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

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

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.

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, 26‐28]. 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.

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 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 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.

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].

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.

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.

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’.

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.

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 [38‐40]. 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.

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.

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.

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.