· web viewmost of the existing research explores nurse prescribers’ views with relatively fewer...
TRANSCRIPT
Independent prescribing in primary care: a survey of patients’, prescribers’
and colleagues’ perceptions and experiences
Ali M.K. Hindi* (BPharm, MSc)
PhD student
Elizabeth M. Seston (BA (Hons), MA(Econ), PhD)
Research Fellow
Dianne Bell (BSc (Hons) DipClinPharm, IPresc, PGCResEval, PGCClinEd, MRPharmS,
FHEA)
Programme Director, Independent Prescribing
Douglas Steinke (BSc (Pharm), MSc, PhD)
Senior lecturer in pharmacoepidemiology
Sarah Willis (BA (Hons), MA(Econ), PhD)
Senior Lecturer in Social Pharmacy
Ellen I. Schafheutle (PhD, MRes, MSc, FRPharmS, FFRPS)
Professor of Pharmacy Policy and Practice
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*Author for correspondence
Full postal address for all:
Centre for Pharmacy Workforce Studies, Division of Pharmacy and Optometry; School of
Health Sciences; Faculty of Biology, Medicine and Health, The University of
Manchester, Oxford Road, Manchester M13 9PT, United Kingdom
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Abstract
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.
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Keywords: independent prescribing, non-medical prescribing, independent prescribers, patients, colleagues, primary care
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What is known about this topic
Policy initiatives have been expanding non-medical prescribing across various healthcare sectors in the United Kingdom.
The current literature suggests independent prescribers are generally making a positive contribution to patient care.
What this paper adds
This study adds to the current limited evidence on the views of independent prescribers, their colleagues and patients in primary care settings.
Suggestion to avoid using “non-medical prescribing” as this term negatively reinforces differences between different healthcare professionals.
This study highlights the need for further research to understand how the implementation of independent prescribing in primary care settings could be enhanced as longstanding barriers relative to independent prescribers training needs, prescribing scope and organisational settings remain unchanged.
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Background
Increasing patient demand has led to unprecedented workload pressures in primary care
(NHS England, 2016, Oliver et al., 2014). With rising patient demands, there is a need for
primary care to efficiently provide high quality and cost-effective services (Baird et al.,
2018). However, primary care has not been backed with adequate resources and
workforce to match increasing workload pressures (Baird et al., 2016, NHS England.,
2017). Workload issues in primary care have been further exacerbated with fewer GPs
working full time in GP practices and many retiring early (Baird et al., 2016). Due to
current funding and workforce shortages in primary care, making the most of healthcare
staff has become essential to meet patients’ needs (Primary Care Workforce
Commission., 2015). Non-medical prescribing has the potential to reduce GP workload,
improve patients’ access to medicines and compensate for shortages in GPs (Kroezen et
al., 2011, NHS Health Education North West., 2015). Therefore, increasing the number
of prescribers in primary care could benefit both patients and other healthcare providers
within these settings.
There have been significant developments to non-medical prescribing since its inception
in the UK in 1992. Initially, non-medical prescribing was exclusive to community nurses
who prescribed from a restricted formulary and for limited conditions (Cope et al., 2016).
A decade later, prescribing rights were given to other groups of nurses. In 2003, nurses
and for the first time pharmacists, were entitled to supplementary prescribing rights,
which involves prescribing medications based on individual written agreements (i.e.
Clinical Management Plan), between the patient, doctor and supplementary prescriber
(Department of Health., 2003). Supplementary prescribing was thus limited to
pharmacists and nurses caring for patients with conditions diagnosed by a doctor, and
within clearly set parameters. In 2005, physiotherapists, podiatrists, therapeutic/
diagnostic radiographers were also granted supplementary prescribing rights and more
recently dieticians in 2016.
Supplementary prescribing paved the way for the introduction of independent prescribing
in 2006. Independent prescribing enabled qualified nurses and pharmacists to
autonomously prescribe medication for diagnosed and undiagnosed conditions within
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their area of competence, not specified by a management plan (Department of Health.,
2006). Since 2006, independent prescribing rights have been extended to include
optometrists, paramedics, physiotherapists, podiatrists and therapeutic radiographers.
Whilst there have been advancements in other countries such as the US, Canada,
Australia, New Zealand, the Netherlands, Ireland, Sweden, Finland and Spain, the UK
has been at the forefront in expanding non-medical prescribing (Abuzour et al., 2018).
Based on the current literature, independent prescribing is generally seen as making a
positive contribution to patient care (Jebara et al., 2018, Cope et al., 2016, Abuzour et al.,
2018, Courtenay et al., 2011, Courtenay & Carey, 2009, Latter et al., 2010), with patients
reporting positive experiences, and high satisfaction with accessibility and length of
consultations with independent prescribers (Famiyeh & McCarthy, 2017, Graham-Clarke
et al., 2018, Latter et al., 2010). Doctors also perceive benefits from working alongside
independent prescribers, such as having more time for complex cases (Latter et al., 2010,
Ross, 2015) , increased job satisfaction and being able to make better use of their
skills/knowledge (Carey et al., 2014, Cousins & Donnell, 2012).
From a global perspective, whilst evidence is limited, independent prescribing has been
viewed positively by patients and healthcare professionals (Bhanbhro et al., 2011, Jebara
et al., 2018, Gielen et al., 2014). Similar to the UK, independent prescribing demonstrates
positive outcomes for patients and benefits for doctors internationally (Famiyeh &
McCarthy, 2017, Bhanbhro et al., 2011, Faruquee & Guirguis, 2015). Patients report
satisfaction with appointment times and length of consultations (Famiyeh & McCarthy,
2017, Gielen et al., 2014). Although doctors’ support for independent prescribing is
tentative, they perceive benefits such as safe and timely access to medicines for patients
(Hatah et al., 2013, Faruquee & Guirguis, 2015). On an international scale, independent
prescribing has also shown to have positive effects on reducing doctors’ workload
(Gielen et al., 2014, Bhanbhro et al., 2011).
Independent prescribing presents novel challenges to both independent prescribers (IPs)
and those working in settings where they practise. Such challenges involve IPs having to
adapt to new roles, manage extra responsibilities and integrating in their practice settings
in a way which supports cohesive teamwork between doctors, IPs and other colleagues
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(Green et al., 2009, Abuzour et al., 2018). As evident from the literature, the
implementation of independent prescribing is strongly influenced by organisational
support (e.g. local policies, workload, funding) and availability of resources (e.g. medical
records, additional staff) (Latter et al., 2010, Courtenay et al., 2011, Jebara et al., 2018,
Graham-Clarke et al., 2018).
Most of the existing research explores nurse prescribers’ views with relatively fewer
studies on pharmacist prescribers, patients and particularly other stakeholders (Graham-
Clarke et al., 2018). Moreover, most of these existing studies are qualitative although the
number of quantitative studies has been gradually increasing with time. However, most of
these studies were conducted during the early implementation of independent prescribing.
Hence, these studies may not provide an accurate indication of the current independent
prescribing landscape. Given the increase of professions with prescribing authority and
recent changes to Nursing and Midwifery Council (NMC) and General Pharmaceutical
Council (GPhC) standards, it is important to investigate more recent stakeholder views on
independent prescribing.
Increasing the number of IPs in primary care could benefit both patients and other
healthcare providers, particularly GPs. Health Education England North West (HEENW)
invested workforce transformation funding in the training of IPs (mainly nurses and
pharmacists) in community pharmacy, GP surgeries and mental health services after it
was identified that uptake was low compared with secondary care and across England
(NHS Health Education North West., 2015)
The aim of this study was to evaluate the impact of this funding by investigating the
experiences and views of IPs funded by HEENW, their colleagues and patients on
independent prescribing in primary care.
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Methods
Design
Separate questionnaires were developed for patients, IPs and their colleagues. IP and
colleague surveys collected data on experiences and impact of independent prescribing.
Patient surveys captured views of independent prescribing and satisfaction with a
consultation. All surveys included a mixture of open and closed ended questions.
Patient questionnaire
The patient questionnaire was developed based on existing literature and a previously
validated instrument (Stewart et al., 2008), asking closed questions and inviting open
comments. The questionnaire was divided into three sections and (1) asked patients
about their previous experiences of independent prescribing and the reasons for their
appointment with the IP, (2) patients’ perceptions and experiences of their most recent
consultation, and (3) patients’ demographics, if they had a long term condition and how
many medications they were taking on a regular basis.
Following piloting to establish face validity with a patient and public involvement (PPI)
group at the authors’ academic institution, the term “non-medical prescriber” used in the
literature was replaced by the term “independent prescriber”. The rationale for this was
that the PPI group considered it ‘odd’ that a group of professionals should be defined by
what they were not.
Independent prescriber and colleague questionnaires
The IP questionnaire was developed based on the existing literature and previously
validated instruments (Latter et al., 2010, McCann et al., 2011). The colleague
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questionnaire was separate from the IP questionnaire but asked similar questions to allow
for comparisons to be made between IP and colleague responses.
Both IP and colleague questionnaires were structured into three sections: The first
collected information on respondents’ characteristics and whether they were using their
prescribing rights in practice (for IPs); the second section asked about perceptions and
experiences of independent prescribing. The final section (open-ended) asked
respondents to list facilitators/barriers to independent prescribing and provide any other
comments regarding their experiences of independent prescribing.
Data collection
This study was aimed at all healthcare professionals (mainly nurses and pharmacists)
whose independent prescribing training was funded by HEENW in the period 2015-2017.
The research team prepared a total of 384 questionnaire packs which were mailed by
HEENW to each funded IP on their database. Each pack consisted of eight
questionnaires: one for the IP, two for colleagues and five for their patients. IPs were
informed to hand one questionnaire to their team manager, a second one to the colleague
they worked with most closely and to five consecutive patients following a consultation
(to avoid selection bias). Patients were handed participant information sheets which
advised that they were under no obligation to complete the survey and that the data
collected was not provided to the prescriber or the practice. Questionnaires were linked to
each IP, their colleagues and patients using a unique ID code. Following the initial mail
out, two email reminders were sent to IPs by HEENW. Completed questionnaires were
returned directly to the research team using FREEPOST envelopes provided. NHS ethics
committee approval was obtained (IRAS ID 224180, REC Reference 17/WA/0226). Data
collection took place between October 2017 and March 2018.
Data analysis
Quantitative data was entered onto SPSS version 22 and analysed using descriptive
statistics. Further statistical analysis was not possible due to the low number of responses
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and lack of variation in the responses. Open ended questions were analysed thematically
to identify commonly reoccurring themes. As the IP and colleague surveys responded to
similar questions, their responses to open-ended questions were collated and are
presented alongside each other.
Results
A total of 24 patients from 9 practices, 20 IPs (5% response rate) and 26 colleagues from
16 practices returned questionnaires.
Characteristics of respondents
Of the 24 patients, 14 (58%) were male, 17 (71%) had a long-term medical condition and
21 (88%) had regular medicines prescribed. The age ranges of patients were almost
equally distributed. Nearly two-thirds of the patients (n=15; 63%) were already familiar
with the IP, with the majority (n=12; 80%) of them having seen the IP at least 3 times in
the past year. Almost half of patients (n=11; 46%) decided to have an appointment with
the IP despite having the option to see the doctor. Seven (29%) specifically requested to
visit the IP whilst six (25%) said they did not have the option to see the doctor. Patients’
main reason for having an appointment with the IP was because they needed medical
information. Patient characteristics are shown in Table 1.
IP and colleague characteristics are summarised in Table 2. Of the 20 IPs, most were
nurses (n=14; 70%), four (20%) were pharmacists, one was a podiatrist, and one was
unknown. The majority of respondents were male (n=15; 75%) and did not have a
previous prescribing qualification (n=14; 70%), i.e. community practitioner nurse
prescriber or supplementary prescriber. Almost two-thirds (n=12; 60%) were between 20-
40 years of age. Half of the IPs (n=10) worked at general practices, 15% (n=3) worked in
mental health settings and 10% (n=2) in other locations. Most IPs worked closely with
doctors and nurses (n=19; 95%), followed by other nurse/pharmacist prescribers (n=13),
pharmacists (n=10; 50%) and other healthcare professionals (n=7; 35%). Half of the IPs
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were current prescribers (n=10; 50%) and the other half were future IPs who were either
still studying for their prescribing qualification (n=5; 25%) or awaiting approval of
course completion (n=5; 25%).
Eighteen of the colleague respondents (69%) were co-workers and eight (31%) were
managers of IPs. Fifteen of the colleagues (58%) were doctors and nurses. The most
common work place was general practice (n=16; 62%), and the number of years
colleagues had worked with the IP was usually 5 years or less (n=19; 73%).
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Table 1: Characteristics of patient respondents (n=24)
Characteristic N %GenderMale 14 58Female 10 42
Age<40 4 1740-50 5 2151-60 4 1761-70 5 2171 and over 6 25
Long-term medical conditionYes 17 71No 7 29
Number of medicines (e.g. tablets, capsules, inhalers, eye/eardrops etc.) taken regularly
No regular medicines 3 131-3 medicines 5 213-6 medicines 6 257-10 medicines 9 38> 10 medicines 1 4
First time to see the prescriberYes 9 38No 15 63
Number of times seen the prescriber in the last 12 months (if not first time seeing the pharmacist or nurse prescriber)<3times 3 20≥3times 12 80
Decision to see the nurse/pharmacist prescriber for appointmentSpecifically requested to see the nurse/pharmacist prescriber 7 29Had the option to see the nurse/pharmacist prescriber or a doctor 11 46Was not given the option to see a doctor 6 25
Reason(s) for the appointment with the pharmacist or nurse prescriberNeeded medical information 15 63Needed medical treatment 9 38Needed general health advice 8 33Needed psychosocial assistance 0 0
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Table 2: Characteristics of independent prescriber (n=20) and colleague respondents (n=26)
Characteristic Independent prescriber (%)* Colleague (%)*RoleNurse 14 (70%) 7 (27%)Pharmacist 4 (20%) 0 (0%)Podiatrist 1 (5%)Doctor 8 (31%)Practice manager 3 (12%)Other Healthcare professional 1 (4%)Other 7 (27%)
GenderMale 15 (75%) 18 (72%)Female 4 (20%) 8 (31%)Age20-40 12 (60%) 12 (46%)41-60 6 (30%) 12 (46%)>60 1 (5%) 2 (8%)
Preceding prescribing qualificationYes 3 (15%)No 14 (70%)Independent prescribing settingsGeneral practice 10 (50%) 16 (62%)Mental health setting 3 (15%) 1 (4%)Hospital setting 1 (5%) 1 (4%)Community pharmacy 0 (0%) 0 (0%)Other 2 (10%) 6 (23%)
Team(s) that the independent prescribers worked withinDoctors 19 (95%)Other nurse/pharmacist prescribers 13 (65%)Nurses 19 (95%)Pharmacists 10 (50%)Other healthcare professionals 7 (35%)Other 2 (10%)Prescribing statusCurrently prescribing 10 (50%)Not currently prescribing 7 (35%)
Role in relation to independent prescriberManager 8 (31%)Colleague 18 (69%)Number of years working with independent prescriber≤1 year 6 (23%)2-5 years 13 (50%)
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≥6 years 5 (19%)* missing data
Patients’ perceptions and experiences of their consultations with the independent
prescriber (n=24)
Patients’ experiences of their consultations with the IP were mostly positive with the vast
majority of respondents agreeing/strongly agreeing that they were very satisfied with
their visit to the IP (n=23; 96%). Most respondents felt safe being treated by the IP
(n=23; 96%) and were able to ask any questions about their medicines (n=22; 92%). Most
perceived that it was easier to get an appointment with the IP in comparison to doctors
and believed they got longer appointments (n=17; 71%). However, nearly two-thirds
(n=15; 63%) neither agreed nor disagreed that they were more likely to take their
medications when prescribed by an IP versus a doctor. In addition, half (n=12; 50%)
neither agreed nor disagreed that they were happier with their medicines since having
been treated by the IP in comparison to their doctor. Whilst ten respondents (42%) did
not have a preference to see the IP for future appointments instead of the doctor, all but
two of the patients reported that they were happy to see an IP if the doctor was
unavailable (n=22; 92%). With regard to reducing GP workload, twelve of the
respondents (50%) reported having fewer GP appointments since being treated by their IP
(see Table 3).
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Table 3: Patients’ perceptions and experience of their consultation with independent prescriber (n=24)
Statements: Strongly agree/agree
Neither agree nor disagree
Strongly disagree/disagree
N/A
I was very satisfied with my visit to this independent prescriber
23 (96%) 0 (0%) 1 (4%) 0 (0%)
I felt safe being treated by the independent prescriber
23 (96%) 0 (0%) 1 (4%) 0 (0%)
I feel able to ask my independent prescriber any questions that I may have about my medicines
22 (92%) 0 (0%) 1 (4%) 1 (4%)
I would be happy to see my independent prescriber for future appointments if the doctor was not available
22 (92%) 0 (0%) 1 (4%) 1(4%)
It is easier to get an appointment with my independent prescriber than with my doctor
17 (71%) 4 (17%) 2 (8%) 1 (4%)
I would choose to see my independent prescriber for future appointments instead of my doctor if given the choice
11 (46%) 10 (42%) 2(8%) 1 (4%)
I am happier with my medicines since being treated by my independent prescriber than when I was treated by a doctor
9 (38%) 12 (50%) 1 (4%) 2 (8%)
I am more likely to take my medicines when they are prescribed by an independent prescriber than when they are prescribed by a doctor
4 (17%) 15 (63%) 4 (17%) 1 (4%)
Number of appointments with your doctor since being treated by your independent prescriber
Increased 0 (0%)
Same 4 (17%)
Decreased 12 (50%)
N/A 8 (33%)
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Current independent prescribers’ (n=10) and colleagues’ perceptions (n=26) and
experiences of independent prescribing role
All ten current IPs agreed or strongly agreed that their prescribing role ensured better use
of their skills and time, meant they were less dependent on doctors and had increased
their job satisfaction. Similarly, the majority of their colleagues also agreed/strongly
agreed that working alongside an IP ensured better use of colleagues’ skills (n=20; 77%)
and increased colleagues’ job satisfaction (n=18; 69%). Both current IPs (n=9; 90%) and
colleagues (n=15; 58%) agreed or strongly agreed that independent prescribing improved
their relationships with patients. In addition, the majority of current IPs (n=9; 90%) and
colleagues (n=25; 96%) believed that independent prescribing improved the quality of
care provided for patients.
Most current IPs (n=8; 80%) and colleagues (n=25; 96%) agreed or strongly agreed that
independent prescribing meant doctors’ time was used more effectively and could be
used for more complex cases. Whilst six IPs (60%) believed their prescriber roles enabled
patient/service users to have a longer appointment time than they would with the doctor,
only ten of their colleagues (38%) believed that working alongside an IP enabled
patients/service users to have a longer appointment time with the doctor. Most current IPs
(n=6; 60%) disagreed that their role meant they could deal with all of the patient/service
user’s prescribing needs. However, colleagues were more positive than current IPs that
working alongside an IP meant they can deal with all of the patient/service user’s
prescribing needs more effectively (n=21; 81%).
The majority of current IPs felt that the doctors were supportive of them working as
prescribers (n=8; 80%). Similarly, nearly all colleagues were supportive of independent
prescribing, understood the role of the IP and believed that they worked well with the IP
(n=25; 96%). Moreover, most colleague respondents trusted the IP (n=25; 96%) and
would feel safe being treated as a patient by the IP (n=24; 92%).
Half of the current IPs (n=5; 50%) were uncertain that their role increased the respect
they received from doctors and some were uncertain that their role increased their
professional status (n=4; 40%). On the other hand, nearly all colleagues agreed or
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strongly agreed that working alongside an IP increased the respect they have for IPs
(n=24/25; 96%) and believed the IP successfully integrated into their team (n=25; 96%).
Most colleagues reported they consulted with the IP for advice on the best treatment
option (n=24; 92%). Conversely, four IPs (40%) disagreed that they received appropriate
feedback about their performance from colleagues. Details of responses are provided in
tables 4 and 5.
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Table 4: Current independent prescribers’ perceptions and experiences of independent prescribing (n=10)
Statement Strongly agree/agree
Uncertain Strongly disagree/ disagree
My role as an independent prescriber ensures better use of my skills
10 (100%) 0 (0%) 0 (0%)
My role as an independent prescriber has increased my job satisfaction
10 (100%) 0 (0%) 0 (0%)
I believe that since qualifying as a prescriber who can prescribe independently, I am less dependent on doctors
10 (100%) 0 (0%) 0 (0%)
My role as an independent prescriber has improved my relationship with patients
9 (90%) 1 (10%) 0 (0%)
My role as an independent prescriber improves the quality of care I am able to provide for patient/service users
9 (90%) 0 (0%) 1 (10%)
My role as an independent prescriber means that the use of the doctors’ time is more effective and can be used for more complex case
8 (80%) 1 (10%) 1 (10%)
The doctors I work with are supportive of me working as an independent prescriber
8 (80%) 1 (10%) 1 (10%)
My role as an independent prescriber has increased my professional status
6 (60%) 4 (40%) 0 (0%)
My role as an independent prescriber enables patient/service users to have a longer appointment time than they would with the doctor
6 (60%) 1 (10%) 3 (30%)
I receive appropriate feedback about my performance from colleagues
6 (60%) 0 (0%) 4 (40%)
My role as an independent prescriber has increased the respect I receive from doctors
4 (40%) 5 (50%) 1 (10%)
My role as an independent prescriber means I can deal with all of the patient/service user’s prescribing needs
3 (30%) 1 (10%) 6 (60%)
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Table 5: Colleagues’ perceptions and experiences of independent prescribing (n=26)
Statement: Strongly agree/agree
Uncertain Strongly disagree/ disagree
Working alongside an independent prescriber improves the quality of care provided for patients/service users
25 (96%) 1 (4%) 0 (0%)
I am supportive of independent prescribing 25 (96%) 1 (4%) 0 (0%)
I understand the role of the independent prescriber 25 (96%) 1 (4%) 0 (0%)
Working alongside an independent prescriber means that the use of the doctors’ time is more effective and can be used for more complex cases
25 (96%) 0 (0%) 1 (4%)
I believe that I work well with the independent prescriber
25 (96%) 0 (0%) 1 (4%)
I believe the independent prescriber has successfully integrated into our team
25 (96%) 0 (0%) 1 (4%)
I trust the independent prescriber 25 (96%) 0 (0%) 1 (4%)
I would feel safe being treated as a patient by the independent prescriber
24 (92%) 1 (4%) 1 (4%)
Working alongside an independent prescriber has increased the respect I have for independent prescribers*
24 (92%) 0 (0%) 1 (4%)
I consult with the independent prescriber for advice on the best treatment option
24 (92%) 1 (4%) 1 (4%)
Working alongside an independent means I can deal with all of the patient/service user’s prescribing needs more effectively
21 (81%) 5 (19%) 0 (0%)
Working alongside an independent prescriber ensures better use of my skills
20 (77%) 5 (19%) 1 (4%)
Working alongside a prescriber has increased my job satisfaction
18 (69%) 6 (23%) 2 (8%)
Working alongside an independent prescriber has improved my relationship with patients/service users
15 (58%) 6 (23%) 5 (19%)
Working alongside an independent prescriber enables patients/service users to have a longer appointment time with the doctor
10 (38%) 10 (39%) 6 (23%)
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* Percentages did not add up to 100% due to missing data
Barriers to independent prescribing
Twelve IPs and 19 colleagues offered written comments on barriers and facilitators to
independent prescribing. They perceived the main barriers to independent prescribing
being: “lack of competence in certain areas”, “inadequate training”, “organisational
barriers” and “lack of independent prescribing awareness”.
Lack of competence in certain areas
Both IPs and colleagues mentioned IPs’ lack of competence in certain areas as a barrier to
independent prescribing. IPs were particularly concerned about consultations which
required them to prescribe outside their clinical areas of competence. On the other hand,
some colleagues believed some IPs lacked knowledge in areas related to medicine use.
“Patients consulting in areas where I lack competence to prescribe” (IP no. 10)
“Limited understanding of pharmacology” (Colleague no. 3)
Inadequate training
IPs and colleagues believed IPs did not receive adequate training for their independent
prescribing roles. Some IPs felt that their training did not cover all areas required for
independent prescribing. Moreover, some IPs mentioned a lack of post-qualification
training and suggested preceptorship for newly qualified IPs.
“Limited training sessions” (Colleague no. 8)
“Lack of post training support. Prescribing preceptorship would be useful” (IP no.2)
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Organisational barriers
IPs and colleagues commonly mentioned time constraints due to workload pressures as a
barrier to independent prescribing. Colleagues also highlighted issues with IPs using
prescriptions which could not be linked to GP IT systems.
“Time constraints regarding consultation” (IP no.7)
“Prescriptions not linked to EMIS [GP IT system] -Not electronic-NMP use handwritten
scripts” (Colleague no. 16)
Lack of independent prescribing awareness
IPs and colleagues believed patients were generally unaware of independent prescribing.
Some colleagues felt this unawareness made patients less confident in IPs decisions and
required confirmation from a doctor. Whilst lack of independent prescribing role
awareness by healthcare staff was not mentioned by colleagues, IPs believed this was
another important barrier to independent prescribing.
“Patients "trust" is very difficult to gain. They will always doubt the decision and
want (in their words) "a proper doctor" to confirm diagnosis or medication”
(Colleague no. 18)
“Lack of GP knowledge around competency and scope of practice” (IP no. 1)
Facilitators to independent prescribing
IPs and colleagues perceived that the main facilitators to independent prescribing were:
“competence and confidence to prescribe”, “support from healthcare team and other
staff”, “cohesive teamwork”, “managing workload” and “building rapport with patients”.
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Competence and confidence to prescribe
IPs and colleagues believed that extensive training and experience were essential for IPs
to competently prescribe. Some IPs mentioned the importance of training received from
their independent prescribing qualification. In addition, pharmacist prescribers believed
their experience from conducting medication reviews enhanced their prescribing practice.
Whilst not mentioned by IPs, colleagues felt it was important for IPs to be confident in
their prescribing roles.
“Previous extensive experience/training in the area of intended prescribing practice” (IP
no. 6)
“Confidence in her role” (Colleague no. 17)
Support from healthcare team and other staff
IPs and colleagues believed it was very important for IPs to be supported by the
healthcare team in their workplace. IPs valued the reassurance of having GPs who were
approachable and available for advice. Colleagues even mentioned that administrative
staff played an important role in facilitating independent prescribing by directing
appropriate patients to IPs.
“Have the full support of all the doctors + colleagues” (Colleague no. 18)
“GPs always nearby and approachable for help and advice” (IP no. 4)
Cohesive teamwork
Colleagues believed that good teamwork between IPs and other members of the
healthcare team was an important facilitator to independent prescribing. Colleagues
stressed the importance of IPs communicating effectively with the healthcare team.
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“Good team work” (Colleague no. 1)
“Having good communication skills within the team” (Colleague no. 14)
Managing workload
IPs believed that managing their workload enabled them to spend more prescribing time
with each patient. Nonetheless, they felt that independent prescribing duties should be
accounted for within their daily workload.
“I am able to prioritise my own workload and change appointments if necessary”
(IP no. 6)
“It would help if NMP time was protected/accounted for within daily workload
pressures etc.” (IP no. 11)
Building rapport with patients
IPs and colleagues highlighted the importance of IPs building relationships with patients.
Colleagues believed that building rapport with patients would enhance IPs prescribing
practise.
“Able to spend adequate time with each patient to build up a therapeutic relationship”
(IP no. 6)
“The personal relationship between prescriber and patient i.e. the nurse may be able to
make a better decision for the patient rather than a locum doctor that doesn’t know
them” (Colleague no. 7)
Patient comments on independent prescribing
24
Qualitative data from patients’ comments on experiences of independent prescribing were
grouped under three themes: “support for the independent prescriber”, “independent
prescriber’s consultation skills” and “convenience of independent prescribers.”
Support for the independent prescriber
Patients were generally satisfied with their decision to have an appointment with the IP.
They were very supportive of and confident in their IP.
“I would be satisfied meeting the nurse in the future” (Patient no. 5)
“I have every confidence in my Podiatrist/Pharmacist prescriber” (Patient no. 2)
Independent prescriber’s consultation skills
Patients were pleased with their IP’s consultation skills. They felt their IP listened to
them and made them feel at ease. In addition, they believed that IPs were very
knowledgeable about medications.
“She was professional, pleasant and made me feel at ease through my consultation”
(Patient no. 8)
“She was thoughtful, explained meds and what was to be prescribed” (Patient no. 5)
Convenience of independent prescribers
Patients found it easier and faster to get appointments with IPs in comparison to their
doctors. In addition, they felt they got more time to discuss their medications with IPs.
“I really think this is a great idea as you can be waiting weeks to get an appointment
with a doctor” (Patient no. 6)
25
“The nurse prescriber sees me much quicker than trying to see the GP. The nurse
prescriber will spend more time sorting and explaining aspects of my condition and
medication” (Patient no. 9)
Independent prescriber comments on independent prescribing
Qualitative data from IPs’ comments on their experiences of independent prescribing
generated the following themes: “benefits of independent prescribing” and “continuing
professional development”.
Benefits of independent prescribing
Current IPs believed that independent prescribing provided benefits to both patients and
the IP. IPs reported feeling more confident as a result of their independent prescribing
roles. They perceived that independent prescribing provided them with the opportunity to
expand their knowledge and utilise their skills effectively. In relation to patients, their
roles reduced GP practice visits for patients as they were able to quickly access IPs and
receive their prescriptions promptly.
“Patients have the confidence in the individual practitioner and the reassurance that
a prescription has been issued in a timely manner” (IP no. 7)
“Patients have really appreciated quick, prompt prescriptions with little time to wait
with fewer visits to the practices as a result” (IP no. 2)
Continuing professional development
Current IPs would have liked additional training after receiving their qualification and
were concerned that continuing professional development (CPD) for their independent
prescribing roles was currently lacking.
26
“Thoroughly enjoyed NMP training. Variable support during+ past training in
Primary care. Would benefit from post training "formal" support” (IP no. 2)
“I have concerns, that apart from my NMP colleague, there is a huge lack of NMP
CPD support” (IP no. 1)
Colleague comments on independent prescribing
Qualitative data from colleagues’ comments on working alongside an IP were
summarised under two main themes: “valuable addition to the team” and “confidence in
independent prescriber”
Valuable addition to the team
Colleagues believed that working with an IP provided a valuable addition to the
healthcare team. This was mainly due to IPs reducing their workload pressures.
“I have highly benefited with the help of our Pharmacist prescriber, it has reduced my
workload and stress levels immensely” (Colleague no. 18)
“She has been a valuable addition to the primary care team” (Colleague no. 19)
Confidence in independent prescriber
Colleagues were very supportive of the IPs they worked with. They were very confident
in their abilities to prescribe and trusted them. In addition, they highly praised the skills
and knowledge of IPs in general.
“The nurse prescriber is very knowledgeable and I have great faith in her skills as a
nurse and prescriber. I feel the same with all the nurse prescribers in our team”
(Colleague no. 15)
“I would happily put my life in her hands, she is knowledgeable and highly skilled”
(Colleague no. 17)
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Discussion
To the authors’ knowledge, this is the first survey study to jointly gather the views of
patients, IPs and colleagues on independent prescribing within primary care. Sample sizes
in this study were small but findings were consistent with previous studies. Previous
studies using the same survey instruments also identified that most patients had positive
attitudes to independent prescribing, were very satisfied with their visit to their IP and
were confident/supportive of their IPs (Tinelli et al., 2015, Stewart et al., 2008). Similar
to our study, the majority of IPs in those previous studies perceived that independent
prescribing elevated their professional status, increased their job satisfaction, increased
professional autonomy and resulted in better use of their skills (McCann et al., 2011,
Latter et al., 2010). Moreover, most patients in those studies also did not report a
preference for their IP over their medical prescriber (Tinelli et al., 2015, Stewart et al.,
2008).
Findings from this study have important implications as they suggest that barriers and
facilitators to independent prescribing remain unchanged since earlier research. Several
authors have reported that appropriate organisational structures facilitate the
implementation of independent prescribing (Latter et al., 2010, Stenner & Courtenay,
2008, Carey et al., 2014). When IPs’ training needs are met, their confidence and
prescribing skills are enhanced (Smith et al., 2014, Maddox et al., 2016, Courtenay et al.,
2011, Green et al., 2009). However, training must co-exist with manageable workload,
sufficient resources (i.e. access to medicines, workforce, formulary, policy) and
supportive colleagues for IPs to efficiently fulfil prescribing roles (Courtenay et al., 2011,
Stenner et al., 2010, Smith et al., 2014, Stewart et al., 2009). On the other hand, the
absence of appropriate organisational structures and supportive colleagues impedes the
implementation and impact of independent prescribing (Stenner et al., 2010, Courtenay et
al., 2011, Latter et al., 2010).
28
As the scope of practice for independent prescribing expands along with the workforce, it
is important to consider strategies to enhance the implementation of independent
prescribing and overcome longstanding challenges. Mainly, for IPs to seamlessly
transition to their new roles, integrate with the wider healthcare team and work as a
cohesive unit, it is essential they are supported by colleagues and other staff in their
workplace. Building a supportive culture for independent prescribing relies upon IPs
establishing strong inter‐professional relationships with colleagues (Stenner et al., 2010,
Smith et al., 2014). However, fostering inter-professional relationships could be
challenging for IPs in primary care settings such as community pharmacy where contact
with physicians and other healthcare professionals are often limited (Noblet et al., 2017,
Hindi et al., 2018, Bradley et al., 2018a). Moreover, IPs could also encounter difficulties
accessing patient records, ongoing training and clinical supervision depending on their
healthcare settings (Stenner et al., 2010, Courtenay et al., 2011, Weeks et al., 2016, Hindi
et al., 2019). Therefore, the implementation process for independent prescribing should
account for organisational complexities within different primary care settings to ensure
IPs have appropriate access to patient records, clinical supervision, ongoing training and
CPD.
Similar to previous studies, IPs in this study reported difficulties and issues with
prescribing outside their clinical areas of competence (Stewart et al., 2009, Graham-
Clarke et al., 2018). As health policy initiatives look to further expand the roles of the
non-medical workforce in primary care, further training should be provided which
supports IPs to broaden their area of competence. However, any further expansion to IPs
role should be clearly defined and understood by IPs and other healthcare professionals to
ensure safe and effective prescribing. Lack of mutual understanding can lead to
duplication of physician/GP efforts and inter-professional tension, thus reducing
workflow and the quality of care provided to patients (Sibbald et al., 2004). Moreover,
lack of acknowledgment and support from colleagues can negatively impact the
confidence of IPs and hinder their professional development (Bradley et al., 2018b, Pottie
et al., 2009, Bosley & Dale, 2008, Maddox et al., 2016).
29
In addition to colleagues’ awareness of independent prescribing roles, patient and public
awareness is also important. Patient awareness of independent prescribing was perceived
to be a barrier by both IPs and colleagues in this study. Research investigating patient and
public awareness of independent prescribing remains limited (Noblet et al., 2017).
However, strategies to enhance patient and public awareness of independent prescribing
should be considered given the increasing number of professions which can now
prescribe.
Based on the insightful suggestion provided by our patient and public involvement group,
we suggest avoiding using the term “non-medical prescribers”. Defining these healthcare
professionals as “non-medical” could negatively impact patients’ perceptions of the
quality of service they are receiving. Moving forward, it is necessary to establish an
egalitarian healthcare ethos which avoids reinforcing differences between different
healthcare professionals.
The main limitation to this study was the very low survey responses which made it not
feasible to conduct comparative statistical analysis. Notably, the independent prescribing
sample consisted of only 20 IPs (only half of whom were qualified and currently
prescribing), and most of those were nurses, which affected the validity of findings and
relevance to other professions. Therefore, we suggest future case studies with IPs from
different professions to further examine the impact of independent prescribing on team
dynamics, collaboration and indeed patient outcomes within primary care. Another
limitation was that IPs distributed questionnaires to their patients and colleagues which
could have led to recruitment/respondent bias. Nonetheless, participant information
sheets reassured that the study was not assessing the practice of individual IPs and
advised patients that survey responses were anonymous.
Conclusion
This study gathered the views of IPs funded by HEENW, their colleagues and patients on
independent prescribing in primary care. Findings from this study were mainly positive
but reveal that barriers to the initial implementation of independent prescribing remain.
Effective implementation of independent prescribing is likely to rely on appropriate
30
training and competence of IPs, effective role integration with the rest of the primary
healthcare team, and acceptance by patients. Future research is needed to examine the
perspectives of a wider range of IPs in primary care settings, and the impact of
independent prescribing on team dynamics, collaboration and indeed patient outcomes.
Funding
This study was funded by Health Education North West (HEENW)
Competing interests
The authors declare that they have no competing interests
Acknowledgements
We would like to thank Health Education North West (HEENW) for funding this study, and for helping with the distribution of questionnaire packs to all individuals funded under the funded training which underpinned this study.
A particular thank you goes to all nurse, pharmacist and podiatrist prescribers, who were funded by HEENW and responded to our questionnaire, as well as their colleagues and patients who returned completed questionnaires.
We are grateful for members of the public who took part in the patient and public involvement group.
We would like to thank Dr Christian Jones and Dr Esnath Magola for overseeing survey distribution and returns. We would also like to thank an Erasmus Plus Intern from the University of Madrid Spain, Mr. Raúl Miguel, who helped setting up the SPSS database and entered most of the quantitative data.
31
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