Negotiating professional boundaries: professional and organisational contingencies for pharmacist prescribing

This thesis explores boundary work, practices and changes in the pharmacy profession. Specifically it examines boundary changes that support non-medical prescribing practice for pharmacists in the context of prescribing policies and strategies which both utilise the skills of the pharmacist and also give patients greater choice and access to services. The last decade has observed a transformation in the boundaries of health professionals enabled through the creation of new roles and the expansion of traditional roles. With reference to the principles set out in the NHS Plan, NHS modernisation and the subsequent introduction of non-medical prescribing have brought about a number of changes in policy and practice for health care professionals. In addition, The Royal Pharmaceutical Society’s 2013 Medicines Optimisation, good practice guidance outlines guiding principles for medicine optimisation that compliment and support improved patient outcomes and NHS policy – in particular empowering patients and the public to make the most of medicines. Research shows that while there are increasing numbers of pharmacists registered as nonmedical prescribers and the numbers of those who are actually practicing as non-medical prescribers has continued to rise, there are still areas where groups are having to make “significant personal sacrifices” to implement and maintain the necessary competence to prescribe. Research suggests that there is still more that needs to be done in order to achieve more supportive environments for non-medical prescribers. Pharmacists have been referred to for many years as being “underutilised” and “over trained” and capable of a far greater remit than the dispensing of medication that has typically been associated with pharmacists. In addition, the policies that developed to address different health care needs and outcomes also go some way towards changing boundaries and adapting the roles that pharmacists have. This thesis first considers, the role of the pharmacist and what their occupational and professional boundaries are perceived to be. The thesis goes on to examine how pharmacists enact extended roles in practice. Lastly, the institutional and organisational factors that impact the subsequent practices of pharmacists and the services they deliver is explored. Using qualitative research techniques, this study was carried out in three NHS Trusts across a range of settings with a range of health care practitioners. The study was organised in two parts. First, a series of exploratory interviews were carried out with a pharmacists, medical and support staff. Second, ethnographic non-participant observations with pharmacists in different settings were undertaken. The empirical findings suggest that the boundary work between third parties is not a tension point or a point of conflict as suggested in theory and previous research around boundary work in the health care setting and the inter-professional context. Rather, the boundary is a non-issue in relation to role expansion of pharmacist non-medical prescribers. The findings imply that the ability to share tasks, expand, and change roles is largely shaped by changing contexts and organisational factors. The study data has been used to help develop a model whereby different practices and principles that affect and guide the position of pharmacists and their boundaries as well as negotiations of practice are considered. The model uses the principles Scott’s (2008b) Three Pillar and combines elements of Zietma and Lawrence’s (2010) boundary and practice work cyclical diagram. The model in this thesis is developed alongside the data analysis. The intention of the model is to provide a template that with further refinement could be used when looking at other professionals or professional groups interchangeably. The features of the model in theory will be able to be adapted when considering different professional interactions, task sharing or role identification within an organisation for example. The model and its development will be discussed in further detail throughout the thesis. The overall research findings, suggest that the scale to which non- medical prescribing is practiced by pharmacists across the range of settings is greatly determined by the organisation. This includes the way in which pharmacist nonmedical prescribing is used in practice, its ease of implementation and the subsequent role of the practicing health care professional

‘We got more than we expected.’ Older people’s experiences of falls-prevention exercise interventions and implications for practice; a qualitative study

AIM: To explore the experiences of older adults participating in strength and balance exercise programmes and understand participants' rationale for programme uptake and completion. BACKGROUND: Regular physical activity, specifically strength and balance exercises, has been shown to improve health and well-being and reduce the risk of falling in older adults. With the number of people living into older age increasing, understanding older people's experiences of strength and balance programmes and what encourages their take-up and completion is extremely important. This paper reports on the qualitative experiences of older adults that previously participated in ProAct65+, a randomised controlled trial of Falls Management Exercise (FaME) programme and Otago Exercise Programme (OEP) versus usual care. METHODS: Ten general practices in Nottinghamshire and Derbyshire, England, who participated in the ProAct65+ trial were approached to take part. Using maximum variation sampling (age, gender, falls history, fear of falling and trial arm) we recruited, via the practices, 30 people that had participated in the FaME (n = 15) or OEP (n = 15) trial arms. Participants were interviewed in their own homes. Interviews were audio-recorded, transcribed verbatim and thematically analysed. FINDINGS: We identified five themes: choice of exercise programme; commitment, discipline and motivation; benchmarking, feedback and monitoring; benefits of the exercise programmes and reactions to the end of the programmes. There were four sub-themes within the benefits theme: pleasure and boredom, social interaction and isolation, physical benefits, and knowledge and understanding.This study has outlined the experiences and identified specific barriers and facilitators to uptake and completion of falls-prevention exercises by older adults. The perspective and experiences of these participants is important if programmes are to be designed to meet the needs of the target population. Insights from this study will enable commissioners to develop and provide appropriate falls-prevention exercise programmes that encourage high uptake and programme completion

Use it or lose it: a qualitative study of the maintenance of physical activity in older adults

BACKGROUND: Lack of physical activity (PA) is a recognised global public health problem, which is increasing in prevalence with a detrimental impact on the pattern of disease worldwide. In the UK, older adults comprise the most sedentary group, with only 57% of males and 52% of females aged 65-74 years and 43% of males and 21% of females aged 75-84 years meeting PA recommendations. PA confers multiple health benefits including increased stamina, muscle, bone and joint strength, increased independence and reduced risk of falls in old age. Despite benefits experienced during time-limited PA programmes, increased PA is not always continued. This study aimed to provide a better understanding of PA maintenance behaviours in older people

Keeping active:maintenance of physical activity after exercise programmes for older adults

Objectives: To explore factors associated with maintenance of moderate-to-vigorous physical activity (MVPA) in community-dwelling adults aged ≥65 years after completing a 24-week exercise programme.Study design: Cohort study nested within a randomised controlled trial evaluating group and home-based exercise programmes for older people in England.Methods: MVPA levels and factors potentially associated with physical activity (PA) were self-reported at recruitment, 6, 12, 18 and 24 months post exercise programme. Multilevel logistic regression estimated odds ratios for achieving target MVPA level (150 minutes/week) 6-24 months after exercise programmes ended.Results: Older people (OR per year increase: 0.89, 95%CI 0.86, 0.93) and women (OR 0.47, 95%CI 0.33, 0.67) were less likely to achieve target MVPA. Those physically active at recruitment (OR 11.28, 95%CI 7.95, 16.01), with wider social networks (OR per unit increase in Lubben Social Network Scale: 1.06, 95%CI 1.03, 1.10) and performing more sit-to-stands in 30 seconds (OR for quartile 3 compared to quartile 1: 1.87, 95%CI 1.12, 3.10) were more likely to achieve target MVPA. Negative exercise expectations increased the odds of achieving target MVPA, but only amongst the less active at recruitment (OR per unit increase in Outcome and Expectation for Exercise Negative Subscale: 1.90, 95%CI 1.39, 2.60). Associations did not differ significantly across the follow-up period.Conclusion: A range of factors are associated with maintenance of PA 6-24 months after exercise programmes. Factors are not more strongly associated with shorter versus longer term PA maintenance. Commissioners and providers should consider targeting maintenance interventions to those least likely to maintain PA

Economic evaluation of the OSAC randomised controlled trial:oral corticosteroids for non-asthmatic adults with acute lower respiratory tract infection in primary care

ObjectiveTo estimate the costs and outcomes associated with treating non-asthmatic adults (nor suffering from other lung-disease) presenting to primary care with acute lower respiratory tract infection (ALRTI) with oral corticosteroids compared with placebo.DesignCost-consequence analysis alongside a randomised controlled trial. Perspectives included the healthcare provider, patients and productivity losses associated with time off work.SettingFifty-four National Health Service (NHS) general practices in England.Participants398 adults attending NHS primary practices with ALRTI but no asthma or other chronic lung disease, followed up for 28 days.Interventions2× 20 mg oral prednisolone per day for 5 days versus matching placebo tablets.Outcome measuresQuality-adjusted life years using the 5-level EuroQol-5D version measured weekly; duration and severity of symptom. Direct and indirect resources related to the disease and its treatment were also collected. Outcomes were measured for the 28-day follow-up.Results198 (50%) patients received the intervention (prednisolone) and 200 (50%) received placebo. NHS costs were dominated by primary care contacts, higher with placebo than with prednisolone (£13.11 vs £10.38) but without evidence of a difference (95% CI £3.05 to £8.52). The trial medication cost of £1.96 per patient would have been recouped in prescription charges of £4.30 per patient overall (55% participants would have paid £7.85), giving an overall mean ‘profit’ to the NHS of £7.00 (95% CI £0.50 to £17.08) per patient. There was a quality adjusted life years gain of 0.03 (95% CI 0.01 to 0.05) equating to half a day of perfect health favouring the prednisolone patients; there was no difference in duration of cough or severity of symptoms.ConclusionsThe use of prednisolone for non-asthmatic adults with ALRTI, provided small gains in quality of life and cost savings driven by prescription charges. Considering the results of the economic evaluation and possible side effects of corticosteroids, the short-term benefits may not outweigh the long-term harms.Trial registration numbersEudraCT 2012-000851-15 and ISRCTN57309858; Pre-results

PHysical activity Implementation Study In Community-dwelling AduLts (PHISICAL): study protocol

Background: Falls in older people are a leading causes of unintentional injury. Due to an ageing population, injuries are likely to increase unless more is done to reduce older people’s falls risk. In clinical trials, the Falls Management Exercise (FaME) programme has reduced the rate of falls and falls-related injuries in community-dwelling older adults. However, the commissioning of FaME is inconsistent across England, potentially due to a lack of evidence that FaME can be delivered effectively in a ‘real world’ setting. The PHISICAL study is designed to study the implementation of FaME in a range of different settings in England. Methods: The PHISICAL study will use mixed-methods triangulation multi-level design to explore the implementation of FaME. Framework analysis of semi-structured interviews with up to 90 stakeholders (exercise programme users, service providers, referrers and commissioners) and observational data from locally-led communities of practice will identify the factors that influence FaME’s implementation. Quantitative, anonymised, routine service data from up to 650 exercise programme users, including measures of falls and physical activity, will allow assessment of whether the benefits of FaME reported in clinical trials translate to the ‘real world’ setting. Conclusion: The findings from this study will be used to develop a toolkit of resources and guidance to inform the commissioning and delivery of future FaME programmes. This study has the potential to inform public health prevention strategies, and in doing so may reduce the number of falls in the older population, whilst delivering cost savings to health and social care services

Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial

Importance: Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence. Objective: To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma. Design, Setting, and Participants: Multicenter, placebo-controlled, randomized trial (July 2013 to final follow-up October 2014) conducted in 54 family practices in England among 401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years. Interventions: Two 20-mg prednisolone tablets (n = 199) or matched placebo (n = 202) once daily for 5 days. Main Outcomes and Measures: The primary outcomes were duration of moderately bad or worse cough (0 to 28 days; minimal clinically important difference, 3.79 days) and mean severity of symptoms on days 2 to 4 (scored from 0 [not affected] to 6 [as bad as it could be]; minimal clinically important difference, 1.66 units). Secondary outcomes were duration and severity of acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, and adverse events. Results: Among 401 randomized patients, 2 withdrew immediately after randomization, and 1 duplicate patient was identified. Among the 398 patients with baseline data (mean age, 47 [SD, 16.0] years; 63% women; 17% smokers; 77% phlegm; 70% shortness of breath; 47% wheezing; 46% chest pain; 42% abnormal peak flow), 334 (84%) provided cough duration and 369 (93%) symptom severity data. Median cough duration was 5 days (interquartile range [IQR], 3-8 days) in the prednisolone group and 5 days (IQR, 3-10 days) in the placebo group (adjusted hazard ratio, 1.11; 95% CI, 0.89-1.39; P = .36 at an α = .05). Mean symptom severity was 1.99 points in the prednisolone group and 2.16 points in the placebo group (adjusted difference, −0.20; 95% CI, −0.40 to 0.00; P = .05 at an α = .001). No significant treatment effects were observed for duration or severity of other acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, or nonserious adverse events. There were no serious adverse events. Conclusions and Relevance: Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity

Economic evaluation of the OSAC randomised controlled trial: Oral corticosteroids for non-asthmatic adults with acute lower respiratory tract infection in primary care

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ. Objective To estimate the costs and outcomes associated with treating non-asthmatic adults (nor suffering from other lung-disease) presenting to primary care with acute lower respiratory tract infection (ALRTI) with oral corticosteroids compared with placebo. Design Cost-consequence analysis alongside a randomised controlled trial. Perspectives included the healthcare provider, patients and productivity losses associated with time off work. Setting Fifty-four National Health Service (NHS) general practices in England. Participants 398 adults attending NHS primary practices with ALRTI but no asthma or other chronic lung disease, followed up for 28 days. Interventions 2× 20 mg oral prednisolone per day for 5 days versus matching placebo tablets. Outcome measures Quality-adjusted life years using the 5-level EuroQol-5D version measured weekly; duration and severity of symptom. Direct and indirect resources related to the disease and its treatment were also collected. Outcomes were measured for the 28-day follow-up. Results 198 (50%) patients received the intervention (prednisolone) and 200 (50%) received placebo. NHS costs were dominated by primary care contacts, higher with placebo than with prednisolone (£13.11 vs £10.38) but without evidence of a difference (95% CI £3.05 to £8.52). The trial medication cost of £1.96 per patient would have been recouped in prescription charges of £4.30 per patient overall (55% participants would have paid £7.85), giving an overall mean 'profit' to the NHS of £7.00 (95% CI £0.50 to £17.08) per patient. There was a quality adjusted life years gain of 0.03 (95% CI 0.01 to 0.05) equating to half a day of perfect health favouring the prednisolone patients; there was no difference in duration of cough or severity of symptoms. Conclusions The use of prednisolone for non-asthmatic adults with ALRTI, provided small gains in quality of life and cost savings driven by prescription charges. Considering the results of the economic evaluation and possible side effects of corticosteroids, the short-term benefits may not outweigh the long-term harms. Trial registration numbers EudraCT 2012-000851-15 and ISRCTN57309858; Pre-results