The aim of this research study was to investigate non-medical prescribers' (NMPs) awareness of compliance when prescribing within an acute NHS trust, for the purpose of an MSc dissertation in Advanced Healthcare Practice. The study investigated issues such as compliance and access to continued professional development (CPD). NMPs have a professional responsibility to be compliant and accountable to provide competent, safe prescribing of medications within their area of practice. As the number of healthcare professionals qualifying as NMPs is increasing, more research in this area is increasingly valuable (Royal Pharmaceutical Society (RPS), 2016; Nursing and Midwifery Council (NMC), 2018; General Pharmaceutical Counci, 2019).
This was a quantitative pilot study that used a survey technique, in the form of an online questionnaire, to obtain objective data. The objective of the study was to establish NMPs' awareness of what is required to be compliant as an NMP and to identify factors that would improve their compliance. The sample consisted of nurse, pharmacist, physiotherapist and dietician NMPs who were actively prescribing in an acute NHS trust. Results from the survey were analysed using IBM SPSS 25 software. A literature review was conducted, to critique previous studies.
Literature search
The literature search systematically reviewed evidence, to investigate if NMPs in an acute NHS trust are aware of what is required to remain compliant as active, competent and safe professional prescribers. The National Institute for Health and Care Excellence (NICE) and Health Education England (HEE) journals, as well as the databases EMBASE, CINAHL, Medline and BNI, were searched. Inclusion parameters for the literature review search terms included: non-medical prescribing, independent prescribing, competency, competency framework, keep up-to-date, proficient, continued professional development, knowledge and staying compliant. Relevant literature was limited to within the last 9 years. The only exception was relevant historic authors for non-medical prescribing and research books.
Studies have demonstrated that NMP competency frameworks provide a useful template, highlighting good prescribing practice (Diggle, 2018; Picton et al, 2016). Furthermore, Caddye and Clair-Jones (2015) in their single-centre study identified validated assessment tools (the mini clinical evaluation exercise, case-based discussions, 360 and peer review) that NMPs used to map their competencies against competency frameworks. Although the findings were positive, the study's response was poor, limiting generalisability. More significantly, the study mapped competencies against the National Prescribing Centre (2012) Single Competency Framework. This framework has since been replaced by the RPS (2016) Competency Framework.
In contrast to assessment tools, since the introduction of the RPS framework, other studies have highlighted reflection and continued CPD as being instrumental in mapping competency and subsequent demonstration of compliance (Diggle, 2018; Lowery-Brady, 2017). In addition to this, attending relevant CPD opportunities was reported to positively influence NMP competency, ensuring safer and more effective patient care (Cleary et al, 2017; Lowery-Brady, 2017; Djerbib, 2018). However, there is limited support available for student NMPs when achieving competence (Lowery-Brady, 2017; Pearce and Winter, 2014). Diggle (2018) highlights that it is the NMP's responsibility to ensure standards of prescribing are upheld. The employer is also responsible for providing access to CPD opportunities that can be evidenced within the NMP's portfolio (Diggle, 2018). A national study of health visitors' prescribing practice demonstrated that lack of updates or CPD opportunities left 2.4% of respondents feeling incompetent and lacking confidence to prescribe (Bishop and Gilroy, 2015).
Research design
Although current evidence is limited from varied research designs and different paradigms, quantitative raw data can be generated from the online survey software Survey Monkey (2020). The data produced can be systematically analysed using descriptive statistics to synthesise and describe the data. A quantitative design using a survey technique with a questionnaire generates objective data and can measure objective phenomena using nominal scales to represent the raw data (Bell and Waters, 2014; Parahoo, 2006).
The inclusion criteria from a purposive sample can be prone to researcher bias, as the sample relies on the judgement of the researcher. However, this can maximise the generalisability of the findings when including a relevant exclusion criterion (Parahoo, 2006; Polit and Beck, 2013).
McPeak et al (2014) suggest that electronic surveys improve responses and can be fast and efficient. According to Parahoo (2006), questionnaires for data collection have both values and limitations, which will be discussed later in this paper. For the questionnaire in the present study, a return date was given, as it is unwise to allow participants too long to complete the survey (Bell and Waters, 2014). Pilot studies validate the effectiveness of the questionnaires (Bell and Waters, 2014).
A Likert scale is another research method advocated by Bell and Waters (2014), Parahoo (2006) and Polit and Beck (2014). The Likert scale was used to measure confidence when prescribing, which is linked to the idea of CPD increasing confidence. Descriptive statistics are used to synthesise and describe the data and a statistical software programme can perform highly complex data manipulation and analysis. Frequency and percentage of the values can be analysed using basic descriptive statistical analysis (Bell and Waters, 2014; Parahoo, 2006; Polit and Beck, 2014). This study used descriptive statistics, which were analysed statistically. Ethical principles need to be considered when undertaking research, such as obtaining informed consent, maintaining confidentiality, beneficence, maleficence and the right to full disclosure (International Council of Nurses (ICN), 2012; Parahoo, 2006; Polit and Beck, 2014).
Methods
Research question
This study aimed to investigate NMPs' awareness of compliance when prescribing, using a quantitative pilot study.
The rationale for using the quantitative design, with a survey technique, was primarily because of the original sample size of 85. In addition to this, the use of a questionnaire ensured that all of the NMPs were asked the same questions, to generate objective data (Bell and Waters, 2014).
The purposive sample (all members of the population of interest) was taken from the Acute Trusts database of NMP, registered nurses pharmacists, physiotherapists and dieticians. The exclusion criterion was NMP's who were no longer actively prescribing in their roles. The exclusion criterion was NMPs who were not actively prescribing. Electronic surveys improve responses, and can be fast and efficient, supporting the choice to use an online survey (McPeak et al, 2014).
The NHS Health Research Authority (2018) medical research council tool deemed that the study would not be considered research by the NHS but was more suited to clinical quality improvement.
Ethical considerations
Research Ethics Committee training was completed, and ethical approval was granted in January 2019 [REF N0 19/NAH/003]. In line with general data protection regulation (Data Protection Act, 2018), the participants' personal data was protected, remaining anonymous and confidential.
The acute NHS Trust's clinical improvement and assurance team assigned a gatekeeper, who was involved at the recruitment phase, providing anonymity, confidentiality and avoidance of power and coercion. This allowed the participants to answer objectively, and minimise any negative psychological consequences, as the researcher was able to be distant from the participants (Bell and Waters, 2018; Parahoo, 2006; Polit and Beck, 2014).
Ethical principles were considered, obtaining informed consent, maintaining confidentiality, beneficence, maleficence and the right to full disclosure (ICN, 2012; Parahoo, 2006; Polit and Beck, 2014).
To gain approval from the University's ethics committee, it was essential for a gatekeeper information leaflet and consent form to be authorised by the NHS Trust clinical research lead before the study could go ahead.
Data collection
The gatekeeper sent a recruitment email to the 85 participants, which included a participation information leaflet and consent form, providing full disclosure. This ensured that the ethical requirements were met. The gatekeeper also facilitated the distribution of the questionnaire, which consisted of 22 questions. The number of questions were carefully considered to reduce the amount of time the participants would have to spend completing the survey. A return date was given, with the aim of preventing poor participation (Bell and Waters, 2014). The purposive sample size was 85 and the response rate was only 14 (16%). An extension of the return date and a recruitment poster displayed in clinical areas, as well as email reminders sent from the gatekeeper were necessary to improve recruitment. The original response rate was 11 and after the improvement efforts (ie poster in work areas and reminder email), three more responded.
Three variables were used to determine compliance:
- The first variable is CPD, which represents NMPs attending any type of CPD
- The second variable is personal formulary, which represents not prescribing any drugs outside of their agreed personal formulary
- The third variable is statement, which represents any knowledge of an annual statement of intent to prescribe.
Data analysis
The quantitative raw data generated from the online survey software SurveyMonkey.com (2020) were systematically analysed using descriptive statistics to synthesise and describe the data. IBM SPSS 25 statistical software was chosen as it can perform highly complex data manipulation and analysis and was available to the researcher from the university (Bell and Waters, 2014; Parahoo, 2006; Polit and Beck, 2014). The data analysis was limited, because of the small sample size and poor participant response (16%). Despite this limitation, frequency and percentage were analysed with basic descriptive statistical analysis. Frequency data can provide precise and visual findings (Parahoo, 2006; Polit, 2010).
Quantitative research measures objective phenomena. For measurement to take place, nominal scales were allocated first to the participants responses: Yes=1, No=2 (Parahoo, 2006).
Nominal scales were also allocated to the professional registration of the NMPs. Those registered with the NMC were classed as 3, General Pharmaceutical Council (GPhC) was 4, and the Health and Care Professions Council (HCPC) was 5.
Four variables were used to measure participation of CPD activity, namely face-to-face CPD, online learning, medication updates from pharmaceutical companies and drug updates within speciality areas of practice.
A Likert scale, as advocated by Bell and Waters (2014), Parahoo (2006) and Polit and Beck (2014), was used to measure participants' confidence in prescribing. A scale of 1–5 was used, starting at 1 (not so confident) up to 5 (confident).
Results
The 14 respondents were from different professional groups as follows:
- NMC: 64.3%
- GPhC: 21.4%
- HCPC:14.3%.
The results also identify the year the participants qualified as NMPs:
- 2006/2007/2008: 7.1%
- 2011/2013/2015: 14.3%
- 2018: 28.6%.
Statistical analysis of compliance data
Compliance variables, ie the findings that examined NMPs' compliance, were measured (Table 1).
Table 1. Compliance variables
| CPD | PF | Statement | ||
|---|---|---|---|---|
| N | Valid | 14 | 11 | 11 |
| Missing | 0 | 3 | 3 |
Personal formulary
The acute NHS trust NMP policy signposts NMPs to the competency framework for monitoring safe and effective prescribing. The policy clearly states that a ratified personal formulary will be reviewed at regular intervals. Participants were asked ‘do you prescribe any new drugs not included in your personal formulary?’
The participants answered as followed:
- Yes: 28.6%
- No: 50.0%.
Statement of intent to prescribe
Question 14 asked the participants ‘do you know what a statement of intent to prescribe is?’
They answered as followed:
- Yes: 34.7%
- No: 42.9%.
Some years are not mentioned, this indicates that none of the NMPs qualified in that year, only the years mentioned. For example, four qualified in 2018, so were newly qualified NMPs
Statistical analysis of CPD data
The majority (85%) of respondents participated in some form of CPD.
Overall compliance
Overall compliance is defined as: yes to attending CPD, yes to knowledge of what is an annual statement of intent to prescribe and no they do not prescribe outside of their personal formulary. Just over 85% are compliant, whereas nearly 15% are not compliant (Table 2; Figure 1):
- Yes: 85.7%
- No: 14.3%
Three results are missing, as three participants failed to answer the question, as highlighted in Table 1.
CPD and confidence
Although over a third (36.4%) of participants reported they were confident in NMP, almost 10% felt they were not so confident and almost 20% rated themselves as a 3, halfway across the scale.
Question 22 asked the participants ‘How do you feel you could be better supported in your role as a non-medical prescriber to increase your confidence when prescribing?’. The majority (72%) of responses requested regular CPD. Tables 3 and 4, and Figure 2 display how the respondents rated their confidence in prescribing.
Table 3. NMPs who attended CPD
| Frequency | Percent | Valid Percent | Cumulative Percent | ||
|---|---|---|---|---|---|
| Valid | 1.00 | 12 | 85.7 | 85.7 | 85.7 |
| 2.00 | 2 | 14.3 | 14.3 | 100.0 | |
| Total | 14 | 100.0 | 100.0 |
Table 4. Likert scale measuring level of confidence when prescribing
| Frequency | Percent | Valid Percent | Cumulative Percent | ||
|---|---|---|---|---|---|
| Valid | 1.00 | 1 | 7.1 | 9.1 | 9.1 |
| 3.00 | 2 | 14.3 | 18.2 | 27.3 | |
| 4.00 | 4 | 28.6 | 36.4 | 63.6 | |
| 5.00 | 4 | 28.6 | 36.4 | 100.0 | |
| Total | 11 | 78.6 | 100.0 | ||
| Missing | System | 3 | 21.4 | ||
| Total | 14 | 100.0 |
Discussion
Compliance
In this study, nearly 15% of NMPs were not compliant. This clearly has implications for patient safety. In addition, this also has implications for practitioners' professionalism in terms of responsibility and accountability (NMC, 2018; RPS, 2016). As a result of the poor response rate, the findings are not generalisable. Further research with a better response rate needs to be undertaken, to better identify NMP compliance. Compliance of 85% is comparable to other studies reviewed (Anguita, 2012; Latter, 2008; Picton et al, 2016). That said, non-compliance of 15% from such a small sample size could still represent a patient safety concern. A further safety concern is that over a quarter of respondents (28.6%) prescribed outside of their personal formulary. This finding highlights a strength of the study design, as anonymous participation enabled honest answers, as well as highlighting non-compliance of NMPs (Parahoo, 2006; Polit and Beck, 2014). Each NMP, together with their employer, needs to take responsibility and accountability for compliance (Djerbib, 2018; Pearce and Winter, 2014; RPS, 2016).
Continuous professional development
Strong evidence from the literature highlighted CPD as being integral to improving non-medical prescriber's knowledge of compliance (Djerbib, 2018; Nimmo et al, 2017; NMC, 2018). Encouragingly, all study respondents identified CPD as being important to maintaining their compliance. The majority (85%) of respondents participated in some form of CPD. Four variables of CPD participation were identified: face-to-face, online learning, medication updates from pharmaceutical companies and drug updates within speciality areas of practice. Nimmo et al (2017) demonstrated that face-to-face methods were the preferred option. In this study, only 42.9% participated in face-to-face CPD. This study would have benefitted from differentiating self-directed CPD and participatory CPD. The researcher could then have made recommendations to the Trust based on participant preference. Unfortunately, because of the structure of the question, the participant's preference was not clear in the present study - this should be better addressed in future studies
Confidence in prescribing
Evidence suggests CPD attendance correlates positively with maintaining NMP confidence (Cleary et al, 2017; Bishop and Gilroy, 2015; Bradley and Riley, 2013; Djerbib, 2018; Weglicki et al, 2015). Smith et al (2014) and Weglicki et al (2015) suggest that a lack of CPD opportunities can reduce confidence in prescribing.
In this study, nearly three-quarters (85%) of participants reported attending regular CPD. An attempt was made to establish a causal link between CPD and confidence. However, because of the poor response rate, the results were not statistically significant. Further inclusion of open-ended comments to ascertain why some NMPs prescribed outside of their personal formulary are recommended for future studies.
Limitations
The rationale for adopting the quantitative research design, using survey technique, was primarily due to the original purposeful sample size of 85 NMPs. The purposeful sample can be prone to researcher bias, as the sample relies on the judgement of the researcher, this can maximise the generalisability of the findings, however the study's poor participant response impeded generalisability of findings, (Parahoo, 2006; Polit and Beck, 2014).
Upon reflection, many questions that were included in the survey were not relevant, which impacts on the study's validity and reliability. Evidence from the literature demonstrates the benefits of a pilot study; the irrelevant questions can be omitted from a future study. An unexpected strength of the study was that the researcher left the trust where the study was undertaken, meaning the power and coercion dynamic was minimised through utilisation of an impartial gatekeeper (Bell and Waters, 2014; Parahoo, 2006; Polit and Beck, 2014). A further strength was using questionnaires to generate objective data (Bell and Waters, 2014; Bishop and Gilroy, 2015; Nimmo et al, 2017; Pearce and Winter, 2014; Smith et al, 2014). The inclusion criteria from a purposive sample (all members of the population of interest) were 85 registered nurse, pharmacist, physiotherapist and dietician NMPs who were actively prescribing. This method is prone to researcher bias as the sample relies on the judgement of the researcher. According to Parahoo (2006), a questionnaire for data collection has its values and limitations. Poor participant response was evident in the study. On reflection, the time available was a constraint, longer study duration and fewer questions may have improved response rate.
Conclusions
Despite the low response rate, this study highlights CPD as being integral to improving NMP compliance and confidence. Although over 85% of NMPs were compliant, a further 15% were not compliant, which could be a patient safety concern and has professional accountability and responsibility implications. Nearly three-quarters of respondents identified CPD as being important to maintaining their compliance and asked for regular updates to improve NMP confidence. The author recommends that the Trust supports NMP compliance with the RPS framework and encourages attendance at CPD, and also that further research is needed. An action plan could include regular updates to improve NMP confidence and introduction of a statement of intent to prescribe or annual declaration. A mandatory audit of all active NMPs could provide the data needed to determine NMP compliance within the Trust. Ultimately, NMPs have a professional responsibility to be compliant and accountable to provide competent, safe prescribing.
Key Points
- Non-medical prescribers have a professional responsibility to be compliant and accountable, and to provide competent, safe prescribing of medications within their area of practice.
- A literature review found links between non-medical prescriber compliance and confidence, and continual professional development.
- Studies have demonstrated that the Royal Pharmaceutical Society Competency Framework (2016) provides a useful template, highlighting good prescribing practice.
- Continual professional development is integral to improving non-medical prescribers' knowledge of compliance. Attendance at development sessions correlates positively with maintaining non-medical prescribers' confidence.
- In this study, nearly 15% of NMPs were not compliant, which has implications for patient safety, and practitioner responsibility and accountability.
CPD reflective questions
- How would you evidence your compliance and accountability when providing competent safe prescribing?
- Specify what is your sole responsibility or joint with the employer?
- Do you feel you attend adequate numbers of CPD sessions or would you benefit from more?
- Does confidence in prescribing come with experience or does regular CPD facilitate knowledge and confidences?