Table 4 Code book description of themes and sub themes, with illustrative quotes

Staff

Overarching theme bringing all staff related themes together

Clinical team

Prescribing within, or supported by, multidisciplinary team. Degree of integration into the team. Team or autonomous working

“I say that because I work in a really small MDT and I, and I work with consultants that because we're such a small team It's all first name terms, we can easily kind of have a dialogue and get hold of each other…” FG1-P2

“I think, for us being able to prescribe has kind of made me more part of the medical team. Yeah, because they kind of see me as more similar to them. So, they've sort of accepted me a little bit more, if that makes sense?” FG2-P3

“I sometimes feel like I'm not fully part of any one team because I sort of dip in and out of different teams.” FG2-P4

“Um, for me, because we mostly work on our own and autonomously, a lot of the decisions fall with just myself with prescribing unless there is an issue, and then I would refer, would ask for advice from our specialist that we have meetings with every week.” FG2-P1

Junior medical staff

Working relationships with junior medical staff. Impact on junior medical staff workload. Potential for deskilling junior medical staff by prescribing. NMP teaching junior medical staff

“…so it is actually taking a lot of workload out of that system for the junior staff particularly so they can focus on things I can't do like bloods…” FG1-P3

“I think the junior medics appreciate having a specific point of call. I, like, during the day I get often get bleeps and queries from all over the hospital about ‘oh I've got this patient on this and we want to switch them to this for discharge.” FG2-P2

“…the junior doctors accept that it's normal to have an ACP, and they prescribe, and it's normal that they're from a variety of backgrounds, because that's what they've been exposed to.” FG2-P3

Senior medical staff

Working relationships with senior medical staff. Building trust between NMP and consultants. Constructive discussions with senior medical staff. Consultant concern regarding accountability

“The only thing I was gonna say is some of the consultants, particularly those when they’re sort of new to having an ACP around still feel that they are responsible and accountable for what you do.” FG2-P3

“I think there is a shift now of um understanding as sort of more junior consultants have come through. Um, it's fine now, but I think this is, I mean, this has been happening over several years now. Now it's, it's much more accepted that physios don't just do exercises or patting on the back. (laughs)” FG2-P1

“And I think the consultants probably work with me in a slightly different way. They tend to ask if they’ve got more complex queries or areas where there's less evidence for kind of my interpretation of it, and that tends to be more of a discussion” FG2-P2

Team awareness

Team awareness of prescribing role, or lack of awareness

“But as for junior doctors, I'm not even sure if they know that I'm a prescriber because I suppose I don’t go around saying ‘I'm a prescriber’.” FG2-P4

“…my, my colleagues, that I've been working with for many years, have gone through that process with me because obviously they’ve been my supervisors and stuff, so, um yeah, it's kind of more the not, not the inexperienced but the ones that haven't been part of the team that are unaware of that.” FG2-P5

Team role

NMP role within the team. Includes team interest in prescribing or lack of, and the effect on the NMP workload and role. Also, is the team in a better position to prescribe than NMP or are NMP’s non-prescribing skills utilised more than prescribing

“I feel like I'm very much part of the team and they recognize my area of expertise and things like that (nods from FG2-P6). So, I think I feel like we work like well together. And it's, it's a really good job. I wouldn't want to give it to someone else!” FG2-P2

“So, I work with consultants, with clinical specialist nurses as well and psychologists. … … So, you know, I don't think it's imperative for my role that I needed to, I need to prescribe. I need to have an understanding, though, of the, of the drugs because I work with, you know, other members that can prescribe. I suppose my skills are elsewhere.” FG2-P5

“I sometimes feel amongst, that certainly some of the doctor teams, I work with, it's, it feels the opposite, and they very much want to palm off work. … … So, I haven't left on time for a long time … … a large part of that is because I'm constantly being stopped by nurses that now know I’m a prescriber and want me to write things up.” FG1-P3

Decision making

Who makes the initial prescribing decision—NMP or medical team? Does the NMP make full use of their taught skills or not? Outcome dependant on role within the team, and medical staff attitude

“So, I think they’re finding it useful to have like an extra prescriber who’s physically there, who can, if he says, ‘I want to increase this dose’, I can physically do the writing of that on the chart. Yes, I think, I mean in psychiatry it's usually the consultant who makes a decision about which medication to use, but they’re quite open to discussion about that and tweaking things.” FG2-P4

“The thought I want to throw in is do you, do you sometimes feel though as if you are… … do you feel sometimes you just seen as the person just doing the writing of the prescription rather than doing the decision making of the prescription or, or is that … …is that accepted now so that we can make the full decision process?” FG1-P1

“No, I'd say, I don't really find that find that I feel like I'm just kind of writing out somebody else instructions, either. so, any new antiretroviral it's always a very sort of team led decision.” FG1-P2

Managers

Impact on NMP. Support for NMP and NMP role and understanding of NMP role. Differences highlighted between prescribing and non-prescribing managers. Links with ‘CPD’, ‘Training’ and ‘Governance’ themes

“…my line manager is, had completed the prescribing course before me. So was very well versed in what it involved and what it could, how it could enhance my role and then has put me in a, in a position to use it in a really effective way.” FG1-P3

“Yeah, I was gonna say so my line manager is nonclinical. They are from management background, so they have no real understanding of the role when they started. So, it was an explanation of the role and what it meant. Um, so they have quite limited understanding about the issues that might be involved.” FG2-P3

“…because often like quite a few people have said your actual line manager doesn't have an understanding of what you might be doing clinically or the risks you might be taking.” FG2-P2

“So, the new one, I think she's just happy that she's got a prescriber, because I was a first pharmacist prescriber in the team. … … she's always kind of offering me out to people, and ‘oh, FG2-P4 can come and do some clinics.’ But I think it's, I don't know if she understands the logistics and sort of how it'd be.” FG2-P4

Self

Overarching theme containing themes relating to the NMP themselves, their views and practice

Personal competence

Personal competence around prescribing. When they refer on to someone else and which areas the NMP is comfortable to prescribe in

“Okay, yeah, I would just say I suppose know what your specialist area is. it's not that you can't ever prescribe off your, your limited formulary. But know what your limits are because I think I know people go, oh I’ve got to get a doctor to need to sign this, can you just sign this and you think well no, that’s not what I'm here to do.” FG2-P4

“I just want to say I don't always necessarily agree with the prescribing of the consultants …. So, I tend to, I wouldn't prescribe that myself and I wouldn't rewrite that because then it's got my signature on it. … …I'll certainly prescribe what I'm happy with prescribing.” FG2-P4

“…some of my colleagues have got more experience in sexual health, whereas I haven't so it might be something that I'll say ‘I'm not comfortable. I would refer you to this service’” FG1-P2

Prescribing Role

Role that prescribing plays within the job. Whether or not prescribing is an essential part of role. For existing jobs, who covers aspects of the existing role. Blurring, or clarity, between NMP and professional role aspects. Links with ‘Stopping’ theme

“…but I've never thought as a prescriber that I've ever been given that allocation of time to make sure that, you know, you can function in the role when you're doing clinics.” FG2-P6

“I think it's probably easier, like my role was a new role and the expectation from the medical side was that this person would prescribe, whereas I think it's maybe slightly harder if you've got an existing role and then do it, because then you need to create the time to do it and some other part of your job has to go somewhere or to someone else, …” FG2-P2

“So, you know, I don't think it's imperative for my role that I needed to, I need to prescribe.” FG2-P5

“you know, we've taken on that role and, er, and, and, particularly sort of with more some more clinical competencies coming along we’re properly taking on newer roles’ um, but we need to make sure that, then the sort of traditional roles are either filled or taken up” FG1-P1

Support

Who, or when, to ask for help. Support from different areas and people. Use of networks for support. Links with ‘Staff’ theme

“…so I asked to have a professional kind of supervisor in a way, that I could go to if there were any issues and to make sure that I sort of safety netted myself…” FG2-P3

“…so if I see a patient that's more complex or slightly unusual, that doesn't fit the usual pattern, then I can just catch him between patients or if it's less urgent I'll discuss that patient with him at the end of the clinic.” FG2-P2

Training

Ease of access to training course, or challenges. Personal development during the training course. Medical supervisor support and change in working relationship resulting from the course. Benefit of an area of expertise when undergoing the course

“And it comes with a whole host of other skills, isn't it, that you're learning as well. It's about, you know, your history taking, examination skills and a whole host of other skills as well” FG1-P2

“…my line manager has supported me in terms of the prescribing, are quite happy for me to go on the course…” FG2-P7

“The, the course itself really enhanced my practice because although it was an absolutely mission, getting the hours in around full time work … … I really do think it helped me hugely because the um so spending time one on one with consultants in their clinics, for example. … …I think they then saw me as more of an integrated member of the team.” FG1-P3

So, so that, yeah, that took a little while to actually get the agreement for the, for the for the funding to, to do that, because they couldn't just quite understand what the purpose of it is, yeah.” FG1-P1

Governance

Overarching theme which incorporates aspects such as policies and guidance, formulary, legislation etc. Certain aspects have cross links with other themes, for example ‘CPD’ links with ‘Managers’

CPD

Support to attend CPD, including provision of time and funding. Availability of CPD within work environment and outside. Self-directed or directed by manager/organisation. Benefits of web-based meetings and conferences

“If it's something that costs money, then it can be a bit more difficult to arrange” FG2-P2

“I book my own diary. Um so I if I need to do CPD, I can just build it in but also, I can attend the monthly non-medical prescribing meetings that we have at our trust, which also has an element of CPD as part of the meetings…” FG2-P1

“In fact, this, this Covid’s been a wonder, because I can actually get to all these webinars, instead of having to go to stuff.” FG1-P3

“…we have a monthly pharmacists clinical supervision meeting and also the monthly NMP supervision meeting so there’s various things that built in that you can do CPD but obviously you can go off and do more reading and things in your own time as well.” FG2-P4

NMP register

Ease of registering as an NMP with organisation. Maintenance of registration. Amending register entry

“I think I've signed a form but I’m really not quite sure what actually happened with it.” FG1-P1

“Um, yeah, I think it's just that attitude in Trusts that NMPs have to jump through many hoops, don't they, and they have to, once you’re qualified, you can't just start prescribing, you have to then go to a committee to be stamped, and they have to prove evidence of things.” FG2-P4

Policies and guidance

Policies and guidelines relating to NMP: the clarity and value of them, or absence of them. The support given by them

“We’ve got a non-medical prescribing policy, haven’t we, but it seems quite a vague in its limitations.” FG1-P3

“So, I think our, our, I guess, policy and things are quite clear that you, you have like an allocated clinical supervisor, as such, and you should be meeting them like once or twice a year to kind of check in…” FG2-P2

Formulary

Personal or organisation formulary affecting NMP role

“And I had to give a list of a maximum of 10 drugs I could prescribe…” FG2-P3

“Have your small, very small personal formulary and build up so that you're prescribing really well, just a small handful of drugs to begin with and then slowly expand it.” FG2-P1

Legislation

Effect of legislation on prescribing, particularly affecting physiotherapists

“…the main sort of medications you would have used, we weren't able to as physio’s, um so, your gabapentin, obviously, and pregabalin’s changed, codeine we weren’t, we weren’t able to, so co-codamol we weren’t able to prescribe.” FG2-P5

Second check

Value of second check by a pharmacist when prescribing. Mentioned by pharmacist prescribers within the context of safety

“I think, I think, I think it's probably both true, isn't it, because FG1-P2 you've got a very, very specialist role and, and so have, I and we can both, our prescriptions will go and be checked by somebody else…” FG1-P1

“…in reality, a lot of TTOs don't come through pharmacy, a lot of them are nurse lead TTOs. so I am, I then become the technician, pharmacist and pharmacist prescriber for that patient. I’m the only pharmacist contact, pharmacy contact, that that patient sees or gets and I'm prescribing as part of that role, which probably opens me up to some risk of error in terms of not getting a second check.” FG1-P3

Practical aspects

Overarching theme which incorporates aspects such as access to clinic rooms, budget, admin support etc

Admin support

Availability of administrative support. Allocated time to complete NMP associated administration

“…like some weeks I might do three clinic sessions, which then generates a significant amount of after clinic work but there's no, there’s not the recognition that you also need time to do that work.” FG2-P2

“I do a mixture of home visits and clinics and we have as much admin time as we need really.” FG2-P1

Budget

For post and equipment. Source of budget – single or multiple departments

“Because I think, particularly I think in pharmacy, they look to get that financial support from the directorates that they're prescribing for rather than just coming out of the pharmacy budget.” FG2-P6

“…I’ve had to sort of justify why I need a laptop, why I need a mobile phone, why I need headset and camera…… my role is jointly funded by pharmacy and the ID directorate as well so it's the barrier I find sometimes is, is well which budget is it going to come from.” FG1-P2

Clinic rooms

Access to, and availability of, clinic rooms

“In our trust, clinic rooms are at a premium. They are really struggling for space and that has been one of, one of the barriers…” FG2-P7

Facilities

Access to facilities needed for prescribing. Includes drug charts, notes etc

“Still on paper. So sometimes it's just physically getting hold of the flaming drug chart.” FG1-P3

“we have a very clear process in the trust, I get my pads from a… …lockable drawer from a named person, everything’s secure where I work, so I've got no problems.” FG2-P1

IT

Access to IT. Integration, or lack of, across areas. Issues using IT

“…the IT infrastructure in our place is just, it's just woeful…” FG1-P3

“we also share in, in our trust, it’s community and acute services, and I have access to the electronic patient record that's used in the hospital, which I can also add records on, if I'm managing a patient that's also managed by the respiratory consultant, so we've got a really seamless um patient record…” FG2-P1

Patient care

Overarching theme exploring the use of NMP in patient care

Impact on patients

Direct or indirect impact on patients and patient care

“…make sure it's happening in a time efficient manner, so patients are, you know, getting the prescriptions when they need because, particularly with the home care prescriptions as you have to work a month ahead.” FG1-P2

“For me, it’s definitely reduced the time to treat, so before we’d have to write, request from GPs to prescribe inhalers or, urgent medications, whereas now writing a script in the patient's home, it’s just so much quicker.” FG2-P1

Quality & Safety

NMP improving quality and safety of prescribed medicines for the patient. Links to ‘Governance’ theme

“I guess for the inpatient side, um, when I do more of that, I guess more of patients are more likely to be started on the appropriate anticoagulation, at the right dose, etc.” FG2-P2

“I suppose, and I probably said this, I think the probably the influence I have on the consultants is their, is their…, you know, assessing the use of their pain meds now, and is that appropriate. … … whereas consultants, if that's been their practice for years and years and years, it, you know, it wouldn’t, er wouldn't change unless it was challenged and I think we've got a good environment now that we can, we can have those discussions. … … And I think we bring a more balanced view possibly (nods from FG2-P4).” FG2-P5

Stopping

Function as NMP to stop medication/refer back to main prescriber/GP

“And also, that they get the medication they need stopping, stopped a lot quicker (nods from FG2-P4, FG2-P5 and FG2-P6).” FG2-P3

“… we do more deprescribing now so I'm using it a lot less and when I do use it, it's more to give advice to GPs on how to maybe rationalize medication more than anything.” FG2-P5

Orphan themes

These themes do not fall easily under one overarching theme. They may cross link to several other themes or stand alone

Conflict of interest

Theme highlighting conflicts of interest identified by participants

“…they don't want to push the case too hard, because they also want additional consultants, and they feel if they're saying I can do it than that weakens their case. So, it's almost like a conflict of interest there at the moment.” FG2-P7

“But I suppose, even, even with herself, there is a conflict of interest because if I'm off prescribing that’s time taken away from delivering our service which she needs to manage.” FG2-P7

Covid

Impact that Covid-19 pandemic has had on NMP and /or their prescribing practice

“…particularly with Covid that aspect of the service has become more and more NMP led. I think at one point I was actually the only prescriber prescribing for that group of patients.” FG1-P2

“my most recent experience was during Covid and being redeployed to wards for a couple of, well it was eight weeks, and you know generally junior medical staff did receive the prescribing well” FG1-P2

Good advice

What advice would the participants give new or prospective non-medical prescribers

“I would say you need to have decided with your organization where you're going to use it before you do the course, because otherwise you end up kind of stuck in limbo maybe without either the time or a role to use it.” FG2-P2

“I think it’s really important that it's not just an additional duty that you take on as part of your role, have a dedicated area, have that time, time carved out so you can actually carry out that role.” FG2-P6

“Don't be afraid to ask for help. You’re independent, but you're not alone.” FG1-P3

Undergrad Px

Prescribing taught at undergraduate level. Preparedness of new prescribers to take on role. Impact on rest of service

“…I share both your concerns, that I think at the moment the undergrads coming out too green to be independently prescribing and what we've already discussed about being not just the prescriber in, on paper, but actually it changes your role and becoming far more embedded into your team.” FG1-P3

“…having undergrads coming out as prescribers, from a trust point of view, they're just going to be really expensive junior doctors, aren't they?” FG1-P3

“…I think that when you’ve got a lot of junior people applying for jobs and you always say ‘Where do you see yourself in five years’, and they always say they want to do the prescribing course and you think, well, who’s going to be left just to do the day job, if everybody sees themself as a prescriber…” FG2-P4

“…they're not really taught an awful lot about medications, never mind prescribing at undergraduate level so I think that’s got a long way to come.” FG2-P1