Risks and concerns about supplementary prescribing: survey of primary and secondary care pharmacists

A qualitative, theory-based exploration of facilitators and barriers for implementation of pharmacist prescribing in chronic kidney disease

BACKGROUND

While there is an accumulation of evidence that pharmacist prescribing is safe and effective, there is a lack of research on processes of implementation into practice, particularly for patients with complex clinical conditions such as chronic kidney disease (CKD).

AIM

The aim was to explore the facilitators and barriers to the implementation of pharmacist prescribing for patients with CKD in the United Kingdom (UK).

METHOD

Semi-structured interviews were conducted with UK Renal Pharmacy Group members who were independent prescribers. The Consolidated Framework for Implementation Research (CFIR) underpinned the interview schedule. Interviews were recorded, transcribed, and independently coded by two researchers. A thematic approach was used for analysis, with data generation continuing until saturation of themes. Ethical approval was granted.

RESULTS

Data saturation was achieved following 14 interviews. Most interviewees were female (n = 11), all had secondary care as their main practice setting, and were highly experienced prescribers with 8 having 11 or more years of prescribing practice. Interviewees were positive regarding the development of their prescribing practice. Facilitators and barriers emerged across all 5 of the CFIR domains. Key facilitators were aspects of inner setting (e.g., organisational support and communication) while key barriers were also related to inner setting, specifically the need for adequate structural and financial resources.

CONCLUSION

This theory-based study has illuminated the facilitators and barriers for the implementation of pharmacist prescribing in CKD. There is a need to consider the resources required for implementation of prescribing practice at an early stage of planning and development.

Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences

Objectives

Non-medical prescribers, including pharmacists, have been found to achieve comparable clinical outcomes with doctors for certain health conditions. Legislation supporting pharmacist prescribing (PP) has been implemented in the United Kingdom (UK), Canada and New Zealand (NZ); however, to date, Australian pharmacists have not been extended prescribing rights. The purpose of this review was to describe the barriers to PP found in the literature from the UK, Canada, NZ and Australia, and examine the implications of these for the development of PP in Australia.

Methods

We conducted a scoping review, which included peer-reviewed and grey literature, and consultation with stakeholders. Sources – Scopus, PubMed and CINAHL; Google Scholar, OpenGrey and organisational websites from January 2003 to March 2018 in the UK, Canada, NZ and Australia. Inclusion criteria – articles published in English, related to implementation of PP and articulated barriers to PP.

Key findings

Of 863 unique records, 120 were reviewed and 64 articles were eligible for inclusion. Three key themes emerged: (1) Socio-political context, (2) Resourcing issues and (3) Prescriber competence. The most common barriers were inadequate training regarding diagnostic knowledge and skills, inadequate support from authorities and stakeholders, and insufficient funding/reimbursement.

Conclusions

If implementation of PP is to occur, attention needs to be focused on addressing identified barriers to PP implementation, including fostering a favourable socio-political context and prescriber competence. As such, a concerted effort is required to develop clear policy pathways, including targeted training courses, raising stakeholder recognition of PP and identifying specific funding, infrastructure and resourcing needs to ensure the smooth integration of pharmacist prescribers within interprofessional clinical teams.

Stakeholders' views and experiences of pharmacist prescribing: a systematic review

AIMS

The aims of this systematic review were to: (1) critically appraise, synthesize and present the available evidence on the views and experiences of stakeholders on pharmacist prescribing and; (2) present the perceived facilitators and barriers for its global implementation.

METHODS

Medline, CINAHL, International Pharmaceutical Abstracts, PsychArticles and Google Scholar databases were searched. Study selection, quality assessment and data extraction were conducted independently by two reviewers. A narrative approach to data synthesis was undertaken due to heterogeneity, the nature of study types and outcome measures.

RESULTS

Sixty-five studies were identified, mostly from the UK (n = 34), followed by Australia (n = 13), Canada (n = 6) and USA (n = 5). Twenty-seven studies reported pharmacists' perspectives, with fewer studies focusing on patients' (n = 12), doctors' (n = 6), the general public's (n = 4), nurses' (n = 1), policymakers' (n = 1) and multiple stakeholders' (n = 14) perspectives. Most reported positive experiences and views, regardless of stage of implementation. The main benefits described were: ease of patient access to healthcare services, improved patient outcomes, better use of pharmacists' skills and knowledge, improved pharmacist job satisfaction, and reduced physician workload. Any lack of support for pharmacist prescribing was largely in relation to: accountability for prescribing, limited pharmacist diagnosis skills, lack of access to patient clinical records, and issues concerning organizational and financial support.

CONCLUSION

There is an accumulation of global evidence of the positive views and experiences of diverse stakeholder groups and their perceptions of facilitators and barriers to pharmacist prescribing. There are, however, organizational issues to be tackled which may otherwise impede the implementation and sustainability of pharmacist prescribing.

A qualitative study exploring physicians' perceptions on the role of community pharmacists in Dubai

Objective:

The aim of this study is to explore the perceptions of physicians operating within the boundaries of Dubai on the role of community pharmacists.

Methods:

Semi-structured interviews were done with 12 physicians working within the boundaries of Dubai Health Authority. Interviews mainly focused on understanding the perceptions of physicians on the role of community pharmacists in addition to willingness to integrating pharmacists in patient care process.

Results:

Key findings show that all interviewees agree that community pharmacists are important healthcare professionals. However, 7 physicians restrict the role of pharmacists to dispensing medicines. Physicians in Dubai are willing to collaborate with pharmacists, but more than half of them (7) think that pharmacists might interfere with their jobs.

Conclusion:

The study concludes that all informants agree that collaboration between community pharmacists and physicians definitely enhances patients’ drug therapy outcomes.

Attitudes and attributes of pharmacists in relation to practice change - A scoping review and discussion

BACKGROUND

Multiple barriers and facilitators to the uptake of cognitive services in pharmacy practice have been identified. Pharmacists' attitudes and attributes have been described as barriers and facilitators in relation to the uptake of extended pharmacy services, in addition to those of a more systemic nature.

OBJECTIVES

To systematically scope and review the literature describing pharmacists' attitudes and attributes in relation to the implementation of cognitive services or role extension and to critically analyze and discuss their relevance as barriers or facilitators.

METHOD

A scoping review of the literature on attitudes and attributes of pharmacists in relation to pharmacy practice was performed, including 47 articles on attitudes and 12 on attributes, forming the basis for a critical analysis within theoretical frameworks.

RESULTS

Pharmacists' attitudes toward role extensions and new pharmacy service models are generally positive and their personal attributes and personality traits appear favorable for roles as health professionals. Pharmacists perceived a number of barriers to the uptake of extended roles.

CONCLUSION

Pharmacists' attributes, including personality traits, and attitudes favor the implementation of cognitive and patient-focused health care services and should not be regarded as major barriers to the uptake of extended pharmacy practice roles. Framing their attitudes and attributes within the theories of planned behavior and personality trait theories indicates that individual motivation needs to be underscored by systemic support for pharmacy practice change to succeed on a wide scale.

What prescribing means to pharmacists: a qualitative exploration of practising pharmacists in Alberta

Objective

In 2007 Alberta, Canada, became the first North American jurisdiction to adopt prescribing legislation for pharmacists. In light of these legislative changes and expanded scope of pharmacy practice, we evaluated what ‘prescribing’ means to pharmacists in Alberta and the application of prescribing in pharmacy practice.

Methods

We invited pharmacists to participate in semi-structured telephone interviews using closed and open-ended questions. Pharmacists working in community, hospital or other settings were selected using a mix of random and purposive sampling. Interviews were audiorecorded and transcribed, and data were entered into nVIVO 9 software. Transcriptions were analysed by two investigators using an interpretive description approach to identify themes.

Key findings

Thirty-eight pharmacists were interviewed, of whom 13 had additional (independent) prescribing authorization. Prescribing had a wide breadth of meaning to the pharmacists in our study, which included writing a new prescription and extending an existing prescription, as well as advising on non-prescription medications. Pharmacists described prescribing in terms of the physical act of writing the prescription and as part of the patient care process as well as the legislated definition of pharmacist prescribing. The sense of increased responsibility associated with prescribing was noted by many pharmacists.

Conclusion

Prescribing had diverse meanings to pharmacists in our study, and appeared to be context-specific. Understanding the meaning prescribing holds for individual pharmacists is important to explore whether pharmacist’s definition of this expanded scope has shaped pharmacists’ enactment of prescribing practice.

Factors influencing pharmacists' adoption of prescribing: qualitative application of the diffusion of innovations theory

Background

In 2007, Alberta became the first Canadian jurisdiction to grant pharmacists a wide range of prescribing privileges. Our objective was to understand what factors influence pharmacists’ adoption of prescribing using a model for the Diffusion of Innovations in healthcare services.

Methods

Pharmacists participated in semi-structured telephone interviews to discuss their prescribing practices and explore the facilitators and barriers to implementation. Pharmacists working in community, hospital, PCN, or other settings were selected using a mix of random and purposive sampling. Two investigators independently analyzed each transcript using an Interpretive Description approach to identify themes. Analyses were informed by a model explaining the Diffusion of Innovations in health service organizations.

Results

Thirty-eight participants were interviewed. Prescribing behaviours varied from non-adoption through to product, disease, and patient focused use of prescribing. Pharmacists’ adoption of prescribing was dependent on the innovation itself, adopter, system readiness, and communication and influence. Adopting pharmacists viewed prescribing as a legitimization of previous practice and advantageous to instrumental daily tasks. The complexity of knowledge required for prescribing increased respectively in product, disease and patient focused prescribing scenarios. Individual adopters had higher levels of self-efficacy toward prescribing skills. At a system level, pharmacists who were in practice settings that were patient focused were more likely to adopt advanced prescribing practices, over those in product-focused settings. All pharmacists stated that physician relationships impacted their prescribing behaviours and individual pharmacists’ decisions to apply for independent prescribing privileges.

Conclusions

Diffusion of Innovations theory was helpful in understanding the multifaceted nature of pharmacists’ adoption of prescribing. The characteristics of the prescribing model itself which legitimized prior practices, the model of practice in a pharmacy setting, and relationships with physicians were prominent influences on pharmacists’ prescribing behaviours.

Preparing hospital pharmacists to prescribe: stakeholders' views of postgraduate courses

OBJECTIVES

To explore pharmacy stakeholders' views on developing a postgraduate course to prepare hospital pharmacists for collaborative prescribing in Australia.

METHODS

Semi-structured interviews were conducted with pharmacy stakeholders from universities, hospitals and professional organisations (n = 25) to gather views on the content, structure and delivery methods of a possible postgraduate prescribing course for pharmacists. Transcripts were analysed thematically and coded using NVivo software.

KEY FINDINGS

There was strong support for collaborative prescribing as an appropriate role for advanced pharmacist practitioners and acknowledgement that further training is needed to implement this new role. It was proposed that postgraduate training for hospital pharmacists should be based on a national prescribing competency framework and participants highlighted key aspects of the prescribing process in which pharmacists need particular up-skilling: diagnosis, physical assessments, clinical decision-making and consultations. The training model used in the UK was favoured, where candidates undertake university-based study combined with collaborative training with a doctor and a practical assessment of competency.

CONCLUSIONS

The findings from this study have provided valuable information which can provide a pathway for the development of a postgraduate course to prepare Australian hospital pharmacists for prescribing. Future research should focus on uncovering the perceptions of Australian doctors, nurses and policy makers on the training requirements needed for pharmacist prescribing in the hospital setting. Stakeholders' views on pharmacist prescribing training in the community setting could also be explored.

An expanded prescribing role for pharmacists - an Australian perspective

Expanded pharmacist prescribing is a new professional practice area for pharmacists. Currently, Australian pharmacists' prescribing role is limited to over-the-counter medications. This review aims to identify Australian studies involving the area of expanded pharmacist prescribing. Australian studies exploring the issues of pharmacist prescribing were identified and considered in the context of its implementation internationally. Australian studies have mainly focused on the attitudes of community and hospital pharmacists towards such an expansion. Studies evaluating the views of Australian consumers and pharmacy clients were also considered. The available Australian literature indicated support from pharmacists and pharmacy clients for an expanded pharmacist prescribing role, with preference for doctors retaining a primary role in diagnosis. Australian pharmacists and pharmacy client's views were also in agreement in terms of other key issues surrounding expanded pharmacist prescribing. These included the nature of an expanded prescribing model, the need for additional training for pharmacists and the potential for pharmacy clients gaining improved medication access, which could be achieved within an expanded role that pharmacists could provide. Current evidence from studies conducted in Australia provides valuable insight to relevant policymakers on the issue of pharmacist prescribing in order to move the agenda of pharmacist prescribing forwards.

An evaluation of Australian pharmacist's attitudes on expanding their prescribing role

OBJECTIVES

To evaluate the views of Australian pharmacists on expanded pharmacist prescribing roles and identify important drivers and barriers to its implementation. Setting Pharmacists in Australia.

METHOD

Data were collected using a self-administered questionnaire distributed nationally to a random sample of pharmacists either directly, or in the case of one state, via community pharmacies. One-way ANOVA and ϰ(2) testing were used to identify significant associations. Factor analysis was conducted to pool variables and the derived factors were subjected to regression analysis.

MAIN OUTCOME MEASURES

Perceptions of Australian pharmacists on expanded prescribing and the relationships between variables derived.

RESULTS

A total of 2592 questionnaires were distributed and a response rate of 40.4% was achieved (n = 1049). Of the respondents 83.9% strongly agreed/agreed to an expanded prescribing role for pharmacists and 97.1% reported they would need further training. Of the respondents 896 agreed that pharmacists should engage in supplementary, independent prescribing or both. Of these 69.1% preferred only supplementary prescribing, 3.3% independent prescribing and 27.4% both models. Both models were found to be positive predictors of expanding pharmaceutical services through prescribing (P < 0.001) with supplementary prescribing showing a stronger association (β = 0.52 vs. β = 0.18). Pharmacists' opinion based on their current perceptions of their clients was an important predictor in expanding pharmaceutical services through prescribing (P = 0.005). Inadequate training in patient assessment, diagnosis and monitoring were the strongest barriers to expanded pharmacist prescribing (P < 0.001).

CONCLUSIONS

The majority of Australian pharmacists supported an expanded pharmacist prescribing role. Support for supplementary was stronger than independent prescribing. Pharmacists acknowledged that they would need further training to perform such roles.

Pharmacist supplementary prescribing training: a study of pharmacists' perceptions and planned participation

Objective

The aim of this research was to investigate in a national sample of pharmacists, who have not yet applied for a supplementary prescribing (SP) course, their planned participation in training, and attitudes towards pharmacist SP. Setting Great Britain.

Method

A postal questionnaire was sent to 4300 pharmacists (approximately 10% of all Great Britain registered pharmacists). The questionnaire had five sections: awareness of SP training; perceptions of aspects of SP training; actions taken relating to SP training based on ‘stage of change’ model; attitudes towards implementing SP into practice; and demographics. Within demographics, respondents were asked to denote themselves as innovators, early adopters, early majority, late majority and laggards, based on receptivity to change. Non-respondents were mailed up to two reminders.

Key findings

The response rate was 55.1% (2371/4300). Of the 1707 with patient contact but who had not commenced training, almost all (1668, 97.7%) were aware of pharmacist SP. A minority had taken any significant SP training action, with most being at the precontemplation/contemplation stage of change. However, most respondents either strongly agreed/agreed that practising SP would improve patient care, but strongly disagreed/disagreed that they had sufficient pharmacist/technical support. Two-hundred and forty-three (73.0%) of the ‘venturesome’ pharmacists (the innovators) and 291 (79.5%) of the ‘role models’ (the role models) had either never thought about training or had not yet explored training options further. Following logistic regression, predictors of prescribing training actions were: awareness of local networks for SP; receptivity to change; knowledge of colleagues who had undertaken or were currently undertaking SP training; postgraduate qualifications; intrinsic (professional) factors such as professional duty to become a prescriber; and extrinsic (infrastructure) factors such as sufficient IT support.

Conclusion

We have demonstrated that pharmacists are aware of SP courses and that certain factors are associated with actions relating to prescribing training. However, the practice setting(s) require(s) attention to ensure readiness to support such innovations in areas such as IT and administrative support. These issues have implications for education providers, the NHS and policy makers; and the extension into independent prescribing. Issues based on receptivity to change and models of change require further investigation.

Benefits and challenges of prescribing training and implementation: perceptions and early experiences of RPSGB prescribers

Objective To investigate the challenges experienced by pharmacists in delivering supplementary prescribing (SP) services, to explore their perceptions of benefits of SP and to obtain feedback on both SP training and implementation.

Method A postal questionnaire focusing on prescribing training, early experiences of prescribing and general demographics was sent in September to November 2005 to all SP pharmacists (n = 488) in Great Britain after excluding a pilot sample (n = 30). The biggest benefits and challenges of SP, and reasons for not practising SP, were identified. Responses to a general open question were content analysed for major themes.

Key findings A total of 401 responses (82.2%) was received; 195 (48.6%) had started practising SP of which 154 (79%) had written at least one prescription. This paper focuses primarily on perceived benefits and challenges to the implementation of SP, and the responses to the open question. Better patient management (n = 58; 29.7%) was identified as the main benefit of SP and inadequate funding (n = 27; 13.8%) as the biggest challenge in delivering SP service. The main reasons for not commencing SP were: no organisational recognition of SP (n = 37; 18%); lack of funding (n = 33; 16%); non-availability of prescription pads (n = 22; 10.7%), and change of jobs (n = 18; 8.7%). The comments to the open question (n = 145; 36.2%) were regarding: SP training; perceived benefits of SP; and barriers to SP. Respondents highlighted the need for greater emphasis on clinical skills development as part of the SP course.

Conclusion Despite optimism among SP pharmacists, the need for support in terms of infrastructure and integration into the healthcare team has been identified. Our findings also inform the need for modifications in the structure, content and delivery of the prescribing course for pharmacists. Greater publicity of pharmacists' roles in medication management, support from the medical profession and healthcare organisations, and high standards by early practitioners are warranted for the success of SP by pharmacists.

Views of pharmacist prescribers, doctors and patients on pharmacist prescribing implementation

Aim

The aim of this study was to explore the perspectives of pharmacist supplementary prescribers, their linked independent prescribers and patients, across a range of settings, in Scotland, towards pharmacist prescribing.

Method

Telephone interviews were conducted with nine pharmacist prescribers, eight linked independent prescribers (doctors) and 18 patients. The setting was primary and secondary care settings in six NHS Health Board areas in Scotland.

Key findings

In general, all stakeholders were supportive of pharmacists as supplementary prescribers, identifying benefits for patients and the wider health care team. Although patients raised no concerns, they had little idea of what to expect on their first visit, leading initially to feelings of apprehension. Pharmacists and doctors voiced concerns around a potential lack of continued funding, inadequate support networks and continuing professional development. Pharmacists were keen to undertake independent prescribing, although doctors were less supportive, citing issues around inadequate clinical examination skills.

Conclusions

Pharmacists, doctors and patients were all supportive of developments in pharmacist supplementary prescribing, although doctors raised concerns around independent prescribing by pharmacists. The ability of pharmacists to demonstrate competence, to be aware of levels of competence and to identify learning needs requires further exploration.

Exploring patients' perspectives of pharmacist supplementary prescribing in Scotland

AIM

The aim of this study was to explore patients' perspectives and experiences of pharmacist supplementary prescribing (SP) in Scotland.

METHOD

A survey in primary and secondary care in Scotland. Pharmacist supplementary prescribers (n = 10) were purposively selected across Scotland. All pharmacists distributed questionnaires to 20 consecutive patients as they attended appointments during October to December 2006. Reminders were mailed to all 20 patients by each pharmacist 2 weeks after initial distribution.

MAIN OUTCOME MEASURES

The questionnaire contained items on: attitudes towards pharmacist SP derived from earlier qualitative research; consultation satisfaction derived from a validated scale developed initially for general practitioners, with the term 'doctor' being replaced by 'pharmacist prescriber'; and demographics. Closed and Likert scales were used as response options.

RESULTS

One pharmacist withdrew. The patient response rate was 57.2% (103/180). The median age was 67 years (interquartile range 56.5-73 years), with 53.4% being female. Most (76, 73.8%) consulted with the pharmacist in a general practice setting. Patients reported positive consultation experiences with 89.3% agreeing/strongly agreeing that they were satisfied with the consultation, 78.7% thought the pharmacist told them everything about their treatment and 72.9% felt the pharmacist was interested in them as a person. Most patients were positive in their attitudes, agreeing that they would recommend a pharmacist prescriber to others and that they had trust in the pharmacist. However, 65% would prefer to consult a doctor.

CONCLUSION

Most patient respondents were satisfied with, and had a positive attitude towards, pharmacist prescribing consultations. However, most patients would still elect to see a doctor given the choice.

Nurse and pharmacist supplementary prescribing in the UK—A thematic review of the literature

OBJECTIVES

Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically, the literature on nurse and pharmacist SP, to inform further research, policy and education.

METHODS

A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic databases, grey literature and journal hand searches.

RESULTS

Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses and under-evaluation of safety, economic analysis and patients' experiences were identified in empirical studies. There was a perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing.

CONCLUSIONS

There is a need for additional research regarding SP and despite nurses' and pharmacists' enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.

Polypharmacy in elderly hospitalised patients in Slovakia

OBJECTIVE

The aims of the present study were to: analyse the prevalence of polypharmacy in a group of older patients; evaluate the influence of hospital stay on the number of drugs taken; assess the most frequently prescribed pharmacological classes; identify risk factors that predisposed the patient to polypharmacy. Setting The study was carried out in the Department of Internal Medicine of a non-university general hospital.

METHOD

In the retrospective study, 600 patients aged 65 years or more were enrolled. They were hospitalised in the period from 1st December 2003 to 31st March 2005. Each person taking six or more medications per day was considered to be a patient with polypharmacy. Particular sociodemographic and clinical characteristics, as well as comorbid conditions, were evaluated as factors potentially influencing the prevalence of polypharmacy.

MAIN OUTCOME MEASURE

The number and type of medications taken at the time of hospital admission and discharge were recorded and compared for each patient.

RESULTS

Polypharmacy on admission and at discharge was observed in 362 (60.3%) and 374 (62.3%) patients, respectively. Hospitalisation led to a significant increase in the number of medications. The spectrum of medications used corresponded to the proportions of diagnoses in the evaluated group, in which cardiovascular diseases were most prevalent. According to the multivariate analysis using a logistic regression model, diabetes mellitus (odds ratio (OR) 2.40; 95% confidence interval (CI): 1.64-3.50), heart failure (OR 2.14; 95% CI: 1.46-3.14), dementia (OR 2.12; 95% CI: 1.26-3.57), living alone (OR 2.00; 95% CI: 1.28-3.10), arterial hypertension (OR 1.63; 95% CI: 1.08-2.44) and cerebrovascular disease (OR 1.58; 95% CI: 1.03-2.44) significantly increased the risk of the presence of polypharmacy.

CONCLUSION

Our study confirmed a relatively high prevalence of polypharmacy in Slovak elderly patients. Polypharmacy risk rose especially with the increased prevalence of diseases of advancing age (diabetes mellitus, heart failure, arterial hypertension, dementia and cerebrovascular diseases). The increasing numbers of medications in inpatients indicate the need for the careful re-evaluation of pharmacotherapy during the stay in hospital.