What is the contribution of a peer support intervention in addressing the challenges faced by novice community pharmacists at transition to independent practice?
Aims and Objectives
The overall aim of the PhD is to develop a peer support intervention for novice community pharmacists at transition to practice. The first and second years provided the theoretical evidence base for challenges that novice community pharmacists face and the use of peer support in transition support programmes. The focus of this application is the third and final year of the PhD. This aims to feasibility test and refine an evidence-based peer support intervention for newly qualified (novice) community pharmacists (NCPs). The objectives of the project are to:-
- Test the feasibility and acceptability of a peer support intervention
- Clarify the suitability of outcomes and their measures
- Identify the variance of outcome measures
- Consult with stakeholders to sense check the findings of the feasibility study and discuss the transferability of the intervention into practice
- Inform iterative changes and refinements for the final intervention framework and make recommendations for wider roll-out and evaluation/testing
The transition to independent practice by newly registered (novice) practitioners starts as a novice practitioner becomes professionally accountable for patient care(1, 2). It has been widely documented in nursing and medical literature as a challenging period that may last up to three years(3-6). During transition, a disconnect occurs between old and new needs, structures and expectations, and the novice practitioner must learn to adapt to their new role and environment(7). There is limited evidence from research studies in pharmacy and anecdotal reports which have documented a number of challenges reported by early career pharmacists(8). It seems that particular challenges are present in community pharmacy, such as high workloads, low job satisfaction, conflict between clinical and commercial work demands, organisational culture and professional isolation(9-13). Despite this, none of these studies have explicitly investigated links between transition experiences of novice community pharmacists (NCPs) and these challenges. The proposal detailed here investigates this link as part of a 3-year PhD programme and provides the background to the proposed research study.
Context of community pharmacy transitions
Though a paucity of research exists about the transition experiences of pharmacists, extensive published literature reporting the transition experiences of novice doctors and nurses was therefore reviewed in the first year of this PhD. This review summarised the challenges they experienced, the effects of these challenges and considered them in the context of the community pharmacy setting. A summary of the findings and their relevance to community pharmacy follows.
The challenges faced by novice practitioners in medicine and nursing resulted from personal, social and workplace experiences during the transition period. Findings showed that these challenges were believed to impact negatively on learning and professional development, practitioner performance, career progression, staff retention and the quality of patient care and patient safety(14-18). It is likely that pharmacists may experience similar challenges at transition however, the impact of contextual differences in the community pharmacy setting which may influence the transition period for NCPs, must be considered.
In recent years, the role of the community pharmacist has evolved, and community pharmacists are providing a more clinical role in public health initiatives, managing long term conditions and medicines optimisation services(19). Despite this paradigm shift, community pharmacists continue to have a managerial, rather than a clinical career pathway to guide their professional development(20). Much of the recent workforce research in community pharmacy has focussed on increasing workload; this is attributed to an increasing elderly population and cuts to pharmacy funding, reduced staffing and a more commercially focussed workplace setting(21, 22).
Moreover, unlike many other healthcare professionals, community pharmacists often work as the sole practitioner on a site, regardless of their level of experience(11). Therefore many NCPs begin their professional careers in isolation, without the developmental support gained from working alongside experienced peers within a community of practice(23). Unlike novice nurses and doctors, they acquire full and immediate accountability for patient care from day one of registered practice, while also assuming leadership and/or managerial demands for established teams(21). Being the least experienced member of the teams they are expected to manage, forces NCPs to negotiate the complexities of an ‘inverse hierarchy’.
The challenges faced by novice community pharmacists at transition
Ongoing GPhC’ proposals for revalidation and standards for pharmacy professionals, and the RPS Foundation Pharmacy Framework, indicate that professional development is a growing priority for the pharmacy profession(24). As such, it is timely to explore the challenges faced by NCPs as they enter practice.
A recent longitudinal study on professionalism in pharmacists followed a group of trainee pharmacists through pre-registration training to four months post registration. Participants from that study reported challenges associated with taking accountability for clinical decisions, adjusting to working procedures, managing workloads and fitting in with the team(25). Recent/ongoing research projects from other organisations conducting workforce development research are exploring pre-registration tutor training, curricular outcomes of degree programmes (University of Manchester), educational support needs of novice pharmacists (University College London) and the challenges facing novice hospital pharmacists (Manchester Royal Infirmary and Birmingham). While some findings may potentially be similar, this PhD is the first to specifically focus on transition challenges in the context of community pharmacy. This focus was the subject of the second year of this PhD.
Empirical work carried out in year 2 of this PhD project aimed to identify the specific challenges faced by NCPs at transition to practice. Nominal group discussions each lasting up to two hours were conducted with four homogenous groups of community pharmacy staff; pharmacists qualified less than 12 months, pharmacists qualified 2 or 3 years, pre-registration tutors and pharmacy staff. Early findings indicate that the transition period for employee and self-employed NCPs appears challenging. In particular, NCPs were fearful and anxious about being professionally accountable, making clinical, legal, and ethical decisions in isolation from professional peers and managing relationships in the workplace.
Furthermore, findings showed the challenges encountered by NCPs were perceived to influence their ability, capacity, and motivation to identify and act upon learning needs, limit their access to developmental feedback and affect their help-seeking behaviours. The consequences of these challenges were reported to affect how NCPs practised; they were very task-focussed, internalised and non-holistic [putting their personal welfare before that of patients], and by admission from all NCPs in the discussion, risk averse.
The argument for peer support and its rationale in other HCPs
Nursing, medical and other professions, have developed evidence-based, formal/informal transition support interventions (TSIs), to ease the challenges faced at transition(26, 27). TSIs are regarded as an effective strategy to ease the transition of novice practitioners and mitigate the effects of transition challenges; they are therefore recommended by professional regulators of medicine and nursing in the UK. A scoping review of the literature during year 1 of the PhD was used to propose a TSI for NCPs. This review reported that the outcomes of TSIs include individual, organisational and patient benefits which are demonstrated through increased measures of confidence, self-reported proficiency and self-efficacy, increased staff retention and improved quality of patient care(28-30). Studies from medicine, nursing and other healthcare professions also conclude that having peer support delivered by a defined/designated person is considered best practice(31, 32).
An individual designated to provide peer support to novices facilitates transition to practice by providing emotional, educational, social, developmental and professional support(33-36). This is perceived to increase confidence, self-efficacy ratings, job satisfaction, practitioner performance, meaningful learning, and ultimately, the quality of patient care(37-39). Taking into consideration the similarities of the challenges faced by NCPs and novice doctors and nurses, as well as the professional isolation that NCPs face, a peer support intervention for NCPs appears to be a logical. There are currently no support interventions [based on empirical evidence] aimed to address the transition challenges of NCPs, despite evidence documenting the challenging experiences of early career pharmacists.
Of the many forms of peer support, the approaches most often used in TSIs, are mentoring, buddying, and coaching(40, 41). The terms are often used interchangeably, however, differences in how these roles are enacted affects the suitability of that approach and the specific problem it addresses. While mentoring applies the long term provision of support for career advancement from a position of benevolent authority, buddying is a less formal mutually beneficial shared experience(40, 42). Peer coaching implies a more collaborative and equal relationship, between an experienced individual and a willing participant(43). For this research it will be defined as ‘a confidential collaborative relationship between an experienced individual and a willing participant, aimed to promote reflection and independent problem-solving, and provide a ‘sounding board and feedback’ function.
Providing peer support through mentoring, buddying, or coaching has traditionally been on a one-to-one, face-to-face basis(41, 44). In recent years, group mentoring or coaching, using virtual rather than face-to-face meetings, has offered a cost-effective, flexible approach to peer support which promotes relational learning(41, 45). Group participants gain support from their coach and each other and in doing do utilise the group as a resource for problem solving and critical thinking.
The overall aim of this proposal is to develop an evidence-based [one-to-group] TSI tailored to address the challenges faced by NCPs at transition. While the literature review for year 1 of the PhD provided the theoretical evidence base for the transition challenges and intervention design, year 2 of the PhD identified the specific challenges experienced by NCPs that the intervention aims to address. Medical Research Council (MRC) guidance on developing complex interventions will be used in conjunction with behaviour change theory, to test the feasibility and acceptability of the intervention and clarify the outcome measures(46, 47). Findings will also be used to inform policy in professional development for foundation years pharmacy and frameworks for implementing peer support and continuing fitness to practice/revalidation.
PART A: FEASIBILITY STUDY
The peer support intervention is a 20-week programme for NCPs where peer coaching is delivered by an experienced practitioner. For the purpose of year 3, NCP is defined as a pharmacist registered with the GPhC in August 2016, and beginning independent practice in the community setting, in the month of August 2016. Novices and coach will attend a meeting at the University of Manchester, in Week 0 of the programme [July 2016] before the first day of independent practice. At the meeting, novices will receive programme resources [handbook containing programme goals/outcomes, modular content, templates, resources, on-line log-in details] sign a learning contract and complete a questionnaire to capture baseline measures. Contact between the novices and the coach will be via social media (WhatsApp), email, telephone and/or face-to-face meetings, according to individual novice needs.
During the programme, novices will attend 3 meetings, complete 5 reflective logs, 5 individualised professional development action plans (IPDAPs), 3 questionnaires and 2 semi-structured interviews. The coach (principal investigator) will organise meetings, keep meeting notes, complete a contact log, and a reflective diary. All these activities will be components of the coaching programme (meetings, novice reflective logs, IPDAPs, contact log) and/or the data collection/evaluation strategy (meeting notes, reflective logs, questionnaires, semi-structured interviews, contact log, coach reflective diary) [Table 1].
- To provide opportunities to engage in peer support and establish a peer support network for novices
- To coach novices on how to develop critical thinking, decision-making skills and team-working skills and increase self-efficacy score
- To support novices to develop reflective practice and self-awareness skills through individualised professional development action plans (IPDAP)
- To promote well-being at work.
Six pre-registration trainees who have passed the 2016 June sitting of the GPhC registration assessment and secured post-registration employment in community pharmacy, will be purposively recruited to provide maximum variation in sampling. While this number may be too low for extensive quantitative analysis or to achieve data saturation from qualitative methods, six participants is sufficient for feasibility testing and is achievable within the scope of this project(55). A case study approach using several methods of data collection will collect detailed data, allow for triangulation of findings, and increase the transferability of those findings(56). The PI (practising pharmacist, former pre-registration tutor and university lecturer) will serve as the group’s single peer coach, to improve consistency in delivery of the intervention.
Eligibility and recruitment
Participants will meet the following inclusion criteria; graduated with a UK MPharm degree and due to commence work as an employee/self-employed community pharmacist in August 2016. They will work in a range of settings (independent, small multiple, large multiple and supermarket pharmacies), to allow contextual variables to be considered, and to improve transferability of the findings across different community pharmacy settings. Geographical boundaries will be set in order that participants are able to attend face-to-face meetings. An email will be sent to employers of pre-registration trainees, pre-registration training companies, university facilitators and the BPSA, to cascade the invitation to potential participants.
Data collection and analysis methods
Data from the feasibility study will be collected by questionnaires, reflective logs, meeting notes, contact logs and semi-structured interviews. Questionnaires completed by novices will monitor changes in likely outcomes [such as self-efficacy, proficiency and teamwork],analyse whether the intervention contributes to changes in these outcomes, and whether the degree of variance would be appropriate and sensitive for future pilot testing of the intervention. Reflective logs and IPDAPs [paper or on-line] will be analysed thematically to investigate the extent of engagement in reflective practice, the development of self-awareness skills and to provide further insight into professional development needs for NCPs(57). Semi-structured interviews lasting 30 minutes will be conducted with the novices during and after completion of the programme by another researcher, as the PI who is delivering the intervention, is known to the novices. Interviews will explore novices’ experiences and perceptions of how the intervention has contributed to addressing the challenges they faced during transition to practice, and whether the length and content of the programme was appropriate. Interviews will be recorded with permission, transcribed verbatim, and analysed thematically in NVivo 10. using an interpretive Heideggerian approach(58, 59). Completion of reflective logs, questionnaires and a contact log will also be analysed to report on engagement with the programme. (Table 1)
PART B: STAKEHOLDER MEETING
A stakeholder meeting will take place where a summary of findings from the intervention will be presented. Consultation on the [pilot-ready] peer mentorship intervention framework, performance/outcomes-related findings, feasibility, and acceptability, with stakeholders will help facilitate likely engagement, implementation, and uptake.
PART C : FINAL MODELLING PROCESS
Findings from data analysis of the feasibility study and the stakeholder consultation will inform final changes to the intervention framework for the NPCCP programme. A statistician from the University of Manchester will then be consulted to discuss the effect sizes and the power calculation required to pilot test the intervention on a national scale(60).
- Krautscheid LC. Defining Professional Nursing Accountability: A Literature Review. Journal of Professional Nursing. 2014;30(1):43-7.
- Donaldson LJ. Professional accountability in a changing world. The Journal of Continuing Medical Education. 2001;77:65-7.
- Sheehan D, Wilkinson TJ, Bowie E. Becoming a practitioner: Workplace learning during the junior doctor’s first year. Medical Teacher. 2012;34(11):936-45.
- Tallentire VR, Smith SE, Skinner J, Cameron HS. Understanding the behaviour of newly qualified doctors in acute care contexts. Medical Education. 2011;45(10):995-1005.
- Maxwell C, Brigham L, Logan J, Smith A. Challenges facing newly qualified community nurses: a qualitative study British Journal of Community Nursing 2011;16(6):428-34.
- Duchscher J. Transition shock: the initial stage of role adaptation for newly graduated Registered Nurses. Journal of Advanced Nursing. 2009;65(5):1103-13.
- Meleis A, Sawyer L, Im EO, Hilfinger Messias D, Schumacher K. Experiencing Transitions- An Emerging Middle-Range Theory. Advances in Nursing Science. 2000;23(1):12-28.
- Anon. Newly qualified are ill-equipped for modern-day pharmacy. Pharmaceutical Journal26 May 2006. p. 623.
- Gidman W. Increasing community pharmacy workloads in England: causes and consequences. International journal of clinical pharmacy. 2011;33(3):512-20. Epub 2011/03/23.
- Eden M, Schafheutle EI, Hassell K. Workload pressure among recently qualified pharmacists: An exploratory study of intentions to leave the profession. International Journal of Pharmacy Practice. 2009;17(3):181-7.
- Cooper RJ, Bissell P, Wingfield J. `Islands’ and `doctor’s tool’: the ethical significance of isolation and subordination in UK community pharmacy. Health:. 2009;13(3):297-316.
- Seston E, Hassell K, Ferguson J, Hann M. Exploring the relationship between pharmacists’ job satisfaction, intention to quit the profession, and actual quitting. Research in Social and Administrative Pharmacy. 2009;5(2):121-32.
- Elvey R, Hassell K, Lewis P, Schafheutle E, Willis S, Harrison S. Patient-centred professionalism in pharmacy: values and behaviours. Journal of Health Organization and Management. 2015;29(3):413-30.
- Wangensteen S, Johansson IS, Nordstrom G. The first year as a graduate nurse–an experience of growth and development. J Clin Nurs. 2008;17(14):1877-85. Epub 2008/06/27.
- Kilminster S, Zukas M, Quinton N, Roberts T. Preparedness is not enough: understanding transitions as critically intensive learning periods. Medical Education. 2011;45(10):1006-15.
- Goh K, Watt E. From ‘dependent on’ to ‘depended on’ : the experience of transition from student to registered nurse in a private hospital graduate program. Australian Journal of Advanced Nursing 2003;21(1):14-20.
- Satterfield JM, Becerra C. Developmental challenges, stressors and coping strategies in medical residents: a qualitative analysis of support groups. Medical Education. 2010;44(9):908-16.
- Kelly B. Preserving moral integrity- a follow up study with new graduate nurses. Journal of Advanced Nursing 1998;28(5):1134-45.
- Schafheutle EI, Hassell K, Noyce PR. Ensuring continuing fitness to practice in the pharmacy workforce: Understanding the challenges of revalidation. Research in Social and Administrative Pharmacy. 2013;9(2):199-214.
- Jacobs S, Ashcroft D, Hassell K. Culture in community pharmacy organisations:what can we glean from the literature? . Journal of Health Organization and Management. 2011;25(4):420-54.
- Jacobs S, Hassell K, Ashcroft D, Johnson S, O’Connor E. Workplace stress in community pharmacies in England: associations with individual, organizational and job characteristics. J Health Serv Res Policy. 2014;19(1):27-33. Epub 2013/09/10.
- Lea VM, Corlett SA, Rodgers RM. Workload and its impact on community pharmacists’ job satisfaction and stress: a review of the literature. The International journal of pharmacy practice. 2012;20(4):259-71. Epub 2012/07/11.
- Thrysoe L, Hounsgaard L, Dohn NB, Wagner L. Newly qualified nurses — Experiences of interaction with members of a community of practice. Nurse Education Today. 2012;32(5):551-5.
- Society RP. Foundation Pharmacy Framework. 2014. p. 1-26.
- Jee S. The process of professional socialisation and development of professionalism during pre-registration training in pharmacy [PhD]: University of Manchester; 2014.
- Whitehead B, Owen P, Holmes D, Beddingham E, Simmons M, Henshaw L, et al. Supporting newly qualified nurses in the UK: A systematic literature review. Nurse Education Today. 2013;33(4):370-7.
- Bjerknes M, Bjork I. Entry into Nursing: An ethnographic study of newly qualified nurses taking on the nursing roel in a hospital setting Nursing research and practice. 2012;2012:7 pages
- Moore ML. Preceptorships: hidden benefits to the organization. Journal for nurses in staff development : JNSD : official journal of the National Nursing Staff Development Organization. 2008;24(1):E9-E15.
- Kramer M, Maguire P, Halfer D, Budin WC, Hall DS, Goodloe L, et al. The organizational transformative power of nurse residency programs. Nursing Administration Quarterly. 2012;36(2):155-68.
- Cameron A, Millar J, Szmidt N, Hanlon K, Cleland J. Can new doctors be prepared for practice? A review. The Clinical Teacher. 2014;11(3):188-92.
- Kramer M, Maguire P, Schmalenberg C, Halfer D, Budin WC, Hall DS, et al. Components and Strategies of Nurse Residency Programs Effective in New Graduate Socialization. Western Journal of Nursing Research. 2013;35(5):566-89.
- Moore P, Cagle CS. The lived experience of new nurses: Importance of the clinical preceptor. The Journal of Continuing Education in Nursing. 2012;43(12):555-65.
- Thomka LA. Graduate nurses’ experiences of interactions with professional nursing staff during transition to the professional role. Journal of Continuing Education in Nursing. 2001;32(1):15-9.
- Bullock A, Fox F, Barnes R, Doran N, Hardyman W, Moss D, et al. Transitions in medicine: Trainee doctor stress and support mechanisms. Journal of Workplace Learning. 2013;25(6):368-82.
- Tyler S, Bourbon E, Cox S, Day N, Fineran C, Rexford D, et al. Clinical competency, self-efficacy, and job satisfaction: perceptions of the staff nurse. J Nurses Staff Dev. 2012;28(1):32-5. Epub 2012/01/21.
- Jordan R, Farley CL. The Confidence to Practice Midwifery: Preceptor Influence on Student Self-Efficacy. The Journal of Midwifery & Women’s Health. 2008;53(5):413-20.
- Allanach BC, Jennings BM. Evaluating the effects of a nurse preceptorship programme. Journal of Advanced Nursing. 1990;15(1):22-8.
- Marks-Maran D, Ooms A, Tapping J, Muir J, Phillips S, Burke L. A preceptorship programme for newly qualified nurses: A study of preceptees’ perceptions. Nurse Education Today. 2013;33(11):1428-34.
- Rush KL, Adamack M, Gordon J, Lilly M, Janke R. Best practices of formal new graduate nurse transition programs: An integrative review. International Journal of Nursing Studies. 2013;50(3):345-56.
- McQuiston LS, Hanna K. Peer coaching: an overlooked resource. Nurse educator. 2015;40(2):105-8. Epub 2014/10/29.
- Emelo R. Group mentoring best practices. Industrial and Commercial Training. 2011;43(4):221-7.
- St-Jean E. Mentoring as professional development for novice entrepreneurs: maximizing the learning1 Mentoring as professional development for novice entrepreneurs: maximizing the learning. International Journal of Training & Development. 2012;16(3):200-16.
- Hampton G. A Practical Guide to Mentoring, Coaching and Peer-networking Teacher Professional Development in Schools and Colleges. Rhodes C, Stokes M, editors. Hoboken: Hoboken : Taylor and Francis; 2004.
- Kostovich CT, Thurn KE. Group mentoring: a story of transition for undergraduate baccalaureate nursing students. Nurse Educ Today. 2013;33(4):413-8. Epub 2013/01/22.
- Hunt JH, Powell S, Little ME, Mike A. The Effects of E-Mentoring on Beginning Teacher Competencies and Perceptions. Teacher Education and Special Education. 2013;36(4):286-97.
- Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: The new Medical Research Council guidance. International Journal of Nursing Studies 2012;50:585-92.
- Cadogan CA, Ryan C, Hughes C. Making the case for change: What researchers need to consider when designing behavior change interventions aimed at improving medication dispensing. Research in social & administrative pharmacy : RSAP. 2016;12(1):149-53. Epub 2015/05/06.
- Whitehead AL, Sully BG, Campbell MJ. Pilot and feasibility studies: is there a difference from each other and from a randomised controlled trial? Contemporary clinical trials. 2014;38(1):130-3. Epub 2014/04/17.
- Williamson GR. Action research in nursing and healthcare. Bellman L, Webster J, editors. London: London : SAGE; 2012.
- Stringer ET. Action research. 3rd ed. ed. Los Angeles, Calif. London: Los Angeles, Calif. London : SAGE; 2007.
- Hilli Y, Melender HL. Developing preceptorship through action research: Part 1. Scandinavian journal of caring sciences. 2015;29(3):470-7. Epub 2015/02/17.
- Magola E, Willis S, Schafheutle E, editors. Transition to independent practice for novice community pharmacists: how do challenges associated with transition influence practitioner performance? RPS Annual Conference; 2015; Birmingham: International Journal of Pharmacy Practice 2015.
- Michie S, Johnston M. Theories and techniques of behaviour change: Developing a cumulative science of behaviour change. Health Psychology Review. 2012;6(1):1-6.
- Hughes CM, Cadogan CA, Ryan CA. Development of a pharmacy practice intervention: lessons from the literature. International journal of clinical pharmacy. 2015.
- Patton MQ. Qualitative evaluation and research methods. 2nd ed. ed. Patton MQ, editor. Newbury Park, Calif. London: Newbury Park, Calif. London : Sage; 1990.
- Bennett A, Elman C. Case Study Methods: Oxford University Press; 2008.
- Padden ML. The effects of guided reflective journaling on nursing students’ level of reflection, self-awareness, and perceived clinical decision making skills: Widener University; 2011.
- Cassell C. Essential Guide to Qualitative Methods in Organizational Research. Symon G, Cassell C, editors. London: London : SAGE Publications; 2004.
- Gill MJ. The Possibilities of Phenomenology for Organizational Research. Organizational Research Methods. 2014;17(2):118-37.
- Eldridge SM, Lancaster GA, Campbell MJ, Thabane L, Hopewell S, Coleman CL, et al. Defining Feasibility and Pilot Studies in Preparation for Randomised Controlled Trials: Development of a Conceptual Framework. PloS one. 2016;11(3):e0150205. Epub 2016/03/16.