Prescribing practice

Fourteen interviews were conducted to reach data saturation. Interviewees’ demographic details are given in Table 1; 9 were based in England, 3 in Scotland and one each in Wales and Northern Ireland. All were practising in secondary care with some also practising in primary care (n = 2) and community pharmacy (n = 3). Within secondary care, most prescribed a full range of renal medicines for inpatients and outpatients and some prescribed specific classes of medication (e.g., tolvaptan) in clinic settings.

Table 1 Interviewees’ demographics (N = 14)

Table 2 summarises the themes, categorised as facilitators or barriers, aligned to CFIR domains and constructs.

Table 2 Themes, categorised as facilitators or barriers, aligned to CFIR domains and constructsThemes aligned to CFIR domain and constructs

1. CFIR domain, Innovation characteristics (key attributes and features of interventions that influence implementation success).

Intervention source

Theme, ‘Pharmacist prescribing need: arisen from a number of different sources’.

Many highlighted that the intervention was a UK government legislative initiative to meet the demands of service providers.

“…the need to make sure that pharmacy … part of the solution to meet the demand in the NHS by being professionally integrated into frontline services, the government extending the prescribing roles to other healthcare professionals…” Pharmacist 5

There had been a transition from supplementary to independent prescribing as services developed.

“Initially it was supplementary….and now because I’ve been here so long, all doctors accepted that I do prescribing independently as much as the doctors.” Pharmacist 2

In the community setting, the intervention was also facilitated by contractual changes for general practitioner (GPs).

“Generally, probably the changes in the GP contracts that asking to get community pharmacist prescribing…it just depends on where you are.” Pharmacist 7

Relative advantage

Theme, ‘Advantages of pharmacist prescribing role’.

Pharmacist prescribing was considered advantageous for several reasons, with reduction in doctors’ workload a facilitator, allowing them to deal with more complex cases by sharing prescribing responsibilities.

“Services are being redesigned and the ability to have more advanced practice, being able to take chronic disease management away from physicians…allowing more time for them to deal with complex cases.” Pharmacist 5

Design quality and packaging

Themes, ‘Prescribing aligned with organisation’s needs’.

The implementation of prescribing practices varied across different geographical regions.. Obtaining a prescribing qualification was an important aspect to start the practice.

“We just have a cohort of prescribers, and bits of prescribing document within the Trust and says that you can use your prescribing qualification in these circumstances.” Pharmacist 10

2. CFIR domain, Outer setting (features of the external environment that have an influence on implementation).

Patient needs and resources

Theme, ‘Pharmacist prescribing is accessible for, patients’.

Many discussed patients’ needs and accessibility of prescribing as key drivers for implementation.

“I’ve managed to establish a telephone tolvaptan clinic. So, we have some patients that were driving for an hour to come to clinic every month, which was a long time. So, managed to negotiate with the consultants to set up a telephone clinic” Pharmacist 3

Theme, ‘Learning and development needs’.

While pharmacist learning and development needs and meeting these needs was a facilitator of implementation, the funding required to meet these ongoing needs in specific areas was also considered to be barriers by some.

“In terms of barriers, I would say, having been able to do the clinical skills course, which wasn’t previously funded for pharmacists, that would have helped building the confidence and allowing you to have an extra skill” Pharmacist 9

Cosmopolitanism.

Themes, ‘Collaboration with external professional bodies’.

Many discussed how external, independent organisations had positive impacts on their prescribing practice, with challenges from other organisations.

“I get a lot of good ideas from the UKRPG and at RPS [Royal Pharmaceutical Society] conference…it’s always good to reach colleagues there, but always a challenge that other units are more advanced in prescribing in specialised clinics…” Pharmacist 6

3. CFIR domain, Inner setting (features of the internal environment that have an influence on implementation).

Network and communications.

Theme ‘Wide range of communication within organisation’.

Within the organisation there were various forms of formal and informal communication related to prescribing practice information or updates. Verbal communication between healthcare professionals were described in a positive way.

“I think obviously because I’ve built a rapport with the team…the thing that helped me develop the practice because you can learn from each other.” Pharmacist 13

A few interviewees emphasised circulation of written communications in the form of emails or bulletins to share prescribing related information.

“Communication bulletins come up via email and on the website in terms of prescribing errors that we think would have an impact across the organisation so shared learning from errors.” Pharmacist 12

Available resources.

Themes ‘Limited fund’, ‘Personnel shortage’, ‘Time to prescribe’, ‘Training resources needed’.

The main hindrance in terms of resources was the availability of funds, time, and personnel to enable the expansion of the prescribing service.

“If you get resources, it will help you. If you don’t get resources, they are hindrance, so money, time, personnel, if they want to expand things, they have got to give you time and money for resources.” Pharmacist 1

However, in relation to a key theme on ‘Training resources needed’ there was general agreement across the interviewees that the independent prescribing course was widely supported by the organisation which aided prescriber development. There were also other prescribing related courses that were available to the pharmacists to advance their prescribing skills.

“There’s a course at [a hospital name], where you can do an advanced clinical practitioner skill. So, I think because you see your patients, and you do a small bit on physical assessment but I wouldn’t be an expert” Pharmacist 8

4. CFIR domain, Characteristics of individuals (key characteristics and features of individuals involved in the implementation success)

Self-efficacy.

Themes ‘Awareness of self-competencies’, ‘Experience’, ‘Willingness to prescribe’.

Interviewees were aware of their own abilities to be able to provide prescribing services, highlighting that they prescribed in their area of competence.

“Unless it was fairly simple stuff, I don’t tend to get too involved in complicated stuff, I would leave that up to the medical staff. I’m not really too keen on prescribing for patients that I don’t really know that well” Pharmacist 1

Some highlighted that they were aware of the need to develop additional skills to allow them to meet the specific needs of CKD patients.

“We’ve got these pharmacological skills so we can develop interactions and things, I think, actually that's the benefit. So, having those, that clinical knowledge means that our patients who are prescribed tolvaptan are kept safe, so something doesn’t interact with it…” Pharmacist 9

A few interviewees felt that they needed to further transfer their prescribing roles into more clinic settings and to more specialised areas of practice.

“I think definitely will be clinic, I think what [colleagues name] doing there, heart failure, I think that will be the future. I think, you want specialist pharmacist doing specialist clinics.” Pharmacist 1

Individual identification with organisation.

Theme ‘Supported by organisation’.

Interviewees acknowledged the positive level of commitment from their organisations.

“I was fully supported by the department, everybody was very keen for me to do it, and yeah, I have not looked back, it's been great.” Pharmacist 14

Other personal attributes.

Themes ‘Consultation and social skills essential’, ‘Awareness of strengths and limitations’, ‘Willingness to learn and develop’.

Some felt that their experience as a pharmacist advanced their practice as prescribers.

“It very much depends on the competencies of the pharmacist, and I’m lucky that I’ve been in my area a long time and feel competent, most of the time, and if I don’t, then I would always have a discussion with medical staff.” Pharmacist 4

5. CFIR domain, Process (key activities of implementation process)

Planning.

Theme ‘Non-medical prescribing implementation planning’.

None of the interviewees were particularly aware of the early planning processes to support pharmacist prescribing implementation. Some highlighted current organisational wide plans to further develop prescribing practice, increasing capacity by supporting the training and practice of pharmacist prescribers.

“There has been a drive within our department, to get prescribers, probably about two years ago, we probably had five to ten prescribers, but over the last three years, there has been some different drive where they need to kind of boost prescriber numbers, so was all building upon numbers.” Pharmacist 10

Some noted that the plan was framed according to the needs identified in each organisation.

“It looks at the needs for the department so if we need more like help, you know, surgical admissions obviously the surgical pharmacist would take priority, and the admissions pharmacist because that’s when we have more of the clerking in issues, and then it is funnelled down in case of priority and need.” Pharmacist 13

Reflecting and evaluating.

Themes ‘Regular monitoring of prescribing practice’, ‘Internal/ external processes’, ‘Need to develop patient feedback systems’, ‘CPD/reflection and work-based appraisal systems in place’.

While interviewees described various activities to allow reflection and assessment of their prescribing practice, they mostly relied on peer review to assess prescribing efficiencies or identify any errors.

“We do a peer review every so often, [a colleague] peer reviewed me, she came through, and I showed her three Kardexes [inpatient prescriptions]. I did the same for her and we evaluated each other.” Pharmacist 1

The electronic prescribing system within organisations was used to identify issues related to prescribing.

“We have an electronic prescribing system, so we can see a log of what we have prescribed and what changes we have amended, literally I press the button it goes through the IT we can audit our work.” Pharmacist 12

Others described the aspiration of an auditing process to assess prescribing efficiencies and sharing these data locally or nationally.

“I guess maybe it would be more useful to have a more formal method of audit and reporting. I must say, I have, have a look at my own prescribing myself using the electronic system but it probably would be helpful if we had a formal way of making sure that everybody did that, and that we shared all the learning formally.” Pharmacist 11