Influences on prescribing decisions by non-medical prescribers: a

qualitative study

Trudi McIntoshDr Scott Cunningham

Professor Derek StewartDr Katrina Forbes-McKay

Dr Dorothy McCaig

Background

Non-medical prescribing (NMP) in the UK:

nurses, pharmacists, physiotherapists, podiatrists, diagnostic and therapeutic radiographers, optometrists and dietitians

• Supplementary(1) and independent(2) prescribing

• All within self-assessed areas of competence

Pharmacist prescribing in the UK

Supplementary prescribing

2003

• voluntary partnership between an independent prescriber and a supplementary prescriber to implement an agreed patient-specific clinical management plan with patient agreement

Independent prescribing

2006

• prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing

Impact of non-medical prescribing

Research mainly among nurse and pharmacist prescribers:

• views of NMPs on education, training and practice(3,4)

• views of patients and the general public(5-7)

• views of medical mentors(8)

• Cochrane review of clinical effectiveness(9)

Little known about influences on NMPs’ prescribing decisions.

PhD research: overview of study

Part of a programme of research:

• Systematic review of literature(10)

• Phase 1: semi-structured interviews with nurse and pharmacist independent prescribers

• Phase 2: participant audio self-recorded reflections on noteworthy prescribing decisions

• Phase 3: interviews about these reflections

University ethics and NHS R&D approval received; advised NHS ethics not required

Underpinning: Theoretical Domains Framework(11)

KnowledgeSkillsSocial/professional role and identityBeliefs about capabilitiesOptimismBeliefs about consequencesReinforcementIntentions

GoalsMemory, attention & decision processesEnvironmental consequences and resourcesEmotionsSocial influencesBehavioural regulation

Recruitment

• Recruitment via e mails sent by NHS Grampian non-medical prescribing Leads

• Sent to all supplementary and independent NMPsemployed by or contracted to Grampian Health Board

• Reminder e mail sent

• “Snowballing” among participants

Interview schedule

Semi-structured interview schedule developed from the literature including the Theoretical Domains Framework of behavioural determinants(11)

• Supervisory team discussions

• Review by senior medical and non-medical prescribers

• “Sense check” by nurse and pharmacist NMPsfrom primary and secondary care

• Pilot

Analysis using N-Vivo®

Data from interviews

Parent nodes (N-Vivo®)

Child nodes (N-Vivo®)

Themes and sub-themes

Analysis using N-Vivo®

Participants

Eight pharmacist independent prescribersTwo in secondary careFive in primary care and community pharmacyExperience as prescriber: 3 – 12 yearsWide range of prescribing areas

Five nurse independent prescribersAll in primary careExperience as prescriber: 8 months – 11 yearsWide range of prescribing areas

Findings

Interviews lasted between 22 and 58 minutes

Patient at the heart of prescribing decisions

Complexity in patient health and/ or social circumstances

Multiple and sometimes contradictory influences on prescribing decisions

Most TDF domains influential, some overlap

Multi-disciplinary working and experience also influential

KnowledgeKnowledge of the patient

“That’s probably the most useful thing to find out: what it is they’re looking for.”

Nurse 4, primary care, female

Knowledge of guidelines and local formulary“Calcium channel blockers you’ve got your amlodipine first choice, felodipine only if you need it.”

Pharmacist 9, primary care, female

Knowledge of specific patient groups or drugs

Skills

Communication “History taking’s probably still the key and, and, dare I say it, listening is the most important thing within that…”

Pharmacist 7, community pharmacy, male

Physical assessment“And the heart failure clinic, if they're not euvolaemic and they're still symptomatic and I can hear fluid in their chest I'm going to give them diuretics and maybe increase other medication.”

Pharmacist 5, primary care, female

Interpersonal, negotiation and documentation skills

Social/ professional role & identityBackground and scope of practiceResponsibility as a prescriber

“I take that responsibility, it is on my head. I sign that prescription and I am happy to do it. I don't have a problem with it.”

Pharmacist 4, primary care and community pharmacy, female

Approach to prescribingProfessional boundariesAwareness of limitations

Beliefs about capabilities

Competence“It is very much about sticking to your own competencies, your own areas of expertise and not, not trying to go outside of that.”

Nurse 2, primary care, female

“You will come across decisions where you think ‘Oh actually I'm not so confident with this or I think I need a bit of extra advice or someone else to say “Yeah , I would do the same.”’”

Pharmacist 2, secondary care, female

Beliefs about consequences

Consequences for the patient, the family and others, for colleagues and for themselves

“We've transformed the lives of a few patients. I have a couple who I've worked with for maybe five years who've now had a baby and bought a house and they're both working. It is amazing to see, but that's unusual.”

Pharmacist 6, community pharmacy, female

“The consequences for me, as the prescriber, if that patient has side effects from the vancomycin … could be severe for the patient and severe for me.”

Pharmacist 2, secondary care, female

Memory, attention and decision processes

“… I can have a quick look before I go out but I can't remember all the allergies and things like that.”

Nurse 1, primary care, female

“With analgesia, I tend to recheck things over and over again, and quantities and break through doses and things like that…”

Nurse 2, primary care, female.

“What I am confident about is the process and the safety net and that steps that I would go through to get to a decision hopefully is reasonably steady.”

Nurse 3, primary care, male

Environmental consequences & resources

Evidence-based guidelines“I do like a nice protocol and a nice guideline.”

Pharmacist 8, primary care, female

Doctors and other colleagues“Sometimes I'll go and I've got a mentor GP, and I'll just go and just run it through with him.”

Pharmacist 5, primary care, female

Practice setting“I would probably prescribe things here that I wouldn't be happy to prescribe to a patient who's going to walk out the door.”

Pharmacist 3, secondary care, female

Emotion

Leave emotions behind

Emotional response to certain patients“The relationship you have with the patient and how you related to them, I think definitely influences your prescribing. Can be tough sometimes.”

Pharmacist 3, secondary care, female

Worry“It is certainly things that you think about, if this treatment goes wrong. Sometimes it keeps you awake at night.”

Pharmacist 4, primary care and community pharmacy, female

Social influences

Respect for others in multi-disciplinary group“What I would hate to do is, to be in a situation where I would be prescribing something that one of my other colleagues has disagreed with.”

Pharmacist 7, community pharmacy, male

Influence of patient“Patients come in sometimes with very fixed ideas of what they like and what they don't like … in some scenarios you almost do just have to give in to what they want.”

Pharmacist 9, primary care, female

References(1) Department of Health. Groundbreaking new consultation aims to extend prescribing powers for pharmacists and nurses. London: HMSO; 2002.

(2) Department of Health. Improving patients’ access to medicines: a guide to implementing nurse and pharmacist independent prescribing within the NHS in England. London. Department of Health; 2006.

(3) Abuzour AS, Lewis P, Tully M. How do pharmacists and nurses learn to prescribe–a qualitative study. International Journal of Pharmacy Practice. 2015; 23(S2):23-23.

(4) Stewart D, MacLure K, George J. Educating non-medical prescribers. British Journal of Clinical Pharmacology. 2012; 74(4):662-667.

(5) Stewart DC, MacLure K, Bond CM, Cunningham S, Diack L, George J, et al. Pharmacist prescribing in primary care: the views ofpatients across Great Britain who had experienced the service. International Journal of Pharmacy Practice. 2011; 19(5):328-332.

(6) MacLure K, George J, Diack L, Bond C, Cunningham S, Stewart D. Views of the Scottish general public on non-medical prescribing. International Journal of Clinical Pharmacy. 2013; 35(5):704-710.

(7) Famiyeh I, McCarthy L. Pharmacist prescribing: A scoping review about the views and experiences of patients and the public. Research in Social and Administrative Pharmacy. 2016; In press DOI: http://dx.doi.org/10.1016/j.sapharm.2016.01.002.

(8) McCann L, Lloyd F, Parsons C, Gormley G, Haughey S, Crealey G, et al. They come with multiple morbidities: A qualitative assessment of pharmacist prescribing. Journal of Interprofessional Care. 2012; 26(2):127-133.

(9) Weeks G, George J, Maclure K, Stewart D. Non‐medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. The Cochrane Library. 2016; (11):CD011227.

(10) Influences on prescribing decision-making among non-medical prescribers in the United Kingdom: systematic review. Family Practice. 2016; 33(6): 572-579.

(11) Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science. 2012; 7(1):37-53.

Acknowledgements

Supervisory team:

Dr Scott Cunningham

Professor Derek Stewart

Dr Katrina Forbes-McKay

Dr Dorothy McCaig

Any questions?