, it would be expected that these arrangements were likely to reflect some of the attributes of teamwork.  However, open communication was problematic and GPs had particular issues around the sharing of information about, for example, laboratory test results and getting access to specialist advice when needed⁷, which does not promote shared decision-making.

This presentation has just skimmed the surface of our published research data with a new set of glasses. I did not reanalyse the raw data, clearly a key limitation.  Nonetheless, what I saw was that, except for what was happening in the traditional ward-based medical team, there was not a lot of strong evidence for teamwork happening in secondary care prescribing.  Poor or total lack of communication seemed to be a particular problem, as it inhibited shared decision making.

One of the analogies that I feel is very relevant here is that of parallel play by toddlers, where they play side-by-side in the same physical space, enjoying each other’s company but not playing together.  It isn’t until children become much older that they co-operative play, and we see teams developing. We might consider what we see happening throughout the prescribing process in secondary care as “parallel working” rather than teamworking.

Unlike in nursing, intensive care and surgery, very little has been written in pharmacy about teamwork.  There are some questions that could be addressed in future research, such as whether engaging in prescribing as a team based activity would make a difference to patient care or whether we should improve the integration of clinical pharmacists and non-medical prescribers into the wider prescribing team.  We might also consider whether, as a prescribing profession ourselves, we could learn from observing teamwork in medical teams as to what to do and not to do.

References

1.     Xyrichis A, Ream E. Teamwork: a concept analysis. J Adv Nurs 2008 Jan;61(2):232-41.
2.     Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. London: General Medical Council; 2009.
3.     Tully MP, Latif S, Cantrill JA, Parker D. Pharmacists’ changing views of their supplementary prescribing authority. Pharm World Sci 2007 Dec;29(6):628-34.
4.     Lewis PJ, Tully MP. Uncomfortable prescribing decisions in hospitals: the impact of teamwork. J R Soc Med 2009 Nov;102(11):481-8.
5.     Tully MP, Cantrill JA. Insights into creation and use of prescribing documentation in the hospital medical record. J Eval Clin Pract 2005;11:430-5.
6.     Crowe S, Tully MP, Cantrill JA. Information in general medical practices: the information processing model. Fam Pract 2010 Apr;27(2):230-6.
7.     Crowe S, Cantrill JA, Tully MP. Shared care arrangements for specialist drugs in the UK: the challenges facing GP adherence. Qual Saf Health Care 2010 Dec 1;19(6e54):1-5.