Background
Methods
Design and setting
Participant sampling and recruitment
Data collection
Data analysis
Identification of key theoretical domains
Triangulation
Mapping of key theoretical domains to BCTs
Draft intervention development
Task group work and selection of final intervention components
Results
Sample characteristics
General practitioners (n = 15) | Community pharmacists (n = 15) | |
---|---|---|
Participant gender | ||
Male | 7 | 8 |
Female | 8 | 7 |
Years of professional practice (range) | 5–30 | 1–27 |
HSC Trust area | ||
Belfast | 3 | 4 |
Northern | 4 | 3 |
Southern | 5 | 2 |
South Eastern | 2 | 3 |
Western | 1 | 3 |
Summary of findings from TDF analysis
Both GPs and community pharmacists believed that adherence was poor amongst PwD, with particular concern about over-adherence (‘Beliefs about consequences’):“ … often I feel that patients might benefit from coming off tablets than being on a lot of things, maybe that would be something in the future that happens more?” [GP_15]
“I think you just have to assume it’s [adherence] not going to be very good. They’re always at risk aren’t they? Even if it’s [medication] in a weekly dispensing pack, there’s many ones that open up the wrong day and take two lots [of tablets].” [GP_13]
“ … because you don’t know if they’re going to not use, or if they’re going to overuse … My concern would also be the overdosing on medicines as well.” [CP_13]
“Whenever you prescribe for an individual, you’re looking at the whole situation.” [GP_01]
This was facilitated by building good relationships with patients and carers (‘Skills’) and, for community pharmacists in particular, a break in continuity of pharmacist care was a barrier to this (‘Social/professional role and identity’):“It’s very good to understand their family situation and who is looking in on them … just checking the patient isn’t becoming isolated and that there are people out there who can support them.” [CP_03]
A small number of pharmacists discussed difficulties in dealing with challenging behaviours that may be exhibited by PwD (e.g. agitation, aggression) and the lack of training in this area (‘Skills’).“ … you really need to know the patient. There’s no point in one pharmacist dealing with the patient one week and another pharmacist dealing with them the next week” [CP_11]
“Carers often feedback to us if they’re [patient] not taking it [medication] correctly, in which case we try and address it.” [GP_05]
“If you’ve done something and want to follow up on it, you can speak to a carer or somebody that you can rely on for them to phone you back, you need to put some sort of safety net there.” [GP_15]
Both HCP groups felt that optimising medicines for PwD was part of their professional responsibility (‘Social/professional role and identity’). Community pharmacists felt that their accessibility within primary care was a facilitator:“…family members know the patient better than anyone, so they can advise you what is going to suit a particular patient better.” [CP_09]
Whilst each HCP group acknowledged the good working relationship they had with the other HCP group as a facilitator to achieving optimal patient care, some professional boundaries were discussed (‘Social/professional role and identity’). GPs focused on the boundaries they encountered with secondary care, and how this influenced their professional confidence when monitoring prescribing of dementia drugs (‘Beliefs about capabilities’):“…we may deal with these patients more than any other healthcare professional. They might not see their GP as often.” [CP_02]
“There’s a bit of a cut-off between GPs and consultants…I don’t feel there’s a very natural relationship.” [GP_07]
Some community pharmacists mentioned professional boundaries with GPs. However, conversely, GPs were positive about community pharmacists’ input with these patients (‘Social influences’/‘Social/professional role and identity’), with many reporting that community pharmacists were a useful resource (‘Environmental context and resources’) often bringing medicines management-related issues to their attention (‘Memory, attention and decision processes’). GPs also recognised the role of practice-based pharmacists in the future, particularly with regard to prescribing and medication review (‘Environmental context and resources’):“…because specialist dementia drugs are secondary care initiated, I am a little bit… more hesitant, because how do I measure whether they’re working or not?” [GP_10]
“…it’s not the first time I’ve prescribed something and the chemist says, ‘Are you sure you want to prescribe this?” [GP_13]
A number of emotions were expressed by participants when discussing medicines management for PwD. Both HCP groups demonstrated empathy towards patients, but expressed concern about their vulnerability, describing feelings of anxiety and worry (‘Emotion’). Such feelings were heightened when dealing with patients alone, without a carer/family member present:“There is certainly a role which needs to be developed for a pharmacist or prescribing pharmacist in surgeries to review all [dementia] patients, but particularly [those] on numerous drugs, say five, ten or more items” [GP_01]
“You do worry more with patients with dementia. You know, just, is it safe? It’s simple as that, is a medication safe, whatever they’re on.” [GP_15]
Some community pharmacists described feeling loss of control once PwD had left the pharmacy and were managing their medicines at home (‘Emotion’) which also influenced their professional confidence (‘Beliefs about capabilities’):“There are times when I am nervous. If it is the patient themselves, sometimes you just don’t know that what you’re saying is going in…” [CP_09]
“What the total unknown is when you give out medication is what really is happening…” [CP_02]
“We can be sure that we have given them the right medications with the right instructions and the right information, but after that it is beyond our control” [CP_05]
“Primary care has changed whereby the patients that we are seeing tend to be complex, they tend to be elderly… to try and sort these patients in ten minutes is now becoming impossible.” [GP_12]
Some participants did not view PwD as any greater a priority than other patient groups (‘Goals’) and lack of financial reward or other incentives (‘Reinforcement’) was also cited as barrier:“We have a great desire… great intention…, but we just haven’t found ourselves with an awful lot of time to do them [medication reviews].” [CP_05]
“My concern would be that those are not the only patients that are looked at…we have a much bigger problem going on in our practice. It is not just dementia.” [GP_08]
“Weekly dispensing isn’t money for the pharmacy anymore. It’s done at a cost to us.” [CP_01]
Identification of key theoretical domains
Theoretical domain | GP | Community pharmacist | ||
---|---|---|---|---|
Prescribing | Conducting medication review | Monitoring adherence | Conducting medication review | |
Knowledge | ✓ | ✓ | ||
Skills | ✓ | ✓ | ✓ | |
Memory, attention and decision processes | ✓ | ✓ | ||
Behavioural regulation | ✓ | ✓ | ✓ | |
Social/professional role and identity | ✓ | |||
Beliefs about capabilities | ✓ | ✓ | ||
Beliefs about consequences | ✓ | ✓ | ✓ | |
Goals | ✓ | ✓ | ✓ | |
Reinforcement | ✓ | ✓ | ✓ | |
Emotion | ✓ | ✓ | ||
Environmental context and resources | ✓ | ✓ | ✓ | ✓ |
Social influences | ✓ | ✓ | ✓ | ✓ |
Mapping of theoretical domains to BCTs
Key TDF domain | Behaviour change techniques (BCTs) selected to target the TDF domain |
---|---|
Knowledge | Health consequencesa |
Skills | Modelling/demonstration of behaviour by othersb |
Memory, attention and decision processes | Self-monitoringb Planning, implementationb (equivalent to ‘Action planning’) |
Behavioural regulation | Self-monitoring of behavioura Planning, implementationb (equivalent to ‘Action planning’) |
Social/professional role and identity | Social processes of encouragement, pressure, supportb |
Beliefs about capabilities | Self-monitoringb Social processes of encouragement, pressure, supportb |
Beliefs about consequences | Salience of consequencesa Social and environmental consequencesa Self-monitoringb |
Goals | Action planning (including implementation intentions)a Social processes of encouragement, pressure, supportb |
Reinforcement | None selectedc |
Emotion | None selectedc |
Environmental context and resources | None selectedc |
Social influences | Modelling or demonstrating the behavioura Social process of encouragement, pressure, supportb Modelling/demonstration of behaviour by othersb |
Draft intervention development
Task group work and selection of final intervention
GP-based intervention | Community pharmacy-based intervention | |
---|---|---|
Strengths | • Likely to be an acceptable and practicable intervention. • One video preferred to multiple versions; preference for focus on medication review than prescribing. • Preference for resources to be made available online rather than paper-based; however online system must be easy to access and simple to navigate. | • Likely to be an affordable, practicable and acceptable intervention. • Presence of carer helpful to reduce patient anxiety/ reliance on patient report of information. • Mentoring system or online forum positively received. Links with local practice-based pharmacist would be useful and would help to strengthen and co-ordinate connections between GP and community pharmacist. |
Limitations | • Due to heterogeneity among dementia patients in terms of staging/severity and medication issues, it will need to be clear to whom the intervention is aimed if it is to be effective (video may need to be tailored for different stages/severities). • Action planning document not considered to be acceptable. • Mentoring system not considered practical, as regular meetings already take place within practices and similar systems are already in place, particularly in large GP surgeries. | • Due to heterogeneity among dementia patients in terms of staging/severity and medication issues, it will need to be clear to whom the intervention is aimed if it is to be effective (video may need to be tailored for different stages/severities). • Time constraints if only one pharmacist on staff – pharmacists may not always be able to watch the video during working hours. Video must be concise. |
Suggestions | • A ‘protocol’ should be developed to complement the video, which could include key information on contraindications and drug interactions, and which could be referred to when prescribing or conducting a medication review with a PwD. • Use of webinars or online discussion forums with multidisciplinary input suggested instead of mentoring systems. | • One video of no more than 15 min’ duration would be most practical. As it could reach a wider audience, it may also be cost-effective. • Further suggestions for ‘protocol’ content, e.g. common instances of potentially inappropriate prescribing, useful resources for healthcare professionals or for signposting patients/carers. |
Description | Embedded BCT(s) | Mechanisms of action |
---|---|---|
A short online video demonstrating how a community pharmacist would conduct a medication review (incorporating adherence checking) with a PwD and their carer. The video would feature an authentic clinical case, incorporating relevant epidemiological data [7] and drawing upon clinical experience of research team. The positive outcomes of the consultation would be emphasised by including feedback from the pharmacist, PwD and their carer. | Modelling or demonstration of behaviour Health consequences Salience of consequences Social and environmental consequences | Skills, social influences, knowledge, beliefs about consequences |
A complementary ‘quick reference guide’ (also made available online) to which pharmacists could refer during the medication review and adherence check. This guide would provide information on, e.g. common instances of potentially inappropriate prescribing, common drug interactions with drugs prescribed for dementia, guidance regarding antipsychotic drug use, tips on communicating with PwD, practice points on monitoring adherence in PwD, and useful sources of further information. | Modelling or demonstration of behaviour | Skills, social influences |
After the pharmacist had watched the video and read the ‘quick reference guide’, they would identify suitable dementia patients from the pharmacy computer system and schedule an appointment for a PwD and their carer to attend the pharmacy for a face-to-face medication review and adherence check. | Action planning | Memory, attention and decision processes, behavioural regulation, goals |
Following the review, the pharmacist would complete a clinical record form outlining any changes to the patient’s medication that they recommended. These would be shared with the patient’s GP and recorded on the pharmacy PMR so that the pharmacist could clearly see if their recommendations had been implemented by the GP. | Self-monitoring of behaviour | Memory, attention and decision processes, behavioural regulation, beliefs about capabilities, beliefs about consequences |
Pharmacists would also be encouraged to liaise with the practice-based pharmacist for support and guidance during the process (e.g. to help resolve any issues arising from the medication review/adherence check). | Social processes of encouragement, pressure, support | Social/professional role and identity, beliefs about capabilities, goals, social influences |