# Community pharmacists’ practices and clinical reasoning towards hospital discharge prescription: a study using simulations and retrospective think-aloud methodology

## TL;DR

Community pharmacists are involved in managing hospital discharge prescriptions, but need better clinical reasoning and patient communication skills to ensure safe post-discharge care.

## Contribution

The study introduces a mixed-method approach combining simulations and think-aloud methodology to assess pharmacists' clinical reasoning in discharge prescription scenarios.

## Key findings

- Most pharmacists performed medication reconciliation but fewer assessed non-adherence or engaged patients actively.
- Clinical reasoning misconceptions like assumptions and premature closure were observed during discharge prescription management.
- Pharmacists showed varied communication structures and often revisited previous discussion points during consultations.

## Abstract

The roles of community pharmacists have evolved from dispensing medications to clinical decision makers. This shift requires a clearer understanding of pharmacists’ clinical reasoning. Managing hospital discharge prescriptions requires analytical reasoning to ensure patient safety through medication reconciliation and patient education.

This study assessed community pharmacists’ practices and their clinical reasoning towards hospital discharge prescriptions.

This mixed-method study consisted of two phases. First, community pharmacists participated in a simulated encounter in their pharmacy, where a patient presented a discharge prescription. Their practices and the structure of the encounter were assessed using a structured checklist of practices adapted from the MEDICODE checklist. Following the simulation, participants verbalised their thought processes in a retrospective think-aloud session. These semi-structured interviews were transcribed and analysed using both inductive and deductive qualitative methods. Charlin et al.’s model was used to assess clinical reasoning, while the Calgary–Cambridge model evaluated communication structure.

Among 14 participating pharmacists, 13 performed medication reconciliation, and 10 contacted the simulated prescriber to address discrepancies. While most provided adherence aids, only seven assessed non-adherence, and five actively collaborated with the patient. Pharmacists exhibited diverse interview structures, often revisiting previous discussion points. Clinical reasoning misconceptions, such as assumptions or premature closure, were observed at multiple stages of the clinical reasoning process.

Community pharmacists demonstrate strong medication-related skills but face challenges in clinical reasoning for discharge prescriptions. Clinical reasoning training, semi-structured consultations, and greater patient engagement would help tailor and improve post-discharge care.

The online version contains supplementary material available at 10.1007/s11096-025-01978-0.