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

Exploring the Perceptions and Behaviours of UK Prescribers Concerning Novel Lipid-Lowering Agent Prescriptions: A Qualitative Study

Reducing low-density lipoprotein cholesterol levels lowers the risk of atherosclerotic cardiovascular disease. With the current and future portfolios of emerging lipid-lowering therapies included in various national and international guidelines, the objectives of this study were (i) to investigate the perceptions of UK prescribers', including doctors, pharmacists, and nurses, on current lipid management for cardiovascular diseases and prescriptions of novel lipid-lowering therapies, and (ii) to explore the challenges and facilitating factors of prescribing novel lipid-lowering therapies through qualitative interviews. Qualitative semi-structured interviews with twelve medical and non-medical prescribers were conducted, around 20-30 min in length. The interviews were audio-recorded and transcribed on an online platform. A thematic analysis was deployed. Four major themes emerged from the analysis: (1) prescribing barriers; (2) prescribing enablers; (3) inter-profession variability; and (4) health literacy. These themes highlighted the contrast between the need for optimal shared decision making and the various constraints in practice. Participants expressed their inexperience with novel lipid-lowering therapies and acknowledged the requirement and importance of these agents for primary cardiovascular disease prevention. Participants recognised confidence and competence as key drivers for prescribing therapies and welcomed further education and training to enhance their skillset. Patients' misconceptions towards current lipid-lowering therapies contributed to their refusal of newer agents, highlighting a requirement to improve patient education. Targeting communities through awareness campaigns was identified as a viable solution.

Implementation of Nurse Prescriptions throughout the Public Health System in Catalonia (2021-2022)

BACKGROUND

Nurses in Catalonia have always prescribed health advice, health products, and medication in line with the professional competency of the discipline. Legislation about nurse prescriptions and the implementation of nurse prescribing varies widely among different countries. This article reports data regarding nurse prescribing in Catalonia in 2021 and 2022.

METHODS

This retrospective longitudinal study analyzed data from all care-providing units in Catalonia's integrated public health system.

RESULTS

The number of nurse prescriptions increased from 139,435 in 2021 to 573,822 in 2022, and the number of nurses issuing prescriptions increased from 3604 in 2021 to 5563 in 2022. The proportion of prescriptions for different products was similar in the two years analyzed. Prescriptions for medication increased by 7.5% in 2022.

CONCLUSIONS

Nurse prescribing is a recent advance in Catalonia. Despite some difficulties in rollout, the data indicate that this practice is becoming consolidated, as in other European countries.

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.

Therapeutic radiographer prescribing practices in the United Kingdom: Questionnaire survey

INTRODUCTION

Non-medical professionals in the United Kingdom (UK) have been granted prescribing rights to improve patient care quality and cost-effectiveness. There is limited evidence on how therapeutic radiographer prescribers have impacted medicine management or patient services.

METHODS

An online survey was conducted amongst non-medical prescribing therapeutic radiographers in the UK between 2019 and 2022. The study teams initially analysed the individual data sets, subsequently combined, and secondary analysis was performed to provide a UK perspective, to understand the services provided and identify areas for improvement. Data was analysed using descriptive statistics from Microsoft Excel® and SPSS®.

RESULTS

74 non-medical prescribing therapeutic radiographers who were predominantly over 40 years old and in full-time work participated. The main job categories were consultant radiographers (n = 23, 31.1%) and advanced practice practitioners (n = 18, 24.3%). Many use their prescribing qualifications (87.5%, n = 62), issuing a mean of 15 independent and seven items by supplementary and prescribing per week. Most received assessment and diagnostic skills training before prescribing courses (91.6%, n = 67). Respondents prescribed from a median of six areas, with the highest being in GI (82%), skin (68%), infections (58%), urinary tract disorders (55%) and ear, nose, and oropharynx conditions (54%).

CONCLUSION

This study presents the first report on therapeutic radiographers prescribing in the UK, offering insights into current practices and highlighting the success of non-medical prescribing. Therapeutic radiographers' roles continue to expand into advanced practice and medicine-prescribing responsibilities, contributing to holistic and patient-centred care.

IMPLICATIONS FOR PRACTICE

The results are relevant for nations grappling with oncology workforce shortages and contemplating similar roles for therapeutic radiographers. The study can be a valuable resource for policymakers and healthcare organisations worldwide.

Non-medical prescribing in critical care: A mixed methods study

BACKGROUND

Little is known about non-medical prescribers in critical care in the United Kingdom. In 2007, a small survey identified few non-medical prescribers; however, in the intervening years, there have been many changes to the Medicine Act 1968. It is likely that prescribing within the non-medical workforce in critical care has changed significantly.

AIM/S

This survey aimed to explore the breadth and diversity of prescribing practices of non-medical prescribers working within the wider critical care environment in the United Kingdom.

METHOD

Data were collected via an online questionnaire adapted from the 2007 version and distributed by the BACCN to their members between 26th October 2021 and 19th November 2021. Freedom of Information requests were made to the Nursing and Midwifery Council, The Health and Care Professions Council and the General Pharmaceutical Council to understand the number of non-medical prescribers.

RESULTS

The survey elicited 259 responses; 105 respondents identified themselves as non-medical prescribers, and 57 used Patient Group Directions only. In the ICU/HDU, 75 respondents identified as non-medical prescribers, with an additional 45 using Patient Group Directions.

CONCLUSION

Since the last survey, there has been a large increase in the number and representation across all professional groups identifying as a non-medical prescriber and/or utilising patient group directions across critical care. Many staff responded to this survey who were neither NMPs nor utilising PGDs; of these, a large proportion were interested in taking on this additional responsibility.

IMPLICATIONS FOR PRACTICE

Many people working within critical care are interested in becoming non-medical prescribers. Assists with understanding characteristics of those working as non-medical prescribers within critical care. Shows variations in practice in respect to PGDs, authorising of blood products and prescribing.

One Year Evaluation of Pharmacist Medication Charting Service in a Principal Referral Women and Newborn Hospital

Background: Accuracy of medication charts on admission to hospital has previously shown that inadvertent omission of therapy was the most common discrepancy, accounting for 40% to 60% of errors. Partnered Pharmacist Medication Charting (PPMC) has shown to reduce medicationrelated problems. Objective: The aim of this study was to evaluate the implementation of Pharmacist Medication Charting (PMC), a derivative of PPMC, in a maternity and gynecological hospital. The occurrence of medication omission identified by the pharmacists was assessed and the pharmacist interventions involving PMC analyzed. Methods: The pharmacist interventions documented from 1st July 2022 to 30th June, 2023 were evaluated using PowerBI for data and trends on the Medication-Related Problems (MRPs) identified, occurrence of PMC, common medications charted by the pharmacists and the pharmacist recommendation and action following the identification of MRPs. Results: A total of 4898 pharmacy interventions was documented in the 12-month period. Of the total interventions documented, 1321 (26.97%) were related to pharmacist medication charting. Of all the interventions related to PMC, 53.29% involved pharmacists charting medications for the continuation or initiation of over-the-counter medications, 13.32% involved pharmacist partnered charting of Prescription Only Medications and Controlled Medications with medical staff, and 33.3% were referred to a credentialled pharmacist for PMC service. With regards to action taken following interventions involving PMC, 1065 (80.62%) were resolved following PMC. Common medications charted by the pharmacists include: macrogol and docusate laxatives (288), pregnancy multivitamin containing iron, iodine and folate (169), colecalciferol (133), iron (127), asthma inhaler (99), paracetamol and ibuprofen (88), nicotine (38), calcium (29), folic acid (26), and pantoprazole (15). Conclusion: Our study demonstrated that hospital pharmacists contribute to the reduction of MRPs, and PMC enables pharmacist to address prescribing omission and conditions untreated in the hospital. This study also reflects skills enhancement in practice for clinical pharmacists and resulted in successful implementation of PMC.

New Zealand pharmacists' views regarding the current prescribing courses: questionnaire survey

Introduction New Zealand pharmacists must complete a joint prescribing course offered by Otago and Auckland universities only, to be qualified as pharmacist prescribers. Aim To identify knowledge and perceptions of New Zealand registered pharmacists, who are not pharmacist prescribers, on: pharmacist prescribing roles, courses and perceived barriers and facilitators to course uptake. Methods Participants comprised registered practising New Zealand pharmacists (n  = 4025), across all New Zealand regions. Invitations to participate in a questionnaire survey were sent in March 2021. Data were analysed using thematic analysis and descriptive statistics. Results The response rate was 12% (482/4025), with 94% community pharmacists. Almost two-thirds (65%) had over 10 years of working experience. Nearly all (95%) agreed that pharmacist prescribing would improve healthcare delivery in New Zealand. Most reported that barriers to pharmacist prescribing course uptake were funding, lack of institutional support, up-to-date pharmacological/pharmaceutical knowledge, and 2 years of experience in collaborative health team prerequisites for enrolment, finding medical supervisors, and lack of remuneration for prescribing roles. Discussion Pharmacist prescribing in New Zealand is still in its growing phase. Optimising uptake of prescribing courses and role requires a multi-level approach including all stakeholders. Government/policymakers should consider pharmacist prescribing training and remuneration in their funding plans. Employing institutions should provide required time and human resources (staff backfills). Training providers should consider methods of course delivery and assessment that are suitable for trainees in full-time employment.

Opinion on the benefits of nurse prescribing in Catalonia. Consensus of health professionals and managers

OBJECTIVE

To study the level of agreement among health professionals and managers in Catalonia on the benefits of nurse prescribing (NP).

METHOD

An online Real Time Delphi was conducted to collect the level of agreement of health professionals and managers. Participants voted in a 6-point scale (1 low benefit and 6 high benefit) for 12 items describing benefits of NP. A total of 1332 professionals participated. The level of consensus was calculated applying interquartile ranges of scores and standardized mean differences among subgroups using effect sizes (ES) and their corresponding 95% confidence intervals.

RESULTS

The scores indicate a general agreement on the perceived benefits of NP among participants. Standardized differences among scores on the perceived benefits among professionals were small to high (ES range between 0.2 and 1.2) between nurses and medical doctors and high between nurses and pharmacists (ES range: 1.2 and 2.4). Differences between scores of nurses and those of managers or other professionals in the present study were smaller for most voted benefits.

CONCLUSIONS

The study shows an agreement on the benefits of NP. Nevertheless, when standardized scores are taken into consideration, differences among professionals' perceptions emerged, and aligned with documented barriers identified in the literature such as corporative aspects, cultural limitations, institutional and organisational inertia, beliefs and unawareness of what NP implies.

Community Pharmacists' Views on the Early Stages of Implementation of a National Pilot Independent Prescribing Service in Wales: A Qualitative Study

Background

A pilot Independent Prescribers' Service (IPS) was introduced in 13 community pharmacies across Wales in June 2020. Independent Pharmacist Prescribers (IPPs) could prescribe in the areas of management of acute conditions, contraception, or opioid withdrawal, as agreed with local commissioners. Access to the patients' medical records was provided via Choose Pharmacy, the national community pharmacy IT platform.

Objective

To explore the experiences of IPPs delivering the service and commissioners responsible for financial resources regarding the IPS in Wales.

Methods

A qualitative methodology was employed, with purposive sampling, semi-structured interviews, and inductive thematic analysis.

Results

Five themes were constructed from 13 interviews (n=9 IPPs; n=4 commissioners): (i) patient experience and safety; (ii) professional enablement and rebalancing workload of GPs; (iii) role and limitations of remote consultations; (iv) funding and business model; (v) functionality on Choose Pharmacy to support patient care. The design of the service allowed pharmacists to determine how best to deliver the IPS, maximizing access for patients and promoting a sense of professional value amongst pharmacists.

Conclusion

This study builds on the body of evidence on enhanced patient experience with prescribing services in the community, reinforcing that IPPs have a key role in rebalancing management of common conditions from GP surgeries to community pharmacies. Several considerations need to be addressed to ensure future success of the service implementation, delivery and enhanced sustainability, such as formal referral pathways and access to medical records. These can be used by other commissioning bodies in the UK and internationally to build a network of suitably supported IPPs, confident to appropriately deal with uncomplicated acute and chronic conditions; and liaise with primary and/or secondary care when referrals are needed.

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.

Translation, Cross-Cultural Adaptation, and Validation of the Galician Version of the Nurse Prescribing Self-Efficacy Scale

Low self-efficacy has been identified as one of the factors that could hinder the prescribing competence of nurses. No valid and reliable existing instruments assess Galician nurses' confidence to prescribe. The aim of this study was to determine the reliability and validity of the Galician version of the Nurse Prescribing Self-Efficacy Scale (G-NP-SES, 19 items). The study was conducted in two phases: the translation and adaptation to the Galician version of the NP-SES, and the assessment of its psychometric properties. G-NP-SES was sent to nurses working in primary healthcare centers in Galicia (Spain) between March and June of 2022. Its content, construct and discriminant validity, and internal consistency reliability were examined. A total of 193 people participated in the study. As the original scale, G-NP-SES also had three dimensions (% of cumulative variance = 80.82%). It showed good internal consistency (Cronbach's alpha coefficient (α) = 0.90, with each factor ranging from 0.86 to 0.89), high content validity (scale's content validity index = 0.92, with item-content validity index ranged from 0.87 to 1), and good discriminant validity. G-NP-SES is an instrument with good psychometric properties which could be used to accurately assess Galician nurses' self-efficacy to prescribe and consequently to improve their job performance.

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 multi-site prospective, observational study of physiotherapist independent prescribing activity across musculoskeletal clinics in the United Kingdom

OBJECTIVE

To establish how advanced practice physiotherapists in the UK working in the musculoskeletal specialty are utilising their independent non-medical prescribing skills.

DESIGN

Multi-site, prospective, descriptive observational study. Ethics reference No: ERN_19-0994).

METHOD

The study was conducted by seven advanced practitioners, across seven clinical sites representative of advanced musculoskeletal practice in the UK, between 1st October 2019-March 31, 2020. Advanced physiotherapy practitioner independent prescribers working in a variety of musculoskeletal specialty areas collected data across 5 contexts of musculoskeletal clinical service: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis.

RESULTS

Prescribing activity data for n = 2470 patients were collected. Prescribing activity was highest for the treatment of nociceptive pain (51.3%) and inflammation (39.6%). Most prescribing activity occurred in the first 2-6 weeks (34.1%) following onset of condition. Medicines optimisation accounted for most of prescribing activity (18.1%), followed by over-the-counter medication recommendation (15.5%). De-prescribing accounted for 10.8% of all prescribing activity recorded. Qualitative data were synthesised into 4 themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity, and legal and regulatory restriction.

CONCLUSIONS

Physiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by the clinicians' clinical reasoning and use of joint decision-making. Prescribing activity for acute back and neuropathic radicular pain was limited secondary to recent reclassification of gabapentin and pregabalin.

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.

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.

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.

A qualitative exploration of the enablers and barriers to the provision of outpatient clinics by hospital pharmacists

BACKGROUND

With increasing demands on the National Health Service (NHS), Scottish Government-led pharmacy strategy has prioritised the development and expansion of outpatient services. Pharmacist-led outpatient clinics have been shown to reduce hospital admissions and improve patient outcomes. However, expanding these contemporary models of care has proved challenging, and there are few qualitative data about the factors affecting the provision of these.

AIM

This study aimed to explore the enablers and barriers to hospital pharmacists providing outpatient clinics within the largest health authority in Scotland, NHS Greater Glasgow & Clyde (NHSGGC).

METHOD

Between August and October 2020, one-to-one semi-structured interviews were conducted virtually using the videoconferencing platform Microsoft Teams^®, with NHSGGC hospital pharmacists who did or did not provide clinics. Audio- and video-recordings of the interviews were transcribed verbatim and underwent thematic analysis.

RESULTS

16 hospital pharmacists were interviewed; 50% were clinic providers and 50% were not. Analysis generated seven themes: clinical or service need, individual factors, clinic structure and processes, additional clinical skills and training, competing priorities, macro-level pharmacy working, and external stakeholder relationships. Many of these were interdependent and had the potential to be an enabler or a barrier to clinic provision, depending on the context or individual.

CONCLUSION

The enablers and barriers to hospital pharmacists providing outpatient clinics are multifaceted, incorporating individual, systematic and professional factors. The implementation of new national professional curricula may help address many of these factors, however prospective research needs to accompany this vision.

A survey of nurses prescribing in diabetes care: Practices, barriers and facilitators in New Zealand and the United Kingdom

AIMS AND OBJECTIVES

To compare diabetes-related prescribing practices, barriers and facilitators amongst nurse prescribers in New Zealand and the United Kingdom.

BACKGROUND

Nurses have been prescribing in the United Kingdom for many years but nurse prescribing in New Zealand is relatively recent. It is unknown whether similar system factors act to facilitate or limit prescribing.

DESIGN

A survey of 250 nurses prescribing in diabetes care in New Zealand (n = 111) and the United Kingdom (n = 139).

METHODS

A SurveyMonkey questionnaire was used to survey nurses about the extent of their prescribing practices, and barriers and facilitators experienced. Quantitative data were explored descriptively, and qualitative responses were grouped according to content, with quotes provided to exemplify thematic content. This study is reported following STROBE guidelines.

RESULTS

Insulin, metformin and sulphonylureas are the drugs most frequently prescribed in both countries. Considerably more New Zealand than United Kingdom nurses reported prescribing for cardiovascular and renal disease. In both countries, direct prescribing to the patient was most common, followed by remote prescribing in New Zealand and via recommendation to other prescribers in the United Kingdom. Most common barriers were lack of time and inadequate mentoring. Most common facilitators were as follows: good supervision; collegial relationships with specialists, pharmacists and peers; and ongoing education.

CONCLUSIONS

These New Zealand and United Kingdom nurses are prescribing a broad range of diabetes-related medications. Similar barriers and facilitators were identified in both countries. Adequate supervision, support from multidisciplinary team colleagues and prescribing education and guidelines are paramount.

RELEVANCE TO CLINICAL PRACTICE

Important insights on barriers and facilitators to implementation of nurse prescribing in two countries are highlighted and, despite a considerable difference in the longevity of prescribing practice, similar issues were identified.

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.

The role of the Radiographer in osteoporosis and fracture prevention services - a narrative review

OBJECTIVE

To explore relevant literature and policy around the role of the radiographer working within osteoporosis services. Discussion will examine the value of radiographers in these services, as well as current limitations and future opportunities for advancing practice in these domains.

KEY FINDINGS

Osteoporosis and fracture prevention are a public health issue that must be addressed to improve patient outcomes following fractures. DXA radiographers currently fulfill an important role in the diagnosis of osteoporosis and collaborative working between radiology and osteoporosis services is to be encouraged. Radiographers are able to extend their role into advanced practice within osteoporosis services such as fracture liaison and rheumatology, they have expert knowledge and experience to bring to these roles and post graduate education can further increase radiographer's expertise in this field. The inability of diagnostic radiographers to become independent prescribers is a current limitation for radiographers working within osteoporosis services.

CONCLUSION

The role of the radiographer working within DXA and osteoporosis services is evolving and is an exciting area of advanced practice. Promoting this specialty within radiography may help to improve job satisfaction as well as recruitment and retention rates. As radiographers scope of practice in osteoporosis changes and evolves, it is hoped that current legislation may change to allow independent prescribing for diagnostic radiographers, which can in turn streamline patient pathways and reduce the burden on primary and secondary care.

Broadening the scope of task shifting in the organisation of healthcare

Task shifting in healthcare has mainly been initiated and studied as a way to react to/or mitigate workforce shortages. Here, we define task shifting as the structural redistribution of tasks, usually including responsibilities and competencies between different professions. As such, task shifting is commonly focused on highly specialised and trained professionals who hand-over specific, standardised tasks to professionals with lower levels of education. It is expected that this type of task shifting will lead to efficiency and cost savings to healthcare organisations. Yet, there are more benefits to task shifting, in particular its contribution to integrated patient-centred quality of care and a tailored system that meets the changing care demands in society. Hence the importance to broaden the scope of task shifting, its goals, manifestations and how task shifting plays a role in addressing both the strengths and weaknesses in the healthcare system. In this focus piece, trends and conditions for task shifting and its (un)anticipated effects are discussed. We argue that, only when designed to face specific complexities at the workplace and taking into account the balance between specialists and generalists, task shifting may substantially contribute to enhanced quality of care that meets the changing needs of society.

Family and health-care professionals managing medicines for patients with serious and terminal illness at home: a qualitative study

Background

More effective ways of managing symptoms of chronic and terminal illness enable patients to be cared for, and to die, at home. This requires patients and family caregivers to manage complex medicines regimens, including powerful painkillers that can have serious side effects. Little is known about how patients and family caregivers manage the physical and emotional work of managing medicines in the home or the support that they receive from health-care professionals and services.

Objective

To investigate how patients with serious and terminal illness, their family caregivers and the health-care professionals manage complex medication regimens and routines of care in the domestic setting.

Design

A qualitative study involving (1) semistructured interviews and group discussions with 40 health-care professionals and 21 bereaved family caregivers, (2) 20 patient case studies with up to 4 months’ follow-up and (3) two end-of-project stakeholder workshops.

Setting

This took place in Nottinghamshire and Leicestershire, UK.

Results

As patients’ health deteriorated, family caregivers assumed the role of a care co-ordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals. Access to support, resilience and coping capacity are mediated through the resources available to patients, through the relationships that they have with people in their personal and professional networks, and, beyond that, through the wider connections – or disconnections – that these links have with others. Health-care professionals often lacked understanding of the practical and emotional challenges involved. All participants experienced difficulties in communication and organisation within a health-care system that they felt was complicated and poorly co-ordinated. Having a key health professional to support and guide patients and family caregivers through the system was important to a good experience of care.

Limitations

The study achieved diversity in the recruitment of patients, with different characteristics relating to the type of illness and socioeconomic circumstances. However, recruitment of participants from ethnically diverse and disadvantaged or hard-to-reach populations was particularly challenging, and we were unable to include as many participants from these groups as had been originally planned.

Conclusions

The study identified two key and inter-related areas in which patient and family caregiver experience of managing medicines at home in end-of-life care could be improved: (1) reducing work and responsibility for medicines management and (2) improving co-ordination and communication in health care. It is important to be mindful of the need for transparency and open discussion about the extent to which patients and family caregivers can and should be co-opted as proto-professionals in the technically and emotionally demanding tasks of managing medicines at the end of life.

Future work

Priorities for future research include investigating how allocated key professionals could integrate and co-ordinate care and optimise medicines management; the role of domiciliary home care workers in supporting medicines management in end-of-life care; patient and family perspectives and understanding of anticipatory prescribing and their preferences for involvement in decision-making; the experience of medicines management in terminal illness among minority, disadvantaged and hard-to-reach patient groups; and barriers to and facilitators of increased involvement of community pharmacists in palliative and end-of-life care.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.

Establishing and Evaluating a Study Questionnaire on Knowledge and Attitudes of Healthcare Professionals Towards Recreational and Medical Cannabis Across Europe

BACKGROUND AND OBJECTIVE

The present survey was a preliminary to a European research project on the attitude and knowledge of healthcare professionals towards the use of medical cannabis. The objective was to evaluate the readability, understandability, and relevance of a first version of the study questionnaire before preparing the finalized questionnaire, which will be subsequently proposed to European healthcare professionals on a large scale.

METHODS

A cross-sectional study was conducted between December 2019 and May 2020. We established an electronic evaluation questionnaire relating to the study questionnaire. This evaluation questionnaire was proposed to multidisciplinary experts from all over Europe. Feedback from the evaluation questionnaire was considered for improving and finalizing the study questionnaire.

RESULTS

66 evaluation questionnaires were collected from nine European countries (Cyprus, France, Germany, Italy, Lithuania, Portugal, Spain, Sweden, United Kingdom), which corresponded to a participation rate of 41.5%. Most participants were women (65.2%, n = 43). The mean age was 39.5 years ± 11.6. Each participant could specify several occupations. There were 25 pharmacologists, 24 physicians, ten pharmacists, four university teachers, three epidemiologists or public health experts, one nurse, one biotechnologist, one microbiologist, and one police researcher. Overall, 84.8% of participants were interested in the topic of the survey on the knowledge and attitudes of healthcare professionals towards recreational and medical cannabis across Europe. Participants were satisfied with all but six of the proposed questions. In addition, two additional questions were subject for comments despite a high level of satisfaction. Consequently, the concerned questions (n = 8) were modified.

CONCLUSION

This evaluation survey was a necessary step to improve the quality of the future research project. The positive feedback encourages the authors to proceed with the project on a European scale, scheduled for 2021.

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.

Identifying New Zealand Public Preferences for Pharmacist Prescribers in Primary Care: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVE

Given increasing patient populations, general practitioner workforce constraints and the growing demand for health services in New Zealand (NZ), the development and provision of pharmacist prescribing services could be used to improve people's access to medicines. A discrete choice experiment (DCE) was utilised to determine NZ public preferences for pharmacist prescribing services in primary care in NZ.

METHODS

A D-efficient DCE design generated 20 choice questions in four blocks of five questions with three labelled alternatives per choice question. The online DCE used a NZ general public online research panel administered by an external organisation (SurveyEngine). The DCE included six attributes with two attributes each with two levels (location of consultation and consultation type), three levels (type of service and operating hours) and four levels (waiting time and cost).

RESULTS

Nine hundred and twenty-four respondents completed the survey with 4620 observations available for analyses. Respondents preferred pharmacist prescribing services with the following characteristics: optimisation of medicines and changes to only current medicine service types (relative to repeat prescribing); lower consultation costs, shorter waiting times, longer operating hours and consultation by appointment (relative to walk-in and wait clinic).

CONCLUSIONS

Prescribing policy could incorporate these public preferences to help develop accessible and effective primary care prescribing services utilising the skills of pharmacist prescribers to improve and reduce inequities in access to medicines in NZ. These results suggest the NZ public see pharmacists as part of the primary care prescribing team and are willing to utilise them if these services are implemented.

Securing a sustainable and fit-for-purpose UK health and care workforce

Approximately 13% of the total UK workforce is employed in the health and care sector. Despite substantial workforce planning efforts, the effectiveness of this planning has been criticised. Education, training, and workforce plans have typically considered each health-care profession in isolation and have not adequately responded to changing health and care needs. The results are persistent vacancies, poor morale, and low retention. Areas of particular concern highlighted in this Health Policy paper include primary care, mental health, nursing, clinical and non-clinical support, and social care. Responses to workforce shortfalls have included a high reliance on foreign and temporary staff, small-scale changes in skill mix, and enhanced recruitment drives. Impending challenges for the UK health and care workforce include growing multimorbidity, an increasing shortfall in the supply of unpaid carers, and the relative decline of the attractiveness of the National Health Service (NHS) as an employer internationally. We argue that to secure a sustainable and fit-for-purpose health and care workforce, integrated workforce approaches need to be developed alongside reforms to education and training that reflect changes in roles and skill mix, as well as the trend towards multidisciplinary working. Enhancing career development opportunities, promoting staff wellbeing, and tackling discrimination in the NHS are all needed to improve recruitment, retention, and morale of staff. An urgent priority is to offer sufficient aftercare and support to staff who have been exposed to high-risk situations and traumatic experiences during the COVID-19 pandemic. In response to growing calls to recognise and reward health and care staff, growth in pay must at least keep pace with projected rises in average earnings, which in turn will require linking future NHS funding allocations to rises in pay. Through illustrative projections, we show that, to sustain annual growth in the workforce at approximately 2·4%, increases in NHS expenditure of 4% annually in real terms will be required. Above all, a radical long-term strategic vision is needed to ensure that the future NHS workforce is fit for purpose.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality assessment with diverse studies (QuADS): an appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies

BACKGROUND

In the context of the volume of mixed- and multi-methods studies in health services research, the present study sought to develop an appraisal tool to determine the methodological and reporting quality of such studies when included in systematic reviews. Evaluative evidence regarding the design and use of our existing Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was synthesised to enhance and refine it for application across health services research.

METHODS

Secondary data were collected through a literature review of all articles identified using Google Scholar that had cited the QATSDD tool from its inception in 2012 to December 2019. First authors of all papers that had cited the QATSDD (n=197) were also invited to provide further evaluative data via a qualitative online survey. Evaluative findings from the survey and literature review were synthesised narratively and these data used to identify areas requiring refinement. The refined tool was subject to inter-rater reliability, face and content validity analyses.

RESULTS

Key limitations of the QATSDD tool identified related to a lack of clarity regarding scope of use of the tool and in the ease of application of criteria beyond experimental psychological research. The Quality Appraisal for Diverse Studies (QuADS) tool emerged as a revised tool to address the limitations of the QATSDD. The QuADS tool demonstrated substantial inter-rater reliability (k=0.66), face and content validity for application in systematic reviews with mixed, or multi-methods health services research.

CONCLUSION

Our findings highlight the perceived value of appraisal tools to determine the methodological and reporting quality of studies in reviews that include heterogeneous studies. The QuADS tool demonstrates strong reliability and ease of use for application to multi or mixed-methods health services research.

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 comparative case study of prescribing and non-prescribing physiotherapists and podiatrists

BACKGROUND

Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights for medicines: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists.

AIM

to compare outcomes of physiotherapist and podiatrist Independent Prescriber (PP- IP) patients with those of physiotherapist and podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications.

DESIGN

a mixed method comparative case study.

METHODS

Using mixed methods of data collection, outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015-2016).

RESULTS

489 patients were recruited: n = 243 IP sites, and n = 246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life (p > 0.05) and patient satisfaction (p ≤ 0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than PP-NP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 min).

CONCLUSION

This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.

Pharmacists' Prescribing in Saudi Arabia: Cross-Sectional Study Describing Current Practices and Future Perspectives

Pharmacist prescribing is being increasingly undertaken to better use their skills and reduce the workload of existing prescribers such as doctors, often using formal processes to legitimate these activities. In developing countries like Saudi Arabia, however, pharmacists' prescribing remains informal with no legislation or formal training and there is a lack of research and understanding into such practices. Therefore, we aimed to describe current pharmacist prescribing practices in Saudi Arabia and explore pharmacists' views about pharmacists' prescribing. This is a cross-sectional survey study using an online questionnaire of hospital pharmacists in Saudi Arabia about pharmacists' prescribing, and associated views about prescribing legislation and barriers to implementing pharmacist prescribing. Over a quarter (28.5%) of pharmacists reported themselves as prescribers, 49% were following a collaborative prescribing model, 18% independent prescribing, and 33% were doing both. Ninety percent of prescribers reported confidence in prescribing the appropriate treatment and 92.3% perceived they will benefit from more prescribing training. Healthcare practice culture and pharmacist's competency were identified as barriers. There is an overall support for pharmacists' prescribing in Saudi Arabia among this sample of hospital pharmacists, with limitations in resources and the absence of standardized prescribing training being perceived as key barriers to pharmacists' prescribing.

Improving psychiatric medication use through the Michigan e-psychopharmacology course for nurse practitioners: A pre-post/follow-up study

PURPOSE

Increasing demands for mental health treatment represent a key opportunity for nurse practitioners (NPs) to provide more psychiatric medication treatment (psychopharmacology). Given this need, NPs could benefit from opportunities to enhance knowledge and skills in psychopharmacology.

DESIGN AND METHODS

A novel videoconference course was developed and tested, with 6 weekly sessions taught by a facilitator and a speaker, evaluated by multiple outcomes.

FINDINGS

Course feasibility and evidence of improved NP confidence and performance in psychopharmacology were both demonstrated.

PRACTICE IMPLICATIONS

Continuing education providers should consider adopting this model for effective and accessible NP psychopharmacology education, potentially expanding NP mental healthcare delivery.

A theoretically based cross-sectional survey on the behaviors and experiences of clinical pharmacists caring for patients with chronic kidney disease

The literature shows a lack of evidence on pharmacists contributing to chronic kidney disease services. The aim was to determine pharmacists' behaviors and experiences and perceptions of barriers and facilitators to implementation of models of care. A theoretically informed survey was developed and sent to pharmacist members of the United Kingdom renal pharmacy group. Sections included: demographics, clinical practice and prescribing practice. Questions were of various types; closed type and some open for comments. Attitudinal items on clinical/prescribing used 5-point Likert scale. Development/implementation items were derived from the Consolidated Framework for Implementation Research (CFIR). Analysis used descriptive statistics and open comments were analysed thematically. Ethical approval was granted by an academic institution. Response rate; 50% (n = 71), seven were incomplete and excluded. Respondents provided; inpatient general pharmaceutical care (n = 56, 87.5%), to those receiving dialysis (n = 54, 84.4%) and transplantation. Non-clinical roles; audits (n = 46, 71.9%), patient education (n = 31, 48.4%), only 7.8% (n = 5) doing academic research. For barrier/facilitators most strongly agreed/agreed with most CFIR items relating to clinical practice. A majority (n = 44, 68.7%) disagreed that they had sufficient time to practice clinically and 44 (68.7%) disagreed there was sufficient cover for services. For prescribing roles, 90.5% (n = 48) were currently actively prescribing. Although prescribing related CFIR items were largely positive, 39.6% (n = 19) disagreed about sufficient time to practice and 18.7% (n = 9) were neutral. Two thirds (n = 33, 68.7%) disagreed that there was sufficient cover for the prescribing. The majority of respondents provided general pharmaceutical care to dialysis and transplant patients, were confident in their abilities and tried new ways of working including independent prescribing. Many expressed that lack of resources was the main barrier to providing more advanced care. Further work is needed to explore these matters in more depth.

Hand Hygiene Compliance in the ICU: A Systematic Review

OBJECTIVES

To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene.

DATA SOURCES

Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened.

STUDY SELECTION

English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included.

DATA EXTRACTION

Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels.

DATA SYNTHESIS

Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%).

CONCLUSIONS

Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

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.

A nurse prescriber-led protocol for anaemia management in established haemodialysis patients: A retrospective study

AIM AND OBJECTIVE

To evaluate the impact of a nurse prescriber-led protocol compared to a traditional physician-led nonprotocol-based approach had on maintaining targeted haemoglobin levels in patients on maintenance haemodialysis.

BACKGROUND

Anaemia is a common complication of chronic kidney disease and has a profound impact on the patients' well-being. Current practices place a greater emphasis on the decision-making role of nurses in renal anaemia management. The introduction of nurse prescribing in this area is a relatively new concept.

DESIGN

A retrospective cohort design, covering an eight-month period pre- and post introduction of a nurse prescriber-led anaemia protocol; study adheres to the STROBE Statement.

METHODS

Using a nonprobability convenience sample, data extracted from the medical records and electronic patient records system (eMed) related to 74 patients at a single outpatient haemodialysis centre located within an acute general teaching hospital. The primary outcome was patients' haemoglobin level pre- and post introduction of the protocol. Secondary outcomes included erythropoietin-stimulating agent and iron dosage, and serum ferritin and transferrin saturation levels.

RESULTS

There were no statistically significant differences between pre- and post protocol serum haemoglobin level and erythropoietin-stimulating agent dosage. Under the management of the nurse prescriber, patients experienced a significant improvement in serum ferritin and transferrin saturation levels and required significantly less intravenous iron dosage.

CONCLUSIONS

This study, the first of its kind, found that patients receiving haemodialysis experience a significant improvement in iron indices while receiving a significantly lower amount of intravenous iron when managed by a nurse prescriber. Furthermore, the nurse prescribers' decision-making capacity is as effective as a physician-led nonprotocol-based approach in achieving haemoglobin target levels.

RELEVANCE TO CLINICAL PRACTICE

Nurse prescribers have a role in implementing a safe, standardised and sustained approach to anaemia management in outpatient haemodialysis settings without compromising patient 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.

Nurse prescribing of medicines in 13 European countries

BACKGROUND

Nurse prescribing of medicines is increasing worldwide, but there is limited research in Europe. The objective of this study was to analyse which countries in Europe have adopted laws on nurse prescribing.

METHODS

Cross-country comparative analysis of reforms on nurse prescribing, based on an expert survey (TaskShift2Nurses Survey) and an OECD study. Country experts provided country-specific information, which was complemented with the peer-reviewed and grey literature. The analysis was based on policy and thematic analyses.

RESULTS

In Europe, as of 2019, a total of 13 countries have adopted laws on nurse prescribing, of which 12 apply nationwide (Cyprus, Denmark, Estonia, Finland, France, Ireland, Netherlands, Norway, Poland, Spain, Sweden, United Kingdom (UK)) and one regionally, to the Canton Vaud (Switzerland). Eight countries adopted laws since 2010. The extent of prescribing rights ranged from nearly all medicines within nurses' specialisations (Ireland for nurse prescribers, Netherlands for nurse specialists, UK for independent nurse prescribers) to a limited set of medicines (Cyprus, Denmark, Estonia, Finland, France, Norway, Poland, Spain, Sweden). All countries have regulatory and minimum educational requirements in place to ensure patient safety; the majority require some form of physician oversight.

CONCLUSIONS

The role of nurses has expanded in Europe over the last decade, as demonstrated by the adoption of new laws on prescribing rights.

Self-medication in pain management: The state of the art of pharmacists' role for optimal Over-The-Counter analgesic use

BACKGROUND AND OBJECTIVE

Self-medication is associated with an important utilization of Over-The-Counter (OTC) analgesics. The medical outcome resulting from therapeutic options bypassing the physician prescription is a major issue. In that context, pharmacists are expected to play a crucial role. The main objective of this review was to analyse the state-of-the art of pharmacists' role in pain management self-medication.

DATABASES AND DATA TREATMENT

An expert multidisciplinary group dedicated to self-medication in pain was established. Selection of publications was performed from PubMedand EMBASE databases which was based on the use of "pain" and/or "self-medication" and/or "self-care" and/or "analgesics" and/or "painkillers" keywords, restricted to the past 10 years.

RESULTS

A total of 480 papers were identified, 49 of which papers were considered relevant and finally kept for final discussion, on OTC pain management and pharmacist's role. Literature analysis demonstrates that OTC analgesics are generally safe when appropriately used. Risks associated with misuse or inappropriateness depend on patients' vulnerability (elderly, pregnancy) or behaviour. Social cognitive theory-based intervention and multimedia applications improve self-medication but do not replace health care professional advice Pharmacists' interventions may improve the benefits and safety of OTC analgesic medication, with a better management of pain.

CONCLUSIONS

Considering the heterogeneity of patients' knowledge and behaviour reported worldwide, inappropriate use of OTC pain medication should not be underestimated. Community pharmacists are ideally placed to guide self-medication or recommend a medical advice when needed. Embedding pharmacists in primary care pain management is essential and pharmacist-led medication coupled with an appropriate training of pharmacy staffs should be encouraged.

SIGNIFICANCE

Analgesics are widely used without prescription, all over the world. They represent the largest market of OTC drugs, with an overall benefit/risk ratio favourable when appropriately used. Because of potential individual risks associated to the ailment or to the patient's behaviour, pharmacists' interventions have proven to optimize analgesic self-medication, provided that pharmacy staffs are both available and more specifically trained. In the future, in pain management, especially self-medication, pharmacists should play an increasing role and should be included in educational programmes and pain management guidelines.

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

Besides doctors and dentists, an increasing range of healthcare professionals, such as nurses, pharmacists and podiatrists, can become independent prescribers (IPs). As part of an evaluation for independent prescribing funded training, this study investigated views and experiences of IPs, their colleagues and patients about independent prescribing within primary care. Questionnaires capturing quantitative and qualitative data were developed for IPs, their colleagues and patients, informed by existing literature and validated instruments. IPs were identified following independent prescribing training funded by Health Education England Northwest in 2015-2017. Quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically. Twenty-four patients, 20 IPs and 26 colleagues responded to the questionnaires. Most patient respondents had a long-term medical condition (n = 17) and had regular medicines prescribed (n = 21). IPs were nurses (n = 14), pharmacists (n = 4), one podiatrist (n = 1) and one was unknown. Half of the IPs were current prescribers (n = 10), the other half were still training (to become) IPs (n = 10). Colleague respondents were doctors and nurses (n = 15) other healthcare professionals (n = 8) and practice managers (n = 3). Both current IPs (n = 9) and colleague respondents (n = 25) (strongly) agreed that independent prescribing improved the quality of care provided for patients. Nearly all colleagues were supportive of independent prescribing and believed that they worked well with IPs (n = 25). Patients' perceptions and experiences of their consultations with the IP were mostly positive with the vast majority of respondents (strongly) agreeing that they were very satisfied with their visit to the IP (n = 23). Key barriers and enablers to independent prescribing were centred on IPs' knowledge, competence and organisational factors such as workload, effective teamwork and support from their colleagues. Findings from this study were mainly positive but indicate a need for policy strategies to tackle longstanding barriers to independent prescribing. However, a larger sample size is needed to confirm findings.

PROCESS AND SYSTEMS: A systems approach to embedding group consultations in the NHS

Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.