Independent prescribing in primary care: A survey of patients', prescribers' and colleagues' perceptions and experiences

Views and experiences of non-medical prescribing: a national survey of prescribing physiotherapists

BACKGROUND

Physiotherapy non-medical prescribing (NMP) is a contemporary development whereby physiotherapists can prescribe medications within their scope of practice. Despite institutional and professional support for its implementation, data regarding physiotherapists' views and experiences of NMP is limited.

OBJECTIVES

To explore the views and experiences of NMP for UK prescribing physiotherapists.

DESIGN

Cross-sectional study, using an anonymous, online survey.

METHODS

Recruitment involved non-probability sampling targeting UK physiotherapists with a NMP qualification. Data was gathered about the role, scope, and activity of prescribing physiotherapists via closed and open-ended questions. Descriptive statistics and inductive content analysis were undertaken.

RESULTS

Of the 552 respondents, most worked in FCP roles (122/552, 22%) and 82% (450/552) prescribed medication. NSAIDs were the most prescribed drug class (267/450, 59%). Perceived benefits were enhanced patient care, reduced burden on other prescribers, and improved medication access. Challenges included restrictions on prescribing or deprescribing controlled drugs (CDs), limited scope of practice, and inadequate CPD. Themes identified to improve physiotherapy NMP were increasing the CDs that physiotherapists can independently prescribe and deprescribe, improving CPD and supervision, and increasing awareness amongst the public and healthcare professionals.

CONCLUSIONS

This study provides novel findings of the perceived benefits, challenges, and development areas for physiotherapy prescribing. There is a need to review and potentially expand the drug formulary for physiotherapists. Improving education and supervision is crucial for the sustainable growth of physiotherapy NMP. Increasing the awareness amongst the public and healthcare professionals may enhance the acceptance of physiotherapy prescribing. CONTRIBUTION OF THE PAPER.

The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review

BACKGROUND

Pharmacist prescribing has been introduced in several countries as a strategy to improve access to health care and medicines. However, the direct impacts of pharmacist prescribing on medicines access, and the overall accessibility of pharmacist prescribing services, are not well known.

OBJECTIVES

This systematic review aimed to assess the direct impacts of pharmacist prescribing on medicines access, and the accessibility of pharmacist prescribing services, in community and primary care settings.

METHODS

PubMed, Embase, and CINAHL were searched for studies published in English between 01 January 2003 to 15 June 2023. Both quantitative and qualitative primary studies were included if they described pharmacist prescribing in a primary care setting. Outcomes included findings related to access to medicines as a result of pharmacist prescribing (primary outcome), and access to pharmacist prescribing services overall (secondary outcome). Narrative synthesis of outcomes was undertaken.

RESULTS

A total of 47 studies were included from four countries (United States, United Kingdom, Canada, New Zealand). Thirteen studies provided evidence that pharmacist prescribing may improve medicines access in several ways, including: increasing the proportion of eligible people receiving medicines, increasing the number of overall dispensed prescriptions, or reducing time to receipt of treatment. The remainder of the included studies reported on the accessibility of pharmacist prescribing services. Published studies highlight that pharmacist prescribers practicing in community settings are generally accessible, with pharmacist prescribers viewed by patients as easy and convenient to consult. There was limited evidence about the affordability of pharmacy prescribing services, and a number of potential equity issues were observed, including reduced access to pharmacist prescribers in more socioeconomically disadvantaged areas and those with greater proportions of populations at risk of health inequities, such as culturally and linguistically diverse communities.

CONCLUSIONS

This systematic review found that pharmacist prescribing services were both highly accessible and beneficial in improving access to medicines. However, measures of medicines access varied, and few studies included direct measures of medicines access as an outcome of pharmacist prescribing, highlighting a need for future studies to incorporate direct measures of medicines access when assessing the impact of pharmacist prescribing services.

Outline of nurse prescribing education programs: A scoping review

BACKGROUND

The role of nurse prescribers is developing rapidly to meet rising health care demands worldwide. However, prescribing is a complex process that requires nurses to receive the proper education.

OBJECTIVES

To identify what is known in the research field on nurse prescribing education.

DESIGN

Arksey and O'Malley's five-stage methodological framework was used to guide this scoping review.

DATA SOURCES

PubMed, Web of Science, CINAHL, Embase, and the Cochrane Library.

REVIEW METHODS

Databases were searched from inception to December 31, 2022. Data were extracted from papers meeting the inclusion criteria using the data chart and synthesized using a narrative method.

RESULTS

Seventy-one studies were included in the scoping review. Five education content themes and four education modes were identified. In addition, positive effects of nurse prescribing education and the learning needs of nurses were also found.

CONCLUSIONS

There is considerable heterogeneity in nurse prescribing education content and mode. This scoping review highlights the benefits of implementing education programs to prepare nurses for prescribing. However, nurses still have some unmet needs for prescribing education. More longitudinal studies and evaluation tools are needed to determine long-term effects. Future nurse prescribing education programs could consider the dual mentorship system, interactive educational activities, and specialized courses to improve the motivation of nurses and the quality of education.

Experiences of Spanish nurses in the rollout of nurse prescribing: a qualitative study

Introduction

Nurse prescribing has legal recognition in Spain, after a long regulatory process, with confusing, changing legislation that does not fully coincide with the reality of nurses' practice. There is currently no research available on how nurses have experienced the rollout of nurse prescribing. The objective of this study is to describe the experiences of nurses in the rollout of nurse prescribing in the province of Barcelona, Spain.

Method

A descriptive qualitative study with intentional sampling was carried out between March 2021 and July 2022. The data were collected through semi-structured individual interviews and discussion groups. The participants were 24 nurses working in the province of Barcelona who were accredited in nurse prescribing or involved in the rollout of nurse prescribing. The data were analyzed using thematic analysis, following Braun and Clark. The COREQ checklist was used to report findings.

Results

We describe nurses' responses on the following themes: internal and external barriers; strategies to support nurse prescribing in the initial rollout and proposals for improvement; and factors linked to nurses' satisfaction.

Discussion

The regulatory process has provided a safety framework for nurse prescribing. Strategies are needed for its comprehensive development and its acceptance among the public. The findings give visibility to nurse prescribing internationally.

Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model

BACKGROUND

The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation.

OBJECTIVE(S)

To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change.

METHODS

An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed.

RESULTS

Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change.

CONCLUSIONS

Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

To be or not to be: The identity work of pharmacists as clinicians

This study explores how pharmacists legitimise the expansion of their clinical work and considers its impact on pharmacists' professional identity work. In the context of pharmacy in the English NHS, there has been an ongoing policy shift towards pharmacists moving away from 'medicines supply' to patient-facing, clinical work since the 1950s. Pharmacists are continuously engaging in 'identity work' and 'boundary work' to reflect the expansion of their work, which has led to the argument that pharmacists lack a clear professional identity. Drawing insights from linguistics and specifically Van Leeuwen's 'grammar of legitimation', this study explains how the Pharmacy Integration Fund, a nationally funded learning programme, provides the discursive strategies for pharmacists to legitimise their identity work as clinicians.

Integration of pharmacist independent prescribers into general practice: a mixed-methods study of pharmacists' and patients' views

BACKGROUND

Since 2015, the National Health Service (NHS) has funded pharmacists to work in general practice (GP practice) to ease workload pressures. This requires pharmacists to work in new roles and be integrated effectively in GPs. Independent prescribing is a key part of the GP pharmacist role, but little is known about pharmacists' integration into GP practice as well as patients' perceptions and experiences of the care provided by GP pharmacists. This study aims to explore the perceptions of pharmacist independent prescribers (PIPs) about their integration into GP practice and gain insight into patients' perceptions about the care provided to them by pharmacists.

METHODS

A mixed-methods study comprising semi-structured interviews with PIPs (n = 13) followed by questionnaire-based assessment of patients' (n = 77) evaluation of pharmacists' care was conducted between December 2019 and March 2020. Quantitative data were analysed using descriptive statistics. Interviews and open comments of the survey were thematically analysed.

RESULTS

Pharmacist independent prescribers reported undertaking a range of patient-facing and non-clinical roles. Lack of understanding about PIPs' clinical role and working beyond their clinical area of competence were some of the barriers to their integration into GP practice. Most patients were satisfied with the consultations they received from pharmacists and reported confidence in the pharmacist's recommendations about their health conditions. However, a few patients (14%) felt they would still need to consult a general practitioner after their appointment and 11% were not sure if a further consultation was needed.

CONCLUSIONS

Pharmacist independent prescribers provide a range of clinical services for the management of long-term conditions which appear to be recognised by patients. However, there is a need to address the barriers to PIPs' integration into GP practice to optimise their skill-mix and patient-centred care.

Speech pathology prescribing in the outpatient setting: A review of requirements, considerations and barriers

BACKGROUND

As health systems face increasing demands, non-medical prescribing is a workforce redesign strategy adopted within some services. Despite successful implementation in other professional groups, non-medical prescribing within speech pathology (SP) has not yet been described.

AIMS

To provide a descriptive account of the development and planned implementation of two SP prescribing models.

METHODS & PROCEDURES

The evolution of two SP-led prescribing models, including relevant training and credentialing, for use of (1) nystatin oral drops (100,000 units/mL); and (2) lidocaine (lignocaine) and phenylephrine nasal spray (5 mg/500 μg/spray), in the outpatient setting is detailed. Challenges to implementation are outlined.

MAIN CONTRIBUTION

The development of relevant governance structures, a research evidenced-based project evaluation framework, and an overview of training pathways and credentialing was successfully completed. However, implementation of the models was unable to be achieved. A thorough review of the requirements and a discussion of contextual considerations that had a negative influence on the implementation of SP-led prescribing within this specific service context is provided.

CONCLUSIONS & IMPLICATIONS

The successful implementation of SP-led prescribing is complex and highly context dependent. This work offers a discussion and review of the complexities of introducing a non-medical prescribing model in an outpatient hospital setting.

WHAT THIS PAPER ADDS

What is already known on the subject Allied Health prescribing is an emerging practice area aiming to reduce current pressures on health services. SP-led prescribing has not been thoroughly investigated in the Australian context. What this study adds to existing knowledge This study describes the development of a SP-led prescribing process in the outpatient setting, and a thorough review and discussion of the drivers and barriers to the model's implementation. What are the potential or actual clinical implications of this work? The successful implementation of SP-led prescribing was identified to be complex from a legislative and operational perspective, as well as being highly context dependent. This study further highlights the importance of a thorough context evaluation and workflow mapping prior to full-scale implementation of SP prescribing trials.

A decade of independent prescribing in the UK: a review of progress

BACKGROUND

2022 marks a decade since the profession of podiatry secured independent prescribing rights in the UK. Widely viewed as a significant milestone, its advent appeared to herald a new age of practice, with increased autonomy, a broader scope of practice and improved patient care. Access to any medicine within the British National Formulary (with a few notable exceptions) seemed to signal an end to the perennial difficulties and frequent disappointments in obtaining ease of access to medicines necessary for effective practice.

MAIN BODY

Recent attempts to expand the scope of prescribing practice to include access to a broader range of controlled drugs (CDs) have led to unanticipated complications which may even threaten existing rights. These issues highlight the limitations of current independent prescribing and the continuing inability of podiatrists to access certain key medicines, primarily controlled drugs. Reliance on specified 'lists' of approved medicines, whether a controlled drug list for prescribers or the use of statutory exemptions by non-prescriber podiatrists, remain inflexible and difficult to change. The data underpinning much of this paper is derived from the work undertaken by the authors as representatives of podiatry on NHS England's Chief Professions' Officers' Medicines project, in particular involving submissions to the Commission on Human Medicines and the Advisory Council on the Misuse of Medicines, spanning the years 2017-2021. It describes a complex process, and highlights a misalignment between two legislative frameworks that threaten to unravel existing rights.

SHORT CONCLUSION

Ongoing difficulties relating to controlled drugs illustrate the problematic nature of current supply, administration and prescribing rights in podiatry. Efforts to keep pace with periodic legal reclassifications of medicines are constrained by limited and inflexible legal mechanisms, and formal approval for extended access via prescribing remains unpredictable and complex. For prescriber and non-prescriber¹ (¹Non- prescriber podiatrists are those who are neither supplementary or independent prescribers, but do enjoy existing administration and supply rights to certain medicines.) podiatrists alike, the profession of podiatry faces a new challenge to its ability to access medicines, and to realise its full clinical potential.

Medicines prescribed by non-medical independent prescribers in primary care in Wales: a 10-year longitudinal study April 2011-March 2021

OBJECTIVES

The therapeutic classes of medicines prescribed by non-medical independent prescribers (NMIPs) working in primary care in Wales has not been studied in detail. The aim of this study was to conduct a 10-year longitudinal analysis of NMIP prescribing in Wales from April 2011 to March 2021. The study examined the British National Formulary (BNF) chapters from which medicines were prescribed by NMIPs, whether this changed over time, and whether there was variation in prescribing across the geographic regions of Wales.

DESIGN

Retrospective secondary data analysis of primary care prescribing data. Monthly prescribing data for the 10 National Health Service financial years (April to March) from April 2011 to March 2021 were obtained from the Comparative Analysis System for Prescribing Audit software. Data were analysed according to BNF chapter, to identify in which therapeutic areas NMIPs were prescribing, and whether this changed over the study period.

RESULTS

The number of items prescribed by NMIPs increased during the study period. From April 2011 to March 2021 prescribing in seven BNF chapters equated to approximately 80% of total items, with cardiovascular system medicines most prescribed. In the financial year 2011-2012 the BNF chapters with the greatest proportion of items prescribed were infection (18%) and respiratory system (13%), while in 2020-2021, these had changed to cardiovascular (23%) and nervous system (19%). The number of items prescribed in each health board in Wales varied, however, the BNF chapters contributing the largest percentages of items to the health board totals were broadly comparable.

CONCLUSIONS

The BNF chapter with the most prescribed items changed from infection to cardiovascular during the study period, suggesting an increase in chronic disease management by NMIPs. The impact of this on the delivery of primary care services and patient outcomes is a focus for future work.

"A little bit more looking…listening and feeling" A qualitative interview study exploring advanced clinical practice in primary care and community pharmacy

Background Growing demands on healthcare globally, combined with workforce shortages, have led to greater skill mix in healthcare settings. Pharmacists are increasingly moving into complex areas of practice, a move supported by policy and education/training changes. Aim To understand the nature of extended roles for pharmacists practising at an advanced level in primary care and community pharmacy settings, to explore how clinical and physical examination was incorporated into practice and to understand the impact of providing such examination on practice and on patient relationships. Method Telephone interviews (N = 15) were conducted with a purposive sample of pharmacists using clinical and physical examination in their practice in Great Britain. The sample included primary care pharmacists (N = 5), community pharmacists (N = 4), pharmacists working across settings (N = 5) and one working in another primary care setting. Participants were recruited through professional networks, social media and snowballing. Results Primary care pharmacists and community pharmacists were utilising clinical and physical examination skills in their practice. Some community pharmacists were operating locally-commissioned services for low acuity conditions. Incorporating such examinations into practice enabled pharmacists to look at the patient holistically and enhanced pharmacist/patient relationships. Barriers to practise included lack of timely sharing of patient data and perceived reluctance on the part of some pharmacists for advanced practice. Conclusion With growing opportunities to provide patient-focussed care, it remains to be seen whether pharmacists, both in Great Britain and elsewhere, are able to overcome some of the organisational, structural and cultural barriers to advanced practice that currently exist in community pharmacy.

Towards transforming community eye care: an observational study and time-series analysis of optometrists' prescribing for eye disorders

OBJECTIVES

This study aimed to provide evidence on the therapeutic prescribing activity by community optometrists in Scotland and to determine its impact on workload in general practice and ophthalmology clinics.

STUDY DESIGN

Scottish administrative healthcare data for a 53-month period (November 2013-April 2018) were used to analyse non-medical prescribing practice by optometrists.

METHODS

Using interrupted time-series regression (Autoregressive Integrated Moving Average), we assessed the impact of optometrist prescribing on ophthalmology outpatient attendances and general practice prescribing for eye disorders.

RESULTS

A total of 54,246 items were prescribed by 205 optometrists over the study period. Since the commencement of data recording, optometrist prescribing activity increased steadily from a baseline of zero to 1.2% of all ophthalmic items prescribed. Neither the monthly number of items prescribed nor the size of optometric workforce were associated with a reduction in ophthalmology outpatient appointments over time.

CONCLUSIONS

Optometrists increasingly contribute to community ophthalmic prescribing in Scotland, releasing capacity and lessening general practice, but not secondary care workload. There appears to be an underutilisation of optometrists related to the management of dry eye, which represents an opportunity to release further capacity.

Examining non-medical prescribing trends in New Zealand: 2016-2020

BACKGROUND

Population growth and general practitioner workforce constraints are creating increasing demand for health services in New Zealand (NZ) and internationally. Non-medical prescribing (NMP) is one strategy that has been introduced to help manage this. Little is known about the NMP practice trends in NZ. The aim of this study was to provide a current overview of the scale, scope, and trends of NMP practice in NZ.

METHODS

All claims for community dispensed medicines prescribed by a non-medical prescriber were extracted from the NZ Pharmaceutical Collection for the period 2016-2020. Patient demographics were retrieved from the Primary Health Organisation enrolment collection. These national databases contain prescription information for all subsidised community pharmacy medicines dispensed and healthcare enrolment data for 96% of New Zealanders.

RESULTS

The proportion of prescriptions written by all NMP providers and patients receiving NMP prescriptions increased each year from 1.8% (2016) to 3.6% (2019) and 8.4% (2016) to 14.4% (2019) respectively. From 2016 to 2019, the proportion of NMP patients who had at least one NMP prescription increased from 26% to 39% for nurse prescribers, from 1% to 9% for pharmacist prescribers, from 2% to 3% for dietitian prescribers, and decreased from 47% to 22% for dentists, and from 20% to 12% for midwives. The most commonly prescribed medicines were antibiotics (amoxicillin, amoxicillin with clavulanic acid, and metronidazole), and analgesics (paracetamol, and codeine phosphate). While some NMP providers were prescribing for patients with greater health needs, all NMP providers could be better utilised to reach more of these patients.

CONCLUSIONS

This study highlights that although the NMP service has been implemented in NZ, it has yet to become mainstream healthcare practice. This work provides a baseline to evaluate the NMP service moving forward and enable policy development. Improved implementation and integration of primary care NMP services can ensure continued access to prescribing services and medicines for our communities.

Paramedic independent prescribing: a qualitative study of early adopters in the UK

Background

Paramedics working in advanced practice roles in the UK can now train to prescribe medicine. This is anticipated to benefit patient access to medicines and quality of care where there is a national shortage of doctors, particularly in primary care.

Aim

To explore the experience of paramedics who are early adopters of independent prescribing in a range of healthcare settings in the UK.

Design and setting

A qualitative study involving interviews between May and August 2019, with paramedics in the UK who had completed a prescribing programme.

Methods

Individual interviews with a purposive sample of paramedics recruited via social media and regional paramedic networks. Interviews covered experiences, benefits and challenges of the prescribing role. A framework analysis approach was used to identify key themes.

Results

Participants were 18 advanced paramedics working in primary care, emergency departments, urgent care centres and rapid response units. All participants reported being adequately prepared to prescribe. Key benefits of prescribing included improving service capacity, efficiency and safety, and facilitating advanced clinical roles. Challenges included technological problems, inability to prescribe controlled drugs and managing expectations about the prescribing role. Concerns were raised about support and role expectations, particularly in general practice.

Conclusion

Paramedic prescribing is most successful in settings with a high volume of same-day presentations and urgent and emergency care. It facilitated advanced roles within multidisciplinary teams. Concerns indicate that greater consideration for support infrastructure and workforce planning is required within primary care to ensure paramedics meet the entry criteria for a prescribing role.

Conceptual aspects, impact, and state of the art of dependent prescription in Brazil: narrative review

BACKGROUND

Nonmedical prescription is recognized in several countries as an excellent strategy in facing emerging demands that put a strain on the health system. It is a practice carried out by professionals who are not doctors and who, after obtaining specific qualifications and legal authorization, can prescribe medication and curatives. In Brazil, although there is already a legal subsidy for prescription in some professions, it is still an underdeveloped activity with few studies.

OBJECTIVE

This study aimed to describe the conceptual aspects and state of the art of this type of prescription in Brazil.

METHODS

It is a narrative review of the literature that included national and international regulations related to the subject, as well as available articles, published in electronic journals in different databases. Key terms used were nonmedical prescription, nursing prescription, and pharmaceutical prescription.

RESULTS

It was evidenced that nonmedical prescription has ample potential for improving the quality of care and the health conditions of patients. One can highlight as positive results the improvement of work satisfaction and self-confidence of those who have developed this practice; improvement of teamwork reported by other professionals due to the reduction of work overload; greater patient satisfaction in relation to access; and care provided by prescribers.

CONCLUSIONS

It is understood that there are many challenges for the consolidation of this activity in Brazil and that its success depends on a joint effort of health and educational institutions, health professionals, and patients.