Educational interventions to ensure prescribing competence in new prescribers: a systematic review of quantitative and qualitative evidence

Problem

Prescribing competency involves the ability to prescribe rationally for the benefit of patients. There has been a sustained policy and workforce shift to increase uptake of prescribing in non-traditional roles. This changing landscape, and new evidence, suggests the need for an updated review of interventions to ensure competence in new prescribers.

Approach

A systematic review was undertaken according to the PRISMA guidelines. The review sought to characterise the training and its impact on knowledge,skills, and behaviours of learners;patient outcomes;and resource use. An exhaustive search strategy included all main databases. No restrictions were applied by date nor language. The MERSQI tool was used to critically appraise studies with the Kirkpatrick evaluation framework used to categorize outcomes.

Findings

5,758 records were screened with 38 studies meeting final inclusion criteria(8 RCTs, 16 quantitative nonrandomised, 9 quantitative descriptive, and 3 mixed methods studies. Studies were conducted in the UK(n=14), the Netherlands(n=6), Turkey(n=3), Bahrain(n=2), Australia(n=2), USA(n=2), with one study in each of South Africa, Germany, Yemen, Canada, India, Sweden and Malaysia and two multisite studies. Most studies focused on medical students(n=32), or a mixture of nursing and medical students(n=1); three studies focused on nurses and one each included dental students or pharmacists only.The evaluation of interventions was heavily weighted towards the reaction(17) and learning(20) of participants with only a few evaluating their behaviour(3). A pharmacist facilitated interventions in some studies(6) with the ‘near peer’ of foundation doctors facilitating teaching in three studies. Some interventions were didactic only(2) but many had applied elements of learning(16).

Consequences

There was much heterogeneity in both study design, outcome choice and reporting quality. The vast majority of studies confined their assessment of learners’ competence to knowledge assessment neglecting the higher order of Miller’s framework of competency. The WHO Guide to Good Prescribing was the most widely evaluated tool and is now incorporated into many national curricula.Future interventions should consider more valuable assessments of higher order downstream competency assessment (e.g. OSCE, prescribing audits) as well as the longer-term impact of educational interventions. Education specific to non-medical prescribers needs more research.