Analysis of experienced pharmacist clinical decision-making for drug therapy management in the ambulatory care setting

Abstract

Objectives: The overarching objective of this research study was to document drug therapy decision-making processes of experienced pharmacists in the ambulatory care setting. The specific aims of this study were to examine the current clinical decisionmaking of experienced pharmacists in the context of the ambulatory care clinic setting, to compare and contrast pharmacist clinical decision-making with current decision-making models, and to identify enabling factors and barriers to clinical decision-making in the specific context of ambulatory care. Methods: This study used the thematic hermeneutic phenomenological human science methodology influenced by Dr. van Manen. After a feasibility pilot study of two experienced pharmacists in the Twin Cities of Minnesota, the main component of the dissertation research project included six experienced pharmacists throughout Minnesota and Iowa. Recruitment was done via e-mail request of eligible pharmacists known by faculty in Minnesota or Iowa and public information with a state association (the Minnesota Pharmacists Association). Three audio-taped data collection methods of participant observation, semi-structured interview, and personal audio-taping were utilized and exactly transcribed to provide textual data for analysis. Thematic analysis provided emerging themes of experienced pharmacist clinical decision-making which were further subdivided into subsuming themes after much reflection and interpretation of the entire study data. Results: Other health professions have identified experienced clinical decision-making to encompass the Hypothetico-Deductive Reasoning Model, Decision Analysis, intuition and pattern recognition. Pharmacists’ clinical decision-making processes are considered in light of other health professionals’ decision-making techniques; however the results show that experienced pharmacists use a different model of clinical decision-making using constant dialogue between two different types of knowledge (objective and context-related). The pharmacist must perform an active modification step necessary to combine the objective, factual information with the contextual, patient-related knowledge. With this modification, pharmacists are able to have complete situational understanding necessary for the final clinical decision. Although experienced, the pharmacist may have inadequate information to conduct the modification step necessary for understanding to make the clinical decision. The analysis suggests that the enabling factors and barriers to clinical decision-making are unique for each context. The availability of time to spend with patients and the effort in consulting with other health professional colleagues have enabled experienced pharmacists to ensure more patientcentered decisions in the general ambulatory care clinic setting; however, practicing within certain disease specialties and potential limited knowledge presented possible barriers in making more optimal clinical decisions. Conclusions: This research study may ultimately increase interprofessional work since there may be significant similarity between pharmacists’ and other health professionals’ experienced clinical decision-making. The cross-communication between different health professions may further improve decision-making processes and collaborative practice agreements. Also, this research may guide pharmacy education necessary to advance patient experiences for clinical decision-making based on better understanding of the practices of those experienced pharmacists with 5+ years of practice. Increased objective teaching should be encouraged in classrooms to provide for longer-lasting learning experiences for students. Finally, this study provides evidence for better understanding of the current pharmacy practice including clinical decision-making in the ambulatory care clinic setting, which may further expand the success of pharmacists’ contributions to improving patient care.