There has been a steady move by the UK government toward extending professional roles within the NHS to meet demand (NHS England, 2016; Carter, 2016; King's Fund, 2019; NHS England, 2020), with many professionals now working within roles which would not have been part of their initial training (Tsiachristas et al, 2015). Armstrong (2016) argued that role extension was both career-enhancing and empowering; however, as Adams et al (2000) found when they investigated the experience of nurses, this is not always the case. Their research indicated that staff often experienced increased isolation and pressure when working in extended roles. Furthermore, as Imison et al (2016) stated, other staff may not be receptive to those in extended roles working alongside them, particularly when the new roles threaten to replace those of existing staff (eg nurses taking on roles that replace those previously undertaken by doctors). One such example of an extended role within the NHS is that of the non-medical prescriber (NMP). The UK currently has over 90 000 NMPs (Jarmain and Carey, 2020) and there has been extensive research into non-medical prescribing safety (Noblet et al, 2018), cost-effectiveness (i5 Health, 2015), patient satisfaction (Weeks et al, 2016) and acceptance by other health professionals (Funnell et al, 2014). However, one under-researched area is how new NMPs manage their transition into the role of the prescriber, and the impact this has on the formation of their identity.
Identity
In order to understand how identity is formed, it is useful to first consider what the term ‘identity’ means and how it can be conceptualised. Hitlin (2003) stated that theories on identity fall into three main categories: personal identity, social identity and role identity.
Personal identity
Personal identity was defined by Rieber (1998) as the set of absolute characteristics that make up an individual. Ashforth et al (2008) elaborated further, describing personal identity as ‘the gestalt of idiosyncratic attributes, such as traits, abilities and interests’. There has been much debate about whether these characteristics make up a single-core identity or if individuals have multiple identities. For example, Landau et al (2009) argued that a person actively builds their identity by grouping personal characteristics into categories by which they define themselves. Schwarz et al (2010) agreed with this and went on to state that a coherent identity led to a greater sense of purpose in life. The hypothesis of a single identity does not necessarily fit with the multiple and contrasting roles that a NMP may take on in their working life (such as educator, counsellor, manager, nurse). This lends support to the assertion made by McConnell (2011) that there was no single self, and that instead, individuals had several different identities that they applied dependent on context. In his multiple-self aspects framework, he proposed that every individual will have a number of self-aspects (eg wife, sister, student), which are connected to a variety of different attributes (eg caring, intelligent, proud). At times, the attributes may belong to more than one self-aspect (eg caring wife and caring sister) but this is not always the case. McConnell (2011) believed that this helped to explain how people behaved in different ways according to context and role. This can be viewed as useful in the context of attempting to understand the identity of NMPs who may undertake multiple roles.
Social identity
In contrast to individual identity, Tajfel (1978) defined social identity as ‘that part of an individual's self-concept which derives from his knowledge of his membership of a social group (or groups) together with the value and emotional significance attached to that membership’. This definition emphasises the significance of social interactions in identity development, whilst acknowledging that the self-concept may also develop in other ways. Traditionally, many NMPs would have worked in teams with other health professionals and the social interactions which took place may have helped them to develop their identity. However, teams are increasingly likely to be ‘virtual’ with less direct social interaction, meaning that traditional social identification is no longer an option (Fiol and O'Connor, 2005). This has become even more pronounced since the COVID-19 pandemic and the increase in individuals working from home (Waizenegger et al, 2020). Ashforth et al (2008) argue that one way people cope with this move toward more virtual working is for them to focus more on work/role-based identity.
Role identity
Whereas social identity theories state that identity derives from the social group, role-based identity theories argue that identity derives from the roles that individuals perform, such as working as a NMP. The majority of prescribers will need to take on multiple work identities in the course of their careers. Spehar et al (2015) argued that the success of these role transitions is dependent on the ability of the individual to integrate the new identity into their existing one. For example, the move to professionalise nursing has meant that some individuals have become disenchanted as they believe their new role as pseudo-manager is not congruent with their identity as a carer (Tuckett et al, 2015). In contrast, Lord and Hall (2005) found that where individuals held values that supported new management roles, the transition was relatively smooth. This lends support to the concept of ‘bricolage identity’, proposed by Carruthers and Uzzi (2000) and based on the work of Levi-Strauss. They believed that in order to adapt to new roles, individuals need to deconstruct their identities into the constituent components and then reform them into a new identity. Ibarra (1999) examined this role transition and proposed that individuals go through three stages when taking on new professional roles: observation of role models, experimentation with a provisional self and evaluation of the new identity. However, her research was predominantly conducted with those working in established professions. This study extends the work of Ibarra (1999), by looking at how health professionals form their identity in the less well-established role of NMP. An understanding of how new NMPs manage their transition into the role of prescriber and the impact this has on the formation of their identity is essential if we are to ensure that they receive appropriate support to implement their qualification effectively.
Methods
Aim and design
This study aimed to investigate how NMPs form and develop their identities, to do this, respondent-led photography was used. This ethnographic research methodology requires that participants take photos on a theme; these photos were then discussed with the author during semi-structured interviews. Respondent-led photography was chosen as a technique because it allows participants to freely identify what is important to them in a way that may not always be possible with some of the more traditional structured interview methodologies (Ray and Smith, 2011).
The data for this study came from interviews with staff and as such, it did not require review through the research ethics committee (Department of Health [DoH], 2012), however, the study was approved by the Research and Development Lead of the author's organisation. All participants were provided with a participant information sheet about the study. They were aware that all data collected would be anonymised and that they were under no obligation to take part.
Participants were all employed by an Acute and Community NHS Trust in the South West of England. It was decided that a completely random sampling approach would not be appropriate, as 86% of NMPs within the Trust were nurses. Instead, a random selection was made of NMPs from three different professional groups employed in the Trust; pharmacists, physiotherapists and nurses. This led to two pharmacists, three physiotherapists and three nurses taking part in the study. The areas in which the NMPs worked varied from in-patient departments to community locations, and they came from a number of different fields including sexual health, orthopaedics and bladder and bowel management.
The study was conducted as part of a MSc research project, and as such was overseen by a University supervisor.
Data collection
Participants were given a week to take and submit 10 photos on their smartphones, which they felt described their identity as a NMP. The photos were then printed and used as the focus of the interviews, by asking participants to describe what each photo meant to them. The interviews lasted between 50 and 75 minutes and were conducted in a private room in the NMP's place of work. The interviews were recorded on an iPad, and the transcripts were then typed up.
Data analysis
A thematic analysis was used to identify patterns in the data, as described by Braun and Clarke (2006). Each transcript was read on repeated occasions and several key themes were identified. These themes were cross-referenced with a University supervisor for additional rigour. The key themes are summarised below.
Results
There were three themes identified from the data. These were: using role models, consolidating the new identity and collectivity versus isolation.
Using role models
The majority of participants used a variety of different role models to assist with the formation and development of their identity as a prescriber. These role models tended to fall into two main categories: medical prescribers and other health professionals.
Medical staff were the professional group most commonly referred to as role models by NMPs, as described in the following statement:
‘I really value the two consultants that I work with. They are young consultants who are more willing to be more dynamic and integrated, there is a much more open dialogue, they've been helpful, they are people whom I'd look up to.’
Physiotherapist 3
For some specialities and professions, there was a significant dearth in appropriate medical role models, particularly where NMPs were practicing in a relatively new field such as in the following example:
‘I feel a bit isolated in the respect of having a role model, I find it quite difficult. When I was doing the training I sat in on a lot of clinics and I guess the consultants who are seeing the sort of patients I would see, they don't prescribe. Whereas GPs don't do the stuff we do….they prescribe a lot but not the stuff we would.’
Physiotherapist 2
This led NMPs to turn to other health professionals for examples of positive role models, who had skills and expertise that the NMP lacked. For some, these were close colleagues, such as in the following example:
‘Because my colleague is lead… this is really his area of expertise… So every time he gets a phone call I listen in to his decision process.’
Pharmacist 2
For others, there was a need for them to look outside of their immediate team for professional support and guidance, for example:
‘None of my colleagues are prescribers, so from a prescriber point of view, they are not going to be able to give me support. Other prescribers elsewhere I'd go to. For example, I'm always on the phone with the heart failure nurse.’
Nurse 2
These latter two statements exemplify two extremes of a continuum evident within the interviews, wherein some NMPs worked more closely with prescribing colleagues, often sitting in the same office, while others worked in complete isolation. The second example, above, illustrates a theme that surfaced repeatedly during the interviews; where NMPs worked within relatively isolated roles they actively sought out other prescribers in alternative specialities to learn from them and to help bolster their decision-making.
Consolidating the new identity
While the importance of role models was acknowledged by all of the NMPs in some way, several of them talked about the need to integrate the knowledge gained from others into their own way of working, rather than adopting the practice of another person in entirety, for example:
‘As I say to students when they come out with me on the wards “look at what everyone is doing, pick the best bits, because everybody has got bad habits they get into, pick the good bits and build your role around that.”’
Pharmacist 2
Non-medical prescribing is still a relatively new area, and every single interviewee is now working within a role that by its nature would not have existed a couple of decades ago. There are not sufficient numbers of experienced NMP role models available and NMPs are therefore often developing their roles by piecing together bits of practice from several different professionals with whom they come into contact. To this effect, a warning was sounded by one of the NMPs:
‘You need to find your own skills, you can't be like anyone else.’
Pharmacist 1
NMPs used different techniques when attempting to consolidate their new identities. For example, some of them described identifying positive elements of a doctors' practice and attempting to incorporate these into their own. At times this process was merely alluded to, such as in the following statement:
‘I'm getting supervision through the consultant which is really helpful because she's amazing and if I pick up on half the stuff she does I'll feel I've done OK cause she's very good.’
Physiotherapist 1
At other times NMPs talked explicitly about trying to copy elements of doctors' prescribing practice, for example:
There have been a couple of consultants who you see work and the way they are with patients, there is efficiency, they go through a checklist…they've thought of everything and they have clear plans. I try to emulate them.’
Pharmacist 1
NMPs saw themselves very much as novice prescribers for some time following qualification. As one of them put it:
‘It is like passing your driving test, you left the course feeling you may not be the greatest of drivers but you've got the skills to go out and be safe.’
Physiotherapist 3
Regardless of their extensive training, many of the NMPs were troubled by insecurities about their new role and how they were viewed by others. They made flippant remarks about this, for example:
‘We always joke that we are scared that the pharmacy will ring up and complain, we're always really proud when a prescription gets dispensed, we're like “yippee, someone took us seriously!”’
Nurse 3
They expressed concern that others health professionals will question their right to prescribe. This was alluded to by many of the NMPs, as in the following statement:
‘I think what I've also been surprised about is that with every letter I've written, I have not yet had a GP write back and contact me and say “what are you writing this for?” None of them have done it!’
Physiotherapist 3
In addition to worrying about having their right to prescribe questioned by others, NMPs also worried about whether they had sufficient knowledge to undertake their extended roles. One of the more experienced interviewees stated:
‘At times people will think you know stuff that you don't know. Sometimes I feel like I don't know any more than they do.’
Nurse 1
The potential challenge to a NMP's right to prescribe was therefore occurring on both an external and an internal basis.
To deal with their insecurities, several of the NMPs emphasised the importance of their professional background in contrast to other professionals. One of the pharmacists compared his profession favourably to medics when he stated:
‘Normally when you have a specialist or GP they are good at treating one specific thing, but once the picture gets muddied and the person has two or more conditions that is when pharmacists show their skills because if they are on a range of different medications we can quite often spot the problems before they arise.’
Pharmacist 1
A similar comparison was made by a nurse who said:
‘Nurses generally are more holistic…I think doctors are generally very focussed on the medical issue.’
Nurse 3
Meanwhile, one of the physiotherapists stressed the skills of her profession in contrast to nurses by stating:
‘I think physios are really good at diagnosis. I think nurses tend to be more task-orientated and have very high-level task management skills. I think the physio training is good for developing assessment and diagnosis skills and being autonomous.’
Physiotherapist 2
At a time when their roles were often undergoing a transformation following completion of the non-medical prescribing course, their professional identity may have allowed them to maintain some stability in the face of an uncertain future. It also gave them a steady basis from which to interact with others.
Collectivity versus isolation
Around 50% of the participants worked alone, either running clinics within a hospital or going to visit patients in their own homes. One of the nurses described his experience as follows:
‘Because of the nature of what you do.. Generally, you're in a room on your own and no one else gets very involved. So you could be doing clinic all day and you can be quite isolated in a way.’
Nurse 1
Some of the NMPs enjoyed the autonomy and independence that this style of working afforded them. They were able to get on with their job without having to concern themselves too much with anything else that was happening within the work environment. The majority, however, really missed the interaction with others. The following statement was taken from an interview with a NMP who had fairly recently qualified as a prescriber:
‘My colleague from the course is using it in his way and I'm using it in my way… but once you get back into your busy day to day working environment you don't always have the time to sit down and talk about it…it feels a bit disjointed.’
Physiotherapist 3
Where NMPs were newly qualified or working within new roles, they were particularly vulnerable to feeling isolated.
For those working within team environments, the feeling of inclusion appeared to play a prominent role in their sense of identity for example:
‘I know in the community when you are running clinics and things a lot of prescribing can be quite isolated and you can be by yourself but because of where I work and the role that I have, integration with other team members and professionals is a core part of my identity as a prescriber.’
Pharmacist 2
NMPs functioning within a team seemed more able to view their role as a significant part of integrated healthcare provision than those running clinics in relative isolation. Patients seeing NMPs in clinics would often also attend appointments with other healthcare providers such as their GP, however, in these cases, there was often less communication between professionals than in situations where a team was working together. NMPs working within a team were therefore often more able to articulate the way in which their prescribing was a positive part of an overall approach to helping a patient. As one of them said:
‘We work as an integrated team and I told the girls [about taking photos for the research] and they said “…why don't you take a photo of everyone around the computer, so it shows we are all working together for patients?”’
Nurse 2
The organisation in which the participants are all employed requires NMPs to attend a peer supervision meeting regularly. The meetings are normally attended by approximately 40 NMPs from different professional backgrounds and specialities. Half of the NMPs referred to these supervision meetings within their interviews, describing the positive impact of attending. One of the NMPs talked of her attendance as follows:
‘Despite the fact that we generally come from quite different backgrounds, there are always common themes…Which is quite nice to know. You kind of have similar issues.’
Nurse 3
Particularly in situations where the NMPs were working in isolation, or within a team where nobody else prescribed, they valued being able to share their concerns and worries with other prescribers. It did not seem to matter that the other NMPs who attended the forum were from different specialities, there was enough of a common interest and bond to bring them together. The forums allowed NMPs to talk through their issues in an environment that felt safe. As one of the nurses said:
‘I gained confidence by talking to colleagues about prescribing, talking in the NMP forum where you realise that other people have similar issues and you realise you're not alone.’
Nurse 1
This was especially relevant for those who had recently qualified and used the forum to learn skills from other NMPs who had been prescribing for some time. One of the physiotherapists gave the following example:
‘I was at the NMP forum, one of the discussions we'd had was about having headspace when you are writing a prescription and making sure you don't feel under pressure so you don't make mistakes. At the time I remember thinking that I need to make a note of that when I qualify and I've taken that quite seriously.’
Physiotherapist 1
The forum gave newly qualified NMPs access to a wide range of role models that they would not otherwise have had access to. It was also useful to those who had been qualified for some time, as they had the opportunity to pass on their skills and reaffirm their own experience and learning, as in the following example:
‘I think because everybody I've talked to at the forums is part of a shared experience. You say “I've only been doing it for a year now” and some people have only just started doing it now and you say “oh I remember how it felt” but it is a positive group because everybody has wanted to do the course.’
Physiotherapist 3
The forum acted as a reminder of how far they had come since they first qualified as a prescriber.
In addition to making links with other prescribers, NMPs made sure that they connected with others in their team. Even those who described their job as being fairly isolated went out of their way to build relationships based on their role as a NMP. One of the physiotherapists gave the following example:
‘I'm based upstairs, I shouldn't need to come into the physiotherapist department for work normally but I come in two or three times a day to see the other physiotherapists and they ask me questions, go through things, I'm always available.’
Physiotherapist 3
Although it would be possible for him to prescribe in isolation, he sees it as part of his job to communicate with others in the wider team. Being a NMP also led to a greater sense of belonging, particularly in roles that have traditionally sat slightly outside of the core multi-disciplinary team, such as those of the ward pharmacist:
‘Instead of isolating me, the prescribing has made me more integral to the team than ever before… Because when I'm in the team meetings and they say someone needs to do something I'm like “I can do that” because I'm a prescriber.’
Pharmacist 2
Prior to completing the course, this NMP had worked solely within a pharmacy-based team. She had not worked with other health professionals on a regular basis. Her statement makes it clear that being a prescriber enhances her position within the wider team. This in turn led to greater job satisfaction and an enhanced understanding of her utility within the team context.
Discussion
Moving into a new role can be extremely challenging, whatever that role may be. As Van Maanan and Schein (1979) state, not only is the individual required to put a range of new skills into practice, but they must also adopt the societal norms inherent to the role. New skills can be acquired relatively easily; in the case of non-medical prescribing all that is required is completion of a six-month course. Understanding how that role should be socially enacted, including concepts such as the level of expressed emotion (Sutton, 1991) and the overall organisational culture (Schein, 1990) is far more complex.
One of the best ways of achieving what Bauer and Erdogan (2011) referred to as organisational socialisation is to observe the behaviour of appropriate role models (Ibarra, 1999). However, this study identified that for NMPs, access to role models was limited due to the relatively recent introduction of the qualification. One of the difficulties of not having appropriate role models to observe at times of transition is that individuals may experience feelings of isolation and insecurity (Hennekam, 2016), emotions that were expressed by several of the NMPs that the authors interviewed. These feelings may lead to NMPs being less likely to use their role in practice. Hacking and Taylor (2010) found that 17% of those who had completed the NMP course were not using their qualification in practice and 19% of the remainder prescribed relatively infrequently.
NMPs in this study did not generally have NMP role models, however, they selected positive attributes from a number of different colleagues including medics and other health professionals. They then used these attributes to construct a personal blueprint of what a good NMP should look like. This is very similar to the process described by Gibson (2003) who investigated how individuals use role models in various ways at different stages of their career. He found that in the middle to late stages of career development, people are more likely to select attributes from a number of different colleagues as opposed to having specific role models.
Once NMPs in this study had developed a personal blueprint of what a good NMP should look like, they attempted to incorporate this model into their new identity as a prescriber. This supports the work of Ibarra (1999) who stated that experimentation with a provisional self was the second stage of role transition, following the identification of role models. For NMPs, their new identity initially felt very alien. They experienced a sense that they were merely playing a role, that they were fraudulent in their claims to have advanced knowledge and they worried that they would be ‘found out’. This finding is reinforced by the work of Clance and Imes (1978). They discussed the way that women in senior roles may often experience what they described as ‘the imposter phenomenon’, however, this study showed that the syndrome was not gender-specific and in fact was experienced by the majority of NMPs as they transitioned into their new roles. Perhaps this is not surprising; as Knights and Clarke (2013) note, whenever individuals working within organisations aim to increase their creativity and productivity, they will automatically experience some level of anxiety about their identity as they move away from what is known and safe.
NMPs in this study often used their tried and tested professional identity to bolster their new prescribing identity. For example, many of them talked about how they made a better prescriber because of their professional background as a nurse, physiotherapist or pharmacist. Spehar et al (2015) described a similar process occurring amongst clinicians taking on managerial roles, whereby staff emphasised their professional background in order to add legitimacy to their authority in undertaking new roles. This study showed that NMPs used this method to compare themselves favourably to negative role models, who they felt may not be able to do the job of prescribing as well as they could because they did not have the same professional background or understanding.
The contact that NMPs had with other colleagues varied enormously in this study. Some were based in offices working alongside other NMPs as part of a cohesive team. They spoke of how the prescribing qualification had increased their perceived utility to the team, sense of belonging and job satisfaction. Others worked in relatively isolated environments and communicated with other professionals primarily by letter or telephone. Individuals working within professionally isolated environments are more likely to consider leaving their jobs or even their careers, particularly when they are relatively inexperienced within their roles (Morrison, 2013). The professional isolation experienced by some NMPs is, therefore, an important factor for organisations to address in terms of the retention of staff. Several of the NMPs spoke of the beneficial impact of attending the quarterly professional forums run by the organisation. They described how these enabled them to learn from each other and to gain support, particularly when feeling professionally isolated. This supports research by Hadar and Brody (2016) who found that support/education groups improved practice and professional development amongst isolated individuals.
Although this study provides an insight into the way in which NMPs form and develop their identity, it has some limitations. The greatest of these was the relatively small sample size. In addition, due to the sample size, there were limited numbers of professionals within each of the groups interviewed; three nurses, three physiotherapists and two pharmacists. Although many of the themes that emerged from the data were raised repeatedly by the NMPs interviewed, there is no guarantee that the findings are generalisable. A further limitation to the study was that due to the small sample size it was not fully representative of the population being researched. The nurses that were interviewed had all been qualified as NMPs for several years, while the physiotherapists had only been qualified for a year. In attempting to select participants randomly the sample was perhaps less representative of the professional groups interviewed. Further research with a larger sample size is therefore recommended.
Conclusions
In this study, NMPs used a variety of role models to assist with the formation and development of their identity as a prescriber, taking aspects from different people and piecing these together to form their own new identity. Role models included both doctors and other health professionals. They relied on their professional background to add legitimacy to their new identity as prescribers. For all NMPs, but particularly those working in isolated roles, contact with other NMPs gave them access to additional role models and support which they found valuable. This helped overcome feelings of anxiety and isolation which may have otherwise limited their ability to prescribe. NMPs felt that their role helped increase their sense of belonging, perceived utility to the team and job satisfaction.
Key Points
- In the absence of NMP role models, NMPs take aspects from a number of different people including doctors and other health professionals, to help them form their new identity as a prescribe
- NMPs rely on their professional background to add legitimacy their new identity as a prescriber
- NMPs felt that their role helped increase their sense of belonging, perceived utility to the team and job satisfaction
- Organisations should consider putting in place support in the form of NMP meetings/forums/supervision, particularly where NMPs are working in isolated roles.
CPD reflective questions
- If someone were to describe you as a role model, what elements of your practice do you think they would be most likely to wish to emulate?
- How much of your identity as a NMP is to do with your professional background and how much is to do with your training/practice as a NMP?
- What support do you have for your role as a NMP? Do you have sufficient opportunity to meet with other NMPs on a regular basis?