Preparedness of newly qualified doctors in Ireland for prescribing in clinical practice

Abstract

Aim

The aim of the study was to investigate the level of preparedness of newly qualified Irish‐trained doctors for prescribing, and to investigate their attitudes towards prescribing and prescribing education, through a national survey.

Methods

A 29‐item online survey was distributed to 686 newly qualified doctors 1 month prior to the completion of their first year of clinical practice (internship). Only graduates from Irish medical schools were included.

Results

The response rate was 20.4% (n = 140; female : male 56%:44%). The majority of respondents felt confident in prescription writing (89%), medication history taking (81%) and accessing drug information in the hospital setting (80%). Only 58% of respondents felt confident in drug dose calculation, and 35% felt confident in preparing and administering drugs. When asked if their undergraduate medical education had prepared them for prescribing in clinical practice, 28% of respondents agreed. Confidence that their undergraduate education had prepared them was associated with receiving formal training in prescribing skills (P = 0.0045; 27% vs. 0%). Thirty‐seven per cent of respondents agreed that they felt stressed about prescribing medications.

Conclusion

This survey of newly qualified doctors in Ireland found that only 28% of respondents agreed that their undergraduate medical education had prepared them for prescribing, which was comparable to a previous survey of UK medical students and graduates. Investigating confidence and preparedness for prescribing provides important insights for educators. Dedicated teaching of prescribing, with an emphasis on practical training and assessment, may help graduates to feel more prepared for the challenges of prescribing in the clinical setting.

What is Already Known about this Subject

• Foundation year doctors are responsible for the majority of prescribing in the clinical setting.

• UK medical students and recently qualified doctors have previously reported that they did not feel prepared for prescribing.

• An Irish Medical Council report demonstrated that 30% of newly qualified doctors did not feel adequately prepared for internship.

What this Study Adds

• This was the first national survey of newly qualified doctors in Ireland investigating preparedness for prescribing.

• Only 28% agreed that their medical education prepared them for prescribing. Receiving clinical pharmacology and therapeutics as a distinct course, and formal training in prescribing skills were associated with increased preparedness.

• Doctors' confidence in prescribing oral medications was higher than that in prescribing intravenous medications.

Introduction

Prescribing is a complex skill that requires a thorough understanding of the pathophysiology of a diagnosis, the pharmacology of an individual medication and how an individuals response may be affected by the pharmacokinetic and pharmacodynamic properties of a particular medication 1. In addition, it requires an understanding of the evidence base for individual drug therapy, the appropriate clinical indications and the potential for drug interactions and adverse effects 1. It is expected that newly qualified doctors are competent in prescribing skills on completion of their medical education. However, in 2008, a large UK survey of medical students and recently qualified graduates found that the majority of respondents did not feel that their medical education had prepared them to meet the prescribing competencies set out by the General Medical Council 2.

In Ireland, the first year of clinical practice after graduation from medical school is a 1‐year internship. The Irish Medical Council investigated the views of trainee doctors on the clinical training environment, and released a report in 2015 entitled ‘Your Training Counts’ 3. This summarized the results of a large national survey of all practising doctors in training for that year. Of the 1035 trainee doctors who responded to the survey, 26% (n = 269) were newly qualified doctors (interns). It found that 30% of newly qualified doctors did not feel that that their previous medical education had prepared them well for their first year in clinical practice. It also found that newly qualified doctors reported poorer overall views of the clinical learning environment in Ireland. The domains that resulted in a significantly greater perception of under‐preparedness were administrative tasks and time management, which are areas of clinical practice that rely heavily on previous participation in the workplace. Feeling prepared was not influenced by the medical school attended 3.

Studies have identified that newly qualified doctors are responsible for a greater number of prescribing errors than their senior counterparts 4, 5. In the UK, newly graduated doctors enter a 2‐year foundation programme – foundation year (FY) 1 and FY2. FY2 doctors have greater prescribing responsibilities than their FY1 colleagues in the UK, with FY2 doctors being responsible for clinical decision making and alterations to prescriptions as well as being allowed to prescribe high‐risk medications such as chemotherapeutic agents. The EQUIP and PRescribing outcomes for trainee doctors Engaged in Clinical Training (PROTECT) studies investigated prescribing error rates among FY doctors in the UK and Scotland, respectively 6, 7. They both identified that FY doctors were responsible for the majority of prescribing in the clinical setting, and for the greatest number of prescribing errors. The contribution of environmental factors to prescribing error rates was acknowledged. However, both studies identified individual factors related to the prescriber (such as prescriber knowledge) and misplaced confidence among FY doctors in prescribing competence as contributing factors to the error rates identified. While a multifactorial approach to reduce prescribing error rates is required, newly qualified doctors are a key target for education strategies to improve prescribing competency.

The aim of the present study was to investigate the preparedness of newly qualified Irish‐trained doctors for prescribing, and to investigate their attitudes towards prescribing and prescribing education, through a national survey.

Methods

A 29 item online survey was designed and modelled on a previous survey investigating background undergraduate education, as well as confidence in a set of five prescribing skills 2. The survey was adapted to include questions investigating the confidence of newly qualified doctors in prescribing specific medications through different routes of administration. The respondents were also asked to rank the importance of prescribing as a skill from a list of eight skills required in the first year of clinical practice in order to investigate their attitudes towards prescribing (Table 1).

Table 1.

Survey administered to all newly qualified doctors in Ireland for the year 2014–2015

Gender (please select): Male/Female

Age category (please select): 18–22 years/23–30 years/31–40 years/>40 years

Graduate entry programme: Yes/No

Undergraduate education
Basic pharmacology was taught as a distinct course in my medical school (as opposed to an integrated course): Yes/No
Clinical pharmacology and therapeutics were taught as a distinct course in my medical school (as opposed to an integrated course): Yes/No
I received formal teaching in prescribing skills during my medical school training: Yes/No
Please select below all that apply to your education in prescribing to date:
Lecture or didactic teaching sessions/online courses/self‐directed learning/opportunistic learning on the wards/practice‐based learning
I had practised filling out a drug prescription the following number of times before becoming an intern:
<5 times/5–10 times/>10 times
Please select the people in the list below who played a major role in teaching you about drugs and medications that you prescribe in clinical practice:
Hospital clinicians/General practitioners/Nurses/Clinical pharmacologists/Pharmacists
I had a local ‘student formulary’ (i.e. a list of common drugs, doses and side effects) available to me in medical school: Yes/No
I had an assessment in prescribing skills at the end of medical school: Yes/No
If yes, I feel that the assessment in prescribing skills during medical school adequately tested my knowledge and skill in this area: Yes/No

Confidence in prescribing skills and medications
I feel confident in taking a drug history:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
I feel confident in prescription writing:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
I feel confident in drug dose calculation:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
I feel confident in preparing and administering drugs:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
I feel confident in accessing drug information in the hospital setting:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
I feel I have sufficient knowledge to prescribe the following drugs (PO = oral; IM = intramuscular; IV = intravenous):
1. Analgesia (excluding opiates) PO/IM/IV:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
2. Opiate analgesia PO/IM/IV
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
3. Laxatives PO/PR
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
4. Antibiotics PO/IM/IV
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
5. Anti‐emetics PO/IM/IV
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
6. Sedation PO/IM/IV
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
7. Cytotoxic medications PO/IM/IV
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree

Attitudes to prescribing and prescribing education
In hospital practice, prescribing accounts for what proportion of my daily duties:
<10%/11–30%/31–50%/51–70%/>70%
I feel that my medical school training has prepared me for prescribing medications in clinical practice:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
I feel stressed about prescribing medications as an intern:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
Please rank the below skills from 1–8 in order of importance for a practising intern:
(1 = most important skill; 8 = least important skill)
Documentation/IV cannulation/Communication/Prescribing/Catheterization/Clinical examination/Resuscitation/Radiographic interpretation
What prescribing resource do you use when prescribing in clinical practice? (e.g. IMF/BNF/online applications)
I feel I have sufficient resources to aid my continued learning in prescribing:
Strongly agree/Agree/Neither agree nor disagree/Disagree/Strongly disagree
Do you have any suggestions as to how to improve education in prescribing? Any other comments?

BNF, British National Formulary; IMF, Irish Medicines Formulary

The survey was distributed online to all newly qualified doctors (interns) in Ireland (n = 686) 1 month prior to completion of their first year in clinical practice in June 2015. The 686 interns worked across a range of hospitals within six distinct national intern training networks. In keeping with the guidelines produced by the Intern Network Executive, ethics approval was sought and granted from each of the six intern training networks and from the Royal College of Surgeons in Ireland Research and Ethics committee (RCSI REC).

All surveys were issued via the online survey tool Surveymonkey. Invitations to participate in the survey were issued directly, via personalized email, to the interns in Networks 1, 2, 3 and 4. The interns in the remaining two networks (Networks 5 and 6) were e‐mailed a request to complete the survey by their respective intern training coordinators. A link to the online survey was included in each email, and a reminder email was sent after 2 weeks. The study period concluded after 4 weeks. Any intern who did not complete their medical training in Ireland was excluded from the study. Not all respondents answered each question. All statistical analysis on the data collected was carried out using Graph Pad Prism Software® version 6.07, La Jolla, California, USA.

Results

Of the 686 interns practising in Ireland for the year 2014–2015, 142 (20.69%) responded to the survey. Two respondents were excluded as they had not completed their undergraduate medical training in Ireland, resulting in a response rate of 20.4% (n = 140). There was good representation of interns from each of the six intern training networks nationwide. The majority of respondents (n = 83/142; 58%) were enrolled in one of the three Dublin intern networks (Networks 1, 5 and 6) in which the majority of interns in Ireland are enrolled (n = 390/686; 56%). The remaining respondents were enrolled in Network 3 (18%, n = 25/142), Network 4 (15%, n = 21/142) and Network 2 (9%, n = 13/142), which represent 19% (n = 131/686), 17% (n = 121/686) and 6% (n = 44/686) of interns nationwide, respectively. The majority of respondents were female (male : female 44%:56%) and had completed an undergraduate medical programme (68%) rather than a graduate entry medical programme. The demographics of the respondents are shown in Table 2.

Table 2.

Demographics of respondents to the survey of newly qualified doctors in Ireland

GENDER	%	n
Male	44%	61
Female	56%	79
AGE GROUP
18–24 years	40%	56
25–30 years	47%	66
30–40 years	12%	17
>40 years	1%	1
MEDICAL PROGRAMME
Undergraduate programme	68%	95
Graduate entry programme	32%	45

Undergraduate education

Regarding their undergraduate education, 47% (n = 62/132) of respondents had received ‘basic pharmacology’ as a distinct course, and 40% (n = 53/132) reported that they had been taught ‘basic pharmacology’ as an integrated course. Clinical pharmacology and therapeutics (CPT) had been delivered as a distinct course for 44% (n = 58/132) of respondents, and 45% (n = 59/132) had received it as an integrated course. A total of 82% (n = 108/132) had received formal training in prescribing skills during medical school, with 15% (n = 20/132) reporting that that they had not received any formal training in prescribing skills during medical school. Only 59% (n = 78/132) reported that they had received a formal assessment in prescribing skills at the end of medical school, and of these, only 42% (n = 33/78) agreed that this assessment had tested their knowledge and skills in this area adequately.

The most commonly reported formats of prescribing education among respondents were didactic teaching (86%) and opportunistic learning on the wards (66%). They reported that self‐directed learning (57%), practice‐based learning (51%) and access to online courses (49%) had also been used to aid their learning. Hospital clinicians (86%) and pharmacists (54%) were the healthcare professionals most frequently reported as playing a major role in teaching the respondents about the medications prescribed in clinical practice.

When asked how many times they had filled a drug prescription during medical school, 62% (n = 81/131) reported less than five times, 28% (n = 37/131) reported between five and 10 times and 10% (n = 13/131) reported more than 10 times. Eight per cent (n = 11/132) reported having had access to a local student formulary during medical school.

Only 48% (n = 60/125) of respondents reported that there were sufficient resources to aid their continued learning in prescribing. When asked which prescribing resources they used for prescribing in clinical practice, 49% used at least two resources. The majority (86%, n = 107/124) reported using the British National Formulary (BNF), 33% (n = 41/124) reported using local hospital guidelines, 23% (n = 29/124) reported using the Monthly Index of Medical Specialities (MIMS) and 23% (n = 28/124) reported using ‘medicines.ie’. Only 3% (n = 4/124) of respondents reported using hospital pharmacy support as a prescribing resource in clinical practice.

Confidence in prescribing skills

Respondents were questioned regarding their confidence across a set of five prescribing skills, including medication history taking, prescription writing, drug dose calculation, preparing and administering drugs, and accessing drug information in the hospital setting. The majority agreed or strongly agreed that they were confident in the skills of prescription writing (89%, n = 113/128), medication history taking (81%, n = 104/128), and accessing drug information in the hospital setting (80%, n = 103/129). However, only 58% (n = 74/128) agreed or strongly agreed that they felt confident in drug dose calculation, and 35% (n = 45/128) agreed or strongly agreed that they were confident in preparing and administering drugs (Figure 1). Confidence in these five prescribing skills was not affected by the respondents' age group, gender, type of medical school programme or having received a distinct course in either CPT or basic pharmacology rather than an integrated course.

Figure 1.

Reported confidence of respondents in five prescribing skills. The majority of respondents felt confident in prescription writing, medication history taking and accessing drug information in the hospital setting. Only 58% of respondents reported feeling confident in drug dose calculation and 35% in preparing and administering drugs

Confidence in prescribing a set list of medications, most commonly prescribed by newly qualified doctors, was determined. The route of administration was also explored as intravenous drugs have been reported as being the most common route involved in medication errors 8 and of high clinical risk 4. The majority of respondents agreed or strongly agreed that they felt confident in prescribing non‐opiate analgesics (97%, n = 123/127), laxatives (97%, n = 122/126), antiemetics (95%, n = 121/127), antibiotics (94%, n = 118/126) and opiate analgesics (89%, n = 112/126) via the oral route. Only 72% (n = 91/127) agreed or strongly agreed that they were confident in prescribing sedative medications via the oral route. With regard to prescribing intravenous medications, the majority of respondents agreed or strongly agreed that they were confident in prescribing intravenous antibiotics (92%, n = 115/125) and intravenous antiemetic medications (75%, n = 105/127). However, only 43% (n = 54/127) agreed or strongly agreed that they were confident prescribing opiate analgesics intravenously and fewer respondents (23%, n = 29/126) agreed or strongly agreed that they were confident in prescribing sedative medications intravenously.

Regarding specific medications, confidence in prescribing non‐opiate analgesics (P < 0.0001, 97% vs. 67%), opiate analgesics (P < 0.0001, 89% vs. 43%), sedative medications (P < 0.0001, 72% vs. 23%) and antiemetics (P = 0.0214, 95% vs. 83%) via the oral route was significantly higher than confidence in prescribing the same medications intravenously (Figure 2). There was no significant difference between confidence in prescribing oral and intravenous antibiotics (P = 0.5949, 94% vs. 92%).

Figure 2.

Confidence of respondents in prescribing oral vs. intravenous medications. A significant difference was demonstrated in the confidence in prescribing medications through different routes of administration. Confidence in prescribing non‐opiate analgesia, antiemetic medications, opiate analgesia and sedative medications intravenously was significantly lower than that of prescribing these medications via the oral route

Attitudes to prescribing and preparedness

When asked to rank a set of eight common skills in order of importance for a doctor in the first year of clinical practice, prescribing was ranked as the most important (number 1) skill by only 8% (n = 10/122) of respondents. Communication (36%), documentation (18%) and intravenous cannulation (13%) were the skills most commonly ranked as the most important (Figure 3). However, prescribing was ranked as a highly important skill (number 2–3) by 39% (n = 47/122) of respondents and as a moderately important skill (number 4–6) by 51% (n = 62/122). Radiographic interpretation (38%), catheterization (27%) and resuscitation (14%) were most frequently ranked as the least important intern skills.

Figure 3.

Skills ranked as the ‘most important’ by respondents. Respondents were asked to rank a set of eight common skills required for a newly qualified doctor in order of importance. Communication, documentation and intravenous (IV) cannulation were the skills ranked most frequently as the ‘most important’. Eight per cent of respondents placed prescribing as the most important skill

When asked if their undergraduate medical education had prepared them for prescribing in clinical practice, 28% (n = 35/125) of respondents agreed or strongly agreed, 53% (n = 66/125) disagreed or strongly disagreed and 28% (n = 35/125) neither agreed nor disagreed with the statement (Figure 4.) Reporting feeling that their undergraduate medical education had prepared them for prescribing in clinical practice was associated with being male (P = 0.034, 17% vs. 11%), receiving CPT as a distinct course rather than an integrated course (P = 0.0329, 16% vs. 8%) and receiving formal training in prescribing skills during medical school (P = 0.0045, 27% vs. 0%).

Figure 4.

Respondents' level of agreement with the statement: ‘My medical education prepared me for prescribing in clinical practice’. Only 28% of respondents agreed or strongly agreed that their medical education had prepared them for prescribing in clinical practice. Agreeing to feeling prepared was associated with being male, and having received formal training in prescribing skills during medical school

In addition, 37% (n = 35/123) of respondents agreed or strongly agreed to feeling stressed about prescribing medications as an intern (Figure 5). Females were more likely to report feeling stressed than males (P = 0.02, 27% vs. 10%). Respondents who had received CPT as a distinct course rather than an integrated course (P = 0.0027, 8% vs. 22%) were less likely to agree to feeling stressed. The respondents in our study who reported that they felt prepared were significantly less likely to report feeling stressed about prescribing medications in their first clinical year compared with those who reported that they did not feel prepared to prescribe (P = 0.0002; 14% vs. 50%).

Figure 5.

Respondents' level of agreement with the statement ‘I feel stressed about prescribing medications as an intern’. A significant proportion of respondents (37%) agreed that they felt stressed about prescribing medications as an intern. Female respondents and respondents who did not receive clinical pharmacology and therapeutics as a distinct course were more likely to agree to feeling stressed

Respondents' comments

When respondents were asked if they had any suggestions to improve prescribing, the emerging theme was that they wanted more teaching in prescribing. Some suggested that this teaching should be done through workshops, mock scenarios or small group tutorials, with one stating: ‘the more practice, the better’. The majority also felt that teaching needed to be focused on the common medications: ‘we actually use’ with ‘more focus on simple medications’ and requested ‘more involvement in prescribing decisions as a student on the wards’. Respondents also requested that a formulary of common medications, side effects and interactions be provided either as a medical student or at the beginning of the intern year, to aid their learning. A few remarked on the need for a compulsory assessment in prescribing skills during their medical school education and some also suggested shadowing a pharmacist for a day, remarking on the need for greater pharmacy participation in the day‐to‐day clinical environment, with one stating that: ‘hospital pharmacists are a greatly underutilized resource’.

Finally, and of significant concern, was a theme of being pressurized into prescribing medications within the hospital setting. One respondent noted that newly qualified doctors often feel pressurized: ‘into prescribing night sedation … especially in the elderly’. Another also remarked that newly qualified doctors often feel pressurized to prescribe medications: ‘especially in the first 3 months,’ when they “can be unsure and doubtful”. Some respondents remarked on the challenges of being asked to prescribe at the start of their first year as a practising doctor, stating that: ‘prescribing can be a pretty daunting experience’ at the beginning. One respondent similarly reported that: ‘when on call … I was asked to prescribe and administer drugs I'd never heard of, and its very daunting to have to put your signature beside that’.

Discussion

This was the first national survey of newly qualified doctors in Ireland specifically investigating preparedness for prescribing in clinical practice. It also investigated the confidence of newly qualified Irish‐trained doctors in prescribing specific medication classes and whether this was affected by prescribing medications via different routes of administration.

Our study showed that only 28% of respondents felt that their undergraduate medical education had prepared them for prescribing in clinical practice, which is comparable to the results of other similar studies 2, 9. In the UK survey of medical students and newly qualified doctors by Heaton et al. 2, only 29% of respondents felt confident that their medical education would enable them to achieve the prescribing competencies set out by the General Medical Council. Reporting that that their medical education had prepared them for prescribing in clinical practice in our study was associated with having received a distinct course in CPT as well as formal training in prescribing skills during their medical school education. This supports the World Health Organization (WHO) recommendations that CPT should be delivered as a distinct course or be clearly defined in the undergraduate curriculum, as outlined in the report ‘Clinical Pharmacology, Teaching and Research’ released in 2012 10, 11. Other recommendations in this report include the development of a set list of drugs or student formulary, the adoption of an interactive style of learning and the development of a clear and robust assessment in prescribing across all medical schools 10. Only 8% of respondents in our study reported having a student formulary available to them and only 59% reported receiving a formal assessment in prescribing skills at the end of medical school, suggesting a lack of formal assessment in prescribing skills in the existing Irish undergraduate curricula.

Respondents reported greater confidence in prescribing oral medications compared with intravenous medications. The administration of intravenous medications is more complex and commonly associated with clinically significant medication errors 4, 8. The confidence of respondents in prescribing sedative medications orally (72%) was lowest, and this reduced to 23% when asked about their confidence in prescribing these medications intravenously. Considering that respondents were surveyed 4 weeks before the completion of their first clinical year, it suggests that education in specific medication classes with significant risk profiles needs to be improved. A similar study by Tobaiqy et al. 9 investigated the confidence of FY1 doctors (n = 64) in prescribing drugs from specific medication classes and found that only a small proportion of respondents were comfortable in prescribing antipsychotic medications unsupervised (17%), although the majority (92%) were confident in prescribing opiate medications; however, routes of administration were not investigated in this study. Similarly, a study of preparedness of newly qualified doctors in New South Wales (n = 191) by Hilmer et al. 12 reported a feeling of being less prepared to prescribe opioid medications, as well as antibiotics, anticoagulants and insulin.

Newly qualified doctors feel less prepared for areas of clinical practice based on experiential learning such as administrative skills and, in particular, prescribing 13. The WHO and EQUIP studies support the use of practice‐based learning with ‘on the job’ training in prescribing skills to improve the preparedness of medical graduates for the challenges of prescribing in the clinical setting 6, 10, 11. A significant proportion (62%) of the respondents in our study had practised filling out a drug prescription fewer than five times. The respondents demonstrated the lowest confidence in the skills of drug dose calculation (58%) and preparing and administering drugs (36%), suggesting a deficit of exposure to the practical aspects of prescribing skills in the existing Irish undergraduate education models.

Finally, 37% of respondents in the present study reported feeling stressed about prescribing medications in their first clinical year. This transition from medical student to doctor has been known to be associated with high levels of stress. A recent study reported higher levels of psychological distress among newly qualified Irish doctors compared with other healthcare professionals 14. Respondents who reported feeling prepared to prescribe were significantly less likely to report feeling stressed about prescribing medications than those who did not feel prepared.

In the UK, in response to the growing concern regarding the lack of preparedness of newly qualified doctors, and the prevalence of prescribing error rates, ‘Tomorrow's Doctors’, released in 2009, set out a list of prescribing competencies to be achieved 15. The competencies were developed in collaboration with a Medical Schools Council Safe Prescribing Working Group, and led to the development of the Prescribing Safety Assessment (PSA) 16. The PSA is targeted at final year medical students across the UK and Irish medical schools, and has been a progressive step in highlighting the importance both of being a competent prescriber and in promoting prescribing as an important skill at undergraduate level 15, 16.

It is clear that the delivery of CPT and prescribing skills in Irish undergraduate curricula needs to be reviewed. Recommendations in the literature, such as the vertical integration of prescribing education, the adoption of an integrated approach to the teaching of prescribing skills 17, 18 and the introduction of interprofessional education as a teaching model for CPT, have been shown to be effective 19. Improving postgraduate education opportunities for newly qualified doctors should also be encouraged as the use of online prescribing modules have been shown to have a partial effect in reducing prescribing breaches in the clinical setting 20.

As newly qualified doctors are responsible for the majority of prescribing in the clinical setting, they are a key target for education initiatives to improve prescriber competence and minimize prescribing errors. Newly qualified doctors should feel confident in their ability to prescribe on completion of their medical school education, to enable them to cope with the pressures of prescribing. In order to improve preparedness for prescribing, it is important to examine current curricula, to ensure that there is sufficient emphasis placed on prescribing education and the practical application of prescribing skills to clinical practice.

Study limitations

The main limitation of the study was the low response rate of 20.4%. This was comparable to the response rate (18.8%) in a previous UK survey of medical students and recently qualified doctors 2. It is known that the response rates of health professionals to online surveys is low, with a systematic review by Braithwaite et al. 21 reporting a wide range of response rates from 9–94% in the 17 online surveys reviewed. Moreover, online surveys have also been shown to yield a lower response rate than telephone or postal strategies 21, 22, 23.

Although the demographic data of our nonrespondents were not available, we minimized the nonresponse bias by sampling only graduates of Irish medical schools in their first year of clinical practice 24. There was also good representation from each of the six intern networks nationwide, although we could not be confident that all six medical schools in Ireland were represented in our sample, as the intern training network represents the hospital in which the individuals are employed rather than medical school attended.

Finally, the information provided by respondents regarding their background undergraduate medical education was dependent on their recall and therefore may have been influenced by recall bias.

Conclusion

Prescribing is a complex skill that has important patient safety implications. It is imperative that graduates feel prepared for prescribing on completion of their medical school education. This can be achieved through dedicated curriculum review and the adaptation of the current curricula to include international recommendations on the delivery of prescribing education. Adequate emphasis should be placed on the practical components of prescribing in the clinical setting, to ensure that newly qualified doctors are adequately equipped to deal with the challenges of prescribing in clinical practice.

Competing Interests

There are no competing interests to declare.

The authors would like to thank Dr Gozie Offiah, Royal College of Surgeons in Ireland (RCSI); Dr Richard Arnett, RCSI; Dr Kathleen Bennett, RCSI; Dr Margaret O′Connor, Limerick General Hospital; Dr Finbar O′Connell, St. James University Hospital; and Dr Carl Vaughan, Cork University Hospital.

Geoghegan, S. E. , Clarke, E. , Byrne, D. , Power, D. , Moneley, D. , Strawbridge, J. , and Williams, D. J. (2017) Preparedness of newly qualified doctors in Ireland for prescribing in clinical practice. Br J Clin Pharmacol, 83: 1826–1834. doi: 10.1111/bcp.13273.