Background
Method
Research design
Sample
Instrument development
Normalisation Process Theory predicts that for a new intervention to become integrated into usual practice, there needs to be continuous investment by all parties in four areas of work. These include |
• Making Sense of the intervention: everyone must understand how the intervention is distinct from other ways of working and why it matters |
• Engagement: individuals and collectively people must commit to do the work of the new practice |
• Action: people must have the skills and resources to deliver the new way of working |
• Monitoring: people must get feedback which reinforces and encourages this way of working |
May and colleagues designed a 16 item questionnaire to support the critical examination of these areas of work in assessing implementation and integration of ways of working [17]. The tool has been updated into a more user friendly format in the NOMAD tool [18]. We have previously used the toolkit to examine the enablers and barriers to delivery of expert generalist practice (EGP) in the primary care setting [15]. In this study, we will use the same approach to examine individually tailored prescribing. |
Analysis
Results
Describing our sample
Nurse prescriber | GP | Pharmacists | Total | |
---|---|---|---|---|
Total number (% of sample) | n = 234 (52.7%) | n = 97 (21.8%) | n = 88 (19.8%) | 419 (100%) |
Gender | ||||
Male (n, %) | 31 (13.2%) | 49 (50.5%) | 54 (61.3%) | 134 (32.0%) |
Female (n, %) | 200 (85.5%) | 48 (29.5%) | 34 (38.7%) | 282 (67.3%) |
Missing data | 3 (1.3%) | 0 | 0 | 3 (0.7%) |
Career stage | ||||
Early career: ≤5 years (n, %) | 58 (24.8%) | 5 (5.1%) | 11 (12.5%) | 74 (17.7%) |
Mid career: 6–15 years (n, %) | 76 (32.4%) | 27 (27.8%) | 53 (60.2%) | 156 (37.2%) |
Later career: 16+ years (n, %) | 99 (42.3%) | 65 (67%) | 24 (27.2%) | 188 (44.9%) |
Missing data | 1 (0.4%) | 0 | 0 | 1 (0.2%) |
Location of practice | ||||
England (n, %) | 400 (95.5%) | |||
Scotland (n, %) | 6 (1.4%) | |||
Ireland (n, %) | 4 (0.9%) | |||
Wales (n, %) | 9 (2.1%) | |||
Missing data | 0 | |||
Reporting currently providing ITP | ||||
Yes, always (n, %) | 96 (41.0%) | 13 (13.4%) | 12 (13.6%) | 121 (28.9%) |
Yes, sometimes (n, %) | 96 (41.0%) | 42 (43.3%) | 78 (88.6%) | 216 (51.6%) |
No (n, %) | 28 (12.0%) | 17 (17.5%) | 5 (5.7%) | 50 (11.9%) |
Missing data (n, %) | 14 (6.0%) | 16 (16.5%) | 2 (2.3%) | 32 (14.6%) |
Sense making
Sense making | Theme | Description |
ITP valued by health care professionals | Meeting needs of the individual part of professional identity | |
ITP valuable to NHS | Professionals recognised the value of ITP to the NHS | |
Clarity on ITP | Prioritising the patient/person as the essence of ITP | |
Value of ITP not shared | Organisation values and processes don’t support ITP; some patients don’t understand value of ITP | |
Engagement | Theme | Description |
Leadership (individual and collective) | Key individual leaders, and collective engagement with ITP | |
Levels of engagement | Variable levels of engagement, with desire for more | |
Patient engagement | Mobilisation of patient engagement through the media | |
Barriers to engagement | Included workload, fragmentation of services, fear, patient resistance | |
Action | Theme | Description |
Formal training | In generalist practice; within specialist | |
Experiential learning – phronesis | Learning from experience, including working with patients and colleagues | |
Collective action | Value of peer discussion | |
Other supports for action | Including the media | |
Partial action | Easier to tailor stopping medicines than starting them | |
Barriers | Governance (fear), time, ‘head space’ and practical support | |
Monitoring | Theme | Description |
Mixed feedback | Both supportive and negative feedback on ITP | |
Challenge of feeding back | Hard to quantify benefit | |
Challenging the status quo | Hard to ‘go against’ the guideline | |
Potential power of feedback | Should be a Key Performance Indicator |
Sense making | Theme | Subtheme | Descriptions from participants |
ITP valued by health care professional | Defines professional role | “our job starts where the guideline ends” (GP) And not just in managing medicines (Nurse Prescriber) | |
ITP valuable to NHS | False economy not to | “could improve care and save money” (GP) “Needs to be developed” (Pharmacist) | |
But uncertain | “so long as patient don’t miss out” (GP) | ||
Clarity on ITP | Prioritising the patient | “advising on the suitability for the patient” (Pharmacist) Principle of personalised medicine | |
Value of ITP not shared | By patients | “pts… need to understand prescribing as important as prescribing” (Pharmacist) | |
By organisational values | “recognition from the powers that be that this is a good thing to do” (GP) | ||
By organisational structures | “would be difficult to instigate in practice due to protocol driven practice” (Nurse Prescriber) “needs recognition that this is clever subtle stuff that needs skilled practitioners…not readily done by rote” (GP) | ||
Engagement | Theme | Subtheme | Descriptions |
Leadership | Individuals | Key leaders, influential colleagues, trained colleagues support engagement. “working through examples with trusted colleagues” (pharmacist) “I remember a Protected Learning Time session where a geriatrician talked about the rationale for stopping nearly all the medication” (GP) Independent contractual status for GPs supports engagement | |
Collective action | Multidisciplinary team working enhances engagement with ITP | ||
Levels of engagement | Variable | Engage with idea if not the practice (GP) Pharmacists role to recognise the potential need even if don’t do ourselves | |
Desire for more | “want to do more discontinuation of meds” (Nurse Prescriber) | ||
Patient engagement | Media | Media input in to dangers and harms of medicines can help as it starts a conversation | |
Barriers to engagements | Excess workload | “limited by time, caseload and so lack of mental capacity” (GP). Time and complexity mitigate against depth of conversation needed. Stopping meds increases workload – follow up consults | |
Fragmentation of care; lack of integration of vision and process | Inefficiency crowding out effort; disparity between primary and secondary perspectives, power and resources; population over individual focus | ||
Fear | Limits engagement “it’s a fear of making a mistake and the potential consequences” (GP) | ||
Patient resistance | Patients can be reluctant to change “can be difficult to persuade carers and patients to change meds they’ve been taking for a long time and were told were for life” (Pharmacist) Patient expectations and lack of understanding of greyness of medicines | ||
Action | Theme | Subthemes | Descriptions |
Formal training | GP training | Generalist training; basic principles; knowing the guidelines before you deviate off “this wasn’t taught when I was training” (GP) | |
Specialist training | Prescribing (stop-start); working within specialist area easier to do ITC | ||
Experiential learning–phronesis | Self taught/experience | “experience gained intuition”; (GP) practiced at doing this over a long time | |
Learn from patients | “just day-to-day learning from patients” (GP) | ||
Learn from colleagues | Trusted colleagues and influential figures; shared reflection including on line discussion | ||
Collective action | Peer discussion | MDT and collaborative action supports ITP (but can inhibit decision making too as need full agreement). Supervision | |
Other support | Media | To start the conversation | |
Partial action | Easier when stopping meds than starting | ||
Barriers | Organisational practice – pay for performance | Lack of joined up thinking and communication; monitoring as a barrier | |
Time | |||
Resource | Qualified and experience staff lacking; resource prioritises opposite approach; imbalance need and supply; peer senior support and continuity of same needed; legal support “resource restriction means prioritise safety and supply” (Pharmacist) | ||
Mental capacity and complexity | “Limited by time caseload and so lack of mental capacity” (GP); exhaustion “To operate outside ‘recognised prescribing’ requires understanding of the clinical evidence supporting the current guidelines, when there are gaps in that evidence and when it is therefore appropriate to choose a different path. An important variable is the patient wishes and how these should be accommodated” (Pharmacist) | ||
Practical advice | Practical advice, a framework, training | ||
Fear | Making and recording defendable decisions; being castigated by others – clinicians, legally, morally; uncertainty re risk “Shared balanced discussions with patients rarely results in a DEFENDABLE decision. If you are way of the mark with clinical decisions then it is probably sensible to share your decision with colleagues” (GP) “Fear of being misunderstood & misinterpreted as undertreatment, apathy, fear of going against guidelines & being medicolegally vulnerable” (GP) | ||
Monitoring | Theme | Subtheme | Discussion |
Mixed feedback | Positive | From patients and colleagues helps confidence, helps staff to prescribe less not more – more PCC “each time I see a positive effect am motivated to do more” (Nurse Prescriber) | |
Negative | From colleagues (secondary care) and patients (complaints) “I stopped metformin in a 90-year-old with dementia, daughter complained, made me wary to deprescribe” (GP) | ||
Challenge of feeding back | Demonstrating impact | Hard to quantify benefits (GP) | |
Challenging the status quo | Fear of feedback | “If there is a problem may be hard if against the guideline” (GP) | |
Monitoring as a barrier | Accept only small deviation, monitoring from population not individual perspective, pressure to prescribe to QOF. “should be a KPI” [KPI = Key Performance indicator] | ||
Potential power of feedback | Should be a KPI |
“I suspect I tailor medicines much less than I would like to think I do” (GP)
“[ITC needs] recognition from the powers that be that this is a good thing” (GP)“patients need to understand not prescribing as important as prescribing” (Pharmacist)
Engagement
“it can be difficult to persuade patients and carers to change medicines they’ve been using for a long time” (Pharmacist)
“limited by time, caseload and so lack of mental capacity” (GP)“I barely get through the day reacting” (GP)
Action
Nurse prescribers (n = 234) | Pharmacists (n = 88) | GP (n = 97) | Total (n = 419) | |
---|---|---|---|---|
Numbers (%) reporting medium or high levels of practice skills in… | ||||
Assessing patient management of medicines | 153 (65.4) | 66 (75) | 75 (77.3) | 309 (73.7) |
Eliciting patient goals | 119 (50.1) | 48 (54.5) | 57 (58.8) | 237 (56.6) |
Deciding medicines meds to change | 111 (47.4) | 55 (62.5) | 72 (74.2) | 250 (59.7) |
Monitoring impact of change | 122 (52.1) | 39 (44.3) | 50 (51.5) | 226 (53.9) |
Described support from [n(%)] | ||||
My training | 114 (48.7) | 47 (53.4) | 43 (44.3) | 219 (52.3) |
My professional status | 80 (34.2) | 38 (43.2) | 48 (49.5) | 176 (42.0) |
My colleagues | 131 (60.0) | 57 (64.8) | 61 (62.9) | 264 (63.0) |
My patients | 130 (55.6) | 53 (60.2) | 73 (75.3) | 272 (65.0) |
Expressed training experience/needs [n(%)] | ||||
Had formal training | 39 (16.7) | 16 (18.2) | 12 (12.4) | 74 (17.7) |
Had informal training | 81 (34.6) | 37 (42.0) | 51 (52.6) | 178 (42.5) |
Would like more training | 129 (55.1) | 59 (67.0) | 67 (69.1) | 267 (63.7) |
“This was not taught when I trained. A guide to implement this safely would be helpful” (GP)
Barriers: | Time | Competing pressures | Risk stratification | Defend decision | Lack risk estimation support |
---|---|---|---|---|---|
Nurse prescriber (n = 234) | 91 (38.9) | 76 (32.5) | 42 (17.9) | 87 (37.1) | 83 (35.5) |
Pharmacist (n = 88) | 48 (54.5) | 45 (51.1) | 31 (35.2) | 38 (43.2) | 39 (44.3) |
GP (n = 97) | 87 (89.7) | 65 (67) | 45 (46.4) | 49 (50.5) | 68 (70.1) |
All (n = 419) | 235 (56.1) | 195 (46.5) | 120 (28.6) | 180 (43.0) | 200 (47.7) |
There was a call for additional qualified and experienced staff to support colleagues in this form of practice. The need for continuity of senior support, in terms of both clinical mentorship and medicolegal advice, was highlighted.“a fear of making a mistake and the potential consequences”(Nurse Prescriber)“hard to record decision and be sure will be understood” (GP)
Monitoring
Others also reported current feedback mechanisms (performance monitoring) as a significant barrier – the “pressure to prescribe to QOF” (GP) with only “small deviations” permitted.“I stopped metformin in a 90-year-old with dementia, daughter complained, made me wary to deprescribe” (GP)
But recognised the potential power of feedback as a source of support for practice commenting that individually tailored prescribing should be a “key performance indicator” (GP).“will be difficult to quantify downstream costs [that] will be saved - mainly by those outside of my practice so i will do work and savings will be made elsewhere” (GP)
Discussion
Summary
NPT Domain | Emerging themes | Identified Enablers and barriers | Implications for practice |
---|---|---|---|
Sense making | ITP is valued ITP is valuable ITP lacks clarity Value is not recognised/shared | ITP is an INTEGRAL part of professional person-centred practice, But LACKS CLARITY amongst professionals, patients and the wider community | Need work to raise UNDERSTANDING of ITP as a legitimate part of the expert generalist clinical role |
Engagement | Leadership Levels of engagement Patient engagement Barriers to engagement | Professionals lack the time, energy and head space to be engaged with this way of working as ITP is NOT PRIORITISED within current models of practice | Need work to PRIORITISE ITP within the range of services within primary care |
Action | Formal training Experiential learning Collective action Partial action Barriers | Much of the support and training for ITP comes from experiential learning and peer support. Particular areas of concern for practitioners are in making and recording DEFENDABLE DECISIONS; and getting PRACTICAL ADVICE on how to translate ideals of professional practice in to care on the ground | Need TRAINING and SUPPORT for INTERPRETIVE PRACTICE |
Monitoring | Mixed feedback Challenges of feeding back Challenging the status quo Potential power of feedback | The importance of feedback from/learning from patients to support ITP emphasises the significance of CONTINUITY of care. The need for formal monitoring/ feedback to RECOGNISE this complex form of practice | Need to support informal feedback and monitoring through peer reflection and continuity with patients; and consider the impact of formal monitoring on care |