Exploring determinants of antimicrobial prescribing behaviour using the Theoretical Domains Framework.

BACKGROUND: Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). OBJECTIVE: (s): To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. METHODS: Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. RESULTS: Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants' beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. CONCLUSIONS: Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship.

Designated prescribing practitioners: a theory-based cross-sectional study of stakeholders' views on implementation of a novel pharmacy regulator mandated preceptorship model.

BACKGROUND: Scottish Government is increasing independent prescribers (IP) in community pharmacy (CP). A new preceptorship model using IPs as Designated Prescribing Practitioners (DPPs) has been introduced. AIM: To investigate stakeholder views of implementation of a novel regulator mandated IP course preceptorship model. METHOD: A theory-based online pre-piloted survey of stakeholders including e.g. directors of pharmacy, prescribing, education leads, policy & strategy leads and CPs. Questionnaire development used Consolidated Framework for Implementation Research (CFIR) and a DPP Competency Framework. Data were analysed descriptively and presented with mapping to CFIR constructs. RESULTS: Of ninety-nine responses 82.5% (80/97) responded 'yes' to '..abilities in reporting concerns..' and 53.1% (51/96) indicating 'no' to '..anticipated issues with clinical and diagnostic skills'. CFIR related facilitators included agreement that; there was tension for change with 84 (85%) indicating '….urgent need to implement role …', that incentives are likely to help (6566%) and small pilots would help (8588%). Barriers were evident related to 'unsure' responses about sufficiency of; DPP capacity (39/97, 40.2%), time (48/96, 50%) and support and resources (4445%) to undertake the role. Concerns were expressed with 81 (83%) in agreement or unsure that leadership commitment may be lacking and 48 (48.9%) were 'unsure' about availability of good training for the DPP role. CONCLUSION: There was DPP role positivity but expressed barriers and facilitators at policy, organisational and individual practitioner levels needing further consideration. Further research is warranted on uptake and embedding of the role.

The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review.

OBJECTIVES: This systematic review (SR) reviews the evidence on use of theory in developing and evaluating behaviour change interventions (BCIs) to improve clinicians' antimicrobial prescribing (AP). METHODS: The SR protocol was registered with PROSPERO. Eleven databases were searched from inception to October 2018 for peer-reviewed, English-language, primary literature in any healthcare setting and for any medical condition. This included research on changing behavioural intentions (e.g. in simulated scenarios) and research measuring actual AP. All study designs/methodologies were included. Excluded were: grey literature and/or those which did not state a theory. Two reviewers independently extracted and quality assessed the data. The Theory Coding Scheme (TCS) evaluated the extent of the use of theory. RESULTS: Searches found 4227 potentially relevant papers after removal of duplicates. Screening of titles/abstracts led to dual assessment of 38 full-text papers. Ten (five quantitative, three qualitative and two mixed-methods) met the inclusion criteria. Studies were conducted in the UK (n = 8), Canada (n = 1) and Sweden (n = 1), most in primary care settings (n = 9), targeting respiratory tract infections (n = 8), and medical doctors (n = 10). The most common theories used were Theory of Planned Behaviour (n = 7), Social Cognitive Theory (n = 5) and Operant Learning Theory (n = 5). The use of theory to inform the design and choice of intervention varied, with no optimal use as recommended in the TCS. CONCLUSIONS: This SR is the first to investigate theoretically based BCIs around AP. Few studies were identified; most were suboptimal in theory use. There is a need to consider how theory is used and reported and the systematic use of the TCS could help.

Piloting the United Kingdom 'Prescribing Safety Assessment' with pharmacist prescribers in Scotland.

BACKGROUND: Prescribing is a complex task requiring considerable knowledge and skills. The Prescribing Safety Assessment (PSA) was developed by the British Pharmacological Society and the United Kingdom (UK) Medical Schools Council. Between February and June 2014, over 7000 final year medical students undertook the PSA, with an overall pass rate of 94%. Independent prescribing for suitably trained pharmacists was introduced in the UK in 2006. To date there has been little focus on any objective measures of prescribing safety. OBJECTIVE: To determine the PSA performance of a pilot group of pharmacist prescribers in Scotland relative to medical students and to test the feasibility and acceptability of running the PSA. METHODS: A group of 59 pharmacist prescribers took part in ten events. The PSA consisted of 30 questions to be completed over 60 min. All questions had been used in the 2014 assessments for final year medical students. The PSA was undertaken online under invigilated conditions, mirroring the medical student assessment. One month later, participants were invited to complete an online evaluation questionnaire. RESULTS: The mean overall PSA scores (±SD) were 87.5% ± 8.7 (range 52-98) compared to a 88.5% for medical students. Based on an Angoff passmark of 76.0%, 53 pharmacists (89.8%) passed compared to an overall pass rate in PSA 2014 of 94%. Pharmacists performed equivalently to medical students in all assessment areas, with a slightly lower performance in the prescribing, drug monitoring and data interpretation questions offset by better performance in prescription review and adverse drug reactions. Feedback was positive in relation to appropriateness, relevance and level of difficulty of the PSA although several commented that they were practicing in very specific clinical areas. CONCLUSION: These pilot events have benchmarked the PSA performance of pharmacist prescribers with final year medical students, and feedback confirmed feasibility and acceptability.

The behaviors and experiences of the community pharmacy team on the provision of multi-compartment compliance aids.

BACKGROUND: Multi-compartment compliance aids (MCAs) are repackaging systems for solid dosage form medicines. Acknowledging the lack of evidence that MCAs improve adherence or clinical outcomes, the Royal Pharmaceutical Society has expressed concern that MCAs have 'become regarded as a panacea for medicines use'. OBJECTIVES: To determine the behaviors and experiences of the community pharmacy team around MCA provision. METHODS: A cross-sectional survey was conducted in 26 community pharmacies in the north east of Scotland. Survey items were grouped into: current activities in the provision of MCAs; potential influences on these activities; reports of patient experiences; and demographics. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis (PCA) was performed on the items of potential influences on activities. RESULTS: Data were collected from 136 community team members (median 4, range1-10 per pharmacy; 32.3% pharmacists). All were involved in some aspect of MCA provision and within the same pharmacy, several different staff positions were commonly involved in the same activity. PCA gave seven components; the lowest scores were obtained for the component of 'others expecting me to provide MCAs'. Participants agreed that GPs, patients and their families, and carers expected them to provide MCAs. Positive experiences of MCA provision were in themes of promoting patient adherence, reducing patient stress and enhancing patient monitoring. Further negative experiences were in of lack of shared patient decision making, worsening adherence and generation of medicines waste, and dealing with changing medicines. MCAs were not always considered to be the most appropriate solution. CONCLUSION: While community pharmacy teams value MCAs, there may be issues around staff assignment to particular roles, expectations from others and reports of negative patient experiences. A systematic approach to MCA provision and monitoring involving the multidisciplinary health and social care team is warranted.

Influences on prescribing decision-making among non-medical prescribers in the United Kingdom: systematic review.

BACKGROUND: Suitably qualified non-medical healthcare professionals may now prescribe medicines. Prescribing decision-making can be complex and challenging; a number of influences have been identified among medical prescribers but little appears to be known about influences among non-medical prescribers (NMPs). OBJECTIVE: To critically appraise, synthesize and present evidence on the influences on prescribing decision-making among supplementary and independent NMPs in the UK. METHODS: The systematic review included all studies between 2003 and June 2013. Included studies researched the prescribing decision-making of supplementary and independent NMPs practising in the UK; all primary and secondary study designs were considered. Studies were assessed for quality and data extracted independently by two researchers, and findings synthesized using a narrative approach. RESULTS: Following duplicates exclusion, 886 titles, 349 abstracts and 40 full studies were screened. Thirty-seven were excluded leaving three for quality assessment and data extraction. While all studies reported aspects of prescribing decision-making, this was not the primary research aim for any. Studies were carried out in primary care almost exclusively among nurse prescribers (n = 67). Complex influences were evident such as experience in the role, the use of evidence-based guidelines and peer support and encouragement from doctors; these helped participants to feel more knowledgeable and confident about their prescribing decisions. Opposing influences included prioritization of experience and concern about complications over evidence base, and peer conflict. CONCLUSION: While there is a limited evidence base on NMPs' prescribing decision-making, it appears that this is complex with NMPs influenced by many and often opposing factors.

A qualitative study of UK pharmacy pre-registration graduates' views and reflections on pharmacist prescribing.

BACKGROUND: Pre-registration pharmacy graduates are a key group in relation to developing and implementing innovations in practice. OBJECTIVE: To explore the views and reflections on pharmacist prescribing of UK pre-registration pharmacy graduates. METHOD: Semi-structured telephone interviews with a sample (n = 12) of pre-registration pharmacy graduates. KEY FINDINGS: Most reported a desire to train as prescribers, largely for reasons of professional development, but acknowledged the need first to develop as pharmacists. They perceived the lack of organisational strategy, pharmacist prescribers' self-confidence and additional workload to be barriers and were aware of the value of interprofessional relationships as potential facilitators to pharmacist prescribing. CONCLUSION: While participants were supportive of pharmacist prescribing, they highlighted the need first to gain experience as pharmacists and were acutely aware of barriers to prescribing implementation.

A cross sectional survey of the views of newly registered pharmacists in Great Britain on their potential prescribing role: a cautious approach.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Pharmacists, along with certain other health professionals, may train and practice as supplementary or independent prescribers. The implementation and sustainability of pharmacist prescribing services throughout Britain will require a sizeable workforce. However, a survey of GB pharmacists highlighted that only a minority has taken any action to investigate prescribing training. Newly registered pharmacists may be keen to explore extended clinical roles and their engagement is likely to be key to the future success of this initiative. WHAT THIS STUDY ADDS: Newly registered pharmacists are cautious in their approach to taking on prescribing training and roles. While almost all expressed interest in prescribing training, they acknowledged training needs in clinical examination, patient monitoring and medico-legal aspects of prescribing. Longitudinal research on a cohort of newly registered pharmacist prescribers is warranted, aiming to identify later prescribing training actions and subsequent impact on patient care. AIM To investigate newly registered pharmacists' awareness of pharmacist prescribing and views on potential future roles as prescribers. METHODS: A mailed questionnaire was sent to all 1658 pharmacists joining the Pharmacist Register in 2009. RESULTS: The response rate was 25.2% (n= 418). While most (86.4%) expressed interest in prescribing training, they acknowledged training needs in clinical examination, patient monitoring and medico-legal aspects of prescribing. Two thirds of respondents (66.3%) thought the current requirement of being registered as a pharmacist for 2 years prior to commencing prescribing training was appropriate. CONCLUSION: Newly registered pharmacists are cautious in their approach to taking on prescribing training and roles.