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Pharmacists’ Clinical Reasoning and Evaluation of Medication Appropriateness: Descriptive Analyses in Community Practice Open Access


Other title
protocol analysis
clinical reasoning
patient care process
decision making
Type of item
Degree grantor
University of Alberta
Author or creator
Nusair, Mohammad Bassam
Supervisor and department
Ken Cor (Pharmacy and Pharmaceutical Sciences)
Lisa Guirguis (Pharmacy and Pharmaceutical Sciences)
Examining committee member and department
Lisa Guirguis (co-supervisor, Pharmacy and Pharmaceutical Sciences)
Ken Cor (co-supervisor, Pharmacy and Pharmaceutical Sciences)
Mary Roduta Roberts (Occupational Therapy)
Tatianna Makhinova (Pharmacy and Pharmaceutical Sciences)
Michelle Chui (University of Wisconsin-Madison, Faculty of Pharmacy)
Faculty of Pharmacy and Pharmaceutical Sciences
Pharmacy Practice
Date accepted
Graduation date
2017-06:Spring 2017
Doctor of Philosophy
Degree level
The prevalence of drug-related problems puts a significant burden on the Canadian healthcare system. The literature that suggests that the majority of these drug-related problems are preventable, and could be identified and managed by pharmacists beforehand. This evidence suggests that pharmacists often miss opportunities to make decisions in regards to medication appropriateness. Therefore, it is essential to understand how pharmacists determine medication appropriateness to ultimately prevent drug-related problems. The research in this dissertation collectively aimed to understand what decisions pharmacists make in respect to medication appropriateness, and how pharmacists make these decisions. This objective was achieved through three related studies conduced in a community pharmacy setting: 1) a pilot study in a real-world setting that characterized what patient information pharmacists gather and how pharmacists apply the pharmacotherapy work-up when evaluating prescriptions, 2) a mixed-method study that characterized how pharmacists employ the patient care process when evaluating the appropriateness of prescriptions for a clinical simulation, and 3) protocol analysis of pharmacists’ verbal reports that described pharmacists’ clinical reasoning approaches. In the pilot study, we found that the majority of pharmacists’ time was devoted to dispensing activities. When pharmacists applied their clinical knowledge to check for medication appropriateness, it was primarily focused on checking medication safety, and covered more content areas when checking for new prescriptions in comparison to chronic refills. Furthermore, this study suggested that pharmacists rely mainly computer profile to collect patient clinical information, and they often asked patients non-specific questions, and missed patient cues. In the second study, we used a clinical simulation almost all pharmacists checked for medication indication, safety, and manageability, but this check primarily occurred at pick-up consultations. The majority of consultations were initiated and led by the pharmacist in a form of a monologue or dyad. Similar to the pilot study, the computer printout often played an important role in shaping a routine check for drug–drug interactions and allergies (i.e., safety). Moreover, pharmacists often missed empathetic opportunities and cues. In the third study, the majority of pharmacists used system 2 (i.e., analytical reasoning) to make decisions and system 1 (i.e., intuitive reasoning) was occasionally identified. In the CTA data, the majority of pharmacists were engaged in technical check for prescription accuracy, and they routinely checked for safety using system 2 reasoning. In structured RTA, pharmacists reported “overlooked” decisions and restructured decisions (i.e., hindsight reasoning) that did not appear in the simulation and CTA sessions. We also identified clinical reasoning approaches that were not identified in pharmacy studies before (i.e., automaticity, if/then, and dual process theory). This dissertation demonstrates that pharmacists follow routines to check for medication appropriateness. This routine was primarily guided by technical check and reliance on patient profile and computer printouts. We suggest adapting these printouts to include the pharmacotherapy work-up elements (i.e., indication, effectiveness, safe, manageability) to create a clinical routine check. Future research should explore if pharmacists’ reliance on technical and business-related routines is hindering them from applying appropriate clinical reasoning skills. We also recommend the replication of our methods (interconnecting phases of data collection and protocol analysis) to increase the depth and the completeness of studies in pharmacists’ clinical reasoning.
This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for the purpose of private, scholarly or scientific research. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.
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