Successfully developing advanced practitioner roles: policy and practice mechanisms

PURPOSE

The purpose of this paper is to lay out how advanced practitioner development occurs in New Zealand primary health care settings. The paper specifically focuses on mechanisms occurring across policy creation and in practice leading to successful role development.

DESIGN/METHODOLOGY/APPROACH

The authors applied a realist approach involving interviews, document review and field log observations to create refined theories explaining how successful development occurs.

FINDINGS

Three final mechanisms were found to influence successful advanced practitioner role development: engagement in planning and integrating roles; establishing opportunities as part of a well-defined career pathway; and championing role uptake and work to full scopes of practice.

RESEARCH LIMITATIONS/IMPLICATIONS

This research focuses on one snapshot in time only; it illustrates the importance of actively managing health workforce change. Future investigations should involve the continued and systematic evaluation of advanced practitioner development.

PRACTICAL IMPLICATIONS

The successful development of advanced practitioner roles in a complex system necessitates recognising how to trigger mechanisms occurring at times well beyond their introduction.

SOCIAL IMPLICATIONS

Potential candidates for new roles should expect roadblocks in their development journey. Successfully situating these roles into practice through having a sustainable and stable workforce supply provides patients with access to a wider range of services.

ORIGINALITY/VALUE

This is the first time a realist evaluation has been undertaken, in New Zealand, of similar programmes operating across multiple sites. The paper brings insights into the process of developing new health programmes within an already established system.

'She taught me': factors consumers find important in nurse practitioner and pharmacist prescriber services

BACKGROUND

Advanced practitioner services, such as those nurse practitioners and pharmacist prescribers provide, are an opportunity to improve health care delivery. In New Zealand, these practitioners remain underutilised, despite research suggesting they offer safe and effective care, and considerable international literature recording patient satisfaction with these roles. This study aimed to explore factors underlying consumer satisfaction with primary health care nurse practitioner and pharmacist prescriber services.

METHODS

As part of a larger realist evaluation, 21 individuals receiving advanced practitioner services participated in semi-structured interviews. These interviews were transcribed and coded against context-mechanism-outcome configurations tested and refined throughout the research.

RESULTS

Study findings emphasise the importance of consumer confidence in the provider as a mechanism for establishing advanced practitioner roles. Underlying this confidence is a recognition that these practitioners work in a more accessible manner, engage at the individual's 'level', and operate with passion.

CONCLUSIONS

This research offers learnings to re-engineer service delivery within primary health care to make best use of the entire health care team by including consumers in the design and introduction of new roles.

The influence of organisational climate on care of patients with schizophrenia: a qualitative analysis of health care professionals' views

BACKGROUND

Organizational climate relates to how employees perceive and describe the characteristics of their employing organization. It has been found to have an impact on healthcare professionals' and patients' experiences of healthcare (e.g. job satisfaction, patient satisfaction), as well as organizational outcomes (e.g. employee productivity). This research used organizational theory to explore dynamics between health care professionals (pharmacists, doctors and nurses) in mental health outpatients' services for patients taking clozapine, and the perceived influence on patient care.

SETTING

Seven clozapine clinics (from one NHS mental health Trust in the UK) which provided care for people with treatment resistant schizophrenia.

METHODS

This study used qualitative methods to identify organizational climate factors such as deep structures, micro-climates and climates of conflict that might inhibit change and affect patient care. Using Interpretative Phenomenological Analysis, semistructured interviews were conducted with 10 healthcare professionals working in the clinics to explore their experiences of working in these clinics and the NHS mental health Trust the clinics were part of.

MAIN OUTCOME MEASURE

Health Care Professionals' perceptions of the care of patients with treatment resistant schizophrenia.

RESULTS

Three superordinate themes emerged from the data: philosophy of care, need for change and role ambiguity. Participants found it difficult to articulate what a philosophy of care was and in spite of expressing the need for change in the way the clinics were run, could not see how 'changing things would work'. There was considerable role ambiguity with some 'blurring of the boundaries between roles'. Factors associated with organizational climate (role conflict; job satisfaction) were inhibiting team working and preventing staff from identifying the patients' health requirements and care delivery through innovation in skill mix. There were mixed attitudes towards the pharmacist's inclusion as a team member.

CONCLUSIONS

Our findings suggest deficiencies within the clinics that may be manifestations of the wider culture of the NHS. The implications for mental health outpatient clinics are that local initiatives are crucial to the implementation of recovery models; clear guidance should be provided on the skill mix required in clozapine clinics and interprofessional learning should be encouraged to reduce role conflict.

"Prescribing for the whole person": A qualitative study exploring prescribing pharmacist views on type 2 diabetes management in New Zealand

BACKGROUND

Pharmacist prescribers have comprehensive pharmacotherapy knowledge that can be useful for management of complex health conditions such as type 2 diabetes, yet the number of pharmacist prescribers working in New Zealand primary care is low.

AIM

To explore the experiences of pharmacist prescribers in supporting type 2 diabetes management in New Zealand primary care.

METHODS

Qualitative research design using semi-structured interviews with six pharmacist prescribers working in NZ primary care. Thematic analysis guided this study and themes were finalised with the wider research team.

RESULTS

Three major themes were identified: team approach, health inequity and the role of a pharmacist prescriber. This study found that pharmacist prescribers may improve health equity by providing advanced pharmacotherapy knowledge within a wider primary care team to support complex patient needs and understanding the wider social determinants of health that impact effective diabetes management. Participants reportedly had more time to spend with patients (than GPs or nurses) and could also contribute to improving health outcomes by directly educating and empowering patients.

CONCLUSION

The views of pharmacist prescribers have seldom been explored and this study suggests that their role may be under-utilised in primary care. In particular, pharmacist prescribers can provide specialist prescribing (and often mobile) care, and may contribute to improving health outcomes and reducing inequity when used as part of a multi-disciplinary team.

Perceptions of underlying practice hierarchies: Who is managing my care?

BACKGROUND

The introduction of new health professional roles, such as that of the nurse practitioner and pharmacist prescriber in primary health care can lead to changes in health service delivery. Consumers, having used these roles, often report high satisfaction. However, there is limited knowledge of how these individuals position nurse practitioner and pharmacist prescriber roles within existing practice structures.

METHODS

Semi-structured interviews were conducted with 21 individuals receiving services from these practitioners in New Zealand primary health care. Interviews were recorded and transcribed verbatim for thematic analysis.

RESULTS

Participant views reflect established practice hierarchies, placing advanced practitioners 'below' general practitioners. Participants are unable to articulate what it was about these practitioners that meant they operated at lower tiers and often considered practitioners to act as 'their doctor'. They also highlight structural barriers impairing the ability of these providers to operate within their full scope of practice.

CONCLUSIONS

While seeing value in the services they receive, consumers are often unable to position nurse practitioner and pharmacist prescriber roles within health system contexts or to articulate how they value their practitioner's skills. Embedded structural barriers may be more visible to consumers than their interactions with the health system suggest. This may influence peoples' ability to receive intended or optimal health services. Consumer 'health professional literacy' around the functions of distinct health practitioners should be supported so that they may make informed service provision choices.

Pharmacist prescriber in Italy and possible changes to current legislation: survey of attitudes among pharmacists, family doctors and users

Background

In many countries in Europe and in the world, pharmacists are allowed to prescribe or modify therapies. In Italy, the only healthcare professions authorised to prescribe are medical doctors and veterinary surgeons. The extension of the duties of the Italian pharmacist to include prescribing would be extremely important considering the challenges the National health system is facing regarding the shortage of healthcare workers.

Methods

In this article, we report the findings of a survey on the role of the pharmacist prescriber conducted among pharmacists, family doctors, and pharmacy users in the North-West of Italy. The investigation was conducted by means of interviews carried out, using category-specific questionnaires.

Results

Interviews were conducted with 234 pharmacists, 926 users and 9 family doctors. The majority of pharmacists and users would agree to the introduction of the prescribing pharmacist. In return for taking on the increased responsibility, the pharmacists stressed the need for appropriate legal status and additional training. The reasons most commonly indicated by pharmacists for introducing such a service are the ability to respond immediately to a pathology or minor condition, and the prevention of inappropriate self-medication by patients. More than three-quarters of pharmacists and family doctors feel that the most suitable pharmacist prescribing procedure would be that within a clinical management plan. The family doctors, expressed reservations regarding the pharmacist prescriber: the cases in which they were really open to a change were the renewal of a prescription.

Conclusions

This study highlights the fact that both pharmacists and pharmacy users tend to be favourable to the introduction of the figure of the pharmacist prescriber in Italy. Many obstacles remain to be overcome but, based on the procedures already experimented in other European countries and worldwide, a route leading to the introduction of the pharmacy prescriber role may be hypothesised.

Assessment of the implementation of pharmacist prescribing: Challenges and pathways for ambulatory practice

BACKGROUND

Prescribing by pharmacists is an increasingly common practice worldwide. In Brazil regulation of this practice began in 2013, and the practice remains unexplored as a research topic.

OBJECTIVE

We aimed to explore and gain insights into pharmacist prescribing practices in Brazil and assessing pharmacist's perceptions of their training and preparedness to prescribe medications.

METHODS

A cross-sectional survey was conducted between October 2022 and March 2023 via convenience sampling. Data were collected using an online questionnaire covering sociodemographic issues, academic training, prescribing practices, and perceptions regarding the provision of pharmacist prescribing in ambulatory care. Exploratory descriptive analysis and Poisson regression were performed to estimate the associations between pharmacist characteristics and their practices in prescribing medicines.

RESULTS

Among the 305 valid responses, 58.7% of the outpatient pharmacists stated that they had not prescribed any medication in the previous three years. Over-the-counter medication prescriptions were most common (42.0%). Only 4.6% of respondents had prescribed prescription-only medicines provided through collaborative agreement, with 2.6% reporting that they had adjusted doses, and 2.3% played a role in prescription renewal. Pharmacists living in Northeast regions tended to be more active prescribers (PR = 1.42; 95%CI 1.03-2.18), whereas those in primary healthcare (PR = 0.61; 95%CI 0.39-0.96) and self-declared Black pharmacists (PR = 0.30; 95%CI 0.10-0.97) prescribed less. Respondents strongly believed in the pharmacist's role as a prescriber, although they remained ambivalent regarding their responsibility for patient outcomes. Progress barriers include infrastructure gaps and strained relationships with physicians.

CONCLUSIONS

This study suggests that pharmacists in Brazil predominantly prescribe over-the-counter medications, and variations in setting, region, and race can influence prescribing by pharmacist in ambulatory care.