Research ProjectLearning and assessment of consultation skills

for Non-Medical Prescribers.

Introduction:Having good consultation skills enables a person to communicate information so that

it is received and understood (Offredy, 2009). The learning and assessment of

consultation skills is essential, as good communication skills are required to bridge

the gap between evidence-based medicine and the individual patients to improve

health outcomes (Silverman et al, 2005). The clinical consultation is a vital step in a

patient's journey (Silverman et al. 2005, Steinberg 2005). It allows the clinician to

form a provisional diagnosis/diagnoses, order further investigations in order to

confirm or refute the diagnosis and formulate a treatment plan (Steinberg 2005). If

performed poorly, the consultation can lead to miss-diagnosis, miss-treatment or

poor patient compliance/concordance with treatment (National Institute for Clinical

Excellence, 2009).

Consultation Skills:Consultations form the basis for patient and practitioner interaction. They play a vital

role in communication between both parties. Observing and analyzing consultations

enables practitioners to evaluate the effectiveness of the communication process.

(Rafiq, 2010).

Nearly all of the literature on the subject of consultation skills and models produced

provides a structured guide to the consultation (Abdel-Tawab et al, 2006, Neighbour,

1987, Silverman et al, 1998).

Non-Medical Prescribing: The introduction of supplementary prescribing for nurses and pharmacists was

announced in November 2002. (Department of Health, 1999) This meant that

pharmacists would be able to prescribe for the first time and nurses would be able to

prescribe for long-term conditions. Then Independent prescribing was introduced in

2007, Independent prescribing involves registered pharmacists to train as pharmacist

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independent prescribers and prescribe any licensed medicine for any medical

condition, excluding all Controlled Drugs at present.

The Welsh School of Pharmacy (WSP) has delivered the non-medical prescribing

course in collaboration with the School of Nursing and Midwifery since 2004. From

the introduction of the course, more than 100 pharmacists and nurses have

successfully attained Non-Medical Prescriber qualification. (Ref WSP website).

This Postgraduate training course at WSP provides an educational and assessment

programme that prepares pharmacists for registration as Independent Prescribers

(IP) with the Royal Pharmaceutical Society of Great Britain (RPSGB) and nurses and

midwives as Independent Prescribers with the Nursing and Midwifery Council (NMC).

DSMP Role:This practice component for Independent Prescribers must be directed and assessed

by a named medical practitioner referred to as a designated supervised medical

practitioner (DSMP), who ideally works within the same area of practice as the

trainee. Whilst many doctors already have a training role and assessment skills, this

new role of supervisor and assessor of trainee non-medical prescriber’s may require

additional knowledge and skills.

Consultation skills are a fundamental component of the training for DSMP’s and IP’s.

Since DSMP’s need to assess the IP’s consultation skills on a regular basis and need

to make sure they are competent in this area. Both DSMP’s and IP’s need to be

aware of the standard of consultations and meet the necessary training

requirements.

This research project focuses on data collected from the teaching and assessment of

Designated Supervised Medical Practitioners (DSMP) and students training for the

non-medical prescribers course (independent prescribers training) at Welsh School

of Pharmacy in Cardiff.

DSMP Training:During the DSMP training day at WSP a simulated consultation is shown to all

DSMP’s and 4 sections of the Medication Related Consultation Framework (MRCF)

are rated. The MRCF was written by pharmacists specifically for pharmacist-patient

consultations and outlines a structured format for consultations focusing on

medication (Abdel-Tawab et al, 2006). The consultation skills of the practitioner in the

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simulated video are assessed by DSMP’s via the ratings. An overall mark for the

consultation is summed up and some comments given by each DSMP who has

attended the course that day (either morning or afternoon group).

Teaching of Consultation Skills to students:The course is taught over 8 months and involves 20 study days at WSP and 12 days

of supervised training which involves learning in practice under the supervision of a

Designated Supervised Medical Practitioner (DSMP). The course also involves

extensive amount of self and DSMP directed study. During the course assignments

and a NMP portfolio is completed.

One Course assignment involves students writing an essay which requires observing

consultation skills. Qualitative analysis of the student essays will enable reflection on

the teaching and practice of consultation skills. This technique is frequently employed

in the training in various medical disciplines (Schon 1983, Burnard 1995, Rolfe et al

2001). These essays have been collected for 2010 taught course and all students

involved have been anonymised. This study method would involve examining each

essay in order to quantify, which consultation models have been used and which

ones have been overlooked.

In both studies, the consultation skills and consultation models are being analyzed.

As both the DSMP and IP need to be on the same teaching level for consultation

skills in order for the DSMP to properly supervise the student independent prescriber.

Research Question:1. Which consultation models are the NMP students using?

2. What is the inter-rater reliability of DSMP ratings of consultation?

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Aims:

To evaluate inter-rater reliability of DSMP ratings of a video-taped consultation and

determine which consultation models students adopt for their new role as a

prescriber.

Objectives:

1. To determine the reliability of DSMP assessments of a videotaped

consultation.

2. To review student essays to elucidate which consultation models are adopted

for their reflective narratives.

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Method:Qualitative and quantitative methods are either explanatory techniques or exploratory

techniques. Therefore, each mode of analysis is applicable to the data itself.

Study 1 consists of inter-rater reliability analysis of DSMP ratings of a videotaped

consultation. Data has been collected since 2005 and 67 DSMP ratings have been

collated. All 67 DSMP’s have been shown the same videotaped consultation;

therefore, the ratings have been consistent.

Study 2 consists of analyzing the consultation models used within student narratives

that form part of the assessment for Independent Prescriber course at WSP. 30

student narratives have been collated for the student intake in 2010. All students

involved were nurses and pharmacists. By providing student numbers for

identification only, the student narratives have been fully anonymised.

Figure 1 gives a brief description of the study method.

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Method

Study 1 Study 2

67 DSMP ratings of a videotaped consultation

were quantitatively analyzed.

30 Non-Medical Prescribing student narratives were

analyzed to deduce which consultation models were used.

SPSS 18.0 was used to

analyze the ratings.

The degree of inter-rater reliability was evaluated between

each DSMP.

Figure 1:

Each essay was analyzed for

various consultation

models.

All essay were also analyzed for

therapeutic area involved and any

other issues.

Ethics Approval:In order to begin the research project it was necessary to obtain ethics approval. A

WSP research ethics approval form was submitted to the School Research Ethics

Committee (SREC). Information on data management, collecting personal data, and

data protection act were followed accordingly. All stored data had been anonymised

prior to the commencement of the project. All participants were informed that their

partaking is voluntary and they were made fully aware that the DSMP ratings (Study

1) and non-medical prescriber student narratives (Study 2) would be used in the

research project. Full consent was gained from all participants.

Study 1: 67 DSMP ‘s ratings were collected from 2005-2010; after the DSMP’s from each

cohort watched a videotaped simulated consultation, they all rated the consultation

sections individually and then noted their individual ratings for each section onto a flip

chart infront of the whole group. The sections involved were introduction, data

collection and problem identification, actions and solutions and closure. Each section

was given a rating between 0 and 4 (where 0 = the practitioner was not able to

demonstrate any of the consultation requirements and 4 = the practitioner was fully

able to demonstrate the consultation requirements.). A total overall mark was given

by summing up the individual section marks. The total mark was out of 20. Each

DSMP had the opportunity to give comments in a separate column on the flip chart.

As 1 DSMP rating for the consultation section was assigned a Zero (0) rating, the

SPSS programme cannot calculate with a rating of 0. Therefore, in order to assess

using SPSS all 67 DSMP ratings were transposed to an overall mark of 25 instead of

20 in order to analyze the ratings.

Participants: All 67 DSMP’s that attended the study day at WSP met the key

principles and criteria required in order to be eligible to attend the course. (See

Appendix 3 for DSMP key principles and criteria).

Recruitment: All participants were registered medical practitioners who have at least

3 years recent clinical experience for a group of patients in the relevant field of

practice.

Data Capture: To fully analyze the consultation observing consultation skills data

capture is essential. Data capture can be carried out using various social research

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methods. E.g. questionnaires, interviews, observation, and documents. This will be

followed by analysis, which can be carried out accordingly depending on the type of

research – which can be quantitative or qualitative analysis techniques.

Analysis: To begin with inter-rater reliability analysis of DSMP ratings was carried

out. The ratings were generated by all 67 DSMP’s watching a videotaped

consultation based on a structured assessment framework. All DSMP’s who have

attended the one-day training event at the WSP since 2005 were analysed and the

degree of consensus was quantitatively analysed.

The primary objective is to determine how reliable the DSMP assessments of

consultations are. Secondly the extent of consensus between the DSMP ratings will

be analysed using a statistical analysis programme – Statistical Package for the

Social Sciences (SPSS 18.0). This statistical package will give Descriptive statistics,

univariate statistics, Non-parametric tests, and prediction for identifying groups’

results, which then can give a clear indication of the degree of agreement between

the ratings.

Inter-rater reliability is the degree of agreement among raters. It gives an estimation

based on the correlation of scores between/among two or more raters who rate the

same item, scale, or instrument. a score is generated of how much concordance or

consensus is present within the data. It is useful in refining the tools given to

determine if a particular scale is appropriate for measuring a particular variable.

There are a number of statistics that can be used to determine inter-rater reliability.

Different statistics are appropriate for different types of measurement. Some options

and their descriptions are shown in Table 2 below:

Table 2:Types of

measurementDescription of measurement

Cohen’s Kappa Statistical measure of inter-rater agreement for qualitative

data. This method is tends to be a more robust measure

than simple percent agreement calculation since κ takes

into account the agreement occurring by chance.

Fleiss Kappa This statistical measure assesses the reliability of

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agreement between fixed numbers of raters. The measure

calculates the degree of agreement in classification over

that expected by chance and is scored as a number

between 0 and 1. Fleiss' kappa is only used with nominal

data.

Concordance correlation

This measures the agreements between two variables. In

order to evaluate reproducibility or for inter-rater reliability.

Cohen’s kappa is appropriate only when you have two judges. If you have more than

two judges, Fleiss Kappa analysis is more suitable.

Fleiss' kappa is a generalisation of Scott’s pi statistic, this is a ststistical measure of

inter-rater reliability. This measurement is also related to Cohen’s Kappa statistic.

Whereas Scott's pi and Cohen's kappa work for only two raters, Fleiss' kappa works

for any number of raters giving categorical rating to a fixed number of items. This can

be interpreted as communicating the degree to which the observed amount of

agreement among raters exceeds what would be expected if all raters made their

ratings completely randomly. It is important to note that whereas Cohen's kappa

assumes the same two raters have rated a set of items, Fleiss' kappa specifically

assumes that although there are a fixed number of raters, different items are rated by

different individuals (Fleiss, 1971 & Byrne, 2002)

SPSS is the most established of the software that can be used to calculate reliability.

A list of how Kappa might be interpreted (Landis & Koch, 1977) is given in the

following table 3 below:

Table 3:Kappa Interpretation

0

0.00 - 0.20

0.21 – 0.40

0.41 – 0.60

0.61 – 0.80

0.81 – 1.00

Poor agreement

Slight agreement

Fair agreement

Moderate agreement

Substantial agreement

Almost perfect agreement

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Study 2:Analysis of Student Non-medical prescriber (NMP) essays was carried out in order to

establish which consultation models were being used and which were not being

used. This would enable the teaching of consultation models and consultation skills

to be altered accordingly. Each year NMP’s from different therapeutic areas register

for the NMP course at Cardiff University and as part of this course all students must

complete a student narrative assignment. Please refer to Appendix 5 for the

assignment details).

Participants: Students of the non-medical prescribing course included nurses and

pharmacists working in a very broad range of therapeutic areas.

Recruitment: All NMP students were registered onto the postgraduate course at

Cardiff University.Data Capture: Students who attended the course in 2010 had to submit essays as

part of their assessments for the non-medical prescribing course at WSP. Student

marks for each essay have been omitted. And only student numbers were visible.

Analysis: A Qualitative analytical review of non-medical prescribing student

reflective narratives was carried out. The non-medical prescribers involved were

pharmacists and nurses. The data collected was reviewed retrospectively in order to

determine which consultation models were used for the basis of their reflection.

There are three main methods of qualitative analysis which are as listed below:

"Content analysis" is the name of the methodology that makes meaning of

communication. (Dey, 1993). In order to analyse the student essays the content

analysis method was chosen, as there is no need to develop formal theories or

cultural interpretation. A systematic qualitative analysis of the student narratives

enabled to determine which theoretical models of consultation are relevant to the

practice of non-medical prescribers. Firstly, indicators of themes in the narratives

were established, and then naming and coding of these indicators performed for

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Content analysis involves coding and counting in order to obtain a

statistical description and then model of analysis.

Qualitative classification involves coding and interpreting the data and

constructing a formal theory.

Discursive approaches this involves delineation of narratives to

allow cultural interpretation.

each document. The codes were then compared to find consistencies and

differences.

In order to begin the content analysis process, the coding framework was created. 10

theoretical models of consulting were chosen initially and each student essay was

analyzed to see which models were used and how many times each model was

mentioned in the text. Other analysis was also noted alongside the consultation

model coding, these included other models, comments, theories, and any issues that

may arise during the coding progression. (Please see Appendix 6 for the full Content

Analysis & Coding Framework).

As each non-medical prescriber student is from a range of theoretical backgrounds,

therefore each student may have used a consultation model relevant to their own

field of practice. Each students therapeutic area was also noted in content analysis in

order to evaluate if there were any differences in consultation models used between

different therapeutic areas.

PILOT of Coding Framework: after creating the coding framework the coding

process was carried out on 1 essay, which was chosen at random.

Then content analysis was performed on all 2010 intake student narratives and 2009

student narratives. 24 students attended the 2010 NMP course and 22 students in

2009.

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Results & Discussion:Study 1:The Kappa statistic corrects the simple inter-rater agreement for chance agreement,

and thus provides a better estimate in most cases of the reliability of categorical

behavioral observation data (Cohen, 1982). The Kappa ratio (k) expresses the

corrected proportion of agreement between raters as a ratio of the total proportion of

agreements corrected for chance responses. Like correlation coefficients, Kappa is a

bounded statistic that varies between -1.00 and +1.00. A positive value indicates that

proportion of agreement is greater than chance, and a negative value indicates that

the proportion of agreement is less than chance. A value of +1.00 indicates perfect

agreement between raters. A Kappa of 0.00 indicates that the raters agreement is

indistinguishable from chance.

In SPSS Kappa can be obtained as part of the cross-tabulation package.

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Discussion:Extending prescribing responsibilities to health care professionals other than doctors

and dentists is already playing a key role in achieving the aims of the NHS Plan by:

Increasing their contribution to meeting the needs of local health economies

Enabling teams of health care professionals to deliver more flexible services and,

sometimes, complete episodes of care for hard to reach and vulnerable groups

The introduction of non-medical prescribing is an integral part of the larger agenda to

modernize the NHS. The government clearly views the extension of prescribing

responsibilities as fundamental to this process. This has been confirmed within

several Department of Health (DH) documents during recent years. (Department of

Health).

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Appendix 1:

Supplementary Prescriber - Key principles

There are a number of key principles that should underpin supplementary prescribing. These

principles emphasize the importance of communication between the prescribing partners,

and the need for access to shared patient records. It is also essential that the patient is

treated as a partner in their care and is involved at all stages in decision making, including

whether part of their care is delivered via supplementary prescribing.

The criteria that are currently set in regulations for lawful supplementary prescribing are:-

The independent prescriber (IP) must be a doctor (or dentist) the supplementary prescriber

(SP) must be a Registered Nurse, Registered Midwife or a registered pharmacist

There must be a written Clinical Management Plan relating to a named patient and to that

patient's specific conditions. Both the independent and supplementary prescriber must record

agreement to the plan before supplementary prescribing begins

The independent and supplementary prescriber must share access to, consult and use the

same common patient record.

For supplementary prescribing, there will be no legal restrictions on the clinical conditions,

which supplementary prescribers may treat. As supplementary prescribing requires a

prescribing partnership and a Clinical Management Plan for the patient before it can begin, it

is likely to be most useful in dealing with long-term medical conditions such as asthma

diabetes or coronary heart disease, or with long-term health needs, such as anti-coagulation.

However, it will be for the independent prescriber with the supplementary prescriber to

decide, in drawing up the Clinical Management Plan, when supplementary prescribing will be

appropriate.

Unlike independent nurse prescribing, there is no specific formulary or list of medicines for

supplementary prescribing. Provided medicines are prescribable by a doctor or dentist (an

independent prescriber) at NHS expense, and that they are referred to in the patient's

Clinical Management Plan, supplementary prescribers are able to prescribe:

All General Sales List (GSL) medicines, Pharmacy (P) medicines, appliances and devices,

foods and other borderline substances approved by the Advisory Committee on Borderline

Substances.

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All prescription-only medicines with the current exception of controlled drugs [NB subject to

Parliamentary approval to changes to the Home Office's Misuse of Drugs Regulations and to

related amendments to NHS Regulations, nurses and pharmacists will be able to prescribe

controlled drugs under a supplementary prescribing arrangement later in 2004]

Medicines for use outside of their licensed indications (i.e. 'off label' prescribing), 'black

triangle' drugs, and drugs marked 'less suitable for prescribing' in the BNF

Unlicensed drugs that are part of a clinical trial, which has a clinical trial certificate or

exemption.

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Appendix 2:

Independent Prescriber – Key Principles:

15

Appendix 3:

DSMP Key Principles:

The role of the DSMP must meet certain criteria in order to supervise a non-medical

prescriber trainee. The doctor must be a registered medical practitioner who and meet the

following criteria:

Must possess at least 3 years recent clinical experience for a group of patients/clients in the

relevant field of practice;

Is within a GP practice / a specialist registrar / clinical assistant or a consultant within a NHS

Trust or other NHS employer and is either vocationally trained or is in possession of a

certificate of equivalent experience from the Joint Committee for Post-graduate Training in

General Practice Certificate (JCPTGP).

Has the support of the employing organization or GP practice to act as the designated

medical practitioner who will provide supervision, support, and opportunities to develop

competence in prescribing practice. Has some experience or training in teaching and or

supervising in practice.

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Appendix 4:

The Independent Prescribing Course at WSP -Postgraduate Certificate Non-Medical Prescribing

The Welsh School of Pharmacy and the School of Nursing and Midwifery Studies have

developed the programme to prepare pharmacists, nurses, midwives, and allied health

professionals to practice as Non-Medical Prescribers and to meet the relevant standards set

by the RPSGB, NMC and HPC. Furthermore, this eight-month programme develops the

critical analysis and personal reflection skills of course participants and prepares them for

lifelong professional development.

The programme consists of:

20 study days at Cardiff University (Cardiff and Caerleon sites) where topics such as

communication, consultation process, decision-making, therapeutics, clinical patient

assessment, and clinical governance will be covered. Prior learning may exempt some

students from some study sessions. Application for exemption will be required as part of the

course application process.

The equivalent of 12 days (as a minimum) learning in practice, developing clinical

assessment and prescribing skills under the supervision of the Designated Supervising

Medical Practitioner (DSMP). This equates to 78 hours for nurses/midwives/allied health

professionals and 90 hours for pharmacists, based upon the NMC, RPSGB, and HPC

requirements.

An extensive amount of study time including self directed, or course/DSMP directed study,

assignment writing, and completion of a Prescribing Portfolio

 

The course is made up of two 30 credit modules, at level HE4 (QAA) which equates to at least 600 hours of student effort.  

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Appendix 5:REFLECTIVE ASSIGNMENT 2

You are required to describe two consultations within your field of practice. One of

these must be a consultation that you have observed and the other one must be one

that you have been involved in. You are expected to critically appraise one or more

specific aspect/s of the consultations and in addition critically analyse the diagnostic

reasoning applied in one of the cases. Finally you are required to draw up a detailed

action plan for your professional practice.

It is expected that you will use the available literature to support your analysis in this

assignment.

The detailed descriptions of the two consultations may be applied as an appendix to

the assignment.

Word count: 3000 words

The marking assessment sheet for both of these assignments can be found overleaf.

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Appendix 6:Content Analysis & Coding Framework 2010:

19

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