You’ve done it – all your hard work has paid off and you’re finally a qualified pharmacist. As a fully-fledged pharmacist, you will have a lot more responsibility than during your foundation training year. So how do you manage it all? Here are our tips, tricks and reflections of things we have learnt from our first year as foundation pharmacists at Gateshead Health NHS Trust.
At Gateshead Health NHS Trust, a rotational pharmacist will be allocated two wards to work on. At first, the thought of having whole wards assigned to you can be daunting, but knowing how to manage your workload can make the job a lot easier.
Preparation and communication
Make sure you are well organised and know your commitments for the day. Do you have dispensary or operational commitments (such as CD checks or mandatory training), or do you have teaching or other responsibilities?
Communication with the staff you are working with every day also helps identify who may need support and who is available. Building a good relationship with the other pharmacy staff will enable you to complete tasks more effectively and efficiently on the ward.
Prioritisation
Depending on your Trust, there may be a prioritisation system in place to identify patients who need medicines reconciliation or pharmacy review. Building prioritisation into your day-to-day workload will help ensure efficient and safe working. It is worth noting that priorities may change depending on the clinical area you are working in. It is a good idea to know which doctors, nurses and allied health care professionals are looking after which patients that day, so that any questions can be directed straight to them.
At Gateshead Health NHS Trust, medicines reconciliation for patients on high-risk medications are prioritised first, followed by patients in order of time since admission. It is important to get medicines accurate and safe from the start of someone’s admission. This reduces any risk of incorrect medicine administration and further work later in someone’s stay. If any new patients are on high-risk medications try to see these patients near the beginning of the day; this way you can ensure that their medications are prescribed correctly and you have time to make amendments with the prescriber if required. This also gives you time to order the medications if they haven’t brought their own ones in from home.
When prioritising the days’ workload, think of your team and colleagues. Are there any pharmacy technicians or pharmacy assistants on your team? Depending on your Trust they may have different roles, skills or tasks they can help with. Utilising the skillset of the team and delegating accordingly will reduce your workload and improve patient care. Looking at when a patient was last reviewed will guide you as to when they need to be seen. If the patient has been reviewed within the past one or two days and are stable, then these reviews can wait until the higher risk reviews are completed.
Within Gateshead we use an internally produced system of prioritisation called the ward dashboard. This system flags key criteria unique to the pharmacy team, including: if a medication history has been completed; if a medication reconciliation has been conducted; when the patient is next due a clinical pharmacist review; and, if a discharge script has been completed for the patient. The system also retains information between hospital admissions, such as if a patient is on any high-risk medications and if the patient has a dosette box including which pharmacy supplies this. The dashboard enables us to plan and prioritise our workload and establishes a way of seeing all high-risk patients.
Clinical queries
A hospital pharmacist conducts a range of jobs throughout a typical day, but perhaps the most varied and unpredictable part of the day comes from queries. These can come from a range of ward staff including consultants, junior doctors, nurses and other members of the pharmacy team. Initially, being called or approached with a query can be daunting but once you take a moment to process the question and can provide the answer you get an accompanying feeling of pride and gratitude that the hard work you put in while training has paid off.
However, there will inevitably be times that you do not know how to answer a query. It is in these situations that you need a clear process in your mind of how to approach the problem. The topic of question will dictate the order in which a problem can be solved. Sometimes, a simple check of a medications monograph can supply the answer. On the other hand, the questions may not be quite so basic and you may need to ask a more senior pharmacist. The natural reaction is to provide an answer immediately but arguably, the best way to deal with questions is to take your time.
At Gateshead, the pharmacists have been really helpful and responsive whenever we have called with queries (and there have been a fair few – thanks everyone!). There is nothing wrong with discussing your query with a senior or another colleague before providing your answer. Think through your options and construct a logical plan. If you receive a call it is more than reasonable to take notes, acquire a contact number and ask if you can call back with the information.
Similarly, if approached on the ward, ask if the information is needed urgently for an acute scenario. If not, establish a period you can work to. It is important to use this time as wisely as possible, considering as many angles as possible to pre-empt additional or follow up questions you may be asked. The more time you take researching your question, the more you can ensure that your answer is the most appropriate.
Being qualified means that you will be seen as the point of contact for any medication queries. This newfound responsibility can be daunting as you may feel that you’re not ready to be providing advice. But remember, if they are asking the question then they don’t know the answer either! If you are able to justify your decision and have documented your reasoning in a clear and concise manner, demonstrating your thought process, then you have done your due diligence and can be confident in your answer.
It can be humbling to accept that you do not know everything and this grounds you as a pharmacist. An interesting model that can be applied to your clinical knowledge is Johari’s window (see below); this model analyses what knowledge is known and unknown to yourself and others, and can be superimposed to look at your knowledge.
The open area contains information you know and can recall and the blind area is comprised of information you are aware of but would research before applying to a situation. The hidden area is information that you don’t remember, however when heard or mentioned by someone else triggers a memory in your head. Finally, the unknown area is information you hear that you do not know. Using this tool can increase your self-awareness of ‘knowing what you know’. Opportunities to learn about topics in the unknown area arise daily and can be used to continue your professional development. We would encourage researching new concepts you come across and discussing these with your peers and seniors to consolidate your learning and fill in any gaps.
Adam’s example of a time he fell into ‘blind area’
“Whilst working on a care of the elderly (COTE) rotation I encountered a patient on raloxifene for the first time. Raloxifene is a medication licenced for the treatment and prevention of osteoporosis in postmenopausal women. I conducted my established routine of a clinical checks and recommended some changes to optimise the patient’s treatment. Being unaware of the medicine, I asked a more senior colleague on the ward to check my work and offer any further suggestions. Here I was taught of the high VTE risk associated with the medication. I read the SPC and educated myself further and suggested the suspension of the medication during the period of acute illness.”
Fariea’s example of a time she fell into ‘hidden area’
“I was asked for some help prescribing eltrombobag by one of the ward doctors. I had come across this once during my pre-reg year but could not remember the specifics of it, I asked a colleague if they would mind reviewing the patient with me and could help me with the query. When it was discussed that this mediation was for the treatment of thrombocytopenia I recalled that this medication interacts with many electrolyte replacement medications. The patient was on both magnesium and calcium supplements so, after discussing with my colleague, I suggested what the optimal timings of medications would be to best prevent any occurrence of drug interactions. I had forgotten I had dealt with this medication in the past but after hearing its indication I remembered some information regarding it.”
Experience offers a great deal of knowledge that can be applied to a range of situations. Initially, when beginning a career as a pharmacist, using your seniors for advice is a very accessible and reliable point of contact. They have the clinical knowledge coupled with the practical aspects that are unique to each hospital, often offering more practical help than any guideline or monograph. To maximise opportunities when consulting a senior colleague, take the chance to ask for some clinical supervision. One-to-one time discussing a case can teach you a great deal of practical and clinical details. It is often the case after qualifying that certain problems are over thought and worried about and other topics may be more serious or essential than previously thought.
Discharges
Screening discharge prescriptions may make up a significant amount of workload, especially in the afternoon. Ensuring a person’s medication is accurate on leaving hospital is a key role of safety and continuity of care. In some clinical areas there may be a ward round or handover towards the middle of the day; this is where the whole multidisciplinary team (MDT) get together to get an update on all the patients on the ward. Attending these handovers is not only a good way to hear which patients will be going home, but also emphasises that there is a pharmacy presence on the ward. These can also be a good opportunity to raise outstanding pharmacy jobs or queries.
Some wards may have a discharge coordinator who is responsible for facilitating the appropriate discharge of a patient, particularly for those who need district nurses, packages of care or social referrals. Liaise with them or the nurse in charge if you have any questions regarding who is being discharged. Knowing who is going home in advance of the script being written allows you to clinically screen the medication and counsel them on new medications. If you’re confident on the plan you could order any medicines required in advance. Pre-emptive discharges can sometimes be tricky as medications can be added at the last minute. Consider on an individual basis if it is appropriate to act proactively. Personally, we would not pre-empt any discharge that requires a new dosette box for the patient or contains control drugs. Like with medicines reconciliation, use any technicians or assistants you have available to support. This frees up your time so that you can focus on the clinical screening of the discharge prescriptions.
Depending on the number of discharges and clinical queries you get asked throughout the day, you may not always complete all of the ward reviews you wanted to that day. Don’t be disheartened by this, if this is the case. By prioritising your reviews as previously stated, you can rest assured that the high-risk patients have been seen and the patients on your ward are clinically safe at the end of the day. If you’re struggling with the workload don’t be afraid to ask for some support on the ward; we’ve all been there when first starting out, but once you get used to usual workload, you’ll learn how to manage your day.
Summary
Hopefully we’ve been able to give you an insight into what you can expect when starting out as a new hospital pharmacist. Keep your eyes peeled for the second article in this series where we discuss teamwork, professional portfolio development and oncall or out of hours services. We wanted to leave you with our top five things we wish we knew before starting:
Adam
- Prioritise your work well
- Take your time with queries – most of your questions won’t need immediate answers
- Ask for help when needed (even just for a review)
- Don’t get out of the habit of learning
- Know where to look
Fariea
- Use the members of the pharmacy team you have available
- Take five minutes at the beginning of the day to decide how you will tackle the days’ workload
- Know that it’s okay if you don’t know an answer
- Don’t be too disheartened if you can’t finish everything
- Ask for help when you need it
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
