Research has identified anxiety and a lack of confidence around prescribing practice (Weglicki et al, 2015; Courtenay et al, 2018; Casey et al, 2020). Continuing professional development (CPD) for all prescribers is a challenge but is a regulatory requirement (Armstrong, 2021; Royal Pharmaceutical Society (RPS), 2021). Prescribers who have not been using their qualification also require support to regain their prescribing knowledge and competence. For independent and supplementary prescribers (those who are not medics or dentists) there is evidence supporting a lack of CPD, but limited research to show this has been addressed. Research is needed to explore and facilitate safe practice for these practitioners.
In comparison with other countries and professions globally, the UK and Ireland have some of the most extensive prescribing privileges for Nursing and Midwifery Council (NMC), Health and Care Professions Council (HCPC) and General Pharmaceutical Council (GhPC) prescribers, giving prescribing autonomy equal scope and jurisdiction for nursing, midwifery, allied health professionals and medical professionals alike (Kroezen et al, 2011).
Independent and supplementary prescribing, formerly referred to as non-medical prescribing, has evolved in the UK since 1992. Independent and supplementary prescribing, as well as the use of the community nurse prescriber role (V100/V150), continues to grow, with more and more health professionals seeking to gain these qualifications in a variety of roles and healthcare settings (Courtenay, 2018). The number of independent and supplementary (V300) prescribers registered with the NMC in March 2018 was 39 777; in March 2021 it increased to 50 693 and then to 59 326 by March 2022 – an increase in 4 years of 49% (NMC, 2023). This number does not reflect those who hold a community nurse prescribing qualification (V100/V150), which also remains prevalent in practice.
There is no data available nationally on the numbers of HCPC independent and supplementary prescribers, but there has been a steady increase locally for those accessing this educational programme of study and registering their qualification for use.
To support prescribing practice, the RPS Prescribing Competency Framework (2021) describes the knowledge, skills, characteristics, qualities and behaviours for all UK-based prescribers regardless of their area of practice, profession or prescribing qualification to maintain patient safety, including pharmacists and General Medical Council (GMC) registrants. Medics and dentists have different requirements for annual updates and are prescribers from their original qualification.
This small study focuses on NMC prescribers, including those with the community nurse prescribing qualification. However, it is also relevant to HCPC registrant prescribers and pharmacist prescribers due to the differences in how to obtain the qualification and the regulatory and annual requirements.
In a large NHS Health Board in Scotland, the research team observed an increase in the number of NMC and HCPC prescribing practitioners returning to practice, requiring advice and support to use their prescribing qualification and regain competence. A variety of circumstances resulted in a pause in individuals using their prescribing qualification, including maternity leave, extended leave due to Covid-19 and shielding, and a change in role where prescribing was no longer required. One practitioner who had undertaken their return to practice programme after 12 years of lapsed registration was also seeking support to return to prescribing as it was a requirement of her new role.
Currently, the NMC standards for return to practice programmes (NMC, 2019) or test of competence do not include any reference to independent or supplementary prescribing as part of the professional register, demonstrating a gap in the mechanism to capture, support and understand prescribers’ experiences returning to clinical practice. This is similar for HCPC registrants with no specific requirements on returning to use a prescribing qualification and solely on returning to the register (HCPC, 2023).
The issue of independent and supplementary prescribers returning after a period of non-prescribing activity has been discussed nationally at the Scottish Lead Prescribers’ Group, where a gap in evidence was identified in the understanding of the experiences of prescribers returning to practice. The group has representation from the 14 Scottish Health Boards, as well as National Education for Scotland and Scottish Higher Education Prescribers’ Group and is supportive of exploring experiences of nurses, midwives and allied health professionals returning to prescribing as part of its ongoing work (Sunter et al, 2023).
In NHS organisations, permission to undertake education and to subsequently generate prescriptions is given when prescribing is identified as being a requirement of a particular clinical role or service, and with the understanding that the knowledge, skills and competencies required to prescribe will be supported, developed and maintained. Being an active prescriber and regularly using the skill in clinical practice will support the maintenance of prescribing competence; however, research shows that there is a level of anxiety and lack of confidence for prescribers, particularly around CPD (Weglicki et al, 2015).
Study aim
If active prescribers using their qualification feel a lack of confidence, it could be deduced that this would be similar or increased for those who have not been actively using their qualification. Therefore, the aim of this study was to understand the experiences of prescribers who have not been active for 12 months or more, and what would be of benefit to support and to regain their prescribing knowledge and competence to facilitate safe prescribing.
Methods
Using a qualitative descriptive approach (Doyle et al, 2020), semi-structured interviews were conducted online.
Recruitment
Two email invitations from the research team were sent out 1 month apart in October and November 2022, to all NMC (V300, V150 and V100) prescribers and HCPC prescribers listed on one large Health Board database of approximately 1300 prescribers. Pharmacist prescribers were not included due to their information being held differently by the organisation. This email invited interested parties who met the inclusion criteria (see Table 1), to contact the research team for more information on the study if they wished.
Table 1. Inclusion and exclusion criteria
| Inclusion criteria | Exclusion criteria |
|---|---|
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Participants were required to be experienced prescribers and have actively worked as a prescriber for at least 12 months to be eligible to take part in the study. They were also required to have a period of non-activity; for example, when a prescriber has an extended period of leave, such as sick or maternity leave, or has been in a role where prescribing was not required and is returning to a role where they are required to use their prescribing skill again. A period of 12 months as an active prescriber was included to attempt to capture those who have had some time as an active prescriber before a break. The database included prescribers from all clinical areas and primary and secondary care.
Following this, six participants responded to the email invitation, but only five were included due to the research timeframe. Potential participants were then provided with information about the study and the opportunity to consider participating. If informed consent was obtained from the participant, the research team arranged the interview at a convenient time to the participant and participants were given the opportunity to select their interviewer. All participants opted for an online interview hosted on the virtual platform.
Semi-structured interviews were conducted to explore experiences of the participants. There was a variety of reasons for absence from clinical practice but all were registered with the NMC. This may be due to the smaller number of HCPC prescribers on the organisational database at the time of the research. Participants worked across a range of settings across primary and secondary care. The interviews were conducted from November 2022 to February 2023 with recordings transcribed using the online interview platform and checked for accuracy against the audio-recording, and de-identified.
Reflexivity was promoted across the research process before, during and after the research interviews (Bradbury-Jones, 2007). The team reviewed existing knowledge, experiences and self-reflection to limit any pre-existing assumptions, thoughts or bias from the research process and analysis. Reflexive conversations and note-taking occurred before and during the interviews, and discussed post-interview between the research team.
Following each interview, the research team reflected on the process, questions and responses prior to analysis, which occurred once all interviews were conducted. While some of the research team had a strategic position in the organisation, the option to use another member of the research team for the interview was presented as an option to all participants should any participant wish this. The research team were cognisant that their knowledge and positions may have an impact on the participants and the responses but the interview was planned with semi-structured open-ended questions to provide opportunities. Participants were invited to discuss:
- Their role, clinical practice and qualifications
- Their prescribing habits
- Their prescribing experiences before and after their break from prescribing practice
- Support and CPD for prescribing practice.
Additional prompts by the interviewer facilitated a detailed exploration of each of these areas.
Permission from the organisation's research lead and chief nurse were given. Ethical approval was gained from Queen Margaret University divisional ethics panel. The study was conducted when the UK was emerging from the pandemic with some local restrictions in place.
Data analysis
All interviews were recorded with the permission of participants, then transcribed verbatim using the online platform. The transcripts were checked by both members of the research team to ensure accuracy from the recording. The research team used a reflective thematic approach (Braun and Clarke, 2019) for analysis, and reflexivity was used by the team to minimise and acknowledge own experiences and biases due to their existing roles and interests. From this process themes were constructed that answered the research question.
Results
Four main themes from the interviews were generated that influenced the return to prescribing: the individual; the team they were working within; and the wider organisation.
There were also challenges posed by the c lear mismatched perspectives experienced by individuals from these three elements, conceptualised in Figure 1.
Theme 1: individual
This theme highlights experiences on an individual level and was further broken down into sub-themes of evolution of practice, CPD and re-setting.
Evolution of practice
‘Evolution of practice’ encompassed various changes to the individual's role and scope of practice, incorporating changes to patient demographics, service delivery models and different service pressures from prior to the period of absence. Participants described the challenges of navigating and understanding changes to clinical services once they returned, and how this affected their confidence to safely prescribe:
‘The landscape has changed quite dramatically over the last couple of years … but the difference in this last year is enormous.’
It was noted that what was being asked of participants was different since returning to prescribing and, in their words, the changes meant patients ‘are a lot more unwell’, prescribing ‘held more risk’ and made them ‘more anxious’. Participants described those increased caseloads, as well as an increase in the size of the clinical teams, reducing the opportunity to reflect on and discuss prescribing decisions:
‘I was comfortable with prescribing back when I had time to read up … some time to reflect and debrief.’
‘We were seeing fewer patients, and it was a smaller team … I'd keep my prescriptions and write up brief case studies and discuss them over a tea break or lunch break … we just don't do that any more.’
These experiences demonstrate some of the challenges when service delivery models change and the impact this has on prescribing practice, especially for returners where there has not been the opportunity to adapt to changes in real time.
Access to CPD opportunities
Participants identified the importance of undertaking CPD opportunities to develop and improve their prescribing following a pause: ‘Some time to reflect and debrief’. All the participants said that they had taken a proactive approach to seeking development opportunities:
‘l feel like I am doing everything I can to keep up for my confidence … but I feel like I am still learning.’
However, the narrative also described that knowing that CPD and support was important to participants when they returned to prescribing did not necessarily mean that it was enabled. Participants described trying to set aside their own time and time with others to support them, but that this was not always possible:
‘We've been told that we can arrange [CPD] if we want. I have tried a couple of times, but it's needed to be cancelled because of staffing or number of patients.’
Participants reflected on the impact on their confidence and competence on returning to prescribing when they were unable to take time to undertake development opportunities:
‘It's difficult to pin someone down to get supervision … I'm worried about doing it on my own and what if I don't do this right? … I'm not feeling that confident.’
Re-setting
In the context of returning to prescribing, the chance to re-set and take some time to re-familiarise with being in the prescribing space was noted as being important among the participants:
‘To start with, I would say you definitely need to allocate time to update your core formulary.’
However, the prescribers recognised that the break from prescribing meant they could not automatically start from where they had left off and felt pressure to do this as ‘expectations are quite high’:
‘What should I do to try and safety net and make myself feel confident that I am doing the right thing … that I was making sure that I was safe.’
A number of the participants described that on their return they had a reduction in exposure to prescribing in their teams, which influenced their confidence to begin to prescribe again. This was due, for example, by taking on a management role which reduced their requirement to hold a clinical caseload, or that they had chosen to reduce their contracted clinical hours. They described being ‘reluctant to prescribe’ and feeling that reduced clinical exposure meant they did not know their patients:
‘Changing my role as a prescriber … I don't feel a confident prescriber who is doing it regularly.’
Theme 2: the team
This theme highlights the expectations and influence of colleagues on returning prescribers. The participants recognised the importance of having access to the wider clinical prescribing team to support their return and improve their confidence to prescribe. One participant described that having this supervision made them feel ‘comfortable and confident’.
Another identified that access to more than one team member was important to them:
‘Your confidence needs to be built … having that group of people to have the conversation with rather than having one person to go to for peer support.’
Some participants suggested that it was important team members were cognisant of the fact that they had taken a break from prescribing and that they may require support over time to re-familiarise themselves with prescribing in clinical practice.
However, the lived experience of participants suggested that, although team members were aware that they were returning to the clinical area after a period away, their colleagues did not factor this in, in terms of a settling in or a supernumerary period to support their prescribing:
‘… the expectation is that you walk straight in the door and you have your prescribing pads on you.’
One participant reflected on not feeling able to discuss her worries about returning to prescribing with her team:
‘I think expectations of me are high … I am more anxious, but I haven't voiced that.’
‘It's hard when you are trying to be pro-active and everyone is busy.’
Theme 3: the organisation
The wider service and organisational role in providing updates and CPD was discussed by participants:
‘I don't think we get enough CPD in a prescribing sense, and understanding and knowing conditions and medications for those conditions.’
Participants also reflected on the relevance of their line manager's understanding of what it meant to be a prescriber and the impact their support had on returning. One participant stated, ‘I think it's useful to have a manager with a prescribing background’. It was identified by one participant that, despite their line manager being a prescriber themselves, this did not translate to a supportive approach in terms of facilitating their return:
‘I didn't get any supernumerary shifts, which wasn't what I was expecting, and I asked about it and my manager said, “Well, it's not in the policy anywhere…”, she's just not getting that.’
The lack of a planned or agreed approach was also described by another participant:
‘… reassurance just to say, like, take your time – but nothing. No meetings or nothing on paper.’
Some of the participants described a feeling of conflicting agendas in their expected role and scope of practice in their service: ‘But, actually, it's not my core job.’ The feeling of being out of their scope of normal prescribing practice was described by one participant as ‘being out of my comfort zone … something that fills me with absolute dread’.
Throughout the interviews, participants reflected on key elements that affected them on their return to prescribing. All participants described a lack of overall confidence and a feeling of the unknown in terms of an agreed and coordinated approach to their return.
One prescriber described having to navigate the ‘simple’ practicalities of prescribing to ensure they felt safe:
‘… given how busy the department is, is there going to be any support available to deal with that to help me? How comfortable and confident am I going to be to prescribe even the medications that I know when I've been out of practice for this long? And, you know, all those little things that just take you a little while to get your head back around.’
Theme 4: mismatch between the three
Participants recognised how the length of time and support back in clinical practice as a prescriber had an impact on their confidence and ability to undertake the role:
‘… a safe place and time put aside to identify that I need support.’
The importance of support for returning prescribers was made apparent by the participants, but they perceived this as not always being important to their colleagues and wider team. This suggests a mismatch between prescriber, the clinical team and wider organisation and may, in part, be due to conflicting agendas around service provision and delivery vs the perceived needs of the returning prescriber. It is a potential reason why this individualised support was not in place:
‘I don't think my manager has that understanding about actually what our role is.’
Discussion
The generated themes that contribute to a practitioner returning to prescribing are complex and not just within the individual's gift. These new insights highlight the challenges for prescribers who have taken a break from using this skill. The results can be used to build on existing approaches and develop new ways of working for prescribers and employers for all involved.
Understanding the needs of an individual on their return to this high-stakes area of clinical activity can now provide some support for individuals, their teams and the wider service to support a smoother more supported transition back into this role. There are parallels with new prescribers and those returning to prescribing. In a systematic review, Edwards et al (2022) highlighted challenges in the implementation of new independent prescribers in primary care. These included training, preparation, transition and sustainment. Themes in this research reflect these, although in a different context, with both highlighting the wider impact of other factors on an individual's prescribing practice and development.
While individuals spoke of their own need and anxieties when returning, there were also concerns about the expectations within the team for the returning prescriber to just ‘hit the ground running’ on their return and a lack of acknowledgment on the ‘evolution of practice’. Some participants shared the challenges of returning to a service which was felt not to be the same as when they took a break, and the difficulty in returning to new systems, processes or role requirements.
Participants felt that managers did not always understand their needs, and individuals did not always feel comfortable or supported to share their identified gaps in knowledge. This knowledge–practice gap following time away from a clinical setting is described in a review by the GMC (2014). The review identifies a correlation between self-assessment of competence and how frequently skills associated with that role are used, finding a slight decline in skills after 4 months. This phenomenon is described in the review as ‘skills fade’ with a recommendation that there is a clear set of standards and assessment processes for health professionals who have taken time out from clinical practice.
Individuals described that their confidence in returning to prescribing had a direct correlation with them feeling competent and safe. This concept is explored by van Boxel et al (2019) who looked at the factors that affected trainee doctors’ confidence after returning from maternity leave. They found that although being competent in a skill is paramount, it is confidence that is adversely affected when returning to clinical practice following an absence, and that the time it takes to regain that confidence differs between individuals.
This understanding and acknowledgement of where an individual sits within their own sphere of confidence, and therefore the time it may take them to feel competent and safe, further supports the complexity of the consideration required by the individual, clinical teams and organisation when returning to prescribing. This lack of an individualised, planned approach reflects the experiences described by the participants in this study, where differing presumptions were made about readiness to return to prescribing, how this might be achieved, and the length of time required to get back into prescribing in clinical practice.
The mismatch in clinical teams and the impact on service delivery and safe patient care was explored by Weller et al (2014). They found that a shared mental model is critical within teams to deliver effective care. Key to this is when all team members are ‘on the same page’ and when team members understand each other's capabilities.
They also found that challenges to effective teamwork arise due to the way different health professionals are trained, psychological factors and the culture and administration of healthcare organisations. These findings directly echo the participants’ experiences of returning to prescribing, and supports some of the barriers and concerns that were described around the perceptions of team members and their re-orientation and development needs.
Implications for policy and practice
The results from this study suggest the need for a wider inclusive approach to support those who return to prescribing to ensure all needs are met and safe practice is facilitated, especially as healthcare roles diversify to include a prescribing qualification. It is imagined that where, traditionally, this was not an issue due to lower numbers of staff, the evolution of healthcare and increased role autonomy and experience may mean this is an issue which needs to be supported more readily.
Mentorship has been shown to be an effective way to support prescribing students who transition once qualified as prescribers (Bowskill et al, 2014). It could be considered that a prescribing mentor would be a supportive measure for those who return to practice and to prescribing. Considering how to support those who are returning to use this skill following an absence requires consideration and commitment from organisations while acknowledging the importance of CPD opportunities to support the returning prescriber. Organisations need to invest in providing these opportunities that practitioners can access to develop their safe and effective prescribing practice.
These considerations echo the NHS England Long Term Workforce Plan(2023), which aims to support the development of healthcare roles with a commitment to train, retain and reform. Additionally, policy initiatives in the devolved nations identify the need to re-imagine and invest in transformational roles across all healthcare sectors. Many of these transformed roles now include the requirement to hold a regulated prescribing qualification and although modernisation and reforms take time to embed, there are challenges and inconsistencies in terms of funding and supervision to support and develop prescribing in practice between professional roles (Lovell, 2023).
Strengths and limitations
This study used reflexivity, a process of peer-review and debriefing to increase trustworthiness of the research; however, generalisability and transferability of the findings are limited. This study focused on a small number of nurses who self-identified as taking a break from prescribing from one Health Board. The inclusion of other professions and wider Health Boards on this topic provides a future research opportunity, although it is anticipated that the results are transferable to other professional groups, as similar results were identified for medical professionals (van Boxel et al, 2019).
Due to the small number of participants and approach to the research design, linking of participant characteristics with data, such as participant age and length of career, was not possible. The design of the study would also contribute to a potential memory bias in participants. Notwithstanding these limitations, the work undertaken in this study provides a foundation for future work focusing on strengthening organisational priorities of the health workforce.
Conclusion
Returning to prescribing after a period of absence has been highlighted from this small exploratory study as an issue that requires attention. While there are elements individual registered prescribers remain accountable for, the team and service that surrounds them also has an impact on their return and requires consideration together, to support those in this position. When these do not align or conflict, it becomes more challenging for the individual prescriber.
Returning to prescribing is unique to each person, with the team and service affecting the return as well as the individual who is generating the prescriptions. Following this study, we recommend that all three elements should be considered not in isolation but together when someone returns to prescribing as part of their role.
Key Points
- Continuing professional development when returning to prescribing requires individualised guidance, support and time
- There may be specific individual needs and requirements for anyone in this position, but protected time and resource is required from the organisation
- As a manager supporting someone into a role where their prescribing has changed or there has been a break, time and resource must be given to identify gaps or challenges and for any identified learning needs to be supported
- Individual practitioners must continue to feel supported to work within their scope of practice and registration
CPD reflective questions
- What continuing professional development activities are available locally within your service to support a return to prescribing?
- If you were supporting someone who was returning to prescribing, what could you do to support this transition?
- Consider the organisational position and context – what is available and are there gaps which could be considered to support others in this position?
- Considering teamwork – what available tools are there to facilitate working together?