An overiew of non medical prescribing across one strategic health authority: a questionnaire survey

Continuing professional development opportunities for Australian endorsed for scheduled medicines podiatrists-What's out there and is it accessible, relevant, and meaningful? A cross-sectional survey

BACKGROUND

Non-medical prescribing is a valuable strategy to enable equitable access to medications in the context of the increasing demands on health services globally. Australian podiatrists have been able to seek endorsement for scheduled medicines (ESM) for over a decade. This project investigates the perceptions and habits of ESM podiatrists in meeting the extra continuing professional development (CPD) requirements associated with their ESM status.

METHODS

Australian ESM podiatrists completed an anonymous, online survey capturing demographics; CPD engagement; and self-reflections of CPD activities.

RESULTS

Twenty percent (n = 33) of Australian ESM registered podiatrists (N = 167) responded to the survey (18 female; median ESM status 2.5 years, (IQR 1.0, 9.0)). For the previous registration period, 88% (n = 29) completed the mandatory CPD hours, with only 35% (n = 11) completing a CPD learning goal plan. Over 80% identified their last ESM CPD activity as accessible, affordable, and could recommend to colleagues. Conversely, 50% or less agreed the activity increased confidence; changed their practice; improved communication skills; or enabled networking. Most respondents (81%, n = 27) indicated improvements should be made to the content, relevance, accessibility, and meaningfulness of CPD. These findings were supported by responses to the open-ended questions.

CONCLUSIONS

Our findings suggest ESM podiatrists engage in CPD that is accessible rather than learning goal driven. Concerningly, CPD activities resulted in low translation of learnings to practice. This brings in to question the value of mandatory CPD systems based on minimum hours, rather than meaningfulness.

Costs, consequences and value for money in non-medical prescribing: a scoping review

OBJECTIVES

Non-medical prescribing (NMP) is a key feature of the UK healthcare system that refers to the legal prescribing rights granted to nurses, pharmacists and other non-medical healthcare professionals who have completed an approved training programme. NMP is deemed to facilitate better patient care and timely access to medicine. The aim of this scoping review is to identify, synthesise and report the evidence on the costs, consequences and value for money of NMP provided by non-medical healthcare professionals.

DESIGN

Scoping review DATA SOURCES: MEDLINE, Cochrane Library, Scopus, PubMed, ISI Web of Science and Google Scholar were systematically searched from 1999 to 2021.

ELIGIBILITY CRITERIA

Peer-reviewed and grey literature written in English were included. The research was limited to original studies evaluating economic values only or both consequences and costs of NMP.

DATA EXTRACTION AND SYNTHESIS

The identified studies were screened independently by two reviewers for final inclusion. The results were reported in tabular form and descriptively.

RESULTS

A total of 420 records were identified. Of these, nine studies evaluating and comparing NMP with patient group discussions, general practitioner-led usual care or services provided by non-prescribing colleagues were included. All studies evaluated the costs and economic values of prescribing services by non-medical prescribers, and eight assessed patient, health or clinical outcomes. Three studies showed pharmacist prescribing was superior in all outcomes and cost saving at a large scale. Others reported similar results in most health and patient outcomes across other non-medical prescribers and control groups. NMP was deemed resource intensive for both providers and other groups of non-medical prescribers (eg, nurses, physiotherapists, podiatrists).

CONCLUSIONS

The review demonstrated the need for quality evidence from more rigorous methodological studies examining all relevant costs and consequences to show value for money in NMP and inform the commissioning of NMP for different groups of healthcare professionals.

Dermatology nurse prescribing in China: a Delphi method

Objectives: To identify the dermatological system drugs that may be prescribed by Chinese dermatological nurses through expert consensus.

Methods: A 2-round study, consisting of 32 medical and nursing experts, was conducted using the Delphi method from September 2019 to June 2020. Microsoft Excel 2019 and IBM SPSS Ver. 22 were used to analyze the results of the consultations.

Results: A total of 63 drugs across 13 categories were identified as relevant to Chinese nurses working in dermatological departments. Among these drugs, 1 drug was generally prescribed independently, 17 drugs tended to be prescribed collaboratively, and 45 were prescribed either independently or in collaboration with others.

Conclusions: This expert consensus determines the prescription drugs that may be prescribed by dermatology nurses in China, which can be used as the key content of prescription drug training for dermatology nurses in future. The results of the study could provide a basis for the implementation of nurses’ prescription rights in China in future and provide a reference for the formulation of relevant legislation on nurses’ prescription rights.

Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals

Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: "understanding of the practice and perceived benefits", "acceptance and adherence to the practice, and "hindrances to the practice". The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Pharmacist prescribing: a review of perceptions and attitudes of patients, pharmacists and other interested professionals

Abstract Pharmacist prescribing is a growing reality in some developed counties, with varied health systems. Understanding the contribution that this activity can offer in the healthcare process, and investigating its acceptance is of utmost importance for the countries that implement and regulate this type of system. This literature review aimed to design a state-of-the-art academic investigation on the perception, opinions, and attitudes in the context of pharmacist prescribing practices in countries that have adopted this system. To achieve this, the present study conducted an investigation of the Medline, Scopus, Embase, SciELO, and Lilacs databases, resulting in the selection of 17 studies. From the analysis of the articles, three categories of discussion arose: “understanding of the practice and perceived benefits”, “acceptance and adherence to the practice, and “hindrances to the practice”. The results showed varied acceptance and perceptions among the different publics, depending, among other questions, on the level of knowledge and experience of the patients and health professionals, on the profile of the pharmacists, or on the prescribing modality. This study highlights some challenges involved in the practice of pharmacist prescribing, and its findings can be useful in suggesting a means through which to strengthen the practice.

Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review

OBJECTIVES

To support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This systematic review of qualitative research studies used a thematic synthesis approach to explore stakeholders' views on IP in primary care and identify barriers and facilitators influencing implementation.

SETTING

UK primary/community care.

PARTICIPANTS

Inclusion criteria were UK qualitative studies of any design, published in the English language. Six electronic databases were searched between January 2010 and September 2021, supplemented by reference list searching. Papers were screened, selected and quality-appraised using the Quality Assessment Tool for Studies with Diverse Designs. Study data were extracted to a bespoke table and two reviewers used NVivo software to code study findings. An inductive thematic synthesis was undertaken to identify descriptive themes and interpret these into higher order analytical themes. The Diffusion of Innovations and Consolidated Framework for Implementation Research were guiding theoretical anchors.

PRIMARY AND SECONDARY OUTCOME MEASURES

N/A.

RESULTS

Twenty-three articles addressing nurse, pharmacist and physiotherapist IP were included. Synthesis identified barriers and facilitators in four key stages of implementation: (1) 'Preparation', (2) 'Training', (3) 'Transition' and 4) 'Sustainment'. Enhancement, substitution and role-specific implementation models reflected three main ways that the IP role was used in primary care.

CONCLUSIONS

In order to address global deficits, there is increasing need to optimise use of IP capability. Although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that IP is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world.

PROSPERO REGISTRATION NUMBER

CRD42019124400.

Exploring the barriers and facilitators to non-medical prescribing experienced by pharmacists and physiotherapists, using focus groups

BACKGROUND

Non-medical prescribing (NMP) was introduced into the United Kingdom to enhance patient care and improve access to medicines. Early research indicated that not all non-medical prescribers utilised their qualification. A systematic review described 15 factors influencing NMP implementation. Findings from a recent linked Delphi study with independent physiotherapist and pharmacist prescribers achieved consensus for 1 barrier and 28 facilitators. However, item ranking differed for pharmacist and physiotherapist groups, suggesting facilitators and barriers to NMP differ depending on profession. The aim of this study was to further explore the lived experiences of NMP by pharmacists and physiotherapists.

METHOD

Study design and analytical approach were guided by Interpretative Phenomenology Analysis principles. Focus groups (November and December 2020) used the 'Zoom®' virtual platform with pharmacist and physiotherapist prescribers. Each focus group followed a topic guide, developed a priori based on the Delphi study results, and was audio recorded digitally. Transcripts underwent thematic analysis and data were visualised using a concept map and sunburst graph, and a table of illustrative quotes produced. Research trustworthiness was enhanced through critical discussion of the topic guide and study findings by the research group and by author reflexivity. The study is reported in line with COREQ guidelines.

RESULTS

Participants comprised three physiotherapists and seven pharmacists. Five themes were identified. The most frequently mentioned theme was 'Staff', and the subtheme 'Clinical team', describing the working relationship between participants and team members. The other themes were 'Self', 'Governance', 'Practical aspects' and 'Patient care'. Important inter-dependencies were described between themes and subthemes, for example between 'Governance' and 'Quality and Safety'. Differences were highlighted between the professions, some relating to the way each profession practises (for example decision making), others to the way the prescribing role had been established (for example administration support).

CONCLUSIONS

The key finding of collaborative working with the clinical team emphasises its impact on successful implementation of NMP. Themes may be inter-dependent, and inter-profession differences were identified. Specifically designed prescribing roles were beneficial for participants. For full NMP benefits to be realised all aspects of such roles must be fully scoped, before recruiting or training non-medical prescribers.

Introducing nurse prescribing in Gibraltar: the impact on palliative care

This article critically explores the impact of the introduction of nurse prescribing on palliative care in Gibraltar. A preliminary audit review of the prescriptions issued by the two palliative independent nurse prescribers over their first full calendar year of prescribing (2020) revealed two primary areas of impact: facilitating end-of-life care at home and improving anticipatory prescribing for end-of-life symptom management. These initial findings will be discussed in the context of the challenges and facilitators encountered during the first year of prescribing practice. Challenges were primarily related to the introduction of an advanced nursing role into an existing medical paradigm. Identified facilitators included comprehensive record keeping, collaborative working and the development of local guidelines, as well as the support of management and peers. The article concludes with a recommendation for further audits of prescribing data as a way to measure the impact of the new role and to inform future palliative service development.

General practitioners' experiences with, views of, and attitudes towards, general practice-based pharmacists: a cross-sectional survey

Background

There is limited United Kingdom (UK) literature on general practice-based pharmacists’ (PBPs’) role evolution and few studies have explored general practitioners’ (GPs’) experiences on pharmacist integration into general practice. Therefore, this study aimed to investigate GPs’ experiences with, views of, and attitudes towards PBPs in Northern Ireland (NI).

Methods

A paper-based self-administered questionnaire comprising four sections was mailed in 2019 to 329 general practices across NI and was completed by one GP in every practice who had most contact with the PBP. Descriptive analyses were used and responses to open-ended questions were analysed thematically.

Results

The response rate was 61.7% (203/329). There was at least one PBP per general practice. All GPs had face-to-face meetings with PBPs, with three-quarters (78.7%, n = 159) meeting with the PBP more than once a week. Approximately two-thirds of GPs (62.4%, n = 126) reported that PBPs were qualified as independent prescribers, and 76.2% of these (n = 96/126) indicated that prescribers were currently prescribing for patients. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n = 162) and knowledge (87.0%, n = 167) to provide safe and effective care for patients. However, 31.1% (n = 61) stated that PBPs only sometimes had the confidence to make clinical decisions. The majority of GPs (> 85%) displayed largely positive attitudes towards collaboration with PBPs. Most GPs agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n = 192) and can provide a better link between general practices and community pharmacists (96.1%, n = 194). However, 24.8% of GPs (n = 50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. An evaluation of the free-text comments indicated that GPs were in favour of more PBP sessions and full-time posts.

Conclusion

Most GPs had positive views of, and attitudes towards, PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Exploring PBPs’, community pharmacists’ and patients’ views of this role in general practice is required to corroborate study findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01607-5.

Evidence-informed implementation of nurse prescribing under supervision: An integrative review

AIM

To explore evidence reporting facilitators and barriers to implementation of nurse prescribing and provide practical recommendations for evidence-informed implementation and adoption of nurse prescribing under a supervision model.

BACKGROUND

As demand for access to quality health care services increases, health professional roles are expanding to meet population needs. Nurse prescribing has been effective in some countries and is being considered globally to address growing health care demand. Successful implementation of health service models requires careful planning and consideration. No existing reviews have examined implementation factors in the literature.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, MEDLINE, PubMed and EMBASE databases were searched from inception to 15 April 2020.

REVIEW METHODS

This integrative review is guided by Whittemore and Knafl and adheres to PRISMA reporting guidelines. The sustainability of innovation framework was used to synthesize data concerning implementation and sustainability factors (i.e. innovation, organizational, political, workforce and financial) for nurse prescribing.

RESULTS

A total of 39 articles were reviewed with literature predominantly reporting findings related to non-medical and nurse prescribing under various models. Variable evidence was found to inform nurse prescribing across five implementation and sustainability factors identifying several areas that require in-depth consideration. Very little evidence is available on nurse prescribing under supervision.

CONCLUSION

Introduction of service reform is often costly. This review highlights gaps in the literature and raises areas for consideration prior to implementation of this new service delivery model. The introduction of nurse prescribing must be planned and informed by available evidence to support effective adoption, practice and patient outcomes.

IMPACT

There are significant gaps in evidence related to nurse prescribing under a supervision model. Based on the evidence synthesized in this review, this paper provides practical recommendations for health service providers, managers, clinicians, educators and researchers to support implementation and adoption of nurse prescribing.

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.

A Delphi study to explore and gain consensus regarding the most important barriers and facilitators affecting physiotherapist and pharmacist non-medical prescribing

Non-medical prescribing was introduced into the United Kingdom to improve patient care, but early research indicated a third of Allied Health Professionals may not use their prescribing qualification. A previous literature review, highlighting factors influencing prescribing, identified only papers with nursing and pharmacy participants. This investigation explored consensus on factors affecting physiotherapist and pharmacist non-medical prescribers. A three round Delphi study was conducted with pharmacist and physiotherapist prescribers. Round One comprised information gathering on facilitators and barriers to prescribing participants had experienced, and underwent content analysis. This was followed by two sequential consensus seeking rounds with participants asked to rate the importance of statements to themselves. Consensus criteria were determined a priori, including median, interquartile range, percentage agreement and Kendall’s Coefficient of Concordance (W). Statements reaching consensus were ranked for importance in Round Three and analysed to produce top ten ranks for all participants and for each professional group. Participants, recruited October 2018, comprised 24 pharmacists and 18 physiotherapists. In Round One, content analysis of 172 statements regarding prescribing influences revealed 24 themes. 127 statements were included in Round Two for importance rating (barriers = 68, facilitators = 59). After Round Two, 29 statements reached consensus (barriers = 1, facilitators = 28), with no further statements reaching consensus following Round Three. The highest ranked statement in Round Three overall was: “Being able to prescribe to patients is more effective and really useful working [in my area]”. Medical support and improved patient care factors appeared the most important. Differences were noted between physiotherapist and pharmacist prescribers regarding the top ten ranked statements, for example team working which pharmacists ranked higher than physiotherapists. Differences may be explained by the variety of practice areas and relative newness of physiotherapy prescribing. Barriers appear to be post or person specific, whereas facilitators appear universal.

A multi-stakeholder approach to the co-production of the research agenda for medicines optimisation

BACKGROUND

Up to 50% of medicines are not used as intended, resulting in poor health and economic outcomes. Medicines optimisation is 'a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. The purpose of this exercise was to co-produce a prioritised research agenda for medicines optimisation using a multi-stakeholder (patient, researcher, public and health professionals) approach.

METHODS

A three-stage, multiple method process was used including: generation of preliminary research questions (Stage 1) using a modified Nominal Group Technique; electronic consultation and ranking with a wider multi-stakeholder group (Stage 2); a face-to-face, one-day consensus meeting involving representatives from all stakeholder groups (Stage 3).

RESULTS

In total, 92 research questions were identified during Stages 1 and 2 and ranked in order of priority during stage 3. Questions were categorised into four areas: 'Patient Concerns' [e.g. is there a shared decision (with patients) about using each medicine?], 'Polypharmacy' [e.g. how to design health services to cope with the challenge of multiple medicines use?], 'Non-Medical Prescribing' [e.g. how can the contribution of non-medical prescribers be optimised in primary care?], and 'Deprescribing' [e.g. what support is needed by prescribers to deprescribe?]. A significant number of the 92 questions were generated by Patient and Public Involvement representatives, which demonstrates the importance of including this stakeholder group when identifying research priorities.

CONCLUSIONS

A wide range of research questions was generated reflecting concerns which affect patients, practitioners, the health service, as well the ethical and philosophical aspects of the prescribing and deprescribing of medicines. These questions should be used to set future research agendas and funding commissions.

Prescribing trends over time by non-medical independent prescribers in primary care settings across Wales (2011-2018): a secondary database analysis

INTRODUCTION

As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs).

OBJECTIVES

This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales.

DESIGN

Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales.

RESULTS

Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p<0.001) after the implementation of primary care clusters compared with 496 (95% CI 445 to 548, p<0.001) prior its implementation. Approximately one-third of the items prescribed by NMIPs was within Betsi Cadwaladr University Health Board (HB) with only 4% in Powys Teaching HB.

CONCLUSION

The number of NMIPs and their volume of prescribing in primary care in Wales has increased following the implementation of primary care clusters in 2015. This suggests that the Government's recommendations of using NMIPs in primary care have been implemented. Future studies should focus on efficiency and quality of prescribing by NMIPs in primary care.

Tackling Antimicrobial Resistance by promoting Antimicrobial stewardship in Medical and Allied Health Professional Curricula

INTRODUCTION

Antimicrobial resistance poses a serious threat to global health with significantly higher morbidity, mortality, and economic burden. This review aims to discuss the importance of the promotion of antimicrobial stewardship in medical and allied health professional curricula and training/educating tomorrow's doctors in combatting antimicrobial resistance. A narrative literature review was conducted to retrieve relevant information related to antimicrobial resistance and stewardship and their implications on medical and allied health professional education and training from searches of computerized databases, hand searches, and authoritative texts.

AREAS COVERED

Antimicrobial stewardship programs improve rational antibiotic use, reduce antimicrobial resistance, decrease complications of antibiotic use, and improve patient outcomes. Though health professional students recognize the importance and impact of antibiotic prescribing knowledge, many studies have consistently demonstrated low levels of confidence and competencies amongst students, highlighting that health professional schools failed to prepare them to prescribe antibiotics accurately.

EXPERT OPINION

There is an urgent call for the integration of antimicrobial stewardship teaching at the undergraduate level of medical education to train future prescribers on this critical aspect of public health. Proper undergraduate education on rational antibiotics use would enable health professional graduates to enter clinical practice with adequate competencies to become rational prescribers.

Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study

Background

Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care.

Methods

This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively.

Results

Data from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70–4.36), multimorbid (OR 1.37; 95%-CI 1.24–1.51; p < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15–1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72–3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09–1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04–1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30–0.41; p < 0.001) were prescribed or changed less frequently in NP consultations.

Conclusions

Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.

Limited pharmaceuticalisation: a qualitative case study of physiotherapist prescribing practices in an NHS Trust in England following the expansion of non-medical prescribing in the UK

Over the last quarter century, non-medical prescribing in the UK has grown significantly; eight non-medical professional groups now have authority to prescribe a wide range of medicines, suggesting it could be a potent driver of pharmaceuticalisation. In this article, we present data from a case study of physiotherapists' prescribing practices. UK physiotherapists have had legal rights to prescribe medicines since 2005, but relatively little is known about the contribution they make to expanding patient access to medicines. We approached our study through a lens of governmentality to capture the mentalities and micro-practices governing physiotherapist non-medical prescribing. Ethnographic methods were used to gather data from an outpatient orthopaedic service in an NHS Trust in England employing physiotherapist prescribers. From the data, we identified a grid of intelligibility - an organising framework formulated by powerful discourses and technologies of government through which physiotherapist prescribing was acted into being. A primary effect of this grid was the constitution of new physiotherapist subjectivities, mostly as non-prescribers of medicines contrary to policy intentions, underpinned by a familiar and enduring template of medical professionalism.

Modeling the Multiple Sclerosis Specialist Nurse Workforce by Determination of Optimum Caseloads in the United Kingdom

Background

It is estimated that there are more than 100,000 people in the United Kingdom who have multiple sclerosis (MS). Patient experience and outcome are improved by access to a specialist nursing service. The aim of this study was to perform demand modeling to understand the need for MS nursing interventions, and thus inform modeling of the future UK MS nursing workforce.

Methods

Existing national data and specific workload and service data were collected from 163 MS specialist nurses who completed a questionnaire on activity and complexity of work both done and left undone.

Results

Data were received from across all of the United Kingdom. Twenty-nine percent of respondents were specialist nurses in the field for 3 years or less. Unpaid overtime was regularly performed by 83.4% of respondents. The MS specialist nurse was part of all areas of the patient journey. Areas of work left undone were psychological interventions, physical assessments, social interventions/benefits, and recommending or prescribing medications.

Conclusions

The current recommended caseload of 358 people with MS per full-time equivalent seems to be too high, with a considerable amount of work left undone, particularly psychosocial care. Factors such as travel time, complexity of caseload, changing drug therapies, and societal issues such as the benefits system contributed to driving demand/workload.

Community palliative care clinical nurse specialists as independent prescribers: part 1

The Department of Health and Social Care has recently reiterated its commitment to improvement in the quality of end-of-life care and emphasised the importance of all patients having rapid access to medication. The aim of this study was to explore the lived experiences of clinical nurse specialists who are able to prescribe independently in their role in providing support for patients with palliative care needs within the community setting. Interpretive phenomenology was employed in order to understand and interpret the experiences of six nurse independent prescribers employed as community palliative care clinical nurse specialists. This purposive sampling was preferred with semi-structured interviews as the most appropriate data collection technique. This is the first of a two-part article. In this part, the authors describe how the study was undertaken. Part 2 will provide the results, outline the key themes that were extracted from the study, and discuss them. It will be published in the next issue of the Journal.

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.

Providing medicines in emergency and urgent care: a survey of specialist paramedics' experiences of medication supply and views on paramedic independent prescribing

Introduction:

Specialist paramedics in the United Kingdom are able to undertake additional training and education in the assessment and treatment of minor illness and injuries. The provision of medication often forms a part of specialist paramedic care, but there is currently no research into the perceived usefulness or impact of the use of patient group directions or on their preparedness to undertake paramedic independent and supplementary prescribing. The aim of this study was to (a) investigate the ways in which medicines are currently supplied by specialist paramedics and (b) establish views on the introduction of paramedic independent and supplementary prescribing, including practitioner preparedness and potential impact on practice.

Methods:

An online questionnaire was sent to 268 specialist paramedics employed by two NHS ambulance Trusts in England who jointly employed 54% of the national population (n = 495) of specialist paramedics. Data were analysed using descriptive statistics and a framework analysis approach.

Results:

Patient group directions were reported to be used regularly and infections, pain and exacerbations of respiratory conditions were the most frequently treated conditions by specialist paramedics.

Although just over half of participants reported that patient group directions did not restrict their ability to supply medication to patients, a significant minority found them too restrictive. Examples of restrictions included contradictions to local antimicrobial guidance and being unable to supply sufficiently strong analgesia.

The majority of participants (66/78, 84.6%) felt confident to undertake paramedic independent and supplementary prescribing and that it would enhance both their scope of practice (70/72, 97.2%) and patient care (67/72, 93.0%). However, participants had concerns regarding organisational readiness for paramedic independent and supplementary prescribing (50/72, 69.4%), including provision of paramedic access to patient records (65/72, 90.2%) and obtaining sufficient clinical support (39/72, 54.1%).

Conclusions:

Patient group directions do enable specialist paramedics to supply medication to patients in order to treat a range of conditions, but at times the paramedics felt that the patient group directions restricted autonomous practice. The majority of participants felt confident to undertake paramedic independent and supplementary prescribing and anticipated that it would enhance patient care.

Modelling the Inflammatory Bowel Disease Specialist Nurse Workforce Standards by Determination of Optimum Caseloads in the UK

BACKGROUND AND AIMS

Crohn's disease and ulcerative colitis are the most common forms of inflammatory bowel disease [IBD], affecting 1 in 250 of the population in the UK. It is accepted that access to a specialist nurse service improves patient experience and outcome. National Standards for the Healthcare of People Who Have Inflammatory Bowel Disease [2013] defined the number of nurse specialists required at 1.5 full time equivalent per 250000 population. The aim of this study was to determine if these standards were being met and to publish a new, robust, validated standard optimising the UK nursing workforce model.

METHODS

Existing national data and specific workload and service data were collected from 164 IBD specialist nurses who completed a questionnaire designed to collect information on activity and complexity of work both done and undone.

RESULTS

Data were received from all of the UK; 36% of respondents were specialist nurses in the field for 3 years or less. A higher caseload than the recommended level was reported by 63% of respondents. Unpaid overtime was regularly carried out by 84% of respondents. The IBD specialist nurse was involved in all areas of the patient pathway. Areas of work left undone were psychological interventions, prescribing medicines and physical assessments.

CONCLUSIONS

Compared with other specialties, IBD specialist nurses are less experienced. It is recommended that the current standard be increased to 2.5 full time equivalent specialist nurses per 250000 patients, to mitigate the increasing complexity of the role, care and the 'rookie' factor.

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.

Patterns of dispensed non-medical prescriber prescriptions for antibiotics in primary care across England: a retrospective analysis

Objectives

To describe the patterns of dispensed non-medical prescriber (NMP) prescriptions for antibiotics in primary care across England between 2011 and 2015.

Methods

A retrospective analysis of dispensed antibiotic prescriptions, written by NMPs and medical prescribers between 2011 and 2015 in primary care in England, obtained from the National Health Service Business Services Authority.

Results

Between 2011 and 2015, the number of NMPs (mainly nurses but also pharmacists and small numbers of allied health professionals) in England, who have independent prescribing capability, has risen by over one-third to nearly 30000. Most of these prescribers provide a broad range of services in primary care. The rate of dispensed NMP prescriptions for antibiotics over this period has increased, as has the percentage of all primary care antibiotics dispensed that were prescribed by NMPs, which is currently nearly 8%. The most commonly dispensed NMP antibiotic prescriptions were penicillin, sulphonamides, trimethoprim, macrolides, tetracyclines and nitrofurantoin.

Conclusions

Increasing numbers of NMPs are working in primary care in England and managing infections. Antibiotics prescribed by this group align with surveillance reports of antibiotic use in primary care. With the numbers of NMPs being set to rise further, they form an important group to involve in antimicrobial stewardship efforts.

Facilitators and barriers to non-medical prescribing - A systematic review and thematic synthesis

Introduction

Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom.

Methods

The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786).

Results

Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances.

Discussion

Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists.

A systematic review of interventions by healthcare professionals to improve management of non-communicable diseases and communicable diseases requiring long-term care in adults who are homeless

OBJECTIVE

Identify, describe and appraise trials of interventions delivered by healthcare professionals to manage non-communicable diseases (NCDs) and communicable diseases that require long-term care or treatment (LT-CDs), excluding mental health and substance use disorders, in homeless adults.

DESIGN

Systematic review of randomised controlled trials (RCTs), non-RCTs and controlled before-after studies. Interventions characterised using Effective Practice and Organisation of Care (EPOC) taxonomy. Quality assessed using EPOC risk of bias criteria.

DATA SOURCES

Database searches (MEDLINE, Embase, PsycINFO, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Cochrane Central Register of Controlled Trials), hand searching reference lists, citation searches, grey literature and contact with study authors.

SETTING

Community.

PARTICIPANTS

Adults (≥18 years) fulfilling European Typology of Homelessness criteria.

INTERVENTION

Delivered by healthcare professionals managing NCD and LT-CDs.

OUTCOMES

Primary outcome: unscheduled healthcare utilisation.

SECONDARY OUTCOMES

mortality, biological markers of disease control, adherence to treatment, engagement in care, patient satisfaction, knowledge, self-efficacy, quality of life and cost-effectiveness.

RESULTS

11 studies were included (8 RCTs, 2 quasi-experimental and 1 feasibility) involving 9-520 participants (67%-94% male, median age 37-49 years). Ten from USA and one from UK. Studies included various NCDs (n=3); or focused on latent tuberculosis (n=4); HIV (n=2); hepatitis C (n=1) or type 2 diabetes (n=1). All interventions were complex with multiple components. Four described theories underpinning intervention. Three assessed unscheduled healthcare utilisation: none showed consistent reduction in hospitalisation or emergency department attendance. Six assessed adherence to specific treatments, of which four showed improved adherence to latent tuberculosis therapy. Three concerned education case management, all of which improved disease-specific knowledge. No improvements in biological markers of disease (two studies) and none assessed mortality.

CONCLUSIONS

Evidence for management of NCD and LT-CDs in homeless adults is sparse. Educational case-management interventions may improve knowledge and medication adherence. Large trials of theory-based interventions are needed, assessing healthcare utilisation and outcomes as well as assessment of biological outcomes and cost-effectiveness.

Establishing priorities on the range of conditions managed by UK community practitioner nurse prescribers: A modified Delphi consensus study

AIM

To provide national consensus on the range of conditions community practitioner nurse prescribers manage and for which it is considered important that they can prescribe.

BACKGROUND

Around 35,000 community practitioner nurse prescribers in the United Kingdom are able to prescribe from a limited formulary. Although prescribing is a key role for these nurses, there has been a decline in the numbers of community practitioner nurse prescribers who prescribe. It is evident that changing patterns of client and service delivery, changes the role of community nurses and the conditions they manage, however, little is known about the conditions community practitioner nurse prescribers manage.

DESIGN AND METHODS

A modified Delphi approach comprising three on-line surveys delivered to a national Expert Panel of 89 qualified community practitioner prescribers. Data collection took place between January-March 2017.

RESULTS

Panelists reached a consensus, with consistent high levels of agreement reached, on nineteen conditions for which it is believed community practitioner nurse prescribers should be able to prescribe. Conditions identified by school nurses (N = 12) and health visitors (N = 7) were mainly acutely focused, whereas those identified by district nurses (N = 9) and community staff nurses (N = 6) included both long-term and acute conditions.

CONCLUSION

Given the high degree of consensus, this list of conditions should influence any decisions about the items community and public health nurses should be able to prescribe. The findings should also influence the education and training of these nurses.

An overview of developments in nurse prescribing in the UK

In the UK and internationally, the nursing profession is continuing to advance and innovate its roles and functions. One area in which this is particularly notable is nurse prescribing. The UK has the most extended nurse prescribing rights in the world, with significant advances in this field over the past two decades. This article reflects on this development, what has been learned and the challenges that remain in relation to nurse prescribing and meeting healthcare service needs.

Clinical and cost-effectiveness of non-medical prescribing: A systematic review of randomised controlled trials

Objective

To evaluate the clinical and cost-effectiveness of non-medical prescribing (NMP).

Design

Systematic review. Two reviewers independently completed searches, eligibility assessment and assessment of risk of bias.

Data sources

Pre-defined search terms/combinations were utilised to search electronic databases. In addition, hand searches of reference lists, key journals and grey literature were employed alongside consultation with authors/experts.

Eligibility criteria for included studies

Randomised controlled trials (RCTs) evaluating clinical or cost-effectiveness of NMP. Measurements reported on one or more outcome(s) of: pain, function, disability, health, social impact, patient-safety, costs-analysis, quality adjusted life years (QALYs), patient satisfaction, clinician perception of clinical and functional outcomes.

Results

Three RCTs from two countries were included (n = 932 participants) across primary and tertiary care settings. One RCT was assessed as low risk of bias, one as high risk of bias and one as unclear risk of bias. All RCTs evaluated clinical effectiveness with one also evaluating cost-effectiveness. Clinical effectiveness was evaluated using a range of safety and patient-reported outcome measures. Participants demonstrated significant improvement in outcomes when receiving NMP compared to treatment as usual (TAU) in all RCTs. An associated cost analysis showed NMP to be more expensive than TAU (regression coefficient p = 0.0000), however experimental groups generated increased QALYs compared to TAU.

Conclusion

Limited evidence with overall unclear risk of bias exists evaluating clinical and cost-effectiveness of NMP across all professions and clinical settings. GRADE assessment revealed moderate quality evidence. Evidence suggests that NMP is safe and can provide beneficial clinical outcomes. Benefits to the health economy remain unclear, with the cost-effectiveness of NMP assessed by a single pilot RCT of low risk of bias. Adequately powered low risk of bias RCTs evaluating clinical and cost effectiveness are required to evaluate NMP across clinical specialities, professions and settings.

Registration

PROSPERO (CRD42015017212).

Community palliative care clinical nurse specialists as independent prescribers: part 2

This study explored the lived experiences of clinical nurse specialists who can prescribe independently in their role of providing support to patients with palliative care needs within the community. Part 1 of this study examined how the study was carried out; this second part explores the findings. The nurses reported that being able to prescribe enabled them to provide seamless, holistic care, which gave patients faster access to medicines, especially at weekends when their GP was unavailable. Prompt availability of medicines led to effective symptom control and consequently a better quality of life for patients. The main barrier to prescribing was difficulty in accessing patient records. Independent prescribing by community nurse specialists is beneficial for patients receiving palliative care and their families while they are being cared for at home, and provides job satisfaction for the nurses.

Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review

QUESTION

What are the factors that affect the implementation or utilisation of independent non-medical prescribing (iNMP)?

DESIGN

Mixed-methods systematic review. Two reviewers independently completed searches, eligibility and quality assessments.

DATA SOURCES

Pre-defined search terms were utilised to search electronic databases. Reference lists, key journals and grey literature were searched alongside consultation with authors/experts.

ELIGIBILITY CRITERIA FOR INCLUDED STUDIES

Qualitative and quantitative studies investigating independent prescribing by any non-medical professional group. Study participants included any stakeholders involved in actual or proposed iNMP. Measurements reported on data describing stakeholders' perceptions and experiences of the barriers to/facilitators of iNMP.

RESULTS

A total of 43 qualitative and seven quantitative studies from three countries (n=12, 117 participants) were included. Quality scores varied from 9 to 35 (Quality Assessment Tool for Studies with Diverse Designs, 0 to 48). Qualitative data were synthesised into four themes (and subthemes): systems (government and political, organisational, formulary); education and support (non-medical prescribing (NMP) courses/continuous professional development (CPD)); personal and professional (medical profession, NMP professions, service users); and financial factors. Quantitative data corroborated the qualitative themes. Integration of the qualitative themes and quantitative data enabled the development of a NMP implementation framework.

CONCLUSION

Barriers to and facilitators of the implementation and utilisation of iNMP are evident, demonstrating multifactorial and context-specific variables within four explicit themes. Professional bodies, politicians, policy and healthcare managers and clinicians could use the resulting NMP implementation framework to ensure the safe and successful implementation and utilisation of NMP. Clinical physiotherapists and other clinicians should consider whether these variables have been adequately addressed prior to adopting NMP into their clinical practice.

REGISTRATION

PROSPERO CRD42015017212. [Noblet T, Marriott J, Graham-Clarke E, Rushton A (2017) Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. Journal of Physiotherapy 63: 221-234].

Overview of the uptake and implementation of non-medical prescribing in Wales: a national survey

OBJECTIVES

To identify (1) the non-medical healthcare professionals in Wales qualified to prescribe medicines (including job title, employer, where the prescribing qualification is used, care setting and service provided); (2) the mode of prescribing used by these healthcare professionals, the frequency with which medicines are prescribed and the different ways in which the prescribing qualification is used; and (3) the safety and clinical governance systems within which these healthcare professionals practise.

DESIGN

National questionnaire survey.

SETTING

All three National Health Service (NHS) Trusts and seven Health Boards (HB) in Wales.

PARTICIPANTS

Non-medical prescribers.

RESULTS

379 (63%) participants responded to the survey. Most of these prescribers (41.1%) were specialist nurses who work in a variety of healthcare settings (primarily in secondary care) within each HB/NHS Trust, and regularly use independent prescribing to prescribe for a broad range of conditions. Nearly a quarter of the sample (22%) reported that prior to undertaking the prescribing programme, they had completed master's level specialist training and 65.5% had 5 years qualified experience. Over half (55.8%) reported that there were plans to increase non-medical prescriber numbers within the team in which they worked. Only 7.1% reported they did not prescribe and the median number of items prescribed per week was between 21 and 30. Nearly all (87.8%) of the sample reported that they perceived prescribing to have ensured better use of their skills and 91.5% indicated that they believed it had improved the quality of care they were able to provide.

CONCLUSION

Non-medical prescribing has been implemented across the whole of Wales; however, its uptake within HBs and NHS Trusts has been inconsistent, and it has not been considered across all services, particularly those in primary care. Opportunities therefore exist to share learning across organisations.

Antibiotics for acute respiratory tract infections: a mixed-methods study of patient experiences of non-medical prescriber management

OBJECTIVE

To (1) explore patients' expectations and experiences of nurse and pharmacist non-medical prescriber-led management of respiratory tract infections (RTIs), (2) examine whether patient expectations for antibiotics affect the likelihood of receiving them and (3) understand factors influencing patient satisfaction with RTI consultations.

DESIGN

Mixed methods.

SETTING

Primary care.

PARTICIPANTS

Questionnaires from 120 patients and follow-up interviews with 22 patients and 16 nurse and pharmacist non-medical prescribers (NMPs).

RESULTS

Patients had multiple expectations of their consultation with 43% expecting to be prescribed an antibiotic. There was alignment between self-reported patient expectations and those perceived by NMPs. Patient expectations for non-antibiotic strategies, such as education to promote self-management, were associated with receipt of those strategies, whereas patient expectations for an antibiotic were not associated with receipt of these medications. 'Patient-centred' management strategies (including reassurance and providing information) were received by 86.7% of patients. Regardless of patients' expectations or the management strategy employed, high levels of satisfaction were reported for all aspects of the consultation. Taking concerns seriously, conducting a physical examination, communicating the treatment plan, explaining treatment decisions and lack of time restrictions were each reported to contribute to patient satisfaction.

CONCLUSIONS

NMPs demonstrate an understanding of patient expectations of RTI consultations and use a range of non-antibiotic management strategies, particularly those resembling a patient-centred approach. Overall, patients' expectations were met and prescribers were not unduly influenced by patient expectations for an antibiotic. Patients were satisfied with the consultation, indicating that strategies used by NMPs were acceptable. However, the lower levels of satisfaction among patients who expected but did not receive an antibiotic indicates that although NMPs appear to have strategies for managing RTI consultations, there is still scope for improvement and these prescribers are therefore an important group to involve in antimicrobial stewardship.

Assessing pharmacists' readiness to prescribe oral antibiotics for limited infections using a case-vignette technique

Background Pharmacist's skills are underutilized whilst they are directly involved with antibiotic supply to the community. Addressing this issue could lead to better use of antibiotics and hence decreased resistance. Objective Explore how pharmacists can prescribe oral antibiotics to treat a limited range of infections whilst focusing on their confidence and appropriateness of prescribing. Setting Community pharmacies, Western Australia. Method Data were collected using a self-administered questionnaire also containing case vignettes. These were distributed to a random sample of metropolitan and rural community pharmacies in Western Australia. A Generalised Estimating Equation was used to compare respondents' level of confidence in treating various infections and to assess appropriateness of prescribing. Main outcome measure Appropriateness and confidence of antibiotic prescribing. Results A response rate of 34.2% (i.e. 425 responses to case vignettes) was achieved from 240 pharmacies. There were high levels of confidence to treat simple infections such as uncomplicated UTIs (n = 73; 89.0%), impetigo (n = 65; 79.3%), mild bacterial skin infections (n = 62; 75.6%) and moderate acne (n = 61; 72.4%). Over 80% of respondents were confident to prescribe amoxicillin (n = 73; 89%), trimethoprim (n = 72; 87.8%), amoxicillin and clavulanic acid (n = 70; 85.4%), flucloxacillin (n = 70; 85.4%) and cephalexin (n = 68; 82.9%). High levels of appropriate antibiotic prescribing were shown for uncomplicated UTI (97.2%), cellulitis (98.2%) and adolescent acne (100.0%). Conclusion This study identified key limited infections and antibiotics for which pharmacists were supportive and confident to prescribe. This role could lead to better use of antibiotics in the community and minimisation of resistance.

[Nurse prescribing rights, the UK experience]

The United Kingdom has gradually introduced nurse prescribing. This authorisation is granted upon completion of a theoretical and practical training course. This evolution has been deemed to have had a positive impact twenty years after its implementation.

Comparison of UK’s Minor Ailments Scheme and US’s retail clinic model: a narrative review

There is a raising demand for unscheduled care in the United Kingdom. Minor Ailments Schemes (MAS) were introduced to reduce the burden of minor ailments on higher cost settings such as general practices and emergency departments. The number of visits for minor ailments at GPs often declined following the implementation of MAS. Retail clinics in America employ nurse practitioners (NPs) and physician assistants (PAs) who can diagnose and treat minor illness, and minor injuries. Similar to the retail clinics, MAS can merge with walk-in centres. PAs and NPs can take over some primary care workload from pharmacists to prevent the pharmacists from being overwhelmed with all their current duties. MAS can also initiate the development of telehealth service to accommodate the home-bound patients. MAS must continue to change and evolve to meet the current and future demands of health care.

Iran's health policymakers' views on barriers and facilitators of nurse prescribing in their context: A qualitative study

BACKGROUND

In most countries, one of the main reasons for developing more advanced roles for nurses is to improve access to care in the context of limited number of doctors. It is considered that the introduction of major policy initiatives, such as nurse prescribing, requires high-level discussion and policy development to ensure successful implementation. This study aimed to identify the barriers and facilitators of nurse prescribing based on policymakers' views in Iran.

MATERIALS AND METHODS

This qualitative study was based on conventional content analysis approach. A purposeful sample of 14 participants were recruited, including 6 members of the Nursing Board, 6 members of the Iranian Nursing Organization, and 2 senior employees of Iran's Ministry of Health and Medical Education. Data were gathered through in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim.

RESULTS

The four emerged categories as facilitators of nurse prescribing were labeled "positive views of health policymakers," "human resources capabilities," "non-medical prescribing experiences," and "governmental and non-governmental organizational activities." The four extracted categories as barriers of nurse prescribing were "socio-cultural factors," "organizational factors," "educational barriers," and "human barriers."

CONCLUSIONS

Barriers and facilitating factors should be considered in order to bring about organizational policy changes and improve perspectives. Nurse prescribing requires the efforts of involved managers and authorities for development and modernization. The results of this study can serve as a compressed resource for policymakers and managers to identify the effective issues on nurse prescribing and can help them to plan for the implementation of nurse prescribing.

The case of pharmacist prescribing policy in Israel

Pharmacy prescribing policy in Israel has been negotiated and changed in recent years in order to improve patient treatment and access to medicines, and reduce national health insurance costs by allowing pharmacists to prescribe medications. Various stakeholders and institutions were involved in the formulation process, affecting the process while representing different motives. The complexity of pharmacy prescribing policy formulation is universal - any policy project needs, for strategic and tactical reasons, to acquire an inventory of institutions involved, identify the key players and explore potential support or opposition among them. This article uses the field (theory) of new institutional economics to explain the process of pharmaceutical institutional change and identifies the stakeholders who are involved in the reform.

In the framework of pharmaceutical policies, seven models of prescribing practices are outlined, and the Canadian and British prescribing models are presented. The paper then focuses on the Israeli case and the main issues that concern decision-makers in the Israeli health system, such as inequality in access to health services and the erosion of the notion of universal health services. These concerns and the involvement of different stakeholders, such as The Israeli Medical Association (IMA) and health funds, influenced and directed the final Pharmacist Prescribing Law. After several rejections and amendments the law was passed, enabling experienced pharmacists to prescribe only to patients with a previous prescription given by a physician in the hope it would improve services to patients and reduce physicians’ workloads. Here, the topic of the new prescribing policy is introduced, using tools from the new institutional school in political economy.

Non-medical prescribing assessment - An evaluation of a nationally agreed multi method approach

In the United Kingdom, legislation permits nurses and allied health professionals to prescribe for patients within their care. Preparation for this role includes learning, teaching and assessment that is embedded in practice, supervised by a designated medical practitioner (DMP) and evidenced in a reflective learning in practice portfolio.

AIM

The objectives were to explore; (1) which assessment in the practice portfolio was ranked most valuable in terms of achieving safe, effective prescribing practice and, (2) whether a practice based assessment (SDEP) was an acceptable alternative to an Observed Simulated Clinical Examination (OSCE).

METHODS

Online surveys were conducted and follow up semi structured telephone interviews were conducted across 5 universities in Scotland with students, DMPs and line managers.

RESULTS

Students ranked the learning log most valuable and DMPs and line managers ranked the SDEP most valuable. Survey and follow up interviews suggested that the portfolio provided the opportunity to develop prescribing skills and knowledge relevant to their specific clinical speciality. There was agreement amongst all participants that clinical assessment in the practice portfolio effectively enable non-medical prescribing students to evidence prescribing competence.

SUMMARY

The novel use of the SDEP and reflective summary offers a viable alternative to an OSCE and was viewed as one of the most valued components of the assessment strategy.

Growth in nurse prescribing of antibiotics: the Scottish experience 2007-13

OBJECTIVES

The objective of this study was to retrospectively analyse patterns of primary care antibiotic prescribing by nurse prescribers in Scotland.

METHODS

Data on dispensed antibiotic prescriptions written by nurse prescribers in 2007-13 were obtained from the Prescribing Information System, a database of all NHS prescriptions dispensed in Scotland.

RESULTS

Since 2007, there has been a steady increase in the volume of antibiotic prescribing in primary care undertaken by nurse prescribers. There was considerable variability in the frequency of antibiotic prescribing among nurses and across NHS regions. Since 2007, an increasing proportion of antibiotics prescribed by nurses are those recommended for first-line empirical treatment of infection, with a reduction in the proportion of broader-spectrum agents. Other measures of prescribing quality (duration of treatment of adult females with urinary tract infection and use of recommended doses) have improved since 2007.

CONCLUSIONS

This paper is the first, to our knowledge, to present an analysis of data on antibiotic prescribing in primary care by nurse prescribers. Inappropriate prescribing is a problem and, given the impact that antibiotic prescribing has on antimicrobial resistance, it is important that the prescribing behaviour of nurses is explored. This is especially significant as this is a growing body of prescribers who predominately work in the community, where the majority of antibiotics are prescribed. This analysis showed that practice varies across NHS regions and between prescribers and although more information is needed to establish whether nurse prescribers are prescribing appropriately, some quality indicators may suggest that they are following best practice.

Non-medical prescribing in palliative care: a regional survey

BACKGROUND

The United Kingdom is considered to be the world leader in nurse prescribing, no other country having the same extended non-medical prescribing rights. Arguably, this growth has outpaced research to evaluate the benefits, particularly in areas of clinical practice where patients have complex co-morbid conditions such as palliative care. This is the first study of non-medical prescribing in palliative care in almost a decade.

AIM

To explore the current position of nurse prescribing in palliative care and establish the impact on practice of the 2012 legislative changes.

DESIGN

An online survey circulated during May and June 2013.

PARTICIPANTS

Nurse members (n = 37) of a regional cancer network palliative care group (61% response rate).

RESULTS

While this survey found non-medical prescribers have embraced the 2012 legislative changes and prescribe a wide range of drugs for cancer pain, we also identified scope to improve the transition from qualified to active non-medical prescriber by reducing the time interval between the two.

CONCLUSION

To maximise the economic and clinical benefit of non-medical prescribing, the delay between qualifying as a prescriber and becoming an active prescriber needs to be reduced. Nurses who may be considering training to be a non-medical prescriber may be encouraged by the provision of adequate study leave and support to cover clinical work. Further research should explore the patients' perspective of non-medical prescribing.

Antibiotic prescribing in primary care: The need for interprofessional collaboration

Patients with self-limiting respiratory tract infections (RTIs) are frequently seen in general practice. Although antibiotics are ineffective for these conditions, they are often prescribed by general practitioners (GPs), and perceived patient expectations for an antibiotic plays an important role in the decision to prescribe one. Superfluous use of antibiotics contributes to antimicrobial resistance. High numbers of nurse prescribers work alongside GPs and these prescribers see education and self-management advice as central to the care of these patients. Multi-faceted interventions, designed to reduce antibiotic prescribing, only exist for GPs. Such interventions should foster interprofessional collaboration and, as such, consider the needs and experiences of the different prescribers, and the views of patients. This paper outlines a research study in which a questionnaire will be distributed to patients who consult with a nurse prescriber to see whether their expectations influence their satisfaction with the consultation outcome. Findings will guide the development of an interprofessional intervention designed to promote collaborative practice and appropriate and responsible antibiotic prescribing in primary care.

Use and evaluation of a mentoring scheme to promote integration of non-medical prescribing in a clinical context

BACKGROUND

Growing numbers of non-medical health professionals are attaining prescribing rights through post-registration non-medical prescribing (NMP) courses in the UK. However, not all implement prescribing post-qualification. This study evaluated the uptake and perceived usefulness of a mentoring scheme for two cohorts of NMP students at the University of Nottingham. The scheme paired students with qualified mentors with whom they had an opportunity to discuss the integration of prescribing theory into practice.

METHODS

Mentors were allocated on days 2-5 of the course. Surveys were distributed to students who completed the NMP course [n = 63] and their mentors. Likert-scale and open-ended questions addressed: use, perceived usefulness, and positive and negative aspects of the mentoring scheme. Semi-structured interviews were conducted with both students (n = 6) and mentors (n = 3) to explore their experience of the mentoring scheme in more detail. Students were purposively selected for interview depending on their level of use of the mentoring system. Interviews were analysed using thematic analysis.

RESULTS

The response rates were 65.1% (n = 41) and 56.3% (n = 36) for students and mentors respectively. Just over half of students (57.1%) accessed their mentor. Having a sufficient support network was the key reason for not using the scheme. Students found mentors helpful for: moral support (68.2%); contextualising prescribing (71.4%); and helping them to think about implementing prescribing in practice (72.7%). Fewer mentors felt they helped in relation to contextualising (57.9%) or implementing prescribing (31.6%). Less than half the students and mentors surveyed agreed that they received/provided assistance related to the integration of prescribing theory into practice (38.1% and 42.2% respectively) and assistance with assignments (36.3% and 45.5% respectively).Interviews suggested that students found it difficult to focus on implementing prescribing because of the academic demands of their course, which impacted on uptake and use of the mentoring scheme. Students emphasised the importance of being paired with a prescriber who was successfully prescribing. Mentors benefited from sharing and refreshing their academic knowledge.

CONCLUSIONS

Students and mentors derived benefits from participation in this scheme. This intervention may be better as a post-qualification support resource when students are ready to consider their future prescribing practice.