How do pharmacy students describe decision-making about drug therapy?

Introduction: Therapeutic decision-making is offered as a term to describe the responsibility that pharmacists have as medicines experts for making decisions about drug therapy for individual patients. There is a lack of research describing how pharmacy students learn to make therapeutic decisions. Methods: Qualitative methods were used to interview twelve final-year undergraduate pharmacy students. Data were analysed inductively to identify the steps in the process, the definition, and attitudes students learned about therapeutic decision-making. Results: According to these pharmacy students, the process and definition involve four steps; identifying medicines related problems via differential diagnosis, exploring treatment options, weighing up the options, and making a recommendation. Attitudes were confidence, open-mindedness, and bias awareness. Discussion: These findings align with a proposed model for therapeutic decision-making in pharmacy practice, however, this study did not determine if the students could apply the model in practice. Conclusion: These findings can be used as a benchmark for enhancing the pharmacy curriculum to include decision-making skills about drug therapy for future practice settings.


Introduction
Clinical decision-making is a fundamental skill for all health care professionals. As experts in medicines use, pharmacists are often responsible for decisions related to drug therapy, termed 'therapeutic decision-making'  or 'management decision-making' in a medical context (Cook, Sherbino and Durning, 2018a;2018b). Pharmacists routinely make therapeutic decisions when providing advice about minor ailments in a community practice setting. A pharmacist will go through a triage process, decide if referral to a physician is required, and if not, may recommend a suitable treatment from the limited range of medicines available without a prescription. While this decision-making scenario has been a routine part of practice for many years, the profession is currently undergoing a rapid change from one focused on the supply of medicines to a profession focused on the provision of patient-facing clinical services such as medicines assessment review and prescribing (International Pharmaceutical Federation, 2015). Practice settings are also expanding, with a trend in some countries for pharmacists to move away from the retail environment to non-dispensing roles in the primary care setting (e.g., GP practices) (Anderson et al., 2019;Hazen et al., 2018). These new roles will require a future pharmacy workforce with suitable skills and knowledge to take responsibility for drug therapy decisions in the face of uncertainty and to handle decisions for complex patients with multiple comorbidities. However, in practice, pharmacists appear to be reluctant to make drug therapy decisions and lack confidence when faced with situations of uncertainty (Gregory, Whyte and Austin, 2016;Sinopoulou, Summerfield and Rutter, 2017). Even pharmacists in advanced practice roles, who acknowledge that difficult therapeutic decisions are commonplace, lack the language to describe how decisions are actually made when designing a patient-centred treatment plan . There is, therefore, a need for a better understanding about how pharmacists learn decision-making about drug therapy so that current teaching models can be enhanced and revised. As a first step, the following study aimed to describe the process of decision-making about drug therapy for pharmacy practice learned by pharmacy students.

Methods
This study used qualitative interview methods (Denzin and Lincoln, 2018;Rubin and Rubin, 2012) to describe process of decision-making about drug therapy learned by final-year pharmacy students at the School of Pharmacy, University of Otago, New Zealand. Ethical approval was obtained from the University of Otago Human Ethics Committee (D19/069). The research team discussed the relevance of this study to Māori with the Ngai Tāhu Research Consultation Committee.
Convenience sampling was used to select participants from the population of 140 fourth-year pharmacy students in their final year of a four-year undergraduate pharmacy programme. This programme prepared students to complete their internship year, prior to registration as a pharmacist qualified to practice in range of care settings across New Zealand. A semi-structured interview protocol was constructed by the first and last authors and content validity was established by peer-review with pharmacy colleagues at the University of Otago. The protocol also included demographic questions (See Appendix 1).
Six of the study participants were co-researchers in this study (the second to eighth authors). Each of six student researchers interviewed one student researcher and one other member of their fourth-year cohort. Interviews were digitally audio recorded then transcribed verbatim by the student researchers. The transcripts were checked for accuracy by the research team and validated by participants who expressed interest in doing so. No participants made changes to their transcript. To maintain participant confidentiality, transcripts were anonymised for analysis and reporting. Transcripts were analysed thematically using a general inductive approach (Thomas, 2006). Each student researcher worked independently to code four transcripts. This procedure ensured that each transcript was coded independently by two different people to reduce bias in the coding procedure. To make the project Anakin M, Cuthbert A, Luo Q, Mwangi B, Scoggins R, Tang A, Wong V, Wright D MedEdPublish https://doi.org/10.15694/mep.2020.000020.1 Page | 3 manageable, three features of therapeutic decision-making in the interviews were coded: the steps in the process, the definition, and attitudes. The research team met to discuss and define potential themes for each feature. A theme was defined when codes assigned to that theme was found in at least three transcripts. To make reporting manageable, similar themes were combined until between 3 to 5 themes remained for each feature of decision-making about drug therapy.

Results/Analysis
The twelve participants were aged between 21 and 26 years old and represented eight different ethnicities (5 New Zealand European, 2 Malaysian Chinese, 1 African, 1 African West Indian, 1 Chinese, 1 Korean, 1 Samoan). The gender ratio of females to males was 8:4. These demographics were generally representative of the cohort of fourthyear pharmacy students.
The decision-making process about drug therapy described by study participants generally consisted of four steps (see Table 1). The first step involved gathering relevant information from a range of sources. Sources included information about medicines from standard sources such as the New Zealand Formulary (NZF http://nzformulary.org/), and the Best Practice Advocacy Centre (BPAC https://bpac.org.nz/) New Zealand, as well as consultation with other healthcare practitioners and the patient. The second step required identifying treatment options and considering them in relation to the information gathered about the patient. The third step involved weighing up the pros and cons for each option and selecting the best option by considering the risk/benefit the medicine's use for their patient specifically. The fourth step involved making a treatment recommendation to the patient or another healthcare practitioner and where the outcome may be unknown to the pharmacist who made the recommendation. Decisions were generally phrased as 'suggestions' (P2), 'recommendations' (P4) or 'treatment option' (P12). Therapeutic decision-making was defined by the study participants as a process that had two main features summed up by participant 6, 'Making decisions is basically differential diagnosis and then treatment options based on the person'. First, it involved preforming a differential diagnosis because 'it's the process of eliminating things to get to the final decision' (P5). This process involves 'identifying the problem, gathering all the information for that problem' (P7). Second it requires 'looking at all of the different options available for the patient' (P4) and 'choosing which of those options is best for the situations presented (P12). Being open to different kinds of opinion, able to digest them and able to compromise and reach consensus … hearing other cases you haven't encountered and put yourself in their shoes and see more possibilities and how other pharmacists deal with the problem and approaches (P5).
Bias awareness was also mentioned by participant 5 who said, 'people might have biases, they might think a particular point weighs more than other points'. This attitude required listening to others and being willing to make compromises because, 'you need to be balanced but not biased" (P7).

Discussion
Results of this study may be interpreted to suggest that final-year undergraduate pharmacy students at the School of Pharmacy at the University of Otago have learned a four step process for therapeutic decision-making. The four steps include information gathering, identifying options in relation to the patient's goal, weighing options, and making recommendations.
The teaching model traditionally used for therapeutic decisions in the pharmacy programme at the University of Otago is based loosely on the Pharmaceutical Care concept (Hepler and Strand, 1990). The model has three steps, the so-called Problems-Options-Plan (POP) approach, where patient drug-related problems are identified, options for management are explored, and a treatment plan is constructed. While a reasonable teaching tool, the POP model lacks detail about how to manage patient complexity, and how a pharmacist or student might distinguish which of the options identified is optimal for a particular patient. To address this lack of detail, a new teaching model called therapeutic decision-making has been trialled based on a four step patient-focused process. The therapeutic decision-making model includes teaching about how to manage patient complexity, prioritisation of drug related problems, mapping of patient goals with medical goals and treatment options, as well as specific skills for determining an optimal treatment plan and implementing a decision . The therapeutic decision-making model has been trialled in a new cohort of students who entered the pharmacy programme in 2018. It is important to note that the students interviewed for this study were in the cohort who entered the programme in 2017 so did not receive teaching using the therapeutic decision-making model. Therefore, the finding that these students described a four step process for making decisions about drug therapy that roughly mirrors the steps of the therapeutic-decision making model, came as a surprise to the research team. This finding may be explained by insider knowledge of the therapeutic decision-making model by the six of the participants who were also co-researchers in this study and because participating students may have looked at the new teaching materials that includes this model. While study participants appear to be able to describe the four steps, we have yet to determine if they can apply these steps when providing patient care. A future study that examines student performance when describing and using their decision-making about drug therapy via an assessment activity might help to clarify the depth of student knowledge about the therapeutic decision-making model and its use in practice.
The attitudes students reported learning along with the process of making decisions about drug therapy were confidence, open-mindedness, and bias awareness. These attitudes may be interpreted to suggest that pharmacy students learn to be cautious when making decisions. They emphasised the importance of consulting with other pharmacists. Language choices for their decisions included recommendation, suggestion, and option which may be interpreted to suggest that they were comfortable to relinquish responsibility of treatment decisions to other healthcare practitioners. This finding reflects the language used by advanced care pharmacist in New Zealand to describe their decisions .
Although the interview protocol was developed by experienced researchers, students inexperienced in research conducted the participant interviews, therefore, key information may not have been gathered as they may not be able to identify when to ask next questions or probe responses. Additionally, the interviews took place before participants' fourth-year community pharmacy placements and, for some, hospital pharmacy placements, which may explain the high prevalence of examples of therapeutic decision-making based on a classroom experiences instead of from practice.
Despite these limitations, findings from this study will be used to enhance the new teaching model for making decisions about drug therapy. This enhancement will allow local pharmacy educators to address the need for explicit teaching about decision-making as pharmacists take on more patient-facing clinical services, prescribing, and move into non-dispensing roles where they will be responsible for patient therapy decisions.
The findings and the methods used in this study may be of interest to pharmacy educators internationally so they can investigate the process of decision-making about drug therapy for pharmacy practice learned by their pharmacy students. We encourage pharmacy educators to replicate this study at their institutions to determine whether similar views to those found in this study are shared by students at a similar level of pharmacy education.

Conclusion
Findings from this study describe four steps in the decision-making about drug therapy process learned by pharmacy students: information gathering, identifying options in relation to the patient's goal, weighing options, and making a recommendation. Confidence, open-mindedness, and bias awareness were decision-making attitudes students learned for pharmacy practice that were also compatible duties performed in community practice settings. These findings can be used as a benchmark for enhancing the pharmacy curriculum to include the teaching of therapeutic decisionmaking skills that can be applied in a wider range of practice settings.

Take Home Messages
The decision-making process about drug therapy described by final-year undergraduate pharmacy students has four steps.
The four steps are information gathering, identifying options in relation to the patient's goal, weighing options, and making a recommendation.
Confidence, open-mindedness, and bias awareness were the therapeutic decision-making attitudes that students learned for pharmacy practice.

Notes On Contributors
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