Social and cognitive influences on prescribing decisions among non-medical prescribers.

Non-medical prescribers make an increasing contribution to healthcare across the UK yet little is known about influences on their prescribing decision-making. The aim of this programme of research was to explore and describe prescribing decision-making by non-medical prescribers. A two stage programme of research was carried out. Stage 1 was a systematic review of the social and cognitive influences on prescribing decision-making by non-medical prescribers. Despite a paucity of research, various influences on prescribing decision-making were reported including evidence based guidelines, peer support and patient (or parental) relationships and expectations. While confidence and clinical experience as a practitioner were cited as influences, the lack of prescribing experience and aspects of pharmacological knowledge also impacted on prescribing decision-making, resulting in a cautious approach. Stage 2 of the research employed a phenomenological methodology underpinned by the Theoretical Domains Framework of behavioural determinants (TDF). It comprised three phases. In Phase 1, semi-structured interviews with five nurse prescribers and eight pharmacist prescribers in NHS Grampian explored their experiences and perceptions of influences on their prescribing decision-making, and the impact of these influences. Multiple and sometimes contradictory influences were uncovered. Twelve of the fourteen domains of the TDF were found to be influential along with multi-disciplinary working and experience; optimism and reinforcement did not feature. In Phase 2, these participants recorded reflections on prescribing decisions which they considered noteworthy in relation to their practice, and in Phase 3 participants were interviewed about their reflections. Complexity was a feature of many, in the patients clinical or social circumstances or in relation to wider concerns. The same 12 domains were found to be influential as were multi-disciplinary working, experience and complexity. This programme of research has produced original findings which it is hoped will impact on the education, training and practice of these increasingly important prescribers

A qualitative study of UK pharmacy pre-registration graduates' views and reflections on pharmacist prescribing.

Background: Pre-registration pharmacy graduates are a key group in relation to developing and implementing innovations in practice. Objective: To explore the views and reflections on pharmacist prescribing of UK pre-registration pharmacy graduates. Method: Semi-structured telephone interviews with a sample (n=12) of pre-registration pharmacy graduates. Key findings: Most reported a desire to train as prescribers, largely for reasons of professional development, but acknowledged the need first to develop as pharmacists. They perceived the lack of organisational strategy, pharmacist prescribers' self-confidence and additional workload to be barriers and were aware of the value of interprofessional relationships as potential facilitators to pharmacist prescribing. Conclusion: While participants were supportive of pharmacist prescribing, they highlighted the need first to gain experience as pharmacists and were acutely aware of barriers to prescribing implementation

Influences on prescribing decision-making among non-medical prescribers in the United Kingdom: systematic review.

Background - Suitably qualified non-medical healthcare professionals may now prescribe medicines. Prescribing decision-making can be complex and challenging; a number of influences have been identified among medical prescribers but little appears to be known about influences among non-medical prescribers (NMPs). Objective - To critically appraise, synthesize and present evidence on the influences on prescribing decision-making among supplementary and independent NMPs in the UK. Methods - The systematic review included all studies between 2003 and June 2013. Included studies researched the prescribing decision-making of supplementary and independent NMPs practising in the UK; all primary and secondary study designs were considered. Studies were assessed for quality and data extracted independently by two researchers, and findings synthesized using a narrative approach. Results - Following duplicates exclusion, 886 titles, 349 abstracts and 40 full studies were screened. Thirty-seven were excluded leaving three for quality assessment and data extraction. While all studies reported aspects of prescribing decision-making, this was not the primary research aim for any. Studies were carried out in primary care almost exclusively among nurse prescribers (n = 67). Complex influences were evident such as experience in the role, the use of evidence-based guidelines and peer support and encouragement from doctors; these helped participants to feel more knowledgeable and confident about their prescribing decisions. Opposing influences included prioritization of experience and concern about complications over evidence base, and peer conflict. Conclusion - While there is a limited evidence base on NMPs' prescribing decision-making, it appears that this is complex with NMPs influenced by many and often opposing factors

Exploring determinants of antimicrobial prescribing behaviour using the theoretical domains framework.

Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants’ beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship

The behaviors and experiences of the community pharmacy team on the provision of multi-compartment compliance aids.

Background - Multi-compartment compliance aids (MCAs) are repackaging systems for solid dosage form medicines. Acknowledging the lack of evidence that MCAs improve adherence or clinical outcomes, the Royal Pharmaceutical Society has expressed concern that MCAs have 'become regarded as a panacea for medicines use'. Objectives - To determine the behaviors and experiences of the community pharmacy team around MCA provision. Methods - A cross-sectional survey was conducted in 26 community pharmacies in the north east of Scotland. Survey items were grouped into: current activities in the provision of MCAs; potential influences on these activities; reports of patient experiences; and demographics. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis (PCA) was performed on the items of potential influences on activities. Results - Data were collected from 136 community team members (median 4, range1-10 per pharmacy; 32.3% pharmacists). All were involved in some aspect of MCA provision and within the same pharmacy, several different staff positions were commonly involved in the same activity. PCA gave seven components; the lowest scores were obtained for the component of 'others expecting me to provide MCAs'. Participants agreed that GPs, patients and their families, and carers expected them to provide MCAs. Positive experiences of MCA provision were in themes of promoting patient adherence, reducing patient stress and enhancing patient monitoring. Further negative experiences were in of lack of shared patient decision making, worsening adherence and generation of medicines waste, and dealing with changing medicines. MCAs were not always considered to be the most appropriate solution. Conclusion - While community pharmacy teams value MCAs, there may be issues around staff assignment to particular roles, expectations from others and reports of negative patient experiences. A systematic approach to MCA provision and monitoring involving the multidisciplinary health and social care team is warranted

Piloting the United Kingdon 'Prescribing Safety Assessment' with pharmacist prescribers in Scotland.

Background: Prescribing is a complex task requiring considerable knowledge and skills. The Prescribing Safety Assessment (PSA) was developed by the British Pharmacological Society and the United Kingdom (UK) Medical Schools Council. Between February and June 2014, over 7000 final year medical students undertook the PSA, with an overall pass rate of 94%. Independent prescribing for suitably trained pharmacists was introduced in the UK in 2006. To date there has been little focus on any objective measures of prescribing safety. Objective: To determine the PSA performance of a pilot group of pharmacist prescribers in Scotland relative to medical students and to test the feasibility and acceptability of running the PSA. Methods: A group of 59 pharmacist prescribers took part in ten events. The PSA consisted of 30 questions to be completed over 60 min. All questions had been used in the 2014 assessments for final year medical students. The PSA was undertaken online under invigilated conditions, mirroring the medical student assessment. One month later, participants were invited to complete an online evaluation questionnaire. Results: The mean overall PSA scores (±SD) were 87.5% ± 8.7 (range 52–98) compared to a 88.5% for medical students. Based on an Angoff passmark of 76.0%, 53 pharmacists (89.8%) passed compared to an overall pass rate in PSA 2014 of 94%. Pharmacists performed equivalently to medical students in all assessment areas, with a slightly lower performance in the prescribing, drug monitoring and data interpretation questions offset by better performance in prescription review and adverse drug reactions. Feedback was positive in relation to appropriateness, relevance and level of difficulty of the PSA although several commented that they were practicing in very specific clinical areas. Conclusion: These pilot events have benchmarked the PSA performance of pharmacist prescribers with final year medical students, and feedback confirmed feasibility and acceptability

Designated prescribing practitioners: a theory-based cross-sectional study of stakeholders' views on implementation of a novel pharmacy regulator mandated preceptorship model.

The Scottish Government is increasing independent prescribers (IP) in community pharmacy (CP). A new preceptorship model using IPs as Designated Prescribing Practitioners (DPPs) has been introduced. The aim of this study was to investigate stakeholder views of the implementation of a novel, regulator-mandated IP course preceptorship model. The research was undertaken through a theory-based, online pre-piloted survey of stakeholders, including e.g. directors of pharmacy, prescribing, education leads, policy and strategy leads, and CPs. Questionnaire development used the Consolidated Framework for Implementation Research (CFIR) and a DPP Competency Framework. Data were analysed descriptively and presented with mapping to CFIR constructs. Of ninety-nine responses, 82.5% (80/97) responded "yes" to "...abilities in reporting concerns...", and 53.1% (51/96) indicating "no" to "...anticipated issues with clinical and diagnostic skills". CFIR-related facilitators included agreement that: a) there was tension for change, with 84 (85%) indicating an "...urgent need to implement role..."; b) incentives are likely to help (65, 66%); and c) small pilots would help (85, 88%). Barriers were evident, relating to "unsure" responses about sufficiency of: DPP capacity (39/97, 40.2%); time (48/96, 50%); and support and resources (44, 45%) to undertake the role. Concerns were expressed, with 81 (83%) in agreement or unsure that leadership commitment may be lacking, and 48 (48.9%) being "unsure" about the availability of good training for the DPP role. The study concluded that there was DPP role positivity, but that there were also barriers and facilitators at policy-, organisational- and individual practitioner levels, which need more consideration. Further research is warranted on the uptake and embedding of the role

Supporting minority students through a reflexive approach to empowerment

Referring to the experiences of three Muslim refugee girls recently settled in Australia, this paper examines issues of schooling and empowerment. The paper draws on teacher and student interview data from a study that investigated inclusive approaches to addressing issues of cultural diversity in a secondary state high school in Queensland. The paper foregrounds the girls’ highly positive views of their experiences at the school; views that reflect the girls’ access to spaces of empowerment but belie the complexity and tensions involved in how empowerment was understood and approached by educators at the school. Theorising empowerment through poststructural understandings of agency, the paper examines conditions and ways of understanding that make possible spaces of empowerment for the girls. In particular, the paper argues for a reflexive approach to empowerment that is informed by an understanding of the framing discourses shaping minority student identity and a critical reflection on educator and school positionality