The pen is mightier than the sword. Reinstating patient care as the object of prescribing education

Figures & data

Figure 1. Two contrasting activity systems (see Table 1 for explanation).

Table 1. An explanation of two contrasting activity systems, shown in Figure 1.

	Activity system of teaching and testing	Activity system of delivering patient care
Subject (S)	Students, who are assumed to be unsafe to participate in practice because their competence has yet to be proven	Doctors, who may only just have graduated but are expected to practise semi-independently, under sometimes very limited supervision, are assumed to be safe, and held accountable for it
Object (O)	Demonstrate competence, the outcome of which is to pass the Prescribing Safety Assessment and OSCEs, both of which take place off-the-job	Care for patients safely. In the context of prescribing, this means prescribing the correct dose, route of administration, frequency and duration of a clinically appropriate medication
Tools (T)	Tools of acquiring and demonstrating competence Books; lecture notes and slides; elearning; virtual patients; questions asked in previous tests; mannikins and other simulators	Tools of practice Stethoscope; pen; (electronic) clinical record and prescription chart; results of clinical examination, imaging, and laboratory tests; pager
Rules (R)	Be trained Attend training sessions in clinical skills (simulation) centres Pass assessments Skills tests: perform skills, as trained Written tests: commit information to memory; anticipate questions; learn answers Workplace-based assessments: be able to perform as expected under observation Be present in workplaces Attend and observe, as instructed; ensure you are signed off as having attended Do not participate in practice until you have passed competence tests Do not demonstrate lack of professionalism Behave as expected by the regulator at all times	Overriding rule Work, as required by supervisors and managers Formal rules Adhere to local policies and clinical guidelines. Ask for help when uncertain Report adverse events Informal rules Above all, ‘get by’; learn for improvement if time and case-load permit, and your seniors are supportive Do not ask for help with ‘easy’ tasks like prescribing unless you absolutely have to; remember others are very busy too Do not allow reporting adverse events to incriminate yourself or others
Community (C)	Community of teaching and assessing Healthcare professionals: members of the community when actively teaching, but membership of the community of clinical practice takes precedence Regulator: lays down a framework for educational content and processes Curriculum leaders: implement training and assessment	Community of clinical practice, comprising Patients Including their friends and relatives Health workforce Clinicians: peers, more senior or junior residents, senior doctors, nurses, pharmacists, other allied professionals Managers
Division of Labour (DoL)	Formal education Teachers teach and train subject matter Learners learn, apply, and reproduce subject matter in assessments	Clinical roles: Determined partly by professional boundaries, and partly by individual capability and local norms. These are fluid, changing as learners accrue experience, and as practices develop Informal education Strongly influenced by the culture of individual clinical teams, most learning takes place in the circumstances of practice; it is often implicit but may be made explicit in teaching rounds, postgraduate clinical meetings, and other educational activities related to work

Figure 2. Three approaches to education for practice.

Table 2. How pre-prescribing expanded the object of learning to care safely for patients.

Knotworking	Pre-prescribing altered the rules of students’ participation in practice. Giving them a role in the same activity system as practitioners involved them in dynamic care processes in busy workplaces, allowed them to learn authentic clinical work, and made them feel included.	“Whenever you … have a chance to … write this for them and all they have to do is sign this and check it for me, it made you feel actually part of the team” (Final Year Medical Student)
	Pre-prescribing involved students in knotworking between doctors and members of other professions within practice. Working interprofessionally allowed them to learn from pharmacists and nurses as well as doctors.	“Pharmacists … were very good to us and it was great to have their input and support as well” (Final Year Medical Student)
	Changing the rules of students’ participation in practice brought curriculum administrators into direct communication with some clinicians for the first time, particularly nurses. An interprofessional workforce having to develop new ways of working together formed new knots within individual Trusts.	“We had to find a way to communicate with nurses on wards and pharmacists … it was very multi-disciplinary” (Medical Education Administrator)
Expansive learning	Pre-prescribing gave residents experience of supervising students and helped whole teams learn to practise more safely because looking closely at pre-prescriptions encouraged residents and other clinicians to verbalise their knowledge and uncertainties before countersigning students’ pre-prescriptions.	“It needs good supervision for the individual (student) … so it was very positive thing for junior medical staff (residents)” (Consultant Physician)
	The need to help students participate in the activity of clinical care in order to learn altered the division of labour and promoted a culture of mutual support and team-based working and learning.	“A lot of people seemed to just know all of a sudden, that PP was a thing now … and some of the nursing sisters were able to come to us … saying would you mind writing this up for the F1 and … at no point did I ever feel like I don’t know what I’m meant to be doing here or put out” (Final Year Medical Student)
Embracing tensions	Before the intervention, it was tacitly accepted in some Trusts that students could help busy clinicians by writing real prescriptions, despite rules forbidding this. Pre-prescribing unearthed this unsafe culture of ‘black pen prescribing’ and used the tension between work and learning to promote safer practice.	“I think the risk of doing what we’ve been doing over the years … is … unsupervised, black pen prescribing, which has gone on for decades … there are bigger risks there, and there are bigger risks for someone if you haven’t practised at all” (Clinical Lecturer)
	Pre-prescribing encouraged students and educators to reflect critically on prescribing education. This increased the value of ‘classroom learning’ by complementing it with authentic experience, whose need had been recognised but which had created contradictions in the previous activity system.	‘I think we still have to provide basic knowledge in a classroom format.. but I think there’s a middle point that we haven’t had until PP and I think it’s that bit that we should be doing.’ (Clinical Lecturer)
	Pre-prescribing highlighted the contradiction that ‘unsafe students’ became ‘safe junior residents’ at the moment of qualification. Providing the traditional stage of ‘safe pre-prescriber’ expanded the system of clinical education and helped students be safer junior residents.	‘It is that bridge between doing the PSA and all of a sudden you can prescribe anything … (Now we are) … so familiar with it that once you come to your first day of (residency) and someone says here prescribe this, you’re like oh, no bother’ (Final Year Medical Student)