non medical prescribing case study examples

Non-medical prescribing: a reflective case study on prescribing anticoagulation for deep vein thrombosis

Affiliation.

• 1 Epsom and St Helier University Hospitals NHS Trust, Sutton, Surrey, England.
• PMID: 31468849
• DOI: 10.7748/en.2019.e1897

Prescribing is a high-risk, complex skill. There are more than 50,000 nurse prescribers in the UK, and it is important that they undertake regular reflection on their clinical practice to enhance their skills. This article reflects on the clinical factors that influenced the author's decision-making when prescribing anticoagulation medication for a patient with deep vein thrombosis. It also explores the evidence base for commonly prescribed anticoagulants.

Keywords: advanced practice; anticoagulants; cardiorespiratory; cardiovascular diseases; deep vein thrombosis; medicines; nurse prescribing; practice development; prescribing; professional issues; vascular diseases.

©2019 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

• Anticoagulants / therapeutic use*
• Decision Making
• Drug Prescriptions / nursing*
• Evidence-Based Nursing
• Practice Patterns, Nurses' / statistics & numerical data*
• Venous Thrombosis / drug therapy*
• Anticoagulants

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Influencing policy and practice in non-medical prescribing (NMP)

Submitting institution, unit of assessment, summary impact type, research subject area(s).

Medical and Health Sciences:  Nursing ,  Public Health and Health Services

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Summary of the impact.

Our ground-breaking research has driven major changes in non-medical prescribing (NMP) legislation. As a result of our research, over 19,000 nurses and 2,000 pharmacists now independently prescribe medicines directly to patients across the most comprehensive range of medicines in the world. This amounts to four million prescriptions per year in England. NMP has improved the quality and efficiency of health care: patients can now access prescribed medicines faster and NMP has reduced the number of professionals required. Study results have also contributed significantly to a recent extension of independent prescribing powers to physiotherapists and podiatrists. Our research is widely cited in international NMP policy development, and our survey methods and evaluation measures are used to assess NMP quality and safety internationally.

Underpinning research

The prescription of medicines is probably the most common intervention patients receive for the management of medical conditions. In 2011, 961 million items were prescribed in England — on average 17.8 items per head of the population. The UK is a world leader in progressive policy and practice for non-medical prescribing; this is underpinned by our research which has shifted prescription from a doctor-only model to one that now allows a range of healthcare professionals including nurses, pharmacists and optometrists to independently prescribe a wide range of medicines. This new policy and practice has been a key part of NHS modernisation since 2008.

Pioneering research by Professor Sue Latter at the Faculty of Health Sciences, University of Southampton (since 2008), has helped drive the direction of this revolution in prescribing. Our research included the first Government-funded national evaluations of NMP in the world, providing large-scale independent evidence on the quality, safety and acceptability of NMP.

The first multi-disciplinary study [Research grant 1; 2003-2005] was led at Southampton by Latter with Dr Jill Maben, Senior Research Fellow (left 2004); Dr Michele Myall, Research Fellow (left 2005); Dr Molly Courtenay, Lecturer (left 2004); Amanda Young, Research Fellow (left 2005) and Dr Nick Dunn, Senior Lecturer, Faculty of Medicine. The study evaluated the extension of prescription powers, first to community nurses and later, in progressive stages, to other appropriately qualified nurses and pharmacists who were allowed, initially, to prescribe a limited number of medicines or with limited independence. We conducted a national survey of nurse prescribers and investigated case studies of different practice settings [3.1, 3.4] and this directly informed UK Government prescribing policy. This research was the first large scale international study to move beyond self-report data to provide direct, objective evidence of the quality and safety of NMP, by including observation of nurse prescribing consultations [3.2, 3.3] and an independent analysis of patient records and nurse prescriptions. Data collection with key stakeholders — prescribing nurses, other healthcare professionals and patients — was conducted to assess on a national scale the benefits of independent prescribing by nurses, and demonstrated the limitations of restricted prescribing which failed to make effective use of health professionals' skills and did not deliver efficient NHS practice. The results of the research paved the way for a significant Government consultation on extending NMP later in 2005, culminating in legislation in 2006 which resulted in a radical extension of NMP over following years.

Building on our reputation, we conducted further Southampton-led multi-centre (Southampton, Keele, London School of Economics) multi-disciplinary (nursing, pharmacy, medicine, health economics and statistics) research to evaluate nurse and pharmacist independent prescribing [Research grant 2; 2008-2010], once NMP was extended to allow nurses and pharmacists to prescribe any licensed medicine for any medical condition — except controlled drugs. The research was with Southampton staff: Dr Karen Gerard, Reader; Dr Peter Nicholls, Senior Research Fellow (left 2012); Dr Alesha Smith, Senior Research Fellow (left 2009) and Professor Paul Little, Faculty of Medicine. Building on and extending the methodology of the first study, including the first ever direct observational data internationally of pharmacist prescribing [3.5], we concluded that prescribing by nurses and pharmacists was generally safe, clinically appropriate [3.5] and acceptable to patients [3.6] and other healthcare professionals. Findings highlighted that training for NMP roles was satisfactory overall, but also found there were some indications that assessment and diagnostic skills associated with prescribing could be improved [3.5].

References to the research

Research grant 1: An Evaluation of Extended Formulary Independent Nurse Prescribing

3.1 Latter S, Maben J, Myall M, Young A. (2007a) Perceptions and practice of concordance in nurses' prescribing consultations: findings from a national questionnaire survey and case studies of practice. International Journal of Nursing Studies 44 (1): 9-18 www.sciencedirect.com/science/article/pii/S0020748905002099

3.2 Latter S, Maben J, Myall M, Young A. (2007b) Evaluating the clinical appropriateness of nurses' prescribing practice: method development and findings from an expert panel analysis. Quality and Safety in Health Care 16: 415-421 www.ncbi.nlm.nih.gov/pmc/articles/PMC2653174/

3.3 Latter S, Maben J, Myall M, Young A. (2007c) Evaluating nurse independent prescribers' prescribing consultations: an observation study of practice in England. Journal of Research in Nursing 12 (1): 7-26 http://jrn.sagepub.com/content/12/1/7.abstract

3.4 Latter S, Maben J, Myall M, Young A. (2007d) Evaluating nurse prescribers' education and continuing professional development for independent prescribing practice: findings from a national survey in England. Nurse Education Today 27: 685-696 www.sciencedirect.com/science/article/pii/S0260691706001687

Research grant 2: Evaluation of nurse and pharmacist independent prescribing

3.5 Latter S, Smith A, Blenkinsopp A, Nicholls P, Little P, Chapman S. (2012) Are nurses and pharmacists making clinically appropriate prescribing decisions? An analysis of consultations using the Medication Appropriateness Index. Journal of Health Services Research and Policy 17: 149-156 www.ncbi.nlm.nih.gov/pubmed/22734082

3.6 Gerard K, Tinelli M, Latter S, Blenkinsopp A, Smith A. (2012) Valuing the extended role of prescribing pharmacist in general practice: Results from a discrete choice experiment. Value in Health 15 (5): 699-707

Research Grants:

Research grant 1 — Latter S (Chief Investigator), Courtenay M, Dunn N. An Evaluation of Extended Formulary Independent Nurse Prescribing. Commissioned and funded by the Policy Research Programme at the Department of Health 2003-2005, £200,000.

Research grant 2 — Latter S (Chief Investigator), Blenkinsopp A, Gerard K, Chapman S, Little P, Nicholls P, Dorer G. An evaluation of nurse and pharmacist independent prescribing. Commissioned and funded by the Policy Research Programme at the Department of Health 2008-2010, £338,000.

Details of the impact

Reach and significance of impact: number of Non-Medical Prescribers and patients

Our research reports were published by the Department of Health (DH) [5.11] and made available on their website [5.1 and 5.2]. The Executive Summaries of our research reports have been downloaded 1698 times [Research grant 1] and 6495 times [Research grant 2] from the University website. Working closely with the DH Policy Lead for NMP, our research findings on the positive contribution of NMP to health care made a direct impact on NMP legislation and NHS modernisation in England, providing key evidential support for Government policy change [5.11]. As a result, the number and range of health care professionals able to train as prescribers has significantly increased, as well as the number of medicines that they can prescribe. Our research has helped extend the role and accountability of the largest sector of the health care workforce such that by 2012, 19,000 nurses across England had qualified as Nurse Independent Prescribers — up from only 6,600 in 2006. Nurse prescribers are now employed across approximately 93% of the 376 NHS Trusts in England, with the majority prescribing for more than 11 patients per week, and a significant minority (15%) prescribing for more than 50 patients per week [5.2]. In 2013, the number of pharmacist prescribers had grown to 2000, and the total number of items prescribed by Non-Medical Prescribers in England had risen from 2.4 million (January — March 2008) to 4 million (July — September 2011).

As a direct result of her research, Latter was invited to join a Government Project Board, chaired by the Chief Health Professions Officer, on allied health professions prescribing in 2009. The Board's report [5.3] cited her research as evidence that NMP training adequately prepared nurses for practice and thus could be adapted for new prescriber categories (e.g. allied health professionals). Our findings on the safety and acceptability to patients of nurse and pharmacist prescribing were the sole research evidence cited in DH consultation documents on extending physiotherapist and podiatrist prescribing [5.4 and 5.5]. These national consultations resulted in widespread support for extending prescribing by physiotherapists and podiatrists and in July 2012, new prescribing powers, enabling these groups to independently prescribe medicines, were announced. Our research was also the sole evidence cited in the Government's consultation document on proposals to introduce prescribing rights for paramedics [5.6]. Building on the research findings, the DH announced in April 2012 that the list of medicines nurse and pharmacist prescribers can prescribe will be expanded to include controlled drugs.

Impact on prescribing quality and efficiency

To ensure effective transfer into health care professional practice, Latter et al presented preliminary findings at a workshop of key stakeholders comprising 43 senior healthcare policy makers, managers and commissioners influential in NMP policy and practice nationally [5.2]. Stakeholders corroborated the value of the study findings and identified priorities for action; these included the development of a cross-profession common competency framework for all prescribers [5.2]. This action has since been taken forward by the National Prescribing Centre, culminating in the 2012 publication of a single competency framework for all prescribers which is the national standard to underpinning quality and safety in prescribing. Following completion of the 2010 study, Latter was invited by DH to present the results and recommendations to the DH Non-Medical Prescribing Programme Board, chaired by the Chief Nursing Officer, and including the Chief Pharmaceutical Officer for England and the DH NMP Policy Lead [5.11]. Latter was also invited to present findings to the Nurse Prescribing Advisory Group of the British National Formulary in 2011 [5.11].

As a direct result of the insights gained from her research, Latter was invited to join the NICE Concordance Guideline Development Group as an expert peer reviewer. The group's recommendations were the foundation for NICE's clinical guideline 76 on Involving patients in decisions about prescribed medicines and supporting adherence , published in 2009, setting a clear template for how patient discussions about medicine are conducted and assessed professionally.

A 2011 Nursing Times review provides evidence of the significance of extending prescribing rights for nurses: NMP has benefited both the nursing profession (through greater autonomy and job satisfaction) and patients, for whom it means timely access to medicines and treatment and reduced waiting times [5.7]. NMP has reduced the number of health professionals that need to be involved in an episode of care, and economic analysis of NMP [5.2] highlights the potential cost savings made by shifting prescribing workload from doctors to nurses. For example, the cost of one hour of patient contact for a GP is £127, compared to £43 for a practice nurse (PSSRU 2011). These data highlight the efficiency and cost savings achieved through expanding NMP and the resulting improvements in patient care.

The key changes in UK prescribing policy resulting from our research have been widely reported across the national news media and more extensively still in professional journals such as the Nursing Times, whose 300,000 monthly readers include nurses in the UK and abroad.

International Impact

Our research findings have been utilised internationally for policy and practice. Study results were cited as key international evidence in a series of Australian Government Consultation Papers [5.8] recommending a new national prescribing pathway to extend prescribing rights to the 268,000 registered nurses in Australia. This represents a radical increase from the current position in which nurse prescribing is limited to around 400 nurse practitioners. With the UK now a global leader in NMP, our study methods and evaluation criteria have been adopted internationally for studies including: a national evaluation by the Netherlands Institute for Health Services Research of nurse prescribing in the Netherlands (Kroezen 2013); an evaluation of diabetes nurse specialist prescribing for the New Zealand Society for the Study of Diabetes in New Zealand [5.9]; a survey of pharmacist prescribing in Canada (Guirguis et al 2012); and Drennan et al's (2009) Health Services Executive funded national evaluation of nurse and midwife prescribing in Ireland [5.10]. Studies' results have led to further impact: for example, the study of nurse prescribing in New Zealand has stimulated national legislation to enable further roll-out of nurse prescribing to other nurses; in Ireland, the number of registered nurse prescribers in 2009 in Drennan's et al's national evaluation was 57; this had risen to 453 in June 2012. Our research findings are also cited in influential international reviews of NMP policy and practice (International Council of Nurses 2009; Kroezen et al 2011).

Southampton-led research on NMP has provided unique evidence to the Government that has significantly influenced national policy on expanding NMP, resulting in higher quality patient care and improved health service efficiency. Our research has informed international policy on NMP and studies drawing on our methods and results have contributed to the expansion of prescribing authority to a greater number of nurses and pharmacists around the world, with an ability to prescribe a greater range of medicines for patients.

Sources to corroborate the impact

5.1 Latter S, Courtenay M, Dunn N. (2005) An Evaluation of Extended Formulary Independent Nurse Prescribing. Final Report.

5.2 Latter S, Blenkinsopp A, Smith A, Chapman S, Tinelli M, Gerard K, Little P, Celino N, Granby T, Nicholls P, Dorer G. (2011) An evaluation of nurse and pharmacist independent prescribing. Final Report www.gov.uk/government/publications/evaluation-of-nurse-and-pharmacist-independent-prescribing-in-england-key-findings-and-executive-summary

5.3 Department of Health. (2009) Allied health professions prescribing and medicines supply mechanisms scoping project report (page 23) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_103948

5.4 Department of Health. (2011a) Consultation on proposals to introduce independent prescribing by physiotherapists (pages 18, 22 and 23) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Liveconsultations/DH_129983

5.5 Department of Health. (2011b) Consultation on proposals to introduce independent prescribing by podiatrists (pages 18, 22 and 23) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Liveconsultations/DH_129981

5.6 Department of Health. (2010) Proposals to introduce prescribing responsibilities for paramedics. London: Department of Health (page 6)

5.7 Carey K, Stenner N. (2011) Does non-medical prescribing make a difference to patients? Nursing Times (July 4) www.nursingtimes.net/nursing-practice/clinical-zones/prescribing/does-non-medical-prescribing-make-a-difference-to-patients/5032082.article)

5.8 Health Workforce Australia. (2012) Health Professionals Prescribing Pathway Project www.hwa.gov.au/sites/uploads/Final_HPPP_Phase_One_Interim_Report.pdf (page 5)

5.9 Wilkinson J, et al (2011) Evaluation of the diabetes nurse specialist prescribing project www.healthworkforce.govt.nz/sites/all/files/DNS%20Final%20evaluation%20report.pdf (page8)

5.10 Drennan J, et al (2009) National independent evaluation of the nurse and midwifery prescribing initiative. Health Services Executive Ireland www.hse.ie/eng/services/Publications/services/Hospitals/prescribing_initiative.pdf (page ix)

5.11 Corroborator: John Wright, Policy Lead, Non-Medical Prescribing. Reports were made available on DH website and provided key evidential support for Government policy change expanding NMP, resulting in higher quality patient care and improved health service efficiency. Latter presented results to the DH Non Medical Prescribing Programme Board and the Nurse Prescribing Advisory Group of the British National Formulary.

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Article Contents

Introduction, declaration.

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

*Correspondence to Scott Cunningham, School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen AB10 7GJ, UK; E-mail: [email protected]

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Trudi McIntosh, Derek Stewart, Katrina Forbes-McKay, Dorothy McCaig, Scott Cunningham, Influences on prescribing decision-making among non-medical prescribers in the United Kingdom: systematic review, Family Practice , Volume 33, Issue 6, 1 December 2016, Pages 572–579, https://doi.org/10.1093/fampra/cmw085

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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).

To critically appraise, synthesize and present evidence on the influences on prescribing decision-making among supplementary and independent NMPs in the UK.

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.

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.

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.

Suitably qualified non-medical healthcare professionals, largely nurses and pharmacists, may now prescribe medicines for their patients. Non-medical prescribing has developed according to different models across the world, reflecting different healthcare systems ( 1–5 ). Nurse prescribing has been implemented in USA, Canada, Australia, New Zealand, the Republic of Ireland, Finland, Sweden, the Netherlands, Spain, and UK although frameworks within which this occurs vary markedly ( 1 , 6 ). Pharmacists have prescribing authority in Canada, USA, New Zealand, and the UK ( 7 , 8 ); again the model varies.

Notwithstanding this variation, development of non-medical prescribing across the world has been driven by a desire to improve access to medicines, sometimes in response to geographical isolation, to improve the quality of care and to make best use of healthcare professionals’ skills ( 6 , 9 ). In most countries, non-medical prescribers (NMPs) work in collaboration with a supervising doctor to treat patients for previously diagnosed or pre-specified conditions ( 5 , 9 , 10 ). In the UK and certain other countries, additionally qualified NMPs practise within their competence as independent prescribers responsible for patient care including diagnosis and prescribing from largely the same range of medicines as doctors across a wide range of acute, chronic and complex conditions in primary and secondary care ( 10 , 11 ). In the UK ‘community practitioner nurse prescribers’ prescribe from a restricted range of products, primarily wound dressings and products for minor ailments and symptomatic relief. The mode and scope of their practice is very limited, as was that of extended formulary nurse prescribers; this role ceased in 2006 with the implementation of independent nurse prescribing. These categories of nurse prescribers fall out with the definition of ‘supplementary and independent prescribers’ in the UK legislative prescribing framework. There are plans to extend both the range and scope of non-medical prescribing still further ( 1 , 12–14 ).

Whatever the profession, practice setting or clinical area, prescribing decision-making is a key skill for all prescribers. It is one of the cornerstones of patient safety ( 15 ) and, like all decision-making, can be challenging. In addition to clinical aspects, prescribers’ and patients’ health beliefs and behaviours are influential. Newell and Simon ( 16 ) described problem solving as a stepwise process of iterative hypothesis development and testing, moderated by the application of heuristics (i.e. a practical method not intended to be optimal or perfect) and/or algorithms informing the development of a plan. The process is evaluated and a final proposed solution arrived at and again tested for suitability. This model may be applied to prescribing decision-making where ‘heuristics’ may be considered to equate to prescribers’ attributes and experiences, and clinical guidelines may approximate to ‘algorithms’. Research into doctors’ prescribing decision-making, mainly in primary care, has identified the importance of both types of influences with ongoing debate about their relative significance ( 17 , 18 ). In 1992 Bradley published a critical incident study on ‘uncomfortable’ prescribing decisions among GPs in England, providing evidence that their decisions were based on a variety of clinical and non-clinical influences including patient expectations, the doctor–patient relationship and the doctor’s previous behaviour ( 17 ). GPs’ discomfort around some of their prescribing decisions was multifactorial. This seminal paper acted as a stimulus to further qualitative research ( 19–27 ).

Prescribing decision-making is therefore clearly complex and challenging; a number of influences have been identified among medical prescribers but little appears to be known about such influences among NMPs. There is limited evidence regarding non-medical prescribing decision-making although it has been evaluated as safe across a range of settings ( 28–31 ). NMPs assert that they adhere strictly to evidence-based practice ( 28 ), yet this may not always be the case ( 32 , 33 ). NMPs have disparate professional backgrounds but unlike doctors, none comes from a tradition of sometimes paternalistic relationships with patients or from a position at the top of the healthcare hierarchy ( 34 , 35 ). It may be that their prescribing decisions are informed by different or additional influences to those of doctors. It is essential that their prescribing decision-making processes are understood so that they may be optimized for patients’ benefit. Systematic reviews constitute the highest level of evidence ( 36 ); a search in eight appropriate databases found no systematic review in this area. The aim of the systematic review was to critically appraise, synthesize and present the evidence on influences on prescribing decision-making among supplementary and independent NMPs in the UK. Given the variation in cultures, health systems and non-medical prescribing practice across the world, the review was restricted to studies examining practice in the UK.

The systematic review protocol development was informed by standard guidance ( 37 ) and registered with PROSPERO at the Centre for Reviews and Dissemination, University of York, UK (registration number CRD42013004729).

Inclusion criteria

Studies researched the prescribing decision-making of supplementary and independent NMPs practising in the UK. All primary and secondary study designs were considered, with searching limited to articles published from 2003, the start of implementation of non-medical prescribing in the UK, to June 2013.

Exclusion criteria

Studies focusing on the administration or supply of medicines via patient group directions were excluded, as were abstracts, conference proceedings, editorials and letters. Multi-professional studies where no data were reported according to participants’ professions were also excluded.

Search strategy

The following databases were searched: Cumulative Index to Nursing & Allied Health Literature (CINAHL), Education Resources Information Centre (ERIC), Google Scholar, International Pharmaceutical Abstracts, Medline, PsycARTICLES and The Cochrane Library. Search terms were as follows: prescrib* and (pharmacist* or nurse* or physiotherapist* or podiatrist* or radiographer* or optometrist*) and (influenc* or decision* or decid* or judge* or factor*). Reference lists were scrutinized and any additional relevant titles were included. During title, abstract and full paper screening, inter-rater reliability was confirmed by two independent researchers (TM and one other of SC, DS and KF-M) comparing a random sample of 10% of titles, abstracts and full papers.

Quality assessment, data extraction and synthesis

Studies were assessed for quality using a standard tool ( 38 ); quality assessment was carried out independently by two researchers (TM and one other of SC, DS and KF-M) and any disagreements resolved by discussion. A data extraction tool was prepared, piloted and used according to the review protocol; data extraction was conducted independently by two researchers, as described above. Review findings were synthesized using a narrative approach.

The primary outcome identified influences on prescribing decision-making by non-medical prescribers; secondary outcomes included their management of otitis media and respiratory tract infections and their pharmacological knowledge and decision-making. Given the small number of papers retrieved, it was decided not to exclude any based on quality.

Following exclusion of duplicates, 886 titles, 349 abstracts and 40 full studies were screened sequentially. Thirty-seven studies were excluded for the following reasons: no NMP prescribing decision-making described ( n = 27); included only extended formulary nurse prescribers ( n = 3); setting outwith the UK ( n = 2); while published post 2003, recruitment of study participants pre 2003 ( n = 2) and medical and non-medical prescribers not differentiated in reporting of results ( n = 3). The PRISMA flow diagram is given in Figure 1 ( 39 ).

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram ( 39 ).

Quality assessment was conducted on the three remaining studies, all of which employed qualitative methodologies, as described in Table 1 . Key strengths of the studies included the justification and appropriateness of the qualitative approaches and corresponding study designs. Two of the studies provided clear statements of study aims ( 32 , 33 ); this was absent in the third ( 40 ). Study limitations were as follows: a general lack of detail over recruitment strategies and processes (e.g. one study described purposive sampling but with no further details of strata ( 40 ); no justification of sample size and consideration of saturation; and the absence in two of the studies of any theoretical underpinning in the construction of the data generation tools and data analysis ( 32 , 33 ). The third study ( 40 ) applied to Hammond’s Cognitive Continuum Theory which places the cognitive activities of decision-makers into six broad categories: scientific experiment, controlled trial, quasi-experiment, system aided judgement, peer-aided judgement and intuitive judgement ( 41 ).

Quality assessment of papers included in the review

Despite study limitations all were included in data extraction, results of which are provided in Table 2 . While all studies reported aspects of prescribing decision-making, this was not the primary research aim for any. The aims centred around use of evidence-based guidelines in the management of otitis media ( 32 ), experience of consultations for respiratory tract infections ( 33 ) and exploring pharmacological knowledge and decision-making around given scenarios ( 40 ). Studies were carried out in primary care almost exclusively among nurse prescribers ( n = 67); only one pharmacist prescriber and one physiotherapist prescriber were included in one focus group and results from the focus group were not differentiated according to profession ( 33 ).

Data extraction summary from papers included in the review

Philp and Winfield studied nurse prescribers treating otitis media in children. While participants reported valuing and using evidence-based guidelines to inform their prescribing decision-making, they felt that guidelines were not appropriate in all circumstances and sometimes prioritized their experience over guidelines when prescribing antibiotics. Prescriber concerns about possible clinical complications were reported as sometimes being more influential; these concerns were due to external factors such as practice setting including out of hours and time-pressured clinics, patient-specific factors and parental pressure. All participants had been aware of parental pressure to prescribe antibiotics which they considered to be inappropriate. While experience, confidence and colleague support were helpful in resisting this pressure, most reported having prescribed antibiotics against guideline recommendations as a result of external influences ( 32 ).

Offredy and colleagues used previously validated clinical scenarios to score participants’ pharmacological knowledge and data generated via semi-structured interviews were used to ascribe participants’ decision-making to one of six modes according to Hammond’s Cognitive Continuum Theory ( 41 ). Participants were also asked to rate their knowledge and confidence of medication used in their area of practice and about medication-related issues. More patient contact increased participants’ comfort with prescribing decision-making. Some participants indicated that the availability of extensive peer and organizational support influenced their prescribing. Participants’ knowledge of pharmacology was poor; most could not respond appropriately to the scenarios but said that in general they would access the British National Formulary before making prescribing decisions. Participants who were unable to respond to scenarios said they would refer the ‘patient’ to the general practitioner as the situations were outwith their experience and competence. Most participants rated themselves as confident in dealing with medication-related issues. Participants’ prescribing decision-making was categorized by the researchers as involving moderately strong or weak quasi-rational thought although the method by which this was done was not always justified.

Rowbotham and colleagues ( 33 ) studied NMPs’ experiences of managing patients with self-limiting respiratory tract infections. NMPs reported that while some patients consulted seeking reassurance that their condition was not serious, others wanted (or sometimes demanded) treatment with antibiotics, generally due to a lack of understanding of the condition and/or previous treatment with antibiotics. Consultations could be time consuming and complex and participants worried about misdiagnosis, leading to a cautious approach to prescribing decision-making. Some had prescribed antibiotics in the past in response to time pressure, adverse social circumstances and patient expectation and/or clinical uncertainty but most said that they would no longer do so. Patient education and good communication skills were considered important and peer support and the use of guidelines helpful in resisting patient pressure for antibiotics however some nurse prescribers reported conflict with GPs who prescribed antibiotics after a ‘no antibiotic’ decision by the nurse prescriber.

This systematic review has identified a paucity of research around NMPs’ prescribing decision-making with only three studies meeting the inclusion criteria. Furthermore, exploring and articulating NMPs’ prescribing decision-making was not the primary aim of any of the studies reviewed. The limited evidence from this systematic review, however, suggests that NMPs perceive prescribing decision-making as challenging and complex. Experience in the role ( 32 ), the use of evidence-based guidelines ( 32 , 33 ) and peer support and encouragement from doctors ( 40 ) helped participants to feel more knowledgeable and confident about their prescribing decisions, and also to resist patient pressure for antibiotics ( 34 ). Evidence-based guidelines were useful in helping NMPs to resist this pressure ( 33 ).

This is the first systematic review to focus on influences on prescribing decision-making by non-medical prescribers and reveals differences from what is known about medical prescribers. Transferability of review findings may be limited by small sample sizes, UK primary care settings and inclusion of almost exclusively nurse prescribers. Furthermore, all three studies focused on prescribing decision-making for acute conditions and hence the findings are not necessarily transferable to decision-making for patients with chronic conditions or instances of multimorbidity.

Only a small number of NMP studies were available for inclusion within this systematic review, however it is evident from these and research involving prescribing within the medical field that prescribing decision-making is complex and influenced by many factors, some of which may be contradictory and complicate further decision-making. This complexity aligns to the stepwise process of hypothesis development and testing described by Newell and Simon ( 16 ). At this stage, in view of the small number of studies the influences identified among NMPs should be interpreted and utilized with caution. It is vital that more high quality research is carried out to explore them further. One limitation of the studies in this review is that none described fully the process of decision-making leading to the development of a prescribing plan with subsequent evaluation and solution definition. Notably, none of the studies identified as paramount the key social and cognitive influences which have been described for medical prescribers, among whom the doctor–patient relationship and perceived patient/parental pressure were found to be highly influential ( 20–22 , 25 , 42–47 ). However, among NMPs prevalent influences were clinical uncertainty including potential risk of development of complications, patient expectations, time pressures and peer support.

Algorithms, in the form of evidence-based guidelines, influenced prescribing decision-making by NMPs and were perceived to offer rigorous, clear guidance on treatment and selection of antibiotics for otitis media and respiratory tract infections ( 32 , 33 ). While most participants claimed to follow such guidelines, some more experienced NMPs described a more heuristic approach to management during which they had chosen to ignore guidelines, and sometimes practice policy, and prescribe antibiotics in response to clinical uncertainty and perceived risk of complications ( 32 , 33 ). They also prescribed antibiotics in response to external factors such as previous experience, perceived patient pressure for antibiotics, patients’ socio-economic status and prescriber’s knowledge of the patient or family ( 32 , 33 ). Prescribing decision-making for self-limiting infections can also be challenging for medical prescribers and there is wide variation in antibiotic prescribing ( 48 ). Antibiotic stewardship is a key public health concern worldwide ( 49 ); it is important that all prescribers follow best practice in this area yet there is ample evidence that this is not happening with potentially serious implications for the future ( 50 , 51 ).

The heuristic approach was also apparent in relation to NMPs relying on intuition and experience when responding to clinical scenarios, rather than on up-to-date pharmacological knowledge. Offredy and colleagues identified poor knowledge despite participants’ claiming knowledge of medicines used in their own clinical areas ( 40 ). Others have highlighted that practising NMPs have identified a need for continuing professional development in the area of pharmacology and drug interactions ( 52 ).

The context within which prescribing occurred was important in influencing prescribing decision-making; a team approach to prescribing with peer support and encouragement from doctors helped to build participants’ confidence ( 40 ) and helped them to resist patient pressure to prescribe ( 32 , 33 ).

Further research on NMPs’ decision-making processes is warranted using qualitative approaches such as interviews and focus groups with rigour to provide trustworthiness and transferable findings. Quantitative methodologies such as widely disseminated questionnaires should provide generalizable results around the extent of cognitive and social issues which could inform education and training. There is also a need to explore the impact of these on prescribing decisions made and the clinical implications, perhaps through case studies.

In conclusion, this high quality systematic review shows that while there is a limited quality evidence base on NMPs’ prescribing decision-making, from the small number of studies it appears that the complexity identified in medical studies may be mirrored among NMPs. More research is required further to explore and confirm this.

Funding: none.

Ethical approval: School of Pharmacy and Life Sciences, RGU Ethical Review Panel.

Conflict of interest: none.

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Author notes

• decision making
• primary health care
• evidence-based practice
• prescribing behavior
• healthcare quality assessment
• peer support

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Exploring the barriers and facilitators to non-medical prescribing experienced by pharmacists and physiotherapists, using focus groups

• Emma Graham-Clarke   ORCID: orcid.org/0000-0001-5657-778X 1 ,
• Alison Rushton 2 &
• John Marriott 1  

BMC Health Services Research volume  22 , Article number:  223 ( 2022 ) Cite this article

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Non-medical prescribing (NMP) was introduced into the United Kingdom to enhance patient care and improve access to medicines. Early research indicated that not all non-medical prescribers utilised their qualification. A systematic review described 15 factors influencing NMP implementation. Findings from a recent linked Delphi study with independent physiotherapist and pharmacist prescribers achieved consensus for 1 barrier and 28 facilitators. However, item ranking differed for pharmacist and physiotherapist groups, suggesting facilitators and barriers to NMP differ depending on profession. The aim of this study was to further explore the lived experiences of NMP by pharmacists and physiotherapists.

Study design and analytical approach were guided by Interpretative Phenomenology Analysis principles. Focus groups (November and December 2020) used the ‘Zoom®’ virtual platform with pharmacist and physiotherapist prescribers. Each focus group followed a topic guide, developed a priori based on the Delphi study results, and was audio recorded digitally. Transcripts underwent thematic analysis and data were visualised using a concept map and sunburst graph, and a table of illustrative quotes produced. Research trustworthiness was enhanced through critical discussion of the topic guide and study findings by the research group and by author reflexivity. The study is reported in line with COREQ guidelines.

Participants comprised three physiotherapists and seven pharmacists. Five themes were identified. The most frequently mentioned theme was ‘Staff’, and the subtheme ‘Clinical team’, describing the working relationship between participants and team members. The other themes were ‘Self’, ‘Governance’, ‘Practical aspects’ and ‘Patient care’. Important inter-dependencies were described between themes and subthemes, for example between ‘Governance’ and ‘Quality and Safety’. Differences were highlighted between the professions, some relating to the way each profession practises (for example decision making), others to the way the prescribing role had been established (for example administration support).

Conclusions

The key finding of collaborative working with the clinical team emphasises its impact on successful implementation of NMP. Themes may be inter-dependent, and inter-profession differences were identified. Specifically designed prescribing roles were beneficial for participants. For full NMP benefits to be realised all aspects of such roles must be fully scoped, before recruiting or training non-medical prescribers.

Peer Review reports

Non-medical prescribing (NMP) was introduced into the United Kingdom (UK) to enhance patient care and improve access to medicines [ 1 ]. Initially this enabled district nurses and health visitors to prescribe from a limited formulary [ 2 ] but in 1999, following the second Crown Report, the concept of independent and supplementary prescribing for nurses and other healthcare professionals was introduced [ 3 ]. Since then, the number of professions with independent prescribing rights has gradually increased and now includes nursing, optometry, pharmacy, podiatry, physiotherapy, paramedics and therapeutic radiography [ 4 ]. Demand exists for other professions to gain independent prescribing rights, with the Health Foundation commenting that until physician associates are able to prescribe independently, they will be limited in their activities [ 5 ]. Since the introduction of NMP, the UK National Health Service (NHS) has experienced increased patient demand, workforce shortage pressures, and funding shortfalls, driving policy emphasis to provision of streamlined care for patients, with NMP playing a pivotal role [ 6 , 7 , 8 ]. For example, prescribing physiotherapists, the first point of contact for many patients with musculoskeletal problems, are able to provide the complete treatment course without referral to other healthcare professionals [ 7 , 9 , 10 ]. A further example is that of pharmacists involved in the care of long term conditions [ 11 ]. These plans will be hindered if qualified non-medical prescribers are deterred, for whatever reason, from utilising their skills. Earlier research indicated that approximately 25% of Allied Health Professionals, qualified as prescribers, may not use this skill in comparison to 10% of qualified prescribing nurses [ 12 , 13 ]. Establishing factors that facilitate or prevent NMP and investigating if these are generic to different NMP professions, or are professional, situational or person specific will aid NMP development.

A previous systematic review described 15 factors or themes that had the potential to influence the implementation of prescribing by non-medical professions [ 14 ]. It was noted that the majority of the included studies focused on prescribing by nurses, with the remainder addressing prescribing by pharmacists. The four most common themes identified included the influence of medical staff, the prescriber’s area of competence, the impact on their time and impact on service. No papers were found that reviewed the experiences of any other NMP profession. It is unclear whether or not the factors that affect prescribing by nurses and pharmacists are also experienced by other non-medical prescribing professions, or if they experience different factors.

To investigate this further a three round Delphi study investigating facilitators and barriers to independent non-medical prescribing was conducted with qualified independent prescribers from an established prescribing profession (pharmacy) and a newer, and relatively unexamined, prescribing profession (physiotherapy) [ 15 ]. The two professions were chosen as they have similar numbers of registrants in the UK (approximately 56,000), may work as individuals or in teams, and may work in all healthcare sectors [ 16 , 17 ]. They differ in the length of time that each profession has had prescribing rights, with pharmacy gaining independent prescribing rights six years earlier than physiotherapy [ 18 , 19 ]. Consensus was gained for 1 barrier and 28 facilitators, however, item ranking orders differed for the pharmacist and physiotherapist groups. This suggested that the facilitators and barriers to NMP differ depending on profession. However, it was possible that the differences arose from chance and did not accurately reflect experiences.

This paper presents the results of focus groups to further investigate the findings of the Delphi study, to explore if the findings reflected the experiences of pharmacist and physiotherapist prescribers, or if additional factors affecting implementation of NMP were also present. This would indicate how generalisable the Delphi study findings are to the wider pharmacist and physiotherapist prescribing populations.

To further explore the lived experiences of non-medical prescribing by pharmacists and physiotherapists.

Research team and reflexivity

EGC, JM and AR developed the study protocol and topic guide and EGC conducted the focus groups. EGC is a doctoral student, researching influences affecting NMP utilisation and inter-professional differences. The research question was prompted by her activity as an independent pharmacist prescriber, and her role as NMP lead for an acute NHS Trust in the Midlands. Her researcher standpoint is balanced by the other two researchers, neither of whom is a prescriber, but who have extensive research experience and represent the pharmacy and physiotherapy professions.

EGC acted as the contact point for participants during recruitment. Participants were made aware of the background to the research via the participant information sheet, issued at the time of recruitment, and this information was reinforced at the start of each focus group.

Study design

The study design and analytical approach were guided by the principles of Interpretative Phenomenology Analysis (IPA) [ 20 ]. IPA acknowledges that the lived experience of each participant reflects their world view, and that interpretation is affected by the researcher’s own experiences. This study sought to understand how non-medical prescribers perceived their practice was affected by outside influences, whether procedural or people. Each participant will have had different formative experiences, shaping their view of NMP, and IPA will aid in interpretation of this, whilst recognising the potential influence of the lead researcher.

Focus groups enable discussion between participants on selected specific topics. The discussion and interaction between the participants allow ideas and views to be developed and refined, and thus provide a deeper understanding of the issues being considered [ 21 , 22 ]. There is also the potential for unanticipated ideas to be expressed, supporting further understanding of the research topic [ 22 ]. Research indicates that 80% of ideas are generated within the first two or three focus groups, and these comprise the most frequently mentioned themes [ 23 , 24 ]. Furthermore, Hennink describes focussed research questions requiring fewer focus groups to generate ideas than research questions where the issues are unknown [ 25 ]. A pragmatic approach to the groups was adopted, balancing available resources and the level of information anticipated from the closely defined topic guide [ 25 ]. Two focus groups were planned, using the ‘Zoom®’ virtual platform (Zoom.us), hosted by the University of Birmingham. Each group was led by a moderator (EGC) and the conversation was audio recorded digitally, using the virtual platform record feature, and handwritten fieldnotes were taken. Each focus group followed a similar format of introduction, main discussion and closing stage, and followed an a priori developed topic guide [ 21 , 26 , 27 , 28 ]. The topic guide was drafted by EGC, using the previous Delphi results as a guide, and debated within the research group to ensure that the guide was clear, followed a logical progression and was appropriate for the aim of the study (Additional File 1 ). The topics chosen were those where there were apparent differences in the Delphi results between the professions when reviewing the ranked statements by profession. The discussion was summarised after each topic and at the end of each focus group, enabling participants to comment and correct any misinterpretation.

Choice of setting

Focus groups are conventionally run face to face, using a location suitable for researchers and participants. However, to reduce transmission of Covid-19, people were advised to physically distance themselves, to meet outdoors rather than inside and to wear face masks [ 29 ], making physical meetings difficult to conduct. Virtual focus groups have been previously reported, with researchers using a variety of techniques such as message boards and video conferencing, with cost of equipment (e.g., webcams) and programmes listed as potential disadvantages [ 30 , 31 ]. The restrictions imposed to limit the spread of Covid-19 accelerated the widespread adoption of virtual meeting platforms such Zoom® for both work and social uses. Indeed, many participants in this study described the benefits of online meetings, indicating that many of the earlier challenges with virtual platforms, such as equipment availability, had been overcome. Table 1 lists potential advantages and disadvantages of physical (under Covid-19 restrictions) and virtual meetings. The assessment was made that, with the ongoing pandemic associated restrictions, the virtual platform was the most appropriate technique to enable the focus groups to be conducted.

Participants and recruitment

Participants for the focus groups included independent prescribing pharmacists or physiotherapists working in primary or secondary care in the West Midlands region. No easily accessible list for pharmacist and physiotherapist independent prescribers was available and therefore participants were recruited indirectly using groups such as the United Kingdom Clinical Pharmacy Association and West Midlands NMP leads. An email, including study details, participant information sheet, screening questionnaire and contact email address, was sent to these groups and recipients were requested to forward the email to potential participants.

The number of qualified independent pharmacist and physiotherapist prescribers in the West Midlands region is unknown, as this information is recorded by individual healthcare providers, and not centrally. Therefore, the intention was to recruit 10 prescribing pharmacists and 10 prescribing physiotherapists, allowing for non-attendees, but providing sufficient participants for a meaningful discussion [ 21 , 25 , 32 ]. The literature on focus groups recommends a group size of 6 to 8 participants, with recommendations to over recruit by approximately 20% in case of non-attendance [ 21 , 25 , 32 ]. Participants were required to have obtained their prescribing qualification since the beginning of 2013 (when physiotherapists gained independent prescribing rights [ 19 ]), and the final selection was guided by the sample matrix in Table  2 .

Participants were asked to sign and return a consent form, including consent to record the focus group, prior to the focus group being conducted. Recruitment was closed in October 2020.

Ethical considerations

Ethical approval for the study was obtained from the University of Birmingham’s Science, Technology, Engineering and Mathematics Ethical Review Committee (ERN_19-1900) and all data were held securely in accordance with university policy. Participation was voluntary and participants were free to withdraw at any time, however they were made aware that if they had already participated in the discussion, then it would not be possible to remove their contribution. All participants gave written consent, including for digital audio recording, prior to the focus group. All recordings were transcribed verbatim and anonymised to ensure that participants, locations, or other identifiable information were removed, and participants were assigned an identification code.

Data analysis

Digital transcripts of each conversation were produced by the virtual platform, and these were checked for accuracy, corrected, and verified by EGC. This process required repeated listening to the recording, hence ensuring all information was captured accurately, and permitting immersion in the data. Following transcription, data were imported into NVivo® 12 (QSR International) for thematic analysis [ 21 , 33 , 34 ]. The transcript for Focus Group One was read and reread to identify emergent themes and patterns, and coded line by line, with new codes created as themes emerged. The process was repeated for Focus Group Two, with further themes added as they emerged. Coding was an iterative process, with repeat reviewing of the coded data to ensure consistency and initial thoughts on the findings recorded using the NVivo memo function. Finally, the themes were reviewed and consolidated where appropriate. A codebook was produced to support the coding process. Data was visualised using a concept map of the major and minor themes and interdependencies, and a sunburst graph which depicted the frequency that themes were mentioned. Quotations illustrating each theme were presented as a table (Table 4 ). The initial coding was done by EGC, and the themes and hierarchy were discussed critically by the research team.

The study is reported in accordance with the COREQ statement (Additional file 2 ) [ 35 ].

Eighteen participants initially expressed an interest in participating in the focus groups. The recruitment window was extended, and further invitation emails sent to encourage further interest in participation, but the response remined low. The decision was taken to conduct the focus groups with the existing pool of potential participants, rather than risk a high dropout rate as participants were called to care for Covid-19 patients. Even with this approach, five potential participants who had previously expressed an interest failed to respond to the focus groups emails. A further three participants were excluded: two were ineligible, and dates were unsuitable for one, leaving ten participants. Three participants participated in Focus Group One and seven participated in Focus Group Two. Brief demographic data are included in Table 3 . Focus Group One was held on 23 November 2020 in the evening and Focus Group Two on 3 December 2020 during the day, each lasting just over one hour.

Initial coding was reviewed by EGC by reading the results for each node coded and the matrix tool in NVivo utilised to check that coding was appropriate. A concept map of themes was derived by EGC following coding of the transcripts, and the map and derived themes were debated by EGC, AR and JM to ensure they reflected participants views. After further discussion, the hierarchy and concept map were re-drawn to reflect the lived experiences of the participants more accurately. For example the original hierarchy did not contain a ‘self’ theme and hence ‘personal competence’ was grouped under ‘governance’ instead. However, as this quote highlights, ‘personal competence’ is derived from the participant’s views and feelings, not externally driven:

‘…as long as it's, it's, something that, you know, you feel comfortable within your competence, because I think that's where sometimes, some of my colleagues have got more experience in sexual health, whereas I haven't so it might be something that I'll say ‘I'm not comfortable. I would refer you to this service’…’ FG1-P2

Obsolete or duplicate codes were also removed, for example the original codebook included an ‘advisory role’ code, but on review the ‘team role’ code was deemed to be more appropriate.

Thematic analysis identified five themes each comprising several subthemes. Figure  1 depicts the themes as a sunburst chart. The size of each segment reflects the number of references to the item, and hence the relative importance of the topic to the participants. The inner ring contains the themes, with subthemes radiating out.

Sunburst chart depicting the themes and subthemes, and their relative importance as indicated by area of segment

Figure  2 is a concept map depicting the hierarchy and interrelationships between themes and subthemes. Table 4 lists the themes and sub themes, their code book descriptions, and illustrative quotes from the participants.

Concept map of hierarchical structure depicting interrelationship between themes and sub themes

The five themes identified were ‘Staff’, ‘Self’, ‘Governance’, ‘Practical aspects’ and ‘Patient care’. Some subthemes did not fall easily under any of these themes, rather they linked disparate themes or subthemes, and are described as orphan themes. These were ‘Conflict of interest’, ‘Covid’, ‘Undergraduate prescribing’, and ‘Good advice’.

This was the most frequently mentioned theme, particularly in relation to the clinical team but also to managers. The theme described the relationship between participants and senior and junior medical staff as well as other team members. Differences were highlighted in interactions between participants and senior or junior medical staff. The role within the clinical team was described and who lead on decision making. A lack of awareness of non-medical prescribing was identified by some, mainly physiotherapist, participants. Managers who prescribed were more supportive compared with non-prescribing managers, who may be unaware of prescribing governance issues. The ‘Managers’ subtheme linked to ‘Training’ and ‘CPD’ through the provision of funding and time.

This was the second most important theme, describing the participants’ practice. It encompassed the role prescribing took within their job and, for some, the challenges associated with incorporating this into their existing role, as well as prescribing within their personal competence, and support they gained from others, such as the clinical team. The theme highlighted training aspects including access to, and skills gained on, the course. The ‘Prescribing role’ subtheme linked to the ‘Stopping’ subtheme as part of ‘Patient care’.

This theme incorporates aspects such as policies and guidelines supporting NMP, organisation NMP registers, formulary and continuing professional development (CPD). Participants highlighted other policies affecting their practice, including accountability for patient care, which may influence senior medical approach to non-medical prescribing. Two minor subthemes were identified, which were profession specific: ‘Legislation’ affecting physiotherapists and ‘Second check’ affecting pharmacists.

Practical aspects

This theme incorporates those resources required to undertake prescribing, such as access to clinic rooms, information technology, appropriate budget and administrative support. Administration time was built into the roles for physiotherapist participants, whereas pharmacist participants described a lack of provision for administration time.

Patient care

This theme incorporates aspects of patient care including the impact on patients by ensuring prescriptions were appropriate and completed in a timely manner. Other benefits included improvements in quality and safety for example by stopping inappropriate medication and having sufficient clinic time to check adherence. ‘Quality and safety’ linked with ‘Governance’.

Orphan themes

Two of these themes were only mentioned by pharmacist participants and they were ‘Conflict of interest’ and ‘Undergraduate prescribing’. Several participants highlighted the impact the Covid-19 pandemic had on their practice and the final theme collated the advice the participants would give to new prescribers.

This study enabled an in-depth investigation of issues affecting pharmacist and physiotherapist non-medical prescribers. Participants’ lived experiences supported further exploration of the findings from a Delphi study [ 15 ]. Five themes, describing the experiences of the participants were identified.

The theme of “Staff” reflected the previous Delphi findings whereby the clinical team (medical, nursing and peer support) accounted for approximately 40% of factors affecting NMP achieving consensus [ 15 ], and further confirming the role of medical professionals and colleagues in supporting NMP, identified in the preceding review [ 14 ]. This is unsurprising as all participants described working collaboratively to share the patient caseload, within a multidisciplinary team usually led by a medical professional. Traditionally senior medical staff were accountable for the patient’s care, and team members had closely defined roles. More latterly the move has been towards advanced practice in the non-medical professions, to develop a flexible workforce that is able to adopt innovative ways of working. This was described in the 2017 draft workforce strategy, which highlighted the increasing demand on the NHS, and the limited number of clinicians to provide care [ 36 ], and which built on earlier work such as developing primary care services [ 9 , 37 ]. In addition, NMP courses require the trainee to complete a period of practice-based training supervised by an experienced prescriber. Until recently all regulatory bodies required this trainer to be a member of the medical profession, fostering closer links between trainer and trainee, which many participants commented on.

The “Self” theme, accounting for approximately a quarter of all references, focused on the “Prescribing role”, the role that prescribing had within the participant’s job and whether prescribing was integral to that role. All prescribers are required to prescribe within their scope of practice and the prescriber’s role implicitly defines that scope, together with guidance from regulatory and professional bodies [ 38 , 39 , 40 ]. Some pharmacist prescribers described challenges when prescribing had been added into their existing role, implying that for this group, the potential impact of prescribing had not been fully considered.

The“Practical aspects” and Governance” themes together highlighted the importance of ensuring adequate facilities for the prescriber, and a strong governance framework to support their prescribing practice. Covid-19 was found to affect some prescribers, either by altering how they practice, or by temporary changes to their role, as found by the “Covid-19″ theme. However, changes brought about by the Covid-19 pandemic also appeared in the “CPD” theme, with many participants describing online conferences and meetings becoming routine practice; enabling participation by a wider audience.

The relatively limited number of references to patient care may be considered surprising when compared with the Delphi study, where the top ranked statement concerned the effectiveness and benefits of prescribing for patients [ 15 ]. However, this finding partially reflects the different research methods, with Delphi seeking consensus whereas focus groups enable deeper exploration of lived experiences of the participants. It also reflects the topics chosen for discussion, which were those where there were areas of potential disagreement between the two prescribing professions, and hence patient care was a subsidiary aspect of the discussion.

Inter-dependencies

The previous review exploring barriers and facilitators to non-medical prescribing identified that many of the factors involved were inter-dependent [ 14 ]. The experiences of the participants in this study supported this finding, with the important secondary co-dependencies depicted in Fig.  2 . The “Quality and safety” theme was interdependent with all aspects of the “Governance” theme, resulting in improved care for patients. For example, participant FG2-P5 described constructive discussions with senior medical staff, informed by policies and guidance, resulting in team-wide changes in prescribing practice and improved patient care. For pharmacy managers, there was an implicit conflict between service delivery and governance, inferred by the “Second check” theme. Pharmacists are experts in medicines [ 41 ]; clinically screening prescriptions, the so called ‘second check’, to ensure appropriateness for the patient. Pharmacy managers are required to maintain the governance structure surrounding medicines supply, within a limited staffing establishment, and this can result not only in limiting time for pharmacist prescribing, but also difficulty in providing the second check. Evidence indicates that pharmacist prescribers make fewer errors than medical staff [ 42 ], but pharmacist participants perceived that they had been left without an important safety net. Further co-dependencies described by participants included the impact on senior medical staff of policies regarding patient accountability, with concern by some senior medical staff that they were accountable for the non-medical prescriber’s actions. This lack of clarity regarding accountability was identified in the previous review [ 14 ]. The prescribing competency framework for all prescribers states that the prescriber is accountable for their prescribing decisions [ 39 ], however if a policy regarding patient accountability states that the consultant is responsible for the actions of their entire team, then this could result in confusion.

Inter-professional differences

Differences were highlighted between professions, many of which could be anticipated from the way in which each profession traditionally works. For physiotherapists, prescribing forms another treatment option when caring for patients, fitting in to existing roles such as in musculoskeletal clinics [ 43 ], whilst also supporting the development of new roles based on existing skills [ 10 ]. For the secondary care pharmacist participants, prescribing in many instances was in addition to their existing role, without due consideration to restructuring job plans to allow sufficient time. Consequently, physiotherapist participants felt well-supported for administration time, whereas for the pharmacist participants, unless expressly included in their job plan, administration time was a source of stress. Similarly, pharmacist participants, used to working in a team, described a team approach to decision making, compared with physiotherapists, used to planning treatment courses for patients, who were more inclined to make their own decisions.

For the physiotherapist participants, the choice of medicines that they can prescribe is limited by their professional scope of practice and legislation [ 38 , 44 ], compared with pharmacists who can prescribe any medication, except certain drugs for the treatment of addiction [ 45 , 46 ]. For the physiotherapists, probable changes in controlled drug legislation have the potential to influence how advanced practice roles develop, particularly if physiotherapists continue to have restricted access to controlled drugs [ 47 ]. One physiotherapist participant described the constraints imposed by controlled drug legislation in chronic pain management, but commented that current guidance was moving away from drug treatment and hence expanding the choice of controlled drugs physiotherapists could prescribe may have limited impact in their case [ 47 , 48 ].

Physiotherapist participants were more likely to describe lack of awareness of physiotherapist prescribing by the clinical team, than pharmacist participants. This reflects both the relatively short time span in which physiotherapists have had prescribing rights (independent prescribing rights since 2013) and the small numbers registered as prescribers (1017 independent prescribers in 2019) [ 17 , 19 ]. In comparison, pharmacists gained independent prescribing rights in 2006, with 8077 independent prescribers on the register in 2019 [ 49 , 50 ].

Planned changes in pharmacist pre-registration training, including at undergraduate level, will result in newly registered pharmacists registering as independent prescribers [ 51 ]. Pharmacist participants expressed concerns about this development, including detraction from training aspects and potential exacerbation of prescribing errors, as previously identified with junior medical staff [ 52 ]. The participants placed their views in the context of their own prescribing training, highlighting the struggle that less experienced pharmacists had with the course, and commenting that routine pharmacy work still needed addressing. However, the development is in line with the Carter report and draft workforce strategy, which both envisaged a clinical pharmacy workforce, with pharmacy technicians adopting some of the traditional pharmacist roles [ 36 , 53 ]. The concerns expressed by pharmacist participants regarding time pressures to complete their tasks suggest that advanced pharmacy technician roles, which would release pharmacist time for prescribing, have still to be adopted.

Trustworthiness of the data is supported by the approach to analysis. Full, in-depth discussion of the findings by all authors, with challenge of the derived themes to ensure that they reflected the participants experiences was undertaken. The differences in background and experiences of the research team composition ensured that EGC’s longstanding prescribing experience in critical care, and possible preconceptions, were counterbalanced by the other team members, who were non-prescribers but clinicians in both physiotherapy and pharmaceutical fields. Data saturation was achieved, with the themes and main subthemes identified by each focus group and profession. This is supported by the answers to the final question regarding advice to new prescribers, added as a positive end note to each session. No new ideas were articulated but participants emphasised the need for a prescribing role, ensuring facilities were in place beforehand, asking for advice and not being pressurised to prescribe medication that they deemed outside their personal competence.

Strengths and limitations

The study allowed in-depth discussion of issues affecting pharmacist and physiotherapist prescribers, with ideas developed by the participants throughout the discussion. Participants drew on their experiences to describe issues affecting them, allowing a greater understanding of the background and contributory factors. As the themes were derived directly from these lived experiences, they acquired content and face validity.

The virtual platform, with choice of dates and times, allowed participants to join who may otherwise have been unable to because of constraints such as work commitments.

The Covid-19 pandemic limited recruitment: in particular fewer physiotherapist participants were recruited than planned. However, findings appeared unaffected with no new themes emerging from the second focus group. This supports the assertion that data saturation was achieved for the major themes identified.

It is acknowledged that recruitment may have been enhanced by widening the geographical catchment area. However, it was possible that some of the variation seen in the previous Delphi results [ 15 ] may have arisen from the wide range of practice and geographic areas in which participants were employed. Therefore a deliberate decision was made to limit recruitment to pharmacist and physiotherapist prescribers working in the NHS West Midlands area (either primary or secondary care), to reduce the risk of introducing variability into the findings.

The key finding from this study related to the theme of collaborative working with the clinical team; emphasising the impact this has on successful implementation of NMP. When their role was specifically designed to include prescribing, this was a benefit for pharmacist participants. Multiple factors contribute to the themes of governance, practical aspects and patients, and each factor is important for successful implementation of NMP. Crucially, the identified themes and subthemes cannot be considered in isolation but are inter-dependent on each other.

Differences between the professions were illustrated from the analysis, most reflecting the way each profession practises and, for pharmacists, the way that prescribing has been introduced into their role. For the pharmacists, managers need to address the skill mix to enable pharmacist prescribers to practise with support.

To ensure NMP is fully enabled, all aspects must be fully scoped before recruiting or training a non-medical prescriber. Failure to do so may limit full utilisation of prescribing skills and result in a poorly motivated workforce.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Continuing professional development

Interpretative Phenomenology Analysis

National Health Service

Non-medical prescribing

United Kingdom

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Graham-Clarke, E., Rushton, A. & Marriott, J. Exploring the barriers and facilitators to non-medical prescribing experienced by pharmacists and physiotherapists, using focus groups. BMC Health Serv Res 22 , 223 (2022). https://doi.org/10.1186/s12913-022-07559-5

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Facilitators and barriers to non-medical prescribing – A systematic review and thematic synthesis

Emma graham-clarke.

1 School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom

Alison Rushton

2 Centre of Precision Rehabilitation for Spinal Pain, School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom

Timothy Noblet

John marriott, associated data.

All relevant data are within the paper and its Supporting Information files.

Introduction

Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom.

The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786).

Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances.

Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists.

The drive behind non-medical prescribing in the United Kingdom (UK) is the need to deliver high-quality healthcare to patients where and when they require it, within a limited financial resource [ 1 – 3 ]. Innovative patient centred care pathways are being developed, using the most appropriate healthcare professionals, such as clinical pharmacists in general practice [ 4 ], or prescribing physiotherapists streamlining musculoskeletal pathways [ 5 ]. The extension of non-medical prescribing to other professional groups continues; with pressure for physician associates to become prescribers [ 6 ] and paramedics; who were unsuccessful at the last consultation [ 7 ].

Non-medical prescribing evolved from limited list prescribing for a few nurses in the early 1990s to the current range of eligible healthcare professionals ( Table 1 ). Each healthcare professional must successfully complete an appropriate and approved prescribing course, and be registered as a prescriber with their relevant regulatory body. Professionally, they are expected to prescribe within their competency area [ 8 , 9 ].

An independent prescriber is responsible for the care of the patient, including prescribing.

A supplementary prescriber works in collaboration with an independent prescriber and the patient to prescribe according to a pre-determined treatment scheme.

The initial uptake of non-medical prescribing was slow, with approximately 240 pharmacists and 4000 nurses having qualified by 2005 [ 10 ], the later contrasting with the government’s anticipated 10000 nurses [ 11 ]. A recent report identified that approximately 53000 nurses and over 3800 pharmacists were registered as prescribers in 2015 [ 12 ], but was unable to identify how many were active. Previous survey evidence indicated 14% of nurse independent prescribers and 29% of pharmacist independent prescribers were not using their prescribing qualification [ 10 ], and other estimates [ 13 ] indicate under 10% of nurse independent prescribers and nearly 40% of pharmacist and allied health professional prescribers are not using their prescribing qualification. Similarly, surveys conducted by the General Pharmaceutical Council indicate varying uptake of prescribing activity. In a 2016 survey of prescribing pharmacists nearly 90% of pharmacist prescribers were reported as active [ 14 ], whereas the previous 2014 report had found that only 61% had prescribed in the previous year [ 15 ]. The 2016 survey had a poor response rate (<18%) possibly overestimating activity through responder bias.

The full cost of training a non-medical prescriber (NMP) has been calculated as approximately £10000 [ 10 ] and, with increasing demand on the NHS and limited funding, there is a need to realise the full benefit of training investment. Previous studies have identified reasons for not prescribing including lack of support from colleagues or within their work environment [ 13 , 14 ], or a role change [ 10 ]; but did not explore these issues in depth. A previous thematic literature review of supplementary prescribing did not address the issue of barriers and facilitators specifically, but identified a limited number including: medical practitioner support, communication, resource limitations and specific supplementary prescribing aspects [ 16 ]. It also did not address independent prescribing. There has been no robust review of the qualitative literature relating to barriers or facilitators of independent non-medical prescribing. Identifying facilitators and barriers to independent non-medical prescribing has the potential for strategy development to optimise its implementation.

The aim of this review was to evaluate the use, facilitators, and barriers of independent non-medical prescribing in primary and secondary care in the UK.

Search strategy and selection criteria

A systematic review and thematic synthesis was conducted to explore the barriers and facilitators to non-medical independent prescribing in the UK. A protocol for the review was developed in advance, following the PRISMA-P statement [ 17 ], and registered with PROSPERO (CRD42015019786). The results are reported in accordance with the PRISMA and ENTREQ statements ( S1 and S2 Appendices ) [ 18 , 19 ].

Qualitative and mixed methods research studies investigating independent non-medical prescribing in the UK were included. Narrative reports describing a service, opinion papers and abstracts were excluded [ 20 ]. The legislation permitting independent prescribing by nurses and pharmacists was enacted in 2006 and therefore only studies published since 2006 were included [ 21 ]. There was no language restriction.

Specific search strategies were developed with expert librarian support, for each electronic database, and included broad and narrow, free text, and thesaurus based terms [ 22 ]. Boolean operators and truncation were used. The selected keywords were: nurse, pharmacist, physiotherapist, podiatrist, non-medical, therapist, allied health professional, chiropodist, independent prescribing, utilisation, barriers, facilitators, role, education, support, guidelines, policy, procedures, attitudes and clinic. The following databases were searched: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of science. Papers that cite, or were cited by, the included papers were screened to identify any further relevant papers. Searches were completed to 26 March 2017 ( S3 Appendix . Medline (Ovid) search strategy).

Titles/abstracts obtained from all searches were screened to remove duplicates and papers that did not meet the eligibility criteria. Full text copies of the papers remaining were obtained and reviewed. Two independent reviewers (EGC and TN) conducted each stage and resolved differences by discussion, with a third reviewer (AR) available for mediation if required [ 23 ]. Numbers excluded at each stage were recorded [ 18 , 23 ].

Quality assessment

A validated quality assessment tool, (Quality Assessment Tool for Studies of Diverse Designs, QATSDD), was used to assess the studies [ 24 ]. The tool was developed to support quality analysis where studies use different designs, including qualitative, quantitative, and mixed methods. The tool comprises 16 elements (listed in S1 Table . QATSDD scores for each paper) covering aspects such as theoretical approach, research setting, data collection, and method of analysis. Each element is rated on a scale of 0 –no evidence, to 3 –full details, with clear reasons defined for each score. Twelve elements are common to all studies, with two specific elements each for qualitative and quantitative studies. The studies included in this review used a variety of research methods, primarily interviews, questionnaires and focus groups, making this tool suitable. Two reviewers (EGC and TN) independently assessed the studies using the tool; resolving any disagreement in the scores through discussion. Including low quality studies in a qualitative systematic review is debated, with some researchers arguing for their inclusion as they may provide valuable insights, whereas others argue they should be excluded [ 20 , 25 , 26 ]. The decision was taken to include all studies to inform synthesis and conclusions regardless of quality assessment, but to report on the quality assessment results (see Table 2 ), particularly as from an initial scoping search, limited studies were identified.

* paper derived from linked theses.

§ paper derived from linked theses.

† linked reports of data from one study.

‡ linked reports of data from one study.

¶ linked reports of data from one study.

‖ linked reports of data from one study.

DMP, designated medical practitioner; F2F, Face-to-Face; GP, general practitioner; GPwSI, GP with a special interest; HEI, Higher education institute; NHSFT, National Health Service Foundation Trust; NP, nurse prescriber; NMP, non-medical prescriber; PP, pharmacist prescriber; PCT, primary care trust; QATSDD, Quality Assessment of Studies of Diverse Designs; SHA, strategic health authority; SSI, Semi-Structured interviews

Thematic analysis, to identify recurrent barriers and facilitators to non-medical prescribing and themes relating to use, was conducted on text from the results and findings sections of the papers together with any included participant quotations [ 69 , 70 ]. The studies were read to identify initial emerging themes, and then underwent line by line thematic coding utilising NVivo®11 (QSR International). As further themes emerged, new codes were created. All codes and themes were reviewed iteratively for consistency and appropriateness and amended if necessary. The findings were summarised under descriptive theme headings, permitting development of a hierarchy. The analysis was conducted by one researcher (EGC) and the initial themes and coding discussed and critically debated by all authors. The final version was agreed by all authors following further refinement of the theme headings and hierarchy. At the end of data analysis no further themes were identified, indicating that data saturation had been reached [ 70 ]. EGC is a practising NMP, and an NMP lead with a role in supporting other NMPs. This researcher standpoint was balanced by the other three authors, none of whom are prescribers.

The search strategy identified 3991 potentially relevant studies. Following exclusion of 459 duplicates and 3436 from title and abstract review, 96 studies were reviewed at the full text stage. Following exclusions, 42 papers were included ( Fig 1 . PRISMA flow diagram).

Overall, the studies were assessed as moderate quality. There were three low scoring papers [ 30 , 57 , 58 ] (score <25%), and four high scoring papers [ 27 , 31 , 43 , 52 ] (score >75%); the latter being doctoral theses ( S1 Table . QATSDD scores for each paper). Key issues highlighted by the scores were poor reporting of theoretical framework, data collection tool choice, analytical method justification, research question and analytical method fit, and user involvement.

Of the 42 papers, 30 (71%) were published between 2007 and 2012, with the remainder published subsequently. Nurse independent prescribers were studied in 24 papers [ 28 – 32 , 34 – 38 , 40 , 42 , 44 , 46 , 48 , 50 , 58 – 60 , 62 , 64 – 67 ], pharmacist prescribers in five papers [ 43 , 49 , 54 , 55 , 57 ], and a mixture of nurse and pharmacist prescribers in a further six papers [ 27 , 33 , 47 , 52 , 53 , 61 ]. The remaining papers investigated the views of patients and staff associated with NMPs [ 39 , 41 , 45 , 51 , 56 , 63 , 68 ].

Thematic analysis identified 17 subthemes of which 15 described the factors that may impact on NMPs and two described the range of activity. These were grouped into three overarching themes, which were 1) factors relating to the NMP themselves, 2) human factors and 3) organisational aspects. The themes and subthemes are presented in Table 3 , together with example factors, and S2 Table lists the papers that the themes were identified in. The 15 subthemes impacting on non-medical prescribing contained factors which could be barriers or facilitators; in many instances, this was dictated by circumstances.

Non-medical prescriber themes

Factors affecting the NMP were subdivided into those arising from the attitude of the NMP and those derived from their practice (See Table 3 ). Prescribing enabled the professional to practice autonomously [ 21 , 28 , 31 , 37 , 42 , 46 , 65 ], enhancing job satisfaction [ 31 , 37 , 42 , 46 , 47 , 49 , 65 ], and supporting professional development [ 27 , 33 , 47 , 50 ]. Some practitioners, however, expressed anxiety [ 29 , 37 ] and cautiousness [ 27 , 48 , 52 , 65 ]. Practitioners indicated that their area of competency enabled them to prescribe confidently [ 44 , 48 , 52 , 65 – 67 ], and to resist pressure to prescribe outside this area [ 34 , 44 , 52 , 65 – 67 ]. Roles were enhanced through including prescribing [ 27 , 33 , 35 , 37 , 42 , 44 , 58 , 63 , 67 ].

Human factor themes

Human factors described the impact that NMPs had on their patients, colleagues, and managers, and the impact that these people had on the NMP themselves. Medical staff that had been involved in the training of NMPs [ 39 , 54 , 63 ] were more supportive than those who were unaware of the training involved [ 39 , 43 ]. This was regardless of seniority [ 55 , 66 ]; junior medical staff were less likely to be supportive [ 39 ]. Managers were instrumental in developing and supporting the NMP role [ 27 , 36 , 41 , 43 ]. Lack of support, flexibility or understanding by managers hindered the implementation and development of non-medical prescribing [ 27 , 29 , 31 , 32 , 37 , 46 , 52 , 54 , 61 , 66 , 67 ]. NMPs gained support from colleagues, describing enhanced team working [ 27 , 32 , 34 , 35 , 41 , 43 , 47 – 49 , 55 , 57 , 65 – 67 ], and were perceived as supportive experts and leaders [ 27 , 32 , 43 , 47 , 67 ]. However, NMPs encountered opposition from some colleagues [ 21 , 27 , 31 , 32 , 38 , 43 , 44 , 47 , 52 , 62 , 66 ].

Organisational aspect themes

Organisational aspects encompassed a range of themes covering administration, development and service delivery. Administration comprised three subthemes: formulary, policy, and remuneration. A formulary could be self-imposed [ 27 , 31 , 32 , 48 , 52 ], or organisation derived [ 27 , 29 , 31 , 32 , 36 , 62 ], and while they could be empowering [ 31 , 36 , 52 , 66 ], they could be restrictive [ 27 , 29 , 32 , 36 , 48 , 52 , 62 ]. Local policies could be supportive [ 27 , 47 , 66 ], restrictive [ 27 , 31 , 43 , 66 ], or missing [ 62 ]. Remuneration was considered to be non-commensurate with skills [ 27 , 43 , 46 , 50 , 54 , 60 , 62 ]. Development covered both training, including selection for course, as well as post course support. Course facilitators included appropriate selection of candidates [ 35 , 39 , 41 , 45 , 47 , 50 ], awareness of course commitments and requirements [ 48 ], and support from medical mentors [ 43 , 63 ], and managers [ 39 , 41 , 45 ]. Post course support included the provision or facilitation of professional development courses [ 27 , 36 , 41 , 47 , 48 , 67 ], mentoring [ 27 , 41 , 48 , 50 ], and clinical supervision [ 27 , 36 , 66 ]. Absence of such support hindered NMP development [ 27 , 33 , 35 – 37 , 43 , 46 , 48 , 52 , 62 , 63 , 66 , 67 ]. Infrastructure covered several issues, each with the potential to support or hinder, including access to: patient records [ 27 , 37 , 43 , 46 , 49 , 51 , 52 , 54 , 63 , 64 ], information technology [ 27 , 31 , 36 , 38 , 43 , 48 ], prescriptions [ 27 , 31 , 32 , 37 , 38 , 43 , 62 , 67 ], and facilities [ 43 , 49 ]. NMPs spent more time with patients [ 35 , 37 , 39 , 47 , 49 , 52 , 55 , 56 , 63 , 68 ], and were considered to provide a responsive, efficient, and convenient service [ 27 , 29 , 33 , 35 – 37 , 40 , 44 , 47 – 49 , 59 , 65 , 68 ]. Doctors’ time was released by NMPs activity [ 29 , 36 , 43 , 51 , 63 , 67 ], but time constraints and workload could hinder the NMP service [ 29 , 34 , 35 , 44 , 46 , 49 , 52 , 63 ]. Some services were now reliant on NMPs [ 36 , 37 ] and had issues when cover was absent [ 36 ]. The settings and patient groups where non-medical prescribing is utilised were diverse. Examples were given of utilising non-medical prescribing to treat patients who may find accessing healthcare difficult such as frail and housebound patients [ 37 , 52 , 63 ], the homeless [ 52 ], and drug users [ 43 , 58 ]. Non-medical prescribing was also utilised in more conventional healthcare settings such as specialist clinics (for example, dermatology [ 36 , 43 ], anti-coagulation [ 56 ], and cardiovascular [ 43 ]), minor illness clinics [ 31 , 36 , 37 , 44 , 50 ], and out-of-hours services [ 36 , 37 , 52 ].

During analysis, it became apparent that many factors were not present in isolation but were interdependent. Frequently, the interdependence was between a member of staff, the NMP, an organisational aspect such as policy, and how this impacted on the NMP’s confidence and ability to prescribe. Examples include a situation whereby a supportive GP had given an NMP confidence to develop her competence area and expand her personal prescribing formulary [ 27 ], and identification by NMP leads that an NMP role was more likely to flourish when linked to a strategic vision and a well-defined area of practice [ 41 ]. Other interdependencies were within organisational aspects, such as the increased time required when the NMP was unable to easily access the patient’s notes [ 37 ], or when the non-medical prescribing policy specifically supported access to continuing training [ 28 ].

This is the first systematic review to investigate and synthesise the qualitative and mixed methods literature regarding barriers and facilitators to, and use of, independent non-medical prescribing. Three overarching themes, each containing subthemes, were identified; the NMP, human factors and organisational aspects. The themes and subthemes could all impact on successful implementation of non-medical prescribing, and could be interdependent.

The NMP theme describes three aspects; one is intrinsic to the person (attitude), one derives from their role, and the final one may be personally or externally derived. The later subtheme ‘Area of competence’ was one of the four most highly mentioned aspects found during analysis, highlighting its importance. This is supported by the ‘Competency framework for all prescribers’ [ 8 ] and the NMC ‘Standards of proficiency for nurse and midwife prescribers’ [ 9 ], which state that practitioners should only prescribe within their scope of practice (in contrast with the traditional medical model). There are implications if the NMP changes role, or in planned service expansion, as further training and support in these new areas would be required. Closely defined areas of competence could hamper full utilisation of non-medical prescribing, particularly in patients with co-morbidities.

The second theme ‘human factors’ describes the complex interrelation between the NMP, their managers, peers, the medical professions they work with, and their patients. This theme included the most frequently mentioned subtheme ‘Medical professionals’, identified in 32 papers. It is notable that, in contrast with the review by Cooper et al, medical professionals generally accepted the NMP role [ 16 ]. Reasons for acceptance may be because non-medical prescribing has become established practice but also because NMPs have made deliberate efforts to gain trust. There was an appreciation that the NMP role permitted medical professionals to concentrate on patients where their expertise was necessary. Changes in managerial personnel could adversely impact on non-medical prescribing, particularly where systems and processes were not embedded into practice. This review found that patients’ views of non-medical prescribing were mixed, with many patients appreciating the time taken and holistic approach of the NMP, whereas others expressed concerns. A lack of public understanding of non-medical prescribing remains, even with patients treated by NMPs. Cooper et al noted that very little research was identified investigating the views of patients about non-medical prescribing [ 16 ]. This review identified one paper investigating public perception of non-medical prescribing [ 51 ] and eight papers that included the views of patients [ 27 , 28 , 40 , 49 , 56 , 59 , 61 , 68 ]; however, one of these only included quantitative ‘rating’ data from patients [ 40 ]. Research into patients’ opinions of non-medical prescribing warrants further investigation.

The final theme covers the organisational aspects that support and enable an NMP to practice. It contains two of the four most frequently mentioned subthemes, ‘impact on time’ and ‘service’. In comparison to other subthemes, these two were frequently interdependent on each other, with both highlighting the perceived improvement to patient care by providing a streamlined, holistic, and convenient service. Funding pressures may make this aspect of the service, appreciated by patients, difficult to sustain. This review identified that contingency and succession planning should be considered during service development.

This review’s strength lies in its rigorous methodology and breadth of search strategy. This compares with the previous investigations, which were limited in scope and rigour [ 14 , 16 ]. The predetermined stringent protocol, registered with PROSPERO, and the use of two independent reviewers are recognised strategies to reduce potential bias associated with paper selection [ 20 , 71 ]. Limitations included the inconsistent definitions used to describe NMPs, which became apparent during the literature search. The terminology would have been appropriate when those studies were conducted, but the meaning changed as prescribing rights evolved (see Table 1 ). Every effort was made to limit the included studies to those investigating full independent non-medical prescribing. The nursing profession dominated the included studies, with limited representation from pharmacist prescribers (mentioned in 11 papers [ 27 , 33 , 43 , 47 , 49 , 52 – 55 , 57 , 61 ]) and none from other non-medical prescribing professions. This reflects the relative numbers of the different professions [ 15 , 72 ] and the numbers of qualified prescribers [ 12 ]. However, the numbers of AHPS are likely to have increased recently following legislation changes and that could be considered a limitation. Research into non-medical prescribing by the other professions is needed to identify if they experience the same barriers and facilitators.

The themes and subthemes identified in this review influence the implementation and development of non-medical prescribing; each could act as a barrier or facilitator depending on circumstances. Where there was a lack of understanding of the non-medical prescribing role, or lack of trust in the non-medical prescriber, then the factors were more inclined to be barriers. For example, medical professionals were less likely to support non-medical prescribing where there was a lack of clarity about who took responsibility for the prescribing practice [ 35 , 39 , 50 ]. Facilitation of NMP occurred when medical professionals trusted the NMP, for example enabling access to patient records [ 37 ]. As a consequence of budgetary constraints, factors may become barriers, such as the use of restrictive formularies as a cost saving measure [ 37 , 52 , 64 ]. Additionally, this review has identified that these themes and subthemes do not stand in isolation but are interdependent on each other. Each of these aspects should be considered when developing a non-medical prescribing service, and could be utilised as a model for developing a non-medical prescribing strategy framework. This review will also inform those currently managing or running a service, enabling service optimisation. Failure to address all these aspects may mean that the full benefit of an NMP service will not be realised.

Supporting information

S1 appendix, s2 appendix, s3 appendix, s1 protocol, funding statement.

The authors received no specific funding for this work.

Data Availability

Transect science

HX NMP The case study will critically analyse and reflect on current practice considering

HX NMP The case study will critically analyse and reflect on current practice considering, the assessment diagnosis and prescribing process, In order to achieve this, a patient has been chosen to critically analyse the management of their care. discussing the challenges and complexities associated with prescribing, incorporating critical thinking and reasoning to formulate a conclusion to treatment. In addition, the case study will consider issues relating to the patient consultation such as legal, ethical and professional guidance and the use of the seven principles of prescribing as recommended by the National Prescribing Centre (1999). Throughout this work, the anonymity and confidentiality of the patient will be maintained in line with the Nursing and Midwifery Council (NMC) Code of Professional conduct (2008). Confidentiality is a legal obligation derived by law; it is a requirement of our professional code of conduct and is also included in our NHS employment contracts (Department of Health, 2003). Nurse prescribing first became part of the government’s policy agenda following the Cumberlidge report (DHSS, 1986). It suggested that nurses should be able to prescribe independently, highlighting that patient care could be improved. Subsequently from this evolved the first Crown report (DHSS, 1989) which recommended qualified nurses, district nurses and heath visitors should be authorised to prescribe in defined circumstances, from a limited formulary. The primary legislation that permitted initial prescribing was the Medicinal products : Prescription by nurse’s act 1992, then in 1997 the government set up a review of the prescribing (under the chairmanship of Dr June Crown, 1999) resulting in a second report being published ‘Making a difference’. Extending nurses roles of nurses, midwives and health visitor better use of knowledge and skills, including making it easier to prescribe. Since the publication of this seminal piece of work, non-medical prescribing has been analysed, reflected upon, researched at great lengths and changes in practice made (DoH 1989, 1999, 2006 & 2008; Luker et al 1994; Latter et al 2011) and is still under constant review. Supplementary precribing was first termed dependant prescribing by Crown (DH,1999) and introduced in 2003. Supplementary prescribing is defining a partnership between an independent prescriber (Doctor or Dentist) and supplementary prescriber to implement an agreed patient specific clinical management plan (CMP) with patient agreement (NMC 2006). However this can only take place once the independant prescriber has made a diagnosis (DH,2003) today this continues in practice particularly for newly qualified nurses prescribers, complex situations, team approach and patients (CMP) that includes the use of controlled drugs. It sets boundaries and parameters for chosen medications in relation to the disease/illness being treated (Nuttall and Rutt-Howard 2011). formalisation of Legislation came into effect on 31st May 2006. which enables all qualified Extended Independent Nurse Prescribers (now known as Nurse Independent Prescribers) and suitably qualified pharmacists to prescribe any licensed medicine. However the DOH 2006 stipulates although nurses and midwifes are legally able to prescribe any licensed prescription only medicine, they must also prescribe within the scope of practice or competence and are accountable for their own actions and emissions and must adhere to local, national policies, NMC code of conduct, NICE guidelines and framework set out by the DOH when formulating the prescribing process. This change in legislation has provided nurses with greater autonomy, in that they are now often able to complete episodes of care for their patients. However, it could also be perceived as a double-edged sword, given the increased responsibility that this additional qualification brings, .. advocates accountability and safe practice is paramount within this field of practice and puts a lot of responsibility on the non-medical prescriber. The author implemented Neighbour inner consultation model five stages connecting, summarising, handing over, safety netting and housekeeping (Neighbour,1987) . The author found it easy and simple to remember, whilst covering all areas needed to make an effective consultation and assessment. Neighbour,1997 firmly believes utilising this approach will ‘enable us to consult more skilfully, more intuitively and more efficiently’…. stipulates Neighbour provides us with a model that is structured and easy to recall. Its five steps feel more achievable than Pendleton’s seven steps. It is patient-centred, but also attends to the doctor’s feelings, and tries to tackle the tricky areas leading to dysfunctional consultations. l Health professionals consider nurses to be more approachable than doctors, better at communicating and more likely to involve patients in discussions about their healthcare (Courtenay et al, 2009a; 2009b; Watterson et al, 2009). Patients also think nurse practitioners ( NPs) offer more patient-centred consultations. This is due to nurses’ approachability, ability to build rapport, listening and communication skills, unhurried style and tendency to invite patient involvement (Stenner et al, 2011; Jones et al, 2007). The author is aware by having these skills make it easier for patients to share information, ask questions, and address problems, meaning they understand their condition and treatment better. It also makes it easier for patients to self-manage long-term conditions and adhere to treatment regimens according to (Courtenay et al, 2011; Stenner et al, 2011). The author, a nurse practitioner based in an Urgent Care Centre (UCC), In the North West England. The practitioner is currently employed as a trainee nurse practitioner. The role entails working autonomously: taking accurate clinical histories, physical examination, gain differential and working diagnosis and organise a plan of care. There is a need to liaise with a GP to prescribe medication if needed. This at times may cause a delay in a patient receiving their treatment. Completing the independent and non-medical prescribing module will enable the author to prescribe therefore providing the patient with an efficient timely access to treatment when required. advocates that prescribing is an enhanced skill that is vital for comprehensive patient care. In practice prescribing medication requires experience and knowledge and with it carries a range of legal and ethical responsibilities that necessitates a structured approach (While 2002). According to the National Prescribing centre (NPC 1999) writing a prescription starts a process that not only impacts on the patient, but on the prescriber and the NHS. Therefore, a seven-step framework, the ‘Prescribing Pyramid’ (NPC1999,) will be utilised to guide the consultation and prescribing decision. Utilizing the framework in this way ensured all relevant factors would be considered: maximum effectiveness, minimal risk and costs and respect for patient choice.

Step one ‘consider the patient’ (Taking the history ; clinical examination). At the outset of the consultation the author made a formal introduction, explaining the role of the non-medical prescriber, a problem orientated medical record was adapted to achieve a systemic approach to history taking and verbal consent was gained from the patient. The author is aware consultation cannot take place if some form of consent has not been obtained from the patient to make their own judgement. ; Stipulates consent is an integral part and must be obtained before any consultation can take place. Suggest consent should be freely and voluntary given therefore no pressure or unduly influences exerted on patients by health care professionals or relatives. …. for informed consent to be achieved the patient must be fully informed of treatment options available to them. … summarises the law of consent to medical treatment is derived from the ethical principles of desirability of self-determination and respect for integrity. The law on informed consent changed following a Supreme Court judgment, in relation to the Montgomery v Lanarkshire health board, 2015 case, enforcing Doctors must now ensure that patients are aware of any “material risks” involved in a proposed treatment, and of reasonable alternatives. The author is aware of the importance of listening carefully and acknowledging the ideas and concerns and expectations the patient may have. ; The consultation process is paramount to achieving an effective result, …. The first 90 seconds are vital to establish good repour. It is during this period the patient decide if he / she likes you. …. Suggest its important during pre-consultation phase we address the appropriate consultation. This involves the author having a fully understanding of the patients expressed hypothesis to attendance. It is important during consultation we establish rapport, explore ideas concerns and expectations, ; supports this stipulating if patients increase control over their health involves developing their competencies for making decisions and enacting behaviours that can lead to desired, and ;attainable, health outcomes.

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Miss A is a twenty-two-year-old female presenting to the urgent care centre with a three-day history urinary symptom, dysuria ( burning sensation), frequency of urination, lower abdominal pain and micturition. No history fever, loin pain or haematuria. No past medical history ( PMH ) no prescribed over the counter or herbal remedies, medications taken. No known allergies. a full patient history was taken can be found in appendix 1 . advocates the presenting features of lower urinary tract infection include frequent urination or an urgent need to urinate, dysuria, suprapubic pain and turbid or foul-smelling urine. Also fever and non-specific lower back pain may be present. ; concludes Loin pain accompanied by systemic symptoms such as fevers, rigors, nausea and vomiting may suggest an ascending infection or pyelonephritis. However, in elderly patient’s diagnosis is more challenging, as confusion may be the only presenting symptom. It’s also important to consider that UTI may not always be due to infection. Following history taking, a physical examination was carried out, with consent, which consisted of reviewing vital signs, and review of system’s including abdominal and flank examination. History taking can be the most important part of the consultation; Fisherman, 2014 believes that history taking is where 90% of diagnosis are made. From the history and clinical examination and routine urinalysis a differential diagnosis of uncomplicated urinary tract infection (UTI) was formulated. Uncomplicated UTI is one in which there are no structural or functional abnormalities within the urinary tract .Urinary tract infection are caused by an invasion of the tissues of the urinary tract, resulting in effecting one or more parts of the urinary system (bladder, kidneys, ureters and urethral A thorough history, examination and routine investigations can help identify if uncomplicated or complicated urinary tract infections, patients with risk factors, defining more specific investigations culture, bloods, referrals to urology or more prolonged treatment. To support the examination, diagnostic testing is required & suggests a formal microscopy, culture and susceptibility testing should be performed in most circumstances to ensure patients receive appropriate antimicrobial therapy, especially given the rising incidence of antibiotic resistance. This is particularly important in men, pregnant women and patients with recurrent infections. The author carried out a routine urinalysis dipstick which is a very common in the primary care setting. The results detected Blood +1 and Leukocyte +2 other finding from test within normal parameters in the urine sample. However, Pan Mersey guidelines recommend not to routinely culture as 90% of cases will give a positive result. When the author considers UTI differential diagnoses other possibilities can include pelvic inflammatory disease, sexually transmitted diseases, urothelial carcinoma and bladder calculi. This highlights the importance of careful diagnosis, investigations and follow-up. To help formulate a diagnose to be confirmed or refuted, clinical examination and investigations are needed. Urinary tract infections (UTIs) are among the most common bacterial infectious diseases encountered in clinical practice and account for significant morbidity and high medical costs. Escherichia coli is the most predominant pathogen causing 80-90% of community-acquired UTIs and 30-50% of nosocomial-acquired UTIs, research reports UTIs are one of the most frequent clinical bacterial infections in women, accounting 25% of all infections, data supports this advising around 50-60% women will develop UTI in their lifetime.

The second stage of the NPC’s prescribing pyramid comprises consideration of appropriate strategy/treatment plan required. The decision to treat in whiles opinion (2002) accumulation of reaching a diagnosis of achieving concordance with the patient. The patients expectation from the consultation is a prescription for antibiotics, however good prescribing practice does not always lead to a prescription; non-medical prescribers can also decide not to treat, instead providing health education and advice or recommend the purchase of an over the counter medicine ( NMP 1999, While 2002) However in order for the nurse prescriber to be able to reach a decision in forming a diagnosis for the patient it is necessary to have a firm underpinning knowledge of various medical conditions and how they can present in different ways (Douglas et al, 2009).

According to Nice Guidelines antimicrobial resistance poses a significant threat to public health, especially because antimicrobials underpin routine medical practice. Following Pan Mersey local guidelines ‘ strategies to optimise prescribing of antimicrobial in primary care, a diagnostic algorithm for UTIs in adults should be implemented in the prescribing decision. The guidelines recommend patients who present with severe or more than 3 symptoms and no vaginal discharge or irritation, empirical antibiotic should be prescribed. If the patient has mild or less than two symptoms of UTI. (see appendix 2) When deciding on empiric therapy for a UTI, local resistance patterns to antibiotics are an important factor in choice of therapy. The decision to prescribe antibiotics is one of the most common treatment decisions faced by frontline primary care clinicians daily, and urinary tract infection (UTI) is one of the most common bacterial infections encountered. Although antimicrobial treatment for UTI is accepted in clinical practice, antibiotic resistance in urinary bacteria is increasing, with rates cited in the literature of between 20% and 40% to trimethoprim and amoxicillin respectively. Bacteria are adept at side-stepping human intervention (for example, antibiotics and vaccines) and are developing resistance to antibiotics faster than the pharmaceutical industry is developing new ones: only two new classes of antibiotics have been developed in the last 30 years. Therefore, given this consideration, antibiotic choice should be based not only on efficacy and safety, but also, on the concept that broad spectrum antibiotics should be spared to safeguard their future effectiveness. Public health England 2017 devised TARGET : Treat Antibiotics Responsibly, Guidance, Education, Tools. The toolkit helps influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing.

Stage 3 – Consider the choice of product. Miss S met the criteria to prescribe antibiotics, symptomatic having 3 indicating symptoms consistent with the algorithm utilised and a positive urine sample. Before consideration of prescribing the antibiotic its important the prescriber is aware of all known allergies, polypharmacy medications and renal profile, to ensure safety in prescribing. Using the Antimicrobial Guidelines Summary (2014) which is devised by the NHS Pan Mersey Area Prescribing Committee and the BNF (2014) formulating a decision to prescribe 1st line of recommended drugs for UTI : Nitrofurantoin 100mg MR twice daily for three days . Referring to number of previous studies cited support this decision that short courses of 3 days of antibiotics are as effective as longer courses in uncomplicated UTI & Collaboration with the mnemonic EASE which is recommended by the NPC (1999) was utilised to help ensure an Effective product, which is Appropriate for the patient, which is Safe to use and one that is cost Effective. The pharmacokinetics of nitrofurantoin are as follows: Nitrofurantoin is readily absorbed and quickly distributed into most of the body fluids. The drug exhibits bacteriostatic or bactericidal effects by inhibiting the synthesis of DNA, RNA, protein and cell wall synthesis. Mechanism of action is activated by bacterial flavoproteins to reduce reactive intermediates, therefore causing inhibition of DNA RNA protein. The overall effect is inhibition of bacterial growth or cell death, partially metabolized in the liver to aminofurantoin. Nitrofurantoin is readily absorbed in GI tract primarily in the small intestine. It is enhanced by food or delayed gastric emptying via enhanced dissolution rate of the drug. It is rapidly excreted in large amounts in bile and urine. Except for the active drug secretion in the kidney tubule and biliary drug transport, nitrofurantoin transfer across body membranes occurs by diffusion. Nitrofurantoin has a short elimination half-life in whole blood or plasma. Its half-life of 0.3-1 hour. The author also advised over the counter analgesia paracetamol 500mg qds for three days, and ibuprofen tablets 400mgs three time daily with food or after food, for analgesia effects and anti-pyrexia effects. This co-insides with Pan Mersey guidance recommends offering symptomatic relief with paracetamol. If the response is insufficient, offer a nonsteroidal anti-inflammatory drug (NSAID) in addition, such as ibuprofen or naproxen, unless not tolerated or contraindicated. The author is aware in practice if a patient presents with mild symptoms who has normal immunity, normal renal function, and a normal renal tract, other option to be considered. Treatment can be delayed seeing if symptoms will resolve without treatment, especially if the urine dipstick test is negative for nitrites and leucocyte esterase (indicating a low probability of a UTI). For all other patients start treatment without delay. Trimethoprim was once the first choice treatment for UTIs before Public Health England (PHE) in 2017 recommended switching to a different antibiotic nitrofurantoin. Due to a comparison study that showed only one in three (34%) of the samples analysed were found to be resistant trimethoprim, compared to 29.1% in 2015.

Negotiating a contract According to While (2002) the fourth stage of the framework emphasizes the importance of client practitioner partnership through negotiation. The expectation from the patient to prescribe antibiotics was highlighted during the consultation, therefore meeting the patient’s expectations. As discussed and agreed it was clinically indicated to prescribe antibiotics. Miss S conveyed she fully understood the rational for taking antibiotics and she did not express any concerns or anxieties. Also, the pain relief for analgesic and anti-pyrexia effects. Patients often attend with clear idea of the outcome that they expect, this can be varying from wanting a prescription or sick note to a simple desire for advice or reassurance ( Little 2005). In current practice the demands for a prescription primary care practice can become a challenging ordeal for practitioners as if the decision to prescribe a drug is not made. DOH (2013) recognises that consultations can often be challenging when patients expect antibiotics and may be unwilling to accept when they do not need them. To support Woodhead et al (2005) also argued that some prescribers perhaps prescribe unnecessary antibiotics for clinical reasons that may have no evidence base or for non-clinical reasons such as the desire to reduce attendance of patients, or for example the belief that patients may expect antibiotics simply based on a presenting symptom. The author is aware of the importance of patients have fully understanding in layman’s terms of how to take the drugs, concordance and side effects. As some patients experience side effects from taking antibiotics and are a common cause of repeat visits to see their GP.(Lim and Macfarlane, 2001). According to the medicines partnership ( 2007), it is becoming increasingly recognised that the notion of concordance or shared decision making is a way for practitioners and patients to come together to make the best use of medications prescribed thus ensuring optimum benefit. Concordance ensures that both parties have their say, A prescribing decision should be a shared contract between the prescriber and the patient. This helps to achieve compliance and adherence (Courtenay and Griffiths 2010). Nurse prescribers appear to place a high priority on respecting patient choice and this could help achieve adherence (Petty 2012). Often non-adherence is due to failure to educate and advise the patient when the prescription is initially given or failure to provide follow-up support. Hall (2010) outlined that if the patient is adequately educated about their treatment they are most likely to concord.

Stages 5, 6 & 7 – The three R’s: Review, Reflect, Record keeping and Reflection. Review In an urgent care centre, it is very often difficult to review patients following treatment as the patients often attending are transient, out of area or hard to reach. Therefore, this does not necessities the process criteria / setting to routinely review patients. Fragmentation of primary care for example, in-hours, out-of-hours, walk-in centres, and telephone call centres) makes this more difficult. The patients are giving safety netting advice, should the unforeseen problems occur, the patients’ needs to be informed of when and how to seek further help. Ruth Lonsdale ( 2007) describes safety netting as ‘worst case scenario’. Patients are advised if symptoms don’t improve after treatment or worsening symptoms, reattend urgent care, follow up with their own general practitioner. Clinical red flags are discussed in the event of severe abdominal, loin pain, uncontrolled fevers, vomiting or deterioration of health access their nearest emergency department, or call NHS 111 If there is a recognised risk of deterioration or complications developing then the safety-net advice should include the specific clinical features (including red flags) that the patient or parent/carer should look out for. So, safety-netting is arguably the most important part of the diagnostic process. Otherwise, the objective must be to empower the patient, parent or carer so that they can take responsibility for monitoring their own situation and are able to take effective action when needed.

Record Keeping It is crucial to understand that the role as a non-medical prescriber includes patient safety, completing clear valid record keeping, effective communication, and documentation. Record keeping is an integral part of a nurse prescriber’s care and treatment that is every bit as important as the direct care you provide to patients. Record keeping also has a vital legal purpose. It provides evidence of your involvement with patients and needs to be detailed enough to demonstrate that you have fulfilled your legal and professional duty of care It is imperative that a high standard of record keeping is maintained and the details of the prescription need to be recorded immediately. Any item prescribed by a designated non-medical prescriber must be entered into all patient records within 24 hours. In accordance the NMC code of conduct (2008) A clear and accurate account of the clinical assessment and examination along with the details of the prescribing decisions were entered into the patients secured electronic records, a copy of which will be forwarded to GP, to ensure continuity of care and safe practice. (Dowell, Williams & Snadden ( 2007) stipulate there are four main roles to & record keeping, assist recall of events enables audit of care, provides communication between colleagues when necessary, provides evidence in litigation. All prescribers are required to keep records, which are accurate, unambiguous and legible in line with requirements of the registering body standards for records.

Reflection On reflection, this case study utilised a structured consultation process in non-medical prescribing, resulting in a successful outcome. The health professional needs to be competent in a wide range of skills and competencies, have underpinning knowledge, to ensure effective outcomes (Medicines Partnership Programme 2007). From the onset the patient had a clear expectation of what she wanted. Through a concise history taking, clinical examination and routine testing achieved accurate diagnosis, enabling an evidence-based drug to be prescribed, however prescribing is not just simply the task of writing a prescription, but it is about the knowledge and skills to assess, examine, diagnose and treat the patient. To be truly independent means having the responsibility of assessment and management from start to finish (Strickland-Hodge 2008). The NMC The author is of the understanding that not all consultations reach a shared agreement, ultimately best practice should demonstrate effective good communication and interpersonal skills, are paramount. However, when patients report they are dissatisfied with their care, it is often a break-down in communication ( While 2002). Misunderstanding can lead to poor outcomes. Barry et al 2000) and inadequate information can result in prescribing errors (Courtenay & Carey 2008). From devising and researching the case study has highlighted and enhanced knowledge of the important areas associated with prescribing such as clinical reasoning, evidenced based research, consultation styles, and legal implications Demonstrated throughout case study was the incorporation of the ‘prescribing pyramid’, Neighbour hoods inner consultation models to help structure the process. It could be argued that there is no correct consultation model and various models which may be used will be effective in different circumstances. Therefore, everyone will need to adapt to suit personal preferences (Coffey and Bowskill, 2010). The case study focused upon prescribing antimicrobials debate, the prescribers followed local and national guidelines, prescribing the shortest effective course, the most appropriate dose, route of administration. considering the risk of antimicrobial resistance for individual patients and the population. Furthermore, it is essential that Health Professionals follow guidelines and question their decision making prior to issuing a prescription for antibiotic therapy. This will hopefully help to tackle the growing issue of antibiotic resistance development and adverse reactions when taking antibiotics (Rowbotham et al, 2012). Importantly, prescribing of antibiotics should always be cautiously approached at every opportunity. To conclude Furthermore, when entering a new expansion of role, it may present the employee with additional barriers. Nurse independent prescribers are accountable in four areas of law which are civil, criminal, professionalism and accountability is implied via signing of a contract of employment. It is therefore paramount to add the prescribing role to a job description to get cover by employers’ vicarious liability (Lovatt, 2010). ). Therefore, it could be argued that nurses are accountable to the profession, the individual, our employer and society itself. It is important that nurses keep up to date with prescribing (Caulfield, 2005) It is crucial to understand that the role as a non-medical prescriber includes patient safety, completing clear valid record keeping, effective communication, team working, risk management and continuous professional development. Also, the importance of keeping up to date with evidence-based practice. As a non-medical prescriber, the author has devised learning outcomes to continue an ongoing portfolio will be used to demonstrate evidence of continued learning. Clinical supervision from non-medical prescribing colleagues within practice, will also be crucial for ongoing professional development and most importantly patient care. This case study has guided the author to define evidence practice and the importance of safe and appropriate prescribing in practice.

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Non-medical prescribing reflection examples

• Non-Medical Prescribing

Why do non-medical prescribers need to learn to become reflective practitioners?

During your non-medical prescribing course and clinical practice, nurse prescribers and pharmacist prescribers will be required to regularly reflect on their clinical practice to develop reflection and reflective practice skills.

Moreover, if you’re undertaking a non-medical prescribing course, you will be expected to submit as part of your coursework many reflective essays, i.e., a reflective account – so understanding what a reflection is and how to reflect is undoubtedly worth the investment.

Do medical prescribers need to reflect on their practice?

There is no one-size-fits-all answer to this question, as the need for reflection will vary depending on the individual and their clinical practice. However, medical prescribers should generally reflect on their practise to improve patient care and ensure they use evidence-based practices. Additionally, reflection can help medical prescribers identify areas where they need further education or training.

Do independent prescribers need to reflect on their practice?

Independent prescribers need to reflect on their practice to ensure that they prescribe safely and effectively. By reviewing their own practice, independent prescribers can identify areas where they may need to improve and make the necessary changes. This is important to protect patients’ safety and ensure that they are receiving the best possible care.

The above is relevant for all non-medical prescribing students, including; (1) future nurse prescribers, ; (2) allied healthcare professionals and (3) pharmacist prescribers wanting to undertake advanced practice training.

What is reflection?

Reflection is a mental process where people examine their experiences to better understand their whole profession. It allows individuals to enhance their work habits or the care they provide to patients regularly. It is an essential, continuous, and routine element of the job of healthcare and social service providers.

Teams comprised of professionals with different backgrounds, skill sets, and working experiences should be encouraged to reflect openly and honestly on what occurs when things go wrong. These practical reflective activities help develop resilience, enhance well-being, and increase professional devotion.

To be reflective during your prescribing practice, healthcare professionals must first be open to new ideas, explore them from various perspectives, be inquisitive – asking questions – and remain patient if the problem isn’t “simple.” (While this may suddenly leap out at you).

Your prescribing practice and reflective accounts need to make transparent to others and what you’re getting wrong or right. Therefore being honest with yourself is essential as a non-medical or independent prescriber.

Why do nurse prescribers, pharmacist prescribers and non-medical prescribing students need to reflect and write reflective accounts?

Reflection may help you learn a lot from your prescribing practice and prescribing decisions. There are several reasons to reflect. You can use it to:

• Learn from the experience of independent prescribing
• Improve your prescribing decision-making skills
• Help you make decisions in the future
• Identify continued professional development (CPD) needs

You can reflect on anything, but as a non-medical or independent prescriber, you should focus on your prescribing experiences. This will help you understand and develop your skills as a prescriber.

When thinking about your experiences, you should consider both the good and the bad. It’s important to reflect on what went well and what didn’t go so well. This will help you learn from your mistakes as well as your successes. Furthermore, it will ensure you identify gaps in your professional development needs.

There are many different ways to reflect. You can use written reflection, audio recordings, or even video. The important thing is that you’re taking the time to think about your experiences and what you can learn from them.

If you’re not sure how to get started, some helpful reflection templates and examples are below. You can also talk to us at MEDLRN for guidance on how to reflect on your independent prescribing experiences.

Remember, reflection is an integral part of being a successful non-medical prescriber. By reflecting on your experiences, you can improve your practice and make better decisions in the future.

Reflective practitioners and the benefits

The General Pharmaceutical Council, the General Chiropractic Council, the General Dental Council, the General Medical Council, the General Optical Council, the Health and Care Professions Council, the Nursing and Midwifery Council, and the Pharmaceutical Society of Northern Ireland’s top executives have signed a joint statement called Benefits of becoming a reflective practitioner.

https://www.pharmacyregulation.org/sites/default/files/document/benefits_of_becoming_a_reflective_practitioner_-_joint_statement_2019.pdf

This is what they say:

“We are committed to supporting our registrants in their professional development and we recognise the benefits of registrants engaging in reflective practice.

Reflective practitioners are more resilient, and adaptable and have a greater capacity to maintain their registration throughout their careers. They demonstrate professionalism by being able to reflect on their own values and behaviours, and how these might impact the people they care for.

Reflective practitioners are able to make well-informed decisions, using a range of strategies including critical thinking, problem-solving and lifelong learning. They can identify their own development needs and are committed to maintaining their registration by engaging in continuing professional development (CPD).

We would encourage all registrants to reflect on their practice and to use reflective tools and resources to support their professional development.

Reflective practice is a key part of being a healthcare professional. It helps us to learn from our experiences, both good and bad so that we can improve our practice and make better decisions in the future.

How to get started with reflective writing

Most people are unfamiliar with the concept of reflective writing. However, the following comments indicate a lack of clarity regarding reflective writing when it comes to courses and assessments: ‘I thought I wasn’t supposed to use “I” in my work.” ,,,,,,,,,, ‘I won’t say what I truly believe unless it is going to be evaluated.’

The following points will help you to understand what is meant by reflective writing and how it can be used to support your non-medical prescribing course:

• Reflective writing is a way of exploring and analyzing your own thoughts and experiences.
• It can help you learn from your own experiences and make better decisions in the future.
• Reflective writing is different from other types of academic writing as it allows you to share your own thoughts and feelings on a subject.
• When writing reflectively, you should use first-person pronouns (I, me, my) to share your own experiences.
• You should also be honest about your thoughts and feelings, as this will help you learn from your experiences.
• Reflective writing is usually informal in style and can be written in the first or third person.
• It is important to remember that reflective writing is about your own thoughts and experiences, so you should use “I” when sharing your reflections.
• When writing reflectively, it can be helpful to use a reflection template or guide. This will help you to structure your thoughts and ensure that you cover all the essential points.
• Reflective writing is an integral part of the non-medical prescribing course, as it helps you learn from your experiences. By reflecting on your prescribing experiences, you can improve your practice and make better decisions in the future.

What is a reflective essay?

A reflective essay is a type of writing in which you (the author) interact with an audience (readers, listeners, viewers) to describe an experience and how that experience has changed you.

Reflective essays are usually written after a milestone. For example, a student may write a reflective essay at the end of a course of study or after completing an internship or other practical work.

The purpose of a reflective essay is to describe the experience and examine the meaning of the experience and how it has affected you as an individual.

Reflective essays are personal pieces of writing, so they should use first-person pronouns (I, me, my, we, us) and express your own thoughts and feelings about the experience.

Reflective essays can take many different forms. Standard formats include journals, letters to the editor, blogs, and photographic essays.

When writing a reflective essay, it is essential to use descriptive language. This will help the reader to understand your experience and how it has affected you.

It is also important to use concrete details and examples in your writing. This will make your essay more attractive and easier to read.

Finally, remember to proofread your essay before you submit it. This will help ensure that there are no errors or typos in your writing.

Writing critically and reflectively during your non-medical prescribing course

Both critical and reflective may be used in a directive to ‘reflect critically’ on anything. The terms describe a writing trait in which the reader can discern that the text has been carefully considered.

To be critical, you must go beyond description and into the analysis. You evaluate ideas or methods (evaluate), apply them in your work (apply), and defend or refute them (defend). You also reflect on what you have read, thought, or experienced.

In both types of writing, the key features are similar: good, strong, and well-written essays. The major distinctions between critical and reflective writing are as follows:

1 You and your thoughts will be more apparent in your writings.

2 Your personal history – what you have done, thought about, read, and changed throughout your life – is a significant source of evidence in your writing.

3 You are more likely to use the present tense when writing reflectively.

The key features of critical and reflective writing:

Critical Writing 

• More formal
• Focuses on ideas and methods
• Uses evidence from other sources
• Tends to use the past tense

Reflective Writing 

• Less formal
• Focuses on you and your thoughts
• Uses your personal history as evidence
• Tends to use the present tense

Reflective writing for non-medical prescribing students and medical prescribers

Non-medical prescribing students and medical prescribers will be expected to:

• Participate in or observe an incident (such as the care of a patient)
• Discuss what went well and not so well about it
• Examine their thoughts about it by linking to relevant theory/policy/science/guidance and to the experience of others in similar circumstances
• Draw conclusions about what might be done differently next time and how this might improve patient care.

The use of frameworks to help non-medical prescribing students and medical prescribers write reflective essays or reflective accounts

A ‘framework’ is a method for structuring and analyzing an issue, scenario, or experience. It may help you extract the learning points from an event by taking a systematic approach:

• What happened?
• What was my role in it?
• What went well and not so well?
• What could I have done differently?
• What did I learn from it?
• How can I use what I learned in the future?

Reflective writing using the Gibbs Reflective Cycle

The Gibbs Reflective Cycle is a framework for reflection that helps you to think about your experiences and how they relate to your learning. The cycle is made up of six stages:

• Description
• Action Plan

These stages can be usefully applied to any reflective writing task.

An example of reflective writing using Gibbs reflective cycle

I recently observed an incident in which a patient was being discharged from the hospital. I was part of the team responsible for their care. I felt that the discharge process could have been better organized and that the patient could have been given more information about their condition and what to expect after leaving the hospital.

I evaluated the situation and identified some areas for improvement. I discussed my observations with the team, and we came up with a plan of action. I learned that it is important to be organized when discharge planning and to make sure that patients are given all the information they need to make a smooth transition from hospital to home. I will use this learning in future when discharge planning.

Example two of a reflective account using Gibbs reflective cycle

When I was first asked to do this reflective essay on weight loss, I was a little apprehensive. I wasn’t sure if I wanted to share my personal journey in this way or not. But after giving it some thought, I decided that it might be helpful for others who are either considering or currently trying to lose weight. So here goes…

I started my weight loss journey about 6 months ago. I had been feeling unhappy with my appearance for a while, and my health was also starting to suffer. I knew I needed to make a change, but I didn’t know where to start. Thankfully, a friend of mine recommended the Atkins Diet, and I decided to give it a try.

The first few weeks were tough. I had to make a lot of changes to my diet and lifestyle, and it was all very new to me. But I stuck with it, and after a few weeks, I started to see results. I felt better, both physically and mentally, and people were starting to notice the difference too.

Since then, I’ve lost a total of 30 pounds, and I’m still going strong. It hasn’t been easy, but it’s definitely been worth it. I’m now at a healthy weight, and I’m feeling the best I’ve ever felt.

The whole experience has taught me a lot about myself. I’ve learned that I’m capable of making big changes in my life, even when it’s hard. I’ve also learned that I’m stronger than I thought I was.

If you’re considering losing weight, or if you’re currently on a weight loss journey, then I encourage you to keep going. It’s not easy, but it’s so worth it. Trust me, I know from experience.

Gibbs’s Reflective Cycle (Gibbs, 1998) helps you to understand and practice your reflective skills. Use the template to reflect on a recent event in which you demonstrated a reflected ability to improve or demonstrate the need for further learning or development.

Description: what happened? 

I had undertaken a supervised consultation as part of the non-medical prescribing course in the presence of my designated medical practitioner(DMP) and university tutor. Mary (pseudonym) middle-aged woman with a previous diagnosis of hypertension, was invited to attend the OSCE, which involved taking a comprehensive medical history in order to undertake a clinical assessment of the patient. Mary was invited to attend the OSCE, and prior to the OSCE, she was informed of the particulars of the assessment, e.g. the presence of my university tutor and DMP etc.

 Mary was called to the consultation room, and verbal consent was gained. The consultation involved the following; undertaking a comprehensive history taking using the Cambridge and Calgary model, taking blood pressure, and an explanation of the pathology of hypertension and its management.

Upon completion of the consultation, I was informed by the DMP I had passed my assessment and feedback was given.

Feelings: what were you thinking and feeling?

As a pharmacist, this was the first time I had undertaken a structured consultation using the Cambridge and Calgary model. However, having been qualified for over 5 years, I was confident with my consultation skills, in particular, my communication skills and my knowledge of the pathophysiology and management of hypertension. In addition, I was comfortable and relaxed when taking Mary’s blood pressure as I have had considerable practice during my placement with taking blood pressure and felt confident when explaining the relevance of the readings as well as offering health advice. After the OSCE, I felt satisfied with the outcome and in agreement with the feedback of my DMP.

Evaluation: what was good and bad about the experience?

On evaluation, the event was good for a number of reasons. Firstly, Mary said she was satisfied with the advice and the explanation she was given regarding hypertension and the relevance of her blood pressure readings. In addition, feedback from my DMP included my good use of communication skills, especially eye contact and body language(NICE,2010). Furthermore, another positive of the consultation was that I was able to follow the Cambridge and Calgary model and address all the relevant assessment requirements. However, a negative of the consultation was that Mary had asked me to quantify how much of various fruits count towards your ‘5-a-day fruits requirements; however, I was a bit unsure and had to double-check the advice with my DMP even though it was correct. As such, I would have liked to have been more confident in providing that advice.

Analysis: what sense can you make of the situation?

Mary had asked me to explain to her what amount of different fruits count toward the ‘5-a-day’ requirement (NHS,2015), and I was unable to provide the answer confidently as mentioned above; this was the ‘part’ of the OSCE that did not go too well. A reason for this was that I had assumed certain health advice is ‘common knowledge and would not require much explanation. As such, It had never occurred that this was a gap in my knowledge. This negative aspect could have been avoided had I thought more deeply about the advice I offered and affirmed the understanding of patients. Conversely, a part of the consultation that did go well was that I was able to utilize the Cambridge and Calgary model to structure my consultations.

This was because I had undertaken considerable learning regarding structuring a consultation and practised the Cambridge and Calgary model on multiple occasions with my DMP and modified it slightly to address my needs. Furthermore, with regards to taking blood pressure, during my training with my DMP, I had reviewed best practice guidelines when undertaken taking blood pressure and asked for regular feedback, which ensured I was constantly improving my technique and skills.

Conclusion: what else could you have done?

As a result of the consultation, I have learned that I must confirm the understanding of the patient with regard to the health advice that is being given (Nursing Times, 2017) and ensure there is no confusion or misunderstandings. In addition, this experience (of undertaking a consultation) has highlighted the importance of ensuring there is structure to consultation and how I can use a model of consultation to suit the needs of the situation (Royal College Of General Practitioners Curriculum, 2010). Furthermore, I would have liked to have undertaken a level 3 clinical medication review (Brent CCG,2014) to determine adherence to the medication, as many hypertensives have poorly controlled blood pressure (heart Foundation,2016) with a lack of adherence to treatment cited as a major reason (Izzat,2009).

Action plan: if the situation arose again, what would you do?

In order to be better prepared to face a similar experience, I have decided I will continually practice using the Cambridge and Calgary model of consultation wherever possible and undertake self-appraisal (Royal College of General Practitioners,2013); in addition, in order to ensure I have adequate knowledge in health education, I will continue to undertake CPD and have decided to attend a training course within the next 4-8 weeks. Also, currently, I am trained to take blood pressure using an electronic machine but am not confident in measuring blood pressure manually, which would be useful if a patient had atrial fibrillation (NICE,2016). As such, I have decided to take further training under the supervision of my DMP to develop this clinical skill.

• Brent CCG ,2014. Medicines Optimisation:Clinical Medication Review [pdf]. Available at:<https://www.sps.nhs.uk/wp-content/uploads/2016/08/Brent-CCG-Medication-Review-Practice-Guide-2014.pdf> [Accessed 2nd April 2018].
• Heart Foundation,2016.  Guideline for the diagnosis and management of hypertension in adults [pdf]. Available at:<https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf> [Accessed 2 April 2018].
• Izzat, L.,2009.  Antihypertensive concordance in elderly patients  [Online] Available at <https://www.gmjournal.co.uk/media/21571/gm2april2009p28.pdf> [Accessed on 28 February 2018]
• National Institution for Health and Clinical Excellence, 2010.  Principles of Good Communication [pdf].Available at:<file:///C:/Users/ProScript%20Link/Downloads/supportsheet2_1.pdf> [Accessed 1 April 2018].
• National health service, 2015.  Nhs Choices 5 A Day portion sizes . [Online] Available at:<https://www.nhs.uk/Livewell/5ADAY/Pages/Portionsizes.aspx> [Accessed 1st April 2018].
• National Institute for Health and Care Excellence (2016).  The clinical management of primary hypertension in adults (NICE Guideline 127). [Online] Available at: https://www.nice.org.uk/guidance/cg127 [Accessed 25 February 2018]
• Nursing Times, 2017.  Communication Skills 1: benefits of effective communication for patients [online]. Available at:<https://www.nursingtimes.net/clinical-archive/assessment-skills/communication-skills-1-benefits-of-effective-communication-for-patients/7022148.article> [Accessed 1 April 2018].
• Royal College Of General Practitioners Curriculum, 2010.  The GP Consultation in Practice [pdf]. Available at:<https://www.gmc-
• uk.org/2_01_The_GP_consultation_in_practice_May_2014.pdf_56884483.pdf> [Accessed 1st April 2018].
• Royal College Of General Practitioners, 2013.  What are consultation models for? [pdf]/ Available at:<http://journals.sagepub.com/doi/pdf/10.1177/1755738013475436> [Accessed 2nd April 2018].

Author:  Faheem Ahmed

Pharmacist Prescriber, 2x Award-Winning Pharmacist, Pharmacy and Clinic Owner, Founder of MEDLRN and loves sharing his experience with pharmacists.

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A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system

• Research Article
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• Published: 09 November 2020
• Volume 43 , pages 884–892, ( 2021 )

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• Fahad Alshahrani 1 , 2 ,
• John F. Marriott 1 &
• Anthony R. Cox   ORCID: orcid.org/0000-0003-2294-3440 1  

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Background Computerised Physician Order Entry (CPOE) is considered to enhance the safety of prescribing. However, it can have unintended consequences and new forms of prescribing error have been reported. Objective The aim of this study was to explore the causes and contributing factors associated with prescribing errors reported by multidisciplinary prescribers working within a CPOE system. Main Outcome Measure Multidisciplinary prescribers experience of prescribing errors in an CPOE system. Method This qualitative study was conducted in a hospital with a well-established CPOE system. Semi-structured qualitative interviews were conducted with prescribers from the professions of pharmacy, nursing, and medicine. Interviews analysed using a mixed inductive and deductive approach to develop a framework for the causes of error. Results Twenty-three prescribers were interviewed. Six main themes influencing prescribing were found: the system, the prescriber, the patient, the team, the task of prescribing and the work environment. Prominent issues related to CPOE included, incorrect drug name picking, default auto-population of dosages, alert fatigue and remote prescribing. These interacted within a complex prescribing environment. No substantial differences in the experience of CPOE were found between the professions. Conclusion Medical and non-medical prescribers have similar experiences of prescribing errors when using CPOE, aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical, and environmental aspects of practice remain important.

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Avoid common mistakes on your manuscript.

Impacts on practice

When implementing e-prescribing a system-wide review of prescribing, including characteristics and behaviours of prescribers, patients and the work environment should be undertaken to design out error.

Prescribers from all professions describe similar difficulties with electronic prescribing, so training provision should be provided for all and should be multi-professional.

Those implementing electronic prescribing systems should warn users of the distinct new forms of prescribing error that can occur.

Introduction

Medication errors, defined as ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’ [ 1 ], are responsible for significant morbidity and mortality, as well as increased costs of healthcare [ 2 , 3 ]. The World Health Organisations Third Global Patient Safety Challenge is focused on a reduction in medication errors by 50% [ 4 ] and reducing prescribing errors is a key part of this drive. In the UK, prescribing errors are estimated to occur in 8.9 to 14.7% of hospital inpatients and discharge medications [ 5 , 6 , 7 ].

Computer Physician Order Entry systems (CPOEs) are seen as essential for improving both efficiency and patient safety in relation to prescribing [ 2 , 8 , 9 , 10 ]. CPOE enables prescribers to enter drug prescriptions via a computer application rather than paper. Evidence suggests that the use of CPOE reduces the prevalence of prescribing errors, [ 11 , 12 , 13 , 14 , 15 ] by removal of legibility issues, guiding prescribers to appropriate prescribing decisions, and providing a robust system of audit.

Although the overall error reduction from CPOEs is uncontroversial, novel types of error have emerged associated with CPOE [ 16 , 17 , 18 ]. Some case studies of CPOE implementation have showed an increase in the number of higher severity medication errors [ 19 , 20 ]. Malfunctions of clinical decision support systems (CDSS) in CPOE can also impact on patient safety [ 21 ] and can arise from the complexity of coding clinical concepts in hierarchies within CPOE [ 22 ]. Staff perceptions of prescribing safety following CPOE introduction may also be counter-intuitive. Davies et al. [ 23 ] found that health care staff’s perception of safety culture deteriorated after electronic prescribing was introduced. Despite this, CPOE remains a key part medication error prevention [ 24 ].

CPOE design choices can also make some errors more likely; e.g. as a result of an incorrect selection on a drop-down menu, an electronic prescription for diamorphine was created at 70 times the required dosage [ 25 ]. Similar unintended adverse consequences of CPOE systems have been reported [ 16 , 26 , 27 ].

Qualitative research on prescribing errors has examined multiple influences of prescribing errors in secondary care [ 5 , 28 , 29 , 30 ], highlighting insufficient training and high workloads. A meta-synthesis of integrating CDSS into clinical work found problems with useability and socio-technical issues on implementation [ 31 ].

In many countries non-medical prescribing is becoming more common [ 32 ], but there are no qualitative studies of prescribing errors by medical and non-medical prescribers in the context of CPOE.

Aim of the study

The study aimed to examine the views of pharmacists, nurses, and medical prescribers on the causes of electronic prescribing errors in a CPOE system in one large, multi-speciality UK NHS hospital.

Ethical approval

The study was approved by the University of Birmingham Research Ethics Committee (ERN_15-0161), Research and Development Department at the University Hospitals Birmingham NHS Foundation Trust (UHBFT) in September 2016 and NHS ethics committee.

The study used a qualitative design, employing semi-structured interviews exploring the potential causes and contributing factors of prescribing errors in an electronic prescribing context. Thematic content analysis was combined with critical incident technique (CIT), to explore the factors influencing prescribing errors. CIT allows interviewees to describe an event, allowing collection of facts, and subsequent evaluation of a cause. It is well suited to studying the interaction of subjects with technology, having been first developed with pilots [ 33 ]. CIT informed the interview guide, as well as prior studies investigating prescribing errors [ 6 , 28 ]. Three case studies of prescribing errors were used to provoke discussion of error in a non-threatening manner, since participants might not be willing to talk comfortably about errors of their own or others owing to fear of incrimination. The final interview guide (See Supplement 1) was piloted with four experienced pharmacists to ensure clarity and face validity. The interview guide also examined prescribers’ specific views on CPOE design; these results will be reported elsewhere. The analysis of the views and experience of three groups of prescribers, with differing standpoints, additionally provided a form of data triangulation.

Study location

Participants were recruited from an academic tertiary care hospital in the West Midlands, which operates a locally developed electronic prescribing system (Patient Information Communication System—PICS). The system includes integrated clinical decision support features, such as dose range checking, drug interactions alerts and contraindications (e.g. drug-disease, allergies). The system is used for in-patient, out-patients, and day care prescribing.

Participants

A purposive sampling methodology was used in order to target varied groups of prescribers. All active medical and non-medical licensed prescribers (pharmacists and nurses) working in the trust were eligible for inclusion.

The prescriber types approached in this study were:

Junior doctors: All training and non-training grades (Foundation Year 1 and Foundation Year 2, Specialty Registrars, Junior Specialist Doctors).

Senior doctors: Staff Grades and Consultants.

Independent Pharmacist Prescribers.

Independent Nurse Prescribers.

All medical and non-medical prescribers in the hospital were contacted via email and invited to interview. All prescribers who expressed an interest received an email consisting of an invitation letter and participant information leaflet. It was made clear to participants that any individuals involved in errors should not be named, and that no blame would be assigned to them as a result of the interviews. Interviews were arranged at a mutually convenient time and place for the interview, in a workplace setting (such as a quiet office). No third parties were present at interviews. Consent was obtained before the interview commenced and participants were provided with a brief explanation of the purpose of the study.

Data collection

The face to face interviews were conducted between 5th December 2016 and 25th April 2017. Interviews were recorded and discussions lasted between 20 and 30 min. Interviews were conducted by a male investigator (FA), a qualified pharmacist of several years clinical experience undertaking a fulltime PhD in electronic prescribing. The interviewer had no prior relationship with any of the participants. Participants were not given transcripts for correction.

Data analysis

Interview data was transcribed verbatim into an anonymous format, which was loaded into NVivo® version 10 for data management. Data analysis and recruitment was conducted in parallel, with ongoing analysis informing the researcher. A response rate could not be calculated there was no reliable figure for the total number of prescribers within the organisation. However, participants were recruited until data saturation was achieved, when it was judged that no new additional themes were arising from the analysis [ 34 ].

An inductive and deductive approach was used in this study, to develop a thematic analysis of the data. Inductively, this was based on the interviewees' responses. The deductive approach was based on a framework for analysing risk and safety in clinical medicine [ 35 ] which is based on frameworks used in the human factors field. It includes institutional contexts, organisational factors, the work environment, team and individual factors, task factors, and patient characteristics. Coding was carried out on a line by line analysis. All transcripts were coded by FA. Following initial analysis, codes were refined and combined where appropriate, and clustered into broad themes. Coding accuracy and thematic analysis was cross-checked by two additional researchers (ARC, JFM), with differences resolved via consensus.

Characteristics of the participants

A total of 23 medical and non-medical prescribers were interviewed. No one who responded to the initial study email refused to participate. We were unable to estimate a response rate, since we have no reliable figure for the total number of prescribers within the organisation. The demographics of the study participants are in Table 1 .

Participants’ perspectives on prescribing errors

Six major themes influencing prescribing errors in CPOE systems emerged from the analysis, which are illustrated in the conceptual framework in Fig.  1 . While these emergent themes were clear, they were interconnected, with participants describing a complex process during the process of prescribing. Multiple causes could contribute to a prescribing error. The following sections describe these major themes.

Conceptual figure of the interaction of the six major themes leading to the production of a prescription

Issues related to the CPOE design were common. Selection of the wrong item from an electronic dropdown list was identified by most participants (18/23). These included juxtaposition errors, where a medication with an entirely different indication than intended, listed before or after the desired medication, is erroneously chosen. Prescribers felt that such issues would not happen when using handwritten order systems.

it’s easy to click on the wrong drug, not double check it and just click again and obviously you are responsible for that’s being tracked, uh, and I think when you are doing written prescribing, you know what you’re writing. Whether you write it fast or slow, you know what you’re writing…” Junior Doctor 2

Prescribers also noted that on entering the first few letters of a drug name, the system would “suggest” a medicine name, which could be easily selected in error. Prescribers suggested the imprecision of touch screen computers worsened this risk.

Prescribers noted that errors can occur by selecting the wrong patient owing to the nature of the patient list structure; the correct medication being prescribed to the wrong patient (which was also linked to prescribing away from the physical location of the patient). The ability to prescribe for patients remotely rather than attending the patient directly, was also believed to lead to a disconnect between the act of prescribing and clinical assessment of the patient.

if you prescribe something without assessing the patient, so if someone rings and says oh, they need some painkillers, you might prescribe a painkiller that they shouldn’t have, based on their clinical picture. Junior Doctor 3

Auto-population of information by the CPOE, such as drug dosing frequencies, to a default setting, led to prescribers allowing defaults stand when inappropriate to the specific patient. Not correcting them led to reduced conflict with the CPOE system. An example of prescribing error from auto-population was:

I had a patient that was prescribed baclofen. We changed it from tablet to oral solution. They were on 10 mg once a day before they changed it, so it was prescribed fine on PICS, baclofen 10 mg tablets once a day. But they had swallowing difficulty, so we changed it to oral solution which defaulted the dose to 5 mg of TDS. Senior Doctor 2

Participants described an expectancy that CPOE’s safety measures would intervene to prevent errors, that they felt made them complacent. Yet, at the same time prescribers described over-riding alerts without conscious jugement. This was due to a perception of too many warnings and alert fatigue.

After a while, you get used to the warnings, so you, sometimes, you probably don’t read them as well as you should so you just keep clicking the warning off and you might miss a warning and still prescribe a drug for a patient that probably shouldn’t be having it. Junior Doctor 3

Prescribers noted the complex nature of electronic prescribing systems and how the rigidity of the process of prescribing medicines has the potential to lead to errors. This was noted particularly for non-standard intravenous products.

The prescriber

Participants noted a lack of knowledge including deficits in drug knowledge for appropriate drug dosing (e.g., giving the wrong dose for renal or older patients) and failure to apply a protocol (e.g. modifying the dose in the presence of renal failure).

there would have needed to be a knowledge by the prescriber about the correct dosing of the enoxaparin and really you should not need a computer to…I would expect a doctor in renal medicine to know what the correct dose was and prescribe the correct dose. Nurse 2

Participants reported that high work load caused rushed working practices that led to prescribing errors. Prescribers’ emotional status and their stress levels and tiredness were described by them as being likely to contribute to an error.

if the doctor is very busy and particularly they’re on call and they have got a lot of things to do; they tend to forget things, we’re human beings and we tend to forget things and when you forget, you make errors. Senior Doctor 1

Participants reported that errors were caused by slips in attention or lapses of memory. Memory lapses included situations such as prescribing a medication to which a patient has an allergy. Forgetting to navigate from the current patient’s profile to prescribe for another patient was reported as an example of slips.

I saw four patients. The nurse comes to me. I’ve got PICS opened up and nurse tells me that your patient has got a heart rate of 200. So I want to prescribe a beta-blocker. Then I look for the patient but I usually don’t concentrate because I’m still stuck with another patient. In the, doing the work, I’m looking after another patient and I’m prescribing medicine in another. So I ended up prescribing a medicine for my patient, the one who I was looking after now. So these are very common errors I see. Senior Doctor 2

Negligence in following standard procedures was identified as a contributing factor to prescribing errors. Those prescribers accustomed to a paper based system were incautious within an e-prescribing system.

it's because people don't understand how electronic prescribing system works, they don't know how to read and follow through because we are so used to paperwork and people are not really, I hate to say this, but people do things without even reading exactly what they are doing, that could cause an error. Nurse 1

The patient

Patients with complex comorbidities receiving multiple medications were cited by many participants as a high risk area for prescribing. These could include issues involving routes of administration, as well as dose and drug choice.

on the critical care particularly the routes that are normally available on the ward are not always appropriate for my patients. So, something that they were previously swallowing is now going down a nasogastric tube – so, we have to make a lot of dose adjustments for going between IV and oral routes, or oral and other enteral routes, so there are quite a lot of errors there” Pharmacist 5

Errors arising from mis-remembered medication history from patients was also raised.

Sometimes patients think they’re on a specific dose, but they’re not on that dose, so you might go from patient information and then you prescribe the wrong dose, but it’s on what the patient said as well. Junior Doctor 3

Prescribing errors were reported to occur when a medication history is unavailable or irretrievable when patients are admitted to hospital.

it becomes a detective case and, and again, that’s not a very safe way of prescribing because, but, you know, the …You're faced with, out of hours you're faced with the option of not prescribing any drugs—and waiting for the next day until the GP surgery opens or a family member can bring in the prescription. Junior Doctor 4

Prescribers reported how unfamiliarity with the patients contributed to their prescribing errors, even in the presence of a good medical history. Treating a patient under the care of others while oncall was a common example given:

You’re asked to prescribe this or, you are asked to see them because they’re deteriorating, you want to prescribe this or that, and you don’t know them as well. Junior Doctor 2.

The task of prescribing was a strong theme. Prescribers noted that errors occur because a medication history is unobtainable, especially after business hours. During these periods GP surgeries are closed and the patient could be unable to provide an accurate medication history. Lack of access to patient records were identified as a contributing factor leading to prescribing errors.

the doctors don’t have access to summary care records so it’s hard for them to get a drug history properly especially if a patient comes in when they’re confused….I’ve seen that sometimes patients say oh, I’m on bisoprolol but they don’t know the dose, so the doctors just prescribe bisoprolol and they just go with the default on PICS” Junior Doctor 4

Prescribers noted that some medications (such as morphine or HIV medications) are not shown on patient records as they may be prescribed by specialists, which could lead to medication omissions. The difficulties of sharing or transferring information between hospital and primary health care sectors was noted. Outdated discharge summaries and modifications to therapy by GPs or out-patient prescribers that had not been updated in care records were cited as specific examples of causes of inaccurate medication histories, inevitably associated with prescribing error.

I mean there is always the barrier in certainly between community and hospital. We don’t have access to their records, they don’t have access to our records. Junior Doctor 4

Prescribers also noted that errors can occur when they want to prescribe a medication in the absence of essential laboratory results.

So sometimes, um, you’ll prescribe a medication before the blood results are back.[.] You might put them on a diuretic before they know they’ve got acute kidney injury. Senior Doctor 4

Several prescribers highlighted poor communication between team members. As an example, using bed numbers rather than patient’s name was reported to cause prescribing errors. Inadequate communication between healthcare professionals when patients were being transferred, or during care team hand-over, was noted as a cause of prescribing errors.

if someone has told you—so you mix them up, yeah, so if someone has told you bed 4 needs paracetamol and bed 5 needs codeine, you might mess it up. Especially when they don’t use names, if they use bed numbers, you could mix it up because it is a pressured environment” Junior Doctor 3

Staffing levels were also mentioned as being associated with prescribing error. Inadequate staff numbers, staff turnover and providing cover for absent colleagues were highlighted to increase workload and thus predispose to error generation.

The environment

Interviewees suggested that the working environment is a major contributor to prescribing error. Heavy workload, time pressures, a chaotic, distracting environment and the need to perform more than one task simultaneously, in the context of the CPOE system, were commonly mentioned.

On differences between non-medical and medical prescribers

This study involved participants from across three differing prescribing professions and found no systematic differences in the experiences of CPOE based on professional background. Although pharmacists’ role as a clinical reviewer of other professions’ prescribing led them to volunteer examples of other professions’ prescribing practice, reflections on their own prescribing practice was similar to that of other professions.

Our study found that the causes and contributing factors to electronic prescribing errors described by prescribers from different professions are multifactorial and interconnected. They have been classified into six high-level categories (the computer system, the prescriber, the patient, the task, the team and the work environment) that contributed to prescribing errors. The causes and contributing factors of electronic prescribing errors reported from different prescribers (medical and non-medical) were similar to many of the prescribing errors that occur with conventional handwritten prescribing [ 5 , 28 , 29 ] with the addition of errors related to the electronic system specifically. A qualitative study of implementing CDSS, rather than CPOE, found some similar categories, including issues such as people, culture, communication, as well as the more technical issues one might expect [ 36 ]. Implemention of CPOE needs at least as much thought put into the human and organisational implementation, as it does the technical implementation.

Types of errors

Electronic prescribing systems reduce prescribing errors overall and they can create or propagate new issues which have been highlighted in previous studies [ 18 , 37 , 38 , 39 ]. Our study confirms this with medical and non-medical prescribers. Whether these errors arise from design interface problems resulting from densely populated medication lists causing juxtaposition problems, prescribers relying on potentially inappropriate default doses, or human factor considerations, the recognition of such problems and their consequences by system designers should improve outcomes when implementing new alerts in e-prescribing systems. Inflexible or complex ordering processes made prescribing particularly difficult and users noted that this could result in forced errors.

Distractions and over-reliance

Also, distracting features of electronic systems caused by excessive alerts generated by the system during prescribing were cited as a disruptive effect by prescribers. A series of best practices have been suggested for alerts in CPOE and CDSS systems [ 40 ], but the evidence base for optimal amount of alerts and nature of such alerts, is weak [ 41 ].

Prescribers in our study also noted the potential for over-reliance on CPOE systems. Such automation bias has been studied in experimental conditions and over-reliance on CDSS in CPOE led to increased prescribing errors [ 42 ].

Prescriber knowledge and training

A lack of knowledge of medication appears to be a major contributor to prescribing errors in previous studies [ 5 ] and arises in our study. Addressing knowledge deficits has been a long term concern [ 43 ], with continuing professional education for safe prescribing practice essential. Online resources such as the eLearning programme tool called Standard Computerised Revalidation Instrument for Prescribing and Therapeutics (SCRIPT) [ 44 ] can promote safer prescribing in both medical and non-medical prescribers ( https://www.safeprescriber.org ).

Hospitals should ensure all users have access to adequate training before accessing the system. Learning outcomes for the electronic prescribing records have recently been published [ 45 ], and similar is required for electronic prescribing systems. A literature review of the training offered in electronic prescribing to qualified prescribers found only seven papers, which rarely covered the potential downsides of electronic prescribing [ 46 ].

However, training may not always be effective. A small randomised control trial of feedback and training in relation to electronic prescribing found little effect and the authors argued that re-designing electronic prescribing systems would change prescriber behaviour more than education [ 47 ]. Latent failures built into CPOE provide the conditions in which prescribing errors occur, when high work load pressure and working environment distractions appear [ 48 ]. However, compulsory condensed technical training on how to use the system effectively, particularly during the “shakedown” phase of implementation would seem prudent [ 49 ].

Socio-technical issues

Our study found prescribing errors related to the hierarchy, culture and poor communication between team members. These errors were mainly owing to barriers in communication between healthcare professionals and the inability to access insufficient drug information and guidelines at the time of prescribing. Prior research on the effect of CPOE on pharmacist-physician communication has shown increased frequency of communications between pharmacists and physicians [ 50 ] provoked by many of the causes of error (such as lack of knowledge of the prescribing system) was also found in our study. A systematic review of the implementation of CDSS found similar socio-technical issues to those we found, including communication issues [ 51 ].

A complex problem

Our study indicated that inadequate access to a medication history of patients across health care sectors leads to prescribing errors. Franklin et al. [ 6 ] found that a lack of information of patients’ medication histories from primary care settings contributed to prescribing errors in hospital settings. Significant improvements in medication histories and documentation of allergies has been shown when pharmacists are given this responsibility [ 52 ].

Our finding that medical and non-medical prescibers described prescribing errors as multifactorial is consistent with previous studies [ 5 , 29 , 30 , 53 , 54 ]. All of these factors would be common to different prescribing professions and all would be subject to the same human cognitive biases, so it is perhaps not surprising that little difference between professions in the experience of CPOE was apparent.

Reducing prescribing errors

Recommendations for implementation of CPOE have been published [ 55 , 56 ] and it is clear that socio-technical changes to interprofessional and patient communications caused by CPOE are also an outcome of CPOE implementation. Many issues are common to both CPOE and paper-based prescribing systems. We did not distinguish between these, since this is not a comparative analysis. We argue that CPOE systems should be examined as a whole, and it can be difficult to make the judgement about whether the CPOE was or was not involved in any particular event.

A policy brief summary analysing 40 systematic reviews, suggested actions dealing with prescribing error, including education for prescribers, incorporating computerised alerts, incorporating tools to guide prescribing, and encouraging multidisciplinary teams, including pharmacists, to care for patients [ 57 ]. This underlines that CPOE is only one intervention to reduce prescribing errors.

Strengths and limitations

This is the first qualitative study to explore the causes of prescribing errors made by different grades of medical as well as non-medical prescribers in an hospital CPOE system setting. Previous research has focussed on prescribing by junior doctors and trainees [ 5 , 29 ].

The interview guide was piloted in clinical pharmacists only. While they have professional insight into prescribing errors, wider piloting with other professions could have given additional insight. Interviewees were not asked for feedback on the interpretation of their interviews. Our study was carried out in one hospital site operating a single CPOE system, limiting the generalisability of the findings, however our results reflect themes found in the wider literature.

Medical and non-medical prescribers have similar experience of prescribing errors when using CPOE, with the broad areas of concern aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. Solutions focused on a single factor, such as system design or training, may only result in only limited impact on prescribing errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical and environmental aspects of practice remain important.

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Acknowledgements

We would like to thank the participants in this study for their time and interest.

The study was funded by the University of Birmingham, and The Saudi Cultural Bureau funded Fahad Alshahrani’s PhD studies.

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Fahad Alshahrani, John F. Marriott & Anthony R. Cox

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Alshahrani, F., Marriott, J.F. & Cox, A.R. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin Pharm 43 , 884–892 (2021). https://doi.org/10.1007/s11096-020-01192-0

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Received : 09 June 2020

Accepted : 29 October 2020

Published : 09 November 2020

Issue Date : August 2021

DOI : https://doi.org/10.1007/s11096-020-01192-0

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