Pharmacists’ changing views of their supplementary prescribing authority

A theoretically informed, mixed-methods study of pharmacists' aspirations and readiness to implement pharmacist prescribing

Background Studies have highlighted advancing clinical pharmacy practice in Qatar. Objective To explore pharmacists’ aspirations and readiness to implement pharmacist prescribing. Setting Hamad Medical Corporation (HMC), the main provider of secondary and tertiary care. Method A sequential explanatory mixed-methods design. Questionnaire items were derived from the Consolidated Framework of Implementation Research (CFIR), in domains of: awareness/support; readiness; implementation; and facilitators and barriers. Following piloting, all pharmacists (n = 554) were invited to participate. Questionnaire data were analysed using descriptive and inferential statistics with principal component analysis of attitudinal items. Focus groups were recorded, transcribed and analysed using the Framework Approach. Main outcome measure Aspirations and readiness to implement pharmacist prescribing. Results The response rate was 62.8% (n = 348), with respondents highly supportive of implementation in Qatar (median 4, scale 0–5, extremely supportive). The majority (64.9%, n = 226) considered themselves ready, particularly those more senior (p < 0.05) and classifying themselves innovative (p < 0.01). Outpatient (72.9%, n = 221 agreeing) and inpatient (71.1%, n = 218 agreeing) HMC settings were those perceived as being most ready. PCA identified 2 components, with ‘personal attributes’ being more positive than ‘prescribing support’. Facilitators were access to records, organizational/management support and the practice environment, with physician resistance and scope of practice as barriers. Focus groups provided explanation, with themes in CFIR domains of innovation characteristics, characteristics of individuals and the inner setting. Conclusion HMC pharmacists largely aspire, and consider themselves ready, to be prescribers with inpatient and outpatient settings most ready. CFIR domains and constructs identified as facilitators and barriers should be focus for implementation.

Pharmacist non-medical prescribing in primary care. A systematic review of views, opinions, and attitudes

BACKGROUND

Uptake of non-medical prescribing by pharmacists working in primary care has been slow. This is despite benefits such as quicker and more efficient access to medicines for patients, a reduction in doctor workload, and enhanced professional satisfaction. This systematic review explores the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing.

METHODS

Medline, ScienceDirect, Embase, and the University of Reading Summon Service were searched to identify qualitative and mixed methods papers that examined the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. Papers published between January 2003 and September 2017 were included. Studies were quality assessed using the CASP checklist and then analysed using thematic synthesis.

RESULTS

After 85 full-text articles were assessed, a final 14 studies were eligible for inclusion. The included studies assessed pharmacists who currently prescribe, and other pharmacists and graduates with familiarity of non-medical prescribing. Thematic synthesis identified two themes: (1) practice environment, and (2) pharmacist's role. Non-medical prescribing was considered a natural extension to the role of a pharmacist despite difficulties in completing the required training. The ability to then prescribe was dependent on funding and access to medical records, time, and support staff. Pharmacists experienced professional rivalry with both support and resistance from members of the primary care team. The provision of training was frequently referred to as unsatisfactory. Pharmacists were motivated to prescribe, deriving increased job satisfaction and a sense of professionalism; however, they often felt underprepared for the reality of unsupervised practice. Furthermore, pharmacists reported a cautious approach with a fear of making errors frequently discussed.

CONCLUSIONS

This review has identified themes and subsequent barriers and facilitators to non-medical prescribing. Many of the barriers are more perceived than real and are diminishing. Consideration of these will assist and advance pharmacist prescribing in primary care, leading to positive outcomes for both patient care and the pharmacy profession.

Assessing Performance and Engagement on a Computer-Based Education Platform for Pharmacy Practice

A computer-based education platform was developed using a theory-based approach to help Canadian pharmacy professionals adopt their full scope of practice. Data from the platform were used to identify factors that impacted user performance and engagement. A de-identified dataset included response data for 21 unique modules, including quiz responses and self-reflection questions. Outcome measures included user performance (mean quiz score) and engagement (completion rate for attempted modules). Analysis of variance (ANOVA), multivariate regression modelling, and machine learning cluster analysis were used to analyze the data. Of the 5290 users, 68% were pharmacists, 11% were technicians, 13% were pharmacy students, and 8% were pharmacy technician students. Four clusters were identified separately for pharmacists and technicians. Clusters with the higher performance and engagement tended to have more users practicing in community pharmacies while the lower performing clusters tended have more internationally trained users. In the regression modelling, pharmacists performed better than technicians and students while students were more engaged (p < 0.0001). Further, internationally trained pharmacists had slightly lower scores but similar engagement compared to domestically trained pharmacists (p < 0.0001). Users demonstrated higher performance on modules related to scope of practice than on clinical topics, and were most engaged with topics directly impacting daily practice such as influenza vaccinations and new and emerging subjects such as cannabis. The cluster analysis suggests that performance and engagement with a computer-based educational platform in pharmacy may be more related to place of practice than to personal demographic factors such as age or gender.

Classic e-Delphi survey to provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services in Wales

OBJECTIVE

To provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services.

DESIGN

Classic e-Delphi survey.

SETTING

National study in Wales.

PARTICIPANTS

Pharmacists, nurses and allied health professionals with the independent/supplementary prescribing qualification.

RESULTS

A total of 55 non-medical prescribers agreed to become members of the expert panel of whom 42 (76%) completed the round 1 questionnaire, 40/42 (95%) completed round 2 and 34/40 (85%) responded to round 3. Twenty-one statements were developed, and consensus was achieved on nine factors representing those necessary for the successful implementation of non-medical prescribing and five representing actions required for its continued development. Strategic fit between non-medical prescribing and existing service provision, organisation preparedness, visible benefits, good managerial and team support, and a clear differentiation of roles were each important influences.

CONCLUSION

Given the high degree of consensus, this list of factors and actions should provide guidance to managers and commissioners of services wishing to initiate or extend non-medical prescribing. This information should be considered internationally by other countries outside of the UK wishing to implement prescribing by non-medical healthcare professionals.

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.

Survey of pharmacist prescribing practices in Alberta

PURPOSE

Results of a survey to characterize pharmacist prescribing in the Canadian province of Alberta are reported.

METHODS

A cross-sectional survey of a random sample of pharmacists registered with the Alberta College of Pharmacists was conducted. The survey was developed in four stages, with evidence of reliability and construct validity compiled. Analysis of variance and chi-square testing were used to compare prescribing behaviors.

RESULTS

Three hundred fifty of 692 invited pharmacists (51%) completed the survey, with 76.9% and 11.1% indicating that they practiced in community and hospital settings, respectively, and 12.0% practicing in a consultant role (i.e., on a primary care team or in a long-term care setting). Overall, 93.4% of the pharmacists had prescribed. The most common practices were renewing prescriptions for continuity of therapy (92.3%), altering doses (74.3%), and substituting a medication due to a shortage (80.6%). Twenty-three pharmacists (6.6%) indicated that they did not prescribe because they were on an interprofessional team, had a consulting role, or preferred to fax physicians to request orders. Pharmacists with additional prescribing authorization (6.3% of the total survey population) were more likely to prescribe to adjust ongoing medications (63.6%) than to initiate a new medication (18.2%).

CONCLUSION

A survey showed that Alberta pharmacists prescribed in a manner that mirrored their practice environment. Compared with other groups, hospital and consultant pharmacists were more likely to adapt prescriptions, and community pharmacists were more likely to renew medications. Pharmacists in rural areas were prescribing most frequently.

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.

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.

Evaluating the labour costs associated with pharmacy adaptation services in British Columbia

BACKGROUND

Pharmacists' scope of practice has been steadily expanding across Canada to encompass clinical activities. In January 2009, pharmacists in British Columbia (BC) were given the authority to adapt prescriptions for renewals; change in dose, formulation or regimen; and therapeutic substitutions. This study evaluated the labour costs associated with pharmacy adaptation services in BC. >

METHODS

Ten high-adapting pharmacies participated in the study. Through workflow observations, we measured the time incurred for adapted and nonadapted prescriptions.

RESULTS

We observed 91 adapted prescriptions and 1081 nonadapted prescriptions. The total average time to provide adapted prescriptions was 6:43 minutes (SD 3:50) longer than to provide nonadapted prescriptions. The total average cost of an adapted prescription was $6.10 greater than a nonadapted prescription. Renewals took the least amount of time to complete, and therapeutic substitutions took the most time to complete.

DISCUSSION

Through workflow observations, it was determined that 10 stages of activity occur when adapting a prescription, with the most time being expended during the documentation and processing phases. Labour costs associated with adapted prescriptions were higher than for nonadapted prescriptions.

Exploring Pharmacists' Understanding and Adoption of Prescribing in 2 Canadian Jurisdictions: Design and Rationale for a Mixed-Methods Approach

Background:

Although pharmacists have been granted prescribing privileges in Alberta since 2007 and most other Canadian provinces have granted or put forward similar legislation since then, there is a lack of Canadian data exploring pharmacists' understanding and adoption of prescribing practice. Therefore, our goal is to investigate pharmacists' perceptions of prescribing, the extent to which prescribing has been incorporated into pharmacists' practices and the factors that have influenced its uptake.

Methods (Study Design):

We are conducting a mixed-methods evaluation of pharmacist prescribing in Alberta and Ontario consisting of 3 consecutive stages: 1) semi-structured interviews with a small cohort of pharmacists in Alberta and Ontario; 2) development of a survey guided by responses identified in Stage 1; and 3) a mixed-methods survey of a large random sample of pharmacists in Alberta.

Conclusion:

When complete, this study will inform researchers, policy-makers and educators about Ontario pharmacists' attitudes towards prescribing and the initial uptake of prescribing practice in Alberta. This will allow for a greater understanding of pharmacists' perceptions of prescribing; the extent to which prescribing has been incorporated into pharmacy practice; and the factors facilitating its uptake.

Improving hypertension management through pharmacist prescribing; the rural Alberta clinical trial in optimizing hypertension (Rural RxACTION): trial design and methods

BACKGROUND

Patients with hypertension continue to have less than optimal blood pressure control, with nearly one in five Canadian adults having hypertension. Pharmacist prescribing is gaining favor as a potential clinically efficacious and cost-effective means to improve both access and quality of care. With Alberta being the first province in Canada to have independent prescribing by pharmacists, it offers a unique opportunity to evaluate outcomes in patients who are prescribed antihypertensive therapy by pharmacists.

METHODS

The study is a randomized controlled trial of enhanced pharmacist care, with the unit of randomization being the patient. Participants will be randomized to enhanced pharmacist care (patient identification, assessment, education, close follow-up, and prescribing/titration of antihypertensive medications) or usual care. Participants are patients in rural Alberta with undiagnosed/uncontrolled blood pressure, as defined by the Canadian Hypertension Education Program. The primary outcome is the change in systolic blood pressure between baseline and 24 weeks in the enhanced-care versus usual-care arms. There are also three substudies running in conjunction with the project examining different remuneration models, investigating patient knowledge, and assessing health-resource utilization amongst patients in each group.

DISCUSSION

To date, one-third of the required sample size has been recruited. There are 15 communities and 17 pharmacists actively screening, recruiting, and following patients. This study will provide high-level evidence regarding pharmacist prescribing.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00878566.

Exploring pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland

Objectives

The introduction of non-medical prescribing in the UK has provided opportunities and challenges for pharmacists to help ensure prudent use of antimicrobials. The objective of this research was to explore pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland.

Methods

Pharmacists' perceptions were explored using focus groups in five Scottish regions representing (a) urban and rural areas and (b) district general hospitals and large teaching centres. Senior hospital pharmacists, both prescribers and non-prescribers, working in specialities where antimicrobials are crucial to patient management, were invited to participate. A topic guide was developed to lead the discussions, which were audio-recorded and transcribed. The framework approach to data analysis was used.

Key findings

Six focus groups took place and some emerging themes and issues are presented. Pharmacists believed that the feasibility of antimicrobial prescribing is dependent upon the patient's clinical condition and the area of clinical care. They identified potential roles and opportunities for pharmacist prescribing of antimicrobials. Perceived benefits included giving patients quicker access to medicines, reducing risk of resistance and better application of evidence-based medicine.

Conclusions

Pharmacists feel they have a good knowledge base to prescribe and manage antimicrobial treatment, identifying possible opportunities for intervention. Roles within a multidisciplinary antimicrobial team need to be clearly defined.

‘It's showed me the skills that he has’: pharmacists' and mentors' views on pharmacist supplementary prescribing

Objectives

Supplementary prescribing has seen pharmacists assume greater responsibility for prescribing in collaboration with doctors. This study explored the context and experiences, in relation to the practice of supplementary prescribing, of pharmacists and physicians (who acted as their training mentors) at least 12 months after pharmacists had qualified as supplementary prescribers.

Methods

The setting was primary and secondary healthcare sectors in Northern Ireland. Pharmacists and mentors who had participated in a pre-training study were invited to take part. All pharmacists (n= 47) were invited to participate in focus groups, while mentors (n= 35) were asked to participate in face-to-face semi-structured interviews. The research took place between May 2005 and September 2007. All discussions and interviews were audiotaped, transcribed and analysed using constant comparison.

Key findings

Nine pharmacist focus groups were convened (number per group ranging from three to six; total n= 40) and 31 semi-structured interviews with mentors were conducted. The six main themes that emerged were optimal practice setting, professional progression for prescribing pharmacists, outcomes for prescribing pharmacists, mentors and patients, relationships, barriers to implementation and the future of pharmacist prescribing. Where practised, pharmacist prescribing had been accepted, worked best for chronic disease management, was perceived to have reduced doctors' workload and improved continuity of care for patients. However, three-quarters of pharmacists qualified to practise as supplementary prescribers were not actively prescribing, largely due to logistical and organisational barriers rather than inter-professional tensions. Independent prescribing was seen as contentious by mentors, particularly because of the diagnostic element.

Conclusions

Supplementary prescribing has been successful where it has been implemented but a number of barriers remain which are preventing the wider acceptance of this practice innovation.

Learning to prescribe - pharmacists' experiences of supplementary prescribing training in England

BACKGROUND

The introduction of non-medical prescribing for professions such as pharmacy and nursing in recent years offers additional responsibilities and opportunities but attendant training issues. In the UK and in contrast to some international models, becoming a non-medical prescriber involves the completion of an accredited training course offered by many higher education institutions, where the skills and knowledge necessary for prescribing are learnt.

AIMS

to explore pharmacists' perceptions and experiences of learning to prescribe on supplementary prescribing (SP) courses, particularly in relation to inter-professional learning, course content and subsequent use of prescribing in practice.

METHODS

A postal questionnaire survey was sent to all 808 SP registered pharmacists in England in April 2007, exploring demographic, training, prescribing, safety culture and general perceptions of SP.

RESULTS

After one follow-up, 411 (51%) of pharmacists responded. 82% agreed SP training was useful, 58% agreed courses provided appropriate knowledge and 62% agreed that the necessary prescribing skills were gained. Clinical examination, consultation skills training and practical experience with doctors were valued highly; pharmacology training and some aspects of course delivery were criticised. Mixed views on inter-professional learning were reported - insights into other professions being valued but knowledge and skills differences considered problematic. 67% believed SP and recent independent prescribing (IP) should be taught together, with more diagnostic training wanted; few pharmacists trained in IP, but many were training or intending to train. There was no association between pharmacists' attitudes towards prescribing training and when they undertook training between 2004 and 2007 but earlier cohorts were more likely to be using supplementary prescribing in practice.

CONCLUSION

Pharmacists appeared to value their SP training and suggested improvements that could inform future courses. The benefits of inter-professional learning, however, may conflict with providing profession-specific training. SP training may be perceived to be an instrumental 'stepping stone' in pharmacists' professional project of gaining full IP status.