http://orcid.org/0000-0001-5657-778X
Figures
Abstract
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.
Methods
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).
Results
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.
Citation: Graham-Clarke E, Rushton A, Noblet T, Marriott J (2018) Facilitators and barriers to non-medical prescribing – A systematic review and thematic synthesis. PLoS ONE 13(4): e0196471. https://doi.org/10.1371/journal.pone.0196471
Editor: Baltica Cabieses, Universidad del Desarrollo, CHILE
Received: December 21, 2017; Accepted: April 13, 2018; Published: April 30, 2018
Copyright: © 2018 Graham-Clarke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
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].
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.
Methods
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.
Analysis
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.
Results
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].
Discussion
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.
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