My journey into specialisation as a hospital critical care pharmacist
Jennifer de Val explains how she went from being clueless about what she wants to do after graduation to becoming a specialist pharmacist in hospital
While I was studying for my pharmacy degree at Nottingham, struggling away with revision for examinations, I could not have predicted the path my career would have taken. But that is the beauty of pharmacy. You can try lots of things and then decide what is best for you.
I am now a critical care pharmacist in the busy London hospital Guy’s and St Thomas’ NHS Foundation Trust. I am in my first senior post and have completed a year in this job. It has been a steep learning curve, and I am sure I am only a bit of the way up it. In this article I will tell you how I got here and what I have enjoyed and not enjoyed along the way.
How it started
I had work experience in hospital and community pharmacies during my degree and I was not particularly passionate about choosing one over the other when it came to applying for a preregistration placement. I applied to the hospital scheme and accepted a place at Barts and The London NHS Trust. It was a whirlwind training experience, learning how to be useful in a busy hospital pharmacy department. I enjoyed my year there and stayed on as a junior pharmacist.
I still have memories of my first forays into being a ward pharmacist. As with all junior pharmacists in a hospital I had initially spent limited time on the wards and was based in dispensaries or production units. Preparation and supply of medicines was my bread and butter. So you can probably imagine my fear when asked by an intensive therapy unit registrar (in one of the first weeks of being a ward pharmacist) on an outreach call to a patient in respiratory distress on my ward how could naloxone be administered as a continuous infusion?
This posed a number of problems for me, namely because I only vaguely understood what naloxone was, I did not know anything about its dosing schedules, I had only come across it in the form of mini-jets (prefilled syringes) in the emergency boxes provided to the wards by pharmacy. Therefore, I thought it was only meant to be given subcutaneously or intramuscularly. I definitely did not have the right end of the stick.
This ITU registrar was an experienced specialist. He knew about the drug, he knew what he needed to do to treat this patient and he wanted advice on the compatibility fluid and rate he should administer it at.
So I asked a senior colleague was guided through the process of finding the information and how to advise. The infusion was set up and the patient taken to the intensive care unit.
I have reflected on this event throughout my whole career. It was one of the moments where I remember thinking that I wanted to understand why there was huddle of senior healthcare professionals around that patient’s bed, and what my role could have been if I were I better equipped.
Moving up the ladder
I moved to another trust during my junior pharmacist training to University College London Hospitals NHS Foundation Trust. I had started the Joint Programmes Board general pharmacy practice postgraduate diploma when I qualified and, after 18 months, I was able to experience longer rotations in different clinical areas in order to develop more in-depth knowledge and clinical pharmacy skills. I chose to move trusts at this point because I wanted a variety of experience and I am glad I did.
On choosing to complete a longer junior pharmacist rotation (termed defined area of practice [DAP]) in critical care at UCLH, I became aware that there was an established community of expert pharmacists in this field. I saw the impact a good pharmacist can have on patient care and decision-making in clinical services.
Once I was aware of this, I was more engaged in following rotations. I went on to experience more general medicine, neurology and neurosurgery. I met more specialist pharmacists and, on seeing them in action and being more aware of how they interacted with senior medical colleagues, what it is they brought to the team, and how they developed, I was inspired to “specialise” as well.
I stayed on as a band 7 pharmacist at UCLH and went back to do a year-long rotation in critical care. I both feared and enjoyed the consultant ward rounds. What was I going to get asked that I would not know the answer to? However, I was getting job satisfaction from the fact that other multidisciplinary team members would seek my opinion on things such as appropriate dosing of drugs, ways of administering drugs or help with the practicalities of prescribing.
I developed good working relationships with more senior nursing staff and began to be involved in service development. I learnt how to find out about developments in the specialist area, tapping into the expert pharmacist network of the UK Clinical Pharmacy Association critical care group. I saw how severely ill patients can be, the work of doctors and nurses to treat them, and how, as a pharmacist, I have a duty to keep them as safe as possible while maximising the benefit of the medicines used.
Critical care specialty
It became clear to me that the year in critical care was not going to be enough to identify all I should or could know about drugs in intensive care. And because I wanted to keep learning in this area I looked for a specialist pharmacist post.
And that is what I am now. My job entails working on the intensive care, high dependency and recovery units at Guy’s and St Thomas’ hospitals. Moving trusts again has meant I am exposed to a different mix of patients since there are different clinical specialties. The critical care unit is one of the extra-corporeal membranous oxygenation centres in the UK and I am seeing patients with severe respiratory distress, and am starting to find out about drug handling in this novel therapy.
In some ways critical care is like general medicine. There are patients with all sorts of conditions on the units. From patients recovering from cardiac surgery, those with severe alcoholic liver disease, acute kidney injury through to patients admitted with sepsis causing multi-organ failure. My role is to be an expert on the critical care drugs and their handling in critical illness, and to help the multidisciplinary team use them well.
All that training as a preregistration trainee, band 6 and band 7 pharmacist has given me a wide knowledge about general pharmacy practice. This is important when helping a specialist critical care doctor prescribe medicines a patient is normally established on because they are not used to prescribing them and are unfamiliar with the indications and usual doses. The layers of training all build on each other and I will always need to be able to go back to knowing what was in the emergency boxes I packed as a trainee.
I work in a team of experienced critical care pharmacists led by a consultant pharmacist. On starting the job I did initially think it was something of a misnomer to be called a specialist pharmacist because I felt woefully underskilled compared with the rest of the team. But I now see I will grow into the post as I am continually learning from my pharmacy, medical and nursing colleagues.
In addition to this, there is now a credentialing process available to pharmacists specialising in critical care which is set up and run by the UKCPA Critical Care pharmacists group. This process is an assessment of your skills against the advanced level framework for critical care, and assesses your skills in key areas. It sets out what would be expected for you to demonstrate that you achieve foundation, advanced and mastery (consultant) level. Your knowledge, clinical pharmacy skills, examples of your work you submit in a portfolio, as well as feedback from colleagues, are all used to build a picture of the level you are practising at and guide you on where would be good to focus future development so you can progress to the next level of practice. I have just been through this process and, although it was daunting and a little bit stressful, I found it thoroughly worthwhile.
So despite regularly having to resit exams at university (just to reassure: not through lack of work, but just not understanding some key concepts until I got to use them in the context of patient care), coming out with a 2:2 and no real plans for what I wanted to do, I have found a specialism that I am interested in and want to get better at. Specialising is an exciting process. As advanced practice frameworks are developed the career of a specialist pharmacist will become even more satisfying. I am just at the beginning, but would recommend it to anyone starting out unsure what their career holds.
Jennifer de Val is a critical care specialist pharmacist at Guy’s and St Thomas’ NHS Foundation Trust. She is also a past president of the British Pharmaceutical Students’ Association
Citation: Tomorrow's Pharmacist URI: 11115031
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