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Nurse and pharmacist supplementary prescribing in the UK--A thematic review of the literature

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Objectives Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent
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  Health Policy 85 (2008) 277–292  Available online at www.sciencedirect.com Review Nurse and pharmacist supplementary prescribingin the UK—A thematic review of the literature Richard Jason Cooper a , ∗ , Claire Anderson a , Tony Avery b , Paul Bissell c ,Louise Guillaume c , Allen Hutchinson c , Veronica James e , Joanne Lymn e ,Aileen McIntosh c , Elizabeth Murphy f  , Julie Ratcliffe c , Sue Read c , Paul Ward d a  Division of Social Research in Medicines and Health, School of Pharmacy, The University of Nottingham, UK  b School of Community Health Sciences, The University of Nottingham, University Park, Nottingham NG7 2RD, UK  c School of Health and Related Research, University of Sheffield, UK  d Flinders University, Adelaide, Australia e School of Nursing, The University of Nottingham, UK  f  School of Sociology and Social Policy, The University of Nottingham, UK  Abstract Objectives:  Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving atripartiteagreementbetweenindependentmedicalprescriber,dependentprescriberandpatient,enablingthedependentprescribertoprescribeinaccordancewithapatient-specificclinicalmanagementplan(CMP).Theaiminthispaperistoreview,thematically,the literature on nurse and pharmacist SP, to inform further research, policy and education.  Methods:  A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronicdatabases, grey literature and journal hand searches.  Results:  Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked aware-ness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriersemergedfromtheempiricalandanecdotalliterature,includingfundingproblems,delaysinpracticingandobtainingprescriptionpads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknessesand under-evaluation of safety, economic analysis and patients’ experiences were identified in empirical studies. There was aperception that nurse and pharmacist independent prescribing may supersede supplementary prescribing. Conclusions:  There is a need for additional research regarding SP and despite nurses’ and pharmacists’ enthusiasm, implemen-tation issues, medical apathy and independent prescribing potentially undermine the success of SP.© 2007 Elsevier Ireland Ltd. All rights reserved. Keywords:  Nurse; Pharmacist; Supplementary prescribing; Literature review; UK ∗ Corresponding author. Tel.: +44 1142220683/7889 932626.  E-mailaddress: richard.cooper@nottingham.ac.uk  (R.J. Cooper).0168-8510/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.healthpol.2007.07.016  278  R.J. Cooper et al. / Health Policy 85 (2008) 277–292 Contents 1. Introduction............................................................................................ 2782. Objectives ............................................................................................. 2793. Scope and method ...................................................................................... 2794. Results ................................................................................................ 2794.1. Empirical research ............................................................................... 2814.1.1. Practitioners’ perspectives................................................................. 2814.1.2. Views of other healthcare professionals..................................................... 2834.1.3. Patients’ and public’s perspectives ......................................................... 2834.1.4. Professional relationships ................................................................. 2844.1.5. Education and training.................................................................... 2844.2. Anecdotal literature .............................................................................. 2854.3. Clinical applications.............................................................................. 2854.4. Facilitators and barriers ........................................................................... 2854.5. Independent prescribing........................................................................... 2864.6. Grey literature ................................................................................... 2865. Discussion............................................................................................. 2876. Conclusions............................................................................................ 290References............................................................................................. 290 1. Introduction Changeswithinhealthcareinrecentyearshaveseena shift in the traditional roles undertaken by healthcareprofessionals and one of the most significant of thesehas been the development of non-medical prescribing.Internationally,severalhealthcaresystemsnowincludesome form of prescribing by non-medical healthcareprofessionals, offering potential benefits in terms of increasing patients’ continuity of care and access tomedicines, better utilisation of economic and humanresources, reductions in patient waiting times and lessfragmentation of care [1]. The nursing and pharmacy professionshavebeenattheforefrontoftheseprescrib-ingchangesandintheUSA,forexample,collaborativeprescribing by pharmacists and nurses has been pos-sible since the 1970s and, in the United Kingdom(UK), district nurses and health visitors have had lim-ited prescribing rights since the late 1990s. A reviewof the international pharmacist prescribing literatureidentified predominantly US studies which reportedbenefitssuchasimprovedcomplianceanddiseasecon-trolmeasures,fewerdruginteractions,betterallocationof resources and economic saving [2], whilst a UK nurse prescribing literature review identified generallypositive evaluations amongst both patients and nurseprescribers but identified concerns involving pharma-cological knowledge and limitations in prescribablemedicines [3].Rapid changes within healthcare, though, havemeant that these reviews did not include more recentnon-medical prescribing models such as supplemen-tary prescribing (SP). Introduced in the UK in 2003,this model is a key part of the UK government’s plansto revolutionise the delivery of healthcare and offersprescribing rights for several healthcare professions,includingnurses,pharmacistsand,mostrecently,phys-iotherapists, radiographers and optometrists. SP is adependent model of prescribing, involving a tripartitearrangement between the supplementary prescriber, anindependent prescribing doctor and the patient. Fol-lowing an initial medical diagnosis, SP allows suitablytrained healthcare professionals to take prescribingresponsibility for patients in accordance with a spe-cific clinical management plan (CMP) [4]. Such is the paceofhealthcarereformsintheUKthat,aswellasSP,nurses and pharmacists can now also undertake inde-pendent prescribing (IP). Non-medical training in theUK now involves, for nurses, a single post-graduateindependent, extended and supplementary prescribing(IESP) qualification whilst pharmacists, at the timeof writing, complete either a SP or an IP conversion   R.J. Cooper et al. / Health Policy 85 (2008) 277–292  279 course.DespitethedevelopmentofIP,SPisintendedtohaveacentralroleinUKhealthcareandisarguedtobeparticularlysuitedtothemanypatientswhohavestable,long-term conditions such as cardiovascular diseaseand diabetes. Safety is paramount in SP, by virtue of continuedmedicalsupervisionandtheguidelinesoftheCMP. Such safeguards have meant that SP can be froma full medicines formulary, including controlled andunlicensed drugs. There are around 1200 SP qualifiedpharmacists (Personal communication, Royal Pharma-ceutical Society of Great Britain 2007) and around10,000 nurses qualified to undertake SP or IP [5]. 2. Objectives Theaiminthispaperistoreviewtheextantliteraturerelating to nurse and pharmacist SP, given its impor-tance to changing UK healthcare roles and NationalHealthService(NHS)aims.Specificobjectivesweretoconsider issues surrounding the implementation of SPand how it has been perceived and experienced by var-ious healthcare professionals and to describe relevantempirical research relating to SP and identify whereadditional research is needed. In so doing, it is hopedthat this review can inform further research and policy,not only in the UK but also internationally. 3. Scope and method The intention in this review is to consider bothempirical pharmacist and nurse SP research and alsoopinion and commentary and the grey literature relat-ing to SP. The reason for including such potentiallydiverseliteraturesisduemainlytoSPbeingarelativelyrecentdevelopmentwithasassociatedlackofempiricalresearch, as previous non-medical prescribing reviewshave found [3]. Hence, a thematic rather than sys- tematic review was considered most appropriate andincludingthegreyliteratureofferedtheopportunitynotonly of identifying research that would not otherwisebefound(suchasfromconferences,non-peerreviewedpublicationsandcommissionedandpolicydocuments)but also of considering more broadly how SP is per-ceived from the perspectives of the nursing, pharmacyand medical professions. Searches were made of thatliterature from 1997 to 2007 using combinations of the following keywords: ‘supplementary prescriber’,‘supplementary prescribing’, ‘nurs* and prescrib*’,‘pharmac* and prescrib*’. These search criteria wereusedtoallowfortheinclusionofpapersonnon-medicalprescribingmoregenerallyifthesewererelevanttoSP,especially since the IESP status of many UK nursesmeans that research may have been undertaken usingsuch nurse samples without specific reference to SP.Although SP was only introduced in 2003, the earliersearch date was used to allow for early consultationor policy documents or reflection on the  proposed   useof SP. Exclusion criteria included papers relating tospecific but non-supplementary forms of prescribingsuch as patient group directions [3] and independentprescribing. The following electronic databases weresearched:MEDLINE,EMBASE,CINAHL,ISIWebof Knowledge and Zetoc. In addition, on-line searches of  The Pharmaceutical Journal ,  International Journal of PharmacyPractice ,  JournalofClinicalNursing ,  Jour-nal of Advanced Nursing ,  Nurse Prescriber  ,  NursingTimes  and Department of Health websites were made. 4. Results Thirty-five empirical research papers were identi-fied: 20 relating to pharmacy [6–25] (Table 1 ), 15 nursing [26–40] (Table 2) and 3 papers that concerned both [41–43] (Table 3). However, several publications reported different aspects of one overall study and dataset [12,13,29–31,37,38]. A further 25 nurse SP papers and 5 pharmacist SP papers were identified offeringanecdotalopinionsandexperiencesofSPpractice.Onebook was identified [44] and 20 policy documents and a number of anonymous journalistic reports on SP inpublications such as  The Pharmaceutical Journal  and  Nursing Times . Several broad categories of literaturewere identified: empirical research papers (from bothpeer reviewed journals and the grey literature), anec-dotaloropinionpieces,governmentalandprofessionalbodypolicydocumentsandgeneraljournalisticreport-ing on SP. It was apparent from this review that this isstillanareaofhealthcareinitsinfancyandtheliteraturewas frequented by phrases such as ‘  first wave ’, ‘ earlyexperiences ’andreferencestothe‘  potential ’ofSP.Theresults and emergent themes of the empirical researchpapersidentifiedaredescribedfirst,beforeaconsidera-tion of other identified literature forms – anecdotal and  280  R.J. Cooper et al. / Health Policy 85 (2008) 277–292 Table 1Pharmacy supplementary (or relevant other) prescribing studiesAuthor(s) Study aims/results Method/sampleCandlish et al. [6] SP pharmacist and barriers survey. 50% of pharmacistspracticing SP. Community a problem due to prescription paddelays and IT issues. Most wanted to train and practice IP.Hospital argued to be more conducive to SP due to existingrelationships, access to medical records and padsFifty-four pharmacists who hadcompleted SP training at oneuniversity returned postalquestionnaire from sample of 107(50%)Cassidy et al. [7] Pilot study of pharmacists’ and mentors’ experiences of SP:relationships, responsibilities and professional progressionwere all emergent issuesThree focus groups with total of 17hospital pharmacists andsemi-structured interviews with 11mentorsChild et al. [8] Few doctors or nurses had experienced pharmacist prescribingbut positive if training, communication skills, resources andliability issues addressedQuestionnaire using conveniencesample of hospital doctors,pharmacists and nurses in five UKhospitalsChild and Cantrill [9] Doctors’ perceived barriers to pharmacist prescribing:communication, pharmacists’ clinical/patient knowledge,doctors’ initial prescription-writing and mechanisms fortreatment reviewQuestionnaire using conveniencesample of hospital doctors in five UKhospitalsChild [10] Nurses’ perceived pharmacist prescribing positively if training,communication skills, resources and liability issues addressedOne hundred and fifteen hospitalnurses from five UK hospitalcompleted questionnaire aboutpharmacist prescribingDawoud et al. [11] Pharmacists’ views after SP training courses: lesspharmacology and more examination, consultation trainingneeded. 88% perceived themselves already competent. 82%foresaw SP problems in co-morbidity, 51% CMP difficulties,and 48% thought pharmacists and not nurses most appropriateto prescribeThirty-five self-responsequestionnaires returned from sampleof 41 (85%) first cohort pharmacistsfrom two universitiesGeorge et al. [12] SP pharmacists reported benefits as patient management, jobsatisfaction and self-confidence but challenges due to lack of:funding, IT support, awareness by othersFour hundred and one questionnaireresponses from postal survey of all488 (allowing for 30 pilot) UK SPpharmacists (82.2%)George et al. [13] Early experiences of SP pharmacists: only half trained SPpharmacists actually practicingFour hundred and one questionnaireresponses from postal survey of all518 (less 30 pilot) UK SPpharmacists (82.2%)Hobson and Sewell [14] Implementation of SP in UK: more barriers to SP in primarycare SP, whereas secondary care SP formalising existingpracticesPostal survey of pharmacists in PCTsresponsible for implementing SP (97secondary, 187 primary careresponses)Hughes and McCann [15] Perceived barriers between pharmacist and GPs: doctors’shopkeeper perception of pharmacists and issues of access,hierarchies and lack of SP awareness were all inter-professionalbarriersSix focus groups involving 22 GPsand 31 pharmacists from three areasof Northern IrelandJackson [16] Baseline survey of implementation of SP in PCTs revealedperceived training issues, greater nurse SP due to existinginfrastructure and pragmatic uptakeOne hundred and ninety two postalquestionnaire returned from sampleof all 302 UK PCTs (63.5%)Jones et al. [17] Pharmacist stakeholders’ views on SP. Positive view of SPemerged, but training and GP relationships an issueSemi-structured interviews with 14stakeholders: SP trainee pharmacists,education providers, policy makersLloyd and Hughes [18] Pharmacists’ and mentors’ views of SP: broadly welcomed byboth but issues of deskilling, IP threat, boundary encroachmentidentified. Some pharmacists cautious about competency &necessary relationshipsNine focus groups involving SPpharmacists and 35 semi-structuredinterviews with medical mentors   R.J. Cooper et al. / Health Policy 85 (2008) 277–292  281Table 1 ( Continued  )Author(s) Study aims/results Method/sampleLloyd, McNally and Hughes [19] Nurses saw pharmacists as most knowledgeable aboutmedicines but not best for prescribing. Pharmacist SP not athreat to nursing but might de-skill doctorsQuestionnaires completed by 205from sample of 820 randomlyselected nurses in 11 UK hospitalsLloyd, McHenry and Hughes [20] Doctors had good relationships with pharmacists, agreed thatSP could reduce their workload and errors but were unaware of SP and felt doctors best prescribersQuestionnaire sent to all 516 juniorand senior house officers in 11 UKhospitals. 115 responsesShulman and Jani [21] SP pharmacists more likely than and doctors to comply withguideline drug dosing for haemofiltrationRetrospective analysis of medicationdetails of 145 ICU patients requiringhaemofiltrationSmalley [22] Patients’ experiences of pharmacist-led SP included: betterunderstanding of their condition, better care and involvement intheir treatmentConvenience sample of patients fromone UK SP hypertension clinic:111/127 returned questionnaireWarchal et al. [23] Pharmacists skills, challenge, patient and profession benefits allreasons for taking SP course but access to records a barrier. IPan eventual aim and a threat to SPThirty-eight pharmacists who hadcompleted SP training given postalquestionnaire and interviewedWeiss et al. [24] Pharmacists positive about SP as challenge and benefit forpatient but communication issues, clinical examination skills,doctors’ and patients’ lack of awareness of SP and delays inprescribing all concernsTwenty-three semi-structuredpharmacist SP interviews and 5 casestudies involving interviews with 7doctors, 5 pharmacists, 3 nurses, 10patients and other staff While et al. [25] Community pharmacists’ views on SP positive in increasingknowledge, job satisfaction, patient benefits but time andmedical record access concerns127/238 (53.4%) pharmacists from 5PCT areas responded to self-reportpostal questionnaire Postalquestionnaire survey additional grey literature – and broader themes such asclinical applications, facilitators and barriers and IP. 4.1. Empirical research A range of methodological approaches was foundin the empirical studies and although qualitative focusgroups, semi-structured interviews and observationalapproaches were found, quantitative postal self-reportquestionnaires were the most frequently used method.Manyofthequantitativestudiesinvolvedconvenience,rather than randomised, samples from particular geo-graphical locations such as health areas, NHS trusts orindividual hospitals and these methodological limita-tions were often recognised by authors as preventinggeneralisations from being made and are consideredagain in the discussion. Key themes to emerge fromthe empirical research literature involved the differingsample groups (nurses, pharmacists, other healthcareprofessionals, patients), training and relationships, andthese are considered first, before describing the otheremergent themes, which overlapped somewhat morewith the anecdotal literature such as clinical applica-tions, facilitators and barriers and IP. 4.1.1. Practitioners’ perspectives The most common focus in empirical research con-cerned the experiences, perceptions and opinions of either nurse or pharmacist SP practitioners or trainees,often using self-report questionnaire methods. In thepharmacy literature, George et al. [12] reported on the early experiences of SP pharmacists and on the bene-fits and challenges to SP [13] using the same data from a postal questionnaire sent to all UK SP pharmacists.This was the only national survey of SP pharmacistsidentified in this review. The studies by George et al.identified themes that were recurrent in this literaturereview such as prescribers’ confidence and increased job satisfaction and independence and their perceptionthat patients were more satisfied and better managedwith SP arrangements. Pharmacists’ views were alsosought in a study in the grey literature by Weiss et al.[24] which reported similar themes to those identifiedabove, in that SP pharmacists perceived many patientbenefits such as being able to spend more time withpatientsandgivemoremedicinesinformationthandoc-tors. Lloyd and Hughes [18] reported that a sample of  the first Northern Ireland pharmacist SP cohorts weregenerally positive about SP as a professional devel-
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