Factors affecting feasibility and acceptability of a practice-based educational intervention to support evidence-based prescribing: a qualitative study
ABSTRACT Inappropriate and costly GP prescribing is a major problem facing Primary Care Trusts. Educational outreach into practices, alongside other measures, such as audit and feedback, have the potential to enable GP prescribing to become more evidence based. High GP prescribing costs are associated with GPs who see drug company representatives; tend to end consultations with prescriptions; and 'try out' new drugs on an 'ad hoc basis' and use this as evidence of the drug's effect. An educational intervention called 'reflective practice' was developed to meet these and other educational needs. The design of the intervention was informed by studies that have identified the pre-requisites of successful behaviour change in general practice.
The study investigated the following: (i) Is it feasible for GPs to attend the sessions included in the educational intervention? (ii) Is the intervention acceptable to the participants and the session facilitators? (iii) What are the barriers to the group educational processes, and how can these be overcome?
Four practices were recruited in South West England, all of them experiencing problems with prescribing appropriateness and cost. Reflective practice sessions (including a video-taped scenario) were run in each of these practices and qualitative methods were used to explore the complex attitudes and behaviour of the participants. A researcher observed and audio-taped sessions in each practice. At the end of the programme, a sample of doctors and all the facilitators were interviewed about their experiences. The recorded data were transcribed and analysed using standard qualitative methods.
The doctors in the largest partnerships were those who had the greatest difficulty in attending the sessions. Elsewhere, doctors were also reluctant to become involved because of previous experience of top-down managerial initiatives about prescribing quality. Facilitators came from a broad range of professional backgrounds. While knowledge of prescribed drug management issues was important, the professional background of the facilitator was less important than group facilitation skills in creating a group process which participating GPs found satisfactory. The video-taped scenario was found to be useful to set the scene for the discussion. Preserving the anonymity of responses of the GPs in the initial stages of the sessions was important in ensuring honesty in the discussion. Reaching a consensus on management of common conditions was sometimes difficult, partly because the use of the term 'best buy' implies economic pressures, rather than benefits to patients, and partly because of the value with which GPs regard the concept of clinical autonomy. 'Reflective Practice' appeared to have the potential to make GPs aware of the link to be made between their clinical management decisions and the evidence provided by the British National Formulary and Clinical Evidence.
The study indicates the importance of preparing the practice adequately, including providing protected time for all GPs to attend the educational intervention. Scenarios and the structure of the sessions need to make more explicit the links between everyday practice and published evidence of effectiveness. Emphasis on cost-effectiveness may be counterproductive and wider benefits need to be emphasized. We have also identified the skill profile of the facilitator role. Our study indicates a need for a clearer understanding of GPs' perception of clinical autonomy and how this conflicts with the goal of agreement on practice guidelines for treatment. The intervention is now ripe for further development, perhaps by integrating it with other interventions to change professional behaviour. The improved intervention should then be evaluated in a randomized controlled trial.
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- "Peer group discussion, especially related to clinical cases, is effective but there can be problems with group dynamics and attendance at these face-to-face meetings can be difficult for busy healthcare professionals. (Watkins et al., 2004) The use of e-learning has the potential to overcome these difficulties, allowing individual healthcare professionals to access educational resources at a time and a place that is convenient. E-learning has already been shown to improve the knowledge and problem-solving skills for a variety of different kinds of health professionals. "
ABSTRACT: Purpose – The aim of this paper is to assess the impact of e-learning resources based on NICE guidelines in improving knowledge and changing practice among health professionals. Design/methodology/approach – NICE in collaboration with BMJ Learning developed a series of e-learning modules based on NICE recommendations relating to osteoarthritis, irritable bowel syndrome, urinary tract infection in children, and antibiotic prophylaxis against infective endocarditis. The impact of these modules was evaluated by looking at the knowledge and skills of the learners before and after they did the modules and also asking the learners about resultant practice change. Findings – A total of 5,116 users completed the modules. Completing them enabled users to increase their knowledge and skills score from the pre-test to the post-test by a statistically significant amount (p < 0.001): from a mean of 65 per cent to 85 per cent. Qualitative feedback to the modules was overwhelmingly positive. To test long-term effectiveness, users were e-mailed six weeks after they had completed the modules to assess practice change. The response rate to the survey was 22.2 per cent. In total 88.6 per cent of those who had cared for patients with these problems since completing the module said that it had helped them put NICE guidelines into practice. Research limitations/implications – E-learning modules have high uptake, are popular and effective at helping health professionals learn about NICE guidelines and help them to put these guidelines into practice. Originality/value – The study is valuable as it shows how interactive and multimedia resources help health professionals learn about guidelines. No previous studies have been identified.Clinical Governance An International Journal 01/2010; 15(1):6-11. DOI:10.1108/14777271011017329
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ABSTRACT: A variety of methods exists for teaching and learning evidence-based medicine (EBM). However, there is much debate about the effectiveness of various EBM teaching and learning activities, resulting in a lack of consensus as to what methods constitute the best educational practice. There is a need for a clear hierarchy of educational activities to effectively impart and acquire competence in EBM skills. This paper develops such a hierarchy based on current empirical and theoretical evidence. EBM requires that health care decisions be based on the best available valid and relevant evidence. To achieve this, teachers delivering EBM curricula need to inculcate amongst learners the skills to gain, assess, apply, integrate and communicate new knowledge in clinical decision-making. Empirical and theoretical evidence suggests that there is a hierarchy of teaching and learning activities in terms of their educational effectiveness: Level 1, interactive and clinically integrated activities; Level 2(a), interactive but classroom based activities; Level 2(b), didactic but clinically integrated activities; and Level 3, didactic, classroom or standalone teaching. All health care professionals need to understand and implement the principles of EBM to improve care of their patients. Interactive and clinically integrated teaching and learning activities provide the basis for the best educational practice in this field.BMC Medical Education 02/2006; 6:59. DOI:10.1186/1472-6920-6-59 · 1.41 Impact Factor
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ABSTRACT: Research has shown that a number of patients, with a variety of diagnoses, are admitted to hospital when it is not essential and can remain in hospital unnecessarily. To date, research in this area has been primarily quantitative. The purpose of this study was to explore the perceived causes of inappropriate or prolonged lengths of stay and focuses on a specific population (i.e., patients with long term neurological conditions). We also wanted to identify interventions which might avoid admission or expedite discharge as periods of hospitalisation pose particular risks for this group. Two focus groups were conducted with a convenience sample of eight primary and secondary care clinicians working in the Derbyshire area. Data were analysed using a thematic content approach. The participants identified a number of key causes of inappropriate admissions and lengths of stay, including: the limited capacity of health and social care resources; poor communication between primary and secondary care clinicians and the cautiousness of clinicians who manage patients in community settings. The participants also suggested a number of strategies that may prevent inappropriate admissions or reduce length of stay (LoS), including: the introduction of new sub-acute care facilities; the introduction of auxiliary nurses to support specialist nursing staff and patient held summaries of specialist consultations. Clinicians in both the secondary and primary care sectors acknowledged that some admissions were unnecessary and some patients remain in hospital for a prolonged period. These events were attributed to problems with the current capacity or structuring of services. It was noted, for example, that there is a shortage of appropriate therapeutic services and that the distribution of beds between community and sub-acute care should be reviewed.BMC Health Services Research 02/2009; 9:44. DOI:10.1186/1472-6963-9-44 · 1.66 Impact Factor