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About this chapter
This chapter deals with the need to intentionally support staff in developing evidence-based skills. While formal teaching has a place, most activity will be mentor based. We present a suggested minimum skill set and discuss ways of maintaining developments.
Evidence-based Pharmacy was first published as a textbook by Phil Wiffen in 2001. The first chapter was published in Eur J Hosp Pharm 2013;20:308–12
In the previous nine chapters, we have presented a good deal of information about the how and the what of evidence-based pharmacy (EBP). What we may not have stated clearly is that all this is based on changing attitudes so that practitioners attitudinally and intentionally set out to use evidence in their practice. While this may seem obvious, in practice we rely far more on what we have been taught or what we think we know rather than basing our decisions on high-quality evidence. Often, negative experiences can strongly influence our opinion in ways that are not always helpful. I (PW) remember the case of a paraplegic patient early in my career who took a single dose of ibuprofen, which led to acute renal failure requiring dialysis over several weeks. While this is an important lesson it does not mean that we should never use non-steroidal anti-inflammatory drugs for such patients but we should proceed with caution.
In this chapter, we share some techniques for mentoring and teaching EBP both in the academic setting and the hospital pharmacy department setting. We also set out some suggested minimum skill sets for evidence-based practice. Much of this is tried and tested rather than evidence based though there are some good quality studies using designs such as cluster randomisation.1
1. Why mentoring is important
Many concepts within EBP are difficult to teach in classroom or by just reading around the topic. Small projects such as those likely to arise in a medicines information service or clinical pharmacy can provide suitable topics for the less experienced to develop their appraisal skills.
Senior hospital pharmacists need to take the lead in ensuring that evidence is sought and applied in all aspects of the hospital pharmacy service, recognising that not all interventions or developments will be supported by high-level evidence. In addition, it is important to understand that the evidence is important in making decisions but is not the only criterion. Patient preference, cost and ethical considerations are also important though it would be good to see pharmacists putting cost lower down in their thinking as it so often leads to unhelpful decisions that can lead to patient harm. One example locally was the case of a patient with neuropathic pain who benefited from local anaesthetic patches. The commissioners decided that such a treatment was too expensive. The pain was such that the patient in the end had part of a limb amputated in an attempt to reduce the pain. Sadly, the pain remained.
2. Developing critical thinking skills
‘Critical thinking refers to the use of cognitive skills or strategies that increase the probability of a desirable outcome. Critical thinking is purposeful, reasoned, and goal-directed. It is the kind of thinking involved in solving problems, formulating inferences, calculating likelihoods, and making decisions. Critical thinkers use these skills appropriately, without prompting, and usually with conscious intent, in a variety of settings. That is, they are predisposed to think critically. When we think critically, we are evaluating the outcomes of our thought processes—how good a decision is or how well a problem is solved.’
These concepts are developed in other papers.2–4
The majority of pharmacists already apply these skills in their daily practice but need to add in the evidence-based concepts as part of the process. It is easy to fall into the trap of looking for the single correct answer, and in some cases such as dose or indication, this is fine. What critical thinking aims for is to develop an overall problem approach in such a way that knowledge is developed and there is greater confidence in the suggested solutions.
3. Teaching methods available and evidence to support them
Just about every method has been used to impart evidence-based practice skills including lectures, short courses, project work and assignments. The key elements of evidence-based learning are presented in box 1. In the experience of the authors a range of approaches seems to be the most effective, often combined with time away from the work base. Some teaching is necessary to provide the background and key elements such as those in the previous chapters published in this journal. Elements such as basic statistics, heterogeneity, bias and methodology have to be taught. However, much can be undertaken as practical exercises, particularly searching, critical appraisal, data extraction and manipulation, building meta-analyses and summarising evidence. Opportunities to gain skills in these areas need to be provided or encouraged by pharmacy management. Where these skills are not present within the pharmacy department, they can often be found within the hospital environment. For example, information specialists based in medical libraries are frequently very skilled at searching databases and are usually willing to help and impart their skills.
4. Role modelling
Act as role models on evidence-based practice and show students and junior staff how to incorporate evidence into practice.
5. Journal clubs
Many teams participate in journal clubs as a means of ongoing professional development. These can be useful for keeping up to date. An intentional evidence-based emphasis can add value to such clubs by taking the additional step of evaluating the evidence within a particular journal of interest or even by concentrating on a report claiming to be high-quality evidence. Ideally, attendees would undertake some appraisal of a paper before attending but a fuller appraisal can form a part of the discussion and is a good way for junior staff to acquire appraisal skills.
6. Promoting a CAT (critically appraised topic) culture6
CATs have been used for getting to grips with evidence-based concepts. The idea is to look for evidence to answer a question that arose from a clinical situation. CATs are designed to get clinicians involved with evidence by conducting a simple search and selecting a systematic review, a randomised controlled trial (RCT) or another type of evidence to answer the question. The next step is to appraise what has been found for reliability and applicability. The job is made easier by help sheets such as those on the Centre for Evidence-Based Medicine website under the heading of CAT maker. There is quite a lot of other useful material on this website to aid in teaching and mentoring.
7. Teaching critical appraisal skills
In the UK, a critical appraisals skills programme (CASP)7 was set up some years ago. The aim is to help professionals make decisions based on the best available evidence. They argue that if healthcare professionals and managers are going to make the best decisions, they need to be able to:
decide whether studies have been undertaken in a way that makes their findings reliable;
make sense of the results;
know what these results mean in the context of the decision that needs to be made.
The issue of critical appraisal was covered in Chapter 5. What CASP has done extremely well is to take the concepts and run short training programmes of 2–3 h outlining the concepts and getting attendees to undertake their own appraisal based on an academic paper. In this way, literally hundreds of mainly hospital staff have acquired critical appraisal skills.
8. EBP teaching integration into academic curricula
Current clinical pharmacy education curricula may provide some exposure to evidence-based practice in undergraduate training. In the UK this is far more likely to form part of postgraduate clinical diploma courses. Universities have a key role in the teaching of evidence-based methods; however, these often get squeezed out of curricula by other pressures.
9. Suggested minimum skill set for hospital pharmacists
The following should be regarded as the minimum skill set necessary to practice an evidence-based approach in the clinical setting:
Understand the basic concepts of EBP and describe the pros and cons of different types of literature.
Generate a meaningful clinical question using relevant concepts such as PICO (P—participants, I—intervention, C—comparison, O—outcomes).
Be able to appraise a systematic review and a RCT.
Be able to search for evidence related to a clinical query and apply the evidence back to the patient need.
Be able to appraise evidence presented in pharma promotional materials.
For those who work in medicines information or equivalent departments.
In addition to the above to be able to:
appraise other types of literature using appropriate critical appraisal tools;
undertake detailed and comprehensive searches across relevant databases for high-level evidence related to a well-defined clinical question;
prepare and present an evidence-based report on a medicine being considered for addition to a formulary or for consideration by a medicines committee.
10. Interprofessional education
Most hospital pharmacy departments will not have the ability to send large numbers away for training. Many courses provide training across professions and there are many benefits from such an approach.
Key elements of evidence-based learning5
Asking—converting the clinical question into a form that can be answered
Accessing—searching suitable resources to find an answer to clinical questions
Appraising—critically evaluating the evidence to decide if it is reliable and robust
Applying—extracting the useful information and addressing the thorny issues of generalisability and suitability to decide what clinical action is best
Educationalists8 talk about three key activities to ensure that developments are maintained:
Maintain the improvement beyond the implementation stage
The challenge is that as one thing changes, such as a move to establish evidence-based practice, there are consequences in other areas, some of which may not have been foreseen. One likely outcome is that a clinical pharmacist will take longer to complete his/her tasks because of the issues that arise from involvement with patients.
Extending the improvement effort after the initial success
Lessons from the business world show that maintaining success is never easy. It is easy to assume that a change has been implemented and that we can move on to something new. It is important to keep asking ‘how can we improve on what we did today?’ At the same time, we need to maintain and improve core services. Some experts call the lack of focus ‘coasting’, essentially a term meaning that we let things run without putting in effort.
Adapting improvement efforts over time
While our core values may not change, successful organisations need to evolve. Such things as practices, structures, job titles and specifications and schedules are all up for grabs.
An evidence-based approach is founded on the perspective and attitude of senior staff and needs to be intentionally modelled, taught and mentored. There are useful resources that can be used. Much useful material has been developed by other healthcare professions but readily transfer to pharmacy.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.