Tip of the Week: Prescribing Medicines Must Be Done With Confidence and Competence
If pharmacists increasingly take up the prescribing mantle, then they must see to their competence to exercise that authority.
Prescribing is seen as sine qua non in the health professions. Pharmacists and other health professionals have long sought some level of prescribing authority and some of these professions, including pharmacy, have made some strides. Most would agree that without dedicated training in being diagnosticians, prescribing should be at least somewhat limited. However, there is a place for limited prescribing authority for other health professionals. How much and how wide a scope can and likely will continue to be debated for quite some time. The point here is not to argue either way. The key point of this Management Tip is that those responsible for prescribing should do so with the greatest level of competence, regardless of profession. What can we learn about competence in prescribing from the existing literature thus far in both pharmacy and in medicine?
This question was addressed in a scoping review of the literature published in the International Journal of Pharmacy Practice.1 The examination of 33 studies demonstrate that medical students and junior doctors are not competent in prescribing when they enter practice, and their perceived confidence is often higher than their assessed competence. Pharmacists, on the other hand, felt competent to prescribe but lacked the confidence to do so. Themes from the review included self-awareness, lack of education and educational improvements, prescribing errors and resources, prescribing culture and barriers to prescribing, gender differences, and benefits to prescribing.
One study reported that junior doctors were aware that they were making prescribing errors, yet rated their self-efficacy as high. However, in a more positive result, a significant association between prescribing confidence and fewer inappropriate prescription was described. In another study, medical residents recommended shadowing clinical pharmacists to improve their prescribing. In yet another group of studies, it was shown that prescribing experience decreases the rate of prescription errors. The lack of use, unfamiliarity or limited access to resources was related to in an increased risk of prescribing errors.
Organizational culture also matters, as in one study that reported a culture where pressures and hierarchies guided prescribing rather than the junior prescriber’s knowledge of adverse effects. Pharmacist barriers to prescribing included lack of confidence, lack of funding, lack of resources and administrative support, inadequate training in diagnosis, and a potential conflict of interest of acting as both prescriber and dispenser. One study found that female physician interns tended to underestimate their level of prescribing competence. Interestingly, a study of pharmacists also saw greater job satisfaction and recognition of the profession upon prescribing.
The relationship between prescribing confidence and competence is complex. While some clinicians might overestimate their ability, there is generally a positive relationship between self-efficacy (confidence) and prescribing competence. Other factors come into play, such as initial education, continuing education, senior mentors, and organizational culture. If pharmacists increasingly take up the prescribing mantle, then they must see to their competence to exercise that authority. Pharmacy managers can be of great help by fostering a culture that promotes competence, reinforces confidence, and which provides the necessary resources as well as technical and logistical knowledge to make prescribing a success.
Additional information about The “Management” in Medication Therapy Management and Managing Yourself for Success can be found in Pharmacy Management: Essentials for All Practice Settings, 5e.
ABOUT THE AUTHOR
Shane P. Desselle, RPh, PhD, FAPhA, is a professor of social and behavioral pharmacy at Touro University California College of Pharmacy.
Woit C, Yuksel, Charrois TL. Competence and confidence with prescribing in pharmacy and medicine: a scoping review. Intl J Pharm Pract. 2020;28(4):312-325.